Nutrition and Aging… Beyond Tea and Toast

1. 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

2. 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

3. 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

4. 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

5. 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%

6. Causes of Malnutrition- System 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/companion/fam/canada.cfm#seniors)

7. Causes of Malnutrition- Organizational1 • 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

8. Causes of Malnutrition – Physiologic Changes related to Aging • 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

9. Causes of Malnutrition – Physiologic Changes related to Aging • 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

10. Practical Outcomes • 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

11. Promoting Nutrition in the Community and Acute Care • Identification of nutrition risk/malnutrition • 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 • Implementation of interventions to address issues: • Specialized meal pattern • Resources to access foods, meal preparation • MOWs, Congregate Dining

12. Promoting Nutrition in the Long Term Care Setting • Use of resources and tools • 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

13. Manitoba Health PCH Standard 14 – Dietary • 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

14. Manitoba PCH Standards- Menus need Dietitian approval that they meet Canada’s Food Guide • 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

15. 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”

17. 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) • 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

18. 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”.

19. Issues Identified • Macronutrient needs – • Protein and Energy • Fibre • Fat • Fluid • Micronutrient needs – Vitamin D • Mealtime Set Up and Meal Patterns

20. 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 Energy/Protein Requirements/Intake

21. Nutrition Indicator Protein Energy Malnutrition Underweight Hypoalbumenia Prevalence 37 to 85% 12% 18 to 60% Protein and Energy –Nutritional Deficiencies in the American Nursing Home Population

22. 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: • Improved nutritional outcomes – weight gain • System benefits – less waste, cost savings. • High protein, high energy, small volume • Given consistently, intake recorded on MARs

23. 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

24. Implications for Planning - Fibre • 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.

25. Fat • DRI reference value for fat – 20 to 35% Did you know… • Gram for gram there is more than twice the calories in fat than protein or carbohydrate • Fat adds moisture and palatability to foods

26. Implications for Planning – Fat • Fat content of the diet up to the high end of the range ( 30 to 35%), to optimize intake through beneficial properties of fat. • With increasing age, the importance of elevated serum cholesterol levels as a risk factor for CHD decreases, and virtually disappears after age 65

27. 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 Fluid – Causes and Consequences of Dehydration

28. System Based Implications of Dehydration • Dehydration is present in 30% of nursing home residents • Half of those admitted to hospital with dehydration came from nursing homes • Mortality rate of those hospitalized was 50%

29. System Based Strategies to Promote Adequate Hydration • 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? • 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! Provide appropriate temperatures Give preferred types of fluids Size and shape of cups

30. 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” • With age there is reduced production of Vitamin D • CFG sources are largely milk and select fish • For those over age 70, it is virtually impossible to meet Vitamin D needs orally • There is evidence that Vitamin D prevents falls • CFG recommends supplement of 400 IU of Vitamin D for all over the age of 50 years.

31. Video Clip

32. 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

33. 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

34. Mealtime Management - Dementia • focus of food delivery during the morning when residents are most responsive to food provided • Simplify the environment – non-distracting visually and audibly • Simply the food – Provision of too many foods at one time leads to over-stimulation, agitation and reduced intake • Communicate • Provide flexible care

35. Mealtime Management Physical and Social Environment: • Noise and Distraction Control • Attend to the resident • Provide level of assistance needed Food and Nutrition Interventions: • Provide acceptable portion size • Between meal snacks to increase eating opportunities • Liberalization of the diet Evaluate outcomes

36. Long Term Care Setting – Community Health Assessment (2004) Distribution by Gender: • 75% Female Most Common Heath Concerns: • CVD • Dementia • CVA • Cancer • Diabetes • Respiratory illness

37. 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 Representative Resident

38. Mrs. Resident • 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

39. In Summary… Not tea and toast…. But Time, Team and Attention…