Nutrition and HydrationNutrition and Hydrationin the Older Adultin the Older Adult

ObjectivesObjectives

Discuss demographics related to nutritional issues in older adults.

Assess diet history and nutritional status, with special attention to cultural, ethnic, or religious preferences.

Evaluate anorexia in older adults. Identify contextual factors that contribute to optimal dining

experiences. Plan care to maximize the self-feeding capacity of an older

adult. Plan mealtime care for an older adult with cognitive and/or

physical impairments.

DefinitionsDefinitions

Malnutrition: any disorder of nutrition status

including disorders resulting from inadequate intake (too little in)

over-nutrition (too much in)

improper metabolism Overweight older adults (75+ years)

Men=56.5% Women=52.3%

Obesity in older adults (75+ years) Men=13.2% Women=19.2%

DemographicsDemographics

Frequency of Malnutrition in Older Adults:

Independent Living: 1% TO 15%

Institutionalized: 25% TO 85%

Hospitalized: 35% TO 65%Worsens during hospitalization

Increased RisksIncreased Risks

Malnourished older adults are more likely to experience:Longer hospital staysIncreased hospital costsDiminished muscle strengthFunctional impairments

Increased RisksIncreased Risks

Nutrition affects CO, HR, BPMedications bound to protein have higher levels

Standard dose could be toxic (dilantin/coumadin)

Immune systemPoor wound healing and new pressure ulcers

InfectionsPost operative complications

Higher risk for emboliEdema/ascites and/or diarrhea if protein drops

Death

Factors InvolvedFactors Involved

Progressive loss of lean body mass - decreased BMR

Disease, stress, injury, chronic drug use Overeating and lack of exercise Diminished sense of taste and smell Loneliness Physical and mental handicaps – immobility

and chronic illness

Screening and AssessmentScreening and Assessment

Nutritional Screen needs to be completed within 24 hrs of admission current weight & weight history

Three-day food diary (if memory intact)Assessments should include

Baseline- nutritional patterns, abilities

Lab results- albumin, prealbumin

Unintentional weight loss prior to admission – red flag if 10# in 6 months!

Screening and AssessmentScreening and Assessment

Calorie countsLess than 50% eaten

document and intervene!NPO for more than a few hours Inconsistencies between reported diet

and what you see physically may indicate poverty, elder neglect/abuseFluid intake correlates to food intake

Screening and AssessmentScreening and Assessment

Physical Assessment skin turgor, lesions, color, thick or brittle

hair, muscle wasting, oral status (loose teeth; poorly fitting dentures), oral lesions, beefy red tongue

Serologic parametersprealbumin & serum transferrin (early

markers); serum albumin (late marker)

Diet History and Nutritional Diet History and Nutritional StatusStatus

Other serologic parameterstotal protein, BUN/Creatinine ratio, CBC,

Blood glucose, iron stores, ferritin, B12, lipids

Performance-based functional status Inconsistencies between reported diet

and biochemical / physical parameters

http://www3.utsouthwestern.edu/geriatrics

DehydrationDehydration

50% mortality if untreated Often primary or secondary reason why the

patient is in the hospital Hydration status must be performed on all

older people Normal aging causes decrease in total fluids I/Os are very important!

DehydrationDehydration

Elderly may present differently than younger people, symptoms can be subtle:Irritability, confusion, lightheadedness,

change in mental status, headache, loss of appetite, lethargy (very tired) or fatigue, low urine output or dark urine, constipation, fecal impaction, infection, muscle weakness

Dehydration Dehydration AssessmentAssessment

Poor skin turgor, dry mouth and lips, subtle change in baseline: families may report “Mom doesn’t seem herself today”

DehydrationDehydration

Check Orthostatics A fall in blood pressure of 20mm Hg systolic

(from lying to standing) and/or a rise in pulse by 15 beats per minute

often means a person is dehydrated

Lab tests NA (hyper and hyponatremia) K+ (hyperkalemia) creatinine (not as reliable in elderly- Why?) BUN urine specific gravity urine electrolytes

DehydrationDehydration

Alleviate dry mouth:Avoid caffeine, dry, bulky, spicy, salty foodsSugarless hard candy or chewing gum to

stimulate saliva (not for patients with dementia or dysphagia)

Applying petroleum jelly to lips or denturesFrequent small mouthfuls of waterArtificial saliva

Cognitive and Physical Cognitive and Physical ImpairmentsImpairments

Assess for possible unrecognized diseases or problems

Allow smaller, more frequent meals Cue the person with cognitive impairments Sit next to or across the person Do not use a syringe to feed Schedule staff Burden-free attitude about feeding.

Be ProactiveBe Proactive

Improve oral intake:Mealtime checksEncourage family members Small, frequent intakePain medsPleasant environmentOOB

Be ProactiveBe Proactive

Cues and Gestures Use adaptive devices that work Allow time – use finger foods Difficulty in swallowing referred to SLP. Dysphagia occurs in advancing dementia

patient may eventually lose the ability to swallow and eat or drink.

Supplements

What Do You Think?What Do You Think?

Which of these situations is an example of nosocomial malnutrition?

1. Decreased intake related to a disease process

2. Failure to replace meals held for tests3. Anorexia related to an underlying

eating disorder

What Do You Think?What Do You Think?

Malnutrition in a hospital usually refers to

1. Carbohydrate- fat intake2. Protein-carbohydrate intake3. Fat-protein intake4. Protein-calorie intake

What Do You Think?What Do You Think?

A patient who fails to consume adequate calories and protein is at increased risk for which of these complications?

1. Thromboembolism2. Heart failure3. Hepatitis

What Do You Think?What Do You Think?

A patient who develops hypoalbuminemia related to protein deficiency should be monitored for toxicity to which of these meds?

1. Warfarin2. Dilantin3. Meperidine4. Digoxin

What Do You Think?What Do You Think?

Which of these approaches would you use with a patient whose appetite deteriorates throughout the day?

1. Limit stimulation at meals2. Encourage a big breakfast3. Reduce physical activity4. Offer double portions

Stechmiller, J. K. (2003). Early nutritional screening of older adults. Journal of Infusion Nursing, 26, (3). 170-176.

http://www3.utsouthwestern.edu/geriatrics Guigoz, Y., Bruno, U., & Garry, P. J (1996). Assessing the nutritional status of the

elderly: The Mini Nutritional Status as part of the geriatric evaluation. Nutrition Review. 54, S59-S65.

www.johnahartfordfoundation.org