Under-nutrition in Elderly People - Report Example

Name : xxxxxxxxxxx Institution : xxxxxxxxxxx Course : xxxxxxxxxxx Title : Under-nutrition in elderly people Tutor : xxxxxxxxxxx @ 2009 Under-nutrition in elderly people Introduction Much emphasize is usually placed on the importance of good diet mainly in the context of concern about the dangers of obesity while ignoring underweight and undernourishment faced by the elderly. This under-nutrition is attributed to a combination of age-related social, physical and psychological factors. This condition referred to as failure to thrive or anorexia of the elderly is linked to morbidity and increased mortality. Under-nutrition is a very frequent condition among the elderly. Studies have revealed that almost 15% of the elderly people eat less than 1000 calories a day while only about 30% of poverty stricken elderly individuals eat over 1000 calories on daily basis. 1000 calories a day are barely enough to support and sustain weight and nutritional status of a person (Tufts University 2002). Elderly people in institutions are the worst affected with one-quarter to about two-thirds of nursing home patients being malnourished and undernourished. Health and nutrition survey indicates that the body mass indices that are more than 30 pounds overweight are healthier for the elderly people than they are for ideal body weight. It can therefore be concluded body mass indices of between 26 and 28 are the healthiest for the elderly people in terms of reduction of mortality rate. A study that was carried out on four million people indicated that body mass indices which exceeded 25 were the most appropriate for many people. Some factors that are associated with nutritional deficiencies include eating low nutritional quality foods such as bread and butter, general and specific inadequacies due to change of needs as a result of co-morbidity and complex medications and unnecessary restrictive diets. Another significant factor is physiological and pathophysiological changes in the gastrointestinal system which influences ingestion and digestion of nutrients (Furchtqott 2006) Effects of under-nutrition The population of the elderly people is increasing and the number of people over 75 years is expected to double in the next 50 years. As a subset of the population, older people are the major users of health and social services resources although they are many times the most economically disadvantaged group. Most of the elderly individuals lead healthy and independent lives though the incidence of frailty, disability and illness increases as they grow older. Of the independent older people 3% and 6% of the men and women respectively are underweight. The figures rise to 16% and 15% respectively for nursing and residential care (Tufts University 2002). The general consequences of under-nutrition include decrease in function ability, delayed wound healing and increased risk of infections. Due to rapid weight loss, the functions of both the gastrointestinal and cardiovascular tissues are impaired. The people affected may look depressed and apathetic due to loss of muscle strength and increased fractures. There at times have incidences of pressure sores and particular micronutrient deficiencies. Elderly people whose nutrition has deteriorated are at risk of getting affected by cancer, cardiovascular heart failure, COPD, liver cirrhosis, renal failure and depression. Some of these consequences are fatal if ignored and thus under-nutrition is a sensitive aspect of nutrition especially with the elderly (Department of Health 2002). A survey carried out in the private household indicated that over a half suffered from terminal illness or some form of a disability while one in every five had problems with their sight even with glasses. Other observations were that one in every ten of the older people was unable to walk properly or even use the stairs while one out of every ten had seen a medical doctor in the preceding three months. Of the people observed half of the women and a quarter of men age above 85 years and beyond were unable to prepare meals. Older people have physiological disadvantages and they also have unique nutritional requirements different from those of normal adult population. Working with these vulnerable members of the population requires an understanding of their fundamental needs (Wilson, et al, 2009). Malnutrition is diagnosed by a collection of clinical and biochemical symptoms and signs. The most significant biochemical marker has been albumin although it has various problems. One of the problems is that the half-life of albumin is 21 days and thus changes in a persons nutritional status of the week prior to their testing can not be reflected in the serum albumin. Another problem of notable significance is that albumin is sensitive to alterations in vascular volume. Cholesterol levels can also indicate under-nutrition whereby cholesterol less than 160 is termed as malnutrition. Transferrin less than 200 though confounded by iron status, lymphocytopenia of below 1800 are also regarded as malnutrition. Lymphocytes which are less than 1000 are indications of severe malnutrition (Wilson, et al, 2009). Of the types of protein calorie malnutrition is kwashiorkor. This is actually pure protein starvation where proteins in the albumin are decreased. The level of calories is at many times adequate which evidenced by the obesity noted in some people. Such people are obese because they consume foods which are low in protein density while they contain high levels of carbohydrates. Another type of malnutrition that elderly people face is cachexia or marasmus type malnutrition which is characterized by a combination of both protein and calorie starvation. Victims of marasmus do not get enough food and they exhibit a history of consistent weight decline and a cachectic appearance. A point worth noting here is that the body starts by metabolizing skeletal proteins before it metabolizes visceral protein. Since albumin is not skeletal protein, the body preferentially metabolizes fat stores. Elderly people who are malnourished are at a risk of getting infections and have a weakened immune system. They have poor ability of healing wounds while they are poor surgical risks. They also have difficulty in healing up their decubitus ulcers (Wilson, et al, 2009). Barriers to appropriate nutrition for the elderly There are various reasons why old people are susceptible to under-nutrition. A common and obvious reason is the deterioration in taste, sight as well as smell which are the pleasurable qualities of eating food. One of the reasons that people eat is because they enjoy the food or the act of eating. Many of the elderly people also eat because they enjoy eating too although quite a number of them eat because they understand that failure to eat is bad. They thus eat for the sake of eating since they have lost all the pleasurable or hedonic aspects of eating. There are also swallowing disorders particularly in dementia and stroke. These people thus face a lot of difficulty in getting the appropriate amounts of calories and proteins orally. Dental problems add the list of the difficulties that these people face in handling under-nutrition. Other reasons include poverty, alcoholism, and bereavement especially for the widowers. Men who have spent most of their lives depending on their wives for their meals are likely to underfeed in case the wife passes on (Bulduci 2008). Oral factors Barriers to access and administration of proper health care leading to under-nutrition among the elderly are mainly a combination of several factors that affect the elderly. The factors can be classified into various groups. One of the categories is the oral factors where the victim experiences swallowing problems as a result of stroke, Parkinson’s illness or any other neurological disorder. Difficulty in swallowing automatically leads to malnutrition due to underfeeding. Other causes of swallowing problems include worsening of the dentition and periodontal disease leading to ill fitting dentures and candida. Another category is the manual dexterity. This is characterized by frail skin on hands, peripheral vascular disease and osteo and rheumatoid arthritis. Hands can also be lost through stroke, Parkinson’s disease or any other neurological disorder. Loss of hands implies that the person has to depend on others for feeding or doing other activities such as preparing a meal. In case the person is left alone, then he/she will not eat and this could lead to poor feeding patterns finally resulting to under-nutrition (Bulduci, 2008). Social-economic factors Another category is the social-economic factors. Elderly people are at times isolated and have limited access to shops. They are therefore unable to purchase foodstuffs for themselves. This makes them skip meals leading to poor feeding patterns. Bereavement is another factor leading to under-nutrition. Most f the elderly people have lost their spouses leaving them with in isolation. The feeding pattern is bound to change under these circumstances since the person has to adapt to leaving or eating alone. In case the man is left, then serious problems are likely to be encountered since men have traditionally been known to depend on their wives for feeding. Disparity Psychological and physical barriers usually affect access to health and social care among the elderly which is influenced more by poverty rather than race. Discrepancy in access to health care among the elderly has well been observed and documented in many countries. The basic reason to this discrepancy is lack of health insurance cover which is usually employer-sponsored or public. In America for instance, more than 16% of people aged 65 years and older who are not covered have been victims of chronic illnesses such s diabetes, heart disease and depression. Majority of these people did not get appropriate medical attention due to its high cost. Though the most important affecting the ability of many elderly people to access health services has been lack of insurance, there are other factors that have slowly emerged. Such factors highly correlate with failure to have insurance cover. Race, level of income and various sociodemographic features have been to poor health care both among the elderly and also in younger populations (Deborah 2009). Dementia A characteristic of the aging process in the population has been a rise in the rate of dementia especially Alzheimer’s disease. It is estimated that there are more than four million cases of dementia all over the world. As dementia approaches the final step, patients are unable to walk or even eat by themselves, they are usually incontinent and aphasic and they do not have the capacity or capability of having relationship with other people. Family members are left with the only option of limiting care to their loved ones. The family members are left with a difficult decision to make of whether they should approve surgery, hospitalization, intravenous medication. The form of treatment is usually burdensome to a person who can not comprehend its importance and who is approaching the last stages of life (Morley & Thomas 2007). Poverty Poverty also results to poor feeding patterns due to inability to purchase appropriate food types considering that not every type of food is appropriate for the elderly. Due to poverty most of the older forks are unable to access proper health care services. As a result, under-nutrition or other medical complications are not diagnosed at all or diagnosed early enough in order to affect the necessary precautions. As mentioned earlier, most of the elderly people affected by under-nutrition are those found in institutions that care for the elderly. In the institutions, the people are limited in terms of the types of foods they can access. Generally the feeding pattern is altered and the people will probably not feed well in the institutions (Breitung 2002). Another factors leading to under-nutrition is malabsorption which leaves the victim prone to successive infections and bacteria overgrowth mainly after previous surgery or due to achlorhydria. Other factors that bar elderly people from access to appropriate health care services include diminishing sensory ability, taste variations, decreased smell perception, hard of hearing and decreased appetite. The elderly are left in a position in which they are unable to discern the best for themselves. They could also be affected by drugs or alcohol resulting to poor eating patterns. To the extreme, the elders might be affected by chronic disease and disability which totally changes their lifestyles (Breitung 2002). Another factor that hinders the elderly people faced with under-nutrition from accessing appropriate health care services is the failure by family members and health professionals in making quick and rational decisions concerning the elderly. Elderly people affected by dementia are required to be fitted with artificial nutrition and hydration systems a decision many family members are reluctant to make. Most of the family members can not accept that their family members have to be fitted with feeding tubes in order to survive but still face the difficult situation of watching the die due to malnutrition. The situation is however changing with many family members claiming that they would rather stand the site of watching their loved ones fitted with feeding tubes other than watching them die in starvation. They are thus left with no other chose apart from authorizing the placement of feeding tubes (Cavanaugh & Whitbourne 2003). A study carried out among 1446 physicians and nurses found out that 30% of the practicing physicians maintain that even if other forms of life support services such as dialysis or mechanical ventilation were to be stopped, nutrition and hydration should not be stopped. This is a boost towards eradication of under-feeding since it has become easier to arrive at the decision of inserting feeding tubes to patients with advanced dementia. Such patients are faced with difficulties in swallowing and often lose interest in eating. Percutaneous endoscopic gastrostomy tubes are widely used in many countries with over 200,000 elderly patients fitted with the tubes all over the world (Cavanaugh & Whitbourne 2003). The health professionals play a significant role when handling dementia victims since they have the responsibility of making ultimate decisions concerning the victims. In many cases, surrogate decision makers for patients of dementia who choose the gastrostomy tubes for feeding usually arrive at the decision due to their desperation to extend life and avert aspiration pneumonia. This is because they are determined to prevent suffering, or because their religious beliefs and other values demand that sustenance must be upheld (Sheikh & Yalom 2003). Solutions to under-nutrition in the elderly Under-nutrition in the elderly is an issue that has been under discussion in various nations throughout the world. This is a reality that has just been unfolded. The data and statistics from the surveys done in this field reveal that the situation is serious and worrying since it concerns more than 40% of this population subset who have eating problems. Although no serious measures have been taken to control the situation in many countries, attempts have been done by various agencies to control the situation (Sheikh & Yalom 2003). Assessment of Nutritional Inadequacy An assessment of the nutritional inadequacy in the elderly is the first step towards overcoming the barriers that the elderly face in their efforts to get appropriate health care services. Unless their nutritional needs or their nutritional requirements and/or deficiencies are identified, proper medical care can not be provided. Nutritional assessment is mainly done by evaluating the eating patterns of an individual by checking specific aspects such as appetite, the groups of foods included in each meal and whether the person is enjoying the meals. Mini Nutritional Assessment also known as behaviour questionnaires can also be applied. In some cases biochemical and clinical analysis is done (Murphy 2006). Assessment of nutritional inadequacy is based on the recommendations for intake of nutrients by the populations which are known as Dietary Reference Values. These are the standards for intakes or energy for each nutrient. If there is concern for inadequacy of a person’s diet, a registered Dietitian will assess the composition of the individual’s diet by dietary analysis and recommend the necessary health care services. Another method of assessing the nutritional inadequacy in an elderly person is by performing laboratory tests. The tests measure the concentration of specific nutrients or variable by a specific nutrient in a tissue. For instance, serum hemoglobin, albumin or individual micronutrients can be analyzed (Morley & Thomas 2007). Another method of assessing nutritional inadequacy is anthropometry which involves the individual’s weight, height and Body Mass index (BMI). These are simple but useful measurements for assessing nutritional requirements. In some case, skin fold breadth, arm circumference and grip strength measurements can be carried out. Nutritional screening is another method that qualified nursing staff can use to assess nutritional adequacies among the elderly people. Nutritional screening tools that focus on nutrition requirements for the elderly have been devised to assist the nursing staff to administer appropriate health care facilities to patients. In order to ensure that elderly people are accorded proper healthcare services, nutritional screening should be a regular activity and should not be carried out only when suspicious cases arise. Since tools for these purposes are available, then the exercise should be done on routine basis (Deborah 2009). The Role of the Health Professionals Health professionals have a huge role to play in ensuring that elderly people get appropriate health care services at the time of need. Using the information generated from the tests carried out, the health professionals should take the necessary action plans to ensure that the elderly people access proper healthcare services. The nutrition support to be offered will vary between clinical cases but could also involve use of oral nutritional supplements and input from a dietitian. It can be deduced from the ongoing discussion that nutritional status for the elderly depends on a number of factor which are correlated (Deborah 2009). One nutritional program that is directly involved in ensuring that the elderly people access proper healthcare services is the development program launched in Canada. The objective of the program is to eradicate the nutritional risks associated with under-nutrition, choking and controllable death in the elderly which resulted from inadequate level of food intake. The program has taken care of a number of victims and has been able to establish data that is applied in making decisions concerning nutritional requirements for the elderly (Deborah 2009). New Standard of Care Proper healthcare services for dementia patients are hindered y some legal or regulatory barriers. Although many cases of artificial nutrition and hydration have been equated with medical therapy, the standard approach towards eating problems in patients with dementia has encountered severe resistance. To ensure that dementia patients get appropriate treatment, many courts have insisted that surrogate decision makers provide evidence that the decisions they are making on behalf of the patient are in line with the patient’s initial preferences. In order for a surrogate decision maker for the patient to withdraw feeding tubes, some courts require that valid evidence that the patient would not have preferred the tubes. All these arguments are based on the fact that tube feeding is a life-sustaining procedure and that the state has an obligation of protecting life (Deborah 2009). Feeding Tubes The invention and application of the feeding tubes was a major step towards the provision of appropriate healthcare services to elderly people facing under-nutrition. A gastrostomy tube is fitted into a patient to offer nutrition and hydration. This is particularly useful to patients suffering from dementia. Although it has been argued that the feeding tubes only provide adequate nutrition only in theory but fail to do so in reality, the tubes have proved to be very useful and of great help to many patients. The application of the tubes is however faced with various problems such as diarrhea, clogging of the tubes and in some cases patients unplug the tubes due to discomfort (Deborah 2009). Conclusion It can be deduced from the above data that there is an interconnection of factors influencing nutritional status for the elderly. These factors involve the process of aging, illness and diseases, medications and social-economic factors. Elderly people are at a great risk when they are hospitalized, nursing or residential care in their homes. The responsibility of caring for the nutritional requirements of the elderly lies with health professionals who are supposed to identify nutritional problems and propose appropriate methods of handling them. A combination of physical changes and decreased availability and social context of food has resulted to low levels of nutrition. With decreased physical exercise and energy needs among the elderly, nutritional intakes may be minimized to levels of under-nutrition (Sheikh & Yalom 2003). It is recommended that dietary assessment be included as part of the general geriatric assessment. Elderly people should be encouraged to eat healthy foods and avoid snacking. They should also be encouraged to consume high quality drinks or supplements and be cautious with prescribed medical diets. Cases of malnutrition should be identified early enough so as to take the necessary precaution measures before the situations become critical. Bibliography Breitung, J.,2002, The Elderlycare sourcebook. New York: Mac Grow-Hill. Bulduci, L., 2008, Blood Disorders in the Elderly. Cambridge: Cambridge University Press. Cavanaugh, J & Whitbourne, S., 2003, Gerontology: An Interdisciplinary Perspective. Oxford: Oxford University press. Deborah, Y., 2009, Taking Care of Our Folks: A Manual for Family Members Caring for the Black Elderly. New York: iUniverse.com. Department of Health, 2002, Report on Health and Social Subjects 31 - The Nutrition of Elderly People. Committee on Medical Aspects of Food Policy. HMSO Furchtqott, E., 2006, Aging and Human Motivation. New York: Springer. Morley, J. & Thomas, D., 2007, Geriatric Nutrition: Nutrition and Disease Prevention. London: CRC. Murphy, M., 2006, The use of the Mini-Nutritional Assessment (MNA) tool in the elderly orthopaedic patients. Eur J Clin Nutr Rev 1996; 54:555-62 Sheikh, J. & Yalom, I., 2003, Treating the elderly. London: Jossey-Bass. Tufts University., 2002, Keep fit For life: Meeting the Nutritional Needs of Older persons. New York: World Health Organization. Under-nutrition in elderly people Rapin, The Journal of the Royal Society for the Promotion of Health.2001; 121: 142-143. Wilson, J et al., 2009, Lecture notes: Elderly Care Medicine. New York: Wiley-Blackwell. Read More