Introduction
The health of the elderly is an important issue defining the health status of a population. Malnutrition in elderly people is very common because daily food consumption decreases with old age. Also, the consumed food is low in calories, contributing to nutritional deficiencies and malnutrition. Multimorbidity associated with increasing age is common and is found to be more frequent in developing countries (World Health Organization (WHO), 2008).
In Nigeria, geriatric age group (aged 60 years and above) constitute 8.6% of the total population as per 2006 census. Majority of them live in rural areas. The magnitude of malnutrition among the elderly in Nigeria is underreported. Studies have shown that more than 50% of the older population is underweight and more than 90% has an energy intake below the recommended allowance (Abebe, 2013).
According to Hickson (2006) malnutrition is caused by an imbalance between intake and the body’s requirements. This imbalance causes tissue loss, in particular muscle tissue loss, with harmful functional consequences with potential risk factors such as reduced food intake due to loss of appetite, episodes of fasting, poor dentition, swallowing difficulties, inability to eat independently, digestive disorders, chronic diseases and depression. This according to Chen, Schilling and Lyder (2011) leads to poor nutritional status which is associated with higher risks of morbidity and mortality in elderly people.
Rashmi, Anku and Rupali (2015) asserted that older people are vulnerable to malnutrition for many reasons including physiological and functional changes that occur with age, lack of financial support and inadequate access to food. The functional status of the elderly is their ability to carry out their day to day activities including preparation of food and intake, thereby affecting nutritional status. The problem of the health of the elderly is compounded by poor nutrition together with medical issues, including both communicable and non-communicable diseases. Malnutrition and morbidity create a vicious cycle.
The nutrition and health of the elderly is often neglected. Most nutritional intervention programs are directed toward infants, young children, adolescents, and pregnant and lactating mothers. However, nutritional interventions could play a part in the prevention of degenerative conditions of the elderly and an improvement of their quality of life. A timely intervention can stop weight loss in those at risk of malnutrition. Unfortunately, not much explanation has been given for the precise estimate of undernutrition in this age group in research. An assessment of nutritional status is important for the creation of a database to assist with the initiation of important programs and formulation of policies.
Conceptual framework
According to Culross (2008), nutritional needs change throughout life. Forthe geriatric, these changes may be related to normal aging processes, medical conditions or lifestyles. Assessment of nutritional status is essential for preventing or maintaining a chronic disease and for healing. Knowing the causes of changing nutritional needs and dietary preferences is needed to understand nutritional status. In order to meet the nutritional needs, consideration must be given to more than just diet.
Taboski (2006) stated that as people age, multiple changes occur that affect the nutritional status of an individual. Sacropenia, or the loss of lean muscle mass, can lead to a gain in body fat that may not be apparent by measuring body weight. It may be more noticeable by loss of strength, functional decline, and poor endurance. This loss also leads to reduced total body water content. Another common loss related to aging is changes in bone density, which can increase the risk for osteoporosis.
Amella (2007) stated that many changes occur throughout the digestive system. A decrease in saliva production—xerostomia—and changes in dentition associated with the geriatric alters the ability to chew and may lead to changes in food choices. There is also a decrease in gastric acid secretion that can limit the absorption of iron and vitamin B12. With ageing peristalsis is slower and constipation may be an issue because fluid intake is decreased. Appetite and thirst dysregulation also occur, leading to early satiety and a blunted thirst mechanism.
Tuft (2007) stated sensory changes affect the appetite of the geriatric in several ways. Vision loss makes shopping, preparing food, and even eating more difficult. Diminished taste and smell take away the appeal of many foods and may lead to preparing or consuming food that is no longer safe. Many other factors that are not necessarily part of the normal aging processes, but are often related to aging, create changes in appetite, what foods are chosen for meals, and the overall nutrition of the individual. Sedentary lifestyle, social isolation, loneliness, or depression can lead to malnourishment. Medications can also change how nutrients are absorbed or how food tastes. Poverty and cognitive impairment are other issues that may affect eating habits and food choices.
Nutritional needs of the geriatric
Bhat and Dhruvarajan (2011) stated that the overall nutritional requirements of the older adult do not change. What does change is the caloric intake. Because of the loss of lean muscle mass, the overall caloric intake requirement decreases while the need for other nutrients remains relatively unchanged. This makes eating nutrient-dense foods even more important for the geriatric. The nutritional needs of geriatric are generally similar to those of younger adults.
Recommended daily intakes for micro nutrients as recommended by the United States Department of Health (2008) is shown below.
Table 1: Recommended daily intake of nutrients for the geriatric
| Nutrient | Recommended daily intake for 50+ years per 100g |
| Calcium (mg) | 700 |
| Phosphorus (mg) | 550 |
| Magnesium (mg) | 270 |
| Sodium (mg) | 1600 |
| Potassium (mg) | 3500 |
| Chloride (mg) | 2500 |
| Iron (mg) | 14.8 |
| Zinc (mg) | 9 |
| Copper (mg) | 1.2 |
| Selenium (μg) | 60 |
| Iodine (μg) | 140 |
| Vitamin A (μg) | 600 |
| Thiamin (mg) | 0.8 |
| Riboflavin (mg) | 1.1 |
| Niacin (mg) | 12 |
| Vitamin B6 (mg) | 1.2 |
| Vitamin B12 (μg) | 1.5 |
| Folate (μg) | 200 |
| Vitamin C (mg) | 40 |
| Vitamin D* (μg) | 10 |
(Source: United States Department of Health, 2008).
The recommendation for vitamin D only applies for adults over the age of 65 years. With the exception of vitamin D, there are no specific recommendations for people aged over 65 years.
Energy
Energy requirements, however, decline with increasing age, particularly if physical activity is restricted.
Table 2: Recommended nutritional intake with age
| Age (years) | Estimated energy requirement for males (kcals per day) |
Estimated energy requirement for females (kcals per day) |
| 19-50 | 2550 | 1940 |
| 51-59 | 2550 | 1900 |
| 60-64 | 2380 | 1900 |
| 65-74 | 2330 | 1900 |
| 75+ | 2100 | 1810 |
(Source: United States Department of Health, 2008).
Although this often means eating less, requirements for protein, vitamins and minerals remain largely unchanged. It is therefore important that older people choose a nutrient-dense diet, including foods which contain protein, vitamins and minerals such as milk and dairy products, meat, eggs, fish, bread, cereals, and fruit and vegetables.
Protein
Protein requirements become slightly lower in men, but increase slightly in women after 50 years of age. However, as energy requirements decrease, the protein density of the diet should be greater for both men and women i.e. more protein containing foods such as lean meat, milk and dairy foods, eggs and pulses should be eaten.
Protein requirements may also be increased in some older people due to illness.
Table 3: Recommended protein intake with age
| Age (years) | Estimated protein requirement for males (g per day) |
Estimated protein requirement for females (g per day) |
| 19-50 | 55.5 | 45.0 |
| 51+ | 53.3 | 46.5 |
(Source: United States Department of Health, 2008).
Important micronutrients
Vitamin D
Vitamin D is needed for the absorption of calcium from food and is therefore important for good bone health. As vitamin D is mainly obtained from the action of sunlight on the skin, people who are housebound or live in institutions may be at risk of deficiency. It is recommended that everyone over 65 years of age takes a vitamin D supplement (10µg/day). Good dietary sources of vitamin D (e.g. oily fish, margarine, eggs and fortified breakfast cereals) should also be eaten regularly.
Calcium
Adequate intakes of calcium can help to slow age-related bone loss, which can result in osteoporosis and fracture. Although requirements for calcium do not change as we become more elderly, it is still important that calcium requirements are met through the diet. Milk and dairy products are the main providers of dietary calcium and consuming them can help geriatric meet calcium requirements.
Table 4: Contribution of dairy products to calcium intake
| Dairy product | Portion size | Contribution to recommended intake (RNI) (%) |
| Semi skimmed milk | 200ml (1 glass) | 35 |
| Cheese | 30g (matchbox sized) | 32 |
| Yogurt | 150g (1 standard pot) | 26 |
| Total | 2330 | 93 |
(Source: United States Department of Health, 2008).
Recommended intake of calcium per day is 700mg in adults over 50 years old. Bread (particularly white bread), green vegetables and canned fish (eaten with the bones) also contain calcium but generally must be consumed in much greater quantities to provide as much calcium as dairy products.
Vitamin C
Vitamin C is needed for several functions in the body including:
- Formation and maintenance of healthy tissues
- Good wound healing.
- Anti-oxidant action i.e. helps to protect the body from damage caused by toxins.
Vitamin C requirements for the geriatric are the same as younger adults, but unfortunately intakes are often sub-optimal.This is because good sources of vitamin C such as fruits and vegetables are often seen as expensive, difficult to prepare and to eat and therefore may be avoided by the geriatric. Good consumption of food rich in vitamin C and other anti-oxidant nutrients such as vitamin E, vitamin A and selenium may help to prevent against cancers, cataracts and heart disease.
Folate and vitamin B12
Folate and vitamin B12 are required together for many functions including cell division and good nerve function. Inadequate intakes have been linked to increased risk of cancer, dementia and heart disease. Requirements for folate, vitamin B12 and other B vitamins such as thiamin and riboflavin are either the same or slightly less than younger adults, however maintaining good intakes is important to prevent deficiency. This may be due to poor dietary intake or due to problems with absorption which are more common in older adults due to certain digestive diseases or side effects of certain medications.
Iron
Iron is important for many functions in the body including formation of red blood cells and transport of oxygen to tissues. Requirements for iron in females over 50 years old are significantly less than younger females as menstruation has normally ended by this age and they no longer lose iron in menstrual blood. Requirements in men over 50 years old remain the same as younger men. Iron absorption from the gut may also be reduced in older people, and this coupled with low intakes can increase the risk of iron deficiency anaemia. Good dietary consumption of iron along with promoters of its absorption such as foods providing vitamin C will help to prevent this risk. Dietary sources of nutrition for the geriatric are as stated in the table below:
Table 5: Dietary sources of nutrition for the geriatric
| Nutrient | Good dietary sources |
| Iron | Meat and meat products, especially red meat and offal (such as liver and kidney); cereal products such as fortified breakfast cereals and bread; eggs; pulses such as baked beans and lentils; dried fruit, dark green vegetables. |
| Calcium | Milk and milk products such as cheese and yogurt; fish with edible bones (such as canned sardines, pilchards and salmon); bread; pulses; dried fruit, dark green vegetables; nuts and seeds. |
| Thiamin | All cereals, especially breakfast cereals and bread; potatoes. Smaller quantities are found in a wide range of foods including meat and meat products, milk and milk products, and vegetables. |
| Riboflavin | Milk and milk products such as cheese; fortified breakfast cereals. Smaller amounts are found in meat and meat products. |
| Vitamin B12 | Found naturally only in foods of animal origin including meat, fish, milk and milk products, and eggs. Also present in fortified breakfast cereals. |
| Folate | Liver; green leafy vegetables, especially sprouts and spinach; green beans and peas; potatoes; fruit, especially oranges; fortified breakfast cereals and bread; yeast extract; milk and milk products. |
| Vitamin C | Fruit and vegetables, especially citrus fruits and fruit juices, blackcurrants, blackcurrant juice, berry fruits, kiwi fruit, tomatoes, green leafy vegetables, green peppers and new potatoes. |
(Source: United States Department of Health, 2008).
Malnutrition among the geriatric
Malnutrition is defined as an imbalance of nutrients caused by either an excess intake of nutrients or a nutritional deficit. Malnutrition is becoming increasingly more common among the geriatric population. This is a cause for concern considering malnutrition negatively affects the health of the older adult. Several risk factors for malnutrition have been identified, including physical, social, and medical factors. Physical factors that affect malnutrition include oral health, physical impairments, early satiety, and taste and smell changes (Hall & Brown, 2005). Poor dentition can cause difficulty with chewing food and swallowing, leading to a decrease in nutrient intake. Physical impairments such as physical immobility or the inability to feed oneself, can cause difficulty in acquiring, preparing, and eating foods. The geriatric also experience early satiety and physiological appetite loss (Visvanathan & Chapman, 2009). Older adults experience less of a feeling of hunger and experience a feeling of fullness more quickly as compared to younger adults (younger than 65 years old). A decrease in both taste and smell are normal parts of aging. This alteration can cause a decreased interest in food as well and a subsequent decrease in the intake of nutrients.
Social factors that affect malnutrition include, living alone, financial concerns, and restrictive diets. Living alone, especially for men, results in the decreased intake of food. Elders experiencing financial concerns, such as poverty or low-income, may not be able to buy a sufficient amount of food. Many times choices need to be made between buying food and paying for other necessities such as medications, heat, rent, etc. Cultures, religions, allergies, and preferences can also cause some elders to have more restrictive diets. These restrictive diets increase the risk for malnutrition, especially for protein malnutrition. Medical factors such as dementia, polypharmacy, chronic illness, and depression can cause malnutrition in the elderly population as well. Dementia and cognitive disabilities can cause self-neglect and decreased food intake. Many older adults take multiple medications daily. These medications interact with food and impact absorption, metabolism, and excretion of nutrients (Visvanathan & Chapman, 2009).
Effect of malnutrition on the geriatric
World Health Organisation (2008) stated that older persons are particularly vulnerable to malnutrition. Moreover, attempts to provide them with adequate nutrition encounter many practical problems. First, their nutritional requirements are not well defined. Since both lean body mass and basal metabolic rate decline with age, an older person’s energy requirement per kilogram of body weight is also reduced.
The process of ageing also affects other nutrient needs. For example, while requirements for some nutrients may be reduced, some data suggest that requirements for other essential nutrients may in fact rise in later life. There is thus an urgent need to review current recommended daily nutrient allowances for this group. There is also an increasing demand worldwide for WHO guidelines which competent national authorities can use to address the nutritional needs of their growing elderly populations.
Many of the diseases suffered by older persons are the result of dietary factors, some of which have been operating since infancy. These factors are then compounded by changes that naturally occur with the ageing process. Dietary fat seems to be associated with cancer of the colon, pancreas and prostate. Atherogenic risk factors such as increased blood pressure, blood lipids and glucose intolerance, all of which are significantly affected by dietary factors, play a significant role in the development of coronary heart disease (Lizaka, Tadaka & Sanada, 2008).
Degenerative diseases such as cardiovascular and cerebrovascular disease, diabetes, osteoporosis and cancer, which are among the most common diseases affecting older persons, are all diet-affected. Increasingly in the diet/disease debate, the role that micronutrients play in promoting health and preventing non-communicable disease is receiving considerable attention. Micronutrient deficiencies are often common in elderly people due to a number of factors such as their reduced food intake and a lack of variety in the foods they eat. Guigoz, Vellas and Garry (2006) stated that elevated serum cholesterol is a risk factor for coronary heart disease in both men and women common in older people and this relationship persists into very old age. As with younger people, drug therapy should be considered only after serious attempts have been made to modify diet.
Measures to improve nutritional status of the geriatric
The signs of malnutrition in older adults can be tough to spot, especially in people who do not seem at risk. However Soini, Routassalo and Lagstom (2014) suggest that measures to detect malnutrition and improve the nutritional status of the geriatric. These measures include:
- Observe eating habits of the geriatric: To improve the nutritional status of the geriatric, it is advisable to spend time with them during meals at home, not just on special occasions.
- Watch for weight loss: It is advisable to monitor the weight of the geriatric at home and watch out for other signs of weight loss, such as changes in clothing fitting.
- Engage specialized health care service: For geriatric losing weight, specialized health care service is needed. This might include changing medications that affect appetite, suspending any diet restrictions until he or she is eating more effectively, and working with a dentist to treat oral pain or chewing problems.
- Encourage geriatric to eat foods packed with nutrients: Spread peanut or other nut butters on toast and crackers, fresh fruits, and raw vegetables. Sprinkle finely chopped nuts or wheat germ on yogurt, fruit and cereal. Add extra egg whites to scrambled eggs and omelets and encourage use of whole milk. Add cheese to sandwiches, vegetables, soups, rice and noodles.
- Restore life to bland food: Make a restricted diet more appealing by using lemon juice, herbs and spices. If loss of taste and smell is a problem, experiment with seasonings and recipes.
- Plan between-meal snacks: A piece of fruit or cheese, a spoonful of peanut butter, or a fruit smoothie can provide nutrients and calories.
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