case 25- nutrition Flashcards
Ageing
A multifaceted process driven by a gradual and lifelong accumulation of molecular and cellular damage that leads to:
Progressive loss of function (in cells, tissues, and organs)
Increased risk of morbidity (multiple diseases)
Disability and death
Heterogeneity and plasticity of ageing process
Diet and ageing
Diet/nutrition play a major determinant in healthy ageing
Diet/nutrition play a pivotal role in health promotion, disease prevention and chronic disease management
Age and changes in the mouth
1) Dry mouth (xerostomia)- Hyposalivation
2) Reduced sense of taste and smell- damage to olfactory cells
3) Reduced power of chewing muscles
4) Reduced pharyngeal phase of swallowing
5) Anorexia of old age
Age and changes to the stomach
1) Reduced gastric acid production
2) Delayed gastric emptying (solids>liquids). Clinically significant with co-morbidities
Age and functional changes to the GI tract
1) Small intestine- Digestion and absorption of macronutrients is preserved but reduced absorption of Ca, Zn, and vitamin D. Unchanged enterocyte and orocaecal transit
2) Large intestine- Changes that lead to slowed motility and transit (constipation)
3) Rectum-Reduced wall elasticity.Increased wall threshold pressure
4) Anus- Reduced sphincter pressure or reduced anal squeeze pressure
Ageing- structural changes to the mouth
1) Teeth loss/poor dentition- poor mastication
2) Gingival recession
3) Dental caries- oral pain and infection
4) Ill-fitted dentures
5) Edentulous mouth
6) Change in oral mucosa- impaired wound healing
7) Change in jaw bone (bone loss)
8) Oral health related quality of life
Ageing- structural changes to the stomach and rectum
Stomach- Increased prevalence of atrophic gastritis
Rectum- decreased content of fibres for wall elasticity
Ageing- structural changes to the small intestine
Bacterial overgrowth / changes in microbiota
Decreases micronutrient absorption (Ca, Zn)
Decrease in vitamin D receptor intestinal Ca absorption
Metabolic changes with ageing- ageing pancreas
1) Change in morphology and function
2) A metabolically active organ with uptake and breakdown of nutritional components
3) Decrease in volume after age 60 (the pancreatic parenchyma)
associated with decreased perfusion, fibrosis and atrophy →
4) impaired pancreatic exocrine function
5) Pancreatic exocrine insufficiency (PEI): 5% in aged 70+, 10% in aged 80+ leading to maldigestion and malnutrition
6) Deficits of fat-soluble vitamins (e.g. vitamin D → decreased BMD)
7) Decreased insulin production of pancreatic beta cells → increase insulin resistance
Metabolic changes with ageing: Glucose intolerance
1) Some degree of glucose intolerance is normal in later life, even in otherwise healthy people
2) After the age of 30: ↑of 5.3 mg/dl in postprandial glucose levels and 1-2 mg/dl in fasting glucose levels for every decade of life1
3) Aetiology: slower glucose absorption, decreased insulin production, reduced lean body mass, decreased physical activity, and altered digestion all contribute to reduced glucose utilisation2
Metabolic changes: Ageing skeletal muscles
1) Skeletal muscle is metabolically active
2) A major site of insulin and exercise stimulated glucose disposal
3) Disruption of the normal rate of glucose uptake by muscles is central to the onset of diabetes
Malnutrition
A state of nutrition in which a deficiency, excess or imbalance of energy, macro and micronutrients causes measurable adverse effects on tissues and body form (body shape, size, and composition), body function and clinical outcomes
Socio-economic factors influencing nutritional health in older adults
Finance, Housing, Neighbourhood, Crime/abuse, Transportation
Personal factors influencing nutritional health in older adults
Nutritional knowledge, Shopping skills, Cooking skills, Diet modification, Physical activity/exercise, Religion
Social factors influencing nutritional health in older adults
Family, friends, isolation
Social factors influencing nutritional health in older adults
Family, friends, isolation
Physiological factors affecting nutritional health in older adults
1) Physiological changes
2) Multiple chronic conditions
3) Mental disorders- depression, anxiety, cognitive impairement/dementia
4) Disability
5) Loss of independence
6) Change in taste, smell and vision
7) Oral health- chewing/swallowing
8) Medication/polypharmacy
9) Poor appetitie
10) Loneliness
Predictors of dietary intake in older adults
1) EU project ‘Food in later life’
2) 5 EU countries
3) Face to face interviews
4) Development of tools to measure nutritional risk and food related quality of life
Prevalence of malnutrition in older adults
1) Most malnourished older adults live in the community: 35% undernourished1 → inadequate intake of nutrient-dense foods. Loneliness & multimorbidity. Underdiagnosed
2) Overnutrition also common contributing to obesity and chronic conditions
3) Energy-dense but nutrient-poor foods- saturated fats (fatty and processed meats), trans fats (margarine, processed baked products), refined carbohydrates (soft drinks, white bread, white rice); sodium (canned and processed foods)
4) Low intake of dietary fibre
5) Alcohol abuse is an important determinant of poor diet
Extent of malnutrition in older adults by health care setting
1) Community: 3.1%
2) Outpatients: 6.0%; home-care services: 8.7%; hospital: 22.0%; nursing homes: 17.5%; long-term care: 28.7%; rehabilitation/sub-acute care: 29.4%.
Medication/Polypharmacy as risk of malnutrition
1) Older adults take multiple medications- On average 6 in the very old (≥85 years) in the Newcastle 85+ Study
2) The risk of food-drug or drug-nutrient interaction is high
3) Food-drug interaction: a process whereby consumption of certain foods can effect the absorption, metabolism, excretion and pharmacodynamics of drugs
4) A drug-nutrient interaction occurs when a drug affects the use of a nutrient in the body and compromises nutritional status
Example of drugs that can affect food absorption
Analgesics- alcohol
Antibiotics- dairy, iron supplements decrease drug absorption
Anticoagulant- foods rich in vitamin K decrease drug absorption
Antihyperlipidemic- food enhances drug absorption
Antihypertensive- grapefruit juice increases drug absorption
Acid blockers- decreases vitamin B12 absorption
Diuretics- increase mineral loss in urine
Laxatives- decrease nutrient absoprtion
Medications as a risk for malnutrition
Medication side effects that affect nutritional status in older adults Appetite changes Nausea Dry mouth Change in taste & smell Gastrointestinal effects Glucose levels Organ system toxicity
Nutritional requirement with ageing- energy
1) Decline in body mass, declining activity levels & reduced basal metabolic rate → reduced caloric requirements
2) 16-20% difference in energy intake between healthy older (~70 years) and younger (~26 years) adults or 0.5% per year
In older adults, calculating caloric needs based on body weight may be less accurate because of changes in body composition
3) Men aged ≥65: 2,000-2,600 kcal & women aged ≥65: 1,600-2,000 kcal
Nutritional requirements with ageing- Macro and micronutrients
Requirements for macro and micronutrients can be similar or increase with ageing. Absorption and utilisation of nutrients may be less efficient so may need more
Protein and ageing muscles
1) Protein recommendations are based in nitrogen balance studies in younger adults
2) EFSA has set a Population Reference Intake (PRI)/Adequate Intake (AI) to 61 g/day (men) and 55g/day (women) or 15-20%E from protein in those aged ≥60
3) ~10% of older adults to not meet the estimated average requirement (EAR)
Recommended protein levels for older adults
1) >0.8g/kg BW/day needed to prevent loss of lean body mass
2) To enhance physical activity: 1.2g/kg BW/day
3) For healthy older adults (aged ≥65): 1.0-1.2g/kg BW/day
4) For older adults with chronic conditions and malnutrition: 1.2-1.5g/kg BW/day
Vitamin D and ageing
1) Deficiency is common in older adults- up to 80% are deficient. Due to skin changes, less sun exposure and a poor diet
2) You will need a 25(OH)D status of 40-50nmol/l to establish a RDA of 15 ug/day and 20 ug/day in those aged >70
Modified food pyramid for older adults
1) Aged >70
2) Nutrient rich food but also supplements or fortified food (Ca, vitamin D, B12)
3) Hydration- decreased thirst response
4) Exercise
Ageing- Mediterranean dietary pattern
1) A healthy DP associated various health outcomes: survival, cardiovascular disease, cognitive health, frailty, sarcopenia, and cancer
2) Higher consumption of plant foods (fruits, vegetables, legumes, and cereals) and olive oil, a moderate intake of fish, eggs, poultry, and dairy foods, a low intake of red meats, and a moderate consumption of red wine during meals
Summary of ageing and nutrition
1) Micronutrient deficiency are common; macronutrient deficiencies are rare
2) However, unfavourable intake of saturated fat, sugar, salt and dietary fibre have been reported
3) Higher protein intake and vitamin D supplementation may be beneficial
4) Healthy dietary patterns: cumulative and synergistic effect of nutrient-rich foods
5) If older adults have healthy diet and no clinical signs of deficiencies, supplementation may not be needed
Most common deficiencies in older adults
1) Protein
2) Fibre
3) Vitamins B (B12, B6, B9), vitamin C and vitamin D
4) Zinc, iron, calcium, selenium
When should a patients nutritional status be assessed
On admission and at regular intervals every patients nutritional status is assessed in order to identify malnourished patients or those at risk of becoming malnourished
Reasons for assessing malnutrition
To ensure that hospital days will not be prolonged because of:
1) Poor (wound) healing and recovery
2) Development of complications
3) Re-admission
Screening for malnutrition in hospitals and in the community
Screening for malnutrition in hospitals
1) All patients
2) Repeated weekly
3) All outpatients on first visit and repeated when there is a clinical concern
Screening for malnutrition in the community
1) Care homes – at admission and monthly and when clinical concern
2) Community: annually older adults aged ≥75
Medical history- general questions about nutrition
1) Appetite
2) Weight gain or loss
3) Meals (number of meals a day; nutrient content)
4) Social support
Tools for assessing nutritional status
1) Body Mass Index (BMI)
2) Anthropometric measurements
3) Malnutrition Universal Screening Tool (MUST)
4) Functional assessment
5) Biochemical test
Measurements of nutritional status: anthropometrics
Weight- Global BMI- Total body fat Skin fold- Percentage body fat Waist-hip ratio- central adiposity Upper arm circumference- Lean body mass Unreliable in certain patient groups= Liver disease (oedema), Congestive heart failure (oedema), Neurological disease (muscle atrophy
When should nutritional support be considered
1) Nutrition support should be considered in people who are malnourished, as defined by any of the following:
2) A body mass index (BMI) of less than 18.5 kg/m2
3) Unintentional weight loss greater than 10% within the last 3–6 months
4) ABMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.
Skin fold thickness measurement
Instrument: CALIPER
Add up all measurements (total skin folds)
Divide this number by body weight (in lbs)
Multiply the results by 28 (men) or 30 (women)
This new figure is your estimated %body fat
Management after MUST- all risk categories
Record malnutrition risk category
Record need for special diet and follow local policy
Treat underlying condition and provide help and advice on food choices, eating and drinking when necessary
Management after MUST- Obesity
Record presence of obesity
For those with underlying conditions, these are controlled before the treatment of obesity.
Functional measure- Grip strength
1) Surrogate measure for overall muscle strength which is suggestive of proper nutrition
2) GS is a biological marker inversely associated with mortality
3) Component of sarcopenia and frailty
Functional measure- Grip strength
1) Surrogate measure for overall muscle strength which is suggestive of proper nutrition
2) GS is a biological marker inversely associated with mortality
3) Component of sarcopenia and frailty
Biological markers of malnutrition
1) Blood index- Anaemia, the earliest manifestation of protein-calorie malnutrition. Total lymphocyte count
2) Serum proteins- Albumin is a poor measure. Retinol binding protein (RBP) and thyroxine binding pre-albumin (TBPA) is a more sensitive indices
Comparing MUST and MNA-SF
Both are good screening tools for malnutrition in older adults
MNA-SF is made specifically for older adults, whilst MUST is for all ages (preferred in the UK)
MNA-SF categorises many more older people admitted to hospital as at risk of malnutrition compared with MUST
MNA-SF better predicts length of hospital stays and readmission rates
The percentage of blood calcium that is filtered by the kidney
60%
Where does the obituary internus insert
The greater trochanter of the femur
What reduces urinary excretion of calcium ions
Increase in plasma levels of the parathyroid hormone
What fracture healing occurs with intramedullary nails
Secondary fracture healing- involves responses in the periosteum and external soft tissue
What is the nerve supply to the hip joint
Femoral nerve, obturator nerve, sciatic nerve and nerve to the quadratic femoris
Which ligament limits extension of the hip joint to 10 degrees
Iliofemoral
Which artery is a branch of the internal iliac artery and supplies the femur via the ligament of the head of the femur
Obturator artery
What causes the production of intercellular calcium binding proteins in intestinal epithelial cells
1,25 dihydroxy vitamin D
Disposable soma theory of ageing
Long term investments in reproductive fitness at the expense of cellular repair
Antagonistic plieotropy theory
Alleles that increase early life fitness are selected for to the detriment of later life fitness
The mutation accumulation theory of ageing
Since organisms in the wild die young there is no evolutionary presssure to prevent ageing
