by Brenda Richardson, MA, RDN, LD, CD, FAND 1 HOUR CE CBDM Approved : The Important Role of Food, Nutrition, and Dining

NUTRITION CONNECTION

NUTRITIONAL CONSIDERATIONS FOR IMPROVED COGNITIVE FUNCTIONING.

Recently when attending a conference on cognition and COGNITION aging, an allied professional approached and asked “Why The number of Americans over age 65 is projected to is a registered dietitian attending this conference? What increase from 40.2 million in 2010 to 88.5 million in 2050. does nutrition have to do with cognition?” Her query It will become increasingly important to understand the prompted me to address these questions in an article cognitive changes that accompany aging, both normal and to reemphasize the important role of nutrition with and pathologic. Although and mild cognitive cognition. The Centers for Medicare & Medicaid Services impairment are both common, even those who do (CMS) focuses on cognition with Quality Measures and not experience these conditions may encounter subtle Regulatory Requirements, and we each need to better cognitive changes associated with aging. These normal understand “best practice” with nutritional care. This changes are important to understand because they can article will address general information about cognition, affect an older adult’s day-to-day functioning in such areas along with nutritional implications to consider for as eating, bathing, dressing, mobility, etc. improved outcomes.

12 NUTRITION & FOODSERVICE EDGE | May-June 2017 [email protected]

Let’s look at cognitive or calculating a tip on a alone or in relation to Brenda Richardson, ability, which can be divided restaurant bill. other objects. MA, RDN, LD, CD, FAND is a lecturer, into specific cognitive • : One of the • Executive functioning/ author, and consultant. domains. most common cognitive reasoning: capacities She works with Dietary • Processing speed: complaints among older that allow a person to Consultants Inc. in the speed with which adults is change in successfully engage in business relations and development, and is cognitive activities are memory. As a group, older independent, appropriate, president/owner of performed as well as the adults do not perform purposive, and self- Brenda Richardson speed of motor responses. as well as younger adults serving behavior. This Associates, Inc. • : the ability on various and includes a wide range of to concentrate and memory tests. cognitive abilities such as focus on specific • Language: Language the ability to self-monitor, stimuli. Simple auditory is a complex cognitive plan, organize, reason, attention, as measured domain. Overall language be mentally flexible, by repetition of a string ability remains intact and problem-solve. of digits, shows only with aging. Vocabulary Research has shown a slight decline in late remains stable and even that concept formation, life. A more noticeable improves over time. A few abstraction, and mental age effect is seen on exceptions include the flexibility decline with more complex attention ability to see a common age, especially after tasks which involves object and name it, which age 70, as older adults the ability to focus on remains about the same tend to think more specific information in until age 70, and then concretely than younger the environment while declines in subsequent adults. Other types of ignoring irrelevant years. executive function, such as the ability to appreciate information. Selective • Visuospatial abilities: similarities, describe the attention is important for a group of cognitive meaning of proverbs, and tasks such as engaging in functions that involves reason about familiar a conversation in a noisy the ability to understand material, remain stable environment. Divided space in two and three throughout life. attention is the ability to dimensions. Visual focus on multiple tasks construction skills, which N U T R I T I O N Brenda Richardson simultaneously, such as involve the ability to put AND COGNITIVE will co-present two talking on the phone together individual parts breakout sessions DECLINE at ANFP’s Annual while preparing a meal. to make a coherent whole Older adults perform Conference & Expo (for example, assembling Preventing and this June in Las Vegas. worse than younger furniture from a box of Reducing Risk Visit www.ANFPonline. adults on tasks involving parts) declines over time. There is significant org/ACE17 for topics, . For descriptions, and to In contrast, visuospatial variability in age-related example, older adults may register. abilities remain intact cognitive changes from have difficulty ordering such as household items individual to individual. a string of letters and or faces, and the ability Some of the variability can numbers in the correct to appreciate the physical be attributed to genetic alphanumerical sequence, location of objects either Continued on page 14

NUTRITION & FOODSERVICE EDGE | May-June 2017 13 Continued from page 13

differences, and studies interventions as effective the MIND diet substantially estimate 60 percent of preventive strategies. slows cognitive decline general cognitive ability There has been research with age. Current studies can be attributed to looking at the cultural- are underway to replicate genetics. Medical illness, based Mediterranean diet the findings to verify its psychological factors, and the blood pressure relevance to health. and sensory deficits such lowering DASH diet The MIND diet was based as vision and hearing (Dietary Approaches to on the dietary components impairment can also Stop Hypertension) and of the extensively studied accelerate age-related their protective effects on cardiovascular diets cognitive decline. cognitive decline. Mediterranean and DASH, Dementia is now the A new dietary pattern including emphasis on sixth leading cause of tailored to protecting natural plant-based foods death in the U.S., and the brain, called MIND and limited intake of animal preventing cognitive (Mediterranean- and high saturated fat decline—the classic DASH Intervention for foods. However, the MIND feature of dementia—is a Neurodegenerative Delay) diet uniquely specifies public health priority. It has been developed at Rush consumption of berries and is estimated that delaying University. The diet is styled green leafy vegetables, and disease onset by just five after the Mediterranean does not specify high fruit years will reduce the cost and DASH diets, but with consumption, high dairy, and prevalence by 50 modifications based on the high potato consumption, percent. most compelling findings or greater than one fish in the diet-dementia field. Recent studies have focused The studies suggest that Continued on page 16 on the potential of dietary

Table 1: Overview of the MIND Dietary Patterns

INCLUDE THESE LIMIT THESE • Green leafy vegetables: every day • Red meats • Other vegetables: at least once per day • Butter and stick margarine: less than 1 • Nuts: every day tablespoon per day • Berries: at least twice per week • Cheese: less than 1 serving per week • Beans: every other day • Pastries and sweets: limit • Whole grains: three times per day • Fried or fast foods: less than one serving per week • Fish: at least once per week • Poultry: at least twice per week • Olive oil • Wine: one glass per day

(Morris, M.C. (2016), Nutrition and risk of dementia: overview and methodological issues. Ann. N.Y. Acad. Sci., 1367: 31–37. doi:10.1111/nyas.13047)

14 NUTRITION & FOODSERVICE EDGE | May-June 2017 Continued from page 14

meal per week. The MIND modifications highlight the • Muscle strength for self-care and nutritional adequacy foods and shown through the scientific literature related to calories, protein, and other nutrients related to be associated with dementia prevention. An overview of to muscle anabolism and fluid maintenance. Provide the MIND diet is included in Table 1. education to resident, staff, and other caregivers. The primary limitation of the study is that it is • Referral mechanism to the RDN for residents observational and thus cannot be interpreted as a cause with high dependence scores. Registered dietitian and effect relation. Replication of the findings in other nutritionists need to work with the certified dietary studies is important for confirmation of the association, manager to be actively involved in care planning, and a diet intervention trial is required to establish a causal with reviews at regular intervals, and at discharge for relation between diet and prevention of cognitive decline. nutrition intervention for eating skills, muscle strength, and hydration. NUTRITION AND COGNITION IN POST- • Interventions/management of mealtime behaviors ACUTE CARE (PAC) FACILITIES by staff: slow pace of eating, distractibility, ineffective Older adults in post-acute care facilities generally are at use of utensils, impaired depth perception, memory loss, the point where maintaining independent dining skills is paranoia. a challenge. Eating and feeding difficulties with cognitive impairment related to dementia make it difficult for CONCLUSION individuals to complete the motor and perceptual tasks The normal aging process is associated with declines in required for eating, and often prevent them from accepting certain cognitive abilities. Nutrition and dietary patterns assistance from providers. may support prevention or risk reduction of cognitive decline, and is an integral component in improving For providers, it’s finding a balance between helping and managing those with cognitive decline. Utilizing individuals maintain independence and also meeting nutritional risk tools, prompt referrals and nutritional nutritional needs. Helping individuals maintain assessments should be used to determine interventions independence with dining can significantly affect quality of and education to improve quality of life for independence life and overall outcomes. with functional status such as activities of daily living, While the following is not all inclusive, some areas for bathing, eating, and mobility. Food, nutrition, and dining food, nutrition, and dining include: are critical in helping individuals facing cognitive decline • Dining atmosphere and environment: comfortable maintain independence while also improving quality of life sound levels, no distracting noises, attractive settings and outcomes. E with adequate lighting, comfortable temperature. • Meal service: proper table height, meals on time, appropriate assistance, adequate staff on hand to serve. REFERENCES • Self-care: Eating: Appropriate utensils to bring food to the mouth and swallow once the meal is presented • Nutritional Care of the Older Adult, Third Edition. Kathleen Niedert, Ed., Academy of (including modified food consistency). Adaptive Nutrition and Dietetics, 2016. equipment: colored plates, built-up handle utensils, • Morris, M.C. (2016), Nutrition and risk of swivel spoons, high-sided plates, scoop bowls, two- dementia: overview and methodological issues. Ann. N.Y. Acad. Sci., 1367: 31–37. doi:10.1111/nyas.13047. handled mugs, wide-handled mugs, non-skid mats. • Morris, Martha Clare et al., MIND diet slows cognitive decline • Oral hygiene: ability to use suitable items to clean with aging, Alzheimer’s & Dementia: The Journal of the teeth. If dentures are present: Ability to remove and Alzheimer’s Association, Volume 11, Issue 9, 1015 – 1022. • https://www.rush.edu/news/diet-may-help-prevent-alzheimers, replace dentures from and to the mouth, and manage accessed March 2017. @ equipment for soaking and rinsing them. • What Are the Components to the MIND Diet? Marcason, Wendy, Journal of the Academy of Nutrition and Dietetics, Volume 115, Issue 10, 1744.

16 NUTRITION & FOODSERVICE EDGE | May-June 2017 1 HOUR CE Questions CE CBDM Approved

NUTRITION CONNECTION

Reading Cognition: The Important Role of Food, Nutrition, and Dining and successfully completing these questions online has been approved for 1 hour of continuing education for CDM, CFPPs. CE credit is available ONLINE ONLY. To earn 1 CE hour, purchase the online CE quiz in the ANFP Marketplace. Visit www.ANFPonline.org/market, select “Publication,” then select “CE article” at left, then search the title “Cognition: The Important Role of Food, Nutrition, and Dining” and purchase the article.

1. Cognitive changes are important to understand because 5. A new dietary pattern developed at Rush University, they can affect an older adult’s day-to-day functioning in tailored to protecting the brain, is the Mediterranean-DASH such areas as: Intervention for Neurodegenerative Delay or ______diet. A. Eating and bathing A. BRAIN B. Dressing and mobility B. MIND C. Both A and B C. RUSH 2. Studies estimate ____ percent of general cognitive ability 6. Eating and feeding difficulties with cognitive impairment can be attributed to genetics. related to dementia make it difficult for individuals to A. 60 complete the ______tasks required for eating, and B. 55 often prevent them from accepting assistance. C. 50 A. Metabolic and physiological 3. Medical illness, psychological factors, and sensory deficits B. Psychological and circulatory such as vision and hearing impairment can ______C. Motor and perceptual age-related cognitive decline. 7. The dining atmosphere and environment needs to A. Neutralize provide comfortable sound levels, no distracting noises, B. Accelerate attractive settings with adequate lighting, and comfortable C. Reduce temperatures. 4. Dementia is now the sixth leading cause of death in the A. True U.S., and it’s estimated that delaying disease onset by just B. False five years will reduce the cost and prevalence by ____ C. Does not apply percent. A. 25 B. 30 C. 50

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