Objectives 1. Describe the presence of malnutrition in the elderly today2. Identify the factors that contribute to malnutrition in the elderly3. Identify when oral nutrition supplements are indicated and should be prescribed4. Identify common oral nutrition supplements available5. Identify methods for improving patient acceptance of oral supplements6. Identify disadvantages associated with the use of oral supplements6. Identify when enteral nutrition support is indicated and should be prescribed7. Identify common enteral nutrition supplements available 8. Identify disadvantages/risks associated with the use of enteral nutrition supplements
Prevalence of Malnutrition in the Elderly (1) • Aging is accompanied by physiologic changes that can negatively impact nutritional status. • Chronic disease can negatively impact nutritional status. • In the United States, the prevalence of malnutrition in the elderly is less than 1% in individuals who are independent and healthy. • The prevalence of malnutrition in the elderly is 23% to 85% in nursing home residents. • The prevalence of malnutrition in the elderly is 33% to 55% in those hospitalized. • An estimated 85% of Americans age 65 and older have one or more chronic disease that may benefit from nutritional intervention for reduction of morbidity and mortality.
Types of Malnutrition • Malnutrition: Any disorder of nutritional status, including disorders resulting from a deficiency of nutrient intake, impaired nutrient metabolism, or over-nutrition. • Protein-energy under-nutrition: The presence of clinical (i.e., physical signs such as wasting, low body mass index [BMI]) and biochemical (i.e., albumin or other serum protein) evidence of insufficient intake.
Dietary intake • Energy needs decrease with age; yet the need for most nutrients remains relatively unchanged resulting in an increased risk of malnutrition. • Little or no appetite • Problems with eating or swallowing • Eating inadequate servings of nutrients • Eating fewer than two meals a day
Limited income • Restriction in the number of meals eaten per day • Reduced dietary quality of meals
Isolation • Older adults who live alone may lose desire to cook because of loneliness • Appetite of widows decreases • Difficulty cooking due to disabilities • Lack of access to transportation to buy food
Chronic illness and acute conditions • Acute and Chronic conditions can affect intake and/or increase nutritional demands. • Drug–nutrient interactions • Disability • Depression • Poor oral health • Dysphagia
Physiological changes • Decrease in lean body mass and redistribution of fat around internal organs lead to decreased caloric requirements. • Change in taste from medications, nutrient deficiencies, or tastebud atrophy can also alter nutritional status. • Bioavailability of micronutrients
Progressive Undernutrition(2) • The cumulative effect of the interaction between nutrition and changes seen in aging is progressiveundernutrition which often goes undiagnosed. • Early detection of malnutrition is important since it has been associated with diminished cognitive function and a diminished ability to care for one's self.
Identifying Malnutrition in the Elderly • BMI alone does not identify undernutrition in obese people and may falsely identify thin people as malnourished. • Plasma albumin, as a nutritional parameter, is difficult to use in people with inflammation or dehydration; two very frequent conditions in the frail elderly.
Nutrition Screening (3) • U.S. hospitals required by Joint Commission to provide nutrition screening to all patients within 24 hours of admission. • This does not cover patients in other settings. • There is not a standardized assessment tool for finding malnutrition in older adults. • There are assessment tools available specifically for the geriatric patient.
Elderly specific screening tools should address the following: • Does patient • Suffer from chronic disease? • Take multiple medications? • Had decline in food intake over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties? • Experienced weight loss during the last 3 months? • Decline/change in mobility ? • Experienced psychological stress or acute disease in the past 3 months? • Have Neuropsychological problems? • Financial concerns? • Body Mass Index (BMI) less than 19 ? Over 25?
Nursing strategies (2) • Collaboration • Alleviate dry mouth • Improve oral intake • Provide conducive environment for meals • Specialized Nutrition Support when indicated
Start Specialized Nutritional Support • When a patient cannot, should not, or will not eat adequately. • If the benefits of nutrition outweigh the associated risks. • If the patient's advanced directives regarding the use of artificial nutrition and hydration allows.
Nutrition Support • Beyond that provided by normal food intake Includes • Modified food and menus • Food fortification • Oral nutrition supplements (ONS) • Vitamin/Mineral supplementation • Enteral nutrition/tube feeding (EN) • Parenteral nutrition
Liberalized Diets • There is a growing recognition that nutrient intake of hospitalized patients and long-term care residents is negatively impacted by overly restrictive diets. • In order to improve patient satisfaction and allow for optimal nutrient intake, the most liberalized diet order possible is encouraged.
Food Fortification • Dietary Manipulation • Food fortification using protein and energy rich food ingredients or commercially available protein or energy powders and liquids added to the diet. • Additional Foods • Snacks, cakes, puddings, icecream
Dietary Fortification • Adding Calories • Oil • Cream • Sour cream • Butter • Milk • Cheese • Sugar • Skimmed milk powder • Commercial Carbohydrate/protein powder or liquids • Flavor enhancers • Monosodium glutamate • Salt Strengths • Availability • Familiarity • Palatability • Extra calories • Cheap Weaknesses • Increase in food volume or quantity may be unsuitable for anorexia. • May be difficult for those with chewing or swallowing difficulties. • Other nutrients. • Ease of use/preparation • high blood pressure or some allergies.
Common Oral Supplements • Ensure, Ensure Plus • Healthshake • Resource Plus • Isosource, Fibresource • Boost • Jevity • Respiratory Product • Pulmocare • Diabetic Products • Glucerna • Glucerna 1.2 cal • Resource Diabetic • Boost Glucose Control • Renal Products • Nepro; dialysis • NovaSource Renal • Suplena; pre-dialysis • Protein Only • Unjury-protein only • Beneprotein • Suitable for patients with poor po intake or increased calorie needs • Standard 1-1.2 kcal/ml with or without fiber • 8-16 grams protein • Flavored • With or without specific micronutrients • Can be added to regular foods • Many can also be used as tube feeding formula • Many available at local pharmacies and grocery stores • General Use • Lactose Free • Gluten Free • Most sodium friendly
Common Clear Liquid Supplements Use for clear liquid diets, pre- and post-surgical, bowel prep, fat-malabsorptive, and fat-restricted diets. Use for providing extra calories and/or protein as an alternative to creamy shake-like supplements. Available in 1-6 oz servings 100-200 calories 8-24 grams protein Flavored or Unflavored With or without specific micronutrients Can be added to regular foods Some can be added to tube feedings to boost protein needs Fat Free Lactose Free Gluten Free Most sodium friendly • Increasing Protein • Healthy Shot, Double Shot • Enlive • Juven • Promod • Increasing Calories • Polycose Powder -100 cal/oz • BeneCalorie
Supplemental Foods May be disease specific Can be used to help increase calories/protein Can be used to provide variety to restricted diets Can be used to enhance nutrient intake with limited added calories • Ensure • Boost • Pudding • Diabetic Products • Glucerna • Snack Bar • Shake • Pudding • Cereal
Specialized nutritional support –Oral Nutrition Supplements (ONS) (5) • At nutritional risk or who are undernourished • Following orthopedic-surgical procedures • In demented patients • At risk for or with Pressure Ulcers • Frail Elderly
Problems associated with the use of ONS (7) • Reduction in the intake of normal food • Low palatability • Adverse effects • Wastage
Palatability of Oral Nutritional Supplements • Poor patient acceptance is a common barrier to intake of oral nutrition supplements. • Taste is a key limiting factor for older people.
Methods of ONS Delivery Shown to Improve Intake • Timing around meals and bedtime • MedPass • Targeted Feeding Assistance • Dietitian Involvement • Group Meals and Snack Service; Nursing Homes, Rehab
Problems associated with the use of ONS cont- • Oral nutritional therapy via assisted feeding and dietary supplements is often difficult, time-consuming and demanding in elderly patients due to multimorbidity and slow responses. • However assisted oral feeding and supplements are able to support the physical and psychological rehabilitation of most elderly patients.
Considerations for ongoing use of a supplement may include: • Is the patient using the supplement? • Is there any wastage? • Is the original clinical indication still valid? • Is the patient gaining weight? • Has a dietician been consulted to assist with the nutritional planning for this patient? • Could the patient be encouraged to adopt a diet that meets their energy needs, through the use of supermarket products or prepared meals? • Is there a plan in place to gradually replace use of the supplement with a regular diet?
Managing Dysphagia • Factors to consider before initiating modified oral nutrition support and hydration and/or enteral nutrition • Recurrent chest infections • Mobility • Dependency on others for assistance to eat • Perceived palatability and appearance of food or drink • Level of alertness • Compromised physiology • Poor oral hygiene • Compromised medical status • Metabolic and nutritional requirements • Vulnerability or immunocompromised • Comorbidities
National Dysphagia Diet (NDD) • In 2002, the American Dietetic Association established the National Dysphagia Diet guidelines for thickened dietary supplements. • This Task Force proposed viscosity ranges for thin, nectar, and honey-thick liquids.
The National Dysphaia Diet, cont (9) • Prescribes four levels of food modification • Level 1 • Patients with significant impairment in control • Levels 2 and 3 • Patients with some ability to chew • Level 4 • Patients able to eat an unrestricted regular diet
National Dysphagia Level 1: Pureed (9) • For people who have moderate to severe dysphagia, with poor oral phase abilities and reduced ability to protect their airway. • Close or complete supervision and alternate feeding methods may be required. • Pureed, homogenous, and cohesive foods • Food should be “pudding-like”. • No coarse textures, raw fruits or vegetables, nuts, and so forth are allowed. • Any food that require bolus formation, controlled manipulation, or mastication are excluded. • Includes all unthickened beverages and supplements • Liquid Consistency • Thin • Nectar-like • Honey-like • Spoon-thick/ pudding
Ready-to-serve vs point of care thickeners • Modified fluids and foods are available for purchase in a ready-to-serve form. • Commercially available thickening agents that specify viscosity ranges include • RESOURCE®ThickenUp® • Hormel Thick & Easy® Instant Thickeners • Thik & Clear®
Consistency of Food and Beverage • Usage Chart for bottle for RESOURCE®ThickenUp® : One stroke will deliver approximately 15g of thickening gel. • Desired Consistency • Per 4oz Per 8 oz. • Nectar • 1 stroke 2 strokes • Honey • 2 strokes 4 strokes • Pudding • 4 strokes 8 strokes
Dysphagia Diet Foods (10) • Are thickened as recommended by the National Dysphagia Diet (NDD) guidelines. • Can be cost effective for the institution. • The viscosities of commercial dysphagia diet foods have been shown to be inconsistent with NDD guidelines.
Pureed Meals • Provides about 550-600 calories per meal and 19-23 gm protein per meal. • Typical Pureed Meal Service Hospital Setting: • Breakfast: • Pureed eggs, strained oatmeal, thickened milk and thickened juice. • Noon/Eve: • Pureed Beef, Pureed Carrots, Mashed Potatoes Brown Gravy 2 oz. thickened milk and thickened juice.
Problems with Dysphagia Diet (11) • Statistically significant results indicate that older people on texture-modified diets have a lower intake of energy and protein than those consuming a normal hospital diet and it is likely that other nutrients will be inadequate. • The viscosity of barium test feeds is much greater than the correspondingly named diet foods and the NDD guidelines. • Variety in pureed menus may be lacking. • Poor patient acceptance. • Lack of or delayed advancement in level.
Recommendations • All patients on texture-modified diets should be assessed by the dietitian for nutritional support. • Evidence based strategies for improving overall nutrient intake should be identified.
Strategies • Educate and inform patients and family members. • Be well informed/trained about modification practices in your facility. • “thicker is not always better” • Monitor status and advocate for reevaluation for diet advancement.
Severe Neurological Dysphagia(5) • Enteral Nutrition (EN) is clearly indicated. • For long-term nutritional support PEG should be preferred to NGT. • EN should be initiated as soon as possible and accompany intensive swallowing therapy until safe and sufficient oral intake from a normal diet is possible.
Indications for enteral nutrition (6) • Unconscious patient • Neuromuscular swallowing disorder • Physiological anorexia • *Upper GI obstruction ,GI dysfunction or malabsorption • Increased nutritional requirements • Psychological problems • Specific treatment • Mental health
Considerations when prescribing enteral formula type (13) • Formulary of Institution • A potential safety issue may arise if limited to products based on an institutional contract in that they might not be appropriate for the patient population or setting. • Should be specific to the institution. • Should be established based on patient population and estimated nutrient needs rather than specific diagnosis.
Considerations when prescribing enteral formula type, cont • Considerations should include • Nutrition and physical assessment, metabolic abnormalities, GI function, overall medical condition, and expected outcomes. • Comparison of the patient’s condition and nutrient needs with the specific properties of the available nutritional formulas.
Standard Formulas (14) • Most contain enough electrolytes and minerals to meet the minimum daily requirement of Sodium, Potassium, Calcium, Magnesium and Phosphorus if the patient is receiving enough to meet energy needs. • Some are designed specifically for patients with low energy needs but still requiring adequate electrolytes vitamins and minerals. • ICU patients not meeting criteria for immune-modulating formulas shouldreceive standard formulas.