Nutrition and Aging: A Transdisciplinary Approach

A Significant Problem

   The elderly population is increasing. Because physical, social, and psychological factors may predispose this population to decreased nutritional status, healthcare providers should be aware of the care implications associated with decreased nutritional status, assess nutritional problems, and individualize treatment plans.¹ This treatment should be transdisciplinary — ie, physicians, nurses, dietitians, therapists, family, and patient all planning care collaboratively.

   To understand the impact poor nutrition has on the older population and the healthcare system, the problem should first be viewed from a global population perspective. The number of older Americans is steadily increasing. In 2002, 35.6 million people were >65 years of age, a number that is expected to double to 71.5 million by 2030. Additionally, a subset of this population (85-plus years old) is expected to increase from 4.6 million to 9.6 million in this time period.²

    Older women outnumber men (20.8 million to 14.8 million) and more than half of older women live alone. In 2002, the average income for older persons was $19,436 and $11,406 for men and women, respectively. Median income for older adults fell by 1.4% from 2001 to 2002. The poverty level (<$9,367 for one person and $11,805 for two people) for older adults was reported to be 10.4% in 2002 and an additional 6.4% were classified as “near poor” by the US Census Bureau.³

   Considering the increasing number of elderly and the high level of poverty, food insecurity (ie, worry that sufficient food will always be available to maintain an active, healthy life for all household members) is a concern. According to year 2000 data, some elderly must chose between buying medications and buying food.^4,5 Older Americans spent much more money on their health than others consumers (12.8% of total expenditures compared 5.8%).⁶ National estimates of food insecurity in the elderly range from 5.5% to 16% depending on methodologies used.^4,7 Limited income puts elderly persons at higher nutritional risk — elderly persons reporting food insecurity have lower intake of protein, vitamins, and carbohydrates and are 2.3 times more likely to report poorer health status.^4,7

Factors that Influence Nutritional Status

   Physical issues. Elderly persons experience a variety of chronic health conditions. Using information from year 2002 hospital discharge data, the Agency for Healthcare Research and Quality (AHRQ) estimated that more than 13.2 million persons >65 years old were admitted to the hospital.⁸ This is more than three times the comparable rate for persons age 45 to 64 years.⁸ Heart disease, chronic obstructive pulmonary disease (COPD), cancer, renal and liver conditions, arthritis, diabetes, or combinations of these conditions impact nutritional status. Physical factors also include digestive changes, decreased sense of taste and smell, dry mouth, mobility issues, and dental problems. Consensus reports^9,10 of research studies indicate that some of these physical factors may occur slowly — ie, elderly people may not realize their favorite food no longer tastes appealing because their sense of smell and taste have declined. Although decreased taste and smell may be normal consequences of aging, a drop in saliva production should be investigated¹¹ — in older adults, dry mouth is often caused by an adverse reaction to a medication or may be a sign of dehydration or another pathological process.¹² Nutritional problems also may be due to gastrointestinal issues. Decreased acid secretion in the stomach leads to impaired gastric functioning. A reduction in the volume of and composition change in pancreatic secretions may impair nutrient digestion and intestinal absorption.¹³

   Psychological issues. Unfortunately, many caregivers and 58% of older adults believe depression is a normal part of aging.¹⁴ According to a government study,¹⁴ a change in living situation, death of a spouse, or declining health status all contribute to depression in the elderly. When a person and/or the caregiver is depressed, appetite declines. The older generation was raised in an era when depression was not openly addressed; communication, discussion, and education are critical to fighting this condition. Government reports also indicate only 38% of persons >65 years old believe depression is a health problem yet symptoms occur in approximately 15% of community dwelling residents and may be as high as 25% in nursing home patients.¹⁴ Older adults are considered the group most at risk of suicide — the suicide rate in older adults has been reported by Prairie Public Broadcasting as more than 50% higher than young people or the nation as a whole.¹⁵

Socioeconomic issues. Income impacts nutrition. In addition to food affordability issues, nearly half (46%) of older people reporting income below the poverty level have no natural teeth, compared to 27% of persons with higher incomes.^3,8,14 Mouth pain and tooth loss inhibit an older adult’s ability to chew food, especially protein-rich foods such as meat, or to eat the raw fruits and vegetables that are important sources of vitamins and fiber. According to the American Dietetic Association (ADA),¹⁶ older persons with dentures often delay or do not have regular dental checkups. A research study of 40 rural elderly found 51% of all the people surveyed had not been to a dentist in the last 2 years and 30% of the denture wearers reported their dentures did not fit well.¹⁷ These findings are important because elderly persons with dentures have 30% to 40% less chewing ability than those with their own teeth, as determined by the ADA and government reports.^14,18 For many elderly, inadequate dental care is due to cost or transportation issues; a lack of understanding of the need for continued dental services also may be a factor.¹⁴

   Other social factors that impact nutrition include decreased mobility, pain, isolation, and loneliness.^5,17,19,20 Restricted or revoked driving privileges make it difficult for older adults to obtain groceries. Even those who are able to drive may have problems in the winter months. Older houses may not be handicap friendly. The elderly with limited mobility may not be able to reach shelves, have the dexterity to open cans or cut up produce and meat, or be able to stand long enough to prepare a meal from scratch. Consequently, even independently living elderly may need home assessment by social service agencies.^21-25

   Stress. Stress from any of these physical, social, or psychological issues has a detrimental effect on nutritional status. The release of catecholamine hormones facilitates immediate physical reactions by triggering increases in heart rate and breathing, constricting blood vessels in many parts of the body and tightening muscles.²⁶ Increased glycogen breakdown mobilizes free fatty acids and protein breakdown for glucose production. Protein from skeletal muscles, the gut, and connective tissue supplies the necessary glucose and amino acids required during this stress response. Conclusions based on reviews and opinion indicate that the end result may mean lean body mass loss is greater than the rate of recovery — nutritional status may rapidly decline.^26-30

   Medication. Medications also may influence nutritional status. Some medications can alter taste either by modifying taste transduction mechanisms or by producing a taste of their own. Clinical reports rather than quantitative research suggest that many commonly prescribed drugs and some medications that address hypertensive/cardiac problems, lipids, mood, allergy/asthma, and Parkinson’s may affect taste.^31,32 Taking multiple medications a day, whether prescription or over-the-counter, also may decrease an elderly person’s sense of hunger.^5,33,34

Assessment

   All persons >65 years old should have their nutritional status checked as part of regular preventive practices. Older adults vary physically and medically; biological aging and chronological aging are not always the same. Consequently, clinicians should not assume an independent 70-year-old is not at risk or that an 85-year-old is — both should be examined with a consideration for weight status, eating patterns, medication usage, and social habits, as well as anthropometric measurement and laboratory testing.^18,20,35

   Nutritional assessment. Nutritional assessment should begin with accurate height and weight documentation. If the person is unable to stand, height can be estimated by measuring arm extension fingertip to fingertip.³⁶ Weight ideally should be taken at the same time of day on a calibrated scale. Using height and weight measurements, body mass index (BMI) can be calculated as follows:³⁷
Weight (kg)/ height (m²) or
Weight (lb)/height (in²) X 705

   A BMI <19 indicates the person is below normal weight and may have decreased nutritional status; a person with a BMI >30 is considered obese.³⁷ However, it is important to realize that obese individuals may be malnourished and BMI is only one component of the assessment process.³⁸

   Because weight loss may be a late sign of malnutrition and the person may not be an accurate historian of personal weight, having an accurate weight record is important for noting significant unintentional weight loss or gain.¹⁶ A significant weight loss is considered to be >10% in 6 months or 5% in 1 month.^25,38 However, weight gain can be as important in lesser amounts. A 2- to 5-lb gain over a short period of time may mean the person is retaining fluid, a serious consideration in a person with a heart condition.³⁹

   Laboratory tests are vital for nutritional assessment. However, hydration status can dramatically affect results. Persons who are dehydrated can have normal or elevated albumin, hemoglobin, and hematocrit levels; once they are rehydrated, these values can drop to alarming levels. Conversely, an overhydrated person also can have altered values. Trends in laboratory values should be monitored for serum albumin (normal 3.5 to 5.0 g/dL), prealbumin (normal >17 mg/dL), and serum transferrin (normal >180 mg/dL) levels.^20,25,28

   Numerous screening surveys are available to use for nutritional assessments, including the Nutrition Screening Initiative (NSI) checklist and the Mini Nutritional Assessment (MNA). Both are self-administered checklists that are useful as a basic tool and have been used with a variety of age groups and in multiple care settings.^19,40,48 Additional general and specific nutritional assessments are available at https://www.medal.org/.

Role of Nutrition in Wound Care

   Elderly persons admitted to the hospital are at particularly high risk for malnutrition. Zulkowski’s⁴⁹ research found elderly persons admitted to acute care for any reason had lower serum albumin levels than persons with pressure ulcers living in nursing homes.^5,33,49 Additional research^50,51 involving older adults has shown that problems eating and/or weight loss is associated with increased risk of pressure ulcer development in a nursing home setting. However, the effectiveness of improving nutrition as part of pressure ulcer prevention is controversial. Research^51-53 involving older adults in nursing home settings has found malnutrition to be associated with pressure ulcer development. Despite this epidemiologic association, nutritional intervention trials have not consistently demonstrated the ability to prevent pressure ulcers^54-56 and Alzheimer’s patients with low body weight were not as likely to benefit from nutritional interventions as persons with higher body mass index.⁵⁷

   Increased protein is required for the body to heal and adequate hydration aids in tissue perfusion.⁵⁸ Research^16,59,60 has shown that in elderly people, the thirst mechanism may be decreased; in addition, older people may limit fluid intake because they mistakenly believe this will decrease incontinent episodes.⁵⁹ Dehydration affects blood volume, circulation, and skin turgor and increases pressure ulcer risk in the elderly population.^16,50

Nutritional Support

   The need for adequate nutrition during illness is not a new concept. The 1925 American Woman Cookbook devoted a chapter to “Foods and Beverages for Invalids”.⁶¹ Suggested fare included not only milk and egg drinks and broths, but also rice, jelly, and flaxseed lemonade. Providing appealing small meals was encouraged.

   Today, many options exist for people at nutritional risk, including commercially prepared products and supplements. These supplements are available for oral as well as tube-fed consumption and are important additions to medical care planning that addresses specific patient deficiencies. Medications and vitamin supplements are also appropriate for elderly persons at risk for nutritional deficiency.^25,60 The ADA recommends that any of the multitude of available supplements, vitamins, and medications should be used only as part of a transdisciplinary plan of individualized care. While dietary concerns regarding older adults are prevalent, no one product or supplement has been found to be universally appropriate. Anyone with questionable nutritional status or specific issues should consult a Registered Dietitian to individualize a plan of care.

Medications

   In recent years, the anabolic steroid oxandrolone has been used for persons with significant unintentional weight loss. A study of burn patients who were given oxandrolone regained weight and lean muscle mass two to three times faster than patients receiving nutrition alone.⁶² Additional research is needed to examine the effectiveness of this medication on elderly patients specifically. Oxandrolone has been approved by the US Food and Drug Administration for this use. Anabolic steroids are a class of natural and synthetic steroid hormones that promote cell growth and division. Their use may result in the growth of muscle tissue, bone size, and strength. The best known natural androgen and natural anabolic steroid is testosterone. Side effects include damage to the liver and spleen.^1,62,63 Consequently, these should be used with caution in the elderly with compromised physiologic function.

   Other medications, including appetite stimulants, have been used to improve nutritional status.^64,65 However, little research is available to determine the effectiveness of these medications in elderly persons.
Any nutritional treatment should reflect individual patient needs and be transdisciplinary in scope. Digestive or swallowing problems, comorbid conditions, and economic considerations should help guide the development of a transdisciplinary treatment plan.

Conclusion

   Nutrition is an important consideration for the increasing number of persons >age 65. The diversity and large age range of this group make generalizations difficult but underscore the importance of accurate individual assessment. Physical, social, and psychological factors must be examined and documented. Adequate hydration and nutritional support must be provided during an acute medical stay, chronic illness, or any time nutrition is less than adequate. Social and psychological factors that will affect the person on discharge also must be addressed to provide effective holistic, transdisciplinary care.

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