Nutrition in the Elderly 36.3 Nutritional screening and assessment Oral refeeding

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1 Nutrition in the Elderly 36.3 Nutritional screening and assessment Oral refeeding Dr. Jürgen J Bauer Medizinsche Klinik 2 - Klinikum NürnbergN Lehrstuhl für f r Geriatrie Universität t Erlangen-Nürnberg rnberg Copyright 2006 by ESPEN

2 Copyright 2006 by ESPEN Diagnosing malnutrition in the elderly

3 Copyright 2006 by ESPEN Medical history Weight loss kilogram / percent of usual weight time course Appetite Restrictive diet Consumption of nicotin and alcohol Help of close relative / caregiver often necessary

4 Medical history Comorbidity Dementia, depression, post-stroke dysphagia Medication Functional limitations ADL/IADL Social environment Copyright 2006 by ESPEN

5 Copyright 2006 by ESPEN Oral intake 7-day food diary 24-hour recall! Memory may be hampered in the elderly! Eating protocols in institutions Completed by nursing stuff Intake estimated via quarters of meal served At least for three days in a row

6 Copyright 2006 by ESPEN Clinical signs Loss of subcutaneous fat Muscle atrophy Peripheral edema Signs of micronutrient deficiencies Skin, mucous membranes, central/peripeheral nervous system, eyes

7 Anthropometry Weight well-calibrated scale! Edema, ascites, pleural effusions, loss of body parts! Height alternatives in the immobile: - knee height - armspan Copyright 2006 by ESPEN

8 Anthropometry BMI = Weight Height ² For the elderly association between BMI and body fat less close For the elderly higher survival for people with higher BMI Treshhold for malnutrition in the elderly 20 (- 22) kg / m² Mortality with risk factors no risk factors Copyright 2006 by ESPEN BMI

9 Copyright 2006 by ESPEN BMI author patients n age prevalence < 16 Maffuli (1999) hip fracture ± 9 11 % < 18 Volkert (1992) acute care, mixt ± 5 9 % Maffuli (1999) hip fracture ± 9 31 % < 18,5 DaCunha (2001) acute care, mixt % < 20 Volkert (1992) acute care, mixt ± 5 21 % Markus (1993) Parkinson % Gariballa (1998) stroke ± 9 31 % Ponzer (1999) hip fracture ± 7 36 % 20 Flodin (2000) acute care, mixt ± 1 36 % < 21 Dardaine (2001) ICU (respirator) 116 > 70 8 % Dormenval (1999) acute care, mixt ± 4 35 % Ponzer (1999) hip fracture ± 7 52 % < 22 Incalzi (1996) acute care, mixt ± 6 22 % Sullivan (1994) rehabilitation ± 6 33 % Volkert (1992) acute care, mixt ± 5 40 % Volkert D et al. Aktuel Ernaehr Med 2004; 29:

10 Anthropometry Calf circumference Most sensitive method to determine muscle mass in the elderly WHO 1998 Significant correlation with BMI, lean body mass, TSF and albumin Bonnefoy M, Gerontology 2002 Best clinical indicator for sarcopenia and strong association with functional parameters Rolland et al, JAGS 2003 Cut off: 31 cm Copyright 2006 by ESPEN

11 Serum albumin level at admission: mortality in geriatric patients 38,6% Mortality p< ,1% < 3.3 gr/dl >3.3gr/dl Albumin D'Erasmo E, et al. Amer J Med Sciences 1997;314:17 Copyright 2006 by ESPEN

12 Albumin Problems Low specifity caused by a large variety of acute and chronic diseases Not valuable for early diagnosis of malnutrition because of long half time (t ½ = 18 days) Suitable for medium- and long-term assessment of nutritional status in patients without significant comorbidity (?) Copyright 2006 by ESPEN

13 Copyright 2006 by ESPEN Laboratory examinations Prealbumin (t ½ = 2 days) Normal range: 0,1 0,4 g/dl Retinol binding globulin (t ½ = 12 h) Normal range: 0,03 0,06 g/dl Transferrin (t ½ = 8 h) Dependency on iron metabolism

14 Nutritional parameters and life-threatening complications in geriatric patients Parameter Complication rate P-Wert UAC < 286 mm 13,8% <0, mm 2,4% > 323 mm 3,2% Weight loss > 5 % yes 19% <0,001 no 4,5% Albumin < 30 g/l 13,3% 0, g/l 5,3% Transthyretin < 18 mg/dl 10,5% 0, mg/dl 4,6% BMI < 22 kg/m² 15,4% 0, kg/m² 4,0% Sullivan DH et al, J Gen Intern Med 2002; 17: Copyright 2006 by ESPEN

15 ESPEN Guidelines for Nutritional Screening 2002 Aims of successful screening/assessment Improvement or at least prevention of detoriation in mental and physical function Reduced number or severity of complications of disease or its treatment Accelerated recovery from disease and shortened convalescence Reduced consumption of resources, e.g. length of hospital stay and other prescriptions Copyright 2006 by ESPEN

16 ESPEN Guidelines for Nutritional Screening 2002 Routine screening of all elderly above age 65 recommended Assessments necessary for Frail elderly people Elderly people with chronic diseases Elderly people depending on social services or living in assisted living facilities Elderly people in hospitals and nursing homes Copyright 2006 by ESPEN

17 Copyright 2006 by ESPEN Mini Nutritional Assessment MNA I. MNA-sf short form Screening 5 min 11 II. MNA long version Assessment min

18 Copyright 2006 by ESPEN Mini Nutritional Assessment MNA 18 questions dealing with Overall assessment of health Nutrition Anthropometry (loss of weight, BMI, UAC, calf circumference) Subjective self estimation Assessment by experienced personnel helpful, but not obligatory Categories: well nourished at risk malnourished > ,5 < 17

19 Problems of the MNA Patients must be able to cooperate Amount of time necessary for its application Too many patients identified as being at risk Meaningful distribution of limited resources difficult Not ideal for use during follow-up Copyright 2006 by ESPEN

20 Copyright 2006 by ESPEN MNA - SF High correlation with the results of the long version (r = 0.945) High diagnostic accuracy with regard to the risk of malnutrition and evident malnutrition Suitable for populations with a low prevalence of malnutrition Rubenstein LZ et al, Journal of Gerontology 2001, 56A,

21 Copyright 2006 by ESPEN NRS 2002 Primary screening Yes or No Is BMI < 18.5? Recent weight loss? Recent decrease in intake? Severely ill (ICUish)? If Yes to 1 question proper screening Kondrup et al. Clin Nutr 2003; 22:

22 Copyright 2006 by ESPEN Mild Score 1 Moderate Score 2 Severe Score 3 Nutritional Risk Screening 2002 (ESPEN guideline) Impaired nutritional status Wt loss >5% in 3 mths Or Food intake <50-75% of normal requirement in preceding week. Wt loss >5% in 2 mths Or BMI impaired general condition Or Food intake 25-50% of normal requirement in preceding week Wt loss >5% in 1 mth ( >15% in 3 mths (17)) Or BMI < impaired general condition (17) or Food intake 0-25% of normal requirement in preceding week Severity of disease ( requirement/stressmetabolism) Hip fracture (9). Chronic patients, in particular with Mild acute complications: cirrhosis (11), COPD (12). Chronic hemodialysis, diabetes, Score 1 malignant oncology. Moderate Score 2 Severe Score 3 Major abdominal surgery (13-15). Stroke (16). Severe pneumonia, malignant hematology. Head injury (18, 19). Bone marrow transplantation (20). Intensive care patients (APACHE>10). Score: Score: = TOTAL SCORE:

23 Copyright 2006 by ESPEN Indication for nutritional support Calculating the score Find score (0-3) for Impaired nutritional status (only one: choose the variable with highest score) and Severity of disease ( stress-metabolism, i.e. increase in nutritional requirements). Add the two scores ( total score) If age 70 years: add 1 to the total score > age corrected total score to correct for frailty of elderly If age-corrected total 3: start nutritional support, i.e. indication for treatment, not just diagnosis.

24 Copyright 2006 by ESPEN Treating malnutrition in the elderly

25 Medications (e.g. Digoxin, Theophyllin, Fluoxetin) Emotional causes (Depression) Alcoholism Late-life paranoia Swallowing problems Treatable medical conditions have Oral problems Nosocomial infections (Tb, Clostridium difficile, Helicobacter pylori) to be systematically considered. Wandering and other behaviour associated with dementia Hyperthyroidism, Hypercalcemia, Hypoadrenalism Enteral problems Eating problems Low salt, low fat diet Shopping Copyright 2006 by ESPEN Morley J, Clin Geriatr Med, 2002

26 Copyright 2006 by ESPEN Screening Assessment Intervention Monitoring

27 Copyright 2006 by ESPEN Multidisciplinary approach Practitioner Physician trained in nutrition Dietitian Nurse Speech therapist Physiotherapist Cook / caterer Social worker

28 Copyright 2006 by ESPEN Interventions Dietary counselling Snacks and additional meals Dietary fortification by including energy- and protein-rich food oil, cream, butter, sugar, high-fat milk and cheese, commercial powders/liquids Supplements

29 Nutritional Supplements Copyright 2006 by ESPEN

30 Meta-Analysis: Protein and Energy Supplementation in Older People Mortality 25 studies analysed Reduction with borderline significance (OD 0.86) Hospital No significant reduction (OD 0.88) Significant in malnourished patients (OD 0.66) Nursing home No significant reduction (OD 0,65) Community dwelling elderly No significant reduction (OD 1,05) Milne AC, Avenell A, Potter J, Ann Intern Med. 2006; 144: Copyright 2006 by ESPEN

31 Meta-Analysis: Protein and Energy Supplementation in Older People Mortality - Subgroup analysis Improved survival in malnourished elderly in people > 75 years when supplement intake > 400 kcal/day in people with a bad overall medical condition Milne AC, Avenell A, Potter J, Ann Intern Med. 2006; 144: Copyright 2006 by ESPEN

32 Copyright 2006 by ESPEN Oral supplements in nursing homes Significant weight gain in comparison with standard nutritional care Only minimal suppressive effect on intake of natural foods On average + 68% of calorie intake via supplement Greatest efficacy in patientents with low BMI < 20 kg/m² + 80 %, bei > 20 kg/m² + 40 % Improved caloric intake in combination with exercise Stratton RJ, Proc Nutr Soc 2005

33 Weight gain and function among nursing home patients Increase in weight (kg) 0 Fiatarone 1994 Fiatarone 2000 Persson 2000 Lauque 2000 Gray-Donald 1995 Volkert 1996 Chandra 1985 Functional improvement No functional improvement Stratton RJ, Proc Nutr Soc 2005 Copyright 2006 by ESPEN

34 Problems of treating malnutrition by nutritional supplements Acceptance - Compliance Application modalities Various, new flavours Consistency Temperature Apllication in between meals Snacks Copyright 2006 by ESPEN

35 ESPEN Guidelines Enteral Nutrition - Geriatrics 2006 Oral supplements are indicated for people with malnutrition and for those at risk for malnutrition (A). Oral supplements and/ or tube feeding should be started early in patients at risk for malnutrition (B): Insufficient oral intake Weight loss > 5% in 3 months, > 10% in 6 months BMI< 20 kg/m² Copyright 2006 by ESPEN

36 Copyright 2006 by ESPEN ESPEN Guidelines Enteral Nutrition - Geriatrics 2006 Oral supplements are indicated in frail elderly people to improve or stabilize their nutritional status (A). Frail elderly people can benefit from tube feeding as long as they are in a stabile condition. Therefore an early application is recommended in people at risk (B).