Transcript What’s the big deal about nutrition??

Nutrition and Aging…
Beyond Tea and Toast
Jean Helps
WRHA Regional Clinical Nutrition
Manager – Long Term Care
October 8, 2008
Long Term Care Association of Manitoba
What’s the big deal about
nutrition??
Promotes
health and well-being
Allows us to achieve our potential
Facilitates best quality of life
But…we also need to be aware that
we are providing care that best
supports individual goals
Malnutrition - Definition
Undernutrition: Often thought to be a problem of third
world countries
 Inadequate consumption, poor absorption, or excessive
loss of nutrients
Overnutrition
 Excessive intake of specific nutrients.
An individual will experience malnutrition if the
appropriate amount of, or quality of nutrients
comprising a health diet are not consumed for an
extended period of time
Obesity in the Older Adult
Obesity may be thought to be the next challenge in LTC
 Rising rates of obesity is reported
 Increased risk of health problems and premature death
 Cost of obesity - $2 billion a year in 1997
2006 Canadian Clinical Practice Guidelines on the management and prevention of
obesity in adults and children (summary). CMAJ 2007 176 (8 suppl):S1-13
In the Elderly
 Lowest mortality associated with BMI range of 25 to 30
 Relationship between BMI and mortality weakens with
increasing age
 Some reduction in cardiovascular risk factors with weight
loss
 But… need to assess benefits vs risks
National Health, Lung, Blood Institute, Clinical Guidelines on the Identification,
Evaluation and Treatment of Overweight and Obesity in Adults
Accessed 13/08/08
Prevalence of Malnutrition in the
Elderly – What the research
shows…
Community Living:
 5 to 20% prevalence of malnutrition
 ~40% are at risk of malnutrition
Long Term Care:
 5 to 85% of residents in Long Term Care suffer from
malnutrition (Average 30%)
 Administration on Aging in the US estimate 50% of
hospital and nursing home residents are malnourished
(2004)
Hospitalized Patients
 32 to 50%
Causes of MalnutritionSystem Issues for the
Individual at Home
Mini Nutrition Assessment (MNA) identified
Psychosocial and Environmental Factors
 Isolation
 Loneliness
 Depression
 Inadequate finances
More seniors are living alone 2001 Census Statistics Canada
http://www12.statcan.ca/english/census01/products/analytic/companio
n/fam/canada.cfm#seniors)
Causes of MalnutritionOrganizational1
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Failure to help residents eat or recognize
malnutrition
Importance of nutrition not realized
Absence of Dietitian
Lack of staff, lack of communication, inadequate
training and education
Monotonous diet, inappropriate diet or mealtime
environment
Inappropriate medication prescribing
Insufficient data collection
1Cowan
et al. Int J Nurs Stud 2004;41(3):225-237
Causes of Malnutrition –
Physiologic Changes related to Aging
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Sensory impairment – thirst, taste, smell, sight, sound
Alimentary system:
– Poor oral health and dental problems
– Difficulty swallowing
– Reduced digestion, absorption and motility
Decline in Immune Function – Increase likelihood of
acquiring infections
Causes of Malnutrition –
Physiologic Changes related to
Aging
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Decreased physical activity:
– depletion of Lean Body Mass (muscle loss)
– Decreased appetite
Altered energy need – diet lacking in essential
nutrients
 Decline in Renal Function – increase potential for
dehydration
 Loss of bone density – increase potential for
fracture and osteoporosis
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Practical Outcomes
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Reduced ability to complete ADLs
 Apathy, anorexia, decreased mobility, pressure
sore formation, osteoporosis, impaired immunity
 Complication of and delayed recovery
…Resulting in…reduced quality of life for the
individual, increased nursing time, delayed
discharge from hospital AND increased costs to
the system
Promoting Nutrition in the
Community and Acute Care
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Identification of nutrition risk/malnutrition
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Appt with the family doctor
Visit with a health care provider
Caregiver in the home
Nutrition Screening in Hospitals
Nutrition Assessment to determine causes:
– Dietitians – Home Care/Ambulatory Care/Inpatient
– WRHA Senior Resource Team
– Family Doctor
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Implementation of interventions to address issues:
– Specialized meal pattern
– Resources to access foods, meal preparation
– MOWs, Congregate Dining
Promoting Nutrition in the
Long Term Care Setting
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Use of resources and tools
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Manitoba Health PCH Standards
Eating Well with Canada’s Food Guide
Dietary Reference Intakes (DRIs)
WRHA Clinical Nutrition Diet Compendium
Individualized assessment and care plans
 Reassessment on a routine basis
Manitoba Health PCH
Standard 14 – Dietary
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Minimum 21 day cycle menu
Choice essential
Nourishments/beverages offered between meals
Meets Residents’ nutritional needs
Meals provided in a group setting with social
aspects of dining and meal enjoyment facilitated
Independence at meals is promoted, assistance
available when required.
Dignity and safety is promoted
and interaction with staff is encouraged
Manitoba PCH Standards- Menus
need Dietitian approval that they
meet Canada’s Food Guide
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Communicates amounts and types of food needed
to help:
- Meet nutrient needs and promote health
- Minimize the risk of obesity, type 2 diabetes,
heart disease, certain types of cancer and
osteoporosis
 Provides the cornerstone for nutrition policies and
programs
www.healthcanada.gc.ca/foodguide
Canada’s Food Guide- Then
and Now…
First Food Guide- “The Official Food Rules”
 Developed in 1942
 Acknowledged wartime food rationing
 Endeavored to prevent nutritional deficiencies and
to improve health
“ Canada at war cannot afford to ignore the power
that is obtainable by eating the right foods”
Further revisions…
Canada’s Food Rules (1944, 1949)
Canada’s Food Guide (1961,1977,1982)
Canada’s Food Guide to Healthy Eating (1992)
Eating Well with Canada’s Food Guide (2007)
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Evolution of the name describes the changes in
positioning and philosophy of the food guide
 Focus on:
- Chronic disease prevention
- Balanced energy intake and moderation
- A total diet approach meeting both energy and nutrient
needs
WRHA Clinical Nutrition
Services Initiative –
Diet Compendium Revision
Evidence based review completed to guide provision
of meals
 Focus on generic definitions and standards
 Use DRIs, Canada Food Guide recommendations
 Adherence/inclusion in care maps
 Long Term Care Diet reviewed to “consider the
unique nutrition needs of the senior population
and ensure “standard” diet for this population are
appropriate”.
Issues Identified
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Macronutrient needs –
– Protein and Energy
– Fibre
– Fat
– Fluid
Micronutrient needs – Vitamin D
 Mealtime Set Up and Meal Patterns
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Energy/Protein
Requirements/Intake
Daily Energy requirement
(CFG):
 1550 cal - sedentary females
 2000 cal – sedentary males
Wendland et al (2003)
 Average intake – 1164+/-230
cal
 Provision – 2079+/-370 cal
Average Adult Canadian
intake – 1790 cal
Daily Protein requirement
(DRIs):
 46 grams – females
 56 grams – males
Wendland et al (2003)
 Average intake 45.5+/-13
grams
 Provision – 87.4 +/-15
grams
Protein and Energy –
Nutritional Deficiencies in the
American Nursing Home Population
Nutrition Indicator
 Protein Energy
Malnutrition
 Underweight
 Hypoalbumenia
Prevalence
 37 to 85%
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12%
 18 to 60%
Implications for Planning –
Protein and Energy
In CFG, no change in recommended portions Meat and
Alternatives– 2 to 3 daily
 Include meat alternatives and fish, choose lean meats
For the Elderly, protein/energy is of concern
 High quality diet, high quality protein sources
 Individualize the care plan – e.g. meal size and frequency
 Consider Supplement Med Pass:
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Improved nutritional outcomes – weight gain
System benefits – less waste, cost savings.
High protein, high energy, small volume
Given consistently, intake recorded on MARs
Fibre – Vegetables and
Fruits/Grains Products
DRI recommendations for fibre are 21 grams for females, 30
grams for males.
 Average intake (elderly) – 8.4 grams, Provision – 15.1 grams
CFG - Vegetables and Fruits and Grains Groups continues to
have highest billing on food guide to promote intake
 Include at least one dark green and one orange vegetable in the
diet daily
 Include half of your grain products as whole grain
 More specific guidelines for different ages given for these
groups compared to 1992 Food Guide
Implications for Planning Fibre
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The older adult may not be able to consume the
recommended amounts of fibre without
fortification.
 “A fiber supplement may be needed when food
intake is low, as is the case among inactive
elderly” – American Dietetic Association Position
Paper: Health implications of dietary fiber (2003)
 Provision of between meal snacks of grains and
vegetables and fruits likely required for needs to
be met.
Fat
DRI reference value for fat – 20 to 35%
Did you know…
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Gram for gram there is more than twice the
calories in fat than protein or carbohydrate
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Fat adds moisture and palatability to foods
Implications for Planning – Fat
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Fat content of the diet up to the high end of
the range ( 30 to 35%), to optimize intake
through beneficial properties of fat.
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With increasing age, the importance of
elevated serum cholesterol levels as a risk
factor for CHD decreases, and virtually
disappears after age 65
Fluid – Causes and
Consequences of Dehydration
Causes:
 Reduced Renal Function
 Decreased thirst
sensation
 Difficulty with access
 Fear of incontinence
Consequences
 Acute Confusion
 Infections – Urinary,
respiratory
 Increased risk of skin
breakdown
 Falls
 Difficulty Swallowing
 Constipation
System Based Implications of
Dehydration
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Dehydration is present in 30% of nursing
home residents
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Half of those admitted to hospital with
dehydration came from nursing homes
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Mortality rate of those hospitalized was
50%
System Based Strategies to
Promote Adequate Hydration
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General Menu Planning/Individualized Care Plan
Address issues related to lack of access
– Do schedules and staff availability support provision of
fluids during the day?
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Implement a Hydration Program
– Twice daily offering and recording of fluid intake
– Provide education about dehydration
– Giving fluids directly into residents’ hands every 1.5 h
increased fluid intake (Hodgkinson, 2003)
Ensure
beverages are
within reach!
Size and
shape of cups
Provide
appropriate
temperatures
Give
preferred types
of fluids
Vitamin D
Benefit of Vitamin D recognized in the first food guide,
“Some sources of Vitamin D such as fish liver oils, is
essential for children, and may be advisable for adults”
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With age there is reduced production of Vitamin D
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CFG sources are largely milk and select fish
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For those over age 70, it is virtually impossible to meet
Vitamin D needs orally
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There is evidence that Vitamin D prevents falls
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CFG recommends supplement of 400 IU of Vitamin D
for all over the age of 50 years.
Video Clip
Mealtime Management –
Individual Specific Interventions
Eating experience is more than the food on the plate
To promote intake and safety guidelines include:
 Readiness to eat
 Dentures
 Positioning
 After the meal
Manitoba Health Manual for Feeding and
Swallowing Management in Long-Term Care
Facilities
Dementia – Increasing
Prevalence with Age
Consequences:
 Change in taste and smell
 Lack of distinction between food and non-foods
 Loss ability to feed self, use utensils
 Loss of memory about when they last ate
 Forget to chew and forget to swallow
 Pocket food, Spit food out
Mealtime Management Dementia
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focus of food delivery during the morning when
residents are most responsive to food provided
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Simplify the environment – non-distracting
visually and audibly
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Simply the food – Provision of too many foods at
one time leads to over-stimulation, agitation and
reduced intake
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Communicate
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Provide flexible care
Mealtime Management
Physical and Social Environment:
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Noise and Distraction Control
Attend to the resident
Provide level of assistance needed
Food and Nutrition Interventions:
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Provide acceptable portion size
Between meal snacks to increase eating opportunities
Liberalization of the diet
Evaluate outcomes
Long Term Care Setting – Community
Health Assessment (2004)
PCH Population - Age Ranges
Under 65 y
65 to 74 y
75 to 84
Over 84 y
Distribution by Gender:
 75% Female
Most Common Heath
Concerns:
 CVD
 Dementia
 CVA
 Cancer
 Diabetes
 Respiratory illness
Representative Resident
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Female
 85 years old
Diagnoses:
 Dementia
 CVD with hx CVA
 Poor dentition
BMI – 20.5
Is semi-dependent:
 Can feed herself with set
up and encouragement to
eat.
 Difficulty attending to her
meals, needs to be
reminded to go to the
dining room, is distracted
 Difficulty chewing and
swallowing
 Elevated serum lipids
 Fall risk due to residual
left sided weakness
Mrs. Resident
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Placed on Supplement Medication Pass program
 Focus on preferences for foods provided
 Meats need to be minced due to difficulty chewing and
swallowing
 Provided with fibre enriched cereal and fruit based
fibre mixture at breakfast time
 Routinely provided with whole grain products
 No restriction on fat content of the diet, intake of
additional fat sources to promote intake through
addition of moisture to foods
 Focus on milk, as an easy to consume food, also
Vitamin D supplementation at the level of 1000 IU
recommended
 Provide appropriate environment and assistance at
mealtimes
In Summary…
Not tea and toast….
But Time, Team
and Attention…