Nutritional Assessment in frail elderly. M. Secher, G.Abellan Van Kan, B.Vellas 1st December 2010 Firenze

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1 Nutritional Assessment in frail elderly M. Secher, G.Abellan Van Kan, B.Vellas 1st December 2010 Firenze

2 Frailty definition Undernutrition as part of the frailty syndrome Nutritional assessment in frail elderly MNA Conclusion

3 Robust older people: Autonomous community dwelling Not presenting disabilities at the moment Active But, At increased risk to adverse health outcomes Unable to face stressors

4 Some degrees of functional or cognitive impairment, socially isolated, numerous comorbidities Not yet dependent but at risk of onset of dependency High risk of health adverse outcomes: Hospitalizations Polypharmacy Falls Institutionalization Increased risk of mortality Cognitive decline

5

6 U-shaped association between frailty and BMI Frailty increased with BMI < 20 and BMI 35 Hubbard RE and al., J Gerontol A Biol Sci Med Sci, 2009

7 Biofrail study: Financial support by NESTLE Cross-sectional study 124 older adults over 70 years Frailty assessed by Fried criteria Body composition assessed by DEXA Blood sampling (nutritional and inflammatory) Comprehensive Geriatric Assessment ADL and IADL MNA MMSE Comorbidities Treatment

8 Unpublished data

9 Score MNA ± ± 3.0 * 21.1 ± 3.6 * not frail intremediate frail * p<0.001 Unpublished data

10 Association gait speed / undernutrition: Gait speed: Usual pace / 4.5 meters Slow gait speed: < 1m/s Nutritional status MNA PINI (albumin, prealbumin, CRP, orosomucoide) => Age OR 1.2 [ ] => MNA (at risk & malnourished) OR 5.2 [ ] Unpublished data

11 Weight loss Body Mass Index (BMI) Nutritional Assessment tools : - Mini Nutritional Assessment (MNA) -SNAQ Dietary intakes Biological parameters (albumin, pre-albumin) Secher M and al., Reviews in Clinical Gerontology, 2007

12 1989: IAGG Meeting in Acapulco : First validation study in Toulouse, France 2001: MNA-SF - Since 1994 MNA has been translated in almost 20 languages, with now more than 200 publications in medline/pubmed A collaborative on-going international research program: Centre de Médecine Gériatrique, Département de Médecine Interne, CHU Purpan Toulouse, France, Prof. B. Vellas Clinical Nutrition Laboratory, School of Medicine,University of New Mexico, Albuquerque, USA, Prof. P.J. Garry Nestlé Research Center, Nestec Ltd., Lausanne, Switzerland,Y. Guigoz, Ph.D. VA Greater Los Angeles Healthcare System, Geriatric Research, Education, and Clinical Center, Sepulveda, California, Prof. L.Z. Rubenstein

13 - Screening & - Assessment a reliable scale clearly define cut points usable by all health carers easy to use acceptable to patient inexpensive less than 10 min Guigoz Y and al., Nutr. Rev, 1996 Vellas B and al., J Am Geriatr Soc, 2000 Rubenstein LZ and al., J Gerontol, 2001 Guigoz Y and al., J Nutr Health Aging, 2006

14 MNA Sensitivity Specificity Guigoz et al. Med Hyg1995;53: % 98 % Delacorte RR et al. JNHA2004;8:531 Visvanathan R et al Age Ageung 2004 ;33 :260 Kzuya M et al. Nutrition 2005;21: % 74.3 % 89.5 % 87.5 % 81 % 86 % MNA-SF Sensitivity Specificity Rubenstein et al. J Gerontol 2001;56A:M % 100 % Sensitivity 90% Specificity 90% Cohendy R et al. Aging 2001; Visvanathan R et al Age Ageung 2004 ;33 :260 Kzuya M et al. Nutrition 2005;21: % 88.8 % 92.5 % 37.8 % 85.9 % 84 %

15 The MNA is a 18-item questionnaire: Anthropometric assessment (BMI, mid-arm & calf circumference, weight loss) Dietary assessment (number of meals consumed, food and fluid intake, and feeding autonomy) General assessment (lifestyle, medication, mobility, presence of acute stress, and presence of dementia or depression) Self assessment (self-perception of health and nutrition)

16 Two step procedure MNA Short Form (MNA-SF) to screen for: - risk of malnutrition Total MNA to assess : - risk of malnutrition - and malnutrition Rubenstein LZ and al., J Gerontol, 2001

17 Scores MNA-SF: maximum score of 14 Total MNA: maximum score of 30

18 MNA Short Form: MNA-SF 1. Body mass index (BMI) (kg/m 2 ) 2. Weight loss in past 3 months 3. Acute illness or major stress in past 3 months 4. Mobility 5. Presence of Dementia or depression 6. Decline in appetite and food intake in past 3 months

19 MNA > 23.5: Good Nutritional Status: General dietary recommendations for older people Weight follow-up (each 6 or 12 months) MNA 17, 23.5: At Risk for Malnutrition Probably no weight loss or low albumin, but generally poor nutritional intake

20 MNA and Prealbumin Further characterization of the elderly at risk of malnutrition can be done using the prealbumin (= transthyretin), and a threshold of 0.2 g/l is proposed. Pepersack et al., JNHA, 2002 However detection of risk of malnutrition by the MNA often occurs before biochemical parameters are affected Vellas B et al., Nutrition, 1999

21 MNA > 23.5: Good Nutritional Status: General dietary recommendations for older people Weight follow-up (each 6 or 12 months) MNA 17, 23.5: At Risk for Malnutrition Probably no weight loss or low albumin, but generally poor nutritional intake Evaluation of loss of points in MNA: poor appetite, too many medications, need help for shopping, eating intervention Oral complementation and vitamins or trace-mineral supplementations if necessary Weight follow-up (each 3 months)

22 MNA < 17 : Protein Caloric Undernutrition Low caloric intake, low albumin level, weight loss Find the cause of undernutrition and treat when possible Evaluation of loss of points in MNA Oral supplementation

23 MNA & Nutritional Intervention & Follow-Up MNA score [points] Supplement Stable weight Control Weight loss 0 60 days days Length of stay in hospital Use of daily oral supplementation during and after hospitalization maintains body weight and increases MNA score in patients at risk of malnutrition Gazzotti and al., Age and ageing, 2003

24 MNA & Nutritional Intervention & Follow-Up Change in MNA score [points] supplement control Oral supplementation significantly improves body weight (specially fat free mass) and nutritional status (MNA) in AD patients Lauque S and al., J Am Geriatr Soc, 2004

25 The newly revised MNA-SF is a valid nutritional screening tool applicable to geriatric health care professionals with the option of using Calf Circumference (CC) when BMI cannot be calculated Kaiser MJ And al., JNHA, 2009

26 REAL.FR 573 AD patients Sensitivity ROC Curves MNA-SF (BMI) vs MNA, by cognitive status Specificity MMSE (AUC: 0.95) MMSE (AUC: 0.94) Test of equality of AUC=0.43 Unpublished data

27 MNA [Mean + SD] n = % 37% 27% ADL [Number of activities with difficulties] Degree of ADL disability was inversely associated with MNA scores p Salvà A. et al. JNHA 2009

28 MNA 30 n = % 31% 40% 20% CDR global score Dementia severity was inversely associated with MNA scores p Salvà A. et al. JNHA 2009

29 Mortaity 28% 40% 50% 89% of the subjects with a MNA score <17 always divided their meal compared with 28% of those with a MNA score >23.5 (p < 0.01) The 3-year mortality was 50% for those who were malnourished, 40% for those at risk of malnutrition, and 28% for the well-nourished group (p<0.05) Saletti A et al., Gerontology, 2005

30 MNA Score [kcal/day] Estimated Energy Requirement < ( ) ( ) ( ) Energy Intake < * ( ) *( ) ( ) The malnourished residents had: worse cognitive performances worse well-being Lower functional ability Greater need or daily assistance ~10 kg median weight loss at 1 year follow-up, while the weight was stable in the others (at risk for malnutrition or wellnourished) *p<0.05;**p<0.01 between intake & requirement Ödlund Olin A et al, Eur J Clin Nutr, 2005

31 Association between nutrition and frailty makes us believe that frail elderly have a higher risk of malnutrition than non frail elderly in the absence of specific studies It seems crucial to assess nutritional status of all frail patients until we dispose of clinical data confirming this hypothesis MNA is by far the most widely used tool for nutritional screening and assessment in older people Recent data suggest that MNA could identify frailty

32 Grazie Mille