Transcript Nutrition Issues and Challenges in the Care of the Older

Nutrition Issues and
Challenges in the Care of
the Older Person
Julian Jensen, Registered Dietitian
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Outline
Weight loss, malnutrition and screening
 Menus, standards, guidelines and RDI’s
 Modified diets – texture modifications
& pureed diets
 Resourcing food and nutrition services.

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Introduction
Nutrition is a key component in
successful ageing
 Malnutrition is a growing problem in the
older person, particularly in hospital
level care.
 The dietitian is a key member of the
multi-disciplinary healthcare team when
nutrition issues are under review.

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Issue 1: Weight Loss

Weight loss is not a normal phenomenon of
ageing

In the US, more nursing homes are cited for
inadequate care re weight loss than any other
nutritional issue

Malnutrition is defined as
– BMI <18.5 kg/m2 OR
– Unintentional weight loss of >10% within the
previous 3-6 months OR
– BMI <20 kg/m2, and unintentional weight loss >5%
within the previous 3-6 months
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Malnutrition Risk Based on BAPEN
Malnutrition Advisory Group Guidelines
High Risk
Medium
Risk
Low Risk
BMI < 18.5
BMI 18.5-20 +
weight loss of
3.2 kg or more
in last 6
BMI >20 +
weight loss of
6.4 kg or more
in last 6
months
months
BMI 18.5-20 +
weight loss of
less than 3.2 kg
in last 6
months
BMI >20 +
weight loss of
3.2 - 6.4 kg in
last 6 months
BMI >20 and no
weight loss
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Undernutrition of Older People
using MNA© screen (US data)
Malnutrition At risk
(%)
(%)
Well
nourished
(%)
At home
5
15
80
Hospital
10
25
65
Long term
care
40
45
15
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Poor Oral Intake predisposes to
Malnutrition:
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Unable to feed themselves
Dysphagia – may be on pureed diets
Poor dentition, mouth problems
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Lack of appetite
Multiple medications
Depression
Dementia
Underlying disease e.g. renal failure
– Sjogrens Disease
– Tumours
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Significant malnutrition
co-morbidities

Renal impairment

Congestive heart failure

Chronic obstructive respiratory disease

Peripheral vascular disease

Ischaemic heart disease

Post-stroke
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Diabetes
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Neurological diseases – PD, MS, MND, Huntingdons
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Traumatic brain injury

Cancer Cachexia
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Challenge 1: Screening for
Malnutrition Risk

Nutrition screening is the process of discovering
characteristics known to be associated with dietary
or nutritional problems

It identifies individuals who are at high risk of
nutritional problems, or who have poor nutritional
status.

Role of nutrition screening is to identify residents
who are currently malnourished, or who are at risk, so
that they can be referred for further assessment
and nutritional intervention as appropriate

CAVEAT: Screening should never replace clinical
judgement, but it should support it
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Key Features of Nutrition
Screening
Food intake
 Anthropometry
 Dietary modifications
 Medical conditions
 Biochemical data
 General observations/comments
 Decision Flow chart/Action plan
 Nutrition Care Plan

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Ethics of screening

A screen is a means of identifying or predicting risk

Resources must be available to act on the results of
the screen

Failure to act appropriately constitutes unethical
behaviour

Therefore, in establishing a screening process,
allowance for registered dietitian intervention for
the high risk categories must be made
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Measuring weight and height

Weight
– Use clinical scales
– Weigh person in light
clothing and without
shoes
– Record weight –
enter on a graph so
trends can be easily
seen
– Recheck if weight
loss or gain seems
unrealistic

Height
– The most reliable
height is selfreported height.
– Use a stadiometer
(height stick).
However this gives
current height, and
we want the normal
height, before
shrinkage!
– Use alternative
height measures
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Alternative Height measures

Demispan
– From sternal notch to base of ring finger

Knee height
– From top of bent knee to heel flat on the ground
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Ulna length
– Measure between the point of the elbow and the
midpoint of the prominent bone of the wrist
These measure all need interpreting from
formulas, or from a table
 All height measures have limitations

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Calculating BMI – Body Mass
Index

Weight in kg, divided by height in m2
– e.g. a person weighing 45 kg and 1.65 m
– 1.65 x 1.65 = ht2 = 2.72
– 45/2.72 = BMI = 16.5

Ideal Range: 22-27 acceptable for older people

BMI < 21 → increased frailty

Higher BMI minimises mortality risk in older people
– Women –
– Men
–
30-33
27–30
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MNA® - Mini Screen

6 questions
– Has appetite and food intake declined in
the past 3 months
– Weight loss in past 3 months
– Mobility
– Acute illness or major stress in last 3
months
– Dementia or depression
– Body mass index
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MNA® Scores
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Screen – 6 questions
– Max score = 14
– ≥ 12 – Normal; not at risk
– ≤ 11 – Possible malnutrition – proceed to
assessment
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Assessment – 12 questions
– Max score = 16; combined max score = 30
– 17-23.5 – at risk of malnutrition
– < 17 - malnourished
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What can we do to reduce risk of
malnutrition?
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Modify diet to meet their needs – modified
textured diet if dysphagia
Small frequent meals- poor appetite or nausea
Assist with oral intake
Review medications
Increase energy value of meals
Utilise appropriate nutritional supplements in
addition to usual intake
Prescribe these on medication charts
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What about Malnutrition? - Some
adverse effects

Impaired immune response
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↓ muscle strength and fatigue → risk of falls

↓ respiratory muscle function → difficulty
breathing → risk of chest infection and respiratory
failure
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Impaired thermoregulation
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Impaired wound healing and delayed recovery from
illness
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Apathy, depression and self-neglect
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↑ risk of admission to hospital and length of stay
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Treatment of Malnutrition
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Use a dietitian for a full nutritional assessment and
review
May need aggressive, but controlled treatment –
especially if previous intake has been poor or very
limited
Nutrition support most likely to be required
– Oral
 Supplements
 Fortified foods/beverages
– Tube

Because of the range of nutritionals available, it
should be the dietitian’s responsibility to prescribe
the most appropriate.
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Issue 2: Menus in Residential
Care

Health and Disability standards require
evidence that menus meet nutritional
standards for older people in care

NZ Guidelines for Healthy Older People are
out of date, and not always relevant for
people with compromised health

Just released are new Nutrient Reference
Values for Australia and New Zealand
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Challenge 2: Assuring potential
Nutritional Adequacy

The NZDA has responded to a call from your
predecessor – Residential Care Association – to
develop a standard audit tool for menu evaluation.

Dietitians in NZ are trained in both Nutrition and
Foodservice, and are ideally placed to audit your
menu.
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The standards are intended to assess the potential of
the menu to meet the nutritional needs and standards
for dietary variety for the residents, but cannot be
used to guarantee the intakes of individual residents.
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The menu audit tool looks at
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–
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Nutritional adequacy
Special dietary requirements
Dietary variety
Purchasing patterns of key items
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Meat, fish, poultry
Eggs and dairy
Bread
Vegetables and Fruit
– Budget, if a comment is requested.
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Items in the audit tool are assessed as compliant/not
yet compliant; and there is room for comments and
recommendations to be noted.
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You should expect your dietitian to use this tool –
many auditors these days are looking for it
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More menu challenges
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Nutrient Reference Values (NRVs)
– Increased Recommended Daily Intakes for
 Protein
 Calcium
 Vitamin D
 Vitamin B12
 Folate
 Iron
 Zinc
 Magnesium
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Comparisons of RDIs
What
Protein (g)
Calcium (mg)
Vitamin D (µg)
Vitamin B12(µg)
Folate (µg)
Iron (mg)
Zinc (mg)
Magnesium(mg)
Then
Now
M=55; F=45
M=81; F=57
M=800; F=1000
1300
10
15
2.0
2.4
200
400
M=7; F=5-7
8
12
M=14; F=8
M=320; F=270
M=420; F=320
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What does this means for our
menus? (Main food groups)
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Importance of good protein intake
– 2 servings lean meat, fish, chicken, egg,
cooked dried peas, beans or lentils most
days (average at least 100 cooked/day
(~125-130 g raw)
– Milk and dairy – use in cooking, and
incidental table use, BUT also strongly
recommend a daily milk drink (morning tea
and supper) for all – no choice ☺. Make
with trim milk – higher calcium & protein.
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
Breads and cereals
– Whole grain and fortified are a good source
of Folate
– Try to use more wholemeal flour in baking
and desserts
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Vegetables and fruits
– Guidelines say 5 +; most facilities I check
easily meet this. But to improve folate
encourage more – even up to 8 serves ☺.
Use dark coloured fruits and vegetables –
‘eat a rainbow’. Offer some raw daily.
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“Eat a Rainbow” – anti-oxidants
– Red
 Tomatoes, strawberries, red peppers, raspberries
– Orange
 Pumpkin, carrots, oranges, apricots, pawpaw
– Yellow
 Banana, pineapple, sweet corn, kumara, swede, grapefruit
– Green
 Broccoli, spinach, peas, kiwifruit, bok choi, brussels sprouts
– Blue
 Blueberries
– Indigo
 Blackberries, prunes, black cherries, black currants
– Purple
 Eggplant, plums, red cabbage, beetroot
– White
 Apples, pears, cauliflower, potato, onions
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Issue 3: Modified Diets
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Advice re modified diets in extended care
facilities is to be as liberal as possible, to
enable residents to achieve a diet of
sufficient energy and protein to sustain good
nutritional status
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Ask for a dietitian review of any restricted
diet, including diabetes, diverticulitis vs
diverticulosis, vegetarianism, self-imposed
weight control.
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
Modified texture diets
– Soft, Modified soft, pureed
– Do you distinguish between soft and puree?
– Do you distinguish between modified soft and
puree?
– And the biggie! Do your pureed diet patients get
enough? We know people on pureed diets have a
higher risk of malnutrition, due to
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Need for assistance with feeding not fully met
Between meal choices not always suitable
Increasing frailty
Limited food choices
Inappropriate pureed diet production methods
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Classifying texture modified
diets
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Soft:
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Modified soft:
– Soft foods with plenty of gravy and sauce – e.g.
casseroles, fish, mince; sauce based items e.g.
cauliflower cheese; spaghetti; Most veges, except
hard ones, e.g. raw.
– Most residential care menus tend to be soft – not
many chops, steaks and schnitzel
– Here the meat is minced, but most other soft
foods are used as above. Serve with plenty of
sauce or gravy
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Pureed:
– All foods, except very tender foods, are pureed
(separately), until smooth and lump free.
– These diets should not be used unless they are
really needed because of a physiological or
mechanical need. They should not be used for
management purposes – e.g. because they are
easier or quicker to feed.
– A Canadian study some years ago suggested that
25% were on pureed diets for this reason.
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Issues with Pureed Diets
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Production Issues
– How is the correct consistency reached?
– How is the food ‘pureed’
Issues with service
 Between meal snacks
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Challenge 3: Pureed diets
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Food-based Recommendations
– Foods cooked for pureed diets must reach safe
temperatures and be treated carefully during processing for
consumption to maintain microbiological safety.
– Those on full pureed diets should be monitored and assisted
with feeding to ensure adequate intake
– Portion sizes of pureed meals need to be standardised to
ensure sufficient food is offered
– High energy, high protein between meal snacks, such as ice
cream, yoghurts, complan drinks should be provided and
encouraged for people on full pureed diets
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– Foods must not be pureed with water or thin juices. Use
mashed potato, white sauce, gravy, soup tomato and other
sauces, custard and cream—to enhance, rather than dilute,
the nutritional value.
– Micronutrients, such as vitamins and minerals, may need
supplementing; check with your dietitian.
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Food Safety-based Recommendations
– Facilities should ensure they have good food safety
procedures in place, and be working towards a registered
Food Safety Programme
– All equipment used in the final preparation of pureeing
cooked food needs to be cleaned and sanitised carefully.
– All parts of the equipment should be detached and washed
separately from other dishes in clean hot soapy water
– Equipment should be rinsed in clean hot water. If equipment
is dishwasher-safe, sanitise in commercial dishwasher at 82
C. It should be sprayed with food-safe chemical sanitiser
solution and allowed to air dry.
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Issue 4: Resourcing to ensure
adequate nutrition
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Do you have ready access to a dietitian?
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Does the cook have enough time available to
provide the extra requirements for your frail
elderly residents, e.g. a milk pudding at the
secondary meal, extra sandwiches, milk
shakes, smoothies?
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Do you have enough staff to assist with
feeding those who need it (even if for part of
the meal when they tire of feeding
themselves).
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IANA Conference 2005
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The 3rd International Academy of Nutrition and Aging
Conference, St Louis 2005.
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John Schnelle reported that even though assistance
with feeding was claimed, on observation, it was far
less than claimed – about 25% of what was claimed.
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When more assistance provided, and people assisted
in small groups of 3-4, intakes increased by up to
80%.
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Assistance with between meal snacks led to a 100%
increase in intake
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For the very frail
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In the US, 1 aid per 8-10 residents. Not
validated, but is an industry standard
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Need 1 aid for 4-6 residents.
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4.1 hours per resident day has been validated
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Staffing levels are a significant predictor of
quality
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Foodservice staff –
Guidelines for cooks
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We suggest that for every 100 subsisted, there
should be 1 cook, + 1: e.g for 250 people, 2.5+1 = 3.5
FTE’s; for 75 people 0.75 +1 = 1.75 FTE’s
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This means that for your 250 residents, you will have
20 hours per day of cooks available (2.5 x 8 hours, or
2 x 10 hours); for your 75 residents, you will have 10
hours per day of cooks.
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Cooks assistants are required over and above this
requirement. Annual leave and special cover is also
extra to this establishment.
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What about the Dietitian?
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Role:
– To provide professional expertise in the field
of nutrition and dietetics
– To assess patients identified as being at high
risk of malnutrition (under- or over-nutrition)
– To develop nutritional care plans
– To assess need for nutritional modification –
diet modification, supplementation etc
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When to call in the dietitian

When nutrition screening identifies a
resident at risk
– Low BMI, malnutrition
– Recent significant, unintentional weight
change
– Poor appetite/dysphagia
– Inappropriate modified diets (e.g.
historical low fat or nutrient restricted
diets) that have not been reviewed for
many years.
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Type 1 diabetes
 To review residents on tube feeds (at
least 6 monthly)
 To provide nutrition in-service
 To audit your menu
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Challenge 4: Resourcing for
adequate nutrition
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Don’t leave to chance!
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Budget for this!
– At the personal level
– At the organisational level
– At the professional level

The Canadian experience
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In Summary
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Today we have looked at 4 major issues and
challenges!
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Take-home messages:
– Malnutrition – screen for it and act
– Menus – the tool to nutritional adequacy
– Modified diets – allow for them in aged care, but be
as liberal as possible to encourage adequate intake.
– Resources – budget for these – it makes them
easier to achieve.
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