Life begins at 60 is a famous proverb. It speaks volume. After 60, we may be free from some of the liabilities but we are never free from the race of breath in and breathe out. So, my friends this life stage also have its own beauty and inherent characteristics. Each stage mirrors your previous years of life and old age is a true reflection and reminiscence of that.
A gentleman in his 70s can walk, play, and does all his personal, professional as well as household chores by himself. For him age may just a chronological number. Another woman in her 40s only continues to grumble for aches and pain and blames her age. Both are live examples in our population at large and give us insight to look deeply the scenario of the term “old age”.
World Health Organization (WHO, 2014) defines 60+ years to be referred as the older or elderly persons. Further classification can be done – oldest old (normally those who are 80+) and centenarian (100+) and even super-centenarian (110+).
Age continues to increase in numbers after birth and aging is a natural (normal) biological process that may slow down certain cellular and physiological processes in the body. The rate of deceleration varies in different population for myriad factors. No doubt certain past experiences can’t be reversed but careful attention at early stage is warranted.
Though it is hard to pinpoint the day aging begins but the neglect or the misuse of the body for any unprecedented reason may increase the vulnerability of the body for illnesses, diseases, infections, accidents, or traumas that have a cumulative effect on health and nutritional status later in life. On contrary, perseverance in taking care of the body in given 24 hours along with active life and positive attitude stimulate smooth sailing. Physical, physiological, psychological conditions, social prestige, financial status, personal life style, family composition, family support are the factors which drastically influence health of the elders. Further loneliness, boredom, depression worrying and lack of food accessibility including restricted food intake for any degenerative chronic disease seriously affect the health outcome. Hence it is crucial to address these factors along with seeking help from friends, family or other community services are effective ways to enhance health and quality of life of elders.
Natural bodily Changes in Elders and Associated Problems and Solutions
Functions of most systems and organs diminish with progression of the adulthood. Apparently, these are visible in the speed and robustness in the physical activities, body contour, skin texture and mental turgor. Invisibly there may be less delivery of oxygen and nutrients to tissues of body, decreased elasticity of the cell membranes, poor absorption of nutrients and diminished digestibility of food, frequent nutrient deficiencies, altered distribution of body fat and low muscle mass and low blood supply to different types of muscles. Waist to hip ratio also increases. There may be lack of protein synthesis in the body which impacts voluntary muscular movement. Loss of muscle mass and the reduced muscle strength and function are referred as sarcopenia. It is not always related to body weight. Obese persons can also be sarcopenic.
Many older persons have frequent aches and pains in different parts of the body and there is high risk of frequent falls and fractures. Arthritis, rheumatism, osteoporosis, and other related problems are common in senior citizens. Regular walk, mild exercise, and sun bath support bone health. Resistance exercises improves muscle mass, reverse sarcopenic effect and thereby strength of the body. Dehydration and dryness are common among elders and need constant attention. Therefore, elders need more water than young adults due to decreased thirst mechanism. Elder man needs 2.8 liters of water then a woman in the same age may require 2.5 liters only. More physical work and hot weather increases the fluid requirement. Maintaining the balance in the body fluids, electrolytes and acid-base is critical in old age. Low /high sodium or potassium may be hazardous in certain clinical conditions like high sodium in cardiac disease and potassium in kidney problem. There are marked changes in kidney function that may be due to reduced number of nephrons and reduced glomerular filtration rate (GFR). It may also be due to imbalance in water, electrolytes, and protein intake.
Immunity though is very important in every age but cannot be ignored in old age for better health and fast recovery from any setback. Poor nutrient intakes impair the immunity hence adequate intake of protein, energy, vitamin A, C, E and minerals like copper, zinc, iron, and selenium helps to synthesize immune system components like antibodies, neutrophils, and T- cells. There is decreased secretion of saliva, gastric juices, and stomach acid and digestive enzymes coinciding with loss or altered sensations of taste and flavour which restrict the nutrient absorption. There is slow movement of food in the alimentary canal resulting in constipation. Use of laxatives to prevent constipation should be discouraged because they interfere with absorption of important nutrients. Judicious selection of food may improve the digestion. Elders often face denture problems or swallowing of food that affects the food intake. Soft and soggy textured food may make swallowing easier. Worry and heavy curry and eating at erratic time can exacerbate the problem of indigestion and other health problems. Circulatory system is affected in terms of losing the elasticity of blood vessels and pooling the blood in feet and legs causing edema. Oxygen carrying capacity is reduced by low production of red blood cells. Further pressure on the heart is increased due to narrowed arteries that often result in cardiac problems. Frequent episodes of headache, vision disturbances, loss of balance, confusion, dizziness for no specific visible reason need attention and connect with the doctor. It is important to know the effects and side effects of medications that are prescribed for the older person.
Besides all other changes many elders tend to suffer from the loss of hearing and vision and fine and gross motor control (holding and handling of objects).
Among women there is reduction of estrogen during menopause (cessation of monthly periods) and increase in prolactin may lead to fat accumulation.
The loss of short-term memory and disorientation is commonly observed that is due to poor nerve transmission.
Many elder persons are frail which calls for extra concern because the frailty is cumulative decline in multiple physiological systems. The frail person exhibits weakness, exhaustion unintentional weight loss and slowness and clumsiness in various motor and physical activities. Frails are highly susceptible for high morbidity, disability, hospitalization, and mortality.
Factors affecting nutrition of elderly people
Nutritional requirements of elders
Energy requirement gradually decreases with age due to reduced BMR and physical activities. With age, anabolic rate reduces and catabolic rate increases that leads to degeneration. Repair and regeneration of newer cells occurs at a slower rate. The heart slows down and its ability to pump blood is less compared to a young adult. Consequently, older people have less energy and stamina to work.
Protein requirements are higher 1.0-1.5 g/Kg of body weight. Adequate intake of good quality protein is warranted to avoid loss of muscle mass and support muscle protein synthesis. It is necessary to consume enough carbohydrate and fluid (water) along with protein. Adequate intake of vitamin A, B complex, C, D, E and K as well as calcium, magnesium, selenium, zinc, phosphorus, sodium, and potassium, is must. Sufficient dose of folate, vitamin B12, and vitamin B6 helps to prevent cognitive decline. Additional amount of fiber which is obtained from several plant foods is highly appreciable not only to prevent constipation but also many complications of chronic diseases.
In addition to the recognized essential nutrients, consumption of phytochemicals will have additional benefits for being anti-inflammatory, anti-microbial, anti-oxidant, and anti-mutagenic and prevention of many chronic diseases like cancer and heart disease. Consuming diverse variety of plant-based foods including whole grains, fruits and vegetables, spices and herbs in suitable forms would be beneficial as they would provide both micronutrients, phytochemicals and at the same time enhance taste, flavour, appearance, and texture in the diet.
Dietary guidelines for elders:
- Higher intakes of fruits, vegetables, nuts, dairy, and whole grains may delay muscle strength and cognitive decline which is common in advanced age.
- Older persons have small appetite: hence small, frequent, and nutrient dense (especially micronutrient) foods should be included. Major meals can also be small and with few dishes. Variety of ingredients can be added in one dish only.
- Invite friends and relatives to share meals with the elderly person.
- Nourishing, digestible, easy to chew and easy to swallow foods and beverages are preferred. Milk shakes, fruit yogurt, biscuits, pancakes, idli etc. can be good choices.
- Try to make meal platter or dining table more welcoming and attractive. Offer familiar, well liked foods.
- When an elderly person has poor appetite or complains about digestive problem(s), it should be taken care.
- Ensure 4-5 serving of fruits and vegetables and cut down on fried foods containing trans fats
- Add full cream dairy products. The fat is easily digested, cream increases energy and calcium content of the diet. It can also facilitate the peristalsis.
- Add some amount of butter to vegetables and bread etc to increase energy content and enhance flavour of the diet.
- Consume fat from whole foods such as nuts, seeds, beans, and fatty fish to get high in ω-3 and ω-9 fatty acids
- Avoid refined fats and fatty spreads
- Emphasize healthy traditional vegetable- and legume-based dishes.
- Limit traditional fat rich dishes and heavily preserved/pickled dishes.
- Ensure adequate intake of fluids preferable in the form of gravy in the vegetable or pulse or meat preparation, soups, and other beverages. Of course, regular, and adequate intake of water is advisable, especially in hot weather. Adequate fluid intake is necessary for maintaining body temperature and functioning of digestive system. It will reduce constipation which is quite common in this age due to reduced motility of the intestine and reduced physical mobility.
- Fluid intake may be inadequate because of decreased thirst sensation and reduced ability to conserve water and because they want to avoid frequent urination. Reliance on laxatives, use of prescribed diuretics, infections, immobility and excessive use of caffeine or alcohol put the person at risk of dehydration.
- In case of medical problems such as kidney disease, fluid intake and output should be monitored and fluid intake should be determined in consultation with the doctor.
- Some signs of dehydration are mental confusion, decreased urine output, constipation, nausea, lack of appetite, dry lips, and elevated body temperature.
- Include natural sources fibre (non-starch polysaccharides) such as whole grains, fruits, and vegetables to reduce constipation. It will also help to control better blood sugar control.
Nutritional deficiencies and Related Problems in old age
Nutrition is an important determinant of health in the elderly especially those who may have any illness. Importance of nutrition has been increasingly recognized as a significant factor for persons older than 65 years of age. Malnutrition in the elderly often goes undiagnosed. Common indicators are involuntary weight loss, abnormal BMI, decreased dietary intake and deficiencies of specific micronutrients. Presence of morbidity such as diabetes, heart disease etc. increases the risk of malnutrition. Often the weight loss goes unrecognized, because since some weight loss is expected as muscle mass decreases. Isolation and depression exacerbate the problem. Elderly population has commonly been found to have cobalamin (vitamin B12) and folate deficiency. Intakes of protein and calcium may be low and vitamin D deficiency can occur since the person may not be exposed to sunshine. There may be increased risk of falls and fractures. Low vitamin D status has been linked to higher risk of decline in cognition as well as muscle strength, low moods, and depression.
Low intake of B vitamins, especially folate, B12 and B6 may increase risk of low functionality, cognitive decline, heart disease and stroke. Inadequate intake of dietary protein has been linked with poor muscle function and decline in physical capacity leading towards sarcopenia.
Lower intake of energy and protein rich foods for prolonged period results in PEM and older person become frail and finds difficulty in walking and maintaining balance. Intake of other nutrients like B- vitamins, iron, calcium, zinc and electrolytes also affects the degree of malnutrition and body functioning. PEM not only affects the physical stature but also the mental functioning.
Elders who have limited access to food, living alone, low income and poor transport facilities are vulnerable to PEM. It is important that the elderly live the last stage of life with dignity and have as good a quality of life as is possible.
Exercise in old age:
Exercise is essential to increase muscle strength and muscle mass in older persons to maintain their functional status and independence. Certain aerobic and strength-training exercises are appropriate for individuals age 60 and older. If not done in earlier life they must be undertaken under able guidance and always first be discussed with one’s health care provider. Older persons can do stationary cycling regularly and strength training 2 to 3 days a week, with a day of rest between workouts.
Before undertaking exercise, or before a dietitian advises exercise, it is important that the elderly person be first evaluated for ability and risks by a physiotherapist, who can then advise the type of exercise, its frequency, duration, and intensity.
Besides muscle health, exercise helps a person to feel fresh, improves insulin sensitivity and improves mood. In addition, for those who can go out of the home for exercise, it provides a great opportunity to make friends.
Regular consumption of dairy products, ragi flour, sesame seeds, sweet lime, guava, amla, egg etc. can fulfill the increased demands for protein, calcium, vitamin D and vitamin C. Plain safe drinking water, soups and juices are good. The combination of rice, pulses and one GLV and starch vegetable will do better than fried fast foods. Milk, fruits, and nuts in different forms can be given to provide nutrients and improve digestion. Inclusion of complex carbohydrates, protein, omega 3 fatty acids, vitamin A and C rich in the diet and exclusion of salt, sugar, refined and processed foods and saturated and trans-fats are essential for good cardiac health.
Various physical challenges necessitate special attention like modifying the texture of food or supplying appropriate cutlery.
Regular contact with friends and relatives, through visits and telephone calls, can help prevent these problems. Mental exercises and involvement also support the cognitive functions and attentiveness.