NUTRITION IN GERIATRIC PATIENTSClick to edit Master subtitle style

BY DR.RAJAT ANAND

5/3/12

Contents

Introduction Classification of nutrients Effect of nutrients on specialized cells Balanced diet Nutrient needs and requirements of the elderly Factors that effect nutritional status Other risk factors Assessing nutritional status of the elderly Protein Energy Malnutrition Nutritional guidelines Diet suggestions for denture wearers5/3/12 Common problems faced by denture wearers and

INTRODUCTION

5/3/12

Brief history

The Canon of Medicine, written by Abu Ali Ibn Sina(Avicenna) in 1025, was the first book to offer instruction in the care of theaged, foreshadowing moderngerontology and geriatrics. In a chapter entitled "Regimen of Old Age", Avicenna was concerned with how "old folk need plenty of sleep" and how their bodies should beanointedwithoil, and 5/3/12 recommendedexercisessuch as

The

famousArabic physician,Ibn AlJazzarAl-Qayrawani (Algizar, circa 898-980), also wrote a special book on the medicine and health of the elderly, entitledKitab Tibb alMachayik

5/3/12

he

first modern geriatric hospital was founded in Belgrade, Serbia in 1881 by doctorLaza Lazarevi. geriatrics in the United Kingdom really began with the "Mother" of Geriatrics, Dr. Marjorie Warren. Warren emphasized that rehabilitation was essential to 5/3/12 the care of older people.

Modern

Classification of nutrients

By origin chemical compositionnutritive valuemicro and macro nutrients.

By By By

5/3/12

Classification

By Chemical Composition carbohydrates proteins fats vitamins minerals5/3/12

Classification

By nutritive value

1.Cereals and millets 2.pulses(legumes) 3.Vegetables 4.Nuts and oil seeds 5.Fruits 6.Animal foods 7.Fats and oils 8.Sugar and jaggery 9.Condiment and spices 10.Miscellaneous foods.5/3/12

Classifications Macro

nutrients

-carbohydrates -proteins -fats. Micro

nutrients

-vitamins-minerals5/3/12

Specialized cells and nutritionEpithelial cell Vitamin

protein

A and

are essential for the normal proliferation of epithelial cells.

Specialized cells and nutritionFibrobla st

Vitamin

c, zinc,

copper and protein Are important in collagen formation.

Specialized cells and nutritionCementoblast and cementocytes

For protein matrix of cementum vit c zinc,copper,and protein are essential. To calcify the matrix;

protein, calcium, phosphorus, and vit D are essential.

Amelobla st

Specialized cells and nutrition

For protein matrix of enamel vit-A, vit-c, zinc,

copper and protein are essential.

To calcify the protein matrix

protein, calcium, phosphorus, vitamin D,and fluoride improve quality of apatite formed.

Specialized cells and nutritionodontobla sts

For protein matrix of dentin; vitA ,vitC, zinc, copper, and protein are essential. To calcify matrix; protein, calcium, phosphorus, and vitD are essential. Fluoride improves apatite crystal.

Specialized cells and nutrition

Osteocyte, osteoblast and osteoclast.

Imp.

Nutrient for formation of alveolar bone are; vitA, vitC, vitD, zinc, copper, calcium and phosphorous.

Balanced Diet

Its defined as a diet which contain different types of foods,possessing the nutrients carbohydrates,fats,proteins,vitamins and mineralsin a proportion to meet the requirements of the body .

Balanced diet is highly variable.

5/3/12

Balanced Diet

The National expert group constituted by the Indian Council of Medical research has recommended the composition of the balanced diet for indians.This is done taking into account the commonly available foods in india.The composition of the balanced diet (vegetarian and non vegetarian)for an adult man and adult woman are shown in the following tables

5/3/12

5/3/12

5/3/12

Group 1. Cereal Grains and Products. Foods such as rice, wheat, jowar, bajra, ragi etc are in this group.

Group 2. Pulses And Legumes. The food stuffs in this group are pulses and legumes (eg beans, soya beans, peas, Rajmah.

Group 3. Milk , Nuts and Meat Products. They include milk, curd, skimmed milk, cheese, almonds, groundnuts, chicken, meat, liver, egg, fish . 5/3/12

Group 4. Fruits And Vegetables. These include green leafy vegetables, yellow or orange fruits and vegetables such as papaya, mango, carrots,tomato, pumpkin, stems, leaves and flowers of plants, ladies finger, bringals, bittergourds and other gourds, cabbage, cauliflower, drumsticks. Fruits such as amla, lemons, oranges.

5/3/12

Group 5. Fats And Sugars All these foods supply energy or calories vegetable oils, vanaspati, ghee, cream, sugar and jaggery ,commonly available cooking oils include mustard oil, coconut oil , groundnut oil, palmolein oil, and sunflower oil.

5/3/12

Nutritional Requirements for elderly PateintsCALORIES

Calories requirement less with advancing age due to decreased energy expenditure and due to a decrease in the BMR. Energy allowances for persons between 51-75 yrs. Is reduced by 10% of that of young adults and for over 75 yrs. It reduces by 20-25% Elderly people should select nutrient dense food as they eat less

5/3/12

Nutritional Requirements for the Older Patient

Estimated total daily energy need (based on body weight): 25-30 kcal/kg/day

Estimated total daily energy need (based on basal energy expenditure; BEE): Harris-Benedict Equation Male BEE = 66 + (13.7 x kg) + (5 x cm) (6.8 x age) Female BEE = 655.1 + (9.563 x kg) + (1.850 x cm) (4.676 x age)

Results should be multiplied by 1.5 to estimate energy expenditure of ill elderly patients5/3/12

Nutritional Requirements for the Older PatientCarbohydrates

should comprise 45-65% of total calories Fat should comprise 20-35% of total calories Protein should comprise 10-35% of total calories Fluid : 30ml/kg/day or 1ml per kcal intake

5/3/12

Nutritional Requirements for the Older Patient Estimation

of protein:

(0.8 to 1.5)gm/kg/day Restriction of these amounts may be indicated in renal or hepatic insufficiency Estimation

of fiber: (complex carbohydrates are the preferred fiber source) Men: Women: 30 gm/day 21 gm/day5/3/12

Proteins

1.

Animal Sources

- eggs, milk, mutton, fish, poultry, liver etc.

Plant sources - pulses and legumes, cereals, nuts, beans, oilseeds etc. Class I proteins are derived from animal sources contain all essential amino acids needed . Egg.2.

Class II is derived from pulses and legumes, cereals, vegetables, nuts and they do not contain all the essential amino acids they lack in one or more amino acids.

5/3/12

Elderly may consumes less protein than adults for the following reasons: Protein foods are more expensive Meat is hard to chew and swallow Preparation of meat requires equipment and physical energy Consumption of milk decreases with age

5/3/12

Fats

The current recommendation by INDIAN NUTRITION BOARD is that fats should comprise 10-35% of dietary calories

it

can lead to CVS problems like hypertension,atherosclerosis etc.

5/3/12

CARBOHYDRATES

They are the compounds of carbon, hydrogen and oxygen. Each gram of carbohydrate provides 4 Kcal of energy.

By the digestion of starch and sugar, glucose is formed and absorbed into the blood.

Some carbohydrates are stored in the form of glycogen in muscles and liver.

5/3/12

WATER Inadequate

intake of fluid by elderly will lead to rapid dehydration and associated problems such as hypotension,elevated body temperature,dryness of mucosa,decreased urine output etc. normal conditions the goal for fluid intake should be at least 30ml/kg body wt/day elderly should at least drink 8 glasses of water or juices or milk.5/3/12

Under

An

Calcium

RDA of calcium is 800mg In elderly it should be increased to 1000mg. There is also an speculation that a long term calcium intake of 1000-1200mg per day can delay or prevent development of osteoporosis Dietary sources milk and its products , dried beans and peas , canned salmon , green leafy vegetables . Functions of calcium are : Formation of bones and teeth Blood clotting Contraction of muscles Cardiac action5/3/12

Calcium intake of post menopausal women is co related with mandibular bone mass, patients with dentures who have excessive ridge resorption report lower calcium intakes .

A chronically low calcium intake results in a negative calcium balance . In 1997 the NATIONAL ACADEMY OF SERVICES recommended that an 5/3/12 adequate amount of calcium for men

NUTRITION IN GERIATRIC PATIENTSClick to edit Master subtitle style

BY DR.RAJAT ANAND

5/3/12

Contents

Introduction Classification of nutrients Effect of nutrients on specialized cells Balanced diet Nutrient needs and requirements of the elderly Factors that effect nutritional status Other risk factors Assessing nutritional status of the elderly Protein Energy Malnutrition Nutritional guidelines Diet suggestions for denture wearers5/3/12 Common problems faced by denture wearers and

Aging factors that effect nutritional status Physiologic Cognitive Oral

factors

factors factors factors

factors

Economic

Psychologic

5/3/12

Physiologic factorsIt

includes physical status gastrointestinal functioning sensory changes immune changes dehydration5/3/12

1) 2) 3) 4) 5)

Physical status

1) during the adult years there is a steady decrease in lean body mass of about 6.3 % for each decade of life

5/3/12

Gastrointestinal functioning

With age there is decreased peristalsis,decreased Hcl secretion and altered oesophageal motility

Reduction in the levels of some digestive enzymes including salivary amylase,pancreatic amylase , lipase,pepsin&trypsin

BrodeurJM,LaurinD: patient intake and gastrointestinal disorders related to masticatory performances in elderly,JPD1970:468473,1993 5/3/12

Sensory changesIt

includes:

Visual Hearing Changes

in taste and smell

5/3/12

Changes in taste and smell TASTE: during normal aging many individuals experience less chemosensory sensation.

SMELL

5/3/12

Immune changes Immune

responsiveness decreases in elderly and as a result infection is the fourth leading cause of death in elderly.

5/3/12

Dehydration It

is caused by a decline in renal function and a total body water metabolism.

Thirst

threshold of elderly is also impaired making thirst a poor indicator of hydration status.5/3/12

Cognitive factors

Cognitive function decline with advancing age.It ranges from simple memory deficit to profound dementia.

5/3/12

Oral factors1) Xerostomia also called dry mouth or hyposalivation effects almost one in five older people

2) Oral infection conditions:

5/3/12

Dentate status Reduced

chewing ability is related to an overall reduction in functional capacity & general health

5/3/12

Economic factors Economic

factors are the major forces that determine the variety & nutritional adequacy of diet.

5/3/12

Psychological factors Because

eating is a very much social activity , loneliness can result in malnutrition, loss of spouse or a friend may result in loss of eating

5/3/12

OTHER FACTORS AFFECTING NUTRITION

5/3/12

Effect of denture on taste & swallowingA

full upper denture can have impact on the taste & swallowing ability .

5/3/12

Effect of dentures on food choices,diet quality & general health

Effects varies among the individuals. Some people compensate the masticatory inability by choosing processed or cooked food rather than fresh foods & by chewing longer than swallowing, others may eliminate the entire food groups from their diet

5/3/12

In

the large group of free living elders , inferior diets were associated by denture wearing, low income & low educational attainment . The elders who were wearing 1 or 2 denture had 20% decline in the nutritional quality of their diets compared to dentate peers intake of vitamin A , calcium & fibers also declines as the number of teeth are decreased . The dentate elders eat more fruits & 5/3/12 vegetables

Replacing

the ill fitting dentures with new ones doesnt necessarily results in improved dietary intake . Similarly exchanging the optimal complete dentures for the implant supported dentures has not resulted in significant improvement in the dietary selection & intake Elders with poor oral function reports decline in quality of life5/3/12

Drugs that can cause ANOREXIA

digoxin / lithium

narcotic K+

analgesics

phenytoin SSRIs Ca++ H2

supplements bromide

furosemide ipratropium

channel blockers receptor antagonists / PPIs chemotherapy

theophylline spironolactone levodopa

Francesco, V.D., et al. The fluoxetine Aging; Anorexia of metronidazole journal of Digestive Diseases 25(2):129-137; 5/3/12 2007

Any

Drug-Nutrient InteractionDrugAlcohol Antacids Antibiotics, broad-spectrum Digoxin Diuretics Laxatives Lipid-binding resins Metformin Phenytoin/Salicylates Trimethoprim

Reduced Nutrient AvailabilityZinc, vitamins A, B1, B2, B6, folate, vitamin B12 Vitamin B12, folate, iron, total kcal Vitamin K Zinc, total kcal (via anorexia) Zinc, magnesium, vitamin B6, potassium, copper Calcium, vitamins A, B2, B12, D, E, K Vitamins A, D, E, K Vitamin B12, total kcal Vitamin D, folate/Vitamin C, folate Folate

ASSESSING NUTRITIONAL STATUS

Methods for evaluation of nutritional status include data collection from the following areas:medical social history,clinical examination including(both physical signs and certain anthropometric measures),dietary assessment and biochemical tests.Appropriate dietary counseling should be offered to the patient only after the collection of data confirms a nutritional problem.5/3/12

TRIPHASIC NUTRITIONAL ANALYSISPhase I Obtaining

information from a medical social history,conducting selected anthropometric measurements

DCNA:NEED FOR GERIATRIC DENTAL EDUCATION;1989Jan:33(1),109125 5/3/12

5/3/12

protein

5/3/12

Iron

5/3/12

Niacin

5/3/12

Riboflavin

5/3/12

Thiamine

5/3/12

Vitamin-A

5/3/12

Goitre

5/3/12

Vitamin-D

5/3/12

QUALITATIVE DIETARY ASSESSMENT

The purpose of the dietary assessment is to determine what an individual is eating now what he or she has eaten in the past and recent changes in the diet.

5/3/12

5/3/12

PHASE II

Semiquantitative dietary analysis assesment

Biochemical

5/3/12

Semiquantitative dietary analysis

The service of a Registered Dietitian,serving as a consultant,is invaluable at this level of assessment.

5/3/12

Biochemical assesmentHeamatologic

tests can be usefull.

5/3/12

PHASE IIIThe

final phase of analysis is reserved for more complex nutritional problems and should be accomplished under the direction of a physician. The analysis in this phase include comprehensive nutritional biochemical assays of blood,urine and tissues,as well as tests of metabolic and endocrine function5/3/12

Nutritional Screening and Assessment

Nutrition Screening Initiative (NSI):

collaborative effort of AAFP, ADA, and the National Council on Aging NSI

completed a study in 1996, revealing evidence that older patients admitted to the hospital in poor nutritional states had longer stays and increased rates of complications than well-nourished patients.

Bagley, B; Nutrition and Health (Editorial); AFP, 57(5): March 1, 1998

5/3/12

Nutritional Screening and AssessmentThe

NSI developed a screening tool that can be completed by patients, family members, or a health care professional The tool consists of 10 questions which are scored and placed in 3 categories: No nutritional risk 0-2 points Moderate nutritional risk 3-5 points5/3/12

Nutritional Screening and Assessment

NSI (points apply to YES answers) I have an illness or condition that made me change the

kind and/or amount of food I eat (2)

I eat fewer than two meals per day (3) I eat few fruits or vegetables, or mild products (2) I have 3 or more drinks of beer, liquor, or wine almost

every day (2) to eat-2

I have tooth or mouth problems that make it hard for me I dont always have enough money to buy the food I

need (4)

I eat alone most of the time (1) I take 3 or more different prescribed or OTC drugs per

day (1)

5/3/12

Nutritional Screening and AssessmentMini

Nutritional Assessment (MNA) is a validated screening and assessment tool for identifying elderly patients with or at risk for malnutrition by the Nestl Research Center, in collaboration with hospital clinicians5/3/12

Developed

Nutritional Screening and AssessmentThe

MNA obviates the need for blood tests to screen and monitor a patients nutritional status of two sections: Screening and Assessment

Composed

5/3/12

Nutritional Screening and Assessment MNA

Screening: In the screening section, five questions are asked, and the patient's BMI (Body Mass Index) is calculated, using the patient's height and weight. From these six items, a score is calculated, which will indicate whether there is possible malnutrition Screening score: (max. 14 pts) > 12 pts Normal; not at risk < 11 pts Poss. malnutrition; go to assessment5/3/12

Nutritional Screening and Assessment MNA

Assessment: Clarifies whether there is a future risk of malnutrition, or if malnourishment is currently present. The assessment section is comprised of 10 questions, and two anthropometric measures mid-arm circumference and calf circumference. Scoring (max. 16 pts); when added to screening score, total max is 30 pts. If total is 17-23.5 pts, pt is at risk of malnutrition and if