23 April 2013 Strategies to Ensure Proper Nutrition for the Seniors in Your Life

In my experience as a home health nurse working with the geriatric population, I have seen many cases in which proper nutrition was dramatically overlooked, especially in those who lived alone with minimal supervision and care.

Malnutrition is defined as an imbalance of nutrients caused by either an excess intake of nutrients or a nutritional deficit. Malnutrition is becoming increasingly more common among the elderly population. In communities across America, an estimated 5-10% of elderly people are malnourished (1), so the problem is much more common than one might think.

Possible Causes of Poor Nutrition

Diminished Sense of Taste/Smell

As we age, we begin to lose our sense of taste and smell (2). It also doesn't help that rich cooking preparation such as frying and the use of excess salt and sugar should be avoided at this age. These two factors together can significantly take the pleasure out of eating.

Side Effects of Medication

If is very common for the elderly to be on multiple medications. What most people don't understand is that many of these drugs can have a significant effect on nutritional status. Nutritional risks induced by drug intake include lack of appetite, drug-induced nutritional deficiencies, and toxic reactions. Drug side effects, such as lightheadedness with standing or sitting up, may also interfere with a person's ability to perform activities of daily living such as shopping or cooking (3).

Poor Dental Health

Missing teeth and loose fitting dentures are common problem among the elderly but most don't usually associate these issues with the development of malnutrition. Poor dental health in the elderly has been demonstrated to lead the poor oral intake, thus leading to poor nutritional status (4). It has also been reported that individuals who wear dentures consume more refined carbohydrates, sugar and dietary cholesterol than those who do not (5).

Financial Hardship

The National Diet and Nutrition Survey showed that people over 65 with low or fixed incomes consumed significantly smaller amounts of energy, protein, fiber, and many vitamins and minerals (6). Lacking money to pay for adequate foods can result in a host of nutrition problems and many seniors are on fixed or limited incomes. If a senior in concerned about money they may cut back on grocery expenses and buy less-nutritious foods to fit in their budget.

Lack of Transportation

Some seniors lack reliable transportation and therefore are less likely to go out grocery shopping. This can lead to a lack of eating, or relying on non-nutritious delivery food options. Even with reliable transportation, without the proper assistance shopping can be difficult with many food stores located in large shopping malls and on crowded streets. In order to go grocery shopping, a senior must drive to the store, navigate through heavy traffic and, oftentimes, park far away from the door.

Physical Impairment

Muscle loss is a normal part of ageing, this muscle loss is called sarcopenia. It is even seen in healthy individuals with the metabolic changes that naturally occur during ageing. A lack of physical activity plays a significant role in the progression of sarcopenia (7). As a result of associated weakness it may be increasingly difficult for the elderly to perform activities of daily living, such as preparing food or even struggling with the use of utensils, which in turn can lead to the development of malnutrition.

Neurological Impairment

Dementia, Alzheimer's disease, and poor memory can hurt a senior's ability to eat a variety of foods on a regular schedule and remember what to buy at the store. Weight loss and changed eating behavior is a common characteristic of progressive dementia. (8). It has also been found that up to 50% of patients with Alzheimer's disease lose the ability to feed themselves within 8 years of diagnosis (9). One may keep eating the same foods over and over without realizing it, or skip meals entirely because they can't remember the last time that they ate.

Swallowing Problems

Many conditions that develop with old age can lead to swallowing problems or dysphagia which can cause malnutrition by leading to a reduction in food intake. It is apparent that dysphagia is a major problem and, in those elderly affected, it can lead to an intake of only 14.5% of estimated energy requirements (10). Research has demonstrated that dysphagia is associated with weight loss and malnutrition in the elderly (11, 12).

Strategies to Ensure Proper Nutrition

Caring for the nutritional needs of the elderly presents a unique challenge but by applying some simple nutritional and cooking fundamentals, you can help ensure that your loved ones receive the nourishment they need to stay healthy.

Offer Nutritionally-Dense Foods

Since many seniors aren't eating as much as they should, the food they do eat must be as nutritious as possible. Encourage whole, unprocessed foods that are high in calories and nutrients. Some examples include: healthy fats such as nut butters, nuts, seeds and olive oil; whole grains including brown rice, whole wheat bread, oats and whole grain cereals, and of course, try to include plenty of fresh fruits and vegetables. If chewing is difficult, stick with nut and seed butters as opposed to whole nuts or seeds. Also, cooking food items well can help soften the food and make it easier to chew. It is important to note that canned and frozen goods are also fine choices though one should try to stay away from products with added salt, (stick to "low sodium" or "no salt added" foods). Protein-rich beans, legumes, lean meats and low-fat dairy products are also very good choices.

Spice It Up

Making food appealing may help stimulate appetite, especially in the elderly whom most likely have a diminished sense of taste and smell. The flavors of dishes can be amplified with the addition of herbs and spices, and low-salt, low-sugar marinades, dressings and sauces. Switching between a variety of foods during one meal can also keep the meal interesting. Combining textures, such as yogurt with granola, to make foods seem more appetizing will help improve the overall experience of eating.

Keep It Social

Many seniors who live alone or suffer from depression may stop cooking meals, lose their appetites, and depend on convenience foods. Food intake in the elderly can be improved when they eat in social settings. It has also been shown that this could potentially lead to weight gain and corresponding improvements in nutritional status and rehabilitation (13). With that being said, it is beneficial to have family get-togethers as often as possible in addition to bringing hot meals over to the home or inviting the senior in your life to your house on a regular basis. This could lead those most at-risk for malnutrition to becoming more interested in food and eating activities.

Promote Healthy Snacking

Snacking helps to increase the intake of vital nutrients and boosts overall health. Many seniors don't like to eat large meals or don't feel hungry enough to eat three full meals a day. One solution is to encourage or plan for several small meals throughout the day. For each of these small meals, it is important to ensure that they are nutritionally-dense with plenty of fruits, vegetables and whole grains. Whole grains and fortified cereals are a good source of folate, zinc, calcium, Vitamin E and Vitamin B12, which are often lacking in a senior's diet. Lean proteins sources such as chicken, turkey, low-fat dairy and beans are also great snack items. It is also important to add that certain processed meats that are high in sodium and saturated fat should be avoided. Good fat sources such as nuts are also quick and healthy snack items, just make sure to stick to the unsalted varieties. For those with chewing or swallowing difficulties, nut butters might be easier to tolerate.

Maintain Dental Health

Maintaining proper oral health can enhance nutrition and appetite. Simple things such as making sure dentures fit properly and addressing problems like cavities and jaw pain can ensure optimal nutritional status.

Get Help

U.S. Administration on Aging highlights several government assistance programs that can help improve nutritional status. Home-delivered meals (Meals on Wheels), adult day care, nutrition education, door-to-door transportation, and financial assistance programs are available to people over the age of 60 who need help.

For more information visit www.AOA.gov. You can also call Eldercare Locator at 1-800-677-1116, or visit eldercare.gov to learn more. This is a nationwide call center and website that connects older Americans and their caregivers with information on senior services in their area.

Help Them Get Around

As mentioned above, lack of transportation can be an issue and it may be beneficial to take your loved one to the grocery store yourself to make sure they are getting the food they need. If possible, you might also be able to hire a helper or neighbor to do this if you aren't available. Another option is to order the groceries yourself, either from local grocers that make home deliveries or from an online grocery website. Check with your local grocery stores and see if this is an option. Some stores will even send at regular intervals so you don't have to remember to order each time.

Remind Them

If poor memory is interfering with good nutrition, schedule meals at the same time each day and give visual and verbal reminders about when it's time to eat.

Provide Dietary Supplements Wisely

It may seem like an ideal intervention for any nutritional shortcomings to supplement, but if not done properly it can lead to toxicity. Dietary supplements may cause a variety of adverse side effects, particularly if an individual takes excessive doses of particular nutrients or uses herbal supplements that contain stimulatory or contaminated ingredients. An excellent example of possible negative outcome is vitamin A supplementation. The elderly do not process vitamin A as quickly as younger people do, making them susceptible to vitamin A toxicity (13). Another example is taking too much vitamin B-6 which can cause nerve damage in the arms and legs (13).

It is recommended to avoid vitamin and mineral supplements that contain "mega" doses (anything that is 10 times greater than the daily value (DRI) of any nutrient) to prevent excessive intake and toxic effects (14). On the food label, that would be roughly 1000% DV listed on the food label. Read and follow dosage instructions carefully. Look for a United States Pharmacopeia (USP) label, which indicates that vitamin and mineral supplements meet USP standards for purity and strength (15). Supplements containing stimulants, such as caffeine, may cause rapid heartbeat, increased blood pressure and anxiety. Additional concerns include interactions with over-the-counter and prescription medication, supplement mislabeling and surgical complications. With that being said, make sure you discuss the idea of supplements with your loved one's health care provider.

For more information, visit the USP's website at: www.usp.org

Closing Thoughts

In the home setting, it is easy for malnutrition to be overlooked due to what is often a very slow progression that may not be noticeable to those who see the person regularly. For this reason, it is important for you to be a strong advocate for your loved one and make sure that these concepts are being applied to their care.

Note: MyNetDiary can be an excellent tool for caretakers to figure out where gaps are in their senior's diet. With a Premium membership you can track essentially any vitamin and mineral to evaluate daily intake compared to the DRI. Also, the web reports are great for printing and sharing with health care providers to help gauge nutritional status.

References

1. Furman E. Undernutrition in older adults across the continuum of care: nutritional assessment, barriers, and interventions. Journal Of Gerontological Nursing. January 2006;32(1):22-27. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed April 15, 2013. Access online at: http://www.ncbi.nlm.nih.gov/pubmed/16475461

2. Duffy V, et al. Measurement of sensitivity to olfactory flavor: application in a study of aging and dentures. Chem Senses.24:671, 1999. Access online at: http://chemse.oxfordjournals.org/content/24/6/671.long

3. Roe D. Medications and nutrition in the elderly. Primary Care. March 1994;21(1):135-147. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed March 24, 2013. Access online at: http://www.diet.com/g/nutrientdrug-interactions

4. Volkert, D. (2002). "Malnutrition in the elderly - prevalence, causes and corrective strategies". Clinical Nutrition 21: 110. Access online at: http://download.journals.elsevierhealth.com/pdfs/journals/0261-5614/PIIS0261561402800140.pdf

5. Ritchie CS, Joshipura K, Hung HC, Douglass CW. Nutrition as a mediator in the relation between oral and systemic disease: Associations between specific measures of adult oral health and nutrition outcomes. Crit Rev Oral Biol Med 2002;13(3):291-300. Access online at: http://cro.sagepub.com/content/13/3/291.long

6. Finch S, Doyle W, Lowe C. et al National Diet and Nutrition Survey: people aged 65 years and over. Vol 1. Report of the diet and nutrition survey. London: The Stationery Office, 1998. Access online at: http://www.esds.ac.uk/doc/4036/mrdoc/pdf/a4036ueb.pdf

7. Roubenoff R. Sarcopenia and its implications for the elderly. Eur J Clin Nutr 2000. 54(suppl 3)S40-S47.S47.

8. Claggett M S. Nutritional factors relevant to Alzheimer's disease. J Am Diet Assoc 1989. 89392-396.396. Access online at: http://www.ncbi.nlm.nih.gov/pubmed/2646348

9. Volicer L, Seltzer B, Rheaume Y. et al Progression of Alzheimer?type dementia in institutionalised patients: a cross sectional study. J Appl Gerontol 1987. 683-94.94. Access online at: http://jag.sagepub.com/content/6/1/83

10. Wright L, Cotter D, Hickson M, Frost G. Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. Journal Of Human Nutrition And Dietetics: The Official Journal Of The British Dietetic Association. June 2005;18(3):213-219. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed April 14, 2013. Access online at: http://www.ncbi.nlm.nih.gov/pubmed/15882384

11. Keller H H. Malnutrition in institutionalized elderly: how and why? J Am Geriatr Soc 1993. 411212-1218.1218. Access online at: http://www.ncbi.nlm.nih.gov/pubmed/8227896

12. Wright L, Hickson M, Frost G. Eating together is important: using a dining room in an acute elderly medical ward increases energy intake. Journal Of Human Nutrition And Dietetics: The Official Journal Of The British Dietetic Association. February 2006;19(1):23-26. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed April 2, 2013. Access online at: http://www.ncbi.nlm.nih.gov/pubmed/16448471

13. The Pennsylvania State University; Nutrition and Aging: Vitamins and Minerals; July 2001. Access online at: http://extension.psu.edu/health/news/2012/vitamins-minerals-and-supplements-proper-use-and-today2019s-marketplace.

14. National Research Council. Recommended dietary allowances. 10th ed. Washington, DC: National Academy Press, 1989. Access online at: http://fnic.nal.usda.gov/dietary-guidance/dietary-reference-intakes/dri-reports

15. The USP Dietary Supplement Verification Program; The USP Verified Mark and What It Means. www.usp.org. April 3, 2013 Access online at: http://www.usp.org/usp-verification-services/usp-verified-dietary-supplements

Scott Roberts

LPN, CDM, DTR: Dietetic Intern (Through July)

Contact Scott via his Linkedin page: www.linkedin.com/scottroberts

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Disclaimer: The information provided here does not constitute medical advice. If you are seeking medical advice, please visit your healthcare provider or medical professional.

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Weight Gain/Calories & Protein Other Health Issues/Aging

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