Is there a role for specialized nutrition support in the acutely stressed old adult?

Size: px

Start display at page:

Download "Is there a role for specialized nutrition support in the acutely stressed old adult?"

Clarence Ryan
6 years ago
Views:

1 ESPEN Congress Nice 2010 Specialised nutrition in the elderly Is there a role for specialized nutrition support in the acutely stressed old adult? Tommy Cederholm

2 Is there a role for specialized nutrition support in the acutely stressed old adult? Tommy Cederholm, MD, PhD, Professor Clinical Nutrition and Metabolism, Uppsala University, Sweden Department of Geriatric Medicine, Uppsala University Hospital

Characteristics of metabolically stressed acutely ill old patients Depletion before

deficiences (vit D) Cachexia Inflammation (CRP ) Anorexia Insulin resistance

Infections - Pneumonia, UTI Acute diseases - AMI, stroke Trauma - Fractures,

3 Characteristics of metabolically stressed acutely ill old patients Depletion before disease/trauma Sarcopenia (Sarcopenic obesity) - CHF, COPD, CKD Micronutrient deficiences (vit D) Cachexia Inflammation (CRP ) Anorexia Insulin resistance Dehydration Immunodeficiency Confusion Frailty Exacerbations of chronic disorders Infections - Pneumonia, UTI Acute diseases - AMI, stroke Trauma - Fractures, Contusions. CRP Beloosesky Y. J Gerontol 2007;62A: Insulin sensitivity Thorell A. Curr Op Clin Nutr Metabol 1999

4 Nutritional treatment objectives calories proteins micronutrients fluid reduce inflammation increase appetite (regain strength)

5 Options for specialized nutrition to acutely ill old patients Nutrition - Energy fortification - Protein fortification - Vitamin D Reduce catabolism - Myostatin inhibitors -Decoy receptors - Megesterol acetate - Proteasome inhibitors - ACE inhibitors Immunomodulation - n3 FA - arginine - glutamine - anti-oxidants Anabolic treatment - BCAA, leucin - GH, Nandrolon, SARM - Resistance training

6 Caloric needs of the metabolically stressed acutely ill old patient Energy expenditure declines by age Fat-free mass (FFM) fl fi Resting EEfl Muscle massfl/organ mass by age fi REE/kg BW Energy requirement in subjects >70 y: Normal weight: BMI<21: 27 kcal x kg bw 31 kcal x kg bw Catabolism during cachexia energy resistance Conservative approach; ~20-23 kcal/kg bw/day when CRP

Energy dense supplementation at medication rounds 24/27 acutely admitted geriatric patients (84 y) 3x30 ml fat emulsion (Calogen )/day, ~420 kcal 60% MUFA, 30% PUFA Effects: 50% higher energy intake

7 Energy dense supplementation at medication rounds 24/27 acutely admitted geriatric patients (84 y) 3x30 ml fat emulsion (Calogen )/day, ~420 kcal 60% MUFA, 30% PUFA Effects: 50% higher energy intake weight stability Kcal/kg body weight/day Energy intake day 2 and 8 IG CG p<0.001 p<0.001 improved appetite beneficial pl-fa profile 0 At start Follow-up Faxén Irving&Cederholm. Clin Nutr, in press

8 Protein need in geriatric patients 36 stable geriatric patients (74y) Nitrogen balance reached at 1.1 g protein/kg bw/d CRP, nutritional status or diagnosis did not influnce nitrogen balance Gaillard C et al. JAGS 2008;56:1045-9

$Protein supplementation is good (for bone) 82 pat, 81 y, recent hip fracture 6 mo RCT + 6 mo follow-up 20 g protein/day vs.$

9 Protein supplementation is good (for bone) 82 pat, 81 y, recent hip fracture 6 mo RCT + 6 mo follow-up 20 g protein/day vs. control Se IGF-1 BMD loss fl Length of Rehab Hospital Stay fl 33 vs. 56 days (p=0.018) Schurch et al. Ann Intern Med 1998;15:801-9

10 Essential amino acid supplementation reduce bed rest induced muscle wasting 22 healthy men ~70 y. Bed rest for 10 days. Essential amino acids vs. placebo. Fractional protein synthesis in muscle was maintained. Ferrando et al. Clin Nutr 2010;29:18-23

11 Leucin increases protein synthesis in old men 20 healthy males, 70y, BMI 25. Oral protein supplementation with/without leucin. Rieu et al. J Physiol 2006;575:305-15

Myostatin decoy receptor reverse cancer cachexia and sarcopenia Myostatin blocks muscle growth via ActRIIB binding sactriib act as a decoy receptor and bind

12 Myostatin decoy receptor reverse cancer cachexia and sarcopenia Myostatin blocks muscle growth via ActRIIB binding sactriib act as a decoy receptor and bind myostatin sactriib administration to cancer cachectic C26 rats Reversed muscle wasting Protected cardiac muscle Prolonged survival Zhou et al. Cell 2010;142:531-43

13 Vitamin D supplementation? Vit D deficiency fi all cause mortality Vit D deficiency fi endothelial dysfunction Trauma/acute disease/inflammation Osteoclast activity Osteoblast activityfl bone resorption Is there a role for Vit D supplementation in the acutely admitted old patient?

Scarcity of Vit D data in old ill patients 105 CHF patients, 80 y, Vit D <50 nmol/l RCT, 100000 IU Vit D 10 weeks (20 w)

14 Scarcity of Vit D data in old ill patients 105 CHF patients, 80 y, Vit D <50 nmol/l RCT, IU Vit D 10 weeks (20 w) function, biochemistry 218 bedridden NH residents, 84 y, Vit D ~23 nmol/l, Baseline CRP ~10 mg/l 6-mo RCT VitD 3 doses No effect on CRP Bjorkman et al. JNHA 2009;13:435-9 Vit D treatment of heart failure patients From 20 to ns 40 nmol/l p<0.04 too low dose? d6 min walk m Vit D Placebo ns dtug s dbnp pg/ml dtnf pg/ml Witham et al. Circ Heart Fail 2010;3: ns

Immunomodulating therapy Immunonutriton Depletion before disease/trauma Sarcopenia (Sarcopenic obesity) Micronutrient deficiences (vit D) Cachexia

15 Immunomodulating therapy Immunonutriton Depletion before disease/trauma Sarcopenia (Sarcopenic obesity) Micronutrient deficiences (vit D) Cachexia Inflammation Anorexia Insulin resistance Dehydration Immunodeficiency Confusion - Reduce inflammation - Boast immune function glutamine arginine fish oil EPA, DHA Frailty

Immunonutriton: still fishing for the truth studies mainly in ICU, surgery, trauma, burn patients Meta-analysis 2008 24 studies -12 ICU, 7 trauma, 5 burn - 4 arg, 6 glu, 3 FO, 2 arg+glu, 9 arg+fo, 2

16 Immunonutriton: still fishing for the truth studies mainly in ICU, surgery, trauma, burn patients Meta-analysis studies -12 ICU, 7 trauma, 5 burn - 4 arg, 6 glu, 3 FO, 2 arg+glu, 9 arg+fo, 2 arg+glu+fo Conclusion: Fish oil (EPA, DHA) reduce mortality infections LOS in medical ICU patients (SIRS/sepsis/ARDS) Treatment effect on mortality OR (95%CI) 0.42 ( ) Marik&Zaloga. ICM 2008;34:

17 Anabolic treatment in the acutely stressed old adult? Physical exercise probably not Growth hormone most likely not Glutamine? Anti-oxidants?

18 Conclusions possible specialized nutrition in acutely ill old adults Energy dense supplementation non-aterogenic fatty acids? High quality protein enrichment! Leucin supplementation? Oily fish and n-3 supplementation Vitamin D? Glutamine? Antioxidants? Physical exercise?

19 Summary & Conclusions Clear benefit of ONS on mortality and complications: Benefit increases when: Undernourished subjects are targeted Subjects are older than 75 years Intake is > 400 Kcal Duration is greater than 35 days Sicker subjects are targeted Clear benefit on weight gain Clear benefit in hospitalized subjects Large benefit vs the relatively small costs of feeding Clear benefit in geriatric conditions

20 Improved Lean Body Mass and ADL in 54 lean women with hip fracture after 6 mo of protein supplementation +/- nandrolon Lean body mass (DXA, kg) Katz ADL 0,5 0-0,5-1 -1,5-2 -2,5 Control Nutrition N+nandrolon Tidermark et al. Clin Nutr 2004;23:587-96

21 Protein and Energy Supplementation in Older People: Mortality by nutrition status Meta analysis with 35 reports/ 3021 randomized subjects 1,2 Nourished Undernourished 1,1 28% reduction in mortality when only undernourished subjects included 1 0,9 0,8 0,7 0,78 0,72 0,6 0,5 0,4 Milne, AC et al. Ann Intern Med. 2006;144:37-48.

22 Pharmacological treatment?

23 High quality protein supplementation prevent muscle wasting and improve function 22 healthy men ~70 y. Bed rest for 10 days. Proteins vs. placebo. Transfer time standing, sitting on the floor, standing maintained by protein supplementation Ferrando et al. Clin Nutr 2009, in press

24 Vitamin D reduces falls by 23% Bischoff-Ferrari HA et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of ransomised controlled trials. BMJ 20091;339:b3692.

Viktutveckling efter w-3 beh vid AD Viktförändring (kg) 1,75 1,5 1,25 1 0,75 0,5 0,25 0-6 mån 6-12 mån OmegAD-studien 174 patienter med

25 Viktutveckling efter w-3 beh vid AD Viktförändring (kg) 1,75 1,5 1,25 1 0,75 0,5 0, mån 6-12 mån OmegAD-studien 174 patienter med Alzheimers sjukdom DHA/EPA vs. placebo i 6 mån DHA/EPA till alla 6-12 mån Vikt korr. till aptit 0 Omega-3 Placebo Faxen-Irving et al. JAGS 2009

ACEi och kakexi/sarkopeni? ACEi viktförlustfl vid CHF 1930 pat, 60 år pg/ml, %, kg/m 2 60 40 20 ACEi och CRF TNF SGA BMI 96 predialys, 52 år Anker et al.

26 ACEi och kakexi/sarkopeni? ACEi viktförlustfl vid CHF 1930 pat, 60 år pg/ml, %, kg/m ACEi och CRF TNF SGA BMI 96 predialys, 52 år Anker et al. Lancet 2003;140: ACEi Non-ACEi Stenvinkel P et al. JIM 1999;46:503-7 ACEi gångsträcka hos äldre 130 ind, 79 år ACEi är anti-inflammatoriskt Andersson P et al. JLCM 2002;140:103-9 Sumudakas et al. CMAJ 2007;177:867-74

Energy intake by Swedish hospital patients 575 patients at UAS, 64 17 y 24 h food registration Energy need: 30 kcal/kg/d

27 Energy intake by Swedish hospital patients 575 patients at UAS, y 24 h food registration Energy need: 30 kcal/kg/d (>70: 25 kcal/kg/d) Median intake % of need ½ received <75% of energy need 20% received <50% of energy need Wegener S et al

Impacting Outcomes With Nutrition

Impacting Outcomes With Nutrition Chairman: Professor Alfonso J Cruz-Jentoft Satellite Symposium Proceedings The 6th Congress of the EUGMS 30 September 2010 Dublin, Ireland A recent survey has shown that geriatricians have good awareness