Nutrition Requirements

During the middle years, cell loss rather than replication occurs. Kcal needs decline as lean body mass is lost and replaced by body fat that is less metabolically active. Women in particular experience an increase in body fat composition. Body fat increases can be slowed by exercise and strength training to continue maintenance of lean body mass. After age 50, daily energy needs drop from 2200 to 1920 kcal for women and from 2900 to 2300 kcal for men. It is a challenge to meet the same nutrient needs with reduced kcal intake. Protein needs remain constant for both genders. Iron requirements for women drop from 18 to 8 mg, which reflects reduced iron loss because of menopause. (See also Box 7-1 or Box 8-3 regarding nutrients and their functions.)

Overall, dietary patterns that are nutrient dense and feature lower-fat protein foods coupled with fiber-containing fruits, vegetables, and grains best meet the nutrient needs of middle-year adults.

Physical Activity

A lifetime of physical fitness and good nutrition allows an individual to enter these years with more stamina, cardiovascular conditioning, and solid health-promoting habits that enable him or her to overcome the inevitable slowing down or physical limitation of the later years (Figure 13-4). Even those who were not always active have been shown to benefit from regular exercise. Strength training has improved the muscle tone and stamina of older men and women.³

Physical, Mental, and Emotional Functioning

During these later years, individuals may struggle with the deaths of family members and friends and adjustment to retirement. Although some delight in retirement, others view retirement as a loss of social status. This combination of death and loss of status may lead to isolation and depression, leading to loss of appetite (anorexia) or other forms of malnutrition. The economic realities of retirement without a solid financial base may thrust some older adults into unexpected poverty, because Social Security and Medicare payments may not be sufficient to adequately cover living and medical expenses. Resources for food purchases may be limited and negatively affect nutritional status. Unless social networking and family supports are strong, these conditions may persist. Older adults may abuse alcohol as a way to deal with these perceived difficult events.

Disorientation or senility often associated with aging may be caused by improper use of medications, marginal nutrient deficiencies (e.g., vitamin B₁₂), or simple dehydration. Older clients may intentionally restrict fluids because of incontinence, nocturia (excessive urination at night), or the inability to get to the toilet on their own. Some older adults lose their sense of thirst and forget to consume enough fluids. Fluid requirements in older adults remain the same as in younger adults (about 8 cups daily is sufficient) unless a medical condition or medication prescribes otherwise. The signs of dehydration are listed in Box 13-2. Medical diagnosis should be sought to determine the specific etiology of these signs.

Nutrition Well-Being

Nutrition status may be affected by restricted access to food and ability to prepare meals. Shopping may be difficult without transportation, and mobility to walk through stores may be limited. Funds for food may be constrained, and often food quantities available are beyond the amounts that can be used by individuals living alone. Once foods are purchased, preparation may be affected by physical limitations caused by progressive chronic illnesses such as arthritis. Some older adults may no longer have an interest in cooking. Others have become so frightened about foods containing too much fat or cholesterol that they become malnourished. For individuals in this age bracket, there is not sufficient evidence to warrant restrictive dietary intake; in actuality, malnutrition and underweight are more detrimental than excess dietary fat and cholesterol intake. Box 13-3 lists risks factors for malnutrition of older adults.

Dietary management for older adults may be more complicated than for other stages of adulthood. For example, obesity is viewed as a form of malnutrition of an older adult.⁴ For younger adults, reducing body mass index (BMI) decreases health risks. For older adults, decreased BMI may be associated with increased risk of strokes. Having an average BMI provides healthful weight reserves during times of illness.⁴ Studies of weight reduction strategies seldom include older participants, so their complex physiologic, behavioral, and social needs are not considered. Additionally such strategies may overly limit intake of essential nutrients, further increasing malnutrition.⁴

Another aspect of older adult dietary management is protein adequacy. Total body protein decreases as aging progresses. Although the loss of skeletal muscle is the most noticeable body protein lost, organ tissue, blood components, and immune bodies are also affected, including compromised wound healing, loss of skin elasticity, reduced ability to battle infection, and longer recuperation from illness and surgeries.⁵ Dietary intake may be further altered when these physical factors combine with social factors, leading to reduced protein intake. Consumption of micronutrients found in protein foods also may be limited, leading to deficiencies of B₁₂, A, C, D, calcium, iron, zinc, and others.⁶ This need, combined with the greater turnover of whole-body protein of aging bodies, results in older adults needing greater dietary protein intake (1 g/kg body weight) compared with younger adults (0.8 g/kg body weight).⁵ Frail elderly women are most at risk for these micronutrient deficiencies.

Living Arrangements

Living arrangements also affect nutritional status. A variety of living arrangements exists for older adults. Although many continue to live in their own homes or with family members, some opt for retirement communities, and others, because of health conditions, may reside in long-term care facilities or nursing homes. Living in one’s own home provides the freedom to prepare and eat foods whenever desired; illness, however, may make shopping for food and preparing it difficult. Retirement communities may provide transportation to food stores and more social events involving meals (Figure 13-5), although residents still are responsible for their own food preparation. Long-term care facilities usually provide prepared meals, but the style of cooking may not be as appealing or comforting as home-prepared meals.

A challenge for meeting the nutritional needs of institutionalized older adults is that the DRIs used to guide nutrient levels are intended to meet the needs of healthy older adults. Adjustments are necessary for individual circumstances of acute or chronic illness to achieve rehabilitation, recuperation, or maintenance to reduce the risk of further complications.⁷ Consequently, it is now recommended that diets in long-term care facilities be liberalized to improve dietary intake of this age group.⁸

Dietary patterns and preferences of older adults are the result of long-established habits. When they are ill, lonely, or under stress, older adults may strongly prefer foods they associate with pleasant memories. Ethnic favorites may provide security and comfort. The psychologic and social meanings of foods can play an important part in helping an older client recover from illness or adjust to changed circumstances.

Demographic and lifestyle characteristics may, as noted, put older adults at nutritional risk. Factors may include gender, smoking, alcohol abuse, dietary patterns, educational level, dental health, chronic illnesses, and living situations. Interventions to assist older adults need to account for these influences and should view support services through a continuum of care. Continuum of care provides continuity of care while the older individual moves through different living situations and services as health, medical, and supportive services are provided in suitable care environments. Care settings may range from acute medical settings to community and daycare, from assisted-living retirement housing to traditional nursing home facilities and hospices.

Nutrition Requirements

The DRIs remain constant from age 51 years and older for men and women, except for vitamin D. What does change is the ability of the body to either process or synthesizes certain nutrients. Synthesis of vitamin D is reduced; the AI for vitamin D for individuals older than age 70 increases to 15 mcg a day compared with 10 mcg a day for ages 51 to 70 years. Older adults either need more exposure to sunlight to produce required amounts of vitamin D or require a supplement if so diagnosed by a physician, qualified nutritionist, or dietitian. Because of decreased production of gastric juices and intestinal enzymes, digestion and absorption may be reduced, further highlighting the need for optimum nutrient intake. The production of the intrinsic factor required for vitamin B₁₂ absorption also may be reduced, increasing the risk of pernicious anemia. New recommendations suggest the use of vitamin B₁₂ supplements or consumption of foods fortified with vitamin B₁₂ to meet the RDA of 2.4 mcg/day (see also Box 7-1 or Box 8-3 regarding functions of nutrients).

Other factors may affect nutritional status. A marginal deficiency of zinc can alter the sensitivity of taste receptors. This deficiency heightens the ability to taste bitter and sour flavors and reduces sweet and salty sensations; excessive use of sugars and salt to make foods taste appealing may result.

Overconsumption of simple sugars and sodium may exacerbate other diet-related disorders such as diabetes and hypertension. As the muscularity of the digestive system weakens, constipation may be a problem, especially after a lifetime of low-fiber foods. Constipation may be alleviated by slowly increasing consumption of whole-wheat products, fruits, vegetables, and fluids, as well as increasing exercise. The Modified MyPyramid for Older Adults, developed by Tufts University, highlights nutrient-dense foods and fluid intake while also suggesting different forms of foods that may be more easily available (Figure 13-6).

Dental health may also affect the ability of older adults to be well nourished. Loss of teeth caused by periodontal disease limits the ability to chew foods such as meats, a prime source of zinc. Chewing ability for some may still be compromised even after dentures have been fitted to replace missing teeth. Dentures may need to be periodically refitted. When dentures do not fit properly, some people do not use them. Instead, they tend to eat foods that can be gummed rather than chewed.