NUTRITIONAL FRAILTY. June 2015

Transcription

1 June 2015 Professor Renuka Visvanathan Aged & Extended Care Services, The Queen Elizabeth Hospital And Adelaide Geriatrics Training and Research with Aged Care (GTRAC) Centre NUTRITIONAL FRAILTY

2 DISCLAIMER I am not a dietician or nutritionist and therefore will not be able to provide specific details about food types, nutrient source, caloric count etc. University of Adelaide 2

3 Conflicts of Interest Member of the Malnutrition In The Elderly Group, Nestle Australia Have participated in international initiatives that have been funded through educational grants from Nestle Inc. One of the research studies presented in this talk received research sponsorship from Organon Pty Ltd. In the past, during training years, I received small travel grants from Pfizer Australia and Servier to attend conferences University of Adelaide 3

4 OUTLINE OF THIS LECTURE Healthy Ageing Frailty Under-nutrition Ideal Body Mass Index Managing Nutritional Frailty University of Adelaide 4

5 Healthy Ageing

6 Australia s Ageing Bulge Squaring Of The Population Pyramid University of Adelaide 6

7 Older People Just Wanna Have Fun! University of Adelaide 7

8 Older People Are Active Contributors To National Productivity University of Adelaide 8

9 Water Man Mr George Lewis (octogenarian), previously a stock broker, is leveraging on his district Rotary Club to help obtain clean drinking water for those less fortunate. He is the founder of the Water Team International. University of Adelaide 9

10 Celebrates His 80 th Birthday By Releasing An Album Cohen s new album, Popular Problems, finds the star at a peak of both productivity and popularity. When the sales figures for Popular Problems arrive in the last week of September, it will likely be the first album of original material by an octogenarian to nearly top the charts. Ironically, Cohen will probably lose the No. 1 spot to another guy in his 80s Tony Bennett, for his duets album with Lady Gaga, Cheek to Cheek. (Three years ago, Bennett became the first person in his 80s ever to hit No. 1). New York Daily News University of Adelaide

11 Olga Kotelko Olga Kotelko who passed away in 2014 at the age of 95 years entered her first Masters athletics competition at the age of 77 years. She won more than 750 gold medals and set world records (more than 30) for every track and field event in her age group ranging from hammer throw to triple jump. University of Adelaide 11

12 Our Nation Benefits From Healthier Ageing University of Adelaide 12

13 Frailty

14 PHYSIOLOGICAL AGEING Mr Kowalski Age 104 Years Frail 100 year old man with some disability Anne Perry University of Adelaide 14

15 FRAILTY IS ALSO A SIGNIFICANT PUBLIC HEALTH ISSUE It is possible that in 2011, more than 270,000 community dwelling Australians aged 70 years and over were frail or at-risk of frailty. By 2050, four million Australians aged 70 years and older will either be frail or at-risk of frailty. Courtesy of Dr Helen Feist, Demography Researcher, UoA University of Adelaide 15

16 FRAILTY- DEFICIT MODEL the collected culmination of a lifetime of assaults on the body by medical problems or lifestyle.. it is marked by reduced resilience Clegg A,.Rockwood K: Frailty in elderly people. Lancet 2013, 381(9868): the frail individual is weak, slow and vulnerable to stressor events, such as illness, falls or any circumstance that compromises their physical and/or mental equilibrium Lack of Physical Activity Low socio economic status High Fat and Salt Diet Low Fibre Diet Diabetes Hypertension Constipation Obesity Diverticulitis Angina Obstructive Sleep Apnoea Increasing Frailty 0 Hip Fracture 80 Colon Cancer Stroke Glaucoma 60 years old 69 years old 72 years old University of Adelaide 16

17 Phenotypic Model- Fried s Criteria FRAIL SCREEN Exhaustion---- Are you fatigued? Unintentional weight loss Have you lost more than 5% of your weight in the past 6 months? Weakness Do you have difficulty walking up one flight of steps? Slow walking speed.do you have more than five illnesses? Low physical activity. Are you unable to walk at least one block (160 metres or 6.5 houses with 24 metre frontage)? FRAIL Screen > 3 = risk Fried et al. J Geront 2001;56:M146 M156 Morley et. al. JNHA 2012; 16(7): University of Adelaide 17

18 UNDERNUTRITION A MAJOR CONTRIBUTING FACTOR TO FRAILTY University of Adelaide 18

19 Nutritional Risk Is Common In The Community And Associated With Hospitalization And Falls 5% Malnourished + 40% At risk Hospitalization Hospital LOS Fall Over 12 months University of Adelaide 19

20 Nutritional Risk Leads To Poor Discharge Outcomes From Rehabilitation Discharge to acute hospital or residential care University of Adelaide 20

21 Poor Outcomes Related To Nutritional Risk Hospitalisation Hospital Length of Stay Falls Residential Care Placement Post-operative complications Delayed wound healing Infections Pressure sores Health Care Costs Health Care Utilization FRAILTY INDEPENDENCE QUALITY OF LIFE University of Adelaide 21

22 Nutritional Risk Is More Common With Increasing Frailty University of Adelaide 22 I N C R E A S I N G F R A I L T Y I N C R E A S I N G F R A I L T Y I N C R E A S I N G U N D E R N U T R I T I O N I N C R E A S I N G U N D E R N U T R I T I O N Visvanathan R 2007

23 The Mini Nutritional Assessment Well nourished (MNA > 24) At risk of malnutrition (MNA= ) Malnourished (MNA<17)

24 Ideal Body Weight

25 The Body Mass Index Weight in Kg / [Height in m] 2 WHO Healthy BMI range is kg/m 2 Overweight BMI range is 25-<30 kg/m 2 Obese BMI range is 30+ kg/m 2 This is different in older people University of Adelaide 25

26 Note increased risk at approximately 22kg/m 2 Note no increased risk in the WHO overweight category 23.5kg/m 2 was used as the reference BMI 65+ AJCN 2014 University of Adelaide 26

27 Body Composition Rather Than Weight WATER BLOOD MARROW BONE FAT MUSCLE University of Adelaide 27

28 Where is the muscle? SARCOPENIA University of Adelaide 28

29 Muscle Is Important In Older Age WATER BLOOD MARROW BONE Reduced OSTEOPOROSIS FRACTURES FAT MUSCLE Increase d Reduced OBESITY Diabetes Myocardial Infarction Stroke Obstructive Sleep Apnoea Hypertension Sarcopenia Loss of Independence Falls and Fracture Frailty University of Adelaide 29

30 Weight Loss In Older People Associated With Muscle Mass Loss With loss of weight there is a loss of lean mass which is undesirable When weight is gained, very little of the weight gain is due to lean mass (i.e. harder to regain) Newman et. al. AJCN 2005; 82: University of Adelaide 30

31 Contributing Factors To Nutritional Risk

32 Contributing Factors To Nutritional Risk "Meals on Wheels" University of Adelaide 32

33 Protein Intake For Older People

34 Protein Requirements In Older People- An International Expert Consensus [2012] LUCKY NUMBER 13! JAMDA 2013; 14: University of Adelaide 34

35 Key Recommendations From The Group To maintain muscle, older people need more dietary protein than younger people : 1.0 to 1.2g/ kg body weight/day It is also recommended that 25 to 30g of protein (2.5 to 2.8g of leucine) is consumed with each of the three main meals In older people with acute or chronic disease, then the protein requirements increase to between 1.2 to 1.5g/kg body weight/day Ingesting protein after exercise is likely to benefit in terms of building muscle University of Adelaide 35

36 Caution With Renal Disease University of Adelaide 36

37 An example of a meal plan -sedentary male aged 70 years, weighs 75Kg, no CVD [8300 kj/day and 90 g protein] Breakfast (27.5 g protein) 2 weet bix with ½banana sliced on top and ½cup full cream milk 1 piece of wholemeal toast, Thin spread margarine, 1 slice cheese (thick) ½cup yoghurt 1 cup black tea + 1 tsp sugar Morning Tea 1 piece fresh fruit 1 cup black tea + 1 tsp sugar Lunch (32.3 g protein) 2 slices wholemeal bread for sandwich, thin spread avocado, 1 slice cheese (thick) 40g sandwich meat 1 cup salad vegetables (lettuce, tomato, cucumber) 1 cup milo and milk Afternoon Tea 1 apple 1 cup black tea + 1 tsp sugar Dinner (25g protein) 120g lean beef cooked with thickened gravy 1 cup cooked vegetables Mashed potato (1 potato) Supper (5g protein) 2 piece fruit toast, thin spread margarine 6 8 glasses of water per day Courtesy of Ms Erin Healy, Graduate Dietitian, Flinders Uni University of Adelaide 37

38 Nutritional Supplementation One example of a common nutritional supplement 240ml and 480 calories (2 calories/ml) or 2006 kj Protein 20g per 240ml drink $4-5/drink A 70Kg individual at 1.2 g/kg BW/day will require= 84g/day of protein Lets say he requires 8500kJ/day Therefore, the above supplement provides for approximately 25% of recommended daily protein and caloric intake University of Adelaide 38

39 Building Strength

40 Vitamin D Natural source is the sun Vitamin D deficiency is very common Blood test and can be easily supplemented either via tablets or liquid booster doses periodically Important for bone health and muscle health (i.e. strength) Professor Chris Nordin Renowned dvocate for calcium and Vitamin D to prevent fractures University of Adelaide 40

41 What To Do To Improve Health University of Adelaide 41

42 Exercise- Its Never Too Late Ideal- daily exercise for at least 20 minutes (anything is better than nothing) Progressive Resistance Exercise -can be chair based for the frail -using exercise bands -lifting dumbbells Aim progressively 8 to 10 exercises with repetitions and 2 minutes rest in between Aerobic Exercise -e.g. walking -e.g. swimming University of Adelaide 42

43 Encourage Socialisation University of Adelaide 43

44 SUMMARY Frailty and Under-nutrition Is A Risk To Healthy Ageing Screening Allows Early Identification Of Those At Risk Addressing Risk Factors Is Important Muscle Mass and Quality Is Important In Older Age Protein Intake Is Important Vitamin D and Exercise Are Important Socialising Is Important University of Adelaide 44

45 THANK YOU FOR LISTENING Questions?