By Dr. Sean M Wells, DPT, PT, OCS, ATC, CSCS, CNPT, NSCA-CPT, Cert-DN
Exercise is certainly medicine but what if we could do more for our older adult clients? As physical therapists (PTs), occupational therapists (OTs), or personal trainers we strive to push our clients with the best exercise selection and most evidenced-based techniques to improve our clients’ strength, balance, and function. But what if all we are doing is for not because of a client’s poor diet?
I have seen this time and time again in my clinical practice: a client enters my practice, I examine them and find weakness and balance deficits; we begin a program of resistance training, balance and neuromuscular work, and notably see little change in their function. As I dive deeper into their lifestyle factors (e.g. sleep, stress management, and nutrition) I find they don’t eat enough, drink too much alcohol, and consume overly processed foods devoid of essential nutrients. Could these factors be the elements holding some of our older adults back from improving better rehabilitation outcomes? Let’s look at some examples and evidence connecting nutrition with geriatric physical therapy and rehabilitation.
Physiologically, older adults' sense of taste and smell diminish with age. Moreover, other factors such as dental changes or pain with mastication, swallowing problems, or GERD may further drive an older adult away from consuming enough food. As a result we often see older adults not enjoying food as much as they did when younger. Not consuming sufficient energy can drive catabolism and, if sustained, drive sarcopenia (muscle mass loss secondary to aging). We also know that data supports the consumption of slightly higher protein intake in older adults. Typically the FDA recommends 0.8g/kg body weight/day of protein for most adults, but some older adults may gain muscle mass and mitigate some bone loss with protein levels slightly higher than this (e.g. 1.0g/kg body weight/day). Having more muscle mass can equate to better functional scores on the Timed Up and Go (TUG), Five Time Sit to Stand (FTSTS), and balance metrics. Rehab professionals can help their patients by asking a client about their diet and trying to understand why an older adult may be undereating. If it is due to a sense of smell or taste, then consider encouraging the use of aromatic spices as another method to improve the smell and taste of food. If it is swallowing or dentition, then consider a referral to a Speech Therapist (SLP) or dentist -- helping them get food into their bodies is essential!
Alcohol is another underestimated portion of an older persons’ diet that can negatively impact their rehab outcomes. Older adults may use alcohol to cope with a loss of a loved one, as a means to control shakes or tremors, or as an aid to meet social requirements. Alcohol is a central nervous system depressant, which data show can translate to more falls, higher rates of depression, and can drive neuroinflammation. Discussing alcohol consumption with older adults during therapy is important. Many mentees and students of mine are utterly surprised at how many and how much alcohol their clients consume once they start asking. Several evidenced-based alcohol assessment tools exist: I encourage Doctors of Physical Therapy (DPTs) to use these tools in their physical therapy practice to screen for referrals to alcohol cessation programs or professionals.
Our final discussion point centers around the high consumption of processed foods. Several NIH studies have shown that ultra processed foods are linked with greater rates of obesity and morbidity. As rehabilitation professionals we know that obesity makes movement difficult and data show it also promotes inflammation. Multiple comorbidities reduce an older patient’s successful rehab prognosis, as well as decreasing their quality of life. Ultra processed foods like potato chips, white-bread sandwiches, and sugary fruit drinks offer little nutrients but lots of calories. Malnutrition is certainly a risk with some older adults and this can be easily detected with the MNA-SF screening tool (it’s very easy to use). Referrals to a registered dietician (RD) is a must in possible malnutrition cases. In addition, sarcopenic obesity, where an older adult loses muscle but gains fat mass, can often present in older adults unknowingly. Individuals with sarcopenic obesity often present without looking thin or atrophy due to the fat mass gain; however, PTs will notice they are weak and cannot perform functional movements with ease. Doctors of Physical Therapy and other rehab professionals need to educate patients on reducing their consumption of processed foods. Detecting junk food consumption is easy using the fruit and vegetable screener or a 3 day diet assessment. Advocating for quality, whole-foods in hospitals, nursing homes, and rehab facilities is also in the wheel-house of rehabilitation professionals. Referrals to RDs should also be considered a mainstay for PTs, especially if multiple comorbid conditions exist.
Afterall, what’s the point in all your skilled services and the patient’s hard work if it all gets sidelined by crappy food?
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Keywords: nutrition, diet, continuing education, online, geriatric, PT, physical therapy, learning, OT, rehab, fall, prevention