COMMON GERIATRIC PROBLEMS: NUTRITION Thierry Pepersack on behalf of the Belgian College for...

COMMON GERIATRIC PROBLEMS:NUTRITION

Thierry Pepersack on behalf of the Belgian College for Geriatrics

USA –Be same problems-different solutionsMarch 22, 2006

Malnutrition

Definition of the “geriatric patient”

1. Decreased homeostasis2. Atypical presentations of the diseases3. Multiple pathologies and functional

dependence 4. Combination of somatic, psychological

and social factors 5. Altered pharmacokinetics

dependence ? 4. Combination of somatic, psychological

and social factors 5. Altered pharmacokinetics6. malnutrition

Busby et al. N Engl J Med 1991

MalnutritionMalnutrition

35 - 40% on admission «under-diagnosed» Nutritional deficit, diseases (liver,

digestive, cancers, chronic) increase mortality, morbidity Increase length of stay

Prevalence of Malnutrition in Hospitalized Patients

Energy % recommended needs

Protein % recommendedneeds

0 100 200 300

patients

399 patients

557 patients

417 patient

Dupertuis YM. Clin Nutr 2003, 22: 115-23

Food intake in 1707 hospitalized patients:a prospective comprehensive hospital survey

Energy % recommended needs

Protein % recommendedneeds

0 100 200 300

patients

399 patients

557 patients

417 patient

Food intake in 1707 hospitalized patients:a prospective comprehensive hospital survey

> 4 / 6 patients underfed !

Prominant influence of the disease on food intake :Only 1/4 patient !!!

Food intake in 1707 hospitalised patients:a prospective comprehensive hospital survey

ECONOMIC IMPACT of MALNUTRITION in 771 HOSPITALIZED PATIENTS

Reilly J.J. et al. J Parent Enteral Nutr 12(4), 371-376, 1988

Protein-depleted Well-nourished

(<80% normal)

All 771 5519 ± 300 3372 ± 138

Medecine 365 2945 ± 242 1783 ± 124

0.0001

Surgery 406 7335 ± 513 4579 ± 182

in US$

Prevalence of Malnutrition in Hopitalized Geriatric Patients

*60% at risk and 30% presenting overt malnutrition

** >60 y: 50; > 70 y: 53, > 80 y: 77 %

Prevalence of Malnutrition in Institutions

Pepersack T. Nutritional approach in long term geriatric institution. Rev Med Brux 2001

History of malnutrition

weight

Acute problem (hospitalization)

15-24 25-34 35-44 45-54 55-64 65-74 75-84 >85Age (years)

Women 95th 90th 75th 50th 25th 10th 5th

Percentiles Percent Fat Mass in 5225 Volunteers (15 - 98 years, 16.0 - 47.1 kg/m2 )

Aging :

The gain of fat m

ass masks

the loss of le

an mass

Kyle U. et al. Nutrition 2001, 17:534-541

Weight loss Protein loss *(%) (%)

5 11.2 - 16.8

10 15.2 - 20.8

15 19.2 - 24.8

20 23.0 - 29.0

25 26.8 - 33.2

* in vivo neutron analysis. Hill G.L. J Parent Enteral Nutr 16, 197-218, 1992

sarcopenia

Low Body Water reduced vol. of dist. for polar drugs eg. Aminoglycosides, Digoxin

High Fat Stores increased vol. of dist. for lipid soluble drugs eg. Phenytoin, Diazepam,

Flurazepam

Body composition and aging

growth retardation

bronchopneumonia

bed sores

urinary infection

anemia

too weak to walk% healthy body weight"

healing impairment

too weak to sit

Heymsfield S. B. Ann. Intern. Med. 1979, 90: 63-71

growth retardation

bronchopneumonia

bed sores

urinary infection

anemia

too weak to walk% healthy body weight"

healing impairment

too weak to sit

Heymsfield S. B. Ann. Intern. Med. 1979, 90: 63-71

intermediar

absent

ADL dependence of outpatients (Katz)N=2588, age:78(9)yr

Pepersack T, Beyer I et al. Facts Res Gerontology 1998

intermediar

absent

ADL dependence of outpatients (Katz)N=2588, age:78(9)yr

Pepersack T, Beyer I et al. Facts Res Gerontology 1998

<30% of the patients need

help to eat

ADL dependence of hospitalized patientsN=655, age: 83(7) yrs

Pepersack T, CUMG . Arch Public Health 1999

ADL dependence of hospitalized patientsN=655, age: 83(7) yrs

Pepersack T, CUMG . Arch Public Health 1999

30% of the patients able to

eat alone

2005 College’s project:Dependence for ADL (Katz)

bathing clothing transfer toilet continence eating

complete

partial

absent

Pepersack on behalf of the College for Geriatrics 2005

30% of the patients able to

eat alone

2005 College’s project:IADL (Lawton) from lowest (0) to highest dependence (4)

phone use shopping meals housework washing transport therapeutics finances

40% of the patients able to prepare their meals

Total comorbidity

0% 10% 20% 30% 40% 50% 60% 70%

Infection

Incontinence

hypertension

vascular

respiratory

digestive

muscles

stroke

Parkinson

anemia

diabetes

cancer

vision

audition

dementia

delirium

depression

Malnutrition screening

Anthropometric measurements

Risk assessment scales Nutritional Screening questionnaire

Biology: Prealbumine

Categories of BMI for identifying risk of chronic PEM in adults

BMI Weight category Interpretation <18.5 18.5-20 20-25 25-30 >30

Underweight Underweight Desirable weight Overweight Obese

Chronic malnutrition probable Chronic malnutrition probable Chronic malnutrition unlikely (low risk) risk of complications associated with chronic overnutrition Moderate (30-35), High (35-40), very high risk (>40) of obesity-related complications

Categories of BMI for identifying risk of chronic PEM in adults

BMI Weight category Interpretation <18.5 18.5-20 20-25 25-30 >30

Underweight Underweight Desirable weight Overweight Obese

Chronic malnutrition probable Chronic malnutrition probable Chronic malnutrition unlikely (low risk) risk of complications associated with chronic overnutrition Moderate (30-35), High (35-40), very high risk (>40) of obesity-related complications

Anthropometric criteria Recommended/type of study using criteria

Reference

BMI < 17.0 BMI < 17.5 BMI < 18.0 BMI < 18.5 BMI < 19.0 BMI < 20 BMI < 20 BMI < 21 BMI < 22 BMI < 23.5 BMI < 24 (and other criteria) BMI < 24 (and other criteria)

Elderly International classification for anorexia nervosa Nursing home Community and hospital Community and hospital Community and hospital Hospital and community studies Elderly in hospital Free-living elders (>70y) Community and hospital Community Recipents of “meals on wheels”

Wilson, Morley 1988 WHO 1992 Lowik et al 1992 Elia 2000, Kelly et al 2000 Dietary Guidelines for Americans 1995, Nightingale et al 1996 Jallut et al 1990, Vlaming et al 1999 McWhirter Pennington 1994, Edington 1996, 1999 Incalzi et al 1996 Posner et al 1994 Potter 1998, 2001 Gray-Donald 1995 Coulston et al 1996

Anthropometric cut-off values that include body mass index for detecting underweight or undernutrition in adults

Anthropometric criteria Recommended/type of study using criteria

Reference

BMI < 17.0 BMI < 17.5 BMI < 18.0 BMI < 18.5 BMI < 19.0 BMI < 20 BMI < 20 BMI < 21 BMI < 22 BMI < 23.5 BMI < 24 (and other criteria) BMI < 24 (and other criteria)

Elderly International classification for anorexia nervosa Nursing home Community and hospital Community and hospital Community and hospital Hospital and community studies Elderly in hospital Free-living elders (>70y) Community and hospital Community Recipents of “meals on wheels”

Wilson, Morley 1988 WHO 1992 Lowik et al 1992 Elia 2000, Kelly et al 2000 Dietary Guidelines for Americans 1995, Nightingale et al 1996 Jallut et al 1990, Vlaming et al 1999 McWhirter Pennington 1994, Edington 1996, 1999 Incalzi et al 1996 Posner et al 1994 Potter 1998, 2001 Gray-Donald 1995 Coulston et al 1996

Anthropometric cut-off values that include body mass index for detecting underweight or undernutrition in adults

MNA (points)

-5 0 5 10 15 20 25 30 35

Pepersack T on behalf of the College for Geriatrics. Outcomes of continuous process improvement of nutritional care program among geriatric units. J Gerontol A Biol Sci Med Sci 2005 60: 787-792.

College’s project 2001

MNA (points)

-5 0 5 10 15 20 25 30 35

MNA <23,5: 60% of patients at risk

College’s project 2001

Nursing Nutritional checklist

The Malnutrition Universal Screening Tool (MUST) (BAPEN)

Risk of malnutrition (MUST)

medium

Risk of malnutrition (MUST)

medium

MUST: 65% of patient at risk

Histogram of frequencies of the values of TPP TK effects

TPP TK effect (%)

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Inpatientsn=118

Outpatientsn=30

Pepersack et al. Gerontology 1999:45; 96-101

30% of inpatients presenting TPP TK>15%

PLASMA ZINC (µmol/L)

6 7 8 9 10 11 12 13 14 15 16 17 18 19

Pepersack et al. Arch Gerontol Geriatrics 2001;33:243-253.30% of patients presenting Zn<10.7 µM

Histogram of frequencies of the values of serum Zinc concentrations

Factors involved in the pathogenesis of the physiological anorexia of aging and energy expenditure.

Wilson MG, Morley JE. Aging and energy balance. J Appl Physiol 2003; 95: 1728–1736, 2003.

Social complexity (SOCIOS)

45% of patients at risk of social complexity

Morley 1994

The « meals-on-wheels approach »

Medicaments Emotions Anorexia Late life paranoia Swallowing

Oral problems No money

Wandering Hyperthyroidism,HPT1 Entry (malabsorption) Eating problems Low salts, low chol

diets Shopping

Polypharmacy

No of drugs

-4 -2 0 2 4 6 8 10 12 14 16 18 20 22 24

depression

-1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Pepersack T, Bastan M. Prévalence de la dépression et caractéristiques du patient gériatrique déprimé. In: L'Année Gérontologique 2001, vol. 15 p. 103-114.Serdi Edition, Paris.

45% of patients at risk of depression

« Frigotherapy… »

dependence ? 4. Combination of somatic, psychological

and social factors 5. Altered pharmacokinetics6. malnutrition

The concept of “comprehensive geriatric assessment”

Holistic approach of

medical psycho-social functional Environmental

problems

Stuck AE et al. Lancet 1993;342:1032-36

Randomized Trial of a HospitalGeriatric Evaluation & Management Unit

Rubenstein et al. N Engl J Med 1984; 311:1664

Mortality (24% vs 48% at 1 yr) NH Use (27% vs 47%; 26 vs 56 days) Rehosps (35% vs 50%; 17 vs 23 days) Costs ($22,000 vs $28,000 /yr surv) ADL (42% vs 24% improved at 1 yr) Morale (42% vs 24% improved at 1 yr)

The Sepulveda GEM Study:

medical psycho-social functional Environmental

problems

medical psycho-social functional Environmental Nutritional

problems

Is nutritional intervention effective ?

% FAVORABLE EVOLUTION

p<0.07

p<0.05p<0.02

N = 60, age ≥ 80 yr

Control

Dietary supplementation in elderly patients

with fractured neck of the femur

+ 250 kcal, 20 g protein

Delmi M et al. Lancet 335, 42-46, 1990

1. High prevalence of malnutrition

2. Nutritional intervention is effective

What can we do to do better ?

« cycle of quality»

What is quality?

« cycle of quality»

1. First, you have to say what you intend to do;2. Then, you have to do what you said;3. And finally you have to write what you have

OUTCOMES OF CONTINUOUS PROCESS IMPROVEMENT OF NUTRITIONAL CARE PROGRAM AMONG GERIATRIC UNITS IN BELGIUM

Pepersack et al. 2001 College’s project

Aims to assess the quality of care concerning nutrition

among Belgian geriatric units to include more routinely nutritional assessments

and interventions into comprehensive geriatric assessment

to assess the impact of nutritional recommendations on nutritional status an on the length of hospitalisation

Methodology: 2 phases

Observation Comprehensive

geriatric assessment and MNA

Routine nutrition

Intervention Comprehensive

geriatric assessment and MNA

« Flow Chart» « Meals on

Wheels » approach

0 3 6 months

FLOW CHART SUGGESTING A RATIONAL APPROACH TO THE MANAGEMENT OF MALNUTRITION

MNA <23.5 points and/or PAB<0.2 g/l

START CALORIC SUPPLEMENTATION RULE OUT TREATABLE CAUSES/ UTILIZE MEALS-

ON-WHEELS APPROACH

IF PAB FAILS TO RAISE CONSIDER ENTERAL (or parenteral) NUTRITION

CHECK PAB AT DISCHARGE

Morley 1994

The « meals-on-wheels approach »The « meals-on-wheels approach »

Medicaments Emotions Anorexia Late life paranoia Swallowing

Oral problems No money

Wandering Hyperthyroidism,HPT1 Entry (malabsorption) Eating problems Low salts, low chol

diets Shopping

Results

12 centers presented evaluable dataN=1140 admissions

MNA (points)

-5 0 5 10 15 20 25 30 35

±Std. Dev.

±Std. Err.

Phase 1 Phase 2

Characteristics of the patients according to period.Phase I: observational period; phase II: interventional period.

Phase I Phase II Valid N Mean Std.Dev. Valid

N Mean Std.Dev. p

PAB variations (g/l)

483 -,007 ,094 278 ,009 ,144 ,045595

CRP variations 585 -2,2 10,5 328 -1,0 23,1 ,276841 Lymphocytes count variations

626 55 472 340 48 574 ,838543

Characteristics of the patients according to period.Phase I: observational period; phase II: interventional period.

Phase I Phase II Valid N Mean Std.Dev. Valid

N Mean Std.Dev. p

PAB variations (g/l)

483 -,007 ,094 278 ,009 ,144 ,045595

CRP variations 585 -2,2 10,5 328 -1,0 23,1 ,276841 Lymphocytes count variations

626 55 472 340 48 574 ,838543

Determinants of hospitalisation stay:

Hospital comparisons

±Std. Dev.

±Std. Err.

Hospital

4 6 7 9 10 11 12 15 18 19 25 28

±Std. Dev.

±Std. Err.

Hospital

4 6 7 9 10 11 12 15 18 19 25 28

Discharge parameters

±Std. Dev.

±Std. Err.

HOSPITAL

4 6 7 9 10 11 12 15 18 19 25 28

Conclusions

High prevalence of malnutrition among geriatric hospitalized patients

Significant decreased hospitalization stay during 2nd phase (Confounding factor?)

Significant decreased PAB concentrations at discharge during the first phase whereas PAB did not decrease during the 2nd phase

Conclusions

By multiple regression analysis, hospitalization stay is determined by Mini-MNA

Quite homogeneous hospital data distribution

Data comparable with those of medical literature

Conviviality & eating behavior

immediate environmental, psychological, social, and cultural stimuli exert powerful but short-lived effects on intake Women intake (+13%) when their husband is

present Old subjects intake (+23%) in presence of their

family.

De Castro JM. How can eating behavior be regulated in the complex environments of free-living humans? Neurosci Biobehav Rev 1996;20:119-131

Conviviality

Intake increased 44% when the meals are given in groups, people eat more during the week-end and at the end of the day

Convivial, calm and well-lighted environment, increase dietary intake

When meals are brought home, when the person who brought the meals stays during the meals, the risk of malnutrition decreases

Morley JE. Anorexia, sarcopenia, and aging. Nutrition 2001;17:660-663

hedonic

Acknowledgments

the geriatric patients and other participants who volunteered in the studies.

members of the College for Geriatrics, the Belgian Society for Gerontology and Geriatrics who participated and encouraged the quality programs

Acknowledgments

the geriatric patients and other participants who volunteered in the studies.

members of the College for Geriatrics, the Belgian Society for Gerontology and Geriatrics who participated and encouraged the quality programs

And you for your attention !

« the most fruitful lesson is the conquest of one’s own error. Who ever refuses to admit error may be a great scholar, but he is not a great learner »

Johan Wolfgang von GoetheMaxims & Reflexions

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