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Sleep night-time sleep and awakening dif culties often precede the drunkenness [also called ‘Schlaftrunkenheit’ in German arrhythmia band chattanooga vasodilan 20 mg with mastercard, onset of excessive daytime sleepiness arrhythmia during stress test order 20mg vasodilan otc. As with narcolepsy arteriogram order vasodilan 20 mg otc, ‘ivresse du sommeil’ in French prehypertension treatment diet 20mg vasodilan with mastercard, or ‘syndrome of Elpenor’ excessive daytime sleepiness is occasionally rst experienced after the youngest of Ulysses’ comrades who killed himself following transient insomnia, abrupt changes in sleep–wake during an incomplete arousal in the middle of the night schedule, overexertion, general anaesthesia, viral illness or (Carrot, 1947)] was present in 50–60% of patients reported minor head trauma. Although habitual problems with awakening as a trigger in predisposed individuals, cause idiopathic were common in our subjects, particularly in those with hypersomnia by themselves, or are coincidental. In our prolonged night-time sleep, sleep drunkenness occurred in experience, apart from viral illness, these factors more often only 21%. This difference may be, in part, related to the appear to aggravate preexisting excessive daytime sleepiness criteria used to de ne the symptom, as a continuum probably than to cause it de novo. In any case, the symptom is not speci c for substantial clinical overlap between narcolepsy and idiopathic idiopathic hypersomnia; it can occur in up to 10–30% of hypersomnia (Nevimalova-Bruhova and Roth, 1972; Roth narcoleptics and in patients with other disorders associated et al. As with narcolepsy, excessive daytime sleepiness in idiopathic Neurovegetative symptoms such as migraine or tension hypersomnia can be exaggerated after alcohol use, intense type headaches, orthostatic disturbances and Raynaud-like exercise or heavy meals and in warm environments. It is symptoms were common in our subjects and in previously Idiopathic hypersomnia 1431 reported patients with idiopathic hypersomnia (Roth et al. Although other vegetative dysfunctions reported polysomnographic differences between subjects with in idiopathic hypersomnia include syncope, altered nocturnal ‘narcoleptic-like’ idiopathic hypersomnia and those with cardiovascular responses to arousals, and elevated heart and ‘classic’ idiopathic hypersomnia. It seems likely that most of the psychiatric symptoms in narcolepsy and idiopathic hypersomnia. Although Dement in these patients are nonspeci c responses to chronic illness et al. Thirdly, although by the existence of familial cases of isolated sleep paralysis depressive hypersomnia is usually attributed to lack of and by the frequent occurrence of sleep paralysis in persons initiative, apathy, clinophilia (tendency to maintain a reclining without narcolepsy (Nevimalova-Bruhova and Roth, 1972; position) and associated with normal or only mildly abnormal Dahlitz and Parkes, 1993). As with of their sleep signi cantly more than control subjects when narcolepsy, subjective improvement of sleepiness was not allowed to sleep ad libitum. Aldrich patients did not report any improvement of their excessive hypersomnia, its good response to stimulants and the rare daytime sleepiness after prolonged sleeping for days, a occurrence of narcolepsy with cataplexy in relatives. They which could thereby account for the rarity of true familial de ned monosymptomatic idiopathic hypersomnia as non cases of narcolepsy with cataplexy, the reports of monozygotic narcoleptic essential hypersomnia, and polysymptomatic twins discordant for the disease and the existence of idiopathic hypersomnia as the association of this hypersomnia symptomatic forms of narcolepsy. A proposed new classi cation of functional hypersomnias Idiopathic and symptomatic forms were described as clinically based on our ndings is shown in Table 4. Our experience, however, suggests that current criteria which we consider preliminary and subject to revision based for idiopathic hypersomnia identify a clinically more on future ndings, is supported by prior studies. A third group has intermediate clinical but without cataplexy; and (iii) narcolepsy without cataplexy characteristics. Several investigators need to be revised in the future based on assessment of larger reported series of narcoleptics in which 7–25% had two or numbers of subjects. Although we found, as did others, that, in the absence of a diagnostic gold standard, remains a that patients with classical idiopathic hypersomnia are usually diagnosis of exclusion. The strong association between recordings are usually normal except for decreased sleep ‘classic’ idiopathic hypersomnia and a family history of latencies. Sleep paralysis and hypnagogic hallucinations are diabetes found in this study suggests a possible linkage of common but are probably not due to abnormal pressure for the disease to other genes. The variable character and course of hypersomnia Secondly, the hypothesis that the subgroup of ‘narcoleptic suggest that the syndrome has multiple aetiologies. J Psychosom hypersomnia that follows viral infection appears to have a Res 1994; 38: Suppl 1: 41–7. This study supports the hypothesis of the existence, daytime sleepiness in narcolepsy [see comments]. Sleep and alertness: Acknowledgements chronobiological, behavioural, and medical aspects of napping. New this research was supported in part by the Schweizerische York: Raven Press, 1989. Idiopathic narcolepsy: a disease sui generis; with remarks narcolepsy-cataplexy using self report measures and sleep diary on the mechanism of sleep. Sleep-wake disorders based on a polysomno Berti Ceroni G, Gambi D, Coccagna G, Lugaresi E. In: Guilleminault C, Lugaresi E, editors Sleep/wake disorders: natural history, epidemiology, and long-term Dement W, Rechtschaffen A, Gulevich G. Acta Neurol daytime sleepiness without cataplexy, and their relationship with Scand 1975; 52: 337–53. Electroencephalographic study on narco C R Seances Soc Biol Fil 1970; 164: 2288–93. The pharmacologic treatment Hishikawa Y, Nanno H, Tachibana M, Furuya E, Koida H, Kaneko of depression. Berlin: Springer gical Diseases and Blindness, Neurological Information Network, Verlag, 1988: 24–57. Signs and symptoms associated with cataplexy in narcolepsy Epworth sleepiness Scale. A clinical and polygraphic study of dreams in polygraphic and clinical data for 100 patients. De cient blood pressure regulation in a case of hypersomnia with sleep drunkenness. By understanding sleep physiology and offering a range of interventions, the primary care physician can turn an unhealthy situation around. The most common is simply a lack of adequate, the consequence of poor sleep behavior, an endemic feature of contemporary life. Work pressures, family obligations, and the creeping shift toward a 24-hour lifestyle have placed heavy demands on waking hours Article at a glance and can intrude upon the ability to sleep at night. Sleep apnea also reduces quality of life, psychological oxygen saturation in the blood, contributing to lower levels of disturbances, and increased energy that may increase the likelihood of daytime sleepiness. Sexual issues, poor self-image, and decreased economic achievement are also features of hypersomnia, while in ex treme cases, psychological disturbances, such as paranoia and hallucinations, may result. Nicotine patch, cigarette smoking Selective serotonin reuptake inhibitor antidepressant Sleep-wake cycles Stimulant laxative near bedtime A sleep cycle consists of 5 stages and lasts about Theophylline 90 to 100 minutes. Stages 3 and 4, when deep sleep takes people who sleep 1 or 2 hours more than the opti place, are the most restful and restorative sleep mal daily amount, which is generally considered stages. This fact is confirmed in sleep labora sleep increases with the duration of wakefulness. Further, hypersomnia is self-re governed by the suprachiasmatic nucleus in the ported, and the physician must identify what, for hypothalamus. The 24-hour circadian rhythm is the patient, constitutes an “adequate” amount of itself set by exposure to light. A patient who lives with an insomniac, for the neurologic underpinnings of the process S example, may believe that he or she is a hyper homeostasis has been supported by research sug somniac in comparison. Some patients who report gesting that adenosine, a substance related to insomnia do not substantially differ in their sleep energy metabolism, may accumulate in the basal patterns from age-matched people who do not forebrain when a person is awake. This discrepancy the brain enters the sleep cycle—adenosine levels is not always easily resolved, and may simply be a diminish until wakefulness returns. Lesion in the posterior hypothala mus causes sleep, while lesion of the anterior hypothalamus causes insomnia. Damage or irri tation to the brain, which may occur in the case of a tumor, but is more commonly the result of ingested brain-active chemicals, could have either one of these effects. Indeed, there are a large number of potentially sleep-inducing med ications including anticholinergics, norepineph rine receptor blockers, and antihistamines. Changing cycles Numerous factors may disrupt, fragment, or shift the normal sleep cycle. Age is a central factor, although the commonly held notion that older people need less sleep is not necessarily the case. Older people often do experience a deterioration of quantity and quality of sleep, but in many cases, this is a consequence of declining health. In extreme cases, such as in patients with pre-Alzheimer’s dementia, sleep may be very severely affected. Adolescents commonly experience de layed sleep phase syndrome, which involves a shift in the circadian rhythm entailing a natural propensity to go to sleep and wake up later than normal.

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Also blood pressure journal free download buy generic vasodilan online, lack of exercise hypertension numbers purchase vasodilan 20 mg line, cold and heavy food arrhythmia loading order vasodilan 20 mg visa, overeating hypertension synonym buy vasodilan 20mg fast delivery, and receptive work (passive versus active) slow them right down. Kaphas need to be active and only recognize their great assets of inner security and steadiness when they are in action. This principle of natural law applies to every living being and to nature as a whole. Yet creating balance is not something you will need to do just once in your life, rather it is an ongoing process that allows your body and mind to function in perfect coordination and harmony with each other and the natural environment. A life of balance will equip you with the ability to joyfully and passionately meet the constantly increasing challenges of our time, endowed with the tools of physical and mental strength, creativity and wisdom. The factors that could possibly disrupt your health have increased tremendously within the relatively short period of the past several decades. Not so long ago, it was relatively easy to live in harmony with the laws of nature and the environment. Now you have to be very alert not to get caught up in the destructive effects of man’s creations. Many big city children grow up with the notion that food means highly processes junk; drinking water is not necessary, but soft drinks are; and that nature is merely something to watch on the Discovery Channel, an American cable television station. Many people recognize that our modern way of life, with its ever-increasing comforts and material acquisitions along with the demands to acquire and maintain them, doesn’t allow for a healthful way of life. As a nation, the United States has become dependent upon a health care system that makes us sicker and which has become unaffordable for most, while pushing the country to the brink of financial ruin. Although we spend more on health care than do most developing countries taken together, 65 percent of the population is unhealthy and suffers from one health problem or another. Never before have we had such a strong need to live a balanced life, but relatively few manage to do so. Yet balance or good health of mind, body and spirit is an option most of us can choose to create by following the simple, yet powerful recommendations given in this chapter. A good number of guidelines presented here are derived from the ancient medical science of Ayurveda and my 35 years of experience in the field of complementary medicine. I have updated and improved them as a result of regular feedback that has been provided to me by thousands of patients who have applied these principles in their daily lives. When you are capable of per forming 100 squats in a row, you body will start relying on Chi (life force) for its energy requirements instead of using up its physical energy resources. Some aerobic exercises are fine as long as you maintain nose breathing versus mouth breathing. For example, if you can swim for 30 minutes before feeling tired, swim only for 15 minutes. Overexercising, such as in endurance training, weakens the immune system, heart and lungs and floods the blood with harmful, acidic chemicals. The Five Tibetan Rites as described in the book Ancient Secret of the Fountain of Youth by Peter Kelder is one of the most excellent and simple exercise routines you can follow. Eating at different times each day makes it difficult for the body to produce the right amount of digestive juices required for each meal. Note: Food cravings have nothing to do with hunger and should be treated like an addiction. Make it a daily habit to drink one glass of water about hour before each meal and one glass of water 2-2 hours after each meal. The digestive system is better able to secrete balanced amounts of digestive juices when you are eating in the seated position. Lying on your left side for a few minutes and then going for a 10 to 15 minute walk afterward also greatly aids digestion. Morning Bowel Movement: > For optimum health, the bowel movement should occur regularly in the morning after rising, ideally at the end of the Vata period (at around 6:00 a. Also, never suppress natural urges, as this may lead to great disturbance of Vata in the body and even cause internal injuries and, possibly, hemorrhoids. This will help to end the “drought” of the night and increase the regularity of the bowel movement. A little while later, drink a second glass of warm water, but add a teaspoon of honey and the juice from one or two slices of fresh lemon. This will improve circulation, strengthen and rejuvenate the skin, and help with lymph drainage. The brushing of the skin also opens the pores and increases the effectiveness of the oil massage, if applied afterward. Abyanga also stimulates growth hormone production and improves immunity because nearly one third of the immune system is located in the skin. Food choices may consist of nutritious wholesome foods, such as oatmeal (porridge) or any other hot cereal. Wetabix or toasted whole-wheat bread (finely ground) with butter, is a good choice, too. Other hot cereals include cream of buckwheat, cream of rice, millet, grits, quinoa and other such grains. Note: Soy milk should be avoided due to its natural food toxins (enzyme inhibitors), possible gene manipulation, and its potentially harmful effects on hormonal balance. Also, do not add fruit to your cereals, as this leads to fermentation and toxicity, which will be explained further below. Sipping a small cup of hot water during the meal, however, can help to increase the digestive power. To maintain thinness of blood and normal secretions of bile, it is best to drink a glass of water about hour before lunch and again 2-2 hours after lunch. Since raw foods require different digestive enzymes than those needed for digesting cooked foods, eating these food 127 Timeless Secrets of Health and Rejuvenation items separately, i. Eating raw food items after having eaten cooked foods will leave them mostly undigested and subject to fermentation. A team of researchers at Iowa State University conducted a study that showed that the salad’s nutrients are only digested and absorbed properly when consumed with a full-fat salad dressing versus a reduced or no-fat product. At that time, the stomach may discharge the now mostly undigested food into the small intestine, prompting destructive bacteria to decompose it. When exposed to the warm and moist environment of the stomach and small intestine during the night, they end up causing indigestion and fermentation (along with plenty of low-grade alcohol). The soup/vegetables may be seasoned with spices and herbs, vegetable bullion, unrefined sea salt, as well as butter, ghee or coconut oil added during or after cooking—about one teaspoon of butter, ghee or coconut oil per person (avoid other oils in the evening since they are more difficult to digest. Most olive oil products were adulterated with vegetable oils, such as canola, corn, cottonseed and soy oils, which have been shown to cause, not prevent heart disease. Avoid the Following brands: Andy’s Pure Olive Oil (Italy), Bertolli (Italy), Castel Tiziano (Italy), Cirio (Italy), Cornelia (Italy), Italico (Italy) Ligaro (Italy), Olivio (Greece), Petrou Bros. Olive Oil (California), Primi (Italy), Regale (Italy), Ricetta Antica (Italy), Rubino (Italy), San Paolo (Italy) Sasso (Italy), Terra Mia (Italy). If you use fruit juice, make sure it is freshly prepared and not older than one hour (best diluted with water). Packaged fruit juices are pasteurized, which makes them acid-forming, deprives them of natural enzymes, and depletes the body of important minerals and vitamins. Many brands contain artificial sweeteners, which dehydrate the body and may damage the brain, nervous system and immune system. Since fruit leaves the stomach within 20-40 minutes without requiring any stomach action, it is important not to eat them with other foods; doing so leads to fermentation, bloating, and even diarrhea. The best times to eat fruit are midmorning and midafternoon, or for breakfast with nothing else. When picked too early, they have not reached their natural ripening stage and lack most vitamins and important sugars. They may also irritate the intestinal walls due to their high concentration of antibodies (acting as antigens in the body) and enzyme inhibitors (highly toxic). If you find that you have trouble digesting fruit, harvesting it too early this is often the reason. Since fruit has a cooling influence, you may want to eat them more often during the summer months.

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Use: Iowa and Utah are known to blood pressure chart by age nhs buy vasodilan 20 mg low cost issue restricted licenses (Stutts blood pressure higher at night order cheap vasodilan on line, 2005; Vernon heart attack vol 1 pt 3 discount vasodilan 20 mg with visa, Diller arrhythmia bat pony buy generic vasodilan online, Cook, Reading, & Dean, 2001). A survey of State licensing agencies found that two-thirds of the States said that restricted licenses would be feasible under current State policies, though two-thirds of these would require legislative changes before restricted licenses could be issued (Staplin & Lococo, 2003). Costs: Once drivers have been screened and assessed, the costs of issuing a restricted license are minimal. Time to implement: Restricted licenses can be implemented as soon as any needed policy or legislation changes are enacted. Lococo (2003) contains the results: detailed documentation of how each State’s medical review is organized; how drivers are identified, referred, screened, and assessed; and what licensing actions can be taken. They should take the lead in defining how various medical conditions and functional impairments affect driving; defining medical assessment and oversight standards; improving awareness and training for healthcare providers, law enforcement, and the public; advising health care professionals how drivers can compensate for certain medical conditions or functional impairments; and reviewing individual cases. To renew an expiring license, drivers in many States must appear in person, pay the license fee, and have new pictures taken for their licenses. More than half the States change license renewal requirements for drivers older than a specified age, typically 65 or 70. These changes may include a shorter interval between renewals, in person renewal (no renewal by mail or electronically), or a vision test at every renewal. A very few States require written or road tests for some older renewal applicants. This observation is supported by Morrisey and Grabowski (2005), who found that in-person license renewal was associated with reduced traffic fatalities among the oldest drivers. Frequent in-person renewals and vision tests may be more useful for older drivers than for younger drivers because their abilities may change more quickly. As of 2001, about one-fourth of the States met them for drivers over some specified age (Staplin & Lococo, 2003). These include 15 States with a shorter interval between renewals, 7 that require in-person renewals, and 9 plus the District of Columbia that require vision tests at renewal. On the other hand, Oklahoma and Tennessee reduce or waive licensing fees for older drivers and Tennessee driver’s licenses issued to people 65 or older do not expire. No data are available on the number of potentially impaired drivers identified through these practices or 7 17 on the effects of more frequent renewals and vision tests on crashes. Furthermore, recent studies regarding the effectiveness of vision screening for license renewal indicate that the value of the vision tests commonly used for licensing decisions as predictors of increased crash risk is inconclusive and that the aspects of vision currently assessed for licensing do not adequately explain unsafe driving (Bohensky et al. Nonetheless, one recent study found that fatalities among drivers 80 years and older in Florida decreased by 17% after the State passed a law requiring these drivers to pass a vision test before renewing their driver licenses (McGwin, Sarrels, Griffin, Owsley & Rue, 2008). Costs: More-frequent license renewals or additional testing at renewal impose direct costs on driver licensing agencies. For example, a State that reduces the renewal time from 6 years to 3 years for drivers 65 and older would approximately double the licensing agency workload associated with these drivers. If 15% of licensed drivers in the State are 65 and older, then the agency’s overall workload would increase by about 15% to process the renewals. If more frequent renewals and vision tests identify more drivers who require additional screening and assessment, then additional costs are imposed. Time to implement: A vision test requirement for renewal or a change in the renewal interval can be implemented within months. The new requirements will not apply to all drivers for several years, until all currently valid licenses have expired and drivers appear at the driver licensing agency for licensing renewal. Langford, Fitzharris, Koppell, and Newstead (2004) compared Australian States with and without these requirements. They found that Australian States with these requirements had higher older-driver crash rates than States without them. They conclude that there are “no demonstrable road safety benefits” to requiring medical reports or road tests for older drivers. In particular, active publicized enforcement of seat belt use laws can help increase belt use for older drivers and occupants. Traffic stops and crash investigations provide officers excellent opportunities to observe and evaluate driving behavior. Law enforcement officers have formed many partnerships with public and private organizations to give talks, teach safe driving courses, work with media on news stories and public service announcements, and other communications and outreach initiatives. They include training for officers, training for older drivers, and community relations programs that promote safety. The four-hour course provides background on older driver issues and discusses traffic stops, referring older drivers to licensing agencies, and community outreach. Effectiveness: Enforcement activities, such as high-visibility seat belt law enforcement, probably affect older drivers even more than other drivers. Law enforcement provides more than one-third of all referrals to licensing agencies for driver screening and assessment (Chapter 7, Section 2. Time to implement: Implementation time varies depending on the nature and scope of activities. Driver Licensing Policies and Practices: Driver Licensing Policies and Practices Database. The Combination of Two Training Approaches to Improve Older Adults’ Driving Safety. Long-term benefits of prompts to use safety belts among drivers exiting senior communities. Acceptability and validity of older driver screening with the DrivingHealth Inventory. Effectiveness of mandatory license testing for older drivers in reducing crash risk among urban older Australian drivers. Fragility versus excessive crash involvement as determinants of high death rates per vehicle-mile of travel among older drivers. Motor-Vehicle Crash History And Licensing Outcomes for Older Drivers Reported as Medically Impaired in Missouri. Impact of an education program on the safety of high-risk, visually impaired, older drivers. Pedestrians Overview In 2008, 4, 379 pedestrians died and about 69, 000 were injured in traffic crashes in the United States. Pedestrian fatalities have dropped gradually over the past 20 years from about 7, 000 to less than 5, 000 annually. Fatality rate trends, that is, fatalities adjusted per number of walking trips or miles traveled by walking, are unavailable because there is no consistent measure of walking to estimate and compare fatality rates. It is likely, however, that more kinds of walking trips were captured in the later survey. The latest survey was conducted in April 2008 through May 2009 but results have not yet been released. From 1998 to 2008, pedestrian fatalities decreased for all ages except the 21 to 24 and 45 to 64 age groups. In particular, child pedestrian fatalities (ages 15 and younger) decreased 46%, from 582 to 316. Pedestrian crashes can be classified into types based on crash location and pedestrian and motor vehicle actions. In the early 1990s this methodology was used to classify more than 5, 000 pedestrian crashes in California, Florida, Maryland, Minnesota, North Carolina, and Utah (Hunter, Stutts, Pein, & Cox, 1996, summarized in Of these pedestrian crashes: • the largest major grouping was crashes occurring at or within 50 feet of an intersection, accounting for 32% of all crashes. Of these intersection crashes, 30% involved a turning vehicle; another 22% involved a pedestrian running across the intersection or darting out in front of a vehicle from a location where the pedestrian could not be seen, and 16% involved a driver violation. In one-third of these, the pedestrian ran into the street and the driver’s view was not obscured; one-sixth were “dart-outs” in which the pedestrian walked or ran into the street from a location where the pedestrian could not be seen. In three-quarters of these crashes the pedestrian was struck from behind while walking in the same direction as traffic. Different crash types at different locations can be addressed by different countermeasures. An emerging issue likely to attract attention in future years is the increasing research establishing cell phone use as a source of distraction, not only for motorists, but for pedestrians.

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Maximizing and maintaining functional status and quality of life becomes the priority healthcare objective in this population group (1) blood pressure medication foot pain purchase vasodilan pills in toronto. The nutritional care goal is to blood pressure medication hair growth generic vasodilan 20mg amex provide health promotion and nutrition education to hypertension 5 hour energy order vasodilan 20mg with amex achieve this objective prehypertension 38 weeks pregnant cheap vasodilan 20 mg without a prescription, as decreased metabolic needs and activity levels, chronic disease management and illness, economic challenges, loss of social support systems, and other variables impact food and nutritional intake (1, 4, 5). Diet quality and quantity play major roles in preventing, delaying onset, and managing chronic diseases associated with aging (5, 6). About 87% of older adults have diabetes, hypertension, dyslipidemia, or combination of these chronic diseases (5, 6). Provision of medical nutrition therapy requires the regular assessment of each older individuals nutritional status and care plan. To optimize overall health and quality of life outcomes, the least restrictive regimen possible should be tailored to each person’s medical condition, needs, desires, and rights (1, 4). Overall nutrient requirements are similar between these age groups with the exception of the vitamin D requirement, which increases with age. To ensure adequate consumption of vitamin B12 and vitamin D, the Dietary Guidelines for Americans recommends consuming vitamin B12 in its crystalline form, eg, fortified foods or supplements, and consuming extra vitamin D from vitamin D–fortified foods and/or supplements (9). Decreases in taste, olfaction, and changes in levels of hormones that control satiety and food intake can diminish appetite and lead to lower energy and overall nutrient intake (4). Food is an essential component of quality of life; an unpalatable or restrictive diet can lead to poor food and fluid intake, resulting in undernutrition and related negative health effects (4). When planning nutrient restrictions or therapeutic diets health care practitioners must assess risk versus benefit to ensure overall adequate nutrition intake (4). Energy and Nutrient Considerations Total and resting energy requirements decrease progressively with age because of decreases in the basal metabolic rate and in a large part decreases in physical activity level (1). The average daily energy intake for persons older than 51 years of age is 2, 400 kcal for men and 2, 000 kcal for women (10). Nutrients consistently found to be deficient in diets of older adults include antioxidants, calcium, zinc, iron, potassium, vitamin D, E, and K (1). In addition nutrients for which the digestion, absorption, or metabolism declines with age, such as vitamin B-12 and other B vitamins are also found to be deficient in this population group (1). A large proportion of adults age > 51 years do not consume sufficient amounts of many nutrients from food (11). When dietary selection is limited, nutrient supplementation with low-dose multivitamin and mineral supplements can be helpful for older adults to meet recommended intake levels (1). Energy requirements: the Academy of Nutrition and Dietetics has reviewed studies to determine the energy needs of adults older than 65 years. The energy needs of healthy adults older than 65 years, as measured by indirect calorimetry, were reported to be 18 to 22 kcal/kg per day for women and 20 to 24 Manual of Clinical Nutrition Management A-22 Copyright © 2013 Compass Group, Inc. Emerging research supports a relationship between an increased number of medications and decreased energy needs, however further research is needed in this area (12). Also, further research is required to determine differences in energy needs based on race and ethnicity (12). Emerging data from the Academy of Nutrition and Dietetics evidence library suggest that a registered dietitian should prescribe a daily energy intake of 25 to 35 kcal/kg for healthy older women and 30 to 40 kcal/kg for healthy older men for weight maintenance. When estimating energy needs for underweight older adults, the registered dietitian should prescribe a daily energy intake of 25 to 30 kcal/kg for weight maintenance or a greater energy intake for weight gain. However, an intake of protein moderately greater than this amount may be beneficial to enhance muscle protein anabolism and reduce progressive loss of muscle mass (13). Experts now recommend that older adults aim to consume between 25 and 30 g of high quality protein at each meal to achieve this higher protein goal (16). This strategy along with regular resistance exercise may help prevent protein undernutrition contributing to sarcopenia in older adults (1). B vitamins: Metabolic and physical changes that affect the status of vitamin B6, B12, and folic acid may alter behavior and general health, whereas adequate intake of these nutrients prevents some decline in cognitive function associated with aging (1, 18). An estimated 6% to 15% of older adults have vitamin B-12 deficiency and approximately 20% are estimated to have marginal status (1, 19). Documented complications of B-12 deficiency include macrocytic anemia, neurologic complications affecting sensory and motor function, osteopenia, and increased vascular risk (1, 18). It has been suggested that persons older than 50 years should consume foods fortified with vitamin B12 or take a supplement containing the crystalline form of vitamin B12, as 10% to 30% of older adults have protein-bound vitamin B12 malabsorption (9). Dietary intake of folic acid intake should be individually assessed in the diets of older adults as folic acid intake above the tolerable upper intake may mask the diagnosis of a vitamin B-12 deficiency (1). Folic acid fortification of cereal grain products and ready-to-eat cereals now provides a significant source of folic acid in the diets of older adults (1). These foods can contribute to significant and potentially excessive folic acid intake by older adults, especially if supplements containing folic acid are also consumed (1). Antioxidants: Dietary antioxidant intake is associated with lower prevalence of degenerative diseases and maintenance of physiologic function in older adults (1). Antioxidants have also been investigated in pathogenesis of cognitive impairment and Alzheimer’s disease by protecting against damage to the brain resulting from oxidative stress (1, 22). Nutrition and the Older Adult Vitamin D and Calcium: Among their numerous benefits, adequate vitamin D and calcium are best known for their crucial role in the prevention and delay of progression of osteoporosis (1). Vitamin D levels may be reduced in the elderly even with adequate exposure to sunlight. This deficiency may be exacerbated by homebound status, use of sun block, poor dietary intake, decreased capabilities to synthesize cholecalciferol in the skin, and a decreased number of gastrointestinal receptors (1, 12, 23). The recommended intake of calcium for adults older than 50 years is 1, 200 mg/day (24). Other nutrients, including protein, vitamins A and K, magnesium, and phytoestrogens, are also involved in maintaining bone health and should be evaluated for adequate intake (1). The Surgeon General’s report on bone health and osteoporosis recommendations include consuming recommended amounts of calcium and vitamin D, maintaining a healthful body weight, and being physically active, along with minimizing the risk of falls (25). Sodium: the 2010 Dietary Guidelines for adults > 51 years of age are recommended to reduce sodium in their diets to 1, 500 mg daily in an effort to lower their risk of high blood pressure and associated chronic diseases such as heart disease, stroke, and kidney disease (1, 9). This recommendation is also supported by the Academy of Nutrition and Dietetics and the Food and Nutrition Board of the Institute of Medicine (1). Nutrition Assessment Considerations for Older Adults Weight is a vital sign that should be routinely evaluated in the older adult population. Evidence-based nutrition practice guidelines recommend a baseline weight measurement, regardless of setting, upon initial visit, admission, or readmission, followed by weekly weight measurements for older adults (12). The registered dietitian should use clinical judgment in interpreting nutrition assessment data to diagnose unintended weight loss and underweight in the older adult (12). Studies also show an association between reduced appetite and poor protein and energy intake, resulting in weight loss and poor nutritional status (Grade I) (12). Medical nutrition therapy that includes a thorough nutrition assessment of biochemical data, medical tests and procedures, client history (see Table A-2 below) and food and nutrition related history is needed to effectively determine the nutrition diagnosis and plan for nutrition interventions (1, 12). On the other side of the spectrum, there is increasing prevalence of sarcopenic obesity in the older adult population (1). Sarcopenic obesity, the coexistence of age-related loss of skeletal mass and strength and excess body fat, puts older adults at special risk for adverse outcomes including cardiovascular disease and functional impairment (1). Excess energy intake, physical inactivity, low grade inflammation, insulin resistance, and hormonal changes associated with aging have all been implicated in the etiology (1). Sarcopenic obesity presents treatment challenges requiring the clinician to weigh the risks associated with weight maintenance versus treatment to promote weight loss to optimize health, cardiovascular risk, and functional status (1). Older adults presenting with risk factors for sarcopenic obesity should have a comprehensive nutritional assessment considering existing comorbidities, weight history, and potential adverse health effects of excess body weight (1). Dehydration, a form of malnutrition, is a major problem for the elderly, especially persons aged <85 years and institutionalized older adults (1). Fluid intake needs are the same for the young and the old, but the elderly are prone to inadequate fluid intake. Frequently, diseases will reduce the ability to recognize thirst, create an inability to express thirst, or decrease access to fluids (1, 26). Even healthy elderly persons have reduced thirst in response to fluid deprivation. Fear of incontinence and difficulty making trips to the toilet, due to arthritic pain or other immobility, may also interfere with adequate fluid consumption (1). An important part of the nutrition assessment in older adults is an assessment of hydration status based on physical signs and symptoms including dry tongue, longitudinal tongue furrows, dry mucous membranes of the nose and mouth, eyes that appear recessed in their sockets, upper body muscle weakness, speech Manual of Clinical Nutrition Management A-24 Copyright © 2013 Compass Group, Inc.

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