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Transcript of 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
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 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
0
100
200
30019
patients
399 patients
557 patients
417 patient
s
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
0
100
200
30019
patients
399 patients
557 patients
417 patient
s
Dupertuis YM. Clin Nutr 2003, 22: 115-23
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
Dupertuis YM. Clin Nutr 2003, 22: 115-23
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
p
(<80% normal)
All 771 5519 ± 300 3372 ± 138
0.001
Medecine 365 2945 ± 242 1783 ± 124
0.0001
Surgery 406 7335 ± 513 4579 ± 182
0.001
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
Time
Acute problem (hospitalization)
15
20
25
30
35
40
45
50
15-24 25-34 35-44 45-54 55-64 65-74 75-84 >85Age (years)
Women 95th 90th 75th 50th 25th 10th 5th
Women
%%
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
100
90
80
70
50
60
growth retardation
bronchopneumonia
bed sores
urinary infection
death
anemia
too weak to walk% healthy body weight"
healing impairment
time
too weak to sit
Heymsfield S. B. Ann. Intern. Med. 1979, 90: 63-71
100
90
80
70
50
60
growth retardation
bronchopneumonia
bed sores
urinary infection
death
anemia
too weak to walk% healthy body weight"
healing impairment
time
too weak to sit
Heymsfield S. B. Ann. Intern. Med. 1979, 90: 63-71
Katz
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
bat
hin
g
dre
ssin
g
tran
sfer
toile
tin
g
con
tin
ence
eati
ng
total
intermediar
absent
ADL dependence of outpatients (Katz)N=2588, age:78(9)yr
Pepersack T, Beyer I et al. Facts Res Gerontology 1998
Katz
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
bat
hin
g
dre
ssin
g
tran
sfer
toile
tin
g
con
tin
ence
eati
ng
total
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)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
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)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
phone use shopping meals housework washing transport therapeutics finances
4
3
2
1
0
Pepersack on behalf of the College for Geriatrics 2005
40% of the patients able to prepare their meals
Total comorbidity
0% 10% 20% 30% 40% 50% 60% 70%
heart
Infection
Incontinence
hypertension
vascular
respiratory
digestive
liver
renal
muscles
stroke
Parkinson
anemia
diabetes
cancer
vision
audition
dementia
delirium
depression
Pepersack on behalf of the College for Geriatrics 2005
Malnutrition screening
Anthropometric measurements
Risk assessment scales Nutritional Screening questionnaire
MNA
MUST
Biology: Prealbumine
Malnutrition screening
Anthropometric measurements
Risk assessment scales Nutritional Screening questionnaire
MNA
MUST
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
Malnutrition screening
Anthropometric measurements
Risk assessment scales Nutritional Screening questionnaire
MNA
MUST
Biology: Prealbumine
Malnutrition screening
Anthropometric measurements
Risk assessment scales Nutritional Screening questionnaire
MNA
MUST
Biology: Prealbumine
Malnutrition screening
Anthropometric measurements
Risk assessment scales Nutritional Screening questionnaire
MNA
MUST
Biology: Prealbumine
MNA (points)
No
of
ob
s
0
42
84
126
168
210
252
294
-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)
No
of
ob
s
0
42
84
126
168
210
252
294
-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.
MNA <23,5: 60% of patients at risk
College’s project 2001
Malnutrition screening
Anthropometric measurements
Risk assessment scales Nutritional Screening questionnaire
Nursing Nutritional checklist
MNA
MUST
Biology: Prealbumine
The Malnutrition Universal Screening Tool (MUST) (BAPEN)
The Malnutrition Universal Screening Tool (MUST) (BAPEN)
Risk of malnutrition (MUST)
low
35%
medium
7%
high
58%
Pepersack on behalf of the College for Geriatrics 2005
Risk of malnutrition (MUST)
low
35%
medium
7%
high
58%
MUST: 65% of patient at risk
Pepersack on behalf of the College for Geriatrics 2005
Histogram of frequencies of the values of TPP TK effects
Nu
mb
er
of
pa
tie
nts
0
1
2
3
4
5
6
7
8
9
10
TPP TK effect (%)
Nu
mb
er
of
pati
en
ts
0
1
2
3
4
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)
No
of
ob
serv
ati
on
s
0
1
2
3
4
5
6
7
8
9
10
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)
A
55%
B
40%
C
5%
45% of patients at risk of social complexity
Pepersack on behalf of the College for Geriatrics 2005
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
No
of
ob
s
0
10
20
30
40
50
60
70
-4 -2 0 2 4 6 8 10 12 14 16 18 20 22 24
Pepersack on behalf of the College for Geriatrics 2005
depression
N=66
GDS
No
mb
re d
'ob
serv
atio
ns
0
1
2
3
4
5
6
7
8
9
-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… »
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 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:
The concept of “comprehensive geriatric assessment”
Holistic approach of
medical psycho-social functional Environmental
problems
Stuck AE et al. Lancet 1993;342:1032-36
The concept of “comprehensive geriatric assessment”
Holistic approach of
medical psycho-social functional Environmental Nutritional
problems
Stuck AE et al. Lancet 1993;342:1032-36
Is nutritional intervention effective ?
post
OP
(orth
oped
ic)
reco
very
(nur
sing
hom
e)
6
mth
s
l
ater
% FAVORABLE EVOLUTION
70
50
30
10
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
So…
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
done
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)
No
of
ob
s
0
42
84
126
168
210
252
294
-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.
±Std. Dev.
±Std. Err.
Mean
Phase 1 Phase 2
STA
Y (
da
ys
)
0
10
20
30
40
50
60
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.
Mean
Hospital
MN
A (
poin
ts)
4
8
12
16
20
24
28
4 6 7 9 10 11 12 15 18 19 25 28
±Std. Dev.
±Std. Err.
Mean
Hospital
MN
A (
poin
ts)
4
8
12
16
20
24
28
4 6 7 9 10 11 12 15 18 19 25 28
Discharge parameters
±Std. Dev.
±Std. Err.
Mean
HOSPITAL
Dis
cha
rge
PA
B (
g/l)
-0,05
0,00
0,05
0,10
0,15
0,20
0,25
0,30
0,35
0,40
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