Nutrition in Older Adults PDF

Nutrition in Older Adults  Learning Objectives Outline how the process of aging alters gastrointestinal tract functioning and therefore the absorption of essential vitamins Describe how nutrition needs are affected by the physiological and biochemical changes that occur with aging Summ...

Nutrition in Older Adults  Learning Objectives Outline how the process of aging alters gastrointestinal tract functioning and therefore the absorption of essential vitamins Describe how nutrition needs are affected by the physiological and biochemical changes that occur with aging Summarize the short-term and long-term impacts of malnutrition on the physical and cognitive status in adults and the elderly Identify social, economic, and medical factors that may affect the nutrient intake in the elderly population Define sarcopenic obesity, and explain its risk factors and resulting health risks Describe nutritional interventions that help prevent malnutrition, sarcopenia, osteoporosis, and cognitive decline Evaluate medications and supplements (prescribed and OTC) to identify potential drug-nutrient interactions 2  Anorexia of Aging Decrease in appetite and/or food intake in old age Major contributing factor to under-nutrition and adverse health outcomes in the geriatric population Recognized as an independent predictor of morbidity and mortality in different clinical settings Not an unavoidable consequence of aging ◦ Advancing age often promotes its development through various mechanisms 3 4  Diminished Hunger and Altered Satiety Control Mechanism Ghrelin ↓ ◦ Chief driver of hunger released during fasting Satiety Hormones ↑ ◦ Cholecystokinin (CCK), glucagon like peptide-1 (GLP-1) and peptide YY (PYY) Leptin ↑ Insulin ↑ 5  Age-Related Gastrointestinal (GI) Changes GI tract is less likely to see effects of aging than other organ systems Changes generally seen ◦ ↓ or slowing of functions ◦ ↑ of digestive tract disorders Mouth1 ◦ Less saliva and decreased force from jaw muscles can cause difficulty in chewing or swallowing ◦ Taste perception changes Esophagus2 ◦ Strength of esophageal contractions and the tension in the upper esophageal sphincter ↓ 6 Age-Related Gastrointestinal (GI) Changes Stomach ◦ Stomach lining loses elasticity ◦ Gastric emptying can be ↑ ◦ Type of food can affect gastric emptying Small Intestine ◦ ↓ lactase levels can lead to dairy intolerance ◦ Excessive growth of certain bacteria can lead to ↓absorption of nutrients (B12, iron, calcium deficiencies) 7 Age-Related Gastrointestinal (GI) Changes Large Intestine ◦ Transit time could be prolonged and is significantly more pronounced in elderly with masticatory deficiency, reduced physical activity, and frailty syndrome ◦ Prevalence of constipation increases with age ◦ 30–40% of community-dwelling older adults and over 50% of nursing home residents experience chronic constipation Rectum ◦ Enlarges somewhat ◦ Constipation becomes more common due to ↓ in contractions when the rectum is filled with stool 8  Other Factors: Taste and Smell ↓ Smell and taste ◦ Taste and smell, plus sensors throughout the oral cavity that register temperature, and the mechanical feel of food, work together to make eating a pleasurable experience ◦ Zinc deficiency can lead to impaired taste sensitivity ◦ Dysphagia and poor mastication reducing taste sensation 9 Other Factors: Depression Loneliness and lack of companionship Functional impairment and lack of caregivers Difficulty in getting and/or preparing food Physical illnesses Endocrinal disturbances can also result in loss of appetite and depression Poor dentition and difficulty chewing Financial issues 10 Other Factors: Drugs System Drug Cardiovascular Amiodarone, furosemide, digoxin, spironolactone Neurological SSRIs, levodopa, lithium Gastrointestinal H2 antagonists, PPIs Antibiotics Metronidazole, griseofulvin Chemotherapies Any Musculoskeletal Colchicine, NSAIDs, methotrexate, penicillamine 11  Malnutrition and Cognitive Status Deficiencies of some micronutrients have been found to be significantly associated with cognitive impairment Vitamins B1, B2, B6, B12, C, and folate 12  Sarcopenia Progressive degenerative disorder affecting ≥40% of older adults over the age of 70 years Characterized by involuntary muscle loss ◦ Functional disability, weakness, and frailty in the elderly Potential contributors to sarcopenia onset ◦ Anorexia of aging ◦ Protein imbalances ◦ Oxidative stress Increased amounts of adipose tissue often accompany sarcopenia ◦ Sarcopenic obesity 13  Sarcopenia Farshidfar et al. Nutrition and Aging. 2015;3:(2)147–170 14 Changes in Body Fat With age, body fat ↑ and fat-free mass ↓ because of loss of skeletal muscle The cause of increase fat is multifactorial ◦ Reduced physical activity ◦ Reduced growth hormone secretion ◦ Diminished sex hormones ◦ Decreased resting metabolic rate The distribution of fat in older people is different from that of younger people ◦ Greater proportion of body fat is intra-hepatic and intra-abdominal ◦ Insulin resistance ◦ ↑ risk of ischemic heart disease, stroke and diabetes 15  Health Consequences of Sarcopenic Obesity Disability and institutionalization ◦ Low muscle strength and poor physical performance were associated with increased risks of hospitalization Mortality Metabolic disease ◦ Associated with insulin resistance, metabolic syndrome, dyslipidemia, inflammation (CRP) and vitamin D deficiency Comorbidities ◦ ↑ risk of falls ◦ ↑ risk of psychological health problems ◦ ↑ risk of knee osteoarthritis 16 Potential Therapies for Sarcopenic Obesity Calorie restriction ◦ Lose body fat and improve physical function Aerobic exercise ◦ Improve cardiorespiratory fitness Resistance exercise ◦ Improve muscle strength and mass; attenuate loss of muscle and bone during weight loss efforts Protein supplementation ◦ Mitigate loss of muscle mass and strength Calcium and Vitamin D supplementation ◦ Prevent potential disturbances in bone metabolism 17 Summary 18 19 Cachexia Complex metabolic process that is associated with several end-stage organ diseases Also associated with advanced dementia, although the pathophysiologic mechanisms are still largely unknown 20 21  Choosing Wisely Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, discontinue medications that may interfere with eating, provide appealing food and feeding assistance, and clarify patient goals and expectations. 22  Choosing Wisely Although high-calorie supplements increase weight in older people, there is no evidence that they affect other important clinical outcomes, such as quality of life, mood, functional status or survival. Use of megestrol acetate results in minimal improvements in appetite and weight gain, no improvement in quality of life or survival, and increased risk of thrombotic events, fluid retention and death. In patients who take megestrol acetate, one in 12 will have an increase in weight and one in 23 will have an adverse event leading to death. The 2012 AGS Beers criteria lists megestrol acetate and cyproheptadine as medications to avoid in older adults. Systematic reviews of cannabinoids, dietary polyunsaturated fatty acids (DHA and EPA), thalidomide and anabolic steroids, have not identified adequate evidence for the efficacy and safety of these agents for weight gain. Mirtazapine is likely to cause weight gain or increased appetite when used to treat depression, but there is little evidence to support its use to promote appetite and weight gain in the absence of depression. 23 24  The BEERS List https://dcri.org/beers-criteria-medication-list/ Make sure to review your patient’s list of medications if they are elderly at every visit. Make sure to reconcile medications you may not have prescribed. 26 Case Study Role Play Scenario: 86 y/o F presents to your clinic accompanied by her daughter who is primary caregiver and is concerned because the patient has lost about 20# over the past 3 months unintentionally. Ht: 5’5”, Wt: 98#, BMI: 16. BP: 108/60, HR: 95, Temp: 98.5 F, RR 14, SpO2 95% on RA. PMHx: HTN, CAD s/p stents x 2, DM, TIA x 3, mild dementia, partially blind, hearing impaired. Medications: Aspirin 81 mg, metformin 500 mg daily, Lipitor 10 mg, Protonix 40 mg, Lisinopril 10 mg, Zyrtec 10 mg, Lexapro 10 mg. Labs: HbA1C 6.7%, Lipids: TC 150, LDL 60, HDL 40. CBC: mild anemia (Hb 10.2, MCV: 89), CMP: low K (3.1), low Magnesium (1.5), otherwise within normal limits (normal renal and liver function). 27  Doctor: Hello ladies, how are we doing today? Ms. Smith: Hey doc, good to see you. Daughter: Hey doc, nice to see you. I’m really concerned about mom. She has lost a lot of weight recently and it’s not like she really needs to. We’re trying to get her to eat more but she just won’t eat. What can we do? Doctor: Well, she’s still living with you right now, is that correct? Daughter: Yes, she lives with us and we have sitters who come whenever I have to leave the house. Doctor: So Ms. Smith, have you noticed you don’t have much of an appetite lately? Ms. Smith: Yeah doc, food just doesn’t taste right. I don’t know how to explain it. It just doesn’t have a taste. Doctor: How long have you noticed this? Ms. Smith: Oh I don’t know, the past few months. I just lost my taste for meat also. Doctor (addressing both patient and daughter): So what kinds of things are you eating during the day? Ms. Smith: Well, I sleep in so I usually miss breakfast, will eat a turkey sandwich for lunch and maybe some noodles for dinner or cheese and crackers. Daughter: Yes doctor, she really hasn’t been eating much. I’m really worried about her. Doctor: Have you noticed any dark or tarry stools? Any nausea or abdominal pain? 28  Ms. Smith: No. Doctor to Daughter: Any confusion that’s out of the ordinary for her? Daughter: You know, she has been a little more confused lately and just weak. Doctor: What about muscle pain or numbness? Ms. Smith: Yeah my feet feel funny and I’m really weak it’s hard for me to get up and walk around too. Doctor: Ok, I think we need to run some more tests to pin it down but I have a little bit of an idea of what’s going on. First, let’s talk about your medicine. I don’t think you need all of it anymore at this point. Let’s get off the metformin since your blood sugar is really good, your cholesterol medication since your lipid panel was really good and at this age it’s really not very useful, and definitely your Protonix. We need to start supplementing with a multivitamin with iron if you aren’t going to get a lot of meat in, and B12 and folate. I’m suspecting you have a mixed anemia both iron, B12 and folate deficiencies. So let’s test first but I’ll go ahead and start those supplements. That might help with your appetite. What foods do you really like to eat Ms. Smith? Ms. Smith: Well, I really used to like milkshakes and shepherd's pie or some casseroles when I used to cook. Doctor: Ok great, we can work with that. Do you like peanut butter? Ms. Smith: Sure peanut butter is ok. 29  Doctor: How about making some milkshakes with whole milk, peanut butter, bananas and maybe even some cocoa powder? Daughter: Oh she’d love that! Ms. Smith: That does sound good. Doctor: Great, ok also, for casseroles at this point we don’t need to worry too much about her cholesterol so we can add butter and whole milk to casseroles. Maybe adding some avocado and spinach blended into smoothies also with fresh fruit. We can also look into getting some protein powder you can mix in or trying some Ensure drinks. Ms. Smith: I don’t like Ensure, but the protein powder I think I could do as long as it tastes good. Doctor: Sure, I hear you loud and clear. I’ll give you guys a list of high protein, high calorie foods you can try and some supplement ideas. I think her taste changes have to do with age but also could be from vitamin deficiency. Now, speaking of her potassium and magnesium, I’m going to send you prescriptions for those also because as she starts to eat more, I expect those numbers to drop some, so we’ll think ahead and supplement. We’ll need to get some labs now to check her iron levels, B12 and folate, and then in a couple weeks we’ll check her electrolytes to see how she’s doing with the new diet and supplements. 30  Daughter: Oh thank you doctor, that sounds like a good plan. I especially like getting off her medications. That metformin still upsets her stomach sometimes. And she’s been on Protonix for as long as I can remember. What do I do if she gets acid reflux. Doctor: Pepcid complete or tums is totally fine to use as needed. But we should avoid PPIs because it puts you at risk for B vitamin deficiencies, especially B12, which can cause taste changes, neuropathy and mental status changes. Daughter: Oh wow, I didn’t know that. Did you mom? Ms. Smith: Oh no dear, I just do what my doctors tell me. Laughing Doctor: Ok, great plan, I’ll see you back in 2 weeks just to check in and we can go from there. Both: Sounds great thanks! 31