Learning objectives

At the end of this session, the learner should be able to:
- Explain physical and chemical changes in the ill and elderly that affect the way their bodies absorb nutrients from food.
- Explain why the body needs fluids.
- Recognize symptoms that may be caused by not getting enough nutrients or fluids.
- Describe foods, nutrients, and fluids that are needed every day.
- Describe ways to encourage healthful eating and drinking.

Physical and chemical changes that influence nutritional needs

People who are sick or elderly have different food requirements than young, healthy people. They are also more likely to suffer harm from not eating the right foods. After age 50, there are chemical and physical changes in the body that affect nutritional needs.
- The metabolic rate, or metabolism, slows down. The metabolic rate is the speed at which the body uses energy. Older bodies burn less fuel for daily operations. This means that seniors need fewer calories for normal everyday activities. This also applies to anyone who is not very active or who is confined to bed.
- Lean tissue and muscle mass decrease. There is less bone mass. Body fat increases.
- Stomach acid may decrease, and the stomach might not empty as quickly. The intestine may absorb less nutrition from the food it gets.
- Tooth and gum problems increase, sometimes making it difficult to chew.
- Some people have trouble swallowing, especially those who have had strokes.
- There is a loss of taste and smell. This causes people to be less interested in food.
- Appetite and thirst decrease. Many elderly or ill people eat and drink less than they should. This leads to fatigue, sadness, infections, skin breakdown, and lack of energy.
- Medications can affect appetite or thirst. Sometimes medicines upset the stomach or cause intestinal problems like diarrhea or constipation.
- Many diseases affect the way the body uses food or water. Someone with an illness usually needs more food and water because the body needs energy to heal. People with some conditions, however, must carefully control the amount and type of calories they take in. Diabetes is one example.

* Although the body may need fewer calories because of age or inactivity, it still needs the same amount of nutrients and fluid it always has—or more. It is important to eat foods that have a high nutritional value.

Malnutrition

Bodies will break down if they do not get the type and amount of fuel they need. Malnutrition means “badly nourished,” another way of saying that the person isn’t getting enough of the right nutrients the body needs to stay healthy. It can be caused by not eating enough nutritious foods or by not adequately digesting and absorbing nutrients from food. Getting too much food is harmful and is also called malnutrition. Someone who does or experiences one or more of these things might be headed for malnutrition:

- Doesn’t eat from the major food groups most of the time.
- Eats less than half of two or more meals a day.
- Eats less than one hot meal a day.
- Changes from solid foods to pureed foods, or other dietary changes.
- Drinks a lot of alcohol.
- Is socially isolated or depressed.
- Is poor, or has difficulty obtaining or preparing food because of physical or mental disabilities. Someone with cognitive problems might not remember to eat.
- Excessive laxative use (hinders digestion of nutrients by causing food to pass through the intestines too quickly).
- Recent surgery or illness, or chronic or multiple diseases.

25–30% of senior citizens are malnourished. Two out of five nursing home residents are malnourished. Nearly two-thirds of people over age 60 are at risk for malnutrition.

Signs and symptoms of malnutrition
If a person shows any of these signs, they should be seen by a doctor. Taking care of someone with malnutrition means helping them get enough of the right nutrients:
- Tiredness and lack of energy
- Loss of appetite
- Loss of or gain in weight
- Sore lips, tongue, or throat
- Infections or slow healing
- Diarrhea or constipation
- Easy bruising
- Depression or confusion

Older adults and those who are chronically ill should be weighed regularly to be sure that they are getting enough calories and are not losing or gaining weight.
*Unless a person is overweight and trying to lose weight, a weight loss of just 5% of body weight can be harmful. Any unintended weight loss or weight gain is a sign of possible malnutrition. Report a client’s changes in weight to a supervisor.*

Dehydration

Dehydration is a serious, sometimes fatal condition. It means there are not enough body fluids and important blood salts in the body for it to carry on normal functions at the best level. This happens by loss of fluids, not drinking enough water, or a combination of both. Water is essential in all the vital functions of the body. It is part of temperature regulation, building new cells, lubricating joints, and keeping the kidneys, brain, heart, and other organs working.

Thirst is the warning signal that we should drink. However, just drinking when we are thirsty is not enough. Many people stay mildly dehydrated much of the time. You are drinking enough water if your urine is always pale in color and you are urinating every two to three hours.

Preventing dehydration
- A healthy adult should drink at least 6–8 eight-ounce glasses of water a day.
- It is possible to get some of the necessary fluids from other drinks, but anything with caffeine in it does not count in the daily requirement. In fact, caffeinated drinks, such as coffee, tea, and cola, actually increase the daily requirement. Caffeine pulls water from the body, increasing the need for fluid intake. For every eight-ounce caffeinated drink, add an extra eight ounces of water to the daily requirement:

o 2 eight-ounce cups of coffee increases the daily water need to at least
8–10 eight-ounce glasses a day.
o 2 twelve-ounce cans of cola increases the daily water need to at least
9–11 eight-ounce glasses a day.

Reasons people don’t drink enough fluid:
- Loss of appetite.
- Lack of thirst.
- Don’t like frequent bathroom trips.

Reasons people lose fluid:
- Fever
- Vomiting
- Diarrhea
- Excessive urine output
- Excessive sweating; exercise
- Heat exhaustion

Symptoms of dehydration
Always pay attention to what clients drink and how much they urinate. The following symptoms could be signs of dehydration and must be reported immediately. Severe dehydration can result in seizures, permanent brain damage, heart and blood vessel collapse, and death if not treated quickly.

Mild dehydration:
- Thirst; dry lips and tongue
- Dry membranes in the mouth
- Skin looks dry

Moderate dehydration:
- Skin is not very elastic, may sag, and doesn’t bounce back quickly when lightly pinched and released
- Sunken eyes
- Decreased urine output

Severe dehydration:
- Small amounts of dark colored urine
- Rapid, weak pulse over 100 (at rest)
- Rapid breathing
- Low blood pressure; dizziness
- Blue lips
- Cold hands and feet
- Confusion, lack of interest, difficult to arouse
- Shock

Pinch a fold of skin on the back of your hand and hold it for a few seconds. Let it go, and time how quickly the skin returns to normal. The skin should return to normal within a second or two. If it stays pinched for longer than that, you may be dehydrated.

Treatment for dehydration
For mild dehydration, giving fluids by mouth is usually enough. This is called oral rehydration.

- The physician may order an oral rehydrating solution (ORS) that replaces important blood salts and water in balanced amounts designed especially for dehydration in sick people. These solutions allow the intestines to absorb
maximum amounts of water.
- Don’t confuse ORS with sports drinks designed for concentrated energy and salt replacement in healthy, high-performance athletes. These drinks can cause vomiting and diarrhea and are so concentrated they can limit intestinal
water absorption.
- IV fluids may be necessary for moderate to severe dehydration.
- Rapid recognition and treatment of dehydration results in a good outcome.

A Healthful, Nutritious Diet

Fruit: at least 2 servings daily
Vegetables: at least 3 servings daily

- Everyone should eat a variety of fruits and vegetables every day.
- Different fruits and vegetables are rich in different nutrients.
- Vegetables and fruits contain fiber, vitamins, and minerals.

Grain products: at least 6 servings daily
- Give clients a variety of whole grain and refined breads, cereals, pasta, and rice.
- Grains provide vitamins, minerals, carbohydrates, and fiber.
- The high fiber content of whole grains promotes proper bowel function.

Milk group: at least 2 servings daily
- Low-fat dairy products are needed daily to provide calcium.
- Adults over age 50 have an especially high need for calcium to maintain bone mass.

Meat and beans group: at least 2 servings daily
- Choose from the meat and beans group each day. Peanut butter, cheese, and eggs may substitute for meats.
- These foods provide protein to build and maintain healthy body tissues.
- People need more protein when they are dealing with illness, surgery, or trauma.

Fat
- Fats are highly concentrated sources of energy, and they provide fatty acids needed for good health.

- Monounsaturated oils (canola, olive) are believed to lower unhealthy cholesterol levels (LDL) and raise healthy cholesterol levels (HDL).
- Avoid saturated fat. Choose lean cuts of meat and remove the skin from poultry.

Water
- Water is the most important nutrient in the body. Oxygen is the only thing the body craves more.
- At least six to eight glasses of fluid are needed every day.

Ways to help people get needed nutrients
Care providers have a responsibility to ensure that clients’ food needs are met.
- Fit the amount and the kinds of food to the individual. Serve tasty food.
- Increase fiber to help move food through the intestines and prevent constipation.
- Encourage people to eat with family and friends.
- Use a blender or food processor for those with chewing or swallowing problems.
- People with swallowing problems can choke on liquids that are too thin. A thickening agent can be added to liquids to help them drink. They may do best using a straw.
- Chop or mash meats and vegetables with a little gravy or broth.
- Use soft foods such as tuna, eggs, cheese, and peanut butter for meat substitutes.
- Small frequent feedings and healthful snacks can encourage some people to eat. Have fruit, yogurt, or vegetables readily available.
- Adding nonfat dry milk powder to foods such as casseroles, cream soups, puddings, or gravy increases calcium and protein intake.
- Food that is served warm (not too hot or too cold) may seem tastier.
- For someone who can’t eat a whole meal, try six small meals a day.
- Offer finger foods, such as sandwiches and fruits, to those who have difficulty managing utensils. Cut food into bite-sized pieces.
- No single food can supply all the nutrients in the amounts needed. The diet should include a variety of plant foods, including whole grains, fruits, and vegetables, plus protein, dairy foods, and fats.
- Combining powdered meal mixes with milk, puddings, or fruit purees bolsters the nutrient content.
- Anyone with mouth or teeth problems will benefit from soft foods like yogurt, cottage cheese, applesauce, mashed potatoes, ice cream, puddings, milkshakes, or custards.
- Clear beef or chicken broth is a good way to get warm liquids in cold weather.
- Some people may need to take vitamins and minerals in a supplement.
-  Fruit juices and milk provide fluid, nutrients, and calories, but they do not fulfill the need for 6–8 glasses of water a day.
- Thirst decreases with age, so encourage older people to drink fluids throughout the day. Offer water often and keep it readily available.

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