1. Issues in Nutrition for the
Frail Elderly
Presented by:
Jonathan Hjelm, PharmD, BCPS, BCNSP, CGP
Clinical Pharmacist
Monique Dowd, MA, RD, LDN, CSG, CDE
Clinical Nutritionist

2. Learning Objectives
Upon completion of this session, the learner will be able to:
1. Discuss physiologic changes associated with aging as
related to nutrition
2. Think about how nutrition influences health and
aging
3. How is nutrition status is assessed
4. Become familiar with nutritional risk factors
5. Understand implications of under- and over-nutrition
for PACE programs
6. Overview nutritional interventions in the context of a
PACE member
7. Identify geriatric nutrition resources

3. Overview
• 1 in every 8 Americans is 65 years of age or older.
• 10,000 Americans enter Medicare each day.
• By 2030 this age group will be double what it was in
2000 (from 35 million to 72 million or 20% of US
population).
• According to US Census Bureau projections, the oldest-
old population could grow to 19 million by 2050. The
impact of nutrition is particularly crucial for successful
aging.
 Lack of tailored nutrient recommendations for
older adults

4. What Age is Elderly
• Older adults are not a homogenous group since the
later years of adulthood can span 35 years or more
• There is no single, chronological timetable of human
aging.
 Genetics, lifestyle, and comorbid disease processes affect
the rate of aging.
 Assessment of nutritional risk depends on a variety of risk
factors:
 Assess overall health and quality of life
Young old (65-74 years) Old (75-84 years)
Oldest old (85-99 years) Centenarians (100+ years)

5. Increase in Demands
• Hospitalization rates increased slightly to 336 per
1000 Medicare enrollees in 2007, with an average
hospital length of stay = 5.6 days.
• 4% of total population ≥ 65 years lives in a long-
term-care setting whereas 15% of adults ≥ 85 use these
facilities.
• Skilled nursing facility stays increased significantly from
28 per 1000 Medicare enrollees in 1992 to 81 per 1000
enrollees in 2007.
• Use of home care services also increases with age.

6. Nutrition – A Call to Action
• Lack of adequate studies, defined methods, and
standards
• Multiple factors that restrict interpretation of available
data (e.g. genetic factors, social environment,
economic status, selection of food, weak methods of
assessing nutritional status)
• Several surveys have been performed
 Do not adequately indicate poor nutritional status
or marked deficiency among older individuals in
the US
 Suggest that intake relates more to health and
poverty than to age

7. Integration of into Geriatric Assessment
• While the number of older adults with obesity has
increased from 22% to 38% over a 12 year period,
malnutrition continues to pose a significant threat
to older adults.
• One way to address this threat is for better
integration of nutrition into the comprehensive
geriatric assessment.

8. Comorbidities

9. Leading Causes of Death in US (CDC)
• Heart disease: 616,067
• Cancer: 562,875
• Stroke (cerebrovascular diseases): 135,952
• Chronic lower respiratory diseases: 127,924
• Accidents (unintentional injuries): 123,706
• Alzheimer's disease: 74,632
• Diabetes: 71,382
• Influenza and Pneumonia: 52,717
• Nephritis, nephrotic syndrome, and nephrosis: 46,448
• Septicemia: 34,828

10. Aging and Nutritional Status
• Almost 80% of older adults have at least 1
chronic health condition and 50% have at
least 2 or more.
• The most costly chronic health conditions
include heart disease, stroke, cancer, and
diabetes.
• Food insecurity and/or Lack of access to
appropriate foods may lead to nutritional
issues, which can have a major impact on
health, the ability to maintain independence,
and quality of life.

11. Aging and Nutritional Status
• Several parameters are used in assessing
nutritional status in older adults.
• The effect of the aging process on lean body
mass is so great that it remains a poor
reflection of nutritional status in older adults.
Assessment Component
Weight Global
Body mass index (BMI) Total fat
Skin fold Percent fat
Waist:hip ratio Central adiposity
Upper arm circumference Lean body mass

12. Aging and Nutritional Status
• For frail older adults, physiological changes
associated with aging can make it difficult
to consume an adequate diet.
• These individuals may need additional
supplementation to their diet to provide
adequate nutrition.

13. Physiological Changes Associated with
Aging That Affect Nutrition Status
System Affected Physiological Change
Body Composition Body fat increases while LBM decreases. Loss of LBM can
affect ability to perform ADLs.
Body Structure A decline in bone density can cause fractures and result in
a period of decreased physical activity and social
interaction.
Enzymes Production of some pancreatic enzymes declines, which
could affect digestion and absorption.
GI tract Older adults have an increased risk of GERD, which can
affect swallowing and foods consumed. Abnormal bacterial
overgrowth might impair digestion and absorption. Liquids
seem to empty from the stomach more slowly with age.
There may be decreased digestion and absorption of
protein and decreased absorption of calcium and vitamin
D. Colon dysmobility may result in constipation.

14. Physiological Change Continued
System Affected Physiological Change
Mouth Missing teeth and deterioration of gums can affect
chewing and swallowing and may contribute to oral
dysphagia. Discomfort and mouth pain can reduce food
intake.
Neurologic Decline in cognition, steadiness, reactions, and
coordination can decline, potentially affecting food and
beverage intake.
Sensory changes Taste perception (dysgeusia) or smell perception
(hyposmia) may be altered with aging and/or chronic
disease. Ability to see, hear, smell, and taste may all
decline with age, resulting in decreased intake. Taste and
smell are closely tied together and loss of one sense may
affect the other sense.
Urinary tract Kidneys decreased in size and function. Age is a risk factor
for chronic kidney disease, leading to increased frailty,
anemia, and depression

15. Nutritional Requirements in Older
Persons
Vitamins Unchanged in older persons
Protein 0.5 to > 1 g/Kg/day
Amino acids Unchanged to increased
Calcium 850-1200 mg/day
Calories Declines by 12.4 Kcal/day/year
from maturity to senescence

16. Reversal of Deficiency by
Supplementation
• There is no impairment of vitamin or
protein absorption in older adults. Data
demonstrate conclusively that low vitamin
levels in older adults can be corrected by
dietary supplementation.
• Higher risk of Vitamin B12 deficiency
• Vitamin D screening

17. Nutritional Screening and Assessment
• It is essential to have a solid nutrition-
screening program in all settings that serve
older adults.
Setting Time Frame
Acute Care 24 hours of admission
Skilled Nursing Facilities 5 days
Other Long-Term-Care
Settings
14 days
Home Care Upon first RN visit
PACE Within 30 days of enrollment
and then annually or as
needed.

18. Evaluation of Nutritional Status
• Up to 25% of all elderly patients may be
suffering from malnutrition.
• Nutrition Screening focusing on the elderly
to promote early intervention as a part of
routine health care for the elderly.
• Collaborative effort

19. Nutrition Screening and Assessment

20. Critical Questions in Assessing a
Patient for Malnutrition
1. Is there any reason to suspect malnutrition?
2. If so, of which nutrient(s) and to what
extent?
3. What are the pathophysiological mechanisms
(e.g. alteration in nutrient intake, digestion
and absorption, metabolism, excretion, or
requirements)?
4. What etiology underlies the
pathophysiological mechanism(s)?

21. Factors That Place Older Adults at Risk
for Malnutrition
• Drugs (e.g. reserpine, digoxin, antitumor
agents
• Chronic disease (e.g. congestive heart failure,
renal insufficiency, chronic GI
disease/conditions
• Depression
• Dental disease and impaired swallowing
• Decreased taste and smell
• Low socioeconomic level
• Physical weakness
• Isolation

22. Nutrition Screening Tools
Screening Tool Tool Identifies Link
Mini Nutrition
Assessment SF
Geriatric individuals ≥ 65 who
are malnourished or at risk for
malnutrition
http://www.mna-
elderly.com
Short Nutritional
Assessment
Questionnaire
(SNAQ)
Identifies patients at risk for
malnutrition.
SNAQ-RC:SNAQ-RC: for older adults in
care home or residential
setting.
SNAQ-65+:SNAQ-65+: for 65+ in
community.
http://www.fightmalnutriti
on.eu/malnutrition/screeni
ng-tools/
Simplified
Nutritional
Appetite
Questionnaire
Identifies risk for significant
weight loss within 6 mo for
older adults in community
and/or residential care settings
http://www.slu.edu/readst
ory/more/6349

24. Nutrition Diagnosis and Intervention
• After the comprehensive nutrition
assessment, the RD will determine a
nutritional diagnosis (i.e. increased need for
protein related to increased demands for
healing as evidenced by delayed wound
healing).
• Determine what nutritional interventions
should be taken based on the comprehensive
nutrition assessment.
• Interventions should be individualized to
needs and desired outcomes.

25. Essential Components for a Comprehensive
Nutrition Assessment
• Height, current weight, usual body weight, weight history, and significant changes in weight
(>5% in 30 days, or >10% in 180 days)
• Current food and fluid intake adequacy compared with calculated nutritional needs
• Eating ability (able to feed self, requires assistance, needs total assistance)
• Interview with the individual and/or family or staff for food preferences and tolerances
• Medications that may affect food/fluid intake or tolerance (food-medication interactions)
• Other factors that may impact nutritional status (such as chewing/swallowing ability,
gastrointestinal problems, depression, pressure ulcers, wounds)
• Signs/symptoms of dehydration (such as poor skin turgor, flushed dry skin, coated tongue,
oliguria, irritability, confusion)
• Current nutrition interventions (such as food or dining interventions, oral nutritional
supplements)
• Monitoring and evaluation of nutritional status and outcomes
• Intolerances and allergies: drug allergies, food allergies or intolerances, food or fluid
aversions
• Dental/oral: chewing and swallowing ability, dentition.
• Mental status: altered cognitive function, altered mental status, dementia, Alzheimer disease
• Cultural factors: religion, customs that influence eating

26. Nutrient Needs for Pressure Ulcers
Based on Individual
Assessment
Prevention Treatment Goals
Calories/Kg body
weight
30-35 • 30-35
• Adjust calories as needed based on weight loss or gain, or level of
obesity
• Increased calories may be needed for individuals who have had
significant unintended weight loss
• 50%–60% of calories from carbohydrate sources
• Least restrictive diet when intake is poor
• Enhanced foods or oral medical nutritional supplements if needed
(between meals)
• Nutrition support if needed and if consistent with the individual’s
goals of care
• Promote anabolism
• Prevent or correct under
nutrition, protein-energy
malnutrition, unintended weight
loss or regain lost weight
Protein, g/Kg body
weight
1.25-1.5 • 1.25-1.5 when compatible with goals of care
• Reassess as condition changes
• Monitor renal function
• Promote a positive nitrogen
balance
• Prevent or correct protein-
energy malnutrition
Fluids, mL/Kg body
weight
1 mL of fluid
intake per
KCal per day
• Adequate fluid to promote hydration
• Monitor for signs and symptoms of dehydration
• Additional fluids needed for insensible fluid losses
• Estimate either using 30 mL/Kg body weight or 1 mL/Kcal
consumed
• Promote sufficient hydration
• Correct known dehydration
Vitamins/ Minerals • Encourage a balanced diet with good sources of vitamins and
minerals
• If deficiencies are confirmed or suspected, provide
supplementation up to 100% of US RDI
• If deficiencies present, provide <40 mg of elemental zinc daily
• Provide adequate nutrients for
prevention or healing
• Correct any known deficiencies

27. Geriatric Problems
• Weight Loss
• Sarcopenia
• Dehydration
• Swallowing
• Dementia
• Pressure Ulcers
• Constipation
• Depression

28. Optimal Weight
• Weight is a primary parameter
• Standard tables vs. Trends
 Identify unintentional weight change
 Attention to individual trends
• Optimal Weight
 Maximize function and quality of life
 Minimize risk from disease or
comorbidities

29. Weight Trends
• Gradual weight gain during middle
age
• Peak weight occurs around age 75
• Gradual weight loss after age 75

30. Weight and Mortality

32. Weight and Mortality

33. Increasing Calories
• Energy requirements are dependent on
activity and physiologic stress levels
• 30 Kcal/Kg based on IBW
• Basal Energy Equation ?
 Harris Benedict Equation
 Multiply X factor of 1-1.5
• Use more frequent meals and consider
supplements or snacks to boost caloric
intake

34. Obesity
• The prevalence of obesity among older
persons is growing (30.5% in NHANES)
• Although increased mortality rate from all
causes extends into the seventh decade,
controversy exists about the potential
harms of obesity in older adults and the
relation between obesity in old age and
total or disease specific mortality.

35. Obesity
• A meta-analysis indicated that being overweight
(BMI 25-29.9 Kg/m2
)is not associated with a
significantly increased risk of mortality in older
adults.
• BMI in the moderately obese range
(BMI>30Kg/m2
) is only associated with a
modest (10%) increase in mortality risk.
• Central fat and relative loss of fat-free mass
may become relatively more important than
BMI in determining the health risk associated
with obesity in older age.
Janssen and Mark, 2007

36. Obesity
• However, obesity causes serious medical
complications, impair quality of life, can
exacerbate the age-related decline in
physical function, and lead to frailty.
• Self-reported functional capacity,
particularly mobility, is diminished
• Have a greater rate of nursing home
admissions
Villareal et al., 2005

37. Nonpharmacologic Treatment
 Primary approach is to achieve lifestyle change.
 In younger overweight and obese patients, no
particular combination of protein, carbohydrate,
and fat in weight loss diets offers any advantage
in losing weight.
 Moderate exercise at 90 min/3x/week and
caloric reduction 500-700 Kcal/day can lead to
weight loss of 10% and improved functional
status.
 Bariatric surgery is often not an option

38. Pharmacological Treatment
• Consider if BMI≥30 or 27-29 if comorbidities
• Weight loss of 10-15% is considered good and >15% is
excellent.
• Orlistat (Xenical, Alli) 120 mg every 8 hours, has the longest-
term data on safety and efficacy.
• Locaserin (Belviq) 10 mg every 12 hours. Discontinue if <5%
weight loss in 12 weeks.
• Phentermine-topiramate (Qsymia). Begin 3.75 mg/23 mg daily
for 14 days then increase. Evaluate weight loss following dose
escalation to phentermine 15 mg/topiramate 92 mg ER after
an additional 12 weeks of treatment. Do not use if CV disease
or HTN
• Other drugs have limited effectiveness or high potential for
adverse effects or abuse.

39. Sarcopenia
• Is the progressive loss of muscle mass and
function resulting in decreased strength,
aerobic capacity, and functional capacity
• Is a multifactorial disease process that may
result from low hormone levels (estrogen
and testosterone), protein and vitamin D
deficiency, decrease in physical activity,
chronic inflammation, and insulin
resistance
• Decline is greater in men than women

40. Sarcopenia
• Prevalence in adults > 60 years is 8% to 40%
and increases to 50% for those > 75 years old
• Estimated healthcare costs of $18.5 billion
• Hispanic men and women have higher rates
• A serious component of sarcopenia is
diminished functional capacity
• 20% of older adults in US are functionally
disabled, and risk of disability is 1.5 to 4.6
times higher in older persons with sarcopenia

41. Dehydration: Causes
• Decreased thirst sensation with aging
• More dependent on others to obtain fluid
• Decreased ability to concentrate urine
• Increased incidence of incontinence with
self-imposed fluid restriction
• Increased use of medications contributing
to dehydration
• Increased losses: vomiting, diarrhea, fever

42. Dehydration: Symptoms
• Decreased Skin Turgor
• Dry Mouth and Mucosal Membranes
• Decreased Urine Volume
• Darker Urine
• Constipation
• Acute Weight Loss
• Confusion

43. Dehydration Management
• Treat Cause
• Set Fluid Goal
• Goal: 30 mL/Kg or 1 mL/Kcal
• Replace Additional Fluid Losses
• Drink Fluid At and Between Meals
• Use Foods Which Have Fluid Value

44. Swallowing Problems
• Swallowing is difficult or hard to initiate
• Wet sounding voice
• Aspiration pneumonia history
• Loss of fluid through the nose
• Leakage of food out of mouth when eating
• Overt coughing or choking with oral intake
• Weight loss
• Involve speech therapist
• Nutrient density
• Go for least restrictive

45. Dementia
• Weight loss is presented as the primary
nutritional problem
• Stage of disease
• Eating behaviors (e.g. distracted at meal
times, eating without utensils, consume
non-food items, eating pieces that are too
big, resist eating).
 Eating is not just food
 Barometer of well being
 Social interaction

46. Case Study
Mrs. B. is a 67 year old cognitively intact
member of PACE, who lives alone and has
limited mobility. Her PMH includes HTN,
asthma, angina and obesity. She has a current
BMI of 34. She has recently had an
unintentional weight loss of 10% in just the
last month. Her medications are as follows:
hydrochlorothiazide, theophylline, and
Norvasc. Mrs. B. has been referred to the
PACE Dietitian for further assessment.

47. Case Study Questions
1) Is the member’s weight loss considered
significant? Why?
2) In the nutrition assessment, what are some of the
nutrition risk factors that the Registered Dietitian
should screen for?
3) What conditions/diseases should the NCP or
physician attempt to rule out?
4) Is Mrs. B taking any medications that have
potential side effects of decreasing appetite?
5) If Mrs. B’s pre-albumin came back from the lab
with a value of 10, what would be the best
supplementation? Why?

48. Resources:
• Oley Foundation. http://www.oley.org
• ASPEN – American Society for Parenteral and
Enteral Nutrition. http://www.nutritioncare.org
• INCC – Infusion Nurses Certification Corporation.
http://incc1.org
• INS – Infusion Nurses Society.
http://www.ins1.org
• NHIA – National Home Infusion Association.
http://nhia.org

49. Thank You!Questions?

50. Thank You!Thank You!

51. References
1. Agarwal E, Miller M, Yaxley A, Isenring E. Malnutrition in the elderly: A narrative review. Maturitas. 2013; 76:
296-302.
2. Chernoff R. Issues in geriatric nutrition. Nutr Clin Pract. 2009; 24 (2): 176-178.
3. Dorner B, Posthauer ME, Friedrich EK, Robinson GE. Enteral nutrition for older adults in nursing facilities. Nutr
Clin Pract. 2011; 26 (3): 261-272.
4. Jyrkka J, Enlund H, Lavikainen P, Sulkava R, Hartikainen S. Association of polypharmacy with nutritional status,
function ability and cognitive capacity over a three-year period in an elderly population.
Pharmacoepidemiology and Drug Safety. 2011; 20: 514-522.
5. Karkeck JM. Invited review: Nutrition support for the elderly. Nutr Clin Pract. 1993; 8: 211-219.
6. Kiesswetter E, Pohlhausen S, Uhliq K, Diekmann R, Lesser S, Heseker H, Stehle P, Sieber CC, Volkert D.
Malnutrition is related to functional impairment in older adults receiving home care. J Nutr Health Aging. 2013;
17 (4): 345-50.
7. Landi F, Cruz-Jentoft AJ, Liperoti R, Russo A, Giovannini S, Tosato M, Capoluongo E, Bernabei R, Onder G.
Sarcopenia and mortality risk in frail older persons aged 80 years and older: results from ilSIRENTE study. Age
Ageing. 2013; 42 (2): 203-209.
8. Landi F, Marzetti E, Martone AM, Bernabei R, Onder G. Exercise as a remedy for sarcopenia. Curr Opin Clin Nutr
Metab Care. 2014; 17 (1): 25-31.
9. Martone AM, Onder G, Vetrano DL, Ortolani E, Tosato M, Marzetti E, Landi F. Anorexia of aging: a modifiable
risk factor for fraility. 2013; 5 (10): 4126-4133.

52. References
10. Mijan de la Torre A, de Mateo Silleras B, Perez-Garcia A. Guidelines for nutrition support in the elderly. Public
Health Nutrition. 2001; 4(6A): 1379-1384
11. Nieuwenhuizen WF, Weenen H, Rigby P, Hetherington MM. Older adults and patients in need of nutritional
support: Review of current treatment options and factors influencing nutritional intake. Clinical Nutrition. 2010;
29: 160-169.
12. Posthauer ME, Collins N, Dorner B, Sloan C. Nutritional strategies for frail older adults. Advances in Skin & Wound
Care. 2013; 26 (3): 128-140.
13. White JV, Brewer DE, Stockton MD, Keeble DS, Keenum AJ, Rogers ES, Lennon S. Nutrition in chronic disease
management in the elderly. Nutr Clin Pract. 2003; 18: 3-11.
14. Strandberg TE, Strandberg AY, Salomaa VV, et al. Explaining the obesity paradox: cardiovascular risk, weight
change, and mortality during long-term follow-up in men. Eur. Heart Jour. 2009; 30: 1720-1727.
15. Persson MD, Brismar KE, Katzarski KS, et al. Nutritional status using Mini Nutritional Assessment and Subjective
Global Assessment predict mortality in geriatric patients. J Am Geriatr Soc. 2002; 50: 1996-2002.
16. Rubenstein LZ, Harker JO, Salva A, et al. Screening for undernutrition in geriatric practice: developing the Short-
Form Mini-Nutritional Assessment (MNA-SF). J Gerontol A Biol Sci Med Sci. 2001; 56A: M366-M372.
17. Janssen I, Mark AE. Elevated body mass index and mortality risk in the elderly. Obesity Rev. 2007.; 8: 41-59.
18. Villareal DT, Apovian CM, Kushner RF, et al. Obesity in older adults: technical review and position statement of
the American Society for Nutrition and NAASO, The Obesity Society. Am J Clin Nutr. 2005; 82: 923-934.