Aging
Aging gracefully
Demographics of Aging Population
Global population of individuals over 65 years is expected to reach 1.6 billion by 2050
Most older people are affected by multiple chronic diseases → complex drug treatments and increased risk of physical and cognitive disability
Improving/preserving the health and quality of life is challenging due to poor clinical guidelines
New focus on understanding how underlying biological mechanisms of aging connect to and impact longitudinal changes in health trajectories
Harnessing how to evoke and control resilience mechanisms in individuals with successful aging could lead to new approaches in human medicine
Overall total population increase of one person every 55 seconds
Elderly and categorisation of older persons
Elderly >65 years
Chronological age vs biological age
Genetic factors account for ~25% of the variance in human lifespan and nutritional and environmental factors determine the rest
Distinct categories
Healthy: minimal or no chronic disease, functionally independent
Chronically ill: several non-curable disorders, functionally independent or minimally dependent, many medications
Frail: many chronic disorders, some serve, functionally dependent, minimal physical reserves, frequent hospital trips
Categories of aging
Successful aging: satisfactory health, function and level of independence maintained
Normative aging: normal chronic disease progression, some compromise to function
Frailty: severe decline in cognition and physical functioning, may be bedridden/need wheelchair (require assistance and care), malnutrition is important
Disability adjusted life years (DALYs): measure of healthy life lost, either through premature death or living with disability due to illness or injury
Often used synonymously with health loss
Life expectancy: based on estimated average age of a particular population will be when they die
For ATSI born in 2015-2017, males (71.6 years) and females (75.6 years)
Male: 8.6 years lower than non-indigenous, Female: 7.8 years lower
Between 2005–2007 and 2015–2017, Indigenous life expectancy at birth for boys increased by 4.4 years and by 2.7 years for girls.
Over the same period, the difference between Indigenous and nonIndigenous life expectancy narrowed by 2.9 years for males and 1.9 years for females
Physical changes in adulthood and relevant NRV
Aging occurs due to molecular damage that is due to reactive oxygen species produced during the metabolism of oxygen to produce cellular energy.
Oxidative damage results in:
damage to nuclear chromosomal DNA
shortening of telomeres – aging is associated with shortening of telomeres
mitochondrial DNA and lipid peroxidation – this results in reduced cellular energy production, eventually causing cell death.
The environment and nutrition have a role in oxidative damage in the aging body.
Insulin signaling pathways, and chronic inflammation drive the production of reactive oxygen species.
Normal aging (a) and different pathways to accelerated aging (b and c)
Robust resilience at a young age fully compensates damage.
Over time, damage accumulates that is not fully compensated by resilience.
Toward the end of life, resiliency breaks down, and new stresses cause fast, unopposed damage accumulation that leads to frailty and eventually to death.
Accelerated aging may occur either because of faster rates of damage accumulation (b) or because of rapid shrinking and eventual collapse of resilience (c).
Note that even in the state of robustness, damage can be already abnormally high (b) and resilience already abnormally low (c)
Physiological and physical changes of aging
Cardiac output decreases, blood pressure increases and arteriosclerosis develops
Lungs show impaired gas exchange, a decrease in vital capacity and slower expiratory flow rates
Creatinine clearance decreases although serum creatinine remains relatively constant due to a proportional age-related decrease in creatinine production
Altered gastrointestinal motility pattern with senescence and atrophic gastritis
Altered hepatic drug metabolism
Progressive elevation of blood glucose
Linear decline in bone mass after the fourth decade leading to osteoporosis
The epidermis of the skin atrophies due to changes in collagen and elastin, the skin loses tone and elasticity.
Lean body mass declines due to loss and atrophy of muscle cells.
Degenerative changes occurs in many joints and together with the loss of muscle mass, impacts locomotion
GI system and nutrition
Reduced production of saliva
Decreased oesophageal sphincter tone
Reduced secretion of hydrochloric acid and pepsin, and a small rise in gastric pH
Decline in the absorption of vitamin B12
Reduced lactase concentration
Reduced efficiency of calcium absorption due to reduced vitamin D receptors and circulating 25(OH) vitamin D
Moderate intestinal villous atrophy
Reduced gut contractility, slowed gastric emptying and prolonged gastrointestinal transit time
Reduction in serum albumin
Reduced blood flow – reduces by 50% between third and tenth decades
Reduced synthesis of vitamin K-dependent clotting factors
Reduced low-density lipoprotein (LDL) receptors, reduced metabolism of LDL
Decreased pancreatic mass and enzyme reserves
Reduced liver mass – reduces by 20–40%
Reduced basal metabolic rate and energy requirements; reduced muscle mass and activity levels
~50% infected with Helicobacter pylori - the presence of the bacteria increases with age
Increased colonic sensitivity to opioids
Clinical manifestations
Considerations for care
Actively promoting healthy aging
Encourage older people to remain physically and socially active
Consider interventions that maintain a patient’s functionality
Making recommendations: take time to understand them (problems, priorities, living circumstances)
Regularly review medical history (medications, diet prescription) and decide what remains relevant and whether the treatment or management remains appropriate
Be vigilant when older patient are unwell, have trauma or surgery (slow recovery)
Think behind presenting complaint and how management will impact other systems
Encourage early mobilisation and avoid prolonged periods in bed
Fluid and electrolyte homeostasis may be impaired – stress to patients and carers the importance of ensuring adequate hydration and avoiding hot environments.
Nutrient vs food group intakes of elderly
National nutrition survey 2011-12
Adults aged 71 and over
Don’t meet recommended daily services for ⅘ food groups, excluding grains for women
Don’t meet recommended serves of dairy products 90% (men) and 94% (women)
22% do recommended amount of physical activity each day
71% are overweight
Dietary approaches
Food first preferred
small, frequent meals
Fortifying foods/meals
Nutrients and food
Energy, protein (distribution and quality), fats, carbohydrate quality and dietary fibre (types, distribution, fluids)\
Make use of mid meals
Milk: based drinks fortified with additional skim milk powder, cream, e.g. hot cholate/milo
Yogurt, custard, milk based pudding, creamed rice
Eggs: boiled, fritters, frittata, quiche
Cheese on toast or crackers
Dip & crackers
Dried fruit & nuts
Protein in foods
Utilising animal protein sources ensures a complete complement of amino acids
Complementary amino acids in grain foods with legumes – do not need to be served together…
Distribution across the day – aim at least 20g/ meal
Dietary fibre in foods and supplements
Soluble fibre: dissolves in water, making a gel-like or softer faecal mass. This can slow the movement of food through the large bowel. It can also help with diarrhoea as it can slow down and thicken waste.
e.g. Bananas, apples, oranges, pears, berries , Oats and oat bran , Legumes and pulses (e.g. kidney beans, chickpeas) , Okra, eggplant, peas, avocado, sweet potato, carrot, turnip , Psyllium husk (Metamucil)® , Benefiber®
Insoluble fibre: does not dissolve in water and adds bulk to the stool. This can speed up the movement of stool through the bowel and can help with constipation.
e.g. Fruit (skin and seeds have the most fibre), Vegetables (skin and seeds), Wholegrain products e.g. breads, pasta, brown rice, quinoa, barley, Nuts and seeds e.g. flaxseed, chia, Wheat and rice bran
Resistant starch: is a fibre that feeds the good bacteria in our gut (prebiotic). As the name suggests, it is resistant to digestion – particularly in the upper part of the bowel. Acts within large bowel.
e.g. Cooked and cooled potato, rice, quinoa, and pasta, Unripe bananas, Legumes, Oats – especially raw oats (e.g. overnight oats)
Supplements
Fibre, protein, multivitamin supplements
Salivary products
Why?
Aging, some medications, some chronic diseases, head and neck cancer treatments
Dehydration, inadequate fluids, soft drinks, alcohol consumption
First steps:
Adequate fluids – mostly water
Oral hygiene – cleaning teeth, cleaning and removing dentures
Liquid meals, soups, sauces to moisten food, low salt/sugar
Secondary steps:
Chewing sugar-free gum
Dry mouth lozengers – containing Xylitol
Saliva replacements – mouthwashes, gels, mouth sprays, toothpastes
Medications via GP
Malnutrition screening
Identify Risk Factors for Malnutrition and Physical Signs
Malnutrition: describes a deficiency, excess or imbalance of a wide range of nutrients → measurable adverse effect on body composition, function and clinical outcome
Caused by reduced dietary intake and adsorption of macro- and/or micronutrients, increased losses/altered requirements and energy expenditure
Frailty: low grip strength, low perceived energy levels, slowed walking speed, low physical activity, unintentional weight loss
Risk Factors:
Dietary Intake Issues: Reduced intake due to physical, psychological, or socioeconomic barriers.
Absorption Problems: Conditions like coeliac disease, IBD, or aging-related decline in digestive function.
Increased Nutrient Requirements or Losses: Chronic illness, wounds, infection, or burns.
Age-Related Changes: Appetite decline, sensory deficits, dental issues, medication interactions.
Physical Signs of Malnutrition:
Loose-fitting clothes/dentures
Pale/cracked lips, sunken eyes
Hair thinning, dry skin, poor wound healing
Muscle wasting, confusion (non-dementia)
Unintended weight loss
Eating less than half of meals/snacks served
Involuntary Weight Loss Criteria:
5% in 1 month or >10% in 6 months
BMI <18.5 for adults; <20 for elderly (≥65 years)
Sarcopenia; age-related progressive loss of skeletal muscle mass and strength as a result of aging
Low muscle mass and strength
Decreased physical performance/function e.g. times up and go, grip strength
No internal consensus on the definition
Can be related to disease, activity or nutrition
Negative outcomes - fails, disability, cardio-metabolic related disorders
54% increased mortality risk in Australian men
Understand and Identify Tools for Nutrition Screening and Assessment
Gain Practical Skills in the Use of Nutrition Screening Tools
SGA (Subjective Global Assessment): for screening. Scored out of 35 (35 is highest risk)
A: well nourished
B: suspected or moderately malnourished
C: severely malnourished
Not good for monitoring change
Hospitalised patients
MNA (mini nutrition assessment): nutrition screening and assessment tool that identifies geriatric patients aged ≥ 65 who are malnourished or at risk of malnutrition
Originally 18 questions, current 6 questions
<11 at risk and long form should be used (anthropometry, general evaluation, dietary assessment, subjective assessment)
<17 malnourished
17-23 at risk of malnutrition
≥24 well nourished
Does not assess severity
ASPEN: similar to SGA
6 items: reduction in take, weight loss, loss of muscle mass, loss of subcutaneous fat, localised or generalised accumulation of liquids, decreased muscle strength via dynamometry
≥ 2 items = malnourished
The degree of malnutrition, moderate or severe is then classified due to acute disease, chronic disease, reduced intake without accompanying inflammatory state
GLIM (global leadership initiative on malnutrition): 1. validated tool to assess the existence of nutritional risk, 2. Assess for diagnosis of malnutrition and its severity
Diagnose using ≥1 phenotypic + ≥1 etiologic criterion
Biochemical tests
Serum albumin: good predictor of surgical risk, long half life of 18 days → not acute, but severity of situation, diluted in hyper hydration
Prealbumin better – more expensive test; Normal values between 20-30mg/dL, moderate malnutrition 10-20mg/dL, and severe <10mg/dL
C-reactive protein (CRP) – inflammation
Creatinine – used to calculate kidney function (e-GFR) but also correlates with muscle mass
Cholesterol also correlated with degree of malnutrition
Role of Nutrition and Non-Nutrition Professionals
Diet modification
Aging may impact dietary changes
Chronic disease
Oral cavity, chewing, saliva and swallowing
Gastric acids and conditions like reflux
Small bowel (nutrient absorption)
Large bowel (gastric mobility and constipation)
Appetite, medication, self care and self feeding
Shared Responsibility:
Nurses, allied health professionals, GPs, and aged care staff can initiate screening.
Screening can be part of routine assessments or community outreach.
Interdisciplinary Care: Team-based approach improves identification and management.
Education and Training: Empower non-nutrition staff with toolkits and protocols.
Apply the Socio-Ecological Framework to Active Aging
The 5 P’s of Active Aging: respects multidimensional nature of aging: micro (person), meso (process), and macro systems (place and policy making), based on health (prime) environments
relationships between the person and the environment at the individual, interpersonal, and environmental levels
Person (micro): Physical health, mental health, autonomy.
Process (meso): Services, support networks, care pathways.
Place (macro): Environment, infrastructure, policies.
Policymaking: Regulation and funding of elderly support.
Prime (Health): Holistic view of aging—body, mind, social life.
Implications:
Nutrition must be seen within the broader context of aging well.
Social prescribing and community interventions can promote well-being.
Screening tools are just one piece—need upstream policies and environments that support aging in place.
Summary
Risk factors for malnutrition and physical signs in older people are useful for practical identification of at-risk individuals
Nutrition screening tools can be easily applied and can form the basis for key questions when in contact with older people
Assessment of the severity of malnutrition will be key to facilitating better health care and more accurately assessing the cost of care
There is a role for nutrition and non-nutrition professionals in malnutrition screening that can be part of everyday practice in communities
The socio-ecological framework may help health professionals consider Active Aging as the ultimate goal in an aging population or community and functions to think outside of health care as to how this can be implemented at the individual level