Julia started a new job as the RD at a continuing care retirement community. She noticed that the community’s assisted living and skilled nursing units had a number of physician orders for gluten-free diets. Julia decided to evaluate each of these orders to determine whether they’re based on a diagnosis of celiac disease (CD), and then follow up with each resident to address issues or concerns with their gluten-free diets.
CD in Older Adults
CD in older adults isn’t well understood or well recognized and often is misdiagnosed as irritable bowel syndrome. Symptoms can be subtle and digestive symptoms may be milder than in younger persons. It may be mistaken for an aging gastrointestinal system, medications, or other medical conditions. Signs of micronutrient deficiencies may be the first and often the only manifestation of CD in the elderly.
Surprisingly, up to 25% of cases are diagnosed in adults older than 60, even though many have had CD for most of their lives. Although data are sparse, incidence of CD in those older than 65 is reported to have increased over time from 4% to between 19% and 34%. Physician orders for gluten-free diets in Julia’s community may have been based on either a long-standing or a recent diagnosis of CD.
Management of CD in Older Adults
Treatment of CD in older adults is the same as in children and younger adults—a strict gluten-free diet for life. Recovery of intestinal villi may occur more slowly in older adults than in younger patients. As with younger adults, symptoms should improve gradually.
Older adults bring a unique set of challenges to the management of CD. Although research indicates that older adults often are motivated to adhere to a gluten-free diet, lifelong habits can be difficult to change, and older adults may not be motivated to make changes if symptoms don’t improve. Challenges with adhering to a gluten-free diet may be exacerbated by vision problems, difficulty reading food labels, barriers related to food shopping and preparation, memory issues, or financial constraints.
In health care and postacute care settings, a CD diagnosis should result in a diet order for a gluten-free diet. Julia should counsel residents diagnosed with CD on the risks and benefits of the gluten-free diet for treatment, but the ultimate decision of whether to follow the diet is up to the individual. Some residents may choose to eat what they want despite a CD diagnosis. Julia should serve as a resource and provide support on issues related to managing their CD.
Gluten-Free Diets in the Absence of CD
Gluten-free diets may also be useful for those with nonceliac gluten sensitivity (a gluten intolerance in the absence of CD), but it’s unknown whether gluten must be strictly avoided for life to manage sensitivity. Some of Julia’s residents probably have nonceliac gluten sensitivity, and they may have been told to avoid gluten. Some of them may have discovered through trial and error that avoiding or limiting gluten minimized their symptoms.
For these individuals, a gluten-free diet may be useful, but it’s unclear whether strict avoidance of gluten is needed. However, because limiting or avoiding gluten may help with symptom management, their food preferences should be taken seriously.
Several of Julia’s residents have gluten-free diet orders based on the individual’s or family’s preference rather than a diagnosis of CD or nonceliac gluten sensitivity. “Going gluten-free” has become trendy for healthy adults and older adults, despite the expense and complications of adhering to the diet. Gluten-free living isn’t necessary for optimum health, weight loss, increased energy, or other health claims unrelated to CD.
Although Julia advises that a restrictive diet isn’t necessary, some residents and/or families disagree and want the gluten-free diet to remain in place. While the facility should honor these preferences to the degree possible, Julia should document in the medical record that the diet is based on preference as opposed to a CD diagnosis. Julia also should discuss the risks of following the diet, which can include unnecessary avoidance of favorite foods and potential nutrient deficiencies.
Obtaining Gluten-Free Foods
Foodservice operations may not always be able to purchase specific brands and types of gluten-free food from their suppliers. Julia needs to inform her residents/families of this issue and let them know that they can bring gluten-free foods in to the facility as long as they follow the facility’s policies based on local, state, and federal regulations for using food from outside sources.
Gluten-free diets can be challenging for postacute care providers. The first step is to determine the need to follow a gluten-free diet based on a diagnosis vs preference to follow the diet based on personal choice. Recognizing that a meaningful percentage of older adults may have a diagnosis of CD or nonceliac gluten sensitivity is important. These older adults need to be offered appropriate foods and encouraged to follow the gluten-free diet, realizing that the ultimate choice is still up to the individual. As the RD, Julia can provide support and resources and counsel residents according to their needs and preferences.
— Becky Dorner, RDN, LD, FAND, is widely known as one of the nation’s leading experts on nutrition and long term health care. Her company, Becky Dorner & Associates, Inc, is a trusted source of valuable continuing education, nutrition resources, and creative solutions. Visit www.beckydorner.com to sign up for free news and information.