Addressing the nutritional needs of older people in emergency situations: ideas for action

Summary of Review¹

Help Age International (HAI) has produced a preliminary review of the nutritional needs of older people in emergency situations. This is part of an ongoing commitment by HAI to develop assessment tools, methodologies and approaches in all aspects of nutrition interventions for older persons in emergencies. The review is based on the premise that older people are a sub-group of the population whose needs must be addressed more systematically in emergency contexts.

The document was prepared by Annalies Borrel a consultant with Valid International (UK) after a thorough review of recent scientific literature and emergency nutrition guidelines, consultation with NGOs and use of practical case studies. The document addresses issues of nutritional requirements of older people and examines these in light of current emergency food and nutrition interventions. It also provides a preliminary framework for the design of emergency nutrition interventions for the purpose of piloting and review. It is hoped that the document will be further developed based on additional casestudies and further lessons learnt from programme experience. In view of the comprehensive nature of this review only some of the findings can be represented in this summary.

Key Findings

General Principles

While older people are commonly accepted as being a vulnerable or potentially vulnerable group in emergency situations, at present humanitarian interventions often ignore older people's specific needs, using systems that discriminate against and on occasion, undermine their capacity to support themselves.

Context and individual-specific risk factors will determine the nutritional status of older people. In emergency situations, the changes that impact directly on older people's nutritional vulnerability includes disruption or loss of social structures, family separations, stressful events, the need to adopt coping strategies and increased public health risks.

There are numerous challenges that need to be overcome before the needs of older people can be addressed more effectively. These include; a recognition that older people are a heterogeneous group of people whose capacities and needs vary greatly between individuals and between situations and the positive contributions that older people have within communities, including during emergency situations.

The United Nations principles for Older Persons (resolution 46/91), which was adopted by the General Assembly in 1991, addresses issues of independence, participation, care, self-fulfilment and dignity. While these principles provide a useful overall framework for action, the report defines more specific principles that can be applied to the design of nutrition interventions for older people in emergency situations.

Nutrient requirements

The report discusses the nutrient requirements for older people in relation to younger adults. While energy requirements for older people, in general decrease, the need for micronutrients does not. There are many factors causing an increase in requirements for micronutrients and in some cases, micronutrient deficiencies among older people. These include; a general decrease in energy intake, a reduction in intake of nutrient dense foods, a lower secretion of intrinsic factor, a high incidence of chronic disease and gastrointestinal bleeding. However, much of the research findings, largely based on studies on older people, in industrialised countries, remain equivocal.

In summary, it is recommended that older people consume:

• Foods that are nutrientdense in vitamins and minerals.
• Vegetables and fruits that are deeply coloured, for provision of folate and antioxidant nutrients.
• Dairy products e.g. milk, for the provision of adequate amounts of calcium and vitamin D.
• Adequate amounts of nutrient-rich foods such as; fish, dried beans, eggs and nuts. Variety in these foods is important but selection will be based on factors such as: availability, cost, chewability, individual preference and ease of preparation.
• Foods that are high in dietary fibre, such as fruit and vegetables.
• Relatively higher volumes of fluid, since thirst sensation is decreased in older people.

Emergency general ration

In theory, the recommended per capita general ration does meet the nutritional requirements of older people in terms of energy, fat and protein. Energy requirements for older people generally decrease in comparison with younger adults. However, the minimum per capita energy requirement of (2,100kcal), when provided in the form of food-aid commodities such as maize, beans and oil, is inadequate in terms of meeting the micronutrient needs of older people.

There are also physical, social, and programme design factors which increase the risk of older people suffering from inadequate food intakes in emergency situations. These include:

An inadequate assessment of needs at the outset: the involvement of older people in decision-making processes concerning food aid needs and programme design is frequently lacking.

Poor physical access to the ration: distances to food collection points in centralised distribution systems are often too great, there are inappropriate queueing systems and the elderly may be left out of the information loop about the general ration distribution.

Constraints in food processing and preparation: whole grains cereals and beans are difficult to prepare needing longer cooking time and involving the collection of water and fuel.

Limited opportunities for accessing food through complementary coping strategies: rarely does the general ration alone fulfil the nutritional needs of emergency-affected populations. Additional food is usually accessed through mechanisms such as informal trade and labour, fishing, labour activities in exchange for food, etc. Older people often do not experience the same opportunities for these complementary activities as those of younger adults.

A number of recommendations for actions to address these inadequacies are outlined in the report. These include:

• Involve older people as key-informants during assessments and collect information on the nutritional status of older people.
• Provide no less than 50g of blended food per person per day as part of the general ration.
• If quantities of blended food are limited, children under five years old and older people should be prioritised over other population groups.
• Ensure physical access to the general ration by establishing mechanisms to inform older people of their entitlements to food rations as well as the intended distribution schedule.
• Decentralise distribution sites and prioritise older people at distribution points.
• Older people must have sufficient support or means to access sufficient fuel and water for cooking.

* Except those older people presenting with bilateral famine oedema (regardless of MUAC status), who should be referred to a clinician.

** With the purpose of preventing any further deterioration in nutritional status.

*** Based on Collins et al (2000)

Selective Feeding Programmes

Malnourished older people should be given equal access to nutritional rehabilitation centres as those of other demographic groups. In many cases however, older people will not necessarily respond to nutritional treatment, especially those who are suffering from underlying chronic illness. In this context, the design of nutritional rehabilitation and support programmes should enable older people who are at nutritional risk to be given the opportunity to remain within their communities with the support of community-based assistance. This strategy will aim to strengthen existing support structures, allow older people some dignity and independence as well as create opportunities for older people to re-establish themselves in their traditional roles within communities. In this context, the Community-based Support Programme (CSP) within the overall framework of selective feeding programmes for older people is most important and should be a priority. This programme focuses on identifying specific risk factors on an individual basis and strengthening family and community support mechanisms.

Elements of overall programme framework

There is no need to create separate selective feeding programmes for older people but rather, expand and adapt existing supplementary and therapeutic feeding programmes to include older people in situations where there is a demonstrated need.

In any given situation, the objectives and design of supplementary feeding for older people will need to be clearly defined. In particular, where nutritional improvement and discharge is not an expected outcome for older people in a supplementary feeding programme, this should be explicitly stated at the design stage of the programme. Small, decentralised, community-based kitchens may be feasible in some situations and may be the most effective and acceptable approach.

Not all older people are equally vulnerable and targeting is necessary, especially where resources are limited. There is no universally agreed index and cutoffs for defining acute severe and moderate malnutrition in older people. For pragmatic purposes, it is recommended that a combination of Mid-Upper- Arm Circumference (MUAC), clinical and social-risk criteria, is used to define admission criteria. The social criteria used in the targeting process will be context-specific and based on the outcome of a community assessment of risk factors or causes of malnutrition, for older people.

The nutrition protocols for treatment of severe and moderate malnutrition among older people are similar to those of children and adults. Additional issues may need to be addressed in the design and management of selective feeding programmes for older people, such as; providing adequate resting facilities and privacy, training staff with adequate skills in communication and emotional support, respecting older people's wishes to die in their communities and ensuring that the nutritional rehabilitation centre is not perceived and used as a hospice-type institution.

During the rehabilitation phase, family and community support systems are identified and all individuals are referred to the Community Support Programme for follow-up.

The monitoring and evaluation criteria will need to be adapted. While standard nutritional and health recovery indicators may be applied to some extent, other important indicators such as the community and family support outcomes and the community's perception of its effectiveness, will be equally important.

The finalised report is due to be published by Help Age International. For copies of the report please contact: Dolline Busolo, Regional Nutritionist, HelpAge International, Africa Regional Development Center, P.O. Box 14888 Westlands, Nairobi, Kenya. Tel: 254 2 444289/4469691/449407. Fax; 254 2 441052 or Email: helpage@net2000ke.com

¹Addressing the Nutritional Needs of Older People in Emergency Situations. This preliminary report was prepared by Annalies Borrel (with support from Valid International) for HelpAge Africa Regional Development Centre (ARDC)