Geriatric Physical Therapy and Nutrition

By Dr. Sean M. Wells

Many facets of nutrition can impact older adults' function and health. The focus on this blog article will be to highlight how inflammation, which can be mediated via diet, impacts older adult function and health.

Using the Dietary Inflammatory Index (DII), physical therapists can quantify the amount of inflammation a client's diet is provoking. Essentially the score ranges from as low as -5 to as high as 5, with a "fast food diet being reported at 4 and a macrobiotic diet being listed at -5. Probably the best diets on the DII are vegetarian Indian diets and other Asian diets rich in vegetables and spices. Another way of "scoring" or ranking the inflammation cause by a diet is to use an A-F system. An "A" score would be ideal and the most negative (e.g. close to -5, which is the least inflammatory), while "F" is the most inflammatory (e.g. most positive, 5). An average, or "C" score, would be a 0.

Using the DII, PTs can see how diet impacts health and functions. Let's dive into some systems and diseases states that we often see are involved in geriatric practice.

Frailty

One major consideration PTs must consider in skilled nursing facilities (SNFs) and inpatient rehabilitation is that of frailty. An frail older adult is more likely to fall, fracture a major bone, sustain a subdural hematoma, or even die. While becoming frail is multi-factorial, involving prolonged inactivity and medical issues, it does also point back to a person's diet.

Data show that older adults with the highest DII score had a significantly higher risk of experiencing frailty (hazard ratio 1.37, P = .04) compared with participants with the lowest DII score. This study started with an average age of 61 and followed these subjects for 8 years. I would like the correlation with diet, inflammation, and frailty would like be higher in those over 69 years of age, if analyzed. Regardless, the authors of this study stated frailty to be:

weight loss,
inability to rise from a chair 5 times, and
poor energy

All of these metrics are related to PT practice. As Doctors of Physical Therapy, we measure waist circumference, mass, and especially focus on the lean muscle mass of our geriatric patients. The 5 times sit to stand test is a measure of power, balance, and function commonly assessed in SNFs, inpatient rehab, outpatient rehab, and clinics worldwide. Lastly, we know that a client having energy and motivation to move is vital to prevent death and failure to thrive. Diet can help instigate or mitigate inflammation that drives frailty.

Memory

Older adults can have difficulty in remembering things. In many cases it is minor, while in some a mild cognitive impairment can impact function, social interactions, and participation in life. As such, if we as PTs can help improve our patient's memories we can help them engage and move in life better.

Data from the DII shows that an inverse relationship exists between memory functions and the subject's DII score. In other words, the higher the score (more inflammatory diet) the worse the memory. Here are the metrics:

Episodic memory (CERAD),
semantic-based memory (Animal Fluency Test), and
executive function and working-memory (DSST)

Subjects' performances on these memory tests were lowest among those with the highest mean DII score. In brief, the worse the diet the worse the memory. As such, physical therapists, PTAs, and other rehabilitation professionals need to encourage older adults to eat healthy, reduce processed foods, and seek help from a registered dietitian or nutritionally trained PT, such as a CNPT.

Orthopedics

Bone health is a major concern of older adults. Many geriatric clients of mine know the risks of falling and fracturing their hips -- they could be stuck in bed, operated on, or even die. Osteoporosis is a major risk factor for good bone health, as it compromises the structural integrity of bones and joints. Given that bones grow from calcium and Vitamin D, which mostly come from diet, there's no surprise that a client's nutrition impacts their osteoporosis.

In postmenopausal women, a low inflammatory DII score had less loss of hip BMD (p = 0.01) by year 6 of a study, despite lower baseline hip BMD, versus women with the most inflammatory DII scores. The inflammation of the diet causes leaching of essential calcium, likely to help buffer acids in the serum, among other factors. Loading, through weight bearing movements and resistance training, are important; however, what if we as PTs could stop the leaching of the of calcium in the first place? The answer to doing this would be to shift a person's diet to one that is least inflammatory. Such a diet would be:

Rich in spices
Very low in processed foods and alcohol
Very rich in plants
Low in animal products, high in plant-sources of protein
Emphasizing a variety of plant foods

Men's Health

Many Geriatric PTs consider prostate health a subset of "men's health", similar to how women's health is focused on the female pelvic floor. Prostate issues arise most commonly in older adults, and as such, falls into the practice arena of Geriatric PT Specialist (GCS). Prostate issues can cause fear, painful or limited flow in urination, and may result in surgical resection of the prostate. The two biggest concerns with the prostate are benign prostate hypertrophy (BPH) and prostate cancer. Cancer surgery can impact muscle function of the hips, pelvis, and lower back, which can impact sitting, transferring, and walking. Fortunately, nutrition can help many of these clients!

Data focused on the DII of men with prostate cancer shows that a less inflammatory diet can improve the survivability of men with more aggressive prostate cancer. Dietary interventions aimed at decreasing inflammation may be considered to improve survival of men with prostate cancer. PTs can educate and refer such patients to help them see the benefits of reducing inflammation while being treated for cancer. Making such lifestyle changes may help reduce the odds of catching other cancers and chronic diseases.

Depression

Older adults are at greater risk of depression. Think about it: they are reaching the end of their lives, may be isolated, and may have a dwindling impact on their family or society due to physical and social limitations. Another mechanism that may be driving depression is diet.

Copious studies have highlighted how alcohol, high fat diets, and fiber deficient diets are strongly associated with higher rates of depression. A well-done meta-analysis on the DII score shows that such a diet above is both pro-inflammatory and increases the rates of depression in older adults. The study found individuals in the highest DII vs. the lowest DII category had a 23 % higher risk of depression (risk ratio (RR)=1·23). A poor diet could be driving changes in the gut biome, which drive depression signals. A healthy diet may reduce neural inflammation which may directly mediate depression behavior. Regardless of the mechanism, physical therapists ought to know, identify, and act when their geriatric patients present with depression. Exercise is medicine but food is a healer.

Cardiac and Metabolic Disease and Mortality

Heart disease is the number one killer, followed closely by cancers and metabolic issues, like diabetes. As such, geriatric PTs should pay close attention to those factors that drive these diseases because they ultimate kill. Many therapists and rehab professionals know that diet is linked to heart disease and diabetes; however, many fail to act and hopefully this article and our courses help motivate you to change.

A thorough systematic review and meta-analysis shows that patients with very poor DII scores are significantly more likely to have cardiovascular heart disease. How much more? How about 35% more heart disease in those with an inflammatory diet vs. those with a low inflammatory diet. More worrying is that such a poor dietary pattern also increases the risk of dying by 21%! As such, getting heart disease is not the only issue, your patients may end of dying as well partly due to their crappy diet! Physical therapists can combat this issue by not only promoting exercise and changes in lifestyle but also promoting anti-inflammatory diets that include:

Mostly whole plants
Very low in processed foods
Rich in spices
Low in meat and alcohol

How hard can that be?

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