PADMINI SHANKAR, Ph.D., RD
Department of Family & Consumer Sciences,
As we enter the 21st century, the life expectancy of older Americans continues to increase and by the year 2030, nearly one-fourth of the total population will be comprised of the elderly. To maintain an optimal quality of life, extended longevity in the elderly should be accompanied by good health, free from disease and disability. However, many of these in dividuals in our society are at risk for malnutrition due to various physiological, socioeco nomic, and psychological factors. The Nutrition Screening Initiative founded in 1989 developed simple screening tools that increase public awareness about the risk factors that af fect the nutritional status of the aged. Family and Consumer Sciences professionals have a vital role to play in helping our senior citizens age well with health and functional independence.As we enter the 21st century, the life expectancy of older Americans continues to increase and by the year 2030, nearly one-fourth of the total population will be comprised of the elderly. To maintain an optimal quality of life, extended longevity in the elderly should be accompanied by good health, free from disease and disability. However, many of these in dividuals in our society are at risk for malnutrition due to various physiological, socioeco nomic, and psychological factors. The Nutrition Screening Initiative founded in 1989 developed simple screening tools that increase public awareness about the risk factors that af fect the nutritional status of the aged. Family and Consumer Sciences professionals have a vital role to play in helping our senior citizens age well with health and functional independence.Georgia Southern University
By the year 2030, nearly 22% of the total population will be comprised of elderly persons (65 years old and over), compared to 4% at the beginning of the 20th century.
America is in the midst of a demographic revolution as the life expectancy of older per sons continues to increase. By the year 2030, nearly 22% of the total population will be comprised of elderly persons (65 years old and over), compared to 4% at the beginning of the 20th century (U.S. Census Bureau, 1990). The fastest growing segment of the elderly population are the oldest-old (85 years and over), which grew by 40% between 1980 and 1990, while the population of all other ages grew by 10% (Smith, 1997). As the baby boomers continue to age, it is the re sponsibility of health care professionals to ensure that they maintain good health and functional independence, thereby enhancing their quality of life. This view is illustrated in the motto of the Gerontological Society of America (1998), “adding life to years, not just more years to life.” Adequate nutrition directly impacts the quality of life of the elderly, by promoting health and preventing dis ease and disability.
FACTORS INFLUENCING THE NUTRITIONAL STATUS OF OLDER AMERICANS
Nutritional status plays a vital role in the overall health of the elderly. Many of these individuals are at high risk for malnutrition (Wellman et al., 1996). Ponza et al. (1996) conducted a comprehensive evaluation of the Elderly Nutrition Program (ENP), which is the largest U.S. community nutri tion program, providing an average of one million meals per day to older Americans with the greatest economic or social need.
The study reported that more than two-thirds of the ENP participants are at risk for malnutrition. This concern is also re flected by Greeley (1990): “Without proper supervision, many millions of older Americans exist in a nutritional twilight zone, grappling with the daily challenge of eating—and often not eating well-bal-anced meals or any meals at all.” Malnutri tion increases morbidity and mortality among the elderly and results in lengthy hospitalizations. Nutritional imbalances are not entirely due to the process of aging and can be caused by other significant risk factors that include chronic diseases, inad equate nutritional consumption, poverty, and social isolation.
One important factor that can place the elderly people at nutritional risk is the prevalence of chronic diseases. Almost 80% of older adults suffer from at least one chronic degenerative condition such as heart disease, cancer, stroke, osteoporosis, osteoarthritis, diabetes, visual and sensory impairments, dementia, and depression (Barrow, 1996; Petrella, 1999; Reker, 1997). Mortality rates from circulatory dis ease increase with age more rapidly than cancer mortality rates. In 1990, cancer was the cause of nearly 40% of deaths in per sons aged 50–69 compared to 4% of deaths among centenarians (Smith, 1997). These chronic conditions can precipitate malnutrition due to loss of appetite, diminished smell and taste perceptions of food, and al tered nutrient digestion, metabolism, and utilization. Confusion or memory loss as sociated with dementia affects at least one out of five elderly people (Wellman et al., 1996) . Disease and disability increases the dependency of the over 80 population, with 33 % of them needing assistance with at least one basic activity of daily living compared to the 5–8% of those 65 years and older (Guralnik and Simonsick, 1993). Over 20% of the oldest-old have increased dependency due to their frailty and need longterm care (Silverstone, 1996).
Nutritional imbalances are not entirely due to the process of aging and can be caused by other significant risk factors that include chronic diseases, inadequate nutritional consumption, poverty, and social isolation.
Second, poor nutritional status is a cause for concern in the elderly. Nutrition ally inadequate diets can put them at risk for malnutrition, worsen chronic health problems associated with aging, and delay recovery from illnesses. The diets of many older Americans do not provide the re quired amounts of nutrients needed to maintain health and vitality. Calories, pro tein, calcium, vitamins D, B-12, B-6, and magnesium and zinc are most frequently below the recommendations for the elderly, whereas the intake of total fat, satu rated fat, cholesterol, and sodium is excessive (Weimer, 1997). Another trend seen among older people is the use of supplements to meet nutrient requirements rather than eating a balanced diet. In the U.S., nearly 50% of the 65 and over popu lation take vitamin or mineral supplements (Mulley, 1995). Due to the possibilities of nutrient toxicities and drug-nutrient inter actions, elderly people should be careful about using supplements. Moreover, ex cessive alcohol consumption can adversely affect the nutritional status in the elderly. Not only does alcohol displace essential nutrients from the diet, but [it] may cause liver disorders. In addition, older people are often at risk for urinary tract infections and dehydration because of inadequate fluid in take. Two major reasons that account for inadequate fluid intake are decreased re sponse to thirst and self-restriction of flu ids due to fear of urinary incontinence (Kendrick and Nelson-Steen, 1994).
Among the socioeconomic factors, pov erty can adversely affect dietary intake in the elderly. Lack of financial resources pre vents some elderly from buying nutrition ally adequate foods and also hinders them from accessing appropriate medical help to treat chronic conditions that arise as a result of malnutrition. The U.S. Bureau of Census (1999) reported that 36 % of the 65+ aged population reported an income of less than $10,000 for 1998, and the net worth was below $10,000 for 16 % of older house holds (including those of 75+ years). One of every six (17%) older persons was poor or near poor (income between the poverty level and 125% of this level) in 1998. Moreover, 1 % of the chronically ill elderly spent at least 25% of the household income on prescription drugs, and the financial burden is three times as high for the 75–84 year-old population compared to those aged 66–69 years (Rogowski et al., 1997).
A social factor that influences the nutri tional status of older people is social isolation. In a study of 516 adults aged 70–105 years, Horgas et al. (1998) reported that most (about 10.5 hours) of the day was spent alone and at home. Elderly, living alone, often lose interest in food; they may not feel the necessity to cook for themselves and this can lead to a diet inadequate in quality as well as quantity (Arcury et al., 1998).
NUTRITION SCREENING INITIATIVE
The Nutrition Screening Initiative (NSI) was founded in 1989 in an effort to main tain the health and vitality of the nation’s elderly and to reduce health care costs associated with the treatment of chronic disease conditions. The NSI is a collaborative effort led by The American Academy of Family Physicians, The American Die tetic Association, and The National Coun cil on the Aging. The primary goal of the NSI is to encourage the incorporation of nutrition screening and intervention as an integral part of the health care for the eld erly. The activities of the NSI are designed to increase public awareness about the fac tors that affect the nutritional status of the aged. The complications associated with malnutrition result in increased expenditure of health care dollars for the treatment of elderly people. Routine nutrition screen ing and intervention are cost-effective because they help health care profession als identify potential nutritional risk fac tors at an early stage.
As the first step toward identifying those elderly people at nutritional risk, the NSI developed a simple self-assessment tool, the Determine Your Nutritional Health checklist. The word DETERMINE is an acronym that stands for the nine warning signs: Disease, Eating poorly, Tooth loss/mouth pain, Economic hard ship, Reduced social contact, Multiple medicines, Involuntary weight loss/ gain, and Needs assistance in self-care, and El der years above age 80. The self-assess-ment checklist contains simple statements that address the nine issues mentioned above, with a numerical score for each is sue. A total score of six or more identifies the elderly person to be at high nutritional risk. Those at risk are then followed up with more elaborate screening proce dures: Level I and Level II screens. The Level I screen, administered by social workers and health care professionals, in cludes assessment of anthropometric (height, weight, body mass index) mea surements, adequacy of dietary intake, so cioeconomic (availability of food, social isolation) factors, and functional status of the elderly. The Level II screen, per formed by physicians and other health care professionals, helps identify serious nutritional problems. In addition to the Level I assessment criteria, Level II screening includes evaluation of lab data, cognitive status, and chronic medication use. Health professionals are encouraged to obtain the Nutrition Screening Initia tive assessment materials and use it as an integral component of routine health care for the elderly.
RECOMMENDATIONS FOR AGING WELL
Consume a Nutritionally Adequate Diet
As one ages, calorie needs decrease, whereas vitamin and mineral requirements remain constant. Older people should be encouraged to choose nutrient dense foods (for example, choosing fruit instead of soft drinks, fat-free cheese and whole-wheat crackers instead of cookies and ice cream). Other nutrients that should be consumed in adequate quantities to achieve optimal health are proteins (from fish, poultry, soy protein foods like tofu, legumes, low-fat dairy products), calcium (from low-fat milk and milk products, tofu, calcium-for-tified orange juice, kale, broccoli, fish with bones), vitamin B12 (from low-fat meat, poultry, fish, low-fat cheese, fortified cere als), vitamin D (from fortified milk and milk products, fortified cereals, and fatty fish), fiber (from vegetables, fruits, le gumes, and whole-grain cereals), and at least 6–8 cups of water every day.
A sedentary lifestyle is an independent risk factor for cardiovascular disease, which is the leading cause of death in older people. Some of the significant health benefits of exercise in the elderly are prevention of os teoporosis, control of Type 2 diabetes and hypertension, and decreased incidence of coronary artery disease. Physical activity can increase muscle strength even in the frail elderly (Mulley, 1995). Light exercise like brisk walking for at least 30 minutes a day, 4–5 times a week is a good way to in corporate physical activity for a healthy lifestyle.
Choose Nutritional Supplements Carefully
Older people should be advised to eat a balanced diet instead of relying on supplements for their nutrient requirements. There is a lack of evidence to support the claims of many of the supplement manu facturers and false advertising often misleads the elderly people. It is important to be aware of nutrient toxicities arising from supplement usage. However, the use of vi tamin E supplements in the elderly has proven to beneficial due to their immuno stimulatory properties (Meydani, 1995).
Limit Alcohol Consumption
Excessive alcohol consumption is associ ated with many liver, cardiovascular, gastrointestinal, and neurological disorders (Patterson and Chambers, 1995). There is some evidence that low-to-moderate alco hol (especially red wine) consumption is as sociated with cardio-protective properties.
The focus of health care delivery should be more on the promotion of a healthy lifestyle rather than the treatment of chronic conditions.
Smoking is a major risk factor for circula tory, respiratory, and malignant diseases. Elderly people should be encouraged to avoid smoking and using tobacco products.
As we enter the new millennium, the great est triumph of science and technology is the extended longevity of human beings. It is, however, essential that longer life be accompanied by good health, free from dis ease and disability. Rowe and Kahn (1997) have defined “successful aging” as multi dimensional, encompassing three compo nents, namely, “the avoidance of disease and disability, the maintenance of high physical and cognitive function, and sus tained engagement in social and produc tive activities.” Optimal nutritional status is vital to maintain good health and func tional independence in the elderly. Peri odic screening to identify nutritional risk factors and early nutrition intervention in the elderly are essential to delay the onset of disabling conditions and to prevent costly hospitalizations. A recent report by the National Academy of Sciences, enti tled The role of nutrition in maintaining health in the nations elderly: Evaluating coverage of nutrition services for the Medicare population reiterated that nutri tion services are an integral component of the comprehensive approach to the treat ment of many chronic conditions affecting the nation’s elderly. The proposed Medi care portion of charges for coverage of nutrition therapy during the 2000–2004 period is estimated to be $1.43 billion.
Family and Consumer Sciences profes sionals have a pivotal role to play in help ing our senior citizens successfully grow old. Many of the chronic diseases in older people are preventable by adopting good nutritional habits throughout life. The fo cus of health care delivery should be more on the promotion of a healthy lifestyle rather than the treatment of chronic conditions. The Nutrition Screening Initiative’s assessment tools have made it easy to iden tify potential risk factors in the aging pop ulation. We should treat every encounter with the elderly as an opportunity to educate and provide resources that will help them age well with good health and vitality.
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From Journal of Family and Consumer Sciences, 2000, Vol. 92, No. 2, pp. 37-39. © 2000 by the American Association of Family & Consumer Sciences.