Nutrition care in Aging

Nurpudji A Taslim
Nutrition Department School of Medicine Hasanuddin University @2009

Topic of study
Classification Factors Contributed to Aging Process Nutrition Requirement Program perbaikan gizi Lansia

CLASSIFICATION
Older population - 55 years older population - 65 years elderly population Median Age (In 2000) - developed countries = 37,4 years - developing countries = 24,3 years Life Expectancy (US, 2000) - average for the population = 76,9 years - = 79,5 years - = 74,1 years

Indonesia
developed country has high life expectancy

In Indonesia 2000 2020 2025

7,28% 11,34% (BPS92) 41,4%

Highest in the world (US Bureau Statistic)

Aging influences by:

gender race/ethnic composition economic status presence of disease health behavior

RATE OF LIVING
A finite amount of vial substance that when depleted result in aging and death

SOMATIC MUTATION Spontaneous changes in the structure of our genes cannot be corrected or eliminated accumulate cause cells to malfunction & die

Physiologic changes
Growth anabolic

Aging catabolic
Physiologic age- reflects health status- may or may not reflect chronologic age Lifestyle factor - adequacy &regularity of sleep - frequency of consumption well balanced meal - physical activity - smoking status - alcohol consumption - body weight

 Body composition changes -aging marked 2-3% loss of lean body mass (LBM)/decade
- sarcopenia-loss of skeletal muscle decreased muscle strenght increased risk for chronic disease - resting metabolic rate decreased 15-20% - reduce energy needs less LBM, >>Fat

Sensory losses
- smell, taste, sight, hearing, touch diminished - number of papilla (tongue) & olfactory nerve ending reduce appetite & pleasure of food, food borne illness - hearing loss, impaired vision, loss of functional status lower food intake

 Oral health status

- xerostomia (dry mouth) difficulty in chewing and

swallowing - dental caries & periodontitis tooth & bone loss - eat less efficiently food intake

Gastrointestinal function
Changes in nutrient intake, absorption & metabolism (McIntosh,2001) Mucosal immune response (Beharka, 2001) Dysphagia Gastritis atrophy affect bioavailability of nutrients, nutritional status risk developing chronic disease Achlorhydria B 12 deficiency (Ziesel, 2000)

 Constipation
Most common digestive complaints caused by prolonged recto-sigmoid transit time Limitation of mobility or activity Psychology factor Medication Manage
dietary fiber, fluid and kilocalories physical activity

 Cardiovascular function - blood vessel less elasticity total peripheral resistance risk for hypertension - inadequate blood flow to the heart CV disease (USA) - correction of hypertension and hyperlipidemia cost effective in morbidity and mortality

Renal function - malfunction & GFR 60% - ability of the kidney to concentrate urine less able to respond changes in fluid status (acid-base balance) - >> of protein waste product & electrolytes difficult to metabolized need dietary modification - complication related to kidney function dehydration, hemorrhage, cardiac failure, improper use of diuretics/toxic antibiotics

 Neurology function - cerebral function- synthesis of neurotransmitter - less efficient nerve conduction - less sleep - changes in central nervous system diminished coordination &balance, changes in mental equity & sensory interpretation, les dexterity, mood alteration & difficulties with information retrieval - need time to identify depression, dementia, alzheimers & parkinsons disease Immuno-competence - affected humoral & cell mediated immunities especially T-cell component - prevalence of infections

 MEDICATIONS
-1/3 medication prescribed in USA are unnecessary (Morrison and Hark, 1999) - poly-pharmacy risk of adverse drug reactions & drug-nutrient interactions - Concern pathologic factor (CV, Liver, renal. GI mal-absorption) - complete drug history reduce risk & lead to safer medication usage - appropriate nutrition assessment, intervention and counseling should be implemented to prevent or correct drug-nutrient interactions and improve nutritional status (Nelms & Anderson, 2002)

Age-Adjusted Prevalence of Overweight and Obese U.S. Adults (Ages 20-74 Yr)

NHANES NHANES (1976-1980) (1988-1994) (N = 11,207) (N = 14,468)

NHANES (1999) (N = 14,446)

Overweight or Obese (BMI 25) Overweight (BMI 25-29,9) Obese (BMI30)

47
32 15

56
33 23

61
34 27

MULTIDISCIPLINARY ASSESSMENT

Multidisciplinary approach Measures and mobility Measures and functional status

Activities of Daily Living and Instrumental Activities of Daily Living

Activity of Daily Living Eating moving into and out of beds and chairs being mobile and outdoors dressing toileting maintaining continence Instrumental Activities of Daily Living using the telephone traveling shopping preparing meals doing light housework taking medication managing money

Nutrition Screening
Older adult risk for malnutrition
Presence of disease Poor dental and oral health Poly-pharmacy Financial limitation - Physical disabilities - Poly-pharmacy - Social isolation - Impaired mental health

Important for primary care Advantage:

Cost effective - improve the quality of life Promote health - reduce complication Reduce health care costs - delay admission into nursing homes Reduce complications and hospital length of stay

Nutritional Health checklist sign use DETERMINE

Disease Eating poorly Tooth Loss/mouth pain Economic hardship Reduced social contact Multiple medicine Involuntary weight loss/gain Needs assistance in self-care Elder years above age 80

warning

NUTRITION REQUIREMENT
BASED ON
NUTRITIONAL STATUS HEALTH STATUS

Desirable Body Mass Index by Age

AGE (YEARS) 19-24 BMI (WEIGHT/HEIGHT [kg/m2]) 19-24

25-34
35-44 45-54

20-25
21-26 22-27

55-65
>65

23-28
24-29

NUTRITIONAL NEEDS
Energy
requirement (changes in body composition, BMR, physical activity) Energy need BW, BEE, REE/TEE, actual BW Average calories intake:
2000 kcal/day

1600 kcal/day

Protein
Campbell,1996 - protein intake 1g /kg BB - stress-full physical & psychological stimuli negative nitrogen balance -infection altered GI function &metabolic changes reduce efficiency of dietary nitrogen and nitrogen excretion

Biomarker Albumin indicator of protein status Pre-albumin and RBP evaluate response to therapy Carbohydrate Needed to protect protein from being used as energy source Approximately 45 -65% of total energy Complex carbohydrate legumes, vegetables, whole grains & fruits to provide phyto-chemical &essential vitamins & mineral

Lipid 25-35% of total energy Reduced SFA Reduced fat weight control & cancer prevention < 10% fat affect quality of diet and negatively affect taste, satiety & intake.

 Vitamin A
Fescanich et al,2002: high losses of vitamin A hip fracture Sources of vitamin A dark green, leafy & yellow-orange fruits and vegetables provide adequate food excessive carotene precursor vitamin A

Vitamin C
Older adult have lower serum level of vitamin C Vitamin C requirement increase : stress, smoking, medication Encouraging the consumption of vitamin C-rich food most effective

Vitamin D
Depend on concentration of calcium and phosphorus in the diet Age, sex, degree of exposure to sunlight ( decreased 60%) Function heal skin lesionspsoriasis, hyperproliferative disorder of cancer, actinic keratoses Need moderate supplementation of vitamin D and calciumimprove bone density and prevent bone fracture (Dawson-Hughes 1977)

VITAMIN E
Epidemiologic studies Vit E reduce the risk of CVD by reducing the susceptibility of LDL to oxidationvascular endothelial cell expression of proinflammary cytokine (Meydani, 2001) Vit Ecancer prevention

Vitamin B6
Many studiesolder adults do not consume enough B6 Atrophic gastritis, alcoholism&liver dysfunctionrequirement Severe deficiencyhomocysteine levelanemia&risk for cardiac disease Encouragedfolate rich foodliver, dried beans, broccoli, avocado, asparagus&spinach

Vitamin B12
Elderly need screening for B12 Prevalence 10-15% in age 60 (Baik& Russel, 1999), cause: athropic gastritis, bacteria overgrowth, anemia pernicious, crohns disease, ileal resection, malabsorbtion syndrome(Hoffbrand & Provan, 1997) Supplement vit.B12 or injectable for all older adults

Water
Daily fluid replacement is essential
Exercise regularly Consume large amount of protein Use laxative or diuretics Live in areas wit high temperatures

Need 30-35 ml/kg BB (actual body weight) or minimum 1500 cc/d Increased agetotal body water decreases (50%) associated with a corresponding decrease LBM

 Older risk for dehydration

Reduced thirst sensation Reduced fluid intake Limited access to fluid Disminished renal function Urinary inconvenience

 Symptoms of dehydration

Electrolyte disturbance Altered drug affected Headache Constipation Thirst, Loss of skin elasticity Weight loss Cognitive status deterioration Dizziness Dry mouth & nose mucous membranous A swollen or dry tongue Change blood pressure Rosessed or sunken eyes Change in urine color or output Speech difficulties

 An insufficient fluid intake with frequent diarrhea or vomiting, fever, illness, organ failure or chronic disease requiring hospitalization
Careful monitoring of fluid intake & output is important

Dietary Planning
Food with nutrient density Sufficient fluid, Ca, Fiber, Iron, Protein, Folic acid & vitamins (A, D, B12 & C) Food is the best source of vitamins Kauffman et al, 2002-- Supplements is often unnecessary; Vitamins, minerals, herbal supplements used for non specific reason to stay healthy aware potentially toxic doses Basic diet planning principles for older based on RDA 4 or 5 smaller meals

Nutrition Issues
Older risk of malnutrition
Lack of education financial constraints Decreasing physical & psychological abilities Social isolation Treatments for multiple Concomitant disorder/diseases

Nutrition Assessment
Tinggi lutut
Laki-laki
(2,02x55cm)-(1,04x umur/th)+ 64,19

Perempuan
82(1,83x55cm)-(0,04x umur/th)+ 84,88

Secondary causes of malnutrition

Feeding impairment Anorexia Mal-absorption (GIT dysfunction) Increased nutrient needs injury or disease Drug nutrient interactions

Disease Issues Older Population

Dysphagia Pressure ulcers Alzheimers Parkinsons Geriatric failure DM type II Hypertension & constipation

Dysphagia
Food can chopped, ground or pureed --eating regular consistencies The consistency of liquids can be modified to thin, nectar, honey or pudding consistency thickening agent Appropriate body positioning reduced the risk of chocking

Pressure ulcers
Most common Location below the waist , but can develop any where Especially: DM, CV (peripheral), chronic illness, cognitive impairment, mobility problems, incontinence, neurologic impairments. Inadequate food; kilocalories, protein, zinc and vitamin C. Frequent monitoring of BW, skin integrity, lab. value for nutritional status

Management of Pressure Ulcers

Based on stage and depth of damage
Therapy; frequent repositioning, use of support surfaces, moisture reduction, debridement and nutritional support Risk factors: BW 15%, serum albumin level <3,5mg/dl, total lymphocyte count <1800/L

Nutrition therapy; high protein, high energy, vitamin C & zinc supplementation, adequate fluid intake 9 spare protein and tissue epithelialization. Commercial oral supplements or tube feeding meet higher nutrient need.

Alzheimers
Alzheimers degenerative brain disorder irreversible memory loss and intellectual and personality deterioration--- malnutrition 2,5 millions USA Fluctuate food intake emotional state, confusion level Strategic to improve care can involve providing a simple, predictable environment and frequent cues relating to daily activities

Parkinson diseases
Neurodegenerative disease that affects voluntary movement Characterized by loss of brain cells that produce dopamine (a chemical that help direct muscle activity) Intervention includes; medication, exercise, nutrition management, particularly in the coordination of dietary protein adequacy and timing ofintake with medication

FAILURE TO THRIVE
Malnutritioncompromises the immune system--contribute to development:
Infection/sepsis Delayed wound healing MODF disability

Key Factors For Assessing Those At Risk For Malnutrition

Weight loss BMI < 21 Serum albumin <3,5g/dl Cholesterol <160mg/dl Decreased food, fluid & nutrient intake Loss of interest in food or desire to eat Anorexia Early satiety Oral health Dysphagia functional status Cognitive and emotional status Medications Alcohol intake institutionalizations Poverty Presence of infectious disease Early Alzheimers disease loss of ingested nutrients through stools or urine metabolic rate from CHF

Conclusion

masalah gizi usia lanjut

GIZI LEBIH: Ditandai kegemukan/obesitas penyakit degeneratif Diabetes Melitus Jantung Koroner MCI Gagal Ginjal Hipertensi stroke Asam urat, kolesterol, lemak sirosis hati, asam empedu kanker Penyakit sendi dan tulang (beban >>)

masalah gizi usia lanjut

GIZI KURANG: ditandai penurunan BB disertai atrofi otot Kurang Energi & Protein (kronik) KEK Kurang Vitamin & mineral (anti-oksidan) << Kalsium osteoporosis, lemahnya otot2 << Protein tonus otot << Fe (heme iron), B12, Asam Folat anemia << Vit. A kulit kering, katarak, kanker payu dara << B1, As Folat, B12 risiko Hipertensi & jantung koroner

masalah gizi usia lanjut

<< Vit C sariawan & perdarahan gusi/mulut << Vit D penurunan densitas tulang << Vit E (anti tua, kanker & penyubur) dementia << Zn daya pengecap nafsu makan << serat susah BaB kanker usus besar/wasir

STATUS GIZI PADA USILA

Kondisi Usia Lanjut 1. Metabolis basal menurun 2. Aktivitas/kegiatan fisik berkurang 3. Ekonomi meningkat Perubahan Pola Makan Kebutuhan kalori menurun Status Gizi Cenderung kegemukan/ obesitas Cenderung kegemukan/ obesitas Cenderung kegemukan/ obesitas Kurang gizi (Kurang Energi Protein Kronis/KEK)

Kalori uang dipakai sedikit

Konsumsi berlebih

4. Fungsi mengecap/ penciuman menurun/hilang 5. Penyakit periodental atau gigi tanggal

Makan tidak enak/nafsu makanmenurun

Kesulitan makan yang Dapat terjadi KEK berserat (sayur, daging), atau kegemukan/ cenderung makan obesitas makanan yang lunak (tinggi kalori)

STATUS GIZI PADA USILA

Kondisi Usia Lanjut
6.

Perubahan Pola Makan

Status Gizi
Defisiensi zat-zat gizi mikro Wasir (perdarahan anemia) Kurang gizi Hepatitis/kanker hati Kurang gizi

Penurunan sekresi asam Menggganggu lambung dan enzim penyerapan vitamin dan pencerna makanan mineral Probilitas usus menurun Sering menggunakan obat-obatan/alkohol Gangguan kemampuan motorik Susah buang air Menurunkan nafsu makan Kesulitan untuk menyiapkan makanan sendiri Nafsu makan menurun

7. 8.

9.

10. Kurang bersosialisasi, kesepian (perubahan psikologis)

Kurang gizi

11. Pendapatan menurun (pensiun)

12. Demensia (pikun)

Konsumsi makan menurun

Sering makan atau lupa makan

Kurang gizi
Kegemukan/obesita s atau kurang gizi

PROGRAM PERBAIKAN
GIZI USIA LANJUT

MASALAH GIZI USILA

BIOLOGI (PROSES MENUA )

INTERNAL
INDIVIDU

EKSTERNAL

LINGKUNGAN

Faktor yang Mempengaruhi Status Gizi Usia Lanjut

Pendidikan
KONSUMSI PENYAKIT INFEKSI/ DEGENERATIF

Faktor
Sosbud

Faktor Proses menua biologi individu

Hig.san /lingk.

KELUARGA/ PENGASUH

Ekonomi

LINGKUP PERGAULAN/ KELOMPOK MASY.

DASAR HUKUM
1. UUD 1945, pasal 27 ayat 2 dan pasal 34 2. UU No. 4 th. 1965, ttg Pemberian Bantuan Penghidupan Orang Tua 3. UU No. 6 th. 1974, ttg Ketentuan-Ketentuan Pokok Kesejahteraan Sosial 4. Program PBB ttg Lanjut Usia, anjuran Kongres International WINA tahun 1983 5. UU no 23 th. 1992 ttg Kesehatan 6. UU No. 10 th. 1992, ttg Perkembangan Kepend. dan Pemb. Keluarga Sejahtera

DASAR HUKUM
7. UU No. 11 th. 1992 ttg Dana Pensiun 8. Hari Lanjut Usia Nasional yang dicanangkan oleh Presiden RI tanggal 29 Mei 2002 di Semarang 9. UU Kesejahteraan No. 13 th. 1998, ttg Kesejahteraan Lanjut Usia 10.Tahun Lanjut Usia Internasional th. 1999 11.UU No. 22 th. 1999, ttg Pemerintah Daerah 12.PP No. 23 th. 2000, ttg Otonomi Pemerintah Daerah dan Desentralisasi

KEBIJAKAN PROGRAM
1) Meningkatkan kesehatan & kesejahteraan masyarakat (USILA) 2) Penanggulangan penyakit kronis dan degeneratif 3) Memperpanjang usia harapan hidup

STRATEGI PROGRAM

1) Paradigma Sehat Menuju Indonesia Sehat 2010 2) Peningkatan kualitas pelayanan oleh tenaga kesehatan bermutu (Profesionalisme) 3) Sistem pembiayaan bersama (Mandiri) mengarah pada asuransi kesehatan masyarakat 4) Desentralisasi pelayanan kesehatan: mendekatkan pelayanan dan tanggung jawab

TUJUAN PROGRAM
GOALS :
Meningkatkan status kesehatan usila agar tetap produktif melalui pelayanan gizi yang bermutu

TUJUAN KHUSUS:
1) Meningkatkan kualitas penyuluhan dan konseling gizi 2) Meningkatkan kualitas pelayanan gizi 3) Meningkatkan kualitas tenaga gizi utk menangani pelayanan gizi pd usila 4) Meningkatkan status gizi 5) Meningkatkan kualitas SDM (Usila)

SASARAN PROGRAM
Usila : > 60 tahun Pra-usila : 50-60 thn

LIFE CYCLE

IMPLEMENTASI PROGRAM
Menuju Pelayanan gizi paripurna (Tim Asuhan Gizi ~ Tim Geriatri)
Penyuluhan (Health Promotion) Perlindungan Khusus (Spesifik Protection) Deteksi Dini (Early Detection) Pengobatan segera (Prompt Treatment) Mencegah ketidak mampuan (Disability Limitation) Rehabilitasi (Rehabilitation)

TEMPAT PELAYANAN

Institusi : Rumah Sakit Puskesmas (DTP & TP) Panti Sosial Tresna Werdha (PSTW)

Masyarakat : Kelompok Usila (Poksila) Keluarga

PELAYANAN DI RUMAH SAKIT/PUSKESMAS DTP

Penyuluhan Gizi Pelayanan Gizi Rawat Inap Pelayanan Gizi Rawat Jalan (Klinik Gizi) Penyelenggaraan Makanan Kunjungan rumah

PELAYANAN DI PUSKESMAS TP
Penyuluhan Gizi Pelayanan Gizi Rawat Jalan (Klinik Gizi) Pembinaan PSTW dan Poksila Kunjungan PSTW dan Poksila (Nasihat gizi pada usila) Kunjungan rumah

PELAYANAN DI PANTI SOSIAL TRESNA WERDHA

Penyuluhan Gizi
Penyelenggaraan makanan Konseling Gizi

PELAYANAN DI POKSILA
Penyuluhan Gizi Konseling Gizi

PELAYANAN DI KELUARGA
Nasihat Gizi Penyiapan makanan Konseling Gizi

Alur Pelayanan Gizi Usila

Tim Geriatri RUMAH SAKIT
Rawat Inap Rawat Jalan

SMF Lain

PUSKESMAS Dengan/Tanpa Perawatan

PSTW

Keluarga

Poksila

SMF = Staf Medik Fungsional

Pengembangan Program
Kekuatan :
Partisipasi dan aktivitas Poksila Keluarga besar Pola patrilinial Kesempatan implementasi pelayanan geriatri (standar) Dukungan Pemda (desentralisasi) Kepedulian LSM & ormas daerah

Kelemahan :
Biaya hidup/poverty (miskin, pensiun kecil)

Kurangnya sarana & prasarana

Keterbatasan tenaga & tempat pelayanan yang berkualitas Kurang kepedulian (kel & masy) Bukan prioritas pemerintah daerah

Kesempatan :

Perkembangan ilmu geriatri Pendayagagunaan sarana & jaringan pelayanan serta rujukan yang sudah ada

Ancaman :
Peningkatan jumlah Usila beban pemerintah menyediakan fasilitas Tidak produktif dan ketergantungan Perubahan gaya hidup (keluarga inti) Perubahan pola penyakit (biaya tinggi) Krisis ekonomi dan ke tidak stabilan

Dukungan pemerintah (UU & PP)

Kepedulian LSM & ormas Standar/jaringan pelayanan geriatri dan rujukan Sistim pembiayaan kesehatan (asuransi)

Untuk meningkatkan kesehatan :

erat badan berlebih agar dihindari turlah makanan dg gizi seimbang indari faktor risiko peny. degeneratif gar terus berguna dgn memp. hobi yg bermanfaat G : erak badan teratur terus dilakukan I : man dan taqwa ditingkatkan, hindari situasi yg menegangkan A : wasi kesehatan dgn pemeriksaan bdn scr berkala
(Prof. Dr. Slamet Sayono, RSCM, 1997)

B A H A

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