Geriatric nutrition.

Continuing education and the APD program

This quiz is an ideal activity for APD members to include in your CPD log, where it relates to personal learning goals. Record the time taken, to the nearest hour, to complete the quiz and any associated research.

This quiz has been prepared by members of the NSW Geriatric Interest Group. Correspondence should be directed to Rudi Bartl at [e-mail]

Australia like many countries has an ageing population which will ultimately cause challenges for the health system. Dietitians will be part of the health team that will need to help manage these challenges. This continuing education quiz focuses on some of the key nutrition health issues for this population group, particularly the frail elderly and those residing in aged care facilities. For those dietitians not currently dealing with this group it provides some valuable information, as well as some important reminders and some references for those who are working with ageing members of the community.

1. Which statement correctly describes the current Australian RDIs for men (64 years and older) and women (54 years and over), when compared with young adults (men 19-64) and women (19-54)?

b. all nutrient requirements decrease as adults age

c. some nutrient requirements decrease and some remain the same as adults age

d. some nutrient requirements decrease, some are the same and some greater as adults age

e. nutrients are required in the same amounts or greater, but not are not decreased as adults age

2. After medical treatment, if serum sodium was still low in an elderly patient, what dietary management may be recommended?

a. 1L/day fluid restriction

b. 1.5L to 2.0L fluid/day

c. no intervention

d. high sodium diet

3. Which of the following statements is true? A sedentary older person living in a temperate climate should:

a. drink at least eight cups of water a day for good health

b. drink at least eight cups of fluids a day for good health

c. remember to count caffeinated beverages and even beer, in moderation, towards fluid intake

d. only count the fluid content of foods with a high water content towards their requirements

4. With what is vitamin D insufficiency in elderly people correlated?

a. bone fragility

b. muscle weakness

c. both a and b

d. neither a nor b

5. Ageing is associated with a decline in immune function and an increased risk of illness and infections. What is the major reason for the immune changes seen in the frail, elderly population?

a. the ageing process per se

b. protein energy malnutrition

c. subclinical micronutrient deficiencies

d. all of the above

6. What is a common cause of vitamin B12 deficiency in older people?

a. inadequate diet

b. medications including omeprazole, ranitidine and metformin

c. pernicious anaemia

d. cognitive impairment

7. When assessing the body weight of an older person, what is most important to consider?

a. age

b. body mass index (BMI)

c. weight history

d. height

8. Low blood cholesterol among frail older people is associated with all of the following, except:

a. morbidity

b. mortality

c. decreased risk of heart disease

d. malnutrition

9. By what can improved intake and weight gain in residents of aged care facilities with dementia be achieved?

a. providing 'finger food' menu options and having food available outside regular meal times

b. using a combination of fortified foods and commercial supplements

c. educating carers about appropriate techniques to assist feeding and interpret apparent food refusal behaviours

d. all of the above

Answers

1. c.

There is variation in the requirements for essential nutrients for adults as they age with some less, some more and some staying the same. Protein, vitamin A (retinol equivalents), total folate, vitamin B12, vitamin C, vitamin E (tocopherol equivalents), zinc, iodine, magnesium, phosphorus, sodium, potassium and selenium requirements (1) remain the same for men and women at any age. Iron requirements, while the same for older men, decrease for older women (1). Thiamin, riboflavin, niacin, B6 requirements are all slightly less in comparison with younger adults (1). Calcium requirements, while the same for older men, increase for older women, when compared with younger adults (1).

2. a.

An excessive amount of water in the body is rare, but water diuresis can fail after trauma, including surgery and head injury, with inappropriate release of ADH or SIADH syndrome of insufficiency of antidiuretic hormone. In older people, thirst, water diuresis and response to ADH weaken with age. If patients with these conditions are given much more than 1L/day, sodium concentration falls. Adding salt to the diet or providing a high salt diet is not recommended (2).

3. c.

Older people need to replace the amount of fluid lost through excretion (urine and faeces) and insensible losses. This amount will vary depending on issues such as age, activity levels, and climate. Eight or more glasses of water a day is not based on scientific evidence, but may just be a handy reference point for people who may be prone to dehydration such as the frail elderly.

The average person loses about 2500 ml a day and takes in about 1000 ml in food and about 300 ml from metabolic water, leaving only about 1200 ml to be made up from fluids such as water, tea, coffee, juice, milk, and even low alcohol beverages such as beer (3). Five glasses of fluids equates to about 1200 ml, which is a much more realistic amount for many older people to achieve. Thus, eight cups of fluids, let alone eight cups of water, are an overestimation of requirements.

The idea that fluid intake should come mostly from water because of the diuretic effects of the caffeine found in tea, coffee, cocoa drinks and some soft drinks appears to be erroneous (4). Thus for many frail older people eight glasses of water may be a little hard to swallow! In addition, it may also displace more nutritious items from the diet, which could be a substantial issue over time. However, if food intake is small, then the 1000 ml of fluid from food may be an overestimation. These issues provide more support to providing nutritious foods and fluids to maintain hydration and nutritional intake. If appetites are small and the sense of thirst diminished, encouraging drinks that are appealing such as tea, coffee or even a glass of beer can be appropriate.

4. c.

Fat-soluble vitamin D is essential for utilisation of dietary calcium. It is present in few foods, and sun exposure (UVB) is the major determinant of vitamin D status (5). It has been estimated that over 90% of our vitamin D comes from exposure to sunlight. Anything that interferes with the penetration of UVB such as sunscreen use or sunlight filtered through windows diminishes cutaneous production of vitamin D. Skin synthesis of vitamin D also decreases with age and degree of pigmentation of the skin (6).

Low levels of vitamin D results in a compensatory rise in parathyroid hormone (PTH) and net withdrawal of calcium from bones. Ionised calcium plays a crucial role in muscle contraction and hence the plasma calcium level is tightly regulated. A landmark study in 1992 showed that supplementation with both vitamin D and calcium significantly reduced hip fractures in elderly women (7).

Interest in the effects of low vitamin D status on muscle strength has resurfaced recently. As early as 1981. Irish researchers (8) argued that muscle weakness and bone pain associated with deficiency of vitamin D would contribute to decreased mobility of frail elderly people, hence an increased risk of falling. A recent meta-analysis of the effect of vitamin D supplementation on falls (9) concluded that vitamin D supplementation of ambulatory older people appears to reduce the risk of falls by over 20%. The authors suggest a direct effect of vitamin D on muscle strength. The role of calcium supplementation was unclear from this study. Noting the high prevalence of vitamin D insufficiency among attendees at a UK falls clinic, routine supplementation has recently been recommended (10). If direct sunlight is not possible, a vitamin D supplement or multivitamin with 800-1000 international units (IU) per day vitamin D is recommended (equivalent to 20-25 [micro]g vitamin D daily) along with monitoring of vitamin D levels (11).

5. d.

Ageing is associated with reduced immune function with significant changes in cell mediated immunity and to a lesser extent a reduction in humoral and innate immune functions. The immune system is undergoing permanent renewal and produces millions of immune cells daily. Immune cell renewal is further increased in infectious disease (12). To support this, the immune system uses the macro and micronutrients involved in DNA, RNA and protein synthesis.

Changes in nutritional status, particularly protein energy malnutrition and even mild micronutrient deficiencies, e.g. zinc, selenium, vitamin B6 and folate that are common in the elderly, are known to affect immune function. Studies investigating the addition of multivitamin and mineral supplements as well as individual micronutrients have shown improvements in various parameters of immune function (13-15). Thus, nutritional status should be assessed and any deficiencies corrected in an effort to optimise immune function and quality of life in the elderly.

6. b.

Vitamin [B.sub.12] deficiency occurs frequently among older people, but is often unrecognised because the clinical manifestations are subtle. A common cause is long-term usage of biguanides (metformin) and antacids, including H2-receptor antagonists and proton pump inhibitors. Symptoms are often non-specific and may include loss of appetite, diarrhoea, numbness and tingling of hands and feet, paleness, shortness of breath, fatigue, weakness, sore mouth and tongue, confusion or change in mental status. Symptoms may appear before a clinical deficiency is detected by biochemistry (16).

Diets of most older people provide recommended intakes of vitamin [B.sub.12], but deficiency may still occur because of an inability to absorb vitamin [B.sub.12] from food, due to gastric atrophy and bacterial overgrowth. Hydrochloric acid in the stomach is necessary to release vitamin [B.sub.12] from protein during digestion. Once released, vitamin [B.sub.12] combines with a substance called intrinsic factor (IF) before it is absorbed into the bloodstream. Bacterial overgrowth in the stomach and/or atrophic gastritis, an inflammation of the stomach, contribute to vitamin [B.sub.12] deficiency in adults by limiting secretions of stomach acid needed to separate vitamin [B.sub.12] from protein in food (17).

7. c.

Investigating the weight history of an older person is a key factor in assessing the appropriateness of an individual's current body weight and the need for nutrition intervention. Age-related changes in body composition and height make determining an ideal body weight problematic, so changes in body weight, specifically weight loss, may be a more sensitive indicator of an individual's risk (18). Beck and Ovesen's review of the literature (19) concludes that for older people an annual weight loss of only 5% is clinically significant. This is less than that for younger age groups. Both voluntary and involuntary weight loss increase fracture risk in older women (20) and weight loss is an independent risk factor for mortality in the elderly (21). Weight change predicts mortality better than does static weight measures and weight stability is associated with a lower mortality risk than either a high or low body mass index (22).

While the age of an individual is an indication of the likelihood of age-related changes (e.g. in height or body composition), the age of an older person should not alter the assessment of their body weight or attitude of the health professional to it. Weight changes, particularly weight loss, are not a normal or automatic consequence of ageing. Therefore the appropriateness of weight change in older people should be assessed and not be dismissed as unimportant as the person is 'old'.

While BMI is an important assessment tool and indicator of mortality risk for younger adults. BMI measurements need to be interpreted with caution in the older population. While it may not be appropriate to accept an elevated BMI for all 65-year-olds, the research does suggest that BMI reference ranges need modification for older people and the basis for this is not due to only age-related changes in height and body composition. With increasing age, the U-shaped mortality curve flattens out, the National Health and Medical Research Council (NHMRC) reference ranges for BMI become less distinct and the general health status of an older person is more important than a moderately elevated BMI (23). Heiat et al. (24) state the USA federal guideline standards for ideal weight (BMI 18.7-< 25) may be overly restrictive for older people as studies do not show an excess mortality risk for overweight individuals. Research suggests that for older people, particularly those over 74 years, a higher body weight (BMI) may be associated with a lower risk of mortality from all causes (25-29). Conversely mortality rates increase for older people with a low BMI (25,30). The National Screening Initiative (USA) uses the BMI range 22-27 for older people (31). The review by Beck and Ovesen (19) concludes that the optimal BMI range for older people is increasing from 20-25 kg/m2 to 24-29 kg/m2.

The height of an older person is likely to decrease with age due to changes in spinal shape and inter-vertebral disc thickness. This makes measuring height and BMI more difficult (23). This difficulty is highlighted by the research of Kirk et al. (32) who reported up to a 10cm difference when comparing the values obtained for height by using measurements of standing height, demi-span and knee height.

8. c.

Low blood cholesterol in the elderly is associated with increased malnutrition, morbidity and mortality. The most accurate evidence of malnutrition in an elderly patient is hypocholesterolaemia and hypoalbuminaemia (33,34). According to the American Dietetics Association's position paper (35): 'Available epidemiological evidence indicates that as age increases above 44 years, the importance of elevated serum cholesterol levels as a risk factor for coronary heart disease decreases and virtually disappears after the age of 65 years' (36-38). 'Therefore, the appropriateness of low-cholesterol diet prescriptions for older adults in long-term care facilities is questionable' (39-41). Malnutrition is a much greater danger to the majority of residents in aged care facilities than high blood cholesterol levels (42).

'Menu planners should not attempt to improve a client's lipid profile by implementing radical shifts in eating habits. The goals of dietary modification are to maintain current weight and blood cholesterol levels, to encourage consistent dietary intake, and to preserve eating pleasure and quality of life' (33).

9. d.

Recent studies indicate that weight loss is not an inevitable part of dementia (43). An enhanced menu using finger foods (44), fortified foods (45) (e.g. mashed potatoes, soups) and having high protein/high energy snacks available outside regular meal and mid-meal times has been shown to enable residents to reverse or arrest weight loss. Interpretation of aversive behaviour differs among different staff members, and this is often not discussed. Anecdotally, many facilities report that certain residents eat better for one or two particular nurses, yet the techniques used by these nurses may not be recorded. By incorporating preferred technique into individual care plans, oral intake can be improved. This also decreases feelings of frustration and inadequacy among staff (46).

References

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5. National Health and Medical Research Council Report of the 108th session, November 1989. Canberra: Australian Government Publishing Service; 1989.

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43. Barratt J. Practical nutritional care of elderly demented patients. Curr Opin Clin Nutr and Met Care 2004;7:35-8.

44. Ford G. Putting feeding back in the hands of patients. Journal of Psychosocial Nursing 1996;35(5):35-9.

45. Keller HH, Gibbs AJ. Boudreau LD, Goy RE, Pattillo MS, Brown HM. Prevention of weight loss in dementia with comprehensive nutritional treatment J Am Geriatr Soc 2003;51:945-52.

46. Biernacki C, Barratt J. Improving the nutritional status of people with dementia. British Journal of Nursing 2001;10:1104-10.