Nutrition in the Elderly

Mouth to Stomach

o Decrease taste, smell and vision

o Decrease saliva
o Decrease gastric acidity
o Decrease gastric movement
Appetite

o Decrease smell, taste

o Medications
o Physical conditions
o Availability of food
o Unable to prepare food
o Lack of social contacts
Carbohydrates

o 4 serving per day

o Decrease intake

o Increase complex carbohydrates / fiber

o 4 calories/ gm

Protein

o 2 serving per day

o Intake same (0-6 gm/kg/day)
o Example:
-

100 grams meat = 18%

- 100 grams fish = 28%

100 grams mushroom = 33%

4 calories / gram

Fruits: 2 serving per day

o Papaya
o Watermelon
o Apple
o Orange
o Banana
o Mango
Vegetable: 2 serving per day

o Leafy: spinach
o Non Leafy: carrots, Potato

Cholesterol and saturated Fats

o decrease caloric intake

o Food high in fat / cholesterol: red meat, o talk to doctor

shell fish

o Preparation:
o food (Hard )
o Gravies (coconut milk)
o Baking (Butter)
Water:
Salt intake

o Salt intake decrease

o Limit
o preserved foods
o salted fish
o soy sauce
o instant nooddles
o Use garlic, onions, ginger,chinese
parsley, chili
Vitamins

o decrease absorption

The Bone Buster: Calcium

o First symptom: Fracture

o Recommendation: Amount
- Menopause: 120 mg/day
- People with osteoporosis: 1500 mg/day
- Older adults: 100 mg/day

o Nutritional Assessment
o Meals on Wheels
o Shopping for food of older persons
o Cooking for Older Person

Diet

o Buying of supplements

o Supplements

o Food Ration

o Check label
- elemental calcium
- amount of tablet per day
- take through out the day
Reading food labels

o No cholesterol , cooking oil

o Super refined deodorized palm olein,
peanut oil and sesame oil

o Oyster sauce
- oyster extract 30.0%
- soy sauce 25.4 %
- sugar

22.5%

- salt

19 %

- corn starch 3.0%

Helping Older Person with Meals

Eating: Special Challenges for Problem

Areas

o Chewing/ Swallowing
o Special considerations
- Getting the food into the mouth
- Dementia: Learn to manage
- Poor grip
Special Consideration:
Dentition

o Keep mouth clean

o Brush teeth and dentures
o Ensure dental fit properly
o Dental Exam

o Modify food preparation

o Food falls out of mouth while eating

Common Causes:

Aspiration

o Stroke - weakness , swallowing

o It went down the wrong tube

o Alzheimers disease forgetfulness

o Protective mechanism

o Parkinsons disease weakness , tremors ,

swallowing

- gagging
- sneezing

o Medications

- reflexive cough

o Other

choking

Signs of Swallowing Problems

- forced expiration

o No Protective Mechanism

o Mouth constantly open

o Airway totally obstructed

o Coughing, drooling and choking

o Breathing stops

o Recurring chest infections

o Skin turns blue

o Pocketing of food

o Know the heimlich maneuver

o Excessive chewing and taking a long time General Guidelines for Eating
to eat
o Environment
o Weight loss
- Quiet , relaxed
o Gurgly wet voice
o Regurgitates through voice
o Slurred speech

- Avoid eating when tired, upset,

stressed
- ensure adequate lighting
- avoid talking while eating
Dentition

- allow enough time 20-25

How help with Common Problem

o Flatulence, burning sensation,heart

o Regular exercise
o Small frequent and meals and snacks

burn

o Belching / bloating
o Difficulty chewing
o Constipation

Activities and Exercise

for older person
Benefits of Exercise

o Prevent falls by maintaining / reversing

the normal ageing process

o Poor Appetite

o Poor appetite

o Prevents common killers by reducing;

Benefits of Exercise

o Eat smaller frequent meals

weight

o Avoid alcohol, carbonated beverages

BP

cholesterol

-stress

and high fat food

including (coconut milk)

o See dentist
o Cut food into small pieces and chew
slowly

o Prevent constipation

o Eat whole grains, vegetables and fruits o Enhances sleep

o Improves / maintains
o Water ( 6-8 glassess)
o Limit greasy and fatty foods and high
fat, sweets and meat

o mental well being

o ability to do activities

o emotional well being

o Lives independently

o Wear appropriate clothing/shoes

o Warm up

o Prevents contracture and deterioration o Begin slowly, increase gradually

o Regain abilities
General safety

o All exercise must be tailored at the

persons abilities.

Environmental Safety

o Obstacle free environment

o Stop if you feel

o giddy
o pain
o -discomfort
o Go at own pace
o Remember: Water

o Avoid throw rugs

o Use walking aid
o Use high sturdy chair with arms
Personal Safety

Types of exercise

o Aerobic exercise
o Aerobic / endurance
o 3 times per week

o Consult doctor

o 20 minutes

o Learn proper techniques

o Breathless

o Check condition each day

o Walking, swimming,bicycling, dancing

o Strength Exercise

o Maintain abilities

o Weight lifting

o physical

o Resistance exercise (Thera-band)

o mental

o Flexibility Exercise

o Maintain self esteem

o Yoga

o Prevents boredom / depression

o Stretching

o Give meaning / purpose to life

o Badminton
Exercise According to abilities

Types of Activities

o Physical

o Bed bound - ROM Exercise

o Strengthening

o Wheel chair and weight exercise

o stretching

weight bear during transfer

o Walking aids walk within homes

o Fully ambulant walk within
neighborhood, swim or

o cycle

o endurance
o Mental
o Social
o Spiritual

Activities for Older Person

o Benefits of activities

Activities must be individualised

o Interest

o Abilities

o Safety

o Older person must find it

o Encourage self expression

o enjoyable

o Opportunities for interaction with

children

o meaningful
o sense of achievement

Adapting Activity

o Poor eyesight/tactile sensation ;

enlarged items

Example of activities

o Reading

o Poor hearing : instructions in written

o Music

o Slow response time; adapt the rules of

o Arts and craft

o The activity you plan should be

form or though demonstrations

the game / use slower moving items

meaningful.

o Games
o Outdoor activities
o Reminiscence

Falls, Fracture and Prevention

Dysfunction of Gait, Balance and
Mobility
Gait: limitations of walking

8-19% of non-institutionalized older

adults have difficulty of walking or
require assistance of another person or
need a special equipment to walk.

o Home making/ child care

Among non-institutionalized adults

Activity Planning

o Involves older person

o Variety and flexibility

aged 85 and over the prevalence can

be higher as 40%
Among the adult nursing home
residents it reaches 60% or higher

Falling
A fall is considered to have occurred
when a person come to rest

inadvertently on the ground or a lower

level.
Falling exclude the association of the
level of consciousness (seizure) and
other overwhelming events such as
violent or sudden onset of paralysis
One of the most common and
challenging problems in caring for the
older person

About 30% of community dwelling

elderly older than 65 experience falls

every year
Number increases to more than 50%
after the age of 80

Philippine Leading Causes of Death 65

years and older

Heart disease
Cancer

CVA
- syncope, heart attack, MI

Sensory deficit
- poor vision, cataract
- vertigo

Nutritional
- malnutrition, dehydration

Assessment
Careful assessment of the fall and
circumstances
surrounding the fall

Determination of syncope and near

syncope leads to a different diagnosis
and work up.

Is there a subacute metabolic or

infectious or sensorial change?

Is there a drastic change in ability to

ambulate?

CVA
COPD/COLD
Pneumonia/Inlfuenza
Diabetes
Accidents

Multifactorial Causes of Falls

Extrinsic
- environment and the activity itself

- stroke,parkinsons

Intrinsic
- Health problems of the individual

Many ascribe their fall to a slip

nadulas lang ako or sudden
weaakness; bumigay ang tuhod ko
but more than often than not, theres
is more to the story.
Risk factors:

Physical Assessment
Consequence
Fracture

Fear of falling
Increase in cost of care
Disability
Death
fall Fracture disability - death

Osteoporosis

Osteopenia
- bone thinning

Multiple drug

Subdural hematoma

Osteoporosis
- decrease bone density
- results in increase fracture

- alcohol intoxication

Infection
- UTI, pneumonia

Late warning signs of osteoporosis

loss of height nor stooped posture

However most people are not aware of

their bone loss until bone is broken.

Mental
- delirium, dementia
- Anxiety, sleep deprivation
Neurological

Fall Prevention
Extrinsic Factors in the home

- Safety inspection
- Emergency needs

Intrinsic or Patient Factors

Balanced
Strength
Nutrition
Mental health
Medication

Prevention: Home Safety

Clutter free environment no
obstruction
careful with pets

Recognized walking path

Slip-resistant floors
Dry slightly rough tiles
No rugs, mats and cords
Grab bars and railings
Safe and well maintained furniture
Sensory support

-well lighted corridors, bathroom

- night light
- visible switch
- no candles and oil lamps
- no glare floor

Fire Prevention
-

Fire exits and fire extinguishers

Fire alarm
check kitchen and gas stove regularly
no open flames and candles

Exercise to Improve Strength and

Balance

Balance
- Tai chi
- Calisthenics
- Yoga

Strenthening
- weight bearing
- weight training
Stretching

Prescription to Healthy living: Exercise

(DOH)

Diet to Improve Bone and Muscle

Strength
Minerals
- Calcium 1500mg / day
- food sources: milk, green leafy
vegetables ,
sardines, tofu
- Vitamin D 400 IU / day
- source: sunlight
Drugs with Excess Potential for Severe
Outcome in Patients over aged 65
Analgesics
- Pentazocine or oral meperidine
- Respiratory depression
- CNS adverse effect ex. delirium
Anxiolytics
- Barbiturates, meprobamate on long
acting benzodiazepine (LABD)
- Addiction, excess sedation, leading to
falls and confusion
- LABD seizure, palsy, withdrawal from
SABD

Anti-depressants
Tricyclic Anti-depressants
-ex. Amitriptyline , Amoxapine,
Clomipramine, Doxepin

High Risk Urinary Retention

Sedation
Anti-cholinergic side effects

Physical Restraints: Warning

Trying up a patient in bed or chair

Cruel punishment and torture

More harm than good
More deaths repeated
What to do if an elderly patient
Falls?

Recognize a fracture:
What does a fracture look like?
- externally rotated leg
- shorter leg on side of the fracture
- Bruise or hematoma
- bulge or deformity hip

Proper transferring

Isolate
Sprint
Protect
Ask for help
Call for ambulance

When should I call the doctor?

LOC
Seizure
Confusion
Head injury
Abnormal position of legs or arms
Severe pain
Bleeding or open wounds
Limping or unsteady walking

Important numbers and resources

Have a checklist with the following

name and numbers to call

Geriatrician in charge
Hospital ER
Ambulance company
Fire department
Police department

SPLAT Information: Symptoms Previous

Falls, Location, Activity and Time
In addition please be prepared to
answer
- How old is the patient?
- Is he / she frail?
- What other medications does the
patient have?
(source: Amerian Geriatric Society
Guidebook
Know the answer to the following
questions before calling the doctor
SPLAT Information: Symptoms Previous
Falls, Location, Activity and Time

In addition please be prepared to

answer
- How old is the patient?
- Is he / she frail?
- What other medications does the
patient have?
(source: Amerian Geriatric Society
Guidebook
Example of Good Emergency call to a
doctor

I am Ning Santos, caregiver of

Dionisia Pacquiao, a patient of Dr.
Miguel Ramos. She fell around 9 p.m.
(time), while standing in a bathroom
(activity and location)
She is complaining pain in her right hip
and leg on that side is turned outward
and seems shorter than the other one
(symptoms). She is unable to move
because of the pain.( Mention the
persons size if extra help will be
needed to lift her)

What information is needed by the

doctor?
Know the answer to the following
questions before calling the doctor
SPLAT Information: Symptoms Previous
Falls, Location, Activity and Time
In addition please be prepared to
answer
What do I bring in the ER?
- How old is the patient?
Medical Records
- Is he / she frail?
- What other medications does the
- lab results
patient have?
- blood type
(source: Amerian Geriatric Society
- list of allergies
Guidebook)
List of medicines
Know the answer to the following
- brown bag
questions before calling the doctor
Advance directives

- who is the legal decision-maker?

Benefits of surgery
To resume previous levels of activity

adoption of behaviors designed to

defer passage of the clinical horizon of
the chronic disease of the adulthood
heart ds, cancer, stroke, diabetes
until the final phase of life, thereby
compressing morbidity into a brief
period (3-5 years), before death
ensues at the age programmed for the
individual and, in the aggregate, for
the human species.

The person can get up and start

walking with the help of PT almost
immediately after surgery.
Control of pain

Decrease disability and death from

immobility
Managing pain at home
Non Pharmacological
- cold compress
- splinting area of fracture
- liniment
-no massage to area

Pharmacological
- Paracetamol
- NSAIDS
- Request for prescription to other

types

Goals of Preventive Gerontology

Longevity
Compression of morbidity
Characteristics of Older Persons
that Impact Health Promotion Strategies
Heterogenecity

Increased risk for disease / disability

Multiple pathologies often present
Iatrogenic problems are common and

frequently recognized
Motivating the person after fall
Physicians Concern
Treat medical problems that could
Patient expectation and needs,
contribute to general weakness.
including quality of life, satisfaction
Recognize a depression or anxiety and
and reassurance.
get proper treatment
Physicians need for diagnostic
Positive words of encouragement
certainty
Maintain dignity
Physicians comfort with risk taking
Encourage family support
and concerns about malpractice
Resume activity outside the home.
The need for cost effective medical
Preventive Health Care for the elderly
Wellness, well-being, being healthy
use interchangeably

Wellness, a state of being, an attitude

and on going process (Travis, 1977)

It also involves, physical ,emotional

,mental, and spiritual, ones whole
being.

Wellness is another way to describe

quality of life.
Preventive Gerontology

Focuses on strategies to enhance

individual and population wide

care
The CGA
Can give guidance to clinicians

Uses physical, functional and cognitive

status as a guide in clinical decision
making.
Screening services for General Elderly
Population (65 and older)
BP

Height and Weight

Vision screening
Hearing impairment
CBE and mammogram

 FOBT and sigmoidoscopy

Pap smear

Vision Screening for Frail OP

There is insufficient evidence to

Hypertension for Frail OP

Extensive literature documenting the

benefit of detection and treatment of
systolic and diastolic hypertension in
those 60-80 years.

Periodic screening for hypertension

recommend for or against routine

fundoscopy by primary physicians.
Similarly screening for glaucoma for
primary physicians is of uncertain
benefits.

Periodic referral to specialist for such

screening is appropriate.
should occur at each visit or every 1-2
Hearing
Screening
years for all elderly.
High frequency hearing loss
Hypertension in the old old particularly
Hearing impairment contributes to the
those with co morbidities, should be
social isolation
treated cautiously to avoid
complications such as orthostatic
Recommends yearly testing and
hypotension
education non treatment options
Screening for Obesity
questioning elderly patients regarding
The risk for obesity and weight related
hearing difficulty with otoscopy and
audiometric testing for patients who
disease such as DM, hypertension,
report difficulty
hyperlipidemia,CAD, degenerative joint
disease, OSA with increased advancing Screening for Breast Cancer
age.
Benefits of CBE and mammography
Period measurement of the height and
Definite for 50-69 years
weight for all patients.
Weak for 70- 74 years
Yearly computation of BMI or Waist
Completely lacking for 75 years and
-hip ratio for healthy adults 60 years
above
and above.
Screening Recommendations for Breast
Cancer
Measures of Nutritional Status
For women older than 50 years
underweight
Teach SBE
normal
Annual CBE and mammography
Overweight
(ACOG, ACS)
Obese 1
For women between 50 and 69 years
Obese 11
CBE and mammography 1-2
Obese 111
years
For Women above 70 years
Vision Screening for Frail OP
Insufficient evidence to benefit
There is insufficient evidence to
Recommendations for
recommend for or against routine
screening women this age who
fundoscopy by primary physicians.
have reasonable life
Similarly screening for glaucoma for
expectancy maybe based on
primary physicians is of uncertain
other grounds.
benefits.
Breast Cancer Screening
Periodic referral to specialist for such
screening is appropriate.

 There is an increasing concensus to

Screening for Prostate cancer

Although screening for prostate cancer

continue annual or biennual
mammography and annual CBE as
inceases with age, the benefits for
long as women remains reasonably
treatment become less clear, given the
healthy within 5-10 years life
slow progression of the disease.
expectancy.
Routine DRE and PSA examinations for
Despite the lack of evidence
all men
concerning women aged 70 and over,
Until more definite evidence is
there is no reason to believe screening
available, healthy men under 65 0r 70
would be less effective in this age
should be counseled about the
group.
potential benefits and known harms of
Screening for colorectal cancer
associated with screenings, specially
Incidence increases with increasing
PSA.
age
Screening in the very old or frail person
is not indicated.
Screening methods and modalities
Screening for diabetes
- DRE , FOBT, Sigmoidoscopy,
Every two years for 60 years and
Colonoscopy,
above
Barium Enema
Screening Recommendations
There is insufficient evidence to
Screening recommendations for
recommend for or against screening
the general population for diabetes.
average risks ( no personal or family
history of cancer or polyps
Clinicians may choose to screen high
Total colon exam (Barium or
risk persons notably older obese
patients, but the net risk and benefits
colonoscopy) every 10 years
of screening elderly persons remains
FOBT annually, flexible sigmoidoscopy
unclear
every 5 years
Considerations in Immunizing the Old old
In the case of positive family history, if
As opposed to influenza vaccine for
only 1st degree relative was affected
which herd immunity is an issue
after age 60 , the person remains at
pneumococcal vaccine is probably not
average risk
apprpriate in the severely in whom
FOBT annually, flexible sigmoidoscopy
palliative care is planned.
every 3- 5 years
Every two years for healthy elderly 60
years and above