Introduction: Nursing care of older people

It has been a well-accepted fact that ageing typically starts very early in fetal life and then continues through childhood, adolescence, young adult period and middle age. Functional capabilities related to every bodily system increase over childhood and adolescence to peak in early adulthood and subsequently decline as a person ages. The rate of decline is largely determined by individual factors related to the adult lifestyle, which can be potentially slowed down with interventions such as healthy diets, physical activity, and cessation of consumption of tobacco products and alcohol. There is scope for interventions for reducing the risk factors of poor health and increasing functionality throughout the life process.

a) Nutrition

Ageing is associated with an increased incidence of weight loss, being underweight and proteinenergy malnutrition. Undernutrition leads to sarcopenia, frailty, physical dependence and premature death, in addition to impairment of the immune system, increased risk of infection and poor wound healing. Overnutrition causes obesity and is associated with hypertension, ischemic heart disease (IHD) and diabetes, which are among the most common health problems in old age.

The energy requirement declines with age due to a reduction in body mass, body metabolism and physical activity. Yet, older people are at a high risk of undernutrition due to several reasons, such as:

• food being less palatable due to changes in taste and smell;
• lack of teeth, gum problems and ill-fitting dentures making eating painful;
• reduced appetite due to lack of exercise, loneliness, depression, chronic debilitating disease, confusion, forgetfulness, side-eff ects of medicines, alcohol and smoking;
• common nutritional deficiencies, including of iron, fibre, folic acid, vitamin C, Vitamin D, Vitamin B12, calcium, zinc, riboflavin and vitamin A.

Figure 4.1: Role of nurses in nutritional management

Table 4.1: MNA score and its interpretation

MNA score	Interpretation	Management strategy
12–14	Normal nutritional status	Reinforce generic health and lifestyle advice or usual care
8–11	At the risk of malnutrition	Off er dietary advice Consider oral supplemental nutrition (OSN) if unable to improve food intake Monitor weight closely Consider multimodal exercise
0-7	Malnourished	Refer to a doctor/nutritionist, if available Nutritional intervention necessary Give OSN with increased protein intake (400–600 kcal/day) Off er dietary advice Monitor weight closely

Note: Oral supplemental nutrition (OSN) is defined by the WHO guidelines as the provision of additional high-quality protein, calories and adequate amounts of vitamins and minerals tailored to the individual’s needs, as assessed by a trained healthcare professional. Source: Integrated Care for Older People, World Health Organization, Geneva, 2019.

b) Dietary advice

• Meals should be small and frequent, and prolonged fasting should be avoided.
• Older people should eat a nutritious and easily digestible diet and should have access to food that is tasty and easy to prepare. A prudent diet, that not only restricts total and saturated fat but also avoids excessive carbohydrate and caloric intake, is recommended.
• A healthy diet varies widely, depending on the availability and cultural acceptability of foods. Most traditional diets are now considered to be close to being ideal, at least for adults and older people. However, older people need more protein, vegetables and fruits as compared to adults.

Table 4.2: Protein requirements for older people:

Condition	Protein requirement
Healthy older people	1–1.2 g/kg/day
Recovering from weight loss, acute illness or injury	Up to 1.5 g/kg/day
Older patients with pressure sores	Very high protein diet (that contains 25% of calories as protein)

• Physical activity should be advised, which helps in better utilization of protein for building muscle.
• Intake of complex carbohydrates and fibres (fruits, vegetables and greens) should be increased. High fibre foods help to lower cholesterol, blood pressure and glucose intolerance and prevent constipation.
• Salt intake should be limited to not more than half a teaspoon every day.
• Certain foods with antioxidant properties (green, yellow and orange vegetables and fruits such as carrots, sweet potatoes, spinach, tomato and orange) should be encouraged.
• Routine prescription of multivitamin supplements is not indicated in older people.
• Calcium and vitamin D in the form of milk, curd, cheese, small fish and certain green vegetables should be increased to compensate for osteoporotic changes.
• Encourage exposure to sunlight to make the skin produce vitamin D. The vitamin D in food is not enough for older people to maintain optimal levels. A blood test is necessary to measure whether a person’s vitamin D level is adequate. (Supplementation of Vitamin D is explained in detail in Module 8).
• Vitamin B12 supplementation is required in vegetarians but after biochemical assessment.

c) Exercise

Ageing causes a progressive decline in power, strength and endurance of skeletal and cardiac musculature. A sedentary lifestyle and lack of physical activity accelerate this decline and are associated with a higher risk of morbidity and mortality. In adults aged 65 years and above, physical activity includes leisure-time physical activity (e.g. walking, dancing, gardening, hiking, swimming), transport-related activity (e.g. walking or cycling), occupational activity (if the person is still engaged in work), household chores, play, games, sports or planned exercise, in the context of daily, family, and community activities.

Evidence suggests that compared to less active men and women, older people who are physically active have lower rates of all-cause mortality, coronary artery disease, high blood pressure, stroke, type 2 diabetes, colon cancer and breast cancer. They also have a higher level of cardiorespiratory and muscular fitness, healthier body mass and composition.

Exercise also has favourable eff ects on bone health and functional (both physical and cognitive) independence.