geriatrics

2. THE ELDERLY:
NUTRITIONAL NEEDS,
CHALLENGES CHALLENGES
SCREENING AND SOLUTIONS

3. OBJECTIVES
 Describe how the nutritional needs of the elderly
are different from other adult populations
 •Identify several nutritional challenges facing the
elderly and the related healthcare risks
 •Describe the importance of nutritional
screening
and intervention with individuals at risk
 •List at least two nutrition intervention solutions
for the elderly

4. NUTRITION: A KEY COMPONENT OF SUCCESSFUL
AGING AND QUALITY OF LIFE
 Quality of Life
 Family, Caregivers, Community
 Social Interactions, Spirituality, Religion
 Independence, Living Arrangements
 Physical, Mental, Emotional Functioning
 Health Status, Disease Management
 Nutritional Well‐Being

5. AGE-RELATED CHANGES AND NUTRITION
 Sacropenia, or the loss of lean muscle mass,
 can lead to a gain in body fat that may not be
 apparent by measuring body weight. It may
 be more noticeable by loss of
strength, functional
 decline, and poor endurance. This loss
 also leads to reduced total body water content.
Another common loss related
 to aging is changes in bone density, which can
 increase the risk for osteoporosis.

6. AGE-RELATED CHANGES AND NUTRITION
 Many changes occur throughout the digestive system. A decrease
in saliva production—xerostomia—and changes in dentition alter
the ability to chew and may lead to changes in food choices.
 There is a decrease in gastric acid secretion that can limit the
absorption of iron and vitamin B12.
 Peristalsis is slower and constipation may be an issue because
fluid intake is decreased.
 Appetite and thirst dysregulation also occur, leading to early
satiety and a blunted thirst mechanism.
 Sensory changes affect the appetite in several ways. Vision loss
makes shopping, preparing food, and even eating more difficult.
 Diminished taste and smell take away the appeal of many foods
and may lead to preparing or consuming food that is no longer
safe.

7. AGE-RELATED RENAL IMPAIRMENT
 In addition to gastrointestinal physiological
changes, renal function declines with age. This
decreases responsiveness to antidiuretic
hormone, which often results in an increased
risk for dehydration in older patients. This
impaired thirst drive makes it difficult to replete
fluid losses by oral intake alone. Renal
impairment may also affect vitamin D
metabolism and result in a reduction of vitamin
D levels, which contributes to osteoporosis in
the elderly.

8.  A comprehensive geriatric assessment also addresses
psychosocial, environmental factors, and affective symptoms of
weight loss in the elderly. The loss of a caregiver, the inability to
drive a motor vehicle, or moving into a new apartment or
residence may precipitate a decline in oral intake and cause
weight loss. Depressive symptoms such as these are important
considerations when evaluating the nutritional health of a senior
patient (Hazzard et al 1994; Kane et al 1994; Williams 1995;
Refai and Seidner 2001). It is especially important to ask older
patients about alcohol intake, which may replace or suppress the
consumption of foods with superior nutritional value. Alcohol
misuse in the elderly is associated with impaired functional
status, poor self-rated health, and depressive symptoms (St John
et al 2002).
 Even slight weight loss in the elderly is an independent predictor
of morbidity and mortality. The medical causes of weight loss may
be compounded by psychosocial and environmental factors.

9. PHYSIOLOGY OF AGING AND NUTRITIONAL STATUS
 basal metabolism or energy requirements for
the elderly diminish by about 100 kcal/day
per decade. For some seniors it may be
difficult to meet daily micronutrient
requirements with this reduced caloric intake.
To combat this, a multivitamin supplement for
seniors is recommended , especially for
those whose caloric intake is less than 1500
kcal/day .

10. PHYSIOLOGY OF AGING AND NUTRITIONAL STATUS
 Cardiovascular, pulmonary, and neurological diseases, as
well as osteoarthritis and osteoporosis, may alter energy
requirements in the elderly either by increasing energy
expenditure or reducing requirements through muscle loss
related to inactivity. Actual energy needs may vary widely
from calculated energy needs because of these factors. This
makes the elderly a heterogeneous group and more difficult
to assess nutritionally. An increase in metabolic
requirements has not been associated with pressure ulcers
(an unfortunately common condition in hospitalized elderly
patients), although frequently concomitant conditions such
as infection might encourage weight loss in older patients as
a result of increased energy expenditure, decreased
albumin, and protein undernutrition

11. NUTRITIONAL NEEDS OF HEALTHY ADULTS:
ESTIMATED ENERGY REQUIREMENTS DECLINE
WITH AGE
Male Female
30 years 2080 1762
80 years 1580 1412

12. NUTRITIONAL NEEDS OF HEALTHY ADULTS:
MACRONUTRIENT DISTRIBUTION TO MEET
ENERGY NEEDS
 A balance of protein, carbohydrate and fat is needed,
 even as calorie (energy) requirements decline with age
%of total average% 70 yrs
cal total 1482
calories
protein 10-35% 15% 224cals
(56g)
Carbohydrat 45-65% 52% 772cals
e (193g)
fat 20-35% 33% 486cals
(54g)

13. CURRENT PROTEIN RECOMMENDATION
MAY NOT BE ADEQUATE FOR ELDERLY
 Current RDA(Recommended Dietary Allowance)
for Protein
 – Established for healthy men and women ≥19 yrs
 – 0.8g protein/kg/day
 – 46g/day (female)
 – 56g/day (male)

14.  Increased Protein Suggested for Elderly
 To help maintain metabolic, physical and
functional status
 – 1.0 – 1.5g protein/kg/day
 – 58g – 86g/day (female)
 – 70g – 105g/day (male)

15. WATER INTAKE
 Total Water*(liters/day)
 Male(19-70+): 3.7
 Female(19-70+): 2.7
*Total water includes all water contained in
food, beverages, and drinking water

16. TOTAL FIBER (GRAMS/DAY)
 Total Fiber (grams/day)
 19-50 51-70 71+ real intake
 male 38g 30g 30g 17.0g
 female 25g 21g 21g 14.3g

17.  Increasing dietary fiber may be useful in the
treatment of constipation, glucose
intolerance, lipid disorders, and obesity, as
well as preventing diverticular disease and
colon cancers. Reduction in sodium has
been shown to reduce blood pressure and
also reduce the risk of developing
hypertension (Patterson 1994).

18. MICRONUTRIENT REQUIREMENTS FOR OLDER ADULTS
(>50 YEARS)
 Food and Nutrition Board Recommendations (RDAexcept where
otherwise
noted) Recommendation Micronutrient Men Women Vitamins
Biotin 30 mcg/day (AI)30 mcg/day (AI) Folic acid 400
mcg/day 400 mcg/day Niacin 16 mgNE*/day 14
mg NE/day Pantothenic acid 5 mg/day (AI)5 mg/day
(AI) Riboflavin 1.3 mg/day1.1 mg/day Thiamin 1.2 mg/day1.1
mg/day Vitamin A 900 mcg (3,000 IU)/day700 mcg (2,333
IU)/day Vitamin B6 1.7 mg/day1.5 mg/day Vitamin B12 2.4
mcg/day#2.4 mcg/day#100-400 mcg/day of crystalline vitamin
B12Vitamin C 90 mg/day75 mg/day≥ 400 mg/day Vitamin D (51-70
years) 15 mcg (600 IU)/day15 mcg (600 IU)/day2,000 IU/day from
supplements Vitamin D (> 70 years) 20 mcg (800 IU)/day20 mcg
(800 IU)/day2,000 IU/day from supplements Vitamin E 15 mg (22.5
IU)/day15 mg (22.5 IU)/day200 IU/day supplement of natural-
source (RRR- or d-) alpha-tocopherol Vitamin K 120 mcg/day
(AI)90 mcg/day (AI) Minerals

19.  Calcium (51-70 years) 1,000 mg/day1,200 mg/day Calcium (> 70
years) 1,200 mg/day1,200 mg/day Chromium 30 mcg/day (AI)20
mcg/day (AI) Copper 900 mcg/day900 mcg/day Fluoride 4 mg/day
(AI)3 mg/day (AI) Iodine 150 mcg/day150 mcg/day Iron 8 mg/day8
mg/dayNo supplement Magnesium 420 mg/day320 mg/dayNo
supplement providing > 350 mg/day Manganese 2.3 mg/day (AI)1.8
mg/day (AI) Molybdenum 45 mcg/day45 mcg/day Phosphorus 700
mg/day700 mg/day Potassium 4.7 g/day (AI)4.7 g/day
(AI) Selenium 55 mcg/day55 mcg/day Sodium (51-70 years) 1.3
g/day (AI)1.3 g/day (AI) Sodium (> 70 years) 1.2 g/day (AI)1.2 g/day
(AI) Zinc 11 mg/day8 mg/day *NE, niacin equivalent: 1 mg NE = 60
mg of tryptophan = 1 mg niacin
 #Vitamin B12 intake should be from supplements or fortified foods
due to the age-related increase in malabsorption
 RDA=Recommended Dietary Allowance; AI=Adequate Intake

20. VITAMIN D
 generally healthy adults take 2,000 IU (50 mcg) of supplemental
vitamin D daily. Most multivitamins contain 400 IU of vitamin
D, and single ingredient vitamin D supplements are available for
additional supplementation. Sun exposure, diet, skin color, and
obesity have variable, substantial impact on body vitamin D
levels. To adjust for individual differences and ensure adequate
body vitamin D status, aiming for a serum 25-hydroxyvitamin D
level of at least 80 nmol/L (32 ng/mL). Numerous observational
studies have found that serum 25-hydroxyvitamin D levels of 80
nmol/L (32 ng/mL) and above are associated with reduced risk of
bone fractures, several cancers, multiple sclerosis, and type 1
(insulin-dependent) diabetes. Daily supplementation with 2,000 IU
(50 mcg) of vitamin D is especially important for older adults
because aging is associated with a reduced capacity to
synthesize vitamin D in the skin upon sun exposure.

21. CAUSES OF VITAMIN D DEFICIENCY IN
THE ELDERLY
• habitually low dietary intake (120-200 I.U./d)
• impaired synthesis in senile skin (see below)
• little sun exposure in homebound and institutionalized elderly people
21

22. RECOMMENDATIONS:
(EXPERT PANEL OF THE NATIONAL OSTEOPOROSIS FOUNDATION, 2003)
 Women under 50 should consume 1200 mg of calcium
and 600 (800) IU of vitamin D
 Physical activity
 Active strategies to avoid falls
 Avoid falls and the consumption of more than two
alcoholic drinks per day
22

23. CALCIUM
 To minimize bone loss, older men (> 70 years)
and postmenopausal women should consume a
total (diet plus supplements) of 1,200 mg/day of
calcium. Men aged 51-70 years should
consume 1,000 mg of calcium per day. No
multivitamin/multimineral supplement contains
the RDA for calcium (1,000-1,200 mg/day)
because the resulting pill would be too large to
swallow. If your total daily calcium intake doesn't
add up to 1,000 mg, It is recommended to take
an extra calcium supplement (combined with
magnesium) with a meal.

24. MAGNESIUM
 Older adults are less likely than younger adults to
consume enough magnesium to meet their needs and
should therefore take care to eat magnesium-rich foods in
addition to taking a multivitamin-mineral supplement daily.
However, no multivitamin/mineral supplement contains
100% of the DV for magnesium. If you don’t eat plenty of
green leafy vegetables, whole grains, and nuts, you likely
are not getting enough magnesium from your diet. If you
add a magnesium supplement, It is recommended a
combined magnesium-calcium supplement containing
133-250 mg of magnesium and 333-500 mg of calcium
with a meal. Because older adults are more likely to have
impaired kidney function, they should avoid taking more
than 350 mg/day of supplemental magnesium without
medical consultation

25. Lack of vitamin B12
Causes
- Poor intestinal absorption
- Decreased binding with intrinsic factor eg:
- Gastric resection
- Atrophic gastritis
- Metabolic disorders
- Low consumption
Consequences
- Pernicious anemia
- Memory loss
- Reduced motor coordination
- Myopathia
25

26. Sources of Vitamin B12
26

27. SODIUM
 There is consistent evidence that diets relatively low in salt (5.8 grams/day or
less) and high in potassium (at least 4.7 grams/day) are associated with
decreased risk of high blood pressure and the associated risks of cardiovascular
and kidney diseases. Diets low in sodium and rich in potassium are likely to be of
particular benefit for older individuals, who are at increased risk of high blood
pressure. Moreover, the Dietary Approaches to Stop Hypertension (DASH) trial
demonstrated that a diet emphasizing fruits, vegetables, whole grains, nuts, and
low-fat dairy products substantially lowered blood pressure, an effect that was
enhanced by reducing salt intake to 5.8 grams/day or less. It is recommended
that a diet that is rich in fruits and vegetables (at least 5 servings/day) and limits
processed foods that are high in salt. Sensitivity to the blood pressure-raising
effects of salt increases with age; therefore, consuming diets that are low in salt
and high in potassium may especially benefit older adults.
 Diets rich in potassium (at least 4.7 grams/day) and low in salt (5.8 grams/day or
less) are likely to be of particular benefit for older adults, who are at increased
risk of high blood pressure along with its associated risks of cardiovascular and
kidney diseases. Since sensitivity to the blood pressure-raising effects of salt
increases with age, consuming diets that are low in salt and high in potassium
may especially benefit older adults.

28. OTHER NUTRIENTS
 Essential Fatty Acids
 L-carnitine
 Flavonoids

29. ESSENTIAL FATTY ACIDS
 Alpha-linolenic acid (ALA), an omega-3 fatty
acid, and linoleic acid (LA), an omega-6 fatty
acid, are considered essential fatty acids
because they cannot be synthesized by
humans. In 2002, the Food and Nutrition
Board of the U.S.Institute of
Medicine established adequate intake (AI)
levels for omega-6 and omega-3 fatty acids.
Essential fatty acid recommendations for
adults over the age of 50 are listed below.

30.  Adequate Intake (AI) for Essential Fatty
Acids Essential Fatty Acid
 ALA (> 50 years) Men 1.6 g/day Women
1.1 g/day
 LA (> 50 years) Men 14 g/day Women 11
g/day Abbreviations: ALA=alpha-linolenic
acid; LA=linoleic acid; g=grams

31.  American Heart Association
Recommendation
The American Heart Association
recommends that people without documented
CHD eat a variety of fish (preferably oily) at
least twice weekly, in addition to consuming
oils and foods rich in ALA. People with
documented CHD are advised to consume
approximately 1 g/day of EPA + DHA
preferably from oily fish, or to consider EPA +
DHA supplements in consultation with a
physician. Patients who need to lower serum
triglycerides may take 2-4 g/day of EPA +
DHA supplements under a physician's care.

32. L-CARNITINE
 Age-related declines in mitochondrial function and increases in
mitochondrialoxidant production are thought to be important
contributors to the adverse effects of aging. Tissue L-carnitine
levels have been found to decline with age in humans and
animals . One study found that feeding aged rats acetyl-L-carnitine
(ALCAR) reversed the age-related declines in tissue L-carnitine
levels and also reversed a number of age-related changes in liver
mitochondrial function; however, high doses of ALCAR increased
liver mitochondrial oxidant production . More recently, two studies
found that supplementing aged rats with either ALCAR or alpha-
lipoic acid, a mitochondrial cofactor and antioxidant, improved
mitochondrial energy metabolism, decreased oxidative stress, and
improved memory . Interestingly, co-supplementation of ALCAR
and alpha-lipoic acid resulted in even greater improvements than
either compound administered alone

33. L-CARNITINE
 Age-related declines in mitochondrial function and increases in
mitochondrialoxidant production are thought to be important
contributors to the adverse effects of aging. Tissue L-carnitine
levels have been found to decline with age in humans and
animals . One study found that feeding aged rats acetyl-L-
carnitine (ALCAR) reversed the age-related declines in tissue L-
carnitine levels and also reversed a number of age-related
changes in liver mitochondrial function; however, high doses of
ALCAR increased liver mitochondrial oxidant production . More
recently, two studies found that supplementing aged rats with
either ALCAR or alpha-lipoic acid, a
mitochondrial cofactor and antioxidant, improved mitochondrial
energy metabolism, decreased oxidative stress, and improved
memory . Interestingly, co-supplementation of ALCAR and alpha-
lipoic acid resulted in even greater improvements than either
compound administered alone.

34. FLAVONOIDS
 Because flavonoids have anti-
inflammatory, antioxidant and metal-chelating
properties, scientists are interested in the
neuroprotective potential of flavonoid-rich diets or
individual flavonoids. At present, the extent to which
various dietary flavonoids and
flavonoid metabolites cross the blood-brain barrier in
humans is not known. Although flavonoid-rich diets
and flavonoid administration have been found to
prevent cognitive impairment associated with aging
and inflammation in some animal studies, prospective
cohort studies have not found consistent inverse
associations between flavonoid intake and the risk
of dementia or neurodegenerative disease in humans

35. DIETARY RECOMMENDATIONS
 Following careful nutritional assessment, guidelines have
been developed to improve and maintain nutritional status
in community-dwelling and hospitalized elderly patients.
For example, the Canada Food Guide recommends the
following daily nutritional intake for adults:
 5â€―12 servings of grains
 5â€―10 servings of fruits and vegetables
 2â€―4 servings of milk products
 2â€―3 servings of meat or meat alternatives
 Foods high in fibre and complex carbohydrates such as
whole grains, vegetables, and fruits are preferred. Fat
intake should be less than 30% of total caloric intake

36. A food pyramid for the elderly
Sweets and fats in moderation Calcium, vitamin D, vitamin B12,
Wholemeal
Milk, yogurt, cheese Fish meat legumes
3 portions 2 portions
Vegetables Fruit 2 portions
3 portions
Wholemeal Cereals and tubers
is better 6 portions
36
Water and liquids 8 glasses

37. EFFECTS OF AGING ON NUTRITION
 Changes Effects
 Sensory Impairment
 –Decreased sense of taste ÎReduced Appetite
 –Decreased sense of smell ÎReduced Appetite
 –Loss of vision and hearing ÎDecreased ability to purchase and
prepare food
 –Oral health / dental problems ÎDifficulty
chewing, inflammation, poor quality diet
 Altered energy need ÎDiet lacking in essential nutrients
 Decreased physical activity ÎProgressive depletion of LBW and
loss of appetite
 Muscle loss (sarcopenia) ÎDecreased functional ability, assistance
needed with ADLs.

38. ASSESSING NUTRITIONAL STATUS
 A comprehensive assessment of nutritional status
includes anthropometric measurements,
 laboratory values, physical exam, and patient history.
Anthropometric measures include
 height, weight, body mass index, body fat
measurement, muscle mass measurement, and
 body mass index. Laboratory values should include
albumin, retinal-binding
prealbumin, transferring, complete blood count, serum
folate, vitamin B12, and cholesterol. A diet history is
helpful if there is good 24-hour recall
 or a food record for 3 days leading up to the exam can be
completed.
 the Mini Nutritional Assessment is a basic screening tool.

39. PREVALENCE OF MALNUTRITION IN THE
ELDERLY
Malnurished At risk Normally
nourished
Nursing home 14% 53% 33%
Hospitalized 39% 47% 14%
Rehablitation 50% 41% 9%
Community 6% 32% 62%

40. PREVALENCE OF MANUTRITION IN THE ELDERLY
 1 of 4 of older adults are malnourished.
 2 of 4 of older adults are risk of malnutrition.

41. POSSIBLE CAUSES OF UNINTENTIONAL WEIGHT LOSS:
 M Medications
 E Emotional Problems
 A Anorexia Nervosa
 L Late‐life Paranoia
 S Swallowing Problems
 Oral Factors (cavities poorly fitting dentures)
 N No Money
 W Wandering and Other Dementia Related
 Behaviors
 H Hyperthyroidism, Hypothyroidism
 E Enteric Problems (malabsorption)
 E Eating Problems (inability to feed self)
 L Low Salt, Low Cholesterol Diets
 S Shopping, Social Problems

42. WEIGHT LOSS
 Weight loss in the elderly is a worrisome clinical sign.
Weight loss in the elderly due to voluntary or involuntary
causes has been associated with mortality (Himes
1999; Newman et al 2001; Baldwin et al 2002). Although
lean body mass may decline because of normal
physiological changes associated with age (Lissner et al
1991), a loss of more than 4% per year is an independent
predictor of mortality (Wallace et al 1995). Rapid weight
loss of 5% or more in one month is considered significant
and needs to be immediately evaluated by a physician
(Jensen et al 2001; Dryden et al 2002). It has been shown
that even moderate declines of 5% or more over three
years is predictive of mortality in older adults (Newman et
al 2001). However, early identification, assessment, and
treatment of weight loss and nutritional deficiencies may
prevent the morbid sequel of malnutrition.

43. WEIGHT LOSS
 Functional, psychological, social, and economic issues
associated with concomitant medical problems may all
contribute to poor nutrition and weight loss in the frail
elderly patient (Bartali et al 2003). A multidisciplinary
geriatric assessment can be helpful to fully address all the
complex interacting issues of the frail senior, such as Mrs
E, who experiences rapid weight loss as a result of
malnutrition. This type of comprehensive assessment
may include the services of
physicians, nurses, dieticians, occupational and physical
therapists, speech and language pathologists, and social
workers, each of which can lend their respective expertise
to the effective diagnosis of the
functional, psychological, and socioeconomic contributors
to malnutrition in older patients.

44. AGEING AND OBESITY
1. Cardiac disease
2. Tumours
3. Cerebrovascular diseases
4. Chronic pulmonary disease
5. Diabetes mellitus

45. NUTRITIONAL ISSUES ASSOCIATED WITH COGNITIVE
IMPAIRMENT AND VASCULAR RISK FACTORS
 Malnutrition has been associated with compromised
cognitive capacity in the elderly. The decreased
ability to prepare a meal, which may adversely affect
an elderly patient's ability to ensure sufficient
nourishment, has been cited as one of the earliest
signs of mild cognitive impairment (MCI), a pre-
Alzheimer disease condition (Borrie et al 2003). For
persons with moderate to severe Alzheimer
disease, forgetting to eat, inability to access food, and
apraxia with utensils may further impair oral intake.
Living alone, as Mrs E does, further compounds the
risk of malnutrition.

46. NUTRITIONAL ISSUES ASSOCIATED WITH COGNITIVE
IMPAIRMENT AND VASCULAR RISK FACTORS
 Vitamin deficiencies, particularly vitamin B12, B6, and
folate, are associated with cognitive impairment (Nilsson
et al 2001; Gill and Alibhai 2003; Lehmann et al 2003).
Deficiencies in these vitamins are also associated with
hyperhomocysteinemia, which is an independent vascular
risk factor. The association of hyperhomocysteinemia
with vascular disease is a direct dose-response
association (Stamphler et al 1992;Selhub et al 1995).
Treatment with folate, vitamin B6, and vitamin B12 has
been shown to reduce homocysteine levels (Omran and
Morley 2000; Nillson et al 2001; Lehmann et al 2003; Scott
et al 2004), improve vascular function in
hyperhomocysteinemic patients with coronary artery
disease (Willems et al 2002), and result in cholesterol
plaque regression (Marcucci et al 2003

47.  Although a recent secondary prevention randomized
controlled trial failed to demonstrate a decrease in morbid
vascular outcomes in stroke patients following
supplementation with vitamins B6, B12, and folate over two
years, it was suggested that confounding factors (such as
the initiation of folate fortification in grain supply concurrent
with the study) might explain the null findings (Toole et al
2004). More research is needed to clarify the complex
interactions between these vitamins and the modification of
vascular risk factors.

48.  Nutritional interventions have an impact on vascular
disease prevention. It is well established that a diet
low in fat and cholesterol is beneficial to modifying
vascular risk factors. Emerging research suggests
that supplementation with omega-3 fatty acids (such
as those found in salmon and other cold-water
fish), and consuming cruciferous vegetables (such
as broccoli, cabbage, and cauliflower) are all
associated with stroke prevention (Joshipura et al
1999; Mozaffarian et al 2005; Robinson and
Maheshwari 2005) and may be beneficial if
integrated into the diet of all elderly patients with
vascular disease or vascular risk factors.

49.  Nutritional antioxidant supplements are generally believed
to be beneficial in reducing free radical cellular and DNA
damage. A large epidemiological study found the
concomitant use of vitamins C and E is associated with
reduced incidences of Alzheimer disease (Zandi et al
2004). More generally, according to a randomized
controlled trial, low blood vitamin C concentrations are
strongly predictive of mortality in patients aged 75â€―84
years (Fletcher et al 2003). The efficacy of vitamin E in the
prevention and treatment of MCI and Alzheimer disease
remains controversial. Used alone in a three-year placebo-
controlled study, a daily dosage of vitamin E (2000 IU) was
not shown to slow the rate of progression to Alzheimer
disease in patients with MCI (Petersen et al 2005). A high-
dose vitamin E supplementation (>400 IU/day) has been
associated with increased mortality (Miller et al 2005).

50.  Other important antioxidants with possibly
beneficial outcomes include foods with high
levels of phytochemicals and flavonoids.
Tomatoes, citrus fruit, blueberries, and certain
spices (Fusheng et al 2005) have all been
linked to reducing oxidative stress and
cognitive impairment. Flavonoids and
antioxidants in red wine have also been
shown to be beneficial in protecting against
dementia (Zuccalà et al 2001; Truelson et al
2002). The increasing amount of research in
this field holds promise for preventive
nutritional strategies based on the benefits of
naturally-occurring antioxidants.

51. ANTIOXIDANT FOOD WHEEL
OLIVE OIL
NUTS AND
DRIED
A good diet should contain FRUIT
PULSEs
antioxidants: vitamin C, vitamin
E, polyphenols. FRUIT
Vitamin C and E make your
immune system more efficient COCOA
(de la Fuente et al. 1998).
―We age because we oxidise
(rust)‖ and anti-oxidants can
mitigate the signs of ageing BREAD CEREALS
AND POTATOES
(Miquel et al. 2002). VEGETABLES
S.E.N.E. C.A.
51 2007

52. POTENTIAL CONSEQUENCES OF MALNUTRITION
 Impaired immune response
 Reduced muscle strength and fatigue
 Inactivity
 Impaired temperature regulation
 Impaired wound healing
 Impaired ability to regulate fluid and
electrolytes
 Impaired psycho‐social function

53. DIET AS ENERGY
 The diet should be the source of energy for all daily
activities.
 Breakfast or lunch should be the highest-energy
meals of the day, in order to complete the most
important activities.
 Dinner should be the least energetic meal of the
day, because few activities are done after dinner.
 Meals (breakfast in particular) should not be skipped.
 The diet should provide calories according to the
needs of each individual.
53

54. How many calories
after the age of 50?
WOMEN
LITTLE PHYSICAL ACTIVITY: 1.600 CALORIES
MODERATE PHYSICAL ACTIVITY: 1,800 CALORIES
ACTIVE LIFESTYLE: 2,000-2,200 CALORIES
MEN
LITTLE PHYSICAL ACTIVITY : 2.000 CALORIES
MODERATE PHYSICAL ACTIVITY : 2.200-2.400 CALORIES
ACTIVE LIFESTYLE : 2,400-2,800 CALORIES
54

55. FOODS RECOMMENDED AS A SOURCE OF
EACH NUTRIENT
PROTEIN: meat, fish, eggs, milk products, pulses
(chickpeas, lentils).
CARBOHYDRATES: bread, rice, pasta, potatoes, pulses.
FATS: olive oil, oily fish, nuts, dried fruit.
VITAMINS: fruit and vegetables, olive oil.
MINERALS: milk products, nuts and dried fruits, fish,
cereals.
55 FIBRE: fruit, vegetables, wholemeal products.

56. Cereals and tubers
CEREALS: RICE, BREAD, PASTA, CORN, WHEAT, BARLEY, SPELT
AND TUBERS (EG. POTATOES) ARE THE PRINCIPAL SOURCE OF
ENERGY.
IT IS ADVISEABLE TO USE, AT LEAST SOMETIMES, WHOLEMEAL
PRODUCTS. THESE CONTAIN PROTEIN AS WELL, AND ARE
RICHER IN MINERALS AND VITAMINS.
AMOUNT PER DAY: 6 PORTIONS
ONE PORTION, FOR EXAMPLE: HALF A PLATE OF PASTA OR
RICE, A SANDWICH, A BOWL OF CEREAL
56

57. Fruit and vegetables
FRUIT AND VEGETABLES CONTAIN VITAMINS, FIBRE AND WATER
AND MINERAL SALTS.
ALIMENTARY FIBRE HELPS YOU TO FEEL MORE FULL AND
REDUCE THE RISK OF TUMOURS, DIABETES, AND HEART
DISEASE.
CHOOSE FRESH SEASONAL OR FROZEN VEGETABLES.
IT IS BEST TO STEAM THEM OR COOK THEM IN A PRESSURE
COOKER WITH VERY LITTLE WATER.
DAILY AMOUNT:
3 PORTIONS OF VEGETABLES
2 PORTIONS OF FRUIT
57

58. Meat, fish and eggs
THESE ARE FOODS RICH IN PROTEIN WITH A HIGH
BIOLOGICAL VALUE, WITH MINERALS AND B VITAMINS.
LEAN MEAT AND FISH ARE PREFERABLE.
IT IS BEST TO GRILL THEM, STEAM THEM, OR COOK THEM
WITH VERY LITTLE FAT
DAILY AMOUNT:
2 PORTIONS
58

59. Milk, yogurt and cheese
MILK AND MILK PRODUCTS (CHEESE, YOGURT) PROVIDE
CALCIUM, PROTEIN AND SOME VITAMINS.
IT IS ADVISABLE TO USE, AT LEAST PARLY SKIMMED, LOW-FAT
PRODUCTS.
DAILY AMOUNTS:
3 PORTIONS
ONE PORTION, FOR EXAMPLE: 50G OF CHEESE, A GLASS OF
MILK OR 1 YOGHURT (100 GR)
59

60. Limit animal fats
 CHOOSE LEAN MEATS, FISH OR POULTRY (WITHOUT THE SKIN)
 REMOVE THE FATTY PARTS BEFORE COOKING
 USE LOW-FAT PRODUCTS
 USE LITTLE FAT FOR COOKING
 CHOOSE VEGETABLE FATS (EXTRA VIRGIN OLIVE OIL)
 AVOID FRIED FOOD
60

61. HYDRATION
 Water does not give energy, but is
fundamental for hydration.
 Sugar-free fruit juice, milk and soups can
also help with hydration.
 The daily dose of liquids should be 1 and a
half or two litres.
 Fruit and vegetables are a good source of
61
water.

62. VARIETY AND BALANCE: THE KEY TO A GOOD
DIET
At every meal:
protein, carbohydrates, fats, vitam
ins, liquids and fibre in adequate
proportions.
62

63. KEY POINTS
• Avoid chilled, pre-cooked or re-heated meals
• Break our food down into three meals and two snacks.
• Have a good breakfast with milk or yogurt.
• Choose food according to the action necessary to eat it
(cut, grind, squash, etc).
• Keep to a good body weight and a good level of physical
activity.
• Drink water frequently during the day.
• Chew each mouthful well before swallowing.
63

64. Key Points (2)
 Tasty and varied food with aromatic herbs and spices
 Avoid the consumption of animal fats
 Eat more fish (especially oily fish)
 Eat more food rich in complex carbohydrates, fibre, vitamins
and minerals (fruit, vegetables, pulses and wholemeal
products)
 Sugar: is obtained from fruit and milk
 Wine: in moderation (1-2 glasse per day); avoid spirits
 Salt: limit what you add at the table
64

65. PRACTICAL ACTIVITIES
Divide participants into 3 groups:
Each participant fills in his or her food diary
They swap diaries with others in the group and analyse the
diaries, classifying 3 of their choices as healthy, and 3 as
unhealthy.
Among all the group members the most interesting case is
selected to be discussed in the plenary.
65

66. MY DAILY FOOD HABITS
TIME 6 8 10 1 1 1 2 2 2
2 6 8 0 2 4
66

67. SELECTION
Write in the two columns:
UNHEALTHY FOOD
HEALTHY FOOD HABITS
HABITS
Write at least four items
67

68. CASE 1
 Mrs E is a 79-year-old female with
Alzheimer-type dementia living alone in her
own home with assistance only for heavy
housework. She has maintained her weight
for one year while taking a cholinesterase
inhibitor. She sees her family doctor every 6
months. Her most recent check-up revealed
a weight reduction of 3 kg from her previous
visit. Patient height 160 cm; weight 48 kg
[BMI=19 kg/m2].

69.  Mrs E has lost 6% of her body weight in six months. This is a cause for
concern. Her physician needs to consider causes for weight loss such as new
hyperthyroidism, diabetes, malignancy, depression, or oral problems. These can
be ruled out by history, physical examination, and laboratory tests. Collateral
history from family or caregivers is very important in assessing a person with
dementia. Patients with dementia often have an atypical presentation of many
illnesses in the elderly, especially in cases of depression.
 A medication review is also an important part of the physician's assessment of
this patient. For example, cholinesterase inhibitors as a class can cause
nausea, vomiting, anorexia, or diarrhea and can be associated with weight loss.
In Mrs E's case, she was able to maintain her weight for a year on this
medication. For this reason, other causes of weight loss associated with
dementia should also be considered. For example, the loss of caregiver
support, social isolation, limited access to food, an inability to cook and prepare
food because of cognitive problems, or inability to recognize hunger may
contribute to her current malnutritive state. Collateral history from a caregiver
and a home visit can provide invaluable insight into these issues. Home care
nurses or occupational therapists can assist in this assessment.
 A nutritional treatment plan for Mrs E may include the treatment of any newly
diagnosed medical issues and the prescription of nutritional supplements. In
this case, considering a referral to social and community programs (such as
adult day care, home care services, or a delivered meal program) would be
appropriate at Mrs E's discharge.

70. CASE 2
 Mrs A is an 82-year-old female living alone, independent
in her activities of daily living, and instrumental activities
of daily living2. She has a history of non-insulin-
dependent diabetes mellitus requiring
insulin, hypothyroidism, osteoarthritis, hypertension
(HTN), ischemic heart disease (IHD), obesity, and
gastroesophageal reflux disorder (GERD). Mrs E
recently suffered a hip fracture following a fall for which
she underwent a hip-replacement surgery. Her
postoperative course is complicated by a urinary tract
infection (UTI) and two episodes of clostridium
difficile (C. difficile) colitis. She was transferred to a
geriatric rehabilitation unit. Patient height 160 cm; weight
94 kg [BMI = 37 kg/m2].

71.  Mrs A's situation is complex and highlights some of the issues of nutritional assessments in the hospital
setting. A physician is needed to immediately address Mrs A's other underlying medical problems such as
obesity, IHD, GERD, and HTN, prior to her general nutritional assessment by a dietician. Diabetes can be
a major issue during her hospital stay. Another possible nutritional issue associated with diabetes is
substantial proteinuria brought on by diabetic renal disease. Sequelae of diabetes include autonomic
dysfunction, which can result in delayed gastric emptying and poor oral intake. This condition can be
exacerbated by the use of narcotics to control postoperative pain, and is further compounded by GERD.
Infection and obesity often increase insulin resistance, so blood sugar control should be optimized not
only for the long-term morbidity prevention, but also for wound healing.
 Prior medical complications and the medications prescribed following her hip surgery are another cause
for concern. Mrs A may have had poor oral intake because of her diarrheal illness, or from the side effects
of antibiotics used to treat C. difficile arising from her UTI. Many elderly hip fracture patients have muscle
deconditioning as a result of being hospitalized and consequently require increased protein
supplementation. Serum prealbumin or albumin is usually used to assess nutritional status and monitor
improvement through a hospital stay. Although Mrs A is obese with a BMI of 37 kg/m2, she likely has a low
albumin level and significant protein undernutrition based on her recent medical history. One complication
in the treatment of obese patients is the provision of adequate calories and protein for wound prevention
and treatment, muscle reconditioning, and therapy-related exercise while concurrently promoting a loss of
total body fat. Generally speaking, achieving an optimal balance of food intake, nutritional status, and
healthy body weight is a particular challenge for health practitioners (Sullivan et al 2004), particularly
when treating patients with extremely high or low BMI measurements.
 Finally, Mrs A's HTN and obesity suggest additional risk factors for ischemic heart disease. Her
cholesterol profile prior to her hospitalization would provide additional information in planning long-term
nutritional goals at discharge. Sodium, fat, and cholesterol restrictions may be appropriate. Other
nutritional goals during Mrs A's hospital stay should include ensuring that she has adequate education to
both understand and follow her dietary advice. Referral to a community dietician or diabetic educator is
recommended in Mrs A's discharge planning.

72. CASE 3
 Mr T is an 83-year-old male who has been
living in a nursing home for the past 12
months since suffering a right middle
cerebral artery stroke. During this time he
has had trouble feeding himself and has lost
10 kg. He has a coccyx ulcer. Patient height
180 cm; weight 55 kg [BMI= 17 kg/m2].

73.  Mr T has severe malnutrition with a BMI of 17 kg/m2 and a corresponding high risk
of morbidity and mortality. Given his acute nutritive needs following his medical
history of stroke (Dennis et al 2005), Mr T's nutritional assessment and treatment
plan should include a physician, dietician, speech and language pathologist, and an
occupational therapist.
 The benefits of stroke rehabilitation are well documented (Gresham et al 1997).
One of the first treatments often recommended immediately following a stroke is a
swallowing assessment and, if necessary, training to facilitate improved swallowing.
For patients who require tube feeding, it has been determined that patients with
significant dysphagia who undergo gastronomy tube feeding have less risk of
aspiration, earlier discharge from hospital, and higher albumen levels with
gastrostomy tube feeding than those who undergo nasogastric tube feeding (Milne
et al 2005). Early tube feeding following stroke has been associated with decreased
mortality in older patients (Dennis et al 2005).
 It is likely that Mr T had the appropriate assessment in hospital following his stroke.
Nevertheless, a bedside swallowing assessment performed by a speech and
language pathologist is very helpful in determining the type of food consistency that
is appropriate in a person with dysphagia. Sometimes it is necessary to refer the
patient for a modified barium swallow to further assess their risk for aspiration.
Furthermore, positioning and seating are important requirements for successful
meals. Occupational therapists can assist with this as well as the provision of
special utensils, plates, or placemats in order to better facilitate self-feeding.

74.  A number of other possibilities may contribute to Mr T's current condition. For
example, Mr T may have extended his stroke resulting in worse dysphagia and
subsequently decreased oral intake. Untreated dysphagia may result in protein
undernutrition, which can result in compromised immunity and an increased risk
of infection (Hudson et al 2000). He may have developed post-stroke
depression, which often manifests a decrease in appetite. It is possible that not
all of the dietary recommendations of the stroke team were followed after
discharge. Sometimes this is because of patient choice; for example, a common
recommendation involves restricting patients' diet to pureed foods. Some
patients assess the relative risks (which include aspiration) and prefer a diet with
varied textures as a quality of life consideration. Nutritional deficiencies have
been suggested, but not clinically confirmed, to adversely affect vascular
outcomes in stroke (Toole et al 2004).
 Mr T needs a comprehensive physical and cognitive examination, and laboratory
tests to exclude new medical problems as contributing causes for his weight
loss. Since protein undernutrition and low vitamin C levels are associated with
poor wound healing and pressure sores, a dietician should participate in Mr T's
treatment plan and consider supplementation in vitamin C, zinc, and other trace
minerals, in addition to increased caloric and protein intake. His albumin level
should be regularly measured to provide objective monitoring of the treatment
plan.


75. KEY POINTS
 Age-related changes in physiology and
immunity may result in a greater need for
vitamin and mineral supplementation in the
elderly.
 Dietary modifications, such as including
foods high in antioxidants and lowering
intake of fat and cholesterol, may improve
cognition and modify vascular risk factors in
elderly patients.

76. KEY POINTS
 Hospitalized elderly patients are at particular
risk for malnutrition and need to be carefully
assessed and aggressively treated.
 There are several effective and easy-to-use
screening tools which assess for malnutrition in
elderly patients. The most extensively validated
tool is the Mini Nutritional Assessment
(MNA), which provides an accurate assessment
of elderly patients from a variety of domiciliary
settings.

77. KEY POINTS
 Dietary assessment and counseling
comprise an important and effective aspect
of preventing and treating a variety of morbid
conditions in elderly patients.

78. TAKE HOME MESSAGE
 Multivitamin supplements are highly recommended for older
patients, especially in seniors whose daily caloric intake is less than
1500 kcal/day.
 Advise patients about nutrient-dense food choices when appropriate.
 Investigate body weight losses of 4% or more.
 Nutritional supplements are recommended for at-risk elderly hip fracture
patients. Also consider supplements for frail seniors with other fractures.
 Calcium and vitamin D supplementation have been shown to reduce hip
fracture rates and are recommended for patients over 65 years of age.
 Advise patients on the merits of whole grains, fruits, and vegetables.
 In hospitalized patients, maintain a high index of suspicion for pre-
existing nutritional deficiencies. Utilize the services of a registered
dietician.
 Consider referrals to other health professionals for nutritional advice
such as dieticians, speech and language pathologists, homecare or
visiting nurse services, or other specialized geriatric services available in
the community.