Chapter 6 Nutrition Assessment of Older Adults Eating Environment

One of the first steps in promoting eating independence and maximizing intake for older adults is evaluating the eating environment, whether that be a senior center or congregate meal site, an assisted living or long-term care facility, or dining alone in their own home. Lifestyle and family changes may affect the older adult living at home. If eating alone, there is less incentive and greater difficulty in preparing foods for one person. For older adults who have become residents in a nursing or assisted-living facility, the dining experience may be very different from what they were accustomed to at home. This represents another major lifestyle change to which the client must become accustomed. Food and the atmosphere in which the food is served have an impact on quality of life. Dining atmosphere is one of the most crucial aspects of creating a pleasurable dining experi- ence and must be evaluated when completing an assessment.

Medications

Chronic use of medication, either self-administered or prescribed, has the potential to significantly affect nutritional status. Many people mix prescribed drugs with over-the-counter medications. The RDN should review the medical record and interview the older adult to determine all medications and supplements taken. Anorexia, nausea, altered bowel functions, taste alter- ations, and drug-nutrient interactions are just a few examples of potential side effects. Lewis et al reported an average of two potential drug-nutrient interactions for each older adult in a nursing facility (see Chapter 17) (22).

Many of the drugs used to treat cognitive disorders, such as antidepressants, antipsychotics, antianxiety agents, and anticholinergics have the potential to cause significant side effects: increased or decreased appetite, nausea, dry mouth, dehydration, changes in bowel status, drowsiness, and anorexia (23).

Alcohol Abuse

Alcohol-related problems manifest themselves in a variety of physical and psychosocial forms, including alcoholic liver disease, alcoholic dementia, peripheral neuropathy, depression, insomnia, loss of libido, late-onset seizure disorder, confusion, poor nutrition, involuntary weight loss, macrocytosis, incontinence, diarrhea, heart failure, hypertension, myopathy, falls, fractures, inadequate self- care, and adverse drug reactions.

There is a strong, specific association between prior alcohol dependence and current or recent major depression (24). With older adults, substance abuse is often invisible, masked and complicated by lack of awareness or other health problems; signs of substance

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abuse may be mistaken for common signs of aging or dementia (25).

Physical Functioning and Feeding Limitations

Review of the occupational therapist’s and speech lan- guage pathologist’s consultations assist the RDN or NDTR in assessing the physical limitations (eg, inabil- ity to drink from a cup, need for special utensils) that affect the client’s nutritional status. Is the older adult alert, able to voice food preferences and able to remem- ber mealtimes? Have the older adult’s thought processes altered the ability to eat independently? Does the older adult display indications of paranoia related to food or meal service? An older adult may be forgetful but may still be able to eat independently if prompted by the caregivers. Sidenvall and Ek reported that 16 out of 18 older adults admitted to a nursing facility had difficulty with upper motor dysfunction or mouth or pharyngeal food handling and required assistance with meals (26). It is important to determine whether the older adult requires limited, extensive, or no assistance with meals and snacks. Older adults with physical limitations from conditions such as arthritis or strokes commonly need some assistance. The institutional use of and consequen- tial need for opening condiment packets or milk contain- ers involves hand-eye coordination. Physical concerns that affect eating are paralysis, lack of hand dexterity, or contracture to hands, which can make handling eating utensils difficult. Paralysis can result in chewing or swallowing problems that require modifying the texture of the food. Some older adults starting to eat inde- pendently have the stamina to feed themselves breakfast and lunch but tire before dinner.

ANTHROPOMETRIC MEASUREMENTS Anthropometry, the measurement of body size, weight, and proportions, is used to evaluate the nutritional status of clients. The RDN should ensure that the methods used to weigh and measure older adults are reliable, as accurate height and weight data are imperative and are often used as a primary screening and monitoring indi- cator. Loss of height, for example, is an early indicator of osteoporosis (27). RDNs should measure and record height annually or per facility policy and procedure; any weight loss should be immediately reviewed. Low body weight, when associated with illness or injury, increases the risk of morbidity (28). On the other end of the weight spectrum, obesity is common among nonambula- tory older adult clients whose energy expenditure is low; however, the prevalence of obesity decreases in extreme old age. Although overweight and obesity for the general population increases mortality and morbidity, some studies suggest that this declines over time and that