nutrition in aging and terminally ill or hospice

the fastest growing segment of the U.S. population

are those age 65-74

gerontology

study of normal aging

geriatrics

study, diagnosis, and treatment of chronic diseases associated with aging

defining older

- in federal retirement programs: 65 and older

- 65-74 years old = young old

- 75 to 84 years old = old

- 85+ = oldest old

- super centenarian = older than 110 years

role of nutrition in disease prevention in primary prevention

health promotion and disease prevention

role of nutrition in disease prevention in secondary prevention

slow progression of chronic nutrition-related diseases; maintain functionality, quality of life, fitness, and mental health

role of nutrition in disease prevention in tertiary prevention

medical nutrition therapy involves:

- chewing/appetite problems

- modified diets

- functional limitations

predetermination theory of aging

built in mechanism determines when aging begins and time of death

accumulated damage theory of aging

systemic breakdown over time

specific predetermination theories

- pacemaker theory

- genetic theory

- rate of living theory

- oxygen metabolism theory

- immune system theory

specific accumulated damage theories

- cross-link theory

- wear and tear theory

- free radical theory

- somatic mutation theory

- telomeres theory

physiologic changes of senescence (aging)

- body comp

- sedentary lifestyle

- sensory losses

- immuncompetence

- oral health

- GI

- CV

- renal

- neurologic

sarcopenia

age-related loss of skeletal muscle, function, and mass

sarcopenic obesity

loss of lean muscle mass in older adults with excess adipose tissue

sedentary death syndrome

life threatening health problems caused by sedentary lifestyle

- burning fewer than 200 calories per day

dysgeusia

loss of taste or altered taste

hyposmia

decreased sense of smell

presbyopia

loss of elasticity in the crystalline lens that causes an inability to focus clearly on close distances

immunocompetence

immune response is slower and less efficient

xerostomia

dry mouth

- difficulties chewing and swallowing

dysphagia

dysfunction with swallowing

achlorhydria

insufficient production of stomach acid

- leads to diminished amounts of vitamin B12

constipation

causes lack of PA, fluidsl and fiber

- decreased motility in the large intestine

cardiovascular changes with age

-heart disease and stroke leading cause of death

- affected by lifestyle (smoking, PA, diet)

- low sodium/low fluid MNT = low intakes

renal changes with age

- GFR declines by 8-10 ml/min every decade after age 30-35

- Cr increases

- inability to excrete concentrated urine

- dehydration, diuretic use, and meds

common health problems affecting quality of life

- depression

- functionality (activities of daily living)

- geriatric failure to thrive

- weight management

- fragile skin

what are the four syndromes in geriatric failure to thrive

- impaired physical functioning, malnutrition, cognitive impairment and depression

failure to thrive

- liberalize diet restrictions

- symptoms: weight loss, decreased appetite, dehydration, inactivity

protein energy malnutrition (PEM) often overlooked

- symptoms: confusion, fatigue, weakness

- low income, difficulty chewing and swallowing meat, smoking, or little to no PA are at higher risk

pressure injury

- tissue injury caused by continuous pressure that impedes blood flow to the skin

- condition of immobility with malnutrition as a contributing facotr

what are the key risk factors to a pressure injury?

immobility, poor circulation, obesity, urinary incontinence

what are the 6 stages to pressure injury

Stage 1: non-blanchable redness on intact skin

Stage 2: partial-thickness skin loss with exposed dermis

Stage 3: full thickness skin loss

Stage 4: full thickness skin and tissue loss

Unstageable: obscured full thickness skin and tissue loss

stage 1 pressure injury

skin intact, non-blanchable redness over bony prominence

stage 2 pressure injury

partial-thickness kin loss involving the epidermis and dermis, presenting as an abrasion or shallow crater

Stage 3 pressure injury

full-thickness tissue loss, subcutaneous fat may be visible

stage 4 pressure injury

full-thickness tissue loss with exposed bone, muscle or tendon

nutrition recommendations for pressure injury

1.2-1.5 g protein/kg/day

30 to 35 kcal/kg/day

supplement as need based on meds and dietary intake

MNA

- mini nutrition screening and assessment tool

- most widely used screening method

- 6 questions and BMI evaluation/calf circumference

calorie and protein requirements for older pop.

- healthy adults: 18 to 22 kcal/kg women; 20 to 24 kcal/kg for men

- 1.0-1.2 g/kg body weight protein

- adjust for disease states and activity (dialysis, pressure injuries, CHF)

aging affects

- absorption, utilization, and excretion of nutrients

- tend to have lower intakes of calories, total fat, fiber, calcium, magnesium, zinc, copper, folate, vitamin B12/C/E/D

nutrient needs for older population

- CHO 45-65% calories

- lipids 20-35% of calories

- water: maintain hydration, 25-30 mL/kg/day >65 years

health care coverage for older adults

- medicare

- medicaid

- 2010 affordable care act

- Older Americans Act Nutrition Program

- SNAP

- Omnibus Reconciliation Act (OBRA)

- Senior Farmers' market nutrition program

- commodity supplemental food program

- Child and Adult Care Food Program

Medicare

annual wellness visit, education and counseling, expanded coverage for reimbursement for RDs

Older Americans Act Nutrition Program

congregate meal sites and home-delivered meals

- home delivered meals is administered by the U.S. department of health and human services

Omnibus Reconciliation Act (OBRA)

reformed legislation aimed at improving skilled nursing care

medicaid

administered by the state and generally covers enteral and parenteral nutrition but not dietitian services

the dining practice standards

- person-centered care at long-term care facilities

- decreased use of therapeutic diets (liberalized diets) they don't encourage strict dietary control for DM or heart disease

- food first and avoidance of canned nutrition supplements

palliative care

- provides symptom relief

- initiated at any time

- can be given in conjunction with curative therapy

hospice

- support for terminally ill person and family

- initiate when life expectance ≤6 months

- advance directives: identifies a patient's health care preferences regarding end-of-life issues

nutrition care of terminally ill and hospice patients

- main goals: maintain comfort and quality of life

- dietary restrictions are rarely appropriate

- consider strategies that facilitate symptoms and pain control

- termination of life support: advance directives