Today’s
CPE
Declining Nutritional Status in Older Adults
Today’s Dietitian
By Mary D. Litchford, PhD, RD, LDN
Vol. 6 No. 7 p. 12
Declining nutritional status is one of the many
reasons older adults lose their independence. Changes in health,
loss of spouse or close friends, changes in financial status, and
lack of social support can all contribute to a self-perpetuating
cycle of poor eating habits, despondency, and apathy, with a resulting
downward spiral in nutritional status and health.
Because our society is aging, breaking the cycle
of declining nutritional status in older adults is of great concern
and should be the focus of dietetics professionals, no matter what
their specialty. Dietitians play a significant role in breaking
the cycle of declining nutritional status to improve older adults’
quality of life through counseling of individuals and families,
providing access to services and support groups, and most of all
by proactive intervention to bolster nutritional status in those
already in decline.
Although emotional factors are often the root cause,
there are many factors in declining nutritional status. The most
common manifestations include the following:
• poor food choices
• changes in cognitive status
• oral health problems
• anorexia
• dehydration
Poor Food Choices
Poor food choices are common for Americans of all ages, as our habituation
to fast food and unhealthful snacks attests. However, older adults
are much more likely to have significant health consequences related
to the foods they eat or choose not to eat. Frisoni and colleagues1
studied the relationship between food intake and mortality of frail
older adults. Among healthy older adults, the study showed that
low intake levels of calories, protein, carbohydrate, and fat were
strong predictors of mortality. Older adults tend to eat smaller
meals and eat more slowly than younger adults.2 This practice may
not result in malnutrition, but it is recognized that lowered reserves
make older adults more sensitive to minor illnesses and surgery.
Food choices are made based on palatability of foods.
Rolls3 studied sensory-specific satiety changes in adults aged 65
or older. Some individuals lacked sensory-specific satiety—their
sense of taste and recognition of “fullness” were impaired.
This may explain the monotonous dietary practices of many older
adults and their lack of desire to eat a complete meal—food
doesn’t taste, look, or smell right, and they don’t
know when they’ve eaten enough.
Poor food choices are often the result of age-related
sensory changes. The impact of alterations in the senses on food
intake is mediated by a variety of other factors, including use
of medications, nutritional status, food preferences, and habits.
Four senses play a role in eating: sight, smell,
taste, and touch (“mouth feel”). The taste, smell, and
appearance of food are not perceived the same by all adults. What
looks, tastes, and smells good to one adult may be repulsive to
another. Few adults will eat foods that do not satisfy these three
senses. Many older adults complain that food tastes bad or is too
tough to chew.
The senses of sight, smell, and taste interact to
stimulate appetite. The appearance of pleasantly prepared foods
stimulates appetite. Individuals who can not see clearly tend to
be less interested in eating. The senses of smell and taste are
interrelated. Hoffman4 reported that the chronic loss of gustatory
sensation is only approximately 1.65% of the population, with the
greatest proportion being found in older adults. The loss of the
sense of smell appears to be related to the decrease in the number
of taste buds rather than a loss of gustatory sense structures.
Studies suggest that older adults are less able
to discriminate food flavors.5 Sweet foods may taste bitter, sour
foods may taste metallic, and salty foods may be tasteless.5 Keep
this in mind the next time an older adult complains that the food
has an unacceptable taste or lacks sufficient salt. Environmental
factors that negatively affect the tongue include chronic smoking,
poor oral hygiene, ill-fitting dentures, and medications. These
factors may contribute to a decrease in the number of papillae or
atrophy of the papillae structure.
The sense of touch involves two components. First
is the ability to sense hot and cold foods. Consumption of very
hot foods can result in burns to a person who cannot sense heat
or is confused and does not understand the potential danger of being
burned. Secondly, loss of touch also impacts the ability to self-feed
and pick up eating utensils, cups, or mugs. Loss of touch coupled
with fatigue and weakness due to loss of lean body mass or chronic
disease can reduce the ability to eat independently. Changes in
dentition can result in pain in teeth or chewing muscles or in extreme
and painful sensitivity to hot and cold foods. All these factors
can combine to produce a lack of interest in eating.
Changes in Cognitive Status
Changes in cognitive status can be due to dementia, depression,
a change in medical condition, or a side effect of a medication
or combination of medications. The end result is often poor dietary
intake and involuntary weight loss. The cause of a change in cognitive
status should be evaluated by a physician, but the nutrition professional
can often be the first to recognize signs and symptoms of impaired
mental functioning or negative emotional states. Because food is
often the focus of the older adult’s day, a change in food
intake, eating habits, or interest in meals should be a signal for
further investigation.
Medication changes or medical treatment often results
in improved cognitive status for individuals who are depressed,
are on medications that depress appetite, or have changes in medical
condition. Failure to address depressive symptoms can impact quality
of life and nutritional status. It is the leading cause of unexplained
weight loss in older adults.6
Cognitive changes due to dementia may be improved
with medications, but the pharmacological interventions do not stop
the disease’s progression. Weight loss is a common consequence
of end-stage dementia despite all efforts to meet nutrient needs.
Individuals frequently forget how to chew and swallow foods7—
foods are either spit out or pocketed in the mouth. Early intervention
to fortify foods with additional protein and calories can be an
effective intervention. However, as the disease progresses, even
a tube feeding may not prevent weight loss, promote weight gain,
prevent skin breakdown, or heal skin breakdown.8,9,10
Oral Health Problems
Anatomic and functional changes in the mouth, throat, and gastrointestinal
(GI) tract occur with aging and affect how food and nutrients are
ingested, absorbed, and metabolized. The most common oral problem
in older adults is inadequate dentition. Vargas11 reported that
one-third of Americans over the age of 75 have no teeth.
Chewing problems may be due to loss of teeth, poorly
fitting dentures, atrophy of oral muscles due to disuse or weakness,
or reduction in saliva due to chronic illness or medication.12 A
dental consultation may provide some insight into the etiology of
the problem and offer an effective intervention strategy. Also,
a change in food consistency may be helpful, especially in cases
where fatigue and weakness associated with many chronic diseases
such as congestive heart disease and chronic obstructive pulmonary
disease are noted.
Xerostomia, or dry mouth, is a major risk factor
for root caries and can be associated with medications such as antidepressants,
diuretics, and antihypertensives.13 Restriction of fluid intake,
anxiety, and mouth breathing can also compound the problem.14
Swallowing problems and dysphagia occur as a result
of an anatomical or physiologic abnormality.15 The initial presentation
of dysphagia can include a constellation of vague to overt signs
and symptoms.16 Problems with swallowing are often overlooked in
an acute healthcare setting because of the short length of stay
and opportunities to intervene are missed. Dysphagia is associated
with many medical conditions but most often occurs with gastroesophageal
reflux (GERD). Diagnosis and conditions associated with increased
risk for dysphagia include the following:
• dementia
• amyotrophic lateral sclerosis
• Parkinson’s disease
• cerebral palsy
• closed head injury
• cerebrovascular accident
• inflammation of pharynx or esophagus
• multiple sclerosis
• history of aspiration pneumonia
• muscular dystrophy
There are three basic categories of dysphagia: oral,
pharyngeal, and esophageal. The oral dysphagia is due to weak tongue
and lip muscles, difficulty propelling food to the throat, and difficulty
initiating a swallow. The pharyngeal dysphagia is due to a delayed
swallow reflex where the swallow does not clear the bolus of food
from the throat. The food may penetrate the larynx and aspiration
may occur. Esophageal dysphagia is due to structural blockages,
stenosis, and strictures due to GERD or esophageal dysmotility.
The nutritional impact of dysphagia results from
inadequate intake. Consequences include unplanned weight loss, dehydration,
and macronutrient and micronutrient deficiencies.17 A trained professional
must determine the underlying cause of the dysphagia before an effective
treatment plan can be implemented.
Anorexia
Advancing age has been associated with anorexia or lack of appetite.
Roberts18 demonstrated that when healthy young and old men were
placed on a weight-reduction diet, the amount of weight loss was
similar. However, after resumption of an unrestricted diet, young
men gained back all the weight they had lost very rapidly, but older
adult men remained hypophagic and maintained lower body weights.
The lack of interest in eating may also be related to the lack of
sensory-specific satiety described in Rolls’ work.3
These data suggest that the involuntary weight loss
that may occur due to acute illness, trauma, or depression could
result in permanent weight loss. They also suggest that providing
more food or even nutritional supplements may not result in weight
gain in older adults.19
Pharmacological intervention may be appropriate
for some individuals with anorexia. Medications most commonly used
for the treatment of unplanned weight loss include Megestrol acetate,
Dronabinol, and Oxandrolone.
Megestrol acetate is a progestational agent that
increases dietary intake. It has been shown to stimulate appetite
and promote weight gain in patients with AIDS20 and cancer-related
cachexia.21 Jacobs22 reported a retrospective study of 27 long-term
care residents in which 74% had an increase in body weight. Weight
gain was greater in women than men. Karcic23 reported increased
food intake, body mass index, albumin, prealbumin, hemoglobin, and
lymphocyte count in a small number of long-term care residents who
received megestrol acetate.
Megestrol acetate does have potential side effects.
Lambert24 reported that the weight gain produced by megestrol acetate
was mainly fat mass rather than lean body mass. Also, megestrol
acetate has been reported to produce hyperglycemia, adrenal suppression,25
and possibly deep vein thrombosis.26
Dronabinol is from the hemp plant. It was first
recognized as an appetite stimulant in Ayurvedic medicine in the
13th century. It has been shown to increase appetite in individuals
with cancer, AIDS, and dementia. It also has antinausea properties,
decreases pain, and enhances general well-being. Adverse effects
include euphoria, somnolence, and fatigue.27
Oxandrolone is an oral anabolic steroid that has
shown a positive impact on weight gain in patients with AIDS-wasting
myopathy and alcoholic hepatitis.27 It has been shown to decrease
weight loss, nitrogen loss, time to healing, and length of hospitalization
in older adult burn patients.28
Recommendations to use pharmacological therapy for
unplanned weight loss should be a collaborative effort of the healthcare
team. The pharmacist, physician, nurse, and other allied healthcare
team members should be consulted before recommending appetite-stimulating
medications. Use of these medications should be closely monitored
for effectiveness and potential side effects.
Dehydration
Dehydration is a special concern for the older hospitalized patient
and long-term care resident. It is one of the 10 most frequent diagnoses
for admission to the hospital for patients aged 65 and older.29
In older adults, the water content of the body decreases
from approximately 60% of total body weight to roughly 45%. Persons
who are seriously ill and older adults tend to have a decreased
thirst sensation due to an altered state of consciousness, confusion,
or severe depression.30 Maintenance of fluid balance is essential
to good health and recovery from surgery, illness, or injury. Increased
fluid losses are associated with the following:
• chronic or acute infections
– fever
• GI losses
– vomiting
– diarrhea
– laxative abuse
– gastric drainage
– ileostomy
• excessive urinary losses
– diuretics
– glycosuria
– diabetes insipidus
– high-protein diet
• environment
– elevated ambient temperature
– low humidity
Accurate assessment of fluid intake and meeting
fluid needs is essential to preventing dehydration. Fluid losses
of 10% or more can cause changes in cognitive status. Early signs
of dehydration include the following:
• headaches
• fatigue
• loss of appetite
• flushed skin
• poor skin turgor
• heat intolerance
• lightheadedness
• dry mouth and eyes
• dark urine with strong odor30
There are three types of dehydration: hypotonic,
hypertonic, and isotonic. Each has a different etiology and different
clinical characteristics.
Hypotonic dehydration occurs when sodium losses
are greater than fluid losses. The individual with hyponatremia
is often on diuretics and a sodium-restricted diet. The hyponatremia
may be due to increased losses of sodium in the urine, sodium-wasting
syndrome, excessive sweating, or an acute spell of illness with
diarrhea or vomiting. Laboratory tests for serum sodium are below
normal and albumin and blood urea nitrogen (BUN) are higher than
normal.
Hypertonic dehydration occurs when water losses
are greater than sodium losses. This individual usually has a reduced
oral intake of fluids or has had significant losses from vomiting,
diarrhea, or sweating. Laboratory tests suggest the individual has
hypernatremia and hyperosmolality. BUN and albumin are elevated.
Individuals who have below-normal levels of serum sodium due to
a sodium-wasting syndrome may not have elevated serum sodium levels.
When serum sodium levels are within normal limits, hypertonic dehydration
may be overlooked.
Isotonic dehydration occurs when the body loses
equal amounts of water and sodium. This type of dehydration typically
occurs following an acute spell of illness, including vomiting,
diarrhea, or severe bleeding. Laboratory tests for serum sodium
and osmolality are within normal ranges.
Each type of dehydration requires intervention and
monitoring. Giving too much fluid or sodium can shift the clinical
status from isotonic dehydration to either hypotonic or hypertonic
dehydration.
Action Plan
The dietetics professional plays a critical role in identifying
patients and residents at risk for or with declining nutritional
status. In an older adult population, early intervention is the
most effective strategy to optimize health and well-being. Remember
that the physiological changes in aging occur in everyone who lives
long enough,31 regardless of nutrition, fitness, or genetic makeup.
Developing an action plan to optimize the health and well-being
of all your older patients or residents will pay huge dividends
in improved health, lowered care costs, and improved quality of
life for them.
It is important to set achievable goals for your
practice. Some goals might include the following:
• Identify individuals with early signs of
declining nutritional status.
• Collaborate with healthcare team members
to identify individuals at risk.
• Talk with family members about their concerns
and observations.
• Audit current caseload for changes in nutritional
status that have not been previously identified.
Make a to-do list. Some items on your list might
include the following:
• Identify individuals with changes in sensory
perception.
• Identify individuals with changes in chewing
or swallowing ability.
• Collaborate with swallowing specialists
to monitor intake of targeted individuals.
• Evaluate the effectiveness and accuracy
of current data collection methods used to assess dietary intake,
such as food and fluid records.
• Evaluate the success of consistency-modified
diets for individuals with dysphagia.
• Consider the use of pharmacological interventions
to treat unplanned weight loss.
• Evaluate the menus for total fluid provided
with meals.
The goal statements and items for the to-do list
are samples of ways to approach declining nutritional status. Use
these as a starting point to develop an action plan that meets the
needs of your population.
— Mary D. Litchford, PhD, RD, LDN, is a
speaker, author, and consultant to healthcare providers and the
food industry.
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Nutrition Dimension Inc.
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References for this article are available upon request
by e-mailing TDeditor@gvpub.com.
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