Perioperativenutritional care for hip fracture patients

Transcription

1 Nutritional management of elderly patients with a hip fracture AmaliaTsagari, PhD Clinical Dietitian General Hospital KAT

2 Contents Perioperativenutritional care for hip fracture patients Malnutrition of elderly ( Prevalence, Assessment, Consequences) Nutritional assessment of elderly hip fracture patients Nutritional management of elderly hip fracture patients (shortterm-longterm) Vitamin D deficiency of elderly hip fracture patients

3 Perioperativenutritional care for hip fracture patients Enhanced Recovery After Surgery (ERAS protocol) Using a multidisciplinary team approach with a focus on stress reduction and promotion of return to function. An ERAS protocol aims to allow patients to recover more quickly from major surgery, avoid mediumterm sequelaeof conventional postoperative care (e.g. decline in nutritional status and fatigue), reduce the risk of complications and reduce health care costs by reducing hospital stay.

4 PREOPERATIVE FASTING AND PREOPERATIVE CARBOHYDRATE LOADING Clear liquids until 2 hrs and Solid foods until 6 hrs prior to starting anesthesia Benefits of this practice include reduced preoperative hunger, thirst, and anxiety Limits Insulin resistance to surgical stress Carbohydrate loading Brady M et al. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev. 2003(4):CD Soreide E et al. Pre-operative fasting guidelines: an update. Acta Anaesthesiol Scand. Sep 2005;49(8):

5 Postoperative nutritional care Proceed to normal food intake as soon as possible Postoperative food preferences POD 1 the most commonly preferred foods and beverages included: toast, fruit juice, broth, fresh fruit, potatoes, egg, coffee/tea, ice cream, crackers, pudding, yogurt, sandwiches POD 2 : cooked vegetables, hot cereal, casseroles Have not been shown to increase the incidence of nausea /vomiting Yeung SE, Fenton TR. Colorectal surgery patients prefer simple solid foods to clear fluids as the first postoperative meal. Dis Colon Rectum. Sep 2009;52(9):

6 Malnutrition of elderly Identifying malnutrition Prevalence of malnutrition Causes and consequences of malnutrition Benefits of screening for malnutrition Recommendations for action

7 Malnutrition does not show up in the streets in Europe. Instead malnutrition is a hidden health problem residing at home or in care homes 1 1.LjungqvistO & de Man F. NutrHosp2009; 24(3):

8 Tools to identify malnutrition risk Practical, validated tools available to screen for risk of malnutrition Specifically designed for different patient groups and care settings Examples include: MUST/ MNA/ NRS 2002 For hospital and community patients For older people For adult hospital patients For children NRS 2002 MUST Strong kids However, they are not routinely used, meaning that malnutrition is often missed

9 Screening for malnutrition risk - Conclusions Malnutrition continues to go unidentified The opportunity for early intervention is often missed Screening must result in action if patients are to benefit

10 Prevalence of malnutrition in older people Malnutrition is significantly more common in older people 1-4 ; an ageing population will only exacerbate the problem in years to come About 1 in 3 older people in hospital at risk 1-7 More than 1 in 3 people in care homes at risk 1,6,8-10 Around 1 in 3 older people living independently at risk 6 1. Russell C & EliaM. Redditch, BAPEN Russell C & EliaM. Redditch, BAPEN Russell C & EliaM. Redditch, BAPEN Russell C & Elia M. Redditch, BAPEN ImoberdorfR et al. ClinNutr2010; 29(1): Kaiser MJ et al. J Am Geriatr Soc 2010; 58(9): Vanderweek et al. J Adv Nurs 2011; 67(4): SuominenMH et al. EurJ ClinNutr2009; 63(2): LelovicsZ et al. Arch GerontolGeriatr2009; 49(1): Parsons EL et al. Proc Nutr Soc 2010; 69:E Elia M. & Russell C. Redditch: BAPEN, 2009./

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12 Malnutrition is prevalent in hospitals worldwide About 1 in 4 patients in hospital are at risk of malnutrition Russell C & EliaM. Redditch, BAPEN Russell C & EliaM. Redditch, BAPEN Russell C & EliaM. Redditch, BAPEN Russell C & EliaM. Redditch, BAPEN MeijersJM et al. Br J Nutr2009; 101(3): ImoberdorfR et al. ClinNutr2010; 29(1): Schindler K et al. ClinNutr2010; 29(5): /

13 Malnutrition is prevalent across a wide variety of diseases Prevalence of malnutrition risk in hospital by diagnosis Republic of Ireland n = 1102 ( MUST medium + high risk), UK n = 7521 ( MUST medium + high risk) 1, The Netherlands n = 8028 (defined by BMI, undesired weight loss, nutritional intake) Russell C & EliaM. Redditch, BAPEN MeijersJM et al. Br J Nutr2009; 101(3): / ENHA

14 Performance of the Mini Nutritional Assessment Score in the Detection of Vitamin D status in an Elderly Greek Population A. Tsagari, A Toulis, P Makras, K Skagias, A Galanos, G Lyritis, Horm Metab Res 2012; 44:

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16 Consequences of malnutrition for individuals Markedly increased morbidity and mortality rates 1-2 Malnourished patients experience more complications than well nourished patients; the risk of infection is more than three times greater in hospitalised malnourished patients 2-3 Associated with poorer quality of life 1 Malnutrition has a particularly high adverse impact in the older person 4 impairing function, mobility and independence 5 1.Stratton RJ et al. Wallingford: CABI Publishing; Sorensen J et al. ClinNutr2008; 27(3): Schneider SM et al. Br J Nutr 2004; 92(1): Stratton RJ et al. Br J Nutr 2006; 95(2): Elia M & Russell C. Redditch, BAPEN /

17 Malnutrition is associated with increased morbidity Malnutrition is associated with increased morbidity in acute and chronic disease including: Development of pressure ulcers 1 Poor wound healing 1 Post-operative complications such as acute renal failure, pneumonia and respiratory failure 1 Increased risk of infection 2 1.Norman K et al. ClinNutr2008; 27(1): Schneider SM et al. Br J Nutr2004; 92(1): /

18 LAST TRIMESTER UNINTENTIONAL WEIGHT LOSS NEGATIVELY AFFECTS LENGTH OF HOSPITAL STAY (LOS) AND MORTALITY M. Chourdakis, T. Lappa, A. Tsagari, C. Dimosthenopoulos, K.-A. Poulia, A. Anastasiadou5, A. Baschali, M. Bletsa, Z. Bouloumbasi, A. Chatzoglou, N. Giannoulaki, P. Detopoulou, G. Kabatzi, P. Kalogirou, D. Karagiannis, S. Karantaglidou, I. Karli, V. Mylona, K. Papageorgiou, E. Papagiannidou, V. Papamikos, S. Zouganeli, M. Kontogianni Clinical Nutrition 2012, 7Suppl 1:181

19 Aim: Assessment of impact of WL on LOS and mortality in the Greek nutritionday (nd) project. Methods: During the nutritiondayproject 2012, 821 patients were randomly selected in nine different Greek hospitals and were included in the analysis. Questionnaires of the nd project were completed and last trimester WL and % of this WL (%WL) were recorded. LOS and patients outcome were recorded and evaluated one month after the nd.

20 Results: 44.8% of patients reported WL %WL was correlated with LOS (r = 0.23, p <0.001) and those who died reported higher %WL than those who were still alive (8.1±8.7 vs. 3.7±5.5, p < 0.001) at one month evaluation. Patients with %WL >5% had higher LOS compared to those with less or no WL (18.9±22.8 vs. 12.6±11.4 days, p < 0.001) and showed greater mortality (p = 0.001). In the multivariate analysis %WL was significantly associated with LOS (beta = 0.24, p < 0.001) and %WL was also associated with higher mortality likelihood (OR = 1.074, 95% CI: ). Conclusion: Last trimester unintentional WL significantly affects LOS and mortality and should be routinely assessed on patients hospital admission.

21 Elderly hip fracture patients

22 Screening tools MUST MNA NRS2002

23 248 elderly patients(129 men, 119 female women, aged 75.2±8.5 years) were examined. Nutritional screening was performed on admission using thefollowing tools: Nutritional Risk Index(NRI), Geriatric Nutritional Risk Index(GNRI), Subjective Global Assessment(SGA), Mini Nutritional Assessment- Screening Form(MNA-SF), Malnutrition Universal Screening Tool(MUST) and Nutritional Risk Screening2002 (NRS 2002). A combined index for malnutrition was also calculated. RESULTS: Nutritional riskand/or malnutrition variedgreatly, ranging from47.2 to97.6%, dependingonthe nutritional screening tool used. MUST was the most valid screening tool(validity coefficient = 0.766, CI 95%: ), 0.841), whilesga wasin better agreement with the combined index(κ=0.707, p=0.000). NRS 2002 although was the highest in sensitivity(99.4%), itwas the lowest in specificity (6.1%) and positive predictive value(68.2%). Clin Nutr Jun;31(3): Epub 2011 Dec 17. Evaluation of the efficacy of six nutritional screening tools to predict malnutrition in the elderly. Poulia KA, et al.

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25 The Nutrition Care Process Assessment Medical, social, & dietary histories Anthropometric data Biochemical analysis Physical exam Diagnosis Actual or potential Problem, etiology, signs & symptoms Intervention Dietary changes Nutrition education Monitoring & evaluation May need to modify the plan Must be flexible 2007 Thomson - Wadsworth

26 Anthropometric Data Difficulties with assessment of BMI

27 Plasma Proteins Albumin Most abundant Slow to reflect changes in status Transferrin Transports iron Indicates PEM & iron status Slow to detect changes in status Prealbumin & retinolbinding protein Also called transthyretin Responds quickly to changes in protein status Expensive test 2007 Thomson - Wadsworth

28 Dietary history Admission day Patient waiting for operation Time since operation ICU stay Age Number of drugs taken orally at home Fluid retention Comorbidity Unintentional weight loss prior to hip fracture Loss of appetite Pain FFQ 24h recall

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30 Management of malnutrition in elderly hip fracture patients A range of strategies can be used to manage malnutrition, e.g. dietary advice, oral nutritional supplements, tube feeding or parenteral nutrition (intravenous nutrition) *Based on the ESPEN definition. 1.Lochs H et al. Clin Nutr 2006; 25(2): /

31 ONS reduce mortality in hospital patients Significantly lower mortality rates found in supplemented hospitalised liver disease, orthopaedic, and surgical patients, and hospitalised older people 1 Represents a 24% reduction in mortality Lower mortality in supplemented versus control patients p < 0.001; odds ratio 0.61 (95% CI, 0.48 to 0.78), meta-analysis of 11 trials, n = 1965; no significant heterogeneity between individual studies 1.Stratton RJ et al. Wallingford: CABI Publishing; 2003./

32 ONS reduce complications in hospital patients Significantly lower complication rates in supplemented surgical, orthopaedic, elderly and neurology hospital patients 1 Represents a 56% reduction in complication rates Lower complication rates in supplemented versus control patients in hospital p < 0.001; odds ratio 0.31 (95% CI, 0.17 to 0.56), meta-analysis of 7 trials, n = 384; no significant heterogeneity between studies 1.Stratton RJ et al. Wallingford: CABI Publishing; 2003/.

33 Management of malnutrition Early identification is key to effective management of malnutrition Screening using validated tools should be routine practice A range of strategies can be used to manage malnutrition, e.g. dietary advice, oral nutritional supplements, tube feeding or parenteral nutrition (intravenous nutrition) *Based on the ESPEN definition. 1. Lochs H et al. Clin Nutr2006; 25(2):

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36 Flodin et al 2014; Clinical Interventions in Aging

37 Dietary Counseling/Food Fortification

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40 U.S. Department of Agriculture s Human Nutrition Research Center on Aging at Tufts University created MyPlatefor Older Adults as a companion to MyPlate, the federal government s food group symbol(2011) For details about the MyPlatefor Older Adults, please see older-adults.

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43 Vitamin D & Calcium

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47 Performance of the Mini Nutritional Assessment Score in the Detection of Vitamin D status in an Elderly Greek Population A. Tsagari, A Toulis, P Makras, K Skagias, A Galanos, G Lyritis, Horm Metab Res 2012; 44:

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49 When only female subjects were considered, MNA scores were again found to be signifi cantly correlated with 25(OH)D levels (rho = 0.664, p < 0.001). Similarly, MNA scores were found to be signifi cantly correlated with 25(OH)D levels (rho = 0.749, p < 0.001) in male subjects.

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51 Thank you for your attention