CLINICAL
Nutrition and the life cycle
5: nutritional needs of older adults
Alison Coutts
T
he health of the older population is a
matter of considerable interest, as
older people make up an increasing
proportion of the population of Western
countries.
Having large numbers of older people is a rel-
atively new phenomenon. We are currently see-
ing the end of a big increase in the population
over 60 years of age. For example, in 1989,
15.1% of the UK population was over 60, but
by 2025 this is only expected to be 18.7% (Coni
et al, 1992). However, while this increase is lev-
elling off, a further change will be an increase in
the very old. In 1989, there were 6852 people
between the ages of 65 and 79 years, and 1990
over the age of 80 years, whereas in 2023 the
respective figures are expected to be 7918 and
2550 (Coni et al, 1992). These increases are
mainly a result of a healthier lifestyle (including
better nutrition) and a decrease in the occur-
rence of fatal infections; there has also been a
fall in the birth rate (Coleman et al, 1993).
There is much interest in the nutritional
health of this population. It is estimated that
one in four elderly people are malnourished,
as are 40% of nursing home residents and
one half of elderly hospital patients (Azad et
al, 1999; Nourhashemi et al, 1999). The
nutrients that are most likely to be lacking
from the diets of fit elderly people are calcium
and the vitamins B6, B12 and D (Sacheck and
Roubenhoff, 1999). The reasons for this can
be described in terms of physiological
changes in the older adult, and changes in
their physical, social and psychological envi-
ronment. These will be discussed in turn.
PHYSIOLOGICAL CHANGES THAT COULD
AFFECT NUTRITION
The physiological changes in older age are
complicated to study, as it is difficult to dis-
tinguish between changes as a result of
pathologies, that should be treated, and the
normal changes associated with ageing, that
are almost inevitable.
BRITISH JOURNAL OF NURSING, 2001, VOL 10, NO 9
Abstract
The previous four articles in this series on nutrition and the life cycle
reviewed the nutritional needs during pregnancy (Vol 9(17): 1133–8),
infancy (Vol 9(21): 2205–16), childhood (Vol 10(1): 26–31) and
adulthood (Vol 10(6): 362–9). This article, the last in the series, will
review the special nutritional needs of the older person. Older adults form
an increasing proportion of our society, and it is important that nurses
appreciate their special needs. The article concentrates on the healthy
older adult, and reviews what nutritional advice nurses should be
providing in order to help them achieve maximal health.
Two of these changes are a decrease in the
ability to smell and taste (Rolls, 1999).
These are particularly difficult areas to
study, as they are not fully understood, dif-
fer between people (controlled by genetic
make-up) and are subjective. However, it is
likely that there is a decrease in both the
number and sensitivity of olfactory and taste
receptors (Rolls, 1999). This may be more of
a problem for individuals who have received
insult to these senses over the years, perhaps
by working in the chemical industry, or
being prone to hay fever and other forms of
rhinitis. As well as reducing the enjoyment
of food, this could lead to a diminished
appetite (Rolls, 1999).
One appropriate response is to use flavour
enhancers. This is one reason why older peo-
ple may be more keen to add salt and sugar to
their food. It is possible to be more adventur-
ous, and add any combination of herbs and
spices, although the use of these is often dic-
tated by culture and tradition.
There is current interest in the taste known
as umami (Coughlan, 2000). Traditionally, it
was believed that taste simply consisted of a Alison Coutts is Lecturer,
combination of four flavours: salt, sweet, Applied Biological Sciences,
sour and bitter. However, umami — a meaty, City University,
St Bartholomew School
savoury taste, provided by the amino acid of Nursing and Midwifery,
glutamate — appears to have its own taste London
buds, and there may be many more different
Accepted for publication:
tastes for which there are specific receptors April 2001
(Coughlan, 2000).
603
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 NUTRITION AND THE LIFE CYCLE 5: NUTRITIONAL NEEDS OF OLDER ADULTS
Umami receptors are activated by the glu-
tamate of savoury foods, and monosodium
glutamate (MSG), a flavour enhancer, can be
added to prepared foods. It is possible that by
adding MSG to their food, older people may
derive more enjoyment from savoury foods,
which can be rich in protein (Belliste, 1998).
Old people can be reluctant to experiment
with new tastes, yet they may find that if they
overcome this reluctance, they will be
rewarded by enjoying their food more and
consequently having an improved diet.
Until the 20th century it was accepted that,
by 40 years of age, most people would have
lost all their teeth through decay and peri-
odontal disease (see Vol 10(6): 362–9).
Improved dental health means that many older
people can maintain effective teeth to the end
of their life. Many older people, however, still
experience problems with their teeth and jaw,
causing them to eat softer food, and to derive
less pleasure from eating (Lamy et al, 1999).
Chewing surfaces can be worn down so
that they do not meet effectively. This can
hasten the loss of bone from the jaw, which
can cause loosening even of healthy teeth.
Poor dental health has repeatedly been shown
to affect adversely the quality of the diet, par-
ticularly for micronutrients (vitamins and
minerals) (Appollonio et al, 1997). However,
well-fitting dentures can be as good as natur-
al teeth in enabling the person to enjoy a
good diet (Lamy et al, 1999).
Many older people also experience malfunc-
tion of their temperomandibular joints. This is
not an inevitable effect of ageing, but of undue
stress, perhaps from loss of teeth (Christiansen
and Grzybowski, 1993). Xerostomia (dry
mouth) is common at all ages, but particularly
in elderly people because of reduced salivary
gland production. This decrease can be exacer-
bated by lack of chewing, which normally
encourages salivation. It can also be a side-
effect of several drugs (Screebny and Schwartz,
1997). A dry mouth makes food difficult to
chew and seem tasteless as food needs to be
dissolved in order to stimulate receptors.
All these changes in the mouth can reduce
appetite, and the older person’s ability to eat
and enjoy certain foods. The nurse needs to
help the client choose a food that has a con-
sistency that the older person can manage, yet
at the same time encourages chewing because
this, in itself, will help keep the mouth clean
and the jaw functioning.
BRITISH JOURNAL OF NURSING, 2001, VOL 10, NO 9
‘
The entire length of the gastrointestinal Many older
tract experiences a reduction of peristaltic
strength, and an increase in non-peristaltic
people...
movements (Christiansen and Grzybowski, experience
1993). This means that transit time is malfunction of their
increased. An increase in transit time may be
beneficial, as it allows maximum extraction of
temperomandibular
nutrients. However, longer transit time facili- joints. This is not an
tates the absorption of water, so that the mate- inevitable effect of
rial in the bowel becomes harder, and more
difficult to pass, resulting in constipation. This
ageing, but of undue
makes the individual uncomfortable, and less stress, perhaps from
likely to enjoy a healthy appetite. loss of teeth
Increasing the amounts of water the indi-
vidual drinks could solve many of the prob-
...Xerostomia (dry
lems discussed above. A gradual reduction in mouth) is common
body water is a normal aspect of ageing at all ages, but
(International Food Information Council
(IFIC), 1993). The kidneys in an older per-
particularly in
son are unable to concentrate urine; thus, elderly people
more water is lost in the urine and less is because of reduced
’
returned to the circulation, and there is a
reduction in the sensation of thirst. The per-
salivary gland
son choosing to restrict fluid intake, perhaps production.
as an attempt to minimize frequency of mic-
turition and consequent incontinence, can
compound this problem.
Atrophic gastritis is an inflammation of the
stomach and the small intestine. It is probable
that it is usually caused by colonization by
Helicobacter pylori (Saltzman and Russell,
1998). This inflammation may occur in as
many as one-third of the older population
(Saltzman and Russell, 1998). It results in a
reduction of all the gastric secretions, and a
rise in the gastric pH (it becomes less acidic).
The altered environment in the stomach can
lead to bacterial overgrowth and impede the
absorption of a variety of nutrients, particu-
larly folic acid, calcium, iron, vitamin B12 and
vitamin K (Baik and Russel, 1999). To com-
pensate for this the diet should be rich in all
these nutrients.
Weight loss is a useful predictor of future ill
health, particularly if combined with low
activity levels (Chin-A-Paw et al, 1999) and
should always be investigated.
NUTRITIONAL NEEDS OF OLDER ADULTS
At the moment, almost all adults are official-
ly advised to take the same diet; however, as
our knowledge base increases, it is likely that
in the future dietary recommendations may
be specifically designed for older adults
605
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CLINICAL
‘
Generally (Saltzman and Russell, 1998; Milward,
1999). There is, however, one important
speaking, the exception, i.e. older people require a diet
older and more frail lower in energy (Evans, 1998). This is
a person is, the less because the proportion of an older person’s
body weight made up of lean body mass is
likely he/she is to eat reduced, and more is made up of adipose tis-
well. This is partly sue and fibrous material. In particular, there
the result of physical is an age-related loss of approximately 15%
of skeletal muscle (Evans, 1998), referred to
incapacity, i.e. the as sarcopenia. In addition, many older people
act of preparing and are physically less active.
eating a meal is quite Older people have a reduced glucose toler-
ance, i.e. a given amount of glucose will cause
demanding and a greater increase in blood glucose than it
many older people would in a younger person. Since appetite is
do not have the suppressed by blood glucose it is possible that
a small amount of energy makes the person
manual dexterity feel replete as a result of the sharp rise in
required for blood glucose. Indeed, the person may have
’
manipulating met his/her energy requirements without
meeting all the other nutritional requirements.
tools. Older people need a better quality diet, with a
greater density of nutrients than other people,
yet the reality is that many older people sur-
vive on a diet of high carbohydrate snacks
(Schlenker, 1993).
A proportion of vitamin D is synthesized by
the skin. In order for this to occur, the skin
must be exposed to daylight, and this expo-
sure may be reduced in older age. For this rea-
son, older people should increase the amount
of this vitamin in their diet, to ensure efficient
absorption and use of calcium. Bone loss is an
almost universal aspect of ageing, at a rate of
0.5–1% per annum (Nordin et al, 1998), and
is termed osteopoenia or osteoporosis.
Osteopoenia can be minimized by exercis-
ing, and by having additional calcium in the
diet. This is because calcium loss increases in
women during and after the menopause, and
all older people become less efficient in
absorbing calcium. A supplement of 800 mg
per day could reduce the incidence of hip
fractures (Lau and Wood, 1998). Calcium
loss can be exacerbated by a diet high in sodi-
um (salt) or high in protein.
Vitamins E and C are both anti-oxidant,
and may have a role in mitigating some
unhelpful aspects of ageing (Meydani et al,
1998; Hughes, 1999). The recommended
nutrient intake for older people is the same as
for all adults, but, as explained above, this
may change in future (Schlenker, 1993). In
the meantime, a diet rich in these vitamins
606
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cannot do any harm. Zinc intake is related to
immune function. There is some evidence
that supplementing the diet of frail elderly
people with zinc and selenium may enhance
response to immunization, particularly for
influenza, and improve resistance to chest
infections (Girodon et al, 1999). Zinc is avail-
able in tablet form, but is also present in dark
green vegetables.
Vitamin A is different: this fat-soluble vit-
amin can build up in the body if it is taken
in excess. The dangers of doing this in preg-
nancy have been discussed in a previous
article (Vol 9(17): 1133–8) and therefore the
recommended nutrient intake (RNI) should
not be exceeded.
SOCIAL AND EMOTIONAL FACTORS
Generally speaking, the older and more frail a
person is, the less likely he/she is to eat well.
This is partly the result of physical incapacity,
i.e. the act of preparing and eating a meal is
quite demanding and many older people do
not have the manual dexterity required for
manipulating tools. For example, opening a tin
with a traditional opener may be impossible
for someone with degenerative joint disease
affecting the wrist. In these instances the advice
of an occupational therapist should be sought,
as there are many useful aides available.
Furthermore, some people cannot reach the
shops, or manage to carry all the food home.
The problem of shopping for people with
no social support is a real one. Younger peo-
ple take it for granted that they can easily
drive to the local supermarket, choose from a
wide variety of good quality foods, load the
car and drive home. Many older people do
not have a car, and are forced to make fre-
quent trips to the local shops, where the qual-
ity and freshness may be questionable, and
the prices higher. Home delivery is a possibil-
ity, and doorstep deliveries of milk and,
increasingly, other fresh produce, are well
established in this country. However, they do
tend to be expensive.
Major supermarket chains have com-
menced a system whereby customers can
place an order using their personal computer
and the Internet (e.g. http://www.tescodi-
rect.com). However, older people seem to be
missing out on the benefits of the electronic
age (Chown, 1999), and also the delivery
charge could be prohibitive.
BRITISH JOURNAL OF NURSING, 2001, VOL 10, NO 9
 NUTRITION AND THE LIFE CYCLE 5: NUTRITIONAL NEEDS OF OLDER ADULTS
Meals-on-wheels could provide an effective
remedy. However, a study of older people on
this sort of programme in the USA (Prothero
and Rosenbloom, 1999) showed that only
6% were receiving a good diet, and 41%
were receiving an inadequate diet. The study
found that diets of older adults were still
dependent on individual income and social
class, despite the supplied meal being
designed to provide up to 50% of nutrients.
Some people do have access to the shops,
are able to prepare suitable meals, but do not
do so. This may be due to depression and iso-
lation. It appears that individuals, particular-
ly men, who have limited social contact are at
risk of malnutrition. Such people may need to
be encouraged to make an ‘occasion’ of some
meals by laying the table, and perhaps having
a glass of wine. If they are able to meet with
a friend, so much the better. For this reason,
luncheon clubs are invaluable. These provide,
at minimal cost, a tasty meal, and also a
social occasion, which, in itself, tends to
increase nutritional intake.
Problems such as these are compounded in
the presence of mental health disorders
(Clarke et al, 1999). Older adults who are
affected by mental health problems could
particularly benefit from the above social
occasions as for them problems of isolation
and motivation can be particularly marked
(Schlenker, 1993).
CONCLUSIONS
Poor nutrition affects immune response
(Girodon et al, 1999), cognitive function,
morbidity, recovery from illness and, ulti-
mately, survival. Furthermore, severe malnu-
trition is more difficult to correct in the elder-
ly than the general population (Nourhashemi
et al, 1999). There are several tools available
for assessing nutritional status, e.g. Green
and McLaren (1998) provide a useful
overview of different approaches, but these
do not generally perform any better than
skilled observation from an informed health-
care professional (Azad et al, 1999). BJN
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KEY POINTS
Green SM, McLaren S (1998) Nutritional assess-
ment and screening tools and instrument selec- ■ Older people may
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Hughes DA (1999) Effects of dietary anti-oxidants
on the immune function of middle-aged adults. a poor diet
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the elderly population. J Dent 27(6): 443–8
Lau EM, Wood J (1998) Nutrition and osteoporo- beneficial.
sis. Curr Opin Rheumatol 10(4): 368–72
Meydani M, Lipman RD, Han SN, Wu D, Beharka ■ Good dental care
A, Martin KR, Bronson R, Cao G, Smith C, is essential in
Meydani SM (1998) The effect of long-term
dietary supplemetation with anti-oxidants. Ann order to benefit
N Y Acad Sci 854: 352–60 from a good diet.
Milward DJ (1999) Optimal intakes of protein in
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Nordin BE, Need AG, Steurer T, Morris HA, Chatterton ■ Many older people
BE, Horowitz M (1998) Nutrition, osteoporosis and should increase
ageing. Ann N Y Acad Sci 854: 336–51
Nourhashemi F, Andrieu S, Rauzy O, Ghisolfi A, their fluid intake.
Vellas B, Chumlea WC, Albarede JL (1999)
Nutritional support and ageing in preoperative ■ Some vitamins
nutrition. Curr Opin Clin Nutr Metabol Care and minerals may
2(1): 87–92
Prothero JW, Rosenbloom CA (1999) Description be particularly
of mixed ethnic, elderly population: demogra- lacking in the diet
phy, nutrient/energy intakes and income status.
Gerodontology 54(6): 315–24 of older people.
Rolls BJ (1999) Do chemosensory changes influ-
ence food intake in the elderly? Physiol Behav ■ Social and
66(2): 193–7
Sacheck JM, Roubenhoff R (1999) Nutrition in the emotional issues
exercising elderly. Clin Sports Med 18(3): are equally as
565–84
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Schlenker ED (1993) Nutrition and Aging. Mosby, in obtaining
Missouri a good diet.
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607
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