Chapter 18 Nutrition Support

the greatest risk for malnutrition associated with those living in long-term care facilities (7). These rates of malnutrition, along with the many confounding factors that affect the nutritional status of older adults, suggest that aggressive nutrition intervention is indicated. Once nutrition risk has been identified, further assessment to determine the level of intervention should follow. This may include enteral or parenteral nutrition support.

NUTRITION ASSESSMENT Nutrition assessment of older adults incorporates the use of anthropometric, clinical, biochemical, dietary, and psychosocial data to determine the appropriate nutrition intervention. Establishing nutrition support goals for older adults begins with a comprehensive nutrition assessment and history accounting for age- related factors. The components of a nutrition assess- ment for an older adult are listed in Box 18.1. Height, weight, and BMI may be included in the nutrition assessment. Body composition changes asso- ciated with aging include decreased lean body mass (LBM), increased body fat, and loss of height. There is a proportional increase in total body fat mass and loss of lean body mass. Height decreases with aging due to

BOX 18.1 Nutrition Assessment

Anthropometrics Ht/wt/BMI/waist circumference Weight history

Food Intake More, less, the same Ability to eat independently, care providers Chewing, swallowing

Inflammatory Status Mild Moderate Severe

Optional Biochemical Levels Albumin (correlate with inflammatory status) Hemoglobin/Hematocrit Hydration

Source: Jensen GL, Bistrian B, Roubenoff R, Heimburger DC. Malnutrition syndromes: a conundrum vs continuum. JPEN J Parenter Enteral Nutr. 2009;33:710-716; Tappenden KA, Quatrara B, Parkhurst ML, Malone A, Fanjiang G, Ziegler T. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. JPEN J Paren Enter Nutr; 2013:37(4): 482-497.

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changes in bone density and postmenopausal osteopo- rosis. The assessment should also include an evaluation of weight changes over time to determine if these are acute or chronic. Sarcopenia is defined as the loss of muscle mass, strength, and function, which affects not only health but also quality of life. Sarcopenia or loss of lean body mass can begin before the age of 50 but speeds up after age 75 (8). While body composition analysis is rarely available, an indirect assessment such as ability to walk a certain distance, ability to get up from a chair, or hand grip strength can be valuable. Actual food intake should be evaluated either from recall or from clinical notes. Because the aging process affects multiple organ systems, GI absorption of nutri- ents may be decreased, renal function compromised, and insulin sensitivity decreased. Chronic diseases in older adults, such as cardiac, renal, and pulmonary dis- eases, can lead to altered nutrient absorption and metabolism. Decreased assimilation of nutrients result- ing from malnutrition and chronic diseases may also occur in this population. Multiple medications fre- quently prescribed for older adults may further contrib- ute to altered nutrient absorption, metabolism, and decreased appetite. Additionally, inability to self-feed or chew foods may lead to the need for an alternative method of nutrition support.

Serum albumin is a marker of inflammation and has been associated with poor outcomes in hospitalized clients. In the hospital setting, hypoalbuminemia in older adults is associated with increased length of stay, complications, readmissions, and mortality (6). In community-dwelling older persons, some studies have suggested that low albumin levels are associated with functional limitations, sarcopenia, increased health care use, and mortality (8). Other risk factors associ- ated with malnutrition in older adults include dementia, depression, alcohol or substance abuse, and adverse social conditions such as isolation and poverty. Altered physical and cognitive ability contribute to difficulties with food shopping and preparation. Some or all of the components of the nutrition assessment are used to classify nutrition status—or perhaps more accurately inflammatory status—as mild, moderate, or severe (1,9). Older adults in a nursing facil- ity or assisted living who are otherwise well may be con- sidered in a mild inflammatory state. For more detailed information on the Nutrition Care Process and nutrition assessment, see Chapters 5 and 6.

NUTRITIONAL REQUIREMENTS

Energy Energy is provided by macronutrients that come primar- ily from carbohydrates and fat but also protein. Food