D. Volkert

ESPEN Guidelines on Parenteral Nutrition: Geriatrics

Older subjects are at increased risk of partial or complete loss of independence due to acute and/or chronic disease and often of concomitant protein caloric malnutrition. Nutritional care and support should be an indispensable part of their management. Enteral nutrition is always the first choice for nutrition support. However, when patients cannot meet their nutritional requirements adequately via the enteral route, parenteral nutrition (PN) is indicated. PN is a safe and effective therapeutic procedure and age per se is not a reason to exclude patients from this treatment. The use of PN should always be balanced against a realistic chance of improvement in the general condition of the patient. Lower glucose tolerance, electrolyte and micronutrient deficiencies and lower fluid tolerance should be assumed in older patients treated by PN. Parenteral nutrition can be administered either via peripheral or central veins. Subcutaneous administration is also a possible solution for basic hydration of moderately dehydrated subjects. In the terminal, demented or dying patient the use of PN or hydration should only be given in accordance with other palliative treatments.

Malnutrition in Geriatric Patients: Diagnostic and Prognostic Significance of Nutritional Parameters

Nutritional status was assessed in 300 geriatric patients aged 75 years or more using clinical, anthropometric, biochemical and immunologic methods. Relations between different assessment methods and their prognostic significance with regard to 18-month mortality were examined. For biochemical variables 10% (prealbumin, vitamin B6) to 37% (vitamins A and C) were below conventional limits. In 44% of the patients lymphocytes were diminished. 44% were anergic. Judgement of nutritional status by clinical impression resulted in 22% being deemed undernourished. Clinical diagnosis of undernutrition was associated with low anthropometric measurements (p less than 0.05 for all parameters) and a high prevalence of low biochemical values (p less than 0.05 for albumin, prealbumin, transferrin, vitamin A, vitamin B1). The mean values of all anthropometric variables, plasma proteins, vitamins A and C were significantly lower in patients who died within the following 18 months compared to survivors. The greatest prognostic significance was related to the clinical diagnosis of malnutrition. We conclude that clinical assessment is useful for the evaluation of nutritional status in geriatric patients and the best of numerous nutritional parameters to estimate risk of long-term mortality.

Nutritional situation of elderly nursing home residents

Malnutrition in institutionalized elderly is of individual and public concern since it negatively affects health outcome and quality of life and is often preventable. Over the past years several studies have examined the prevalence of malnutrition in institutionalized elderly and reported greatly diverse results. The purpose of the present literature review is to give an overview of the current knowledge about the nutritional situation of institutionalized elderly having specific regard to the prevalence of protein-energy malnutrition and nutrition-related problems. Based on a literature search and additional articles from the files of the authors, observational studies with relatively unselected populations reporting figures for the prevalence of malnutrition and/or the prevalence of nutrition-related problems (e. g. poor appetite, chewing or swallowing problems, eating dependency or poor intake) and published between 1990 and 2006 were considered. Relevant information was extracted and compiled. A total of 42 eligible studies with 41 to 6832 participants were found. BMI was the most frequently used parameter for nutritional assessment with mean values mostly between 21 and 24 kg/m2. Eight studies applied a cut-off value of 20 kg/m2 and reported between 10% and 50% low values. Weight loss was reported in 7 studies with prevalence rates between 5 and 41%, reduced serum albumin (< 35 g/L) in 10 studies with prevalence rates between 0 and 50%. According to the MNA (12 studies) malnutrition was observed in 2 to 38% and a risk of malnutrition in 37 to 62%. Nutritional problems were reported in 17 studies, again with great variability between the studies. In physically and mentally capable study populations malnutrition was relatively unfrequent. Prevalence rates were highest in studies with great proportions of disabled and severely impaired residents.It can be concluded that malnutrition is generally widespread in institutionalized elderly. Prevalence rates vary according to the parameters and cut-off values used for nutritional assessment and according to the population under study. Future studies should carefully characterize their participants and use standardized nutritional assessment tools in order to achieve better comparability of study results as up to now.ZusammenfassungÄltere Heimbewohner haben aufgrund häufiger funktioneller und gesundheitlicher Beeinträchtigungen ein erhöhtes Risiko für Mangelernährung. Studien über die tatsächliche Verbreitung von Mangelernährung kamen in den letzten Jahren zu unterschiedlichen Ergebnissen. Ziel der vorliegenden Übersichtsarbeit war es daher, einen Überblick über die verfügbaren Daten zur Ernährungssituation, speziell zur Häufigkeit von Mangelernährung und von Ernährungsproblemen, bei älteren Heimbewohnern zu geben. Mit Hilfe einer Literaturrecherche mit definierter Suchstrategie wurden Beobachtungsstudien mit gemischten Kollektiven älterer Heimbewohner und Angaben zur Prävalenz von Mangelernährung und/oder zur Prävalenz von Ernährungsproblemen (z. B. Appetitlosigkeit, Kauprobleme, Schluckbeschwerden) gesucht, die seit 1990 in englischer Sprache publiziert worden waren. Zusätzlich wurden relevante Arbeiten aus den Beständen der Autoren berücksichtigt. 42 Studien mit 41 bis 6832 Teilnehmern wurden identifiziert. Zur Beschreibung der Ernährungssituation wurde am häufigsten der BMI herangezogen. In 8 Studien wurde ein Grenzwert von 20 kg/m2 gewählt und zwischen 10 und 50% erniedrigte Werte festgestellt. Ein Gewichtsverlust wurde in 7 Studien mit Häufigkeiten zwischen 5 und 41% beschrieben, erniedrigte Albuminkonzentrationen (< 35 g/L) in 10 Studien mit Häufigkeiten zwischen 0 und 50%. Mittels Mini Nutritional Assessment (MNA; 12 Studien) wurde Mangelernährung bei 2 bis 38% und ein Risiko für Mangelernährung bei 37 bis 62% der Teilnehmer berichtet. Ernährungsprobleme wurden in 17 Studien auf sehr unterschiedliche Weise erfasst, auch hier war eine große Streubreite auffällig. Bei funktionell wenig beeinträchtigten Populationen wurde Mangelernährung relativ selten beobachtet, dagegen waren Bewohnerkollektive mit großen Anteilen funktionell beeinträchtigter Senioren vergleichsweise häufig betroffen. Zusammenfassend lässt sich festhalten, dass Mangelernährung bei älteren Heimbewohnern weit verbreitet ist. Die Häufigkeit variiert je nach Methode und Grenzwert zur Erfassung von Mangelernährung und in Abhängigkeit von der untersuchten Population. Um in Zukunft besser vergleichbare Studienergebnisse zu erhalten, sollten die Teilnehmer weiterer Studien sorgfältig charakterisiert und zur Erfassung der Ernährungssituation einheitliche, standardisierte Methoden verwendet werden.

Energy and nutrient intake of young-old, old-old and very-old elderly in Germany

Background: Reliable information about the nutritional status of elderly people in Germany is lacking.Objective: To describe energy and nutrient intake of elderly people living in private households in Germany with special focus on age-related differences in the elderly.Design: Descriptive nationwide cross-sectional study.Setting: Germany, 1998.Subjects: A random sample of 4020 elderly men and women living independently in private households stratified in three age groups (65–74, 75–84, 85+ y), of which 1550 participated and 1372 (789 female subjects) provided reliable 3-day estimated dietary records.Results: The median daily energy intake was 2207 kcal (9.2 MJ) in men and 1994 kcal (8.3 MJ) in women without difference between the age groups. Protein intake amounted to 91 and 81 g/day, respectively, corresponding to 1.2 g/kg body weight per day. The median intake was well above the recommended amount for all nutrients except dietary fibre, calcium, vitamin D and folate, where 38, 35, 75 and 37% did not reach two-thirds of the recommended amount. An age-related decline was observed for calcium intake in male and for dietary fibre, water, calcium, magnesium, iron, vitamins A, E, C and thiamin intake in female participants; however, the overall picture was unaffected by these differences.Conclusions: Dietary intake in these independently living elderly, including the very-old, is adequate for most of the evaluated nutrients. Increased intake of foods rich in dietary fibre, calcium, vitamin D and folate as well as regular sunlight exposure is recommended in order to optimize nutrient supply in this population group.Sponsorship: German Ministry of Health.

Nutritional status according to the mini nutritional assessment (MNA®) and frailty in community dwelling older persons: A close relationship

ObjectiveThis study investigates the association between MNA results and frailty status in community-dwelling older adults. In addition the relevance of singular MNA items and subscores in this regard was tested.DesignCross-sectional study.SettingCommunity-dwelling older adults were recruited in the region of Nürnberg, Germany.Participants206 volunteers aged 75 years or older without cognitive impairment (Mini Mental State Examination >24 points), 66.0% female.MeasurementsFrailty was defined according to Fried et al. as presence of three, pre-frailty as presence of one or two of the following criteria: weight loss, exhaustion, low physical activity, low handgrip strength and slow walking speed. Malnutrition (<17 points) and the risk of malnutrition (17–23.5 points) were determined by MNA®.Results15.1% of the participants were at risk of malnutrition, no participant was malnourished. 15.5 % were frail, 39.8% pre-frail and 44.7% non-frail. 46.9% of the frail, 12.2% of the pre-frail and 2.2% of the non-frail participants were at risk of malnutrition (p<0.001). Hence, 90% of those at risk of malnutrition were either pre-frail or frail. For the anthropometric, dietary, subjective and functional, but not for the general MNA subscore, frail participants scored significantly lower than pre-frail (p<0.01), and non-frail participants (p<0.01). Twelve of the 18 MNA items were also significantly associated with frailty (p<0.05).ConclusionsThese results underline the close association between frailty syndrome and nutritional status in older persons. A profound understanding of the interdependency of these two geriatric concepts will represent the basis for successful treatment strategies.

The first nutritionDay in nursing homes: Participation may improve malnutrition awareness ☆

BACKGROUND & AIMS A modified version of the nutritionDay project was developed for nursing homes (NHs) to increase malnutrition awareness in this area. This report aims to describe the first results from the NH setting. METHODS On February 22, 2007, 8 Austrian and 30 German NHs with a total of 79 units and 2137 residents (84+/-9 years of age, 79% female) participated in the NH-adapted pilot test. The NHs participated voluntarily using standardized questionnaires. The actual nutritional intake at lunch time was documented for each resident. Six-month follow-up data were received from 1483 residents (69%). RESULTS Overall, 9.2% and 16.7% of residents were classified as malnourished subjectively by NH staff and by BMI criteria (<20 kg/m(2)), respectively. Independent risk factors for malnutrition included age>90 years, immobility, dementia, and dysphagia (all p<0.001). In total, 89% of residents ate at least half of the lunch meal, and 46% of residents received eating assistance for an average of 15 min. Six-month mortality was higher in residents with low nutritionDay BMI (<20 kg/m(2): 22%, 20-21.9 kg/m(2): 17%) compared to residents with BMI >or= 22 kg/m(2) (10%, p<0.001). Six-month weight loss >or= 6 kg was less common in residents with nutritionDay BMI<22 kg/m(2) compared to residents with higher nutritionDay BMI (3.4% vs 12.4%, p<0.001). CONCLUSIONS The first nutritionDay in NH provided valuable data on the nutritional status of NH residents and called attention to the remarkable time investment required by NH staff to adequately provide eating assistance to residents. Participation in the nutritionDay project appears to increase malnutrition awareness as reflected in the outcome weight results.

Prospective Validation of the Modified Mini Nutritional Assessment Short-Forms in the Community, Nursing Home, and Rehabilitation Setting

To validate the modified Mini Nutritional Assessment (MNA) short‐forms (MNA‐SFs) with respect to agreement with full MNA classification in the target populations of the MNA.

ESPEN guidelines on nutrition in dementia

BACKGROUND Older people suffering from dementia are at increased risk of malnutrition due to various nutritional problems, and the question arises which interventions are effective in maintaining adequate nutritional intake and nutritional status in the course of the disease. It is of further interest whether supplementation of energy and/or specific nutrients is able to prevent further cognitive decline or even correct cognitive impairment, and in which situations artificial nutritional support is justified. OBJECTIVE It is the purpose of these guidelines to cover these issues with evidence-based recommendations. METHODS The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds and accepted in an online survey among ESPEN members. RESULTS 26 recommendations for nutritional care of older persons with dementia are given. In every person with dementia, screening for malnutrition and close monitoring of body weight are recommended. In all stages of the disease, oral nutrition may be supported by provision of adequate, attractive food in a pleasant environment, by adequate nursing support and elimination of potential causes of malnutrition. Supplementation of single nutrients is not recommended unless there is a sign of deficiency. Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Artificial nutrition is suggested in patients with mild or moderate dementia for a limited period of time to overcome a crisis situation with markedly insufficient oral intake, if low nutritional intake is predominantly caused by a potentially reversible condition, but not in patients with severe dementia or in the terminal phase of life. CONCLUSION Nutritional care and support should be an integral part of dementia management. In all stages of the disease, the decision for or against nutritional interventions should be made on an individual basis after carefully balancing expected benefit and potential burden, taking the (assumed) patient will and general prognosis into account.

Oropharyngeal dysphagia in older persons - from pathophysiology to adequate intervention: a review and summary of an international expert meeting.

Oropharyngeal dysphagia (OD) is a highly prevalent and growing condition in the older population. Although OD may cause very severe complications, it is often not detected, explored, and treated. Older patients are frequently unaware of their swallowing dysfunction which is one of the reasons why the consequences of OD, ie, aspiration, dehydration, and malnutrition, are regularly not attributed to dysphagia. Older patients are particularly vulnerable to dysphagia because multiple age-related changes increase the risk of dysphagia. Physicians in charge of older patients should be aware that malnutrition, dehydration, and pneumonia are frequently caused by (unrecognized) dysphagia. The diagnosis is particularly difficult in the case of silent aspiration. In addition to numerous screening tools, videofluoroscopy was the traditional gold standard of diagnosing OD. Recently, the fiberoptic endoscopic evaluation of swallowing is increasingly utilized because it has several advantages. Besides making a diagnosis, fiberoptic endoscopic evaluation of swallowing is applied to evaluate the effectiveness of therapeutic maneuvers and texture modification of food and liquids. In addition to swallowing training and nutritional interventions, newer rehabilitation approaches of stimulation techniques are showing promise and may significantly impact future treatment strategies.

The role of nutrition in the prevention of sarcopenia

ZusammenfassungDer Ernährung wird neben anderen Faktoren wie Hormon- und Entzündungsstatus, Erkrankungen und körperlicher Inaktivität bei der Entstehung von Sarkopenie eine zentrale Rolle zugesprochen. Zusammenhänge zwischen verschiedenen Ernährungsfaktoren und Muskelmasse, Kraft und körperlicher Leistungsfähigkeit wurden in den letzten Jahren in einer wachsenden Zahl von Studien beschrieben. Demnach ist die Vermeidung von Gewichtsverlust und der damit einhergehenden Abnahme der Muskelmasse von zentraler Bedeutung. Adäquate Mengen an hochwertigem Protein sind zur optimalen Stimulation der Muskelproteinsynthese essentiell. Vitamin D, Antioxidantien und ω3-Fettsäuren können möglicherweise ebenfalls dazu beizutragen, den Verlust von Muskelmasse und -funktion zu minimieren. Darüber hinaus sollten Ernährungsprobleme wie Appetitverlust, geringe Essmenge, einseitige Ernährungsgewohnheiten und Gewichtsverlust möglichst frühzeitig erkannt werden. Zugrunde liegende Ursachen müssen identifiziert und rasch beseitigt werden. Schließlich muss die Bedeutung von körperlicher Aktivität, speziell Krafttraining, betont werden – nicht nur um den Muskelaufbau zu erleichtern, sondern auch um Energieverbrauch, Appetit und Nahrungsaufnahme bei älteren Menschen mit Risiko für Mangelernährung zu steigern.SummaryNutrition is regarded as one important contributing factors in the complex etiology of sarcopenia. Associations between several nutritional factors and muscle mass, strength, function and physical performance were reported in a growing number of studies in recent years. Accordingly, the avoidance of weight loss is crucial to prevent the concomitant loss of muscle mass. Adequate amounts of high-quality protein are important for optimal stimulation of muscle protein synthesis. Vitamin D, antioxidants and ω 3-polyunsaturated fatty acids may also contribute to the preservation of muscle function. In order to ensure adequate intake in all elderly, nutritional problems like loss of appetite and weight loss should be recognized early by routine screening for malnutrition in the elderly. Underlying causes need to be identified and subsequently corrected. The importance of physical activity, specifically resistance training, is emphasized, not only in order to facilitate muscle protein anabolism but also to increase energy expenditure, appetite and food intake in elderly people at risk of malnutrition.