Standardized process for elderly nutrition management

The core logic of the standardized process of nutrition management for the elderly has never been to provide a unified recipe template for all elderly people, but to focus on the four core nodes of "stratified assessment - precise intervention - dynamic tuning - long-term support" and an individualized operating system that can be flexibly adjusted based on the elderly's physical condition, living habits, and disease conditions - this is the consensus that has been gradually unified in the clinical practice of domestic geriatric medicine and nutrition departments in the past 10 years.

Don’t underestimate this hierarchical evaluation. The differences in operations under different scenarios are actually quite large. When conducting large-scale screening in the community, MNA-SF (Micro Nutritional Assessment Short Form) is mostly used. The 6 questions can be completed in three to five minutes. It is very efficient and can quickly pick out the elderly with nutritional risks. Many scholars feel that this method is too crude and has a high rate of missed diagnosis. Especially for the elderly with chronic diseases, biochemical indicators, skeletal muscle mass testing, swallowing function assessment, and even a three-day diet diary must be added to accurately determine the true nutritional status. Last month, we met a 72-year-old Aunt Zhang at a community free clinic. She has type 2 diabetes and always says she has no appetite. Her children bought a bunch of protein powder after listening to the live broadcast, and they got bloating and diarrhea as soon as they ate. The MNA-SF score has reached the critical value of the risk of malnutrition. The albumin was only 32g/L, and she has mild lactose intolerance. The previous protein powder was ordinary soy protein, which was certainly not suitable for her.

How to provide solutions after screening out problems is more controversial. Recently, I admitted an 80-year-old man with COPD. His BMI was only 17. According to the nutritional guidelines, he had to ensure a daily protein intake of 1.2g/kg. The previous plan prescribed elsewhere was two hard-boiled eggs, a cup of milk, and 20 ounces of lean meat every day. As a result, the old man had poor swallowing function. He always choked when eating hard-boiled eggs. He didn't eat enough for half a month, and he choked and was hospitalized with aspiration pneumonia. We later adjusted it into steamed egg custard and multigrain rice porridge with hydrolyzed whey protein added. We also chopped the meat into minced meat and cooked it in the porridge, so he didn't have to chew hard. In less than a month, he gained two pounds. Some people think that as long as they are the elderly, they must strictly limit oil, salt and sugar. Even if they have no appetite, they must follow the standards. Our current view in Corey is that for the elderly over 80 years old and without serious metabolic diseases, priority should be given to ensuring the total intake without being too stuck - for example, the elderly like to nibble on a sauced elbow. As long as the blood lipids are stable, it is okay to eat it once a week. It is better than not being able to eat this or that, and ending up being unable to eat due to malnutrition. Of course, if you have problems such as gout or renal insufficiency, you should avoid foods that you should avoid. This is not negotiable.

Don’t think that once the plan is finalized, it will be settled once and for all. I have seen too many family members come in with nutritional prescriptions from six months ago and ask why they are suffering from stomach bloating and constipation after taking them now. The physical condition of the elderly changes much faster than that of young people. Last week, he could still go downstairs for a walk and eat normally. This week, he fell and fractured his body and was lying in bed. His gastrointestinal motility immediately slowed down. If he were to give him food high in oil and protein in the same amount as before, he would definitely accumulate food. Our current practical rules are that hospitalized elderly people undergo nutritional re-evaluation once a week, and those at home measure their weight and do a simple screening once a month. If there is an infection, surgery, or acute illness, the plan can be adjusted at any time. For example, there was a 90-year-old grandmother who usually had bad teeth and could only eat soft and rotten food. Later, she received full dentures and was able to chew chopped vegetables and minced meat. We adjusted her liquid diet to a semi-liquid diet, adding chopped spinach and lean pork. She said that her meals tasted a lot better. If she had been eating mushy food according to the previous plan, she would easily be lacking in dietary fiber.

There are also many people who tend to ignore the last step of long-term support. They always feel that nutritional management is a matter for the hospital, and that’s it once they write a prescription. In fact, the elderly spend 80% of their time eating at home. If their family members don’t know how to do it, no matter how scientific the plan is, it will be useless. Nowadays, the practices are different in various places. Some places have built canteens for the elderly and uniformly prepare meals according to nutritional standards. It is convenient, but it is difficult to adjust. Some elderly people think that the dishes are too bland and do not like to eat them, so they secretly throw them away, which is useless. ； Some places provide training to community volunteers and family members, teaching them how to read nutrition labels, how to change recipes for elderly people with bad teeth, and even go to the elderly people's homes to look through their refrigerators to see if there are any leftovers that have been there for too long and how to mix them more appropriately. Both modes have their own advantages and disadvantages, and there is currently no way to say which one is definitely better. They are both trying to cross the river by feeling for the stones.

To put it bluntly, there is no absolutely rigid "standardized process". All standards are given as a broad framework, and ultimately they have to revolve around the actual feelings of the elderly. After all, our purpose in providing nutrition for the elderly has never been to keep all indicators of the elderly stuck within perfect reference values, but to enable them to eat well, walk steadily, get less sick, and have a higher quality of life in their later years, which is better than anything else.