44 CHAPTER 4 | Nutrition Assessment of Older Adults


food models, cups, and measuring spoons to help the older adult identify portion sizes. Family or caregivers who are included in this process may help provide additional insight into the older adult’s eating pat- terns. If the assessment occurs in the home environ- ment, health care providers have an opportunity to access cupboards, pantries, and the refrigerator and freezer to determine the types, quality, and quantity of food available.


In the community setting, it is common for older


adults to experience a lack of food security, a lack of transportation, and an inability to prepare food.17 (Food insecurity is discussed later in this chap- ter.) Older adults who are frailer may have reduced strength and mobility to shop for or physically carry groceries. The diet history should be complemented with any SDoH to identify root causes that may neg- atively affect nutritional intake. For example, if the older adult’s typical intake is 75% less than usual, it is important that the health care practitioner look beyond physiological factors such as decreased appe- tite and investigate other potential factors.


Food and Nutrient Intake General and Therapeutic Diets


The diet order can be a regular, modified, or ther- apeutic diet prescribed by the primary care practi- tioner or RDN (if allowed by state statute, permitted by the facility’s medical director and medical staff, and stated within a policy approved through the facil- ity’s processes). The diet order is documented in the medical record as part of the treatment plan. Older adults may have previously followed a modified diet prescribed at disease onset; they may have received structured diet education or counseling from a health care professional or selected their diet after reading commercial books or using online resources. Assessment of the diet order should include the


older adult’s current nutritional status and the poten- tial effect of limiting or increasing nutrients. Restricted diets are known to pose nutrition problems, especially for older adults who previously enjoyed eating a vari- ety of foods. Limitation of nutrients, such as sodium or fat, often leads to reduced intake, which can lead to weight loss. In studies conducted with older adults with diabetes, following a calorie-specific diet vs a


controlled carbohydrate diet did not lead to signifi- cantly different outcomes.18-20


Other studies reported


that in long-term care, the benefits of a liberalized diet outweigh the risks for most older adults. The Acad- emy of Nutrition and Dietetics position on individ- ualized nutrition approaches for older adults details the positive benefits of a liberalized diet.21


Food is an


important part of life and should meet basic nutrition needs while enhancing quality of life. An estimation of energy, fluid, and protein needs should be completed for each older adult and is dis- cussed in the following sections.


Energy Needs


Indirect calorimetry is the gold standard for deter- mining energy expenditure, but this is unrealistic in most settings with older adults.22


RDNs can thus


use predictive equations when estimating energy needs for most older adults. Several methods exist for estimating energy requirements (refer to Box 4.3).23 Cioffi and colleagues24


observed that none of the


predictive equations provided precise resting energy expenditure calculations in healthy older adults, but the Mifflin-St Jeor and Harris-Benedict equations had the most accurate predictions. To estimate kilocalo- ries, calculate the resting metabolic rate and multi- ply by an activity factor and an injury factor (when applicable).25


Deciding which method to use is gen-


erally based on data availability and the older adult’s clinical status. Several online calculators can be easily accessed to calculate energy needs. Box 4.4 on page 46 shows a shortcut for estimating adult energy needs per kilogram.23


Fluid Needs


Baseline fluid requirements can be determined by several methods. In older adults, water accounts for approximately 50% of the person’s weight, which is 10% less than in a younger adult.26


This decrease


is associated with a corresponding decrease in lean body mass.23


Older adults tend to have a decreased


thirst sensation; even healthy adults have reduced thirst after extended water deprivation. Meeting fluid needs is critical for overall health.


Adequate total water intake is set at 2.7 and 3.7 L/d for females and males aged 51 years or older,


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