VISHNU DENTAL COLLEGE

DEPARTMENT OF PROSTHODONTICS AND IMPLANTOLOGY

SEMINAR ON NUTRITION IN GERIATRIC PATIENTS

PRESENTED BY GUDURI VINEETH

NUTRITION IN GERIATRIC PATIENTS

CONTENTS: Introduction Etymology of Nutrition and Geriatrics Definitions Nutrition in-brief Components Measurement Utilization History of Geriatrics Nutrition and Old age Objectives of nutrition in geriatric patients Aging factors Nutritional needs Nutritional requirements, assessment and recommendations in the Senile Prosthodontics and Nutrition Conclusion References

Introduction: The existence of millions of arts is only for the purpose of earning a daily bread. - Telugu maxim The phrase daily bread here points or emphasizes the role of food and its vital elements i.e. the nutrients in the life of a human being. Survival of the Fittest - Charles Darwin It is this nutrition which supports the living beings in carrying out their metabolic and physiological processes of growth, learning, living and altogether surviving and sustaining ones own life. Relating to our topic of discussion, we can say that nutrition plays an important role in upbringing or developing man from a single cell(zygote) to a fully grown wise individual in the matter of a lifetime. Etymology: Nutrition is derived from the Latin words Nutritio (n) - a nourishing or a feeding Nutrire (v) - to nourish or to suckle Geriatrics is derived from the Greek words Geras/ Geros - old age Iatrikos - of a Physician

Note: The root word Gere in Greek means to grow old.

Definitions: Nutrition: Process by which living things use food to obtain biochemical substances known as nutrients in adequate amounts from food for energy, growth, development and maintenance. (Breathdoc: Online journal) Diet: The customary amount and kind of food and drink taken by a person from day to day or the kinds of food that a person, animal, or community habitually eats. (Online Medical Dictionary) Balanced Diet: Balanced diet is one which contains different types of foods possessing the nutrients in adequate proportions to meet the requirements of the body. (Online Medical Dictionary) Geriatrics: Area of medicine that studies the prevention and treatment of chronic and acute age-related diseases and elderly rehabilitation and socializing. (Federal Council of Dentistry) Geriatric dentistry: It is the specialty that focuses on age-related phenomena that affect the mouth and related structures and promotes health, diagnoses, prevents and treats oral and stomatognathic system diseases of the elderly. (Resolution CFO 12/2001 adds to section IX from article 29) Nutrition in-brief: ComponentsBy definition, Nutrition is a biological process which again comprises of smaller processes namely Ingestion Digestion Assimilation Transport Absorption Excretion

 The most important role in nutrition for the physiologic and metabolic activities is played by the nutrients which are the biochemical substances that can be metabolized to give energy and build tissues. The basic nutrients being: Carbohydrates Proteins Fats Vitamins Minerals Water Each of the following nutrients is valued by the energy it provides when it is metabolized in a healthy human being.

Measurement In a general sense, nutrition is usually confused with the food we eat. As it is a physiological process of obtaining energy, it is measured in terms of the energy yield. Energy obtained from the nutrients is measured in terms of calories. Calorie: Amount of heat required to raise the temperature of 1 g of water by 10C. 1 Calorie (Cal) = 4.128 Joules

1 Kilocalorie (K Cal) = 1000 Calories = 4128 Joules

1g water

= 1 Cal

1g carbohydrate = 4 K Cal 1g protein 1g fat = 4 4.5 K Cal = 9 K Cal

UtilizationThe energy is utilized for carrying physiologic functions i.e. Basal Metabolic Rate Specific Dynamic Action Physical Activity

Basal Metabolic Rate: Minimum amount of energy required by the body to maintain life. 1600 K Cal/ day Women 2400 K Cal/ day Men Specific Dynamic Action: Extra heat produced by the body above calculated caloric value when food is metabolized. The reason for SDA is not clear. Since it is the extra amount of energy that is generated it cannot be measured in particular. The present hypothesis explaining SDA is that certain active processes performed by a cell during metabolism are carried out passively which leads to the saving of energy and thereby showing its result on the energy yield. Physical Activity: Comprises of the daily work performed by an individual. Light work : 2200 2500 K Cal/ day Moderate work : 2500 2900 K Cal/ day Heavy work : 2900 3500 K Cal/ day Very Heavy work : 3500 4000 K Cal/ day (S.Ramakrishnan; Textbook of medical biochemistry; 2004; 1st edition; Pg.- 495500)

History of Geriatrics: The sixth age shifts Into the lean and slippered pantaloon, With spectacles on nose and pouch on side; His youthful hose, well saved, a world too wide For his shrunk shank, and his big manly voice, Turning again toward childish treble, pipes And whistles in his sound. Last scene of all, That ends this strange eventful history, Is second childishness and mere oblivion, Sans teeth, sans eyes, sans taste, sans everything.

- All the Worlds a stage Shakespeare (1564 -1616) Even though the practitioners knew the fact that elderly people do need special attention and care, it was not practiced separately from the adults until mid 1800s. 1849 George Day: published Diseases in advanced life 1881 Dr Laza Lazarevic started Geriatric hospital in Belgrade 1909 Dr Ignatz Leo Nascher Father of Geriatrics in USA 1909 Dr Marjorie Warren Mother of Geriatrics in UK 1950 Dr Saul Kamen conducted first dental studies in the institutionalized elderly Father of Geriatric Dentistry

Nutrition and Old age: o Adequate nutritional requirements ought to be met for healthy maintenance of tissues in elderly patients whose metabolic demands vary with age and health. o However, many other factors also are essential for the nutritional status of older people i.e. Masticatory efficiency Socio-economic status Dietary habits Medical condition of the individual Hence the dietary suggestions must be tailored to meet the patients specific needs.

Objectives of the nutrition in elderly: To establish a balanced diet which is consistent with the physical, social, psychological and economic background of the patient. To provide temporary dietary supportive treatment in specific debilitating conditions. To interpret factors peculiar to age group of patients, which may relate to or complicate nutritional therapy.

Aging Factors: Physiological factors Decline in body mass decrease in caloric needs Osteoporosis risk of falling Vitamin D deficiency metabolic bone disease Decline in gastric acidity malabsorption of food Nutrient deficiencies of zinc and Vit B6 modified immune responses Dehydration decline in kidney function Neurological and behavioural impairment Decreased salivation altered taste and mastication

Psychosocial factors Elders living alone Physically handicapped patients Chronically diseased elders Restrictive diet in elders Low economic status

Functional factors Stroke Renal Failure Oral infections Effect of dentures on food choice

Pharmacological factors Some prescribed drugs and their prolonged usage are the primary cause of anorexia, nausea, vomiting, gastro-intestinal disturbances, xerostomia, taste loss etc. which leads to nutritional deficiencies, weight loss and malnutrition.

Nutritional needs: Energy requirements decline due to decrease in basal metabolic rate and decreases physical activity. Average energy consumption of 65-74 year old

1300 K Cal Women Minimum 1800 K Cal Men 1600 K Cal Women RDA mean 2400 K Cal Men

Terminology: RDA: Recommended Dietary Allowance Amount of nutrients to meet the requirements of nearly all healthy individuals. RDI: Recommended Daily Intake It is the daily intake level of a nutrient that is considered to be sufficient to meet the requirements of 9798% of healthy individuals in every demographic in the United States

DRI: Dietary Reference Intakes Amount of nutrients necessary to prevent disease state. Estimate amounts required to improve long term health. Establish maximum safe levels of tolerance. EAR: Estimated Average Requirement Amount of nutrient required to meet the needs of half of healthy individuals in a specific age & gender group.

Nutritional requirements: Carbohydrates: o They are consumed the largest in quantity because Low cost Ability to be stored Ease of preparation RDA 130g per day Sources cereals, vegetables, fruits, dairy products etc. Fiber: o It is a complex carbohydrate. o RDA 38g per day o Sources dry cereals, vegetable fiber, fruits o Advantages lowers serum cholesterol, prevents diverticular disease and promotes bowel function. o Disadvantages it is less consumed due to difficulty in chewing and provokes gastro-intestinal disturbances in edentulous patients.

Proteins: o They should be consumed maximum by the patients. o RDA 56g per day o Sources poultry, meat, fish (boiled), legumes, dairy products o Deficiency causes edema. Fat: o It should be consumed minimum by the elderly. o RDA 25-30% of the total calorie intake o Sources oils, ghee, milk, meat o Deficiency of essential fatty acids can lead to dermatitis, vitamin deficiencies especially those synthesized by the normal gut flora. Vitamin A: o Also known Retinol. o Maintain integrity of epithelial tissues o RDA 1.2 mg per day o Sources liver, milk and milk products, deep green and yellow fruits and vegetables i.e. carrots, apricots, spinach o Deficiencies Bitots spots, night blindness, Xerosis of skin and eye, decreased taste acuity etc.

Vitamin B1: o Physiologic role coenzyme in Krebs cycle Carbohydrate metabolism Synthesis of niacin

o RDA 1mg per day o Sources meat, peas, whole grains, cereals, yeast o Deficiency causes Beriberi.
o Deficiency is more common in poor, institutionalized and alcoholic elderly

people. Vitamin B2: o Physiologic role Metabolism of proteins Release of cellular energy RDA 3 g per day o Sources Kidney, heart, milk, eggs, liver and green leafy vegetables o Deficiency naso-labial seborrhoea, angular cheilitis Vitamin B6: o Physiologic role Protein metabolism Hemoglobin synthesis Synthesis of neurotransmitters RDA 1.2-1.4mg per day o Sources meat, eggs etc. o Deficiency glossitis, anaemia, depression and anxiety

Vitamin B12: o Physiologic role Synthesis of nucleic acids Maturation of RBC RDA 2-4g per day o Sources milk and meat o Deficiency Pernicious anemia, glossopyrosis, haemorrhagic gingiva Folic acid: o Plays an important role in synthesis of DNA & RNA. o RDA - 400g/day o Sources green leafy vegetables & fruits. o Deficiency anemia, cancers, glossitis. Vitamin C: o Physiological Role Ensure activity of WBC Collagen synthesis RDA 90mg per day o Sources Citrus fruits, tomatoes, green leafy vegetables o Deficiency Bleeding gums, Delayed wound healing and Painful joints

Vitamin D: o Also known as Calcitriol. o Plays an important role in regulating the calcium metabolism in the human body. o RDA 5g per day o Sources Sun exposure, fish liver oils, milk etc. o Deficiency Bow legs, beading of ribs etc. Intestinal absorption of Ca Calcitonin PTH Postprandial indirect due to increase 1,25(OH)2D3 Renal excretion of Ca Bone Ca Mineralization Resorption Resorption Effect on plasma Ca

Vitamin D

Mineralization Resorption

Vitamin E: o Also known as Tocoferol and Anti-sterility vitamin. o RDA 8-10g per day o Sources nuts, seeds and vegetable oils o Total plasma levels increases with age. o Deficiency in elderly does not seem to be a problem except for rare neuropathies.

Vitamin K: o Physiological role Protein modification Blood clotting RDA 120g per day o Sources Green leafy vegetables and the symbiotic gut flora o Deficiency Bleeding problems

Minerals: Calcium-

o RDA 800mg per day o Calcium must be acidulated before digestion in elderly because of the lack of sufficient HCl in the stomach. o Sources Milk and milk products, dried beans and peas, canned salmon, leafy green vegetables and tofu o Negative calcium balance - Osteoporosis Irono Physiological role Transport of oxygen Synthesis of collagen & nucleic acids o RDA - 10mg/day o Sources Meat, fish, poultry, whole grains, cereals, dried beans, leafy green vegetables. o Deficiency anemia , pallor of mucosa , atrophy of tongue , angular chelitis, glossitis. o Iron deficiency anemia is rare among elderly. o Blood loss should always be suspected when anemia is observed in the senile.

Zinco RDA - 8-11mg/day o Sources animal products, whole grains and dried beans o Deficiency impaired keratinization, mental lethargy, slow wound healing. o Increased susceptibility to periodontal diseases. o Flattened filiform papillae & loss of taste.

Nutritional Assessment: Nutritional assessment in elderly is divided into the following phases Phase I: Screen all patients Obtaining information from medical and social history Listing carefully about any dietary issues Observing clinical signs of deficiency Conducting anthropometric measurements Qualitative dietary assessment If nutritional problems are detected, the evaluation progresses to the next phase Questionnaire for assessing nutrition:
I have an illness or condition that made me change the kind & / or the amount of food I eat I eat fewer than 2 meals per day I eat few fruits , vegetables or milk products I have 3 or more glasses of beer, liquor or wine per day I have tooth or mouth problems that makes it hard for me to eat I dont have enough money to buy the food I need I eat alone most of the times I take 3 or more prescribed or OTC drugs per day Without wanting to I have lost or gained 10 lb in the last 6 months I am not always able to shop , cook or feed myself 2 2 2 3 2 2 2 4 1 1

Evaluation0-2 3-5 6 or > = Good nutritional health = Moderate nutritional risk = High nutritional risk (Vogt et al, 1995)

Phase II: Semi-quantitative dietary analysis Routine blood chemistry Phase III: This phase should be accomplished under the direction of a physician. Biochemical assays of blood, urine and tissues. Tests of metabolic and endocrine functions. According to a study by Dormenval et al. in 1995, the effects of protein and energy deprivation from those of disease in a sick individual had good correlation with anthropometric parameters but no correlation with serum albumin level.

Recommended Food Intake: In healthy individuals, optimal health can be maintained by eating a variety of foods in adequate amounts and the recommendations for them are 1. Four servings of vegetables and fruits, subdivided in 3 categories a. 2 servings of good sources of vitamin C, such as citrus fruits, salad greens and raw cabbage b. 1 serving of good source of provitamin A such as deep green and yellow fruits and vegetables c. 1 serving of potatoes and other vegetables and fruits d. Four servings of enriched breads, cereals and flour products 2. Two servings of milk and milk- based foods such as cheese 3. Two servings of meat, fish, poultry, eggs, dried beans, peas and nuts 4. Additional miscellaneous foods fats, oils, sugars, alcohol (only serving recommendation is about 2-4 tablespoons of Poly Unsaturated Fatty Acids which supply essential fatty acids)

Prosthodontics and Nutrition: o We as professionals provide an alternative to the patients mastication i.e. we replace the lost natural teeth and supporting structures with artificial substitutes that will help the patient to nourish oneself with the food of ones choice. o The limitations that we have in rehabilitating the patient also hold good for the nutritional intake by the patient. o Hence, we are directly responsible for the variety of food intake by the patient and also the healthy lifestyle and long-life of the patient.

Keeping the above points in mind, the duties of a Prosthodontist should be o Provide the best alternative for the lost teeth, that will enable the patient to maintain adequate food intake. o Provide good qualitative and quantitative dietary counseling.
o Alter the dietary recommendations as per the patients needs and health

condition. Diet Counseling: o Providing nutritional care o Obtain a nutrition history & an accurate record of food intake over a 5 day period. o Evaluate the diet & assess nutrition risk. o Teach about the components of diet that will support the oral mucosa , bone health & total body health. o Help patient establish goals to improve the diet. o Follow up to support patient in efforts to change food behaviors. o When the record received actual food intake & quality of patient diet is assessed. o At second appointment the relation of diet to health of oral tissues & evaluation and alteration of patients diet is done.

Dietary recommendations for a new denture wearer: Biting Chewing Swallowing

It is much easier for a new denture wearer to master these complex masticatory movements in reverse order. Hence the dietary recommendations for a new denture wearer are as follows: First few days Swallowing Liquids Next few days Chewing Soft food particles or pieces bilaterally

End of the week Biting Soft food and then firm food

First post-insertion day: Vegetable fruit group: Juices Bread cereal group: Gruels cooked in either milk or water Milk group: Fluid milk Meat group: Meat broths and soups The sample menu should contain a glass of milk at least once a day.

Second and third post-insertion day: Vegetable fruit group: Juices, tender cooked vegetables and fruits Bread cereal group: Cooked cereals, softened bread, boiled rice, noodles macaroni Milk group: Fluid milk, cottage cheese Meat group: Scrambled eggs, thick meat soups, tender chicken or fish in cream sauce, ground liver The sample menu must include butter or margarine, a glass of milk at least once a day.

Fourth post-insertion day and after: After the sore spots have healed, firm food can be eaten in addition to soft food. Ideally the food should be cut into small pieces before chewing. The sample menu must contain butter or margarine and a glass of milk.

Conclusion: o Good health and nutrition in older patients are necessary for the successful wearing of dentures. o Being aware of the patients nutritional needs, a Prosthodontist can provide good quality treatment in a systematic fashion. o With the addition of nutritional expertise, we can combine our talents to be of immeasurable service to the expanding population of geriatric dental patients.

References: Ejvind Budtz Jrgensen, Prosthodontics for the elderly: Diagnosis and Treatment; 1st edition; Pg.: 56-67. S. Ramakrishnan; Textbook of Medical Biochemistry; 2004; 1st edition; Pg.495 500. Bandodkar, et al.: Nutrition for geriatric denture patients; The Journal of Indian Prosthodontic Society; March 2006; Vol 6; Issue 1; Pg.: 22-28. AFL ribeiro et al.: Geriatric dentistry and nutrition aspects; RGO - Rev Gaucha Odontol., Porto Alegre; Jun, 2012;Vol 50; no.2; Pg: 241-245. Anthony M. Iacopino, William F. Wathen: Geriatric prosthodontics: An overview-Part I: Pretreatment considerations; Quintessence Int.; 1993; 24; 259-266. J. Crystal Baxter: The Importance of Nutrition in Prosthodontic Treatment of the Older Patient; Quintessence Int.; 1983; no.2; report 2176; Pg.: 185 191. Dormenval et al: Nutrition, general health status and oral health status in hospitalized elders; Gerodontology; 1995; 12(2): Pg: 73 80. http://medical-dictionary.thefreedictionary.com/ Online Medical Dictionary RDA recommendations of dietary allowances to the elderly; 2010. Anne Bosy: We are what we eat: Nutrition and bad breath; Breathdoc Online Journal.