Anorexia of Aging: Page 3 of 4
Chewing and Swallowing Problems
Mouth conditions, poor dentition, or ill-fitting dentures can make chewing difficult, causing patients to limit food selection, thus interfering with energy intake.11 In the United States, 23% of individuals aged 65 to 75 years and 36% of adults ≥75 years have severe periodontal disease, and 30% of adults ≥65 years are toothless.23 Many LTC residents also have problems with chewing and swallowing (dysphagia) due to stroke, pain, lethargy, dry mouth, confusion, upper gastrointestinal disease,4 and neurologic disease. Between 50% and 75% of nursing home residents are thought to have dysphagia.24 The causes of swallowing and chewing issues should be investigated and appropriate interventions taken. It may be something as simple as positioning the patient properly during meals or could be more involved, such as treating an underlying medical condition (eg, gastroesophageal reflux disease, dental problems).4
Some illnesses raise the patient’s resting metabolic rate, increasing energy and protein requirements. Cancer is strongly associated with anorexia-cachexia, a syndrome of progressive loss of adipose tissue and muscle mass triggered by a tumor-related increase in the patient’s basal metabolic rate.25 Significant weight loss often precedes diagnosis of a tumor,25 and cancer should be included in the differential diagnosis for anorexia of aging.
Other conditions associated with a hypermetabolic state, such as wound recovery, infections (eg, pneumonia), fevers, advanced COPD, and hyperthyroidism, increase energy and protein requirements. Practitioners should watch for signs of undernutrition in these patients even before evidence of weight loss.4 It may be prudent to encourage residents with postsurgical wounds or chronic ulcers or who are at risk of wounds (ie, pressure ulcers) to eat as much protein as they can tolerate.4
Many elderly adults routinely take prescription medications for multiple medical conditions, such as hypertension, pain, high cholesterol levels, and breathing problems. Drugs used to treat these and other conditions can cause dry mouth, metallic taste, nausea, vomiting, constipation, and diarrhea—adverse effects that typically inhibit the desire to eat. Adverse effects of chemotherapy, particularly nausea and oral mucositis, can also decrease energy intake. Some drugs, such as digoxin and metformin, cause malabsorption of one or more nutrients.26 As noted previously, anticholinergics and narcotics can slow digestion and increase the risk of unintended weight loss. CMS notes that it may be necessary to “change, stop, or reduce the doses” of drugs associated with an increased risk of weight loss to stabilize weight for a resident who is not eating well.4
Sociologic and Psychologic Factors
Although residents in LTC facilities face challenges different from those of community-dwelling elders—many of whom experience declining income after retirement and may struggle to shop for food or prepare meals—older adults in both settings often lose motivation to eat.11,13 People generally associate mealtimes with company, conversation, and a pleasant atmosphere, which are not always available to LTC residents, who frequently experience the loss of their social networks and may have little control over their dining situation.
Isolation and Depression
The loss of a spouse and friends or changes in the daily routine that accompany retirement and institutionalization can contribute to social isolation and, in some cases, feelings of depression and loneliness that dampen the desire to eat.3 Van Staveren and colleagues13 reported that older adults eat larger meals when eating in a group versus eating alone. A study of elderly adults living in inner city areas showed having a visitor during mealtimes reduced an elderly person’s risk of developing dysphoria and improved food intake.27 Caregivers can cultivate the enjoyment and social aspects of eating by encouraging older adults to eat with someone.13
Depression can also be pathologic. Between 30% and 40% of patients with Parkinson’s disease develop depression.28 Higher rates of depression have also been reported for individuals with Alzheimer’s disease, vascular dementia, cardiovascular disease, type 2 diabetes mellitus, arthritis, cancer, and stroke, although it is not clear whether these cases of depression are connected with the underlying disease process.29,30 Unlike younger adults with depression, who tend to increase food consumption, studies indicate that older adults eat less when they are depressed.18 Depression screening may be needed, followed by appropriate interventions to relieve depression.5
Loss of Independence in LTC
Some residents may refuse to eat in response to limited food choices and stipulated mealtimes in the nursing home. Residents may also eat less when caretakers fail to provide sufficient attention to the resident and his or her needs during mealtime.13 According to van Staveren and associates,13 33% of adults ≥65 years of age need assistance with activities of daily living,and staff may need to make eating easier for these patients by cutting food into bite-sized pieces, opening packets, removing lids, buttering bread,5 and providing assistance with utensils.
CMS is increasingly encouraging person-centered care at LTC facilities,4 contributing to a change in the culture of care at nursing homes that promotes residents’ independence, especially when it comes to dining.5 Some facilities are offering family-style mealtimes; more freedom to choose when, where, and what to eat; buffet-style dining; restaurant-style menus; five meals instead of three; and social functions with snacks (Table 3 [click thumbnail for full view]).5
A randomized controlled study found that Dutch nursing home residents who were given their meals family-style for 6 months significantly increased energy intake by a mean of 115 kcal, compared with a meal decline of 100 kcal in the control group.31 The family-style diners maintained body weight, physical and psychosocial function, and quality of life, all of which declined significantly in the control group.