Nutrition in Older Adults

1. What Is Nutrition?

A basic fact of the living body is that it is never static. As cells and tissues wear out with daily use, the “trash is taken out” while new cells and tissues replace the old. This process, known as metabolism, is ongoing, especially during sleep. Nutrition refers to the body’s intake of food containing vitamins, minerals, proteins, fiber, fats, micronutrients, and other substances needed for the mobilization of chemicals and water to carry on metabolism.

A nutritional deficiency is usually present long before it becomes visible, so optimum health involves daily adequate intake of food and water. Natural food is the most beneficial form of nutrition because the body has evolved to take advantage of it with its many micronutrients, but laboratory-manufactured supplements are available as a backup.

Why Nutrition Is Especially Important to Older Adults

Nutritional needs vary during each life stage because of different primary activities. Because reproduction and child-rearing no longer drive behavior, elder adults require another kind of diet. The aging process takes a toll on the immune system, the speed of digestion, and the efficiency of tissue repair. In addition, issues like absent or damaged teeth and insufficient saliva production make eating more difficult.

2. Hydration

Humans are approximately 60% water because it’s used in all body systems. Without sufficient water, hearts couldn’t beat, brains couldn’t think, joints would stiffen, body temperature would rise out of control, toxins would accumulate, and intestines wouldn’t move.

2.1 Why Hydration Is Especially Important to Older Adults

Hydration is of special concern in the elderly. Statistically, they are chronically dehydrated. Many avoid drinking enough water due to mobility impairments that interfere with reaching the bathroom in time to prevent accidents. Such accidents cause disruptions not only with sleep but also interfere with social interaction. In addition, elderly people often experience a legitimate fear of choking due to dry mouth from the aging process compounded by dehydration. Also, a normal part of the aging process (and exacerbated by cognitive impairment) is the diminished thirst drive.  Elderly people frequently won’t have the hydration drive as to drink as much fluid as they need to maintain optimum health.

3. Undernutrition vs. Overnutrition vs. Malnutrition

3.1 Undernutrition

Undernutrition refers to a lack of the required amount of adequate food. It results from limited access to a sufficient quantity of food in general and from limited access to enough of the right kind of food. Undernutrition is a major problem in the elderly because decreased intake of vitamins and minerals prevents efficient tissue repair, leading to weakness and an increased risk of falling. Gradual muscle wasting, known as sarcopenia, is a normal part of aging as the body’s ability to effectively manufacture proteins decreases, making protein in the diet especially critical. Loss of muscle tissue leads to inactivity, compounding the problem of osteoporosis already compromised by insufficient calcium. The aging body also loses its ability to maintain the protective fat layers that preserve internal heat, so increased daily caloric intake becomes a necessity to sustain a normal body temperature.

As people age, they become prone to unwanted weight loss for reasons besides undernutrition. Malignant cancers, gastrointestinal disease, medication side effects and psychiatric or neurological conditions (such as dementia) are the most common causes that predispose people to undernutrition.

3.2 Overnutrition

Overnutrition refers to excessive food intake, often calorically dense with few nutrients. People overeat for various reasons: a cultural predisposition of poor dietary habits, history of suffering from hunger in the past, unrelieved malnutrition, endocrine and metabolic disturbances, emotional compensation for depression and loneliness, and cognitive disabilities. Imbalanced overnutrition can also result when people follow fad diets promoted on mass media and by well-meaning friends. Overnutrition is an important cause of obesity, which is the most common condition increasing morbidity and mortality.

3.3 Malnutrition

Malnutrition is a blanket definition that may involve undernutrition as well as overnutrition. It refers to an imbalanced diet providing inadequate amounts of proper nutrition. Common deficiencies all over the world affecting people in all age groups include scurvy (vitamin C deficiency) and kwashiorkor (protein deficiency). Osteoporosis affects everyone as they age, but a lack of bone-building nutrients including calcium, vitamin D, and magnesium puts older people at high risk for falls and fractures. Failure to thrive is heartbreakingly common, resulting from a tangle of interrelated causes that are frequently ignored as inevitable consequences of aging. Several medication may also predispose malnutrition.

Malnutrition in the elderly is best addressed by a team approach including the individual, the family, the caregivers, and the professional healthcare providers.

One recent example of potential malnutrition is the inappropriate use of the highly marketed gluten-free diet. Gluten is a protein found in many grains such as wheat, rye, and barley. A small percentage of the population demonstrates a genetic predisposition to developing an immune reaction against gluten, known as celiac disease, that can evolve into a medically serious condition when left untreated. However, it is important to note that the signs and symptoms of celiac disease are also characteristic of many non-digestive conditions. Celiac disease can only be diagnosed by a doctor. Although studies indicate that celiac disease is on the rise in the elderly, a gluten-free diet should not be initiated without consulting the personal healthcare provider. Unmilled whole grains are rich in vitamins, minerals, and fiber, making them a beneficial part of a nutritious diet.

4.What are the Barriers to Good Nutrition in Older Adults?

4.1 Poverty

Food is a topic for jokes among young people living on their own and unable to afford much more than ramen noodle packets, potatoes, rice, and hot dogs. However, the urban legend of elderly poor people eating cat food as a source of protein is no legend. In today’s society, government food assistance subsidizes a surprising number of nutritionally useless foods containing excessive amounts of sugar, fat, and salt. People on a limited monthly income find it difficult to afford healthful choices throughout the entire month. Since the onset of the pandemic in 2019, the need for food bank assistance has increased exponentially as families have lost their income and homes.

4.2 Difficult Living Conditions

Underused utilities to conserve money, dangerous neighborhood environments, violent social conflicts within the living environment, the presence of invasive pests, and neglect are all barriers to maintaining health in home and institutional settings.

4.3 Lack of Transportation

Many seniors no longer drive or have access to transportation to visit meal sites or to collect food to bring home.

4.4 Medications

All medications, whether prescription or over-the-counter, have side effects and interactions with other drugs. Unfortunately, several of these affect nutritional intake in the elderly, capable of causing nausea, loss of appetite, abnormal taste or smell, constipation, diarrhea, tremors, dizziness, sleepiness, confusion, or loss of coordination.

Examples include:

• Chronic proton pump inhibitor: Chronic proton pump inhibitor (PPI) can cause deficiencies in multivitamins, particularly B12
• Metformin: Metformin which is used to treat diabetes naturally will suppress apatite, therefore may become inappropriate in a person that is losing weight.
• Statin: Statin medication can sometimes decreased apatite and in very elderly patients their use should be carefully considered.

4.5 Medical Conditions

Several medical conditions and even past surgical operations can lead to malnutrition.

Example include:

• Gastro intestinal disorders: Celiac disease, pancreatic insufficiency, peptic ulcer, gallbladder, gastric bypass surgery can all cause issues with digestion and absorption of nutrients.
• Neurologic diseases: Conditions such  as dementia or stroke can impair appetite and ability to swallow.
• Lung disease: Severe COPD (Chronic Obstructive Pulmonary disease) can impair food intake by making it difficult without shortness of breath and the disease will also cause increased use of calories as the work of breathing becomes harder. It is not uncommon for people to appear like they are wasting away.
• Cardiac disease:   CHF (Congestive Heart Failure) can impair appetite as blood flow to the intestine is impaired.
• Kidney disease: When toxins in the body are not eliminated properly, this can impair appetite.
• Hormonal diseases: Both low or high thyroid hormone can impair appetite.
• Dental Diseases: Dental diseases can lead to pain with eating or inability to manage certain diets.

4.6 Mobility Impairment

Even when the home is filled with an abundance of nutritious and digestible food, a person must be able to get to it. Moving from one room to another at times requires great effort. Devices such as canes provide support but don’t eliminate unsteadiness, and leave the user one-handed. Holding a walker requires two hands. Oftentimes individuals are limited with only one functional arm or without being unable to lift either arm above shoulder level. Raw foods need to be washed and often sliced. Devices such as manual can openers require two functional hands; electric can openers can be messy if a person has tremors. Someone intending to heat food must be able to carry it to the heat source and then manipulate the buttons or dials. Carrying heated food is dangerous.

4.7 Sensory Impairment

Many sightless people are able to prepare food independently but only after the kitchen has been set up for them. Hearing is less important in food preparation than other senses but is still a strong factor in maintaining a safe home environment due to whistling tea kettles, crackling skillets, buzzing timers, and other such indicators that hearing people take for granted. The senses of smell and taste tend to decrease in acuteness with age, so an elderly person might not be able to detect mold or excessive salt in a dish that otherwise seems edible.

The sense of touch is critical for determining temperature and texture; a diner might not notice an overheated dish or a chunk of glass. The next time you take a bite, notice how you locate the food with your tongue and automatically move the food forward if it slides backward toward your throat before you’ve fully chewed it. If saliva builds up, you swallow without thinking so it won’t “go down your Sunday throat” — an old expression referring to food in your windpipe. Although most of these actions are spinal cord reflexes, they depend on your sense of touch. Pain from irritated nerve endings can range from distracting to disabling, and many analgesics cause excessive sleepiness.

4.8 Cognitive Impairment

In addition to your nervous system responses, your conscious mind is involved in the status of the food in your mouth, especially if something is wrong. Unlike you, people with dementia may not pause between bites but often stuff their mouths until their cheeks can hold no more. Cognitive impairment can block the ability to recognize edible from non-edible substances.

People with dementia may eat sticks of butter, raw hamburger, dry dog food, paper, hand cream, and anything else they can reach. Perception of time is another factor controlled by cognition, resulting in eating hurriedly without chewing or swallowing, usually unable to perceive social cues from others at the table. Conversely, a commonly reported observation is the inability to follow through with simple tasks such as consuming a meal due to high distractibility or episodes of sleepiness.

4.9 Depression

Only recently is the power and pervasiveness of depression being recognized by society, including the medical community. Although anyone can experience depression as a mood resulting from events, clinical depression is a biochemical imbalance in the brain now classified as a medical condition. The results can be crippling and are too often ignored in the elderly population. Signs and symptoms of depression in the elderly are ironically similar to several signs of malnutrition itself, including poor appetite, missing meals, desire for sweets, and lack of motivation and energy to prepare meals.

5. Ensuring Adequate Nutrition and Hydration

5.1 Summary of the Basic Functions of Nutrients

Based on some of the resources provided above, here is a list of the basic components of a healthful diet tailored to the aging body:

• Carbohydrates: Provide energy-giving calories.
• Proteins: Promote growth, tissue repair, immune function, muscle mass, hormones, and enzymes.
• Fats and oils: Provide energy, building blocks of certain cells, tissues, hormones, and enzymes.
• Water: Makes up most of the body as well as fluids such as urine, blood, lymph, and sweat.
• Fiber: Aids with digestion.
• Vitamins: Enable bodily functions.
• Minerals: Enable bodily functions, forms bones and hemoglobin.
• Special diets: Required by people with certain medical conditions as determined by the healthcare team; although fad diets have always been common, it’s important to discuss any questions with the doctor to avoid the possibility of losing valuable nutrients or overdosing on undesirable substances; special diets include diabetic, low-fiber, renal, soft-texture, and pureed, as well as those adjusted to individual allergies.

5.2 Resources on Seniors’ Special Dietary Needs

Awareness of the special needs of the elderly is critical. If necessary, a librarian or healthcare provider can assist in printing out information from the following online resources:

• https://www.myplate.gov/
• https://www.mealsonwheelsamerica.org/
• https://medlineplus.gov/nutritionforolderadults.html
• https://www.ncoa.org/article/healthy-eating-tips-for-seniors
• https://www.nutrition.gov/topics/whats-food
• https://www.webmd.com/diet/healthtool-food-calorie-counter

5.3 Ways to Improve Nutritional Intake in the Home Setting

Staying abreast of local and national news will ensure current information on programs for people suffering from food insecurity. In response to hardships directly caused by the COVID-19 pandemic, SNAP (Supplemental Nutrition Assistance Program, formerly known as “food stamps”) has been upgrading its monthly allocations. Local food banks, stressed by high demands, have attention to the reality of food insecurity. Some religious organizations and nonprofits offer free or low-cost meals.

Meals on Wheels is recognized one of the most important organizations that improves proper nutrition among older adults in the United States.

5.4 Helpful Members of the Healthcare Team

Several professionals may be involved in in older adults’ nutritional care, including:

• Dietician: Assesses patients’ nutritional and hydration status, then designs individualized menu plans.
• Speech therapist: Works not only with language but performs diagnostic swallow evaluations, teaches the preparation of foods and liquids with special textures, and demonstrates safe eating strategies.
• Occupational therapist: Examines individuals’ ability to perform tasks involved in independent eating and drinking; recommends assistive utensils such as plate stabilizers, thick-handled spoons, covered sipping cups, etc.; provides exercise regimens for strengthening muscles used in eating and drinking; recommends positioning strategies to ensure comfort during eating.
• Physical Therapist: May be able to help improve general muscle strength, balance, and stamina.
• Social Worker: Evaluates family situation to determine eligibility for various local, state, and federal programs; may assist with teaching effective learning techniques for patients, family, and caregivers with learning impairments, illiteracy, or transportation challenges.
• Registered Nurse: Assesses and integrates outcome of recommendations, assists with follow-up.
• Dentist: Regular professional dental care is imperative to maintain oral health.
• Primary Care Provider or Geriatrician: They can evaluate and treat underlying medical conditions. They can manage medications and their side effects. They can often recommend sources of local assistance as well as write referrals for insurance-funded consultations in the above disciplines.

5.5 How to Promote Good Dietary Intake in Older Adults?

• Fun: Meals should be something to look forward to. In the early 1960s, a candy bar commercial featured a bouncy tune urging children to “open wide for Chunky!” Singing a silly song from times gone by can often encourage someone to “open wide.” Anyone assisting elderly persons at mealtime should avoid giving orders but instead offer suggestions such as “Let’s both have another bite” or “Here’s another spoonful of soup.” Playing enjoyable familiar music that is meaningful to them will go a long way. It should go without saying that caregivers should focus on nothing else but their companions’ well-being.
• Comfort: The room needs to be at a temperature that’s comfortable according to the elderly individual’s standards. The lighting should be adequate without being too bright, and noise should be at a minimum. Clothing should be soft and loose without being twisted or binding, and the seating should be comfortable. It’s common courtesy to adhere to their past habits by making sure that their hands, face, hair, and teeth or dentures are clean. Pain medication should be administered in advance to give it enough time to take effect. Assisting them in the bathroom before the meal will prevent restlessness. Be aware that filling the stomach often stimulates the bowels to move, a natural action known as the gastrocolic reflex, so a bathroom trip after the meal may be in order.
• Simplicity: The table should be clear of clutter to prevent distraction from the activity of eating, especially for people with cognitive disabilities. Because many elderly adults contend with slowed thought processes due to medical conditions and medications, they often eat better when given extra time without being rushed.
  Empathetic visitors will call ahead to schedule the best times to drop by.
• Safety: Dentures need to be cleaned regularly to prevent choking and infection. A meal should be postponed if someone is too sleepy to effectively swallow. More dangerous is the possibility of silent aspiration, which occurs when small amounts of food slip unnoticed into the trachea without triggering a cough reflex, later resulting in a bacterial infection in the lungs. A safe alternative to large meals is to provide frequent small but nutritious snacks during waking hours. An elderly or disabled person should sit up at least half an hour after eating so regurgitation won’t interfere with breathing.
• Respect: If protective bibs are used, it needs to be appropriate for an adult rather than children. Some elders may feel more at home with shop aprons or cooking aprons instead of towels as protectors. Keep paper towels or wipes available to tidy food on the mouth and chin.

Nutritional Care Plan

Care plans should clearly outline preferences, safety precautions, and details of menus based on physician recommendations. Frequent small meals are best spread throughout the waking hours. As much as possible, each should contain natural, unprocessed fresh food including vegetables, fruit, protein, nutritious carbohydrates, and sufficient fluid.

Unless restricted, fluids should be readily available throughout the day. In general, heavier meals are better digested and utilized when served earlier in the day, and meals consumed nearer bedtime should be lighter. The resources listed earlier provide many more suggestions, including substitutions for vegan diets.

Final Thoughts

Our first real social contact at birth involved one-on-one attention and food. Why should that ever end? Mealtimes provide the opportunity to savor a few peaceful moments, especially if we can enjoy each other’s company. We can reminisce over old memories or create new ones. Now you know how to make meals nourishing for body and soul!