Six-month-old babies are fed purees before they can swallow solids, and 86-year-old adults who can no longer swallow and digest chunky food are fed purees as well. But providing the right nutrition for these two age groups is very different. The elderly cannot be fed like regular adults any more than babies and toddlers can.
About 70 clinical dietitians, nurses and communications specialists (all women, except for two) recently attended a conference on “Issues in Nutritional Care of the Geriatric Patient” at Jerusalem’s 300-bed Sarah Herzog Hospital (named in memory of Rabbanit Sarah Herzog, mother of the late sixth president of Israel Chaim Herzog).
Given Israelis’ increased longevity and the aging of the population, knowing how to properly feed elderly patients in nursing homes and geriatric hospitals will become an increasingly important skill.
In the coming years, about one quarter of the population in developed countries, including Israel, will be over the age of 65.
Already today, 10 percent of the population are elderly; half of them suffer from at least two chronic diseases and their healthcare costs constitute 30% of all public medical expenditures. Successful prevention and treatment of chronic illness will improve their quality of life and also lead to savings in medical costs.
Hospital director-general Dr. Yehezkel Caine, who greeted conference participants, noted that it’s important to accumulate scientifically-based know-how in the field of nutrition for the elderly, as they suffer from different illness and have a different metabolism than do young adults and children.
“Just as children should not be treated like small adults, the elderly are also different,” he said. “Once, old age was considered to begin at 65, and fortunately, as I get closer to that age, it gets pushed off to an older age.”
Caine noted that Herzog – which provides geriatric care for the elderly and psychiatric care for adults of varying ages as well as chronic care for ventilated children in separate wings – is the only Jerusalem hospital that is building to make room for more geriatric beds. “It’s frightening that no others are under construction here. The crunch is coming.”
Just a peek out the windows of the main building in the Givat Shaul neighborhood discloses the skeleton of the huge six-story Edithaand Dr. Heinz E. Samson Medical Pavilion, in which space for 240 more much-needed beds is being constructed.
The first wings to be occupied will move in at the end of 2013.
The new pavilion will house a number of departments, including an expanded psycho-geriatrics department catering mainly to patients with dementias such as Alzheimer’s disease; an expanded respiratory care unit for children; and additions to the adult respiratory unit. The hospital currently houses over 90 patients of all ages on respirators – the largest concentration of its kind in the country. Other departments will include internal medicine/acute geriatric medicine, complex nursing care, dialysis and other departments as need dictates.
A fortified emergency hospital in one of the underground levels will accommodate and treat patients in their beds during any enemy attack. Part of an underground parking lot and equipped with the latest protective equipment, the emergency hospital is a direct result of the Second Lebanon War and the recent Gaza conflict, as building requirements for hospitals have been revised to include expanded shelters for the protection of patients from rocket fire. In addition, an expanded radiology suite and a synagogue will be built into the side of the mountain on one of the hospitalization floors and double as a shelter in case of attack.
MICHAL KREITER, the hospital’s chief of nutrition who organized and hosted the conference, said that every patient who is admitted to the hospital is visited at the outset by one of six dietitians. An elderly patient “doesn’t decide when to get up in the morning, what to do and what to wear.
His main option is what to eat and whether to consume what he is served. Good food is the spice of life, something to look forward to. The elderly patient will refuse to eat if he doesn’t have good choices.”
Some of the patients are over the age of 100. Kreiter noted that the “food pyramid” of recommended menus for the old and for the young are quite similar, but the variation comes from how much geriatric patients eat and drink and the texture of the food.
“We serve three main meals and two intermediate small meals, and the food is regular, soft, processed in a blender or pureed.”
While many studies have shown that special diets that limit potentially harmful components such as fat, salt, sugar or protein can be effective in treating chronic diseases, she continued, “there is very little information on the diets’ effect on the elderly. Hypertension, overweight and obesity, diabetes and kidney diseases are affected by diet. Most research is on people up to the age of 65 and there is almost none on octogenarians, she said. Some conditions require extra – but strictly controlled – levels of salt and sugar. A poor nutritive state is an independent risk factor for morbidity and death. Thus, if the elderly patient is not fed properly, he could become undernourished, she said.
Kreiter has a degree in nutrition from the Hebrew University’s Robert H. Smith Faculty of Agriculture, Food and Environment and worked for eight years in the field at Assaf Harofeh Medical Center in Tzrifin.
She began to work at Herzog on Jerusalem four years ago. She also has a master’s degree from Ben-Gurion University of the Negev in Beersheba.
Although some general and geriatric hospitals now bring in and warm up prepackaged frozen meals, Herzog insists on cooking for their patients every day. “We have a four-week cycle of menus so that patients don’t get bored,” Kreiter said in an interview with The Jerusalem Post. “There are certain benefits to serving prepackaged frozen meals, but those of providing meals cooked on site outweigh them. Our food is known to be excellent. Our well-trained chef, Asher Suissa, cares so much about patients that he makes the rounds in the wards. He hugs patients and treats them as if they were his relatives. I visit the kitchen every day and eat even the pureed food to see how it tastes. Everybody has different tastes, and the same dish could be called salty by one patient and bland by another, but our patients are very satisfied with what they’re served. We suit the texture to every patient. There is poultry, fish or meat prepared in different styles and for patients of different ethnic backgrounds and tastes. Obviously price is a factor, but we maintain our standards and don’t save at the patients’ expense. We also don’t waste.”
Although communications specialists are known for helping the deaf and those with speech difficulties, their little-known other training is in understanding swallowing problems in infants, children and adults.
One of the lecturers at the conference outlined the seven different stages of swallowing food and how to cope with problems.
While a body weight index within normal limits in children and younger adults is desirable, studies have shown that older people survive longer if they are not very thin, Kreiter said. “And if their cholesterol level is a bit elevated, that is also protective, as too little blood fat also means poor nutrition at this age.” Herzog nurses weigh each patient once a month to keep track of their weight as an indication of their condition.
Generally, significant weight loss is a bad sign. We give cream and other high-calorie foods – or, if necessary, calorie supplements like Ensure. We regard nutrition of the chronically ill elderly with a holistic approach and watch the risks in diet and not only the medical benefits.”
Too much salt generally raises blood pressure and is harmful. A careful balance must be reached. Too little is not good either. Herzog medical director Dr. Ady Sasson, who is a nephrologist (kidney specialist), lectured on the risks of hyponatremia in elderly patients. This is a metabolic condition of the electrolytes in which there is not enough sodium (salt) in the bodily fluids surrounding the cells.
A minimum of salt is vital for maintaining blood pressure, but it is also needed for nerves and muscles to work properly. When the sodium level in the cellular fluids drops, water moves into the cells to balance the levels. This causes the cells to swell with too much water. Although most cells can handle this swelling, brain cells cannot because the skull bones hold the fluid in. Therefore, swelling of the brain (cerebral edema) causes the most serious symptoms of hyponatremia.
This condition, which can appear very suddenly, has a variety of symptoms, including confusion, reduced consciousness, hallucinations, headache, tiredness, loss of appetite, irritability, muscle weakness or cramps, nausea, vomiting, restlessness and coma, abnormal mental status, The elderly, Sasson said, “have a diminished sense of thirst, especially when they aren’t independent enough to have access to food and drink. An anti-diuretic hormone synthesized in the hypothalamus gland – the body’s thirst center – in the brain has an important role. Blood pressure is reduced when a patient is thirsty. Their kidneys can excrete 15 to 20 liters a day. As sodium is a main component of the cellular fluid, neurological disturbances can result.”
But the medical staff can’t just take a salt shaker and add sodium to the patient’s food to treat hyponatremia. “If we do it too fast, it can cause irreversible problems. One has to know if the condition is acute or chronic, know body weight and calculate exactly how much sodium is needed,” he said. “We use the little one-gram packets of salt given out in hotels or give intravenous saline solution.”
DR. ESTHER-LEE Marcus, head of Herzog’s department for ventilated patients, lectured on the role of vitamin D in the elderly as well as in younger adults and children. “It’s a hot subject in medicine today. The health funds increasingly test members’ vitamin D levels. It isn’t exactly, a vitamin but a hormone that the body synthesizes,” she said. There isn’t enough in the diet, so the skin produces it by using ultraviolet light from the sun. Just 10 minutes in the sun is enough to produce it in the skin, but those with dark skin are more likely to suffer from deficiency.
Vitamin D is very important for bone development, and a deficiency can cause rickets in children. “But every day there’s another medical journal article on the benefits of vitamin D. There’s a connection between insufficiency [of vitamin D] to almost every disease, from depression, cardiac diseases and schizophrenia to cancer, muscle problems, multiple sclerosis, Alzheimer’s, diabetes and tuberculosis, as well as many cognitive diseases,” Marcus pointed out. Vitamin D deficiency in pregnant women has even been linked to speech problems in their children.
Kreiter concluded that balancing the diet of elderly patients is a very delicate matter. What they eat can affect the development of bed sores, diarrhea and constipation.
“We want to do a survey about the energy needs of ventilated patients. It is known from research that in Israel, patients are kept alive longer than they are in many other Western countries. It is our Jewish morals. We keep them alive as long as we can. But obviously, some of them could suffer without palliative care. We avoid attaching a feeding tube as much as possible. We prefer for our staff or family members to feed patients by hand. We want to do research on this.”
Asked whether some patients beg to be allowed to die, Kreiter said: “Of course. We identify patients with depression by talking to them. There are always those who starve themselves; for us at the hospital, it’s very frustrating, as depression can be treated. We look at our patients as our own parents and grandparents. We insist on honoring them.”