Nutrition and Aging… Nutrition and Aging… Beyond Tea and ToastBeyond Tea and Toast

Jean Helps

WRHA Regional Clinical Nutrition Manager – Long Term Care

October 8, 2008

Long Term Care Association of Manitoba

What’s the big deal about What’s the big deal about nutrition??nutrition??

Promotes health and well-beingAllows us to achieve our potentialFacilitates best quality of life

But…we also need to be aware that we are providing care that best supports individual goals

Malnutrition - DefinitionMalnutrition - Definition

Undernutrition: Often thought to be a problem of third world countries

Inadequate consumption, poor absorption, or excessive loss of nutrients

Overnutrition Excessive intake of specific nutrients.

An individual will experience malnutrition if the appropriate amount of, or quality of nutrients comprising a health diet are not consumed for an extended period of time

Obesity in the Older AdultObesity in the Older AdultObesity may be thought to be the next challenge in LTC Rising rates of obesity is reported Increased risk of health problems and premature death Cost of obesity - $2 billion a year in 19972006 Canadian Clinical Practice Guidelines on the management and prevention of

obesity in adults and children (summary). CMAJ 2007 176 (8 suppl):S1-13

In the Elderly Lowest mortality associated with BMI range of 25 to 30 Relationship between BMI and mortality weakens with

increasing age Some reduction in cardiovascular risk factors with weight loss But… need to assess benefits vs risksNational Health, Lung, Blood Institute, Clinical Guidelines on the Identification,

Evaluation and Treatment of Overweight and Obesity in Adults Accessed 13/08/08

Prevalence of Malnutrition in the Prevalence of Malnutrition in the Elderly – What the research Elderly – What the research

shows…shows…Community Living: 5 to 20% prevalence of malnutrition ~40% are at risk of malnutritionLong Term Care: 5 to 85% of residents in Long Term Care suffer from

malnutrition (Average 30%) Administration on Aging in the US estimate 50% of

hospital and nursing home residents are malnourished (2004)

Hospitalized Patients 32 to 50%

Causes of Malnutrition- Causes of Malnutrition- System Issues for the System Issues for the

Individual at HomeIndividual at HomeMini Nutrition Assessment (MNA) identified

Psychosocial and Environmental Factors Isolation Loneliness Depression Inadequate finances

More seniors are living alone 2001 Census Statistics Canada http://www12.statcan.ca/english/census01/products/analytic/companion/fam/canada.cfm#seniors)

Causes of Malnutrition- Causes of Malnutrition- OrganizationalOrganizational11

Failure to help residents eat or recognize malnutrition Importance of nutrition not realized Absence of Dietitian Lack of staff, lack of communication, inadequate

training and education Monotonous diet, inappropriate diet or mealtime

environment Inappropriate medication prescribing Insufficient data collection1Cowan et al. Int J Nurs Stud 2004;41(3):225-237

Causes of Malnutrition – Causes of Malnutrition – Physiologic Changes related to AgingPhysiologic Changes related to Aging

Sensory impairment – thirst, taste, smell, sight, sound Alimentary system:

– Poor oral health and dental problems– Difficulty swallowing– Reduced digestion, absorption and motility

Decline in Immune Function – Increase likelihood of acquiring infections

Causes of Malnutrition – Causes of Malnutrition – Physiologic Changes related to Physiologic Changes related to

AgingAging Decreased physical activity:

– depletion of Lean Body Mass (muscle loss)– Decreased appetite

Altered energy need – diet lacking in essential nutrients

Decline in Renal Function – increase potential for dehydration

Loss of bone density – increase potential for fracture and osteoporosis

Practical OutcomesPractical Outcomes

Reduced ability to complete ADLs Apathy, anorexia, decreased mobility, pressure

sore formation, osteoporosis, impaired immunity Complication of and delayed recovery

…Resulting in…reduced quality of life for the individual, increased nursing time, delayed discharge from hospital AND increased costs to the system

Promoting Nutrition in the Promoting Nutrition in the Community and Acute CareCommunity and Acute Care

Identification of nutrition risk/malnutrition– Appt with the family doctor– Visit with a health care provider– Caregiver in the home– Nutrition Screening in Hospitals

Nutrition Assessment to determine causes:– Dietitians – Home Care/Ambulatory Care/Inpatient – WRHA Senior Resource Team– Family Doctor

Implementation of interventions to address issues:– Specialized meal pattern– Resources to access foods, meal preparation– MOWs, Congregate Dining

Promoting Nutrition in the Promoting Nutrition in the Long Term Care SettingLong Term Care Setting

Use of resources and tools– Manitoba Health PCH Standards– Eating Well with Canada’s Food Guide– Dietary Reference Intakes (DRIs)– WRHA Clinical Nutrition Diet Compendium

Individualized assessment and care plansReassessment on a routine basis

Manitoba Health PCH Manitoba Health PCH Standard 14 – Dietary Standard 14 – Dietary

Minimum 21 day cycle menu Choice essential Nourishments/beverages offered between meals Meets Residents’ nutritional needs Meals provided in a group setting with social aspects

of dining and meal enjoyment facilitated Independence at meals is promoted, assistance

available when required. Dignity and safety is promoted and interaction with staff is encouraged

Manitoba PCH Standards- Menus Manitoba PCH Standards- Menus need Dietitian approval that they need Dietitian approval that they

meet Canada’s Food Guidemeet Canada’s Food Guide

Communicates amounts and types of food needed to help:

- Meet nutrient needs and promote health - Minimize the risk of obesity, type 2 diabetes,

heart disease, certain types of cancer and osteoporosis

Provides the cornerstone for nutrition policies and programs

www.healthcanada.gc.ca/foodguide

Canada’s Food Guide- Then Canada’s Food Guide- Then and Now…and Now…

First Food Guide- “The Official Food Rules” Developed in 1942 Acknowledged wartime food rationing Endeavored to prevent nutritional deficiencies and

to improve health

“ Canada at war cannot afford to ignore the power that is obtainable by eating the right foods”

Further revisions…Further revisions…Canada’s Food Rules (1944, 1949)Canada’s Food Guide (1961,1977,1982)Canada’s Food Guide to Healthy Eating (1992)Eating Well with Canada’s Food Guide (2007)

Evolution of the name describes the changes in positioning and philosophy of the food guide

Focus on: - Chronic disease prevention - Balanced energy intake and moderation - A total diet approach meeting both energy and nutrient needs

WRHA Clinical Nutrition WRHA Clinical Nutrition Services Initiative – Services Initiative –

Diet Compendium RevisionDiet Compendium RevisionEvidence based review completed to guide provision

of meals Focus on generic definitions and standards Use DRIs, Canada Food Guide recommendations Adherence/inclusion in care maps Long Term Care Diet reviewed to “consider the

unique nutrition needs of the senior population and ensure “standard” diet for this population are appropriate”.

Issues IdentifiedIssues Identified

Macronutrient needs – – Protein and Energy– Fibre– Fat– Fluid

Micronutrient needs – Vitamin DMealtime Set Up and Meal Patterns

Energy/Protein Energy/Protein Requirements/IntakeRequirements/Intake

Daily Energy requirement (CFG): 1550 cal - sedentary females 2000 cal – sedentary males

Wendland et al (2003) Average intake – 1164+/-230

cal Provision – 2079+/-370 cal

Average Adult Canadian intake – 1790 cal

Daily Protein requirement (DRIs):

46 grams – females 56 grams – males

Wendland et al (2003) Average intake 45.5+/-13

grams Provision – 87.4 +/-15

grams

Protein and Energy –Protein and Energy –Nutritional Deficiencies in the Nutritional Deficiencies in the

American Nursing Home PopulationAmerican Nursing Home Population

Nutrition Indicator Protein Energy

Malnutrition Underweight Hypoalbumenia

Prevalence 37 to 85%

12% 18 to 60%

Implications for Planning – Implications for Planning – Protein and EnergyProtein and Energy

In CFG, no change in recommended portions Meat and Alternatives– 2 to 3 daily

Include meat alternatives and fish, choose lean meatsFor the Elderly, protein/energy is of concern High quality diet, high quality protein sources Individualize the care plan – e.g. meal size and frequency Consider Supplement Med Pass:

– Improved nutritional outcomes – weight gain– System benefits – less waste, cost savings.– High protein, high energy, small volume– Given consistently, intake recorded on MARs

Fibre – Vegetables and Fibre – Vegetables and Fruits/Grains ProductsFruits/Grains Products

DRI recommendations for fibre are 21 grams for females, 30 grams for males.

Average intake (elderly) – 8.4 grams, Provision – 15.1 grams

CFG - Vegetables and Fruits and Grains Groups continues to have highest billing on food guide to promote intake

Include at least one dark green and one orange vegetable in the diet daily

Include half of your grain products as whole grain More specific guidelines for different ages given for these

groups compared to 1992 Food Guide

Implications for Planning - Implications for Planning - FibreFibre

The older adult may not be able to consume the recommended amounts of fibre without fortification.

“A fiber supplement may be needed when food intake is low, as is the case among inactive elderly” – American Dietetic Association Position Paper: Health implications of dietary fiber (2003)

Provision of between meal snacks of grains and vegetables and fruits likely required for needs to be met.

FatFat

DRI reference value for fat – 20 to 35%

Did you know…

Gram for gram there is more than twice the calories in fat than protein or carbohydrate

Fat adds moisture and palatability to foods

Implications for Planning – FatImplications for Planning – Fat

Fat content of the diet up to the high end of the range ( 30 to 35%), to optimize intake through beneficial properties of fat.

With increasing age, the importance of elevated serum cholesterol levels as a risk factor for CHD decreases, and virtually disappears after age 65

Fluid – Causes and Fluid – Causes and Consequences of DehydrationConsequences of DehydrationCauses: Reduced Renal Function Decreased thirst

sensation Difficulty with access Fear of incontinence

Consequences Acute Confusion Infections – Urinary,

respiratory Increased risk of skin

breakdown Falls Difficulty Swallowing Constipation

System Based Implications of System Based Implications of DehydrationDehydration

Dehydration is present in 30% of nursing home residents

Half of those admitted to hospital with dehydration came from nursing homes

Mortality rate of those hospitalized was 50%

System Based Strategies to System Based Strategies to Promote Adequate HydrationPromote Adequate Hydration

General Menu Planning/Individualized Care Plan Address issues related to lack of access

– Do schedules and staff availability support provision of fluids during the day?

Implement a Hydration Program– Twice daily offering and recording of fluid intake– Provide education about dehydration– Giving fluids directly into residents’ hands every 1.5 h

increased fluid intake (Hodgkinson, 2003)

Size and shape of cups

Give preferred types

of fluids

Ensure beverages are within reach!

Provide appropriate temperatures

Vitamin DVitamin DBenefit of Vitamin D recognized in the first food guide,

“Some sources of Vitamin D such as fish liver oils, is essential for children, and may be advisable for adults”

With age there is reduced production of Vitamin D CFG sources are largely milk and select fish For those over age 70, it is virtually impossible to meet

Vitamin D needs orally There is evidence that Vitamin D prevents falls CFG recommends supplement of 400 IU of Vitamin D

for all over the age of 50 years.

Video ClipVideo Clip

Mealtime Management – Mealtime Management – Individual Specific Interventions Individual Specific Interventions Eating experience is more than the food on the plateTo promote intake and safety guidelines include: Readiness to eat Dentures Positioning After the mealManitoba Health Manual for Feeding and

Swallowing Management in Long-Term Care Facilities

Dementia – Increasing Dementia – Increasing Prevalence with AgePrevalence with Age

Consequences: Change in taste and smell Lack of distinction between food and non-foods Loss ability to feed self, use utensils Loss of memory about when they last ate Forget to chew and forget to swallow Pocket food, Spit food out

Mealtime Management - Mealtime Management - DementiaDementia

focus of food delivery during the morning when residents are most responsive to food provided

Simplify the environment – non-distracting visually and audibly

Simply the food – Provision of too many foods at one time leads to over-stimulation, agitation and reduced intake

Communicate

Provide flexible care

Mealtime ManagementMealtime Management

Physical and Social Environment: Noise and Distraction Control Attend to the resident Provide level of assistance needed

Food and Nutrition Interventions: Provide acceptable portion size Between meal snacks to increase eating opportunities Liberalization of the diet

Evaluate outcomes

Long Term Care Setting – Community Long Term Care Setting – Community Health Assessment (2004)Health Assessment (2004)

PCH Population - Age Ranges

Under 65 y

65 to 74 y

75 to 84

Over 84 y

Distribution by Gender: 75% FemaleMost Common Heath

Concerns: CVD Dementia CVA Cancer Diabetes Respiratory illness

Representative ResidentRepresentative Resident

Female 85 years old

Diagnoses: Dementia CVD with hx CVA Poor dentition

BMI – 20.5

Is semi-dependent: Can feed herself with set up

and encouragement to eat. Difficulty attending to her

meals, needs to be reminded to go to the dining room, is distracted

Difficulty chewing and swallowing

Elevated serum lipids Fall risk due to residual left

sided weakness

Mrs. ResidentMrs. Resident Placed on Supplement Medication Pass program Focus on preferences for foods provided Meats need to be minced due to difficulty chewing and

swallowing Provided with fibre enriched cereal and fruit based fibre mixture

at breakfast time Routinely provided with whole grain products No restriction on fat content of the diet, intake of additional fat

sources to promote intake through addition of moisture to foods Focus on milk, as an easy to consume food, also Vitamin D

supplementation at the level of 1000 IU recommended Provide appropriate environment and assistance at mealtimes

In Summary…In Summary…

Not tea and toast….

But Time, Team and Attention…