R. Nieczaj

Clinical value of automatic reporting of estimated glomerular filtration rate in geriatrics.

Background: Geriatric patients frequently have impaired renal function. Multimorbidity leads to polypharmacy with high risk of adverse drug reactions. Objective: The aim was to evaluate the prevalence of renal impairment and risk of overdosing renally excreted drugs in hospitalized geriatric patients. Methods: In 221 patients aged ≥65 years, GFR was estimated by the MDRD, Cockcroft-Gault (CG) and lean body mass (LBM)-adjusted CG equations. Results: A reduced renal function (<60 ml/min/1.73 m2) was found in 43% by MDRD, 61% by CG, and 71.9% by LBM-CG. The prevalence of severe impairment (<30 ml/min/1.73 m2) was 3.3% based on MDRD, 5.4% on CG, and 13.6% on LBM-CG. At mean 10 medications were applied simultaneously. In patients with reduced eGFR, 52% of medications required dosage adjustment. Unfractionated heparins, ACE inhibitors, antibiotics, diuretics, and potassium were frequently used. Conclusions: For all limitations of formulaic GFR estimation in the elderly, routine assessment of renal function by reporting of eGFR helps to identify patients with chronic kidney disease and supports drug dosing. Implementation of routine reporting of eGFR is mandatory in standardized geriatric assessment.

Which are the most efficient items of mini nutritional assessment in multimorbid patients

Objective: The aim of the study was to identify the most significant MNA-items to accelerate the determination of nutritional risk of elderly patients in routine clinical practice in a geriatric hospital. Since MNA requires 10–15 min it is hardly applicable to clinical routine.Design: The study was a cross-sectional study. Setting: The study centre was an acute geriatric hospital. Participants: In total 808 multimorbid elderly patients were recruited. Methods: We applied the MNA in 808 (528f/280m) geriatric multimorbid patients (78.5 ± 8.7f / 74.6 ± 9m yrs) without cognitive impairment 48h after hospital admission. Admission diagnoses covered orthopaedical (40%), internal (34%) and cerebrovascular (24%) diseases. According to analysis of reliability the consistency of the MNA scale for multimorbid patients has been verified. In preparation for scale reduction a factor analysis was applied. A reduced scale with selected cutoffs was configured and compared with MNA.Results: According to MNA, 15% of patients were well-nourished, 65% at risk of malnutrition and 20% were malnourished. The reliability analyses showed a Cronbach’s Alpha of 0.60 that represented a satisfactory result. By means of factor analysis the MNA-items were reduced from 18 to 7 items (weight loss, mobility, BMI, number of full meals, fluid consumption, mode of feeding, health status), with new cutoffs (12.5–15 well-nourished, 9–12 at risk of malnutrition, <9 malnourished). According to the modified MNA (m-MNA) 21.7% of the patients were well-nourished, 54.5% at risk of malnutrition and 21.7% were malnourished. The score of the MNA and m-MNA correlated with r=0.910. Furthermore, there was a strong correlation between MNA and m-MNA group classification of 83%.Conclusion: The m-MNA enables a rapid (3min) and efficient screening of malnutrition in multimorbid geriatric patients. The m-MNA is easy to apply and may also be suitable in multimorbid patients with cognitive dysfunction. Due to the variety of items the m-MNA seems to be superior to other screening tools.

[Dysphagia treatment in a clinical-geriatric setting PEG and functional therapy of dysphagia].

OBJECTIVES Patients with dysphagia whose food intake is inadequate and who may compromise their airways need to receive nasogastric (NG) or gastrostomic (PEG) feeding. There are controversial discussions about the best time for intervention and the best method. Each approach has its advantages and disadvantages. Further research is required to assess the optimum method of treating patients with dysphagia. A retrospective study was undertaken to investigate the influence of functional dysphagia therapy with or without PEG feeding. METHODS A total of 164 patients with dysphagia were investigated in a center for geriatric medicine (EGZB) within one year. Patients were divided into two groups: those with PEG (group 1, n=59) and those without (group 2, n=105). Both groups received functional training (training of oral motor skills and sensation, compensatory swallowing techniques) by speech-language therapists.Geriatric basic assessment was used. Speech-language therapists also evaluated language, speech and swallowing disorders pre- and post-training. Diet modification for oral intake altering viscosity and texture of foods and liquids was used. Additional data on the time between being admitted to hospital and receiving a PEG tube, the hospitalization period, the number of complications and mortality were collected. RESULTS Both groups benefited from functional dysphagia therapy. The patients of group 2 showed a significant improvement in functional oral intake post-treatment. In most of the cases, diet modification improved from pasty consistency to firm meals. Swallowing abilities were much better than those of the more severely disabled patients of group 1. Group 1 still needed PEG feeding post-treatment but could also take in some food orally. However even the patients of group 1 showed a significant increase in functional oral intake.Group 2 also showed significantly stronger improvements in communication abilities and speech intelligibility after training compared to the severely disabled patients of group 1.In terms of the clinical outcome of group 1 it was demonstrated that the sooner a PEG was placed, the more significantly functional oral intake improved. The results of a multiple regression analysis showed a small but nevertheless significant association between an early supply of PEG and improvement of functional oral intake which had been achieved by functional dysphagia therapy.Significantly more complications and significantly higher mortality occurred in group 1 (PEG feeding) compared to group 2 (exclusively oral feeding). CONCLUSION The treatment of dysphagia in the elderly requires a multi-professional setting, differentiated assessment and functional training of oral motor skills and sensation and swallowing techniques. Compared to patients with severe dysphagia, however, patients with mild to moderate dysphagia benefit most from functional training. The results reveal the importance of precise and early diagnosis of swallowing disorders in order to introduce PEG supply early in cases of persistent dysphagia.ZusammenfassungEine nasogastrale Sonde (NSG) oder eine perkutane endoskopische Gastrostomie (PEG) ist bei Dysphagie dann indiziert, wenn eine ausreichende Flüssigkeits- und/oder Nahrungszufuhr auf oralem Wege nicht aspirationsfrei möglich ist. Die Entscheidung über den richtigen Interventionszeitpunkt und die adäquate Methode wird in der Literatur kontrovers diskutiert. Die vorliegende Studie geht der Frage nach, welchen Einfluss die funktionelle Dysphagietherapie mit oder ohne PEG-Anlage auf die Nahrungsaufnahme von Patienten mit Dysphagie hat.In der retrospektiven Untersuchung eines Zentrums für Akutgeriatrie (EGZB) wurden 164 Dysphagiepatienten innerhalb eines Jahres in zwei Gruppen unterteilt: Dysphagiepatienten mit PEG (Gruppe 1; n=59) und Dysphagiepatienten ohne PEG (Gruppe 2; n=105). Beide Gruppen wurden nach der funktionellen Dysphagietherapie von Sprachtherapeuten behandelt.Erhoben wurde das Geriatrische Basisassessment, die logopädische Diagnostik zur Einschätzung der Schluckfunktion und der Nahrungsaufnahme, sowie der Sprechverständlichkeit und der kommunikativen Leistungen. Es wurden ein Ernährungsplan bei Dysphagie mit fünf Viskositätsstufen und angedickte Getränke eingesetzt. Zusätzlich gingen der Zeitpunkt der PEG-Versorgung, Krankenhausverweildauer, die Anzahl der Komplikationen und die Mortalität in die Untersuchung ein.Die Ergebnisse zeigten, dass beide Untersuchungsgruppen (mit oder ohne PEG) von der funktionellen Dysphagietherapie profitierten. Die Nahrungsaufnahme der Gruppe 2 konnte im Verlauf der Therapie signifikant verbessert werden. Es zeigten sich Steigerungen der Koststufe von breiiger Konsistenz bis zu festen Speisen. Die Schluckleistung der Gruppe 2 war damit bei Entlassung deutlich besser als bei den schwer gestörten Patienten der Gruppe 1. Die Patienten der Gruppe 1 konnten bei Entlassung zwar weitgehend oral ernährt (in Kombination mit der PEG) werden, waren aber in der Regel auf diätetische Maßnahmen (z. B. Breikost, Andicken von Getränken) angewiesen. Die Therapieverläufe zeigen aber, dass auch die schwer gestörten Dysphagiepatienten (Gruppe 1) trotz eines geringeren Rehapotentials signifikant von der Schlucktherapie profitierten.Die Patienten der Gruppe 2 zeigten zusätzlich im Bereich der kommunikativen Leistungen und der Sprechverständlichkeit signifikant höhere Verbesserungswerte als die schwer gestörten Dysphagiepatienten (Gruppe 1).Darüber hinaus konnte nachgewiesen werden, dass je früher eine PEG angelegt wurde, desto stärker die Schluckfunktion (FOIS) der Patienten gesteigert wurde. Die Ergebnisse einer multiplen Regressionsanalyse zeigten bei Gruppe 1 geringe aber dennoch signifikante Zusammenhänge zwischen einer frühzeitigen Versorgung mit PEG und den Verbesserungen der oralen Nahrungsaufnahme durch die funktionelle Dysphagietherapie.Die Gruppe 1 wies signifikant mehr Komplikationen und eine signifikant höhere Mortalität auf als die Patienten der Gruppe 2, die nicht mit PEG versorgt war.Die Ergebnisse belegen, wie wichtig eine präzise Schluckdiagnostik ist, um eine frühzeitige PEG-Versorgung gezielt bei persistierenden Dysphagien einzuleiten. Die Behandlung der Dysphagie in der Geriatrie erfordert einen multidisziplinären Ansatz, ein differenziertes Assessment und eine auf die spezifische Störung angepasste logopädische Übungsbehandlung.AbstractObjectives Patients with dysphagia whose food intake is inadequate and who may compromise their airways need to receive nasogastric (NG) or gastrostomic (PEG) feeding. There are controversial discussions about the best time for intervention and the best method. Each approach has its advantages and disadvantages. Further research is required to assess the optimum method of treating patients with dysphagia. A retrospective study was undertaken to investigate the influence of functional dysphagia therapy with or without PEG feeding.Methods A total of 164 patients with dysphagia were investigated in a center for geriatric medicine (EGZB) within one year. Patients were divided into two groups: those with PEG (group 1, n=59) and those without (group 2, n=105). Both groups received functional training (training of oral motor skills and sensation, compensatory swallowing techniques) by speech-language therapists.Geriatric basic assessment was used. Speech-language therapists also evaluated language, speech and swallowing disorders pre- and post-training. Diet modification for oral intake altering viscosity and texture of foods and liquids was used. Additional data on the time between being admitted to hospital and receiving a PEG tube, the hospitalization period, the number of complications and mortality were collected.Results Both groups benefited from functional dysphagia therapy. The patients of group 2 showed a significant improvement in functional oral intake post-treatment. In most of the cases, diet modification improved from pasty consistency to firm meals. Swallowing abilities were much better than those of the more severely disabled patients of group 1. Group 1 still needed PEG feeding post-treatment but could also take in some food orally. However even the patients of group 1 showed a significant increase in functional oral intake.Group 2 also showed significantly stronger improvements in communication abilities and speech intelligibility after training compared to the severely disabled patients of group 1.In terms of the clinical outcome of group 1 it was demonstrated that the sooner a PEG was placed, the more significantly functional oral intake improved. The results of a multiple regression analysis showed a small but nevertheless significant association between an early supply of PEG and improvement of functional oral intake which had been achieved by functional dysphagia therapy.Significantly more complications and significantly higher mortality occurred in group 1 (PEG feeding) compared to group 2 (exclusively oral feeding).Conclusion The treatment of dysphagia in the elderly requires a multi-professional setting, differentiated assessment and functional training of oral motor skills and sensation and swallowing techniques. Compared to patients with severe dysphagia, however, patients with mild to moderate dysphagia benefit most from functional training. The results reveal the importance of precise and early diagnosis of swallowing disorders in order to introduce PEG supply early in cases of persistent dysphagia.

Behandlung der Dysphagie in einem klinisch-geriatrischen Setting: funktionelle Dysphagietherapie und PEG-Einsatz

OBJECTIVES Patients with dysphagia whose food intake is inadequate and who may compromise their airways need to receive nasogastric (NG) or gastrostomic (PEG) feeding. There are controversial discussions about the best time for intervention and the best method. Each approach has its advantages and disadvantages. Further research is required to assess the optimum method of treating patients with dysphagia. A retrospective study was undertaken to investigate the influence of functional dysphagia therapy with or without PEG feeding. METHODS A total of 164 patients with dysphagia were investigated in a center for geriatric medicine (EGZB) within one year. Patients were divided into two groups: those with PEG (group 1, n=59) and those without (group 2, n=105). Both groups received functional training (training of oral motor skills and sensation, compensatory swallowing techniques) by speech-language therapists.Geriatric basic assessment was used. Speech-language therapists also evaluated language, speech and swallowing disorders pre- and post-training. Diet modification for oral intake altering viscosity and texture of foods and liquids was used. Additional data on the time between being admitted to hospital and receiving a PEG tube, the hospitalization period, the number of complications and mortality were collected. RESULTS Both groups benefited from functional dysphagia therapy. The patients of group 2 showed a significant improvement in functional oral intake post-treatment. In most of the cases, diet modification improved from pasty consistency to firm meals. Swallowing abilities were much better than those of the more severely disabled patients of group 1. Group 1 still needed PEG feeding post-treatment but could also take in some food orally. However even the patients of group 1 showed a significant increase in functional oral intake.Group 2 also showed significantly stronger improvements in communication abilities and speech intelligibility after training compared to the severely disabled patients of group 1.In terms of the clinical outcome of group 1 it was demonstrated that the sooner a PEG was placed, the more significantly functional oral intake improved. The results of a multiple regression analysis showed a small but nevertheless significant association between an early supply of PEG and improvement of functional oral intake which had been achieved by functional dysphagia therapy.Significantly more complications and significantly higher mortality occurred in group 1 (PEG feeding) compared to group 2 (exclusively oral feeding). CONCLUSION The treatment of dysphagia in the elderly requires a multi-professional setting, differentiated assessment and functional training of oral motor skills and sensation and swallowing techniques. Compared to patients with severe dysphagia, however, patients with mild to moderate dysphagia benefit most from functional training. The results reveal the importance of precise and early diagnosis of swallowing disorders in order to introduce PEG supply early in cases of persistent dysphagia.ZusammenfassungEine nasogastrale Sonde (NSG) oder eine perkutane endoskopische Gastrostomie (PEG) ist bei Dysphagie dann indiziert, wenn eine ausreichende Flüssigkeits- und/oder Nahrungszufuhr auf oralem Wege nicht aspirationsfrei möglich ist. Die Entscheidung über den richtigen Interventionszeitpunkt und die adäquate Methode wird in der Literatur kontrovers diskutiert. Die vorliegende Studie geht der Frage nach, welchen Einfluss die funktionelle Dysphagietherapie mit oder ohne PEG-Anlage auf die Nahrungsaufnahme von Patienten mit Dysphagie hat.In der retrospektiven Untersuchung eines Zentrums für Akutgeriatrie (EGZB) wurden 164 Dysphagiepatienten innerhalb eines Jahres in zwei Gruppen unterteilt: Dysphagiepatienten mit PEG (Gruppe 1; n=59) und Dysphagiepatienten ohne PEG (Gruppe 2; n=105). Beide Gruppen wurden nach der funktionellen Dysphagietherapie von Sprachtherapeuten behandelt.Erhoben wurde das Geriatrische Basisassessment, die logopädische Diagnostik zur Einschätzung der Schluckfunktion und der Nahrungsaufnahme, sowie der Sprechverständlichkeit und der kommunikativen Leistungen. Es wurden ein Ernährungsplan bei Dysphagie mit fünf Viskositätsstufen und angedickte Getränke eingesetzt. Zusätzlich gingen der Zeitpunkt der PEG-Versorgung, Krankenhausverweildauer, die Anzahl der Komplikationen und die Mortalität in die Untersuchung ein.Die Ergebnisse zeigten, dass beide Untersuchungsgruppen (mit oder ohne PEG) von der funktionellen Dysphagietherapie profitierten. Die Nahrungsaufnahme der Gruppe 2 konnte im Verlauf der Therapie signifikant verbessert werden. Es zeigten sich Steigerungen der Koststufe von breiiger Konsistenz bis zu festen Speisen. Die Schluckleistung der Gruppe 2 war damit bei Entlassung deutlich besser als bei den schwer gestörten Patienten der Gruppe 1. Die Patienten der Gruppe 1 konnten bei Entlassung zwar weitgehend oral ernährt (in Kombination mit der PEG) werden, waren aber in der Regel auf diätetische Maßnahmen (z. B. Breikost, Andicken von Getränken) angewiesen. Die Therapieverläufe zeigen aber, dass auch die schwer gestörten Dysphagiepatienten (Gruppe 1) trotz eines geringeren Rehapotentials signifikant von der Schlucktherapie profitierten.Die Patienten der Gruppe 2 zeigten zusätzlich im Bereich der kommunikativen Leistungen und der Sprechverständlichkeit signifikant höhere Verbesserungswerte als die schwer gestörten Dysphagiepatienten (Gruppe 1).Darüber hinaus konnte nachgewiesen werden, dass je früher eine PEG angelegt wurde, desto stärker die Schluckfunktion (FOIS) der Patienten gesteigert wurde. Die Ergebnisse einer multiplen Regressionsanalyse zeigten bei Gruppe 1 geringe aber dennoch signifikante Zusammenhänge zwischen einer frühzeitigen Versorgung mit PEG und den Verbesserungen der oralen Nahrungsaufnahme durch die funktionelle Dysphagietherapie.Die Gruppe 1 wies signifikant mehr Komplikationen und eine signifikant höhere Mortalität auf als die Patienten der Gruppe 2, die nicht mit PEG versorgt war.Die Ergebnisse belegen, wie wichtig eine präzise Schluckdiagnostik ist, um eine frühzeitige PEG-Versorgung gezielt bei persistierenden Dysphagien einzuleiten. Die Behandlung der Dysphagie in der Geriatrie erfordert einen multidisziplinären Ansatz, ein differenziertes Assessment und eine auf die spezifische Störung angepasste logopädische Übungsbehandlung.AbstractObjectives Patients with dysphagia whose food intake is inadequate and who may compromise their airways need to receive nasogastric (NG) or gastrostomic (PEG) feeding. There are controversial discussions about the best time for intervention and the best method. Each approach has its advantages and disadvantages. Further research is required to assess the optimum method of treating patients with dysphagia. A retrospective study was undertaken to investigate the influence of functional dysphagia therapy with or without PEG feeding.Methods A total of 164 patients with dysphagia were investigated in a center for geriatric medicine (EGZB) within one year. Patients were divided into two groups: those with PEG (group 1, n=59) and those without (group 2, n=105). Both groups received functional training (training of oral motor skills and sensation, compensatory swallowing techniques) by speech-language therapists.Geriatric basic assessment was used. Speech-language therapists also evaluated language, speech and swallowing disorders pre- and post-training. Diet modification for oral intake altering viscosity and texture of foods and liquids was used. Additional data on the time between being admitted to hospital and receiving a PEG tube, the hospitalization period, the number of complications and mortality were collected.Results Both groups benefited from functional dysphagia therapy. The patients of group 2 showed a significant improvement in functional oral intake post-treatment. In most of the cases, diet modification improved from pasty consistency to firm meals. Swallowing abilities were much better than those of the more severely disabled patients of group 1. Group 1 still needed PEG feeding post-treatment but could also take in some food orally. However even the patients of group 1 showed a significant increase in functional oral intake.Group 2 also showed significantly stronger improvements in communication abilities and speech intelligibility after training compared to the severely disabled patients of group 1.In terms of the clinical outcome of group 1 it was demonstrated that the sooner a PEG was placed, the more significantly functional oral intake improved. The results of a multiple regression analysis showed a small but nevertheless significant association between an early supply of PEG and improvement of functional oral intake which had been achieved by functional dysphagia therapy.Significantly more complications and significantly higher mortality occurred in group 1 (PEG feeding) compared to group 2 (exclusively oral feeding).Conclusion The treatment of dysphagia in the elderly requires a multi-professional setting, differentiated assessment and functional training of oral motor skills and sensation and swallowing techniques. Compared to patients with severe dysphagia, however, patients with mild to moderate dysphagia benefit most from functional training. The results reveal the importance of precise and early diagnosis of swallowing disorders in order to introduce PEG supply early in cases of persistent dysphagia.

Does an association between increased homocystein levels and cognitive dysfunction also exist in multimorbid geriatric patients

ZusammenfassungHintergrundDer Zusammenhang zwischen Homocystein (Hcys)- bzw. Folsäurespiegeln im Blut und kognitiven Defiziten wurde bisher bei gesunden, nicht aber bei multimorbiden Senioren beschrieben. Die aktuelle Fragestellung ist daher, ob sich dieser Zusammenhang bei multimorbiden geriatrischen Patienten bestätigt.MethodikDer kognitive Status wurde von 189 (131 f/58 m) multimorbiden geriatrischen Patienten im Alter von 78,6 ± 7,3 Jahren mittels Syndrom-Kurztest (SKT) in einer Querschnittserhebung untersucht. Neben biochemischen Parametern (Plasma-Hcys, Serum-Folsäure, Vitamin B12, Blutbild), Ernährungsstatus (BMI, Mini Nutritional Assessment) wurde die Selbstständigkeit der Patienten erfasst. Die Bestimmung der Vitaminzufuhr erfolgte anhand des 3-Tage- Ernährungsprotokolls.ErgebnisseNach SKT zeigten 25,4% keine kognitive Leistungsstörungen, bei 21,2% lag ein Verdacht auf leichte kognitive Defizite vor, 12,7% hatten leichte, 9,0% mäßige und 31,7% schwere kognitive Defizite. Plasma Hcys-Spiegel waren unabhängig von kognitiven Defiziten um 20% erhöht. Folsäure und Vitamin B12 im Serum lagen im Normbereich, obwohl die Folsäurezufuhr um 75% vermindert war. Unterschiede zwischen SKT-Gruppen waren weder hinsichtlich Ernährungsstatus, Selbständigkeit, Anzahl der Diagnosen oder Medikation noch hinsichtlich biochemischer Parameter signifikant.SchlussfolgerungenEs wurden erhöhte Hcys-Spiegel bei multimorbiden geriatrischen Patienten mit kognitiven Defiziten und normalen Folsäure- und Vitamin B12- Konzentrationen analysiert. Hcys im Plasma erscheint als kein geeigneter biologischer Risikofaktor für kognitive Defizite bei multimorbiden geriatrischen Patienten.AbstractBackgroundTotal blood homocysteine (Hcys) and folate have been investigated in association with cognitive dysfunction (CD) in healthy but not in multimorbid elderly patients. We hypothesized that total Hcys and folate are adequate markers to identify multimorbid elderly patients with CD.MethodsAccording to the Short Performance Cognitive Test (SKT) CD was determined in a cross-sectional study with 189 (131 f/58 m) multimorbid elderly patients with a mean age of 78.6 ± 7.3 yrs. Besides the analyses of biochemical parameters (Hcys, folate, vitamin B12, hemogram) nutritional status (BMI, Mini Nutritional Assessment) as well as activities of daily living were assessed. Daily nutritional intake was measured with a 3-day nutrition diary. For analysis, we used the nutritional software program DGE-PC professional.ResultsAccording to SKT 25.4% showed no cerebral cognitive dysfunction, 21.2% had a suspicion about incipient cognitive dysfunction, 12.7% showed mild, 9.0% moderate, 31.7% of patients severe cognitive deficits. Median plasma Hcys was about 20% elevated in multimorbid elderly patients independent of CD. Serum folate and vitamin B12 levels were within range, though dietary folate intake (97 [80–128] µg/d) was reduced about 75% (recommendation 400 µg/d). Significant correlations between vitamin intake and plasma/serum levels of Hcys, folate and vitamin B12 were not present. We did not find significant differences between SKT groups of nutritional status, activities of daily living, index of diseases, medications, or selected biochemical parameters.ConclusionWe analysed elevated serum Hcys levels in multimorbid elderly patients with normal plasma folate and vitamin B12 concentration and CD. Plasma Hcys or serum folate did not appear as an important biological risk factor on CD in multimorbid elderly patients.BACKGROUND Total blood homocysteine (Hcys) and folate have been investigated in association with cognitive dysfunction (CD) in healthy but not in multimorbid elderly patients. We hypothesized that total Hcys and folate are adequate markers to identify multimorbid elderly patients with CD. METHODS According to the Short Performance Cognitive Test (SKT) CD was determined in a cross-sectional study with 189 (131 f/58 m) multimorbid elderly patients with a mean age of 78.6 +/- 7.3 yrs. Besides the analyses of biochemical parameters (Hcys, folate, vitamin B(12), hemogram) nutritional status (BMI, Mini Nutritional Assessment) as well as activities of daily living were assessed. Daily nutritional intake was measured with a 3-day nutrition diary. For analysis, we used the nutritional software program DGE-PC professional. RESULTS According to SKT 25.4% showed no cerebral cognitive dysfunction, 21.2% had a suspicion about incipient cognitive dysfunction, 12.7% showed mild, 9.0% moderate, 31.7% of patients severe cognitive deficits. Median plasma Hcys was about 20% elevated in multimorbid elderly patients independent of CD. Serum folate and vitamin B(12) levels were within range, though dietary folate intake (97 [80-128] microg/d) was reduced about 75% (recommendation 400 microg/d). Significant correlations between vitamin intake and plasma/serum levels of Hcys, folate and vitamin B(12) were not present. We did not find significant differences between SKT groups of nutritional status, activities of daily living, index of diseases, medications, or selected biochemical parameters. CONCLUSION We analysed elevated serum Hcys levels in multimorbid elderly patients with normal plasma folate and vitamin B(12) concentration and CD. Plasma Hcys or serum folate did not appear as an important biological risk factor on CD in multimorbid elderly patients.

Behandlung der Dysphagie in einem klinisch-geriatrischen Setting: funktionelle Dysphagietherapie und PEG-Einsatz@@@Dysphagia treatment in a clinical-geriatric setting PEG and functional therapy of dysphagia

OBJECTIVES Patients with dysphagia whose food intake is inadequate and who may compromise their airways need to receive nasogastric (NG) or gastrostomic (PEG) feeding. There are controversial discussions about the best time for intervention and the best method. Each approach has its advantages and disadvantages. Further research is required to assess the optimum method of treating patients with dysphagia. A retrospective study was undertaken to investigate the influence of functional dysphagia therapy with or without PEG feeding. METHODS A total of 164 patients with dysphagia were investigated in a center for geriatric medicine (EGZB) within one year. Patients were divided into two groups: those with PEG (group 1, n=59) and those without (group 2, n=105). Both groups received functional training (training of oral motor skills and sensation, compensatory swallowing techniques) by speech-language therapists.Geriatric basic assessment was used. Speech-language therapists also evaluated language, speech and swallowing disorders pre- and post-training. Diet modification for oral intake altering viscosity and texture of foods and liquids was used. Additional data on the time between being admitted to hospital and receiving a PEG tube, the hospitalization period, the number of complications and mortality were collected. RESULTS Both groups benefited from functional dysphagia therapy. The patients of group 2 showed a significant improvement in functional oral intake post-treatment. In most of the cases, diet modification improved from pasty consistency to firm meals. Swallowing abilities were much better than those of the more severely disabled patients of group 1. Group 1 still needed PEG feeding post-treatment but could also take in some food orally. However even the patients of group 1 showed a significant increase in functional oral intake.Group 2 also showed significantly stronger improvements in communication abilities and speech intelligibility after training compared to the severely disabled patients of group 1.In terms of the clinical outcome of group 1 it was demonstrated that the sooner a PEG was placed, the more significantly functional oral intake improved. The results of a multiple regression analysis showed a small but nevertheless significant association between an early supply of PEG and improvement of functional oral intake which had been achieved by functional dysphagia therapy.Significantly more complications and significantly higher mortality occurred in group 1 (PEG feeding) compared to group 2 (exclusively oral feeding). CONCLUSION The treatment of dysphagia in the elderly requires a multi-professional setting, differentiated assessment and functional training of oral motor skills and sensation and swallowing techniques. Compared to patients with severe dysphagia, however, patients with mild to moderate dysphagia benefit most from functional training. The results reveal the importance of precise and early diagnosis of swallowing disorders in order to introduce PEG supply early in cases of persistent dysphagia.ZusammenfassungEine nasogastrale Sonde (NSG) oder eine perkutane endoskopische Gastrostomie (PEG) ist bei Dysphagie dann indiziert, wenn eine ausreichende Flüssigkeits- und/oder Nahrungszufuhr auf oralem Wege nicht aspirationsfrei möglich ist. Die Entscheidung über den richtigen Interventionszeitpunkt und die adäquate Methode wird in der Literatur kontrovers diskutiert. Die vorliegende Studie geht der Frage nach, welchen Einfluss die funktionelle Dysphagietherapie mit oder ohne PEG-Anlage auf die Nahrungsaufnahme von Patienten mit Dysphagie hat.In der retrospektiven Untersuchung eines Zentrums für Akutgeriatrie (EGZB) wurden 164 Dysphagiepatienten innerhalb eines Jahres in zwei Gruppen unterteilt: Dysphagiepatienten mit PEG (Gruppe 1; n=59) und Dysphagiepatienten ohne PEG (Gruppe 2; n=105). Beide Gruppen wurden nach der funktionellen Dysphagietherapie von Sprachtherapeuten behandelt.Erhoben wurde das Geriatrische Basisassessment, die logopädische Diagnostik zur Einschätzung der Schluckfunktion und der Nahrungsaufnahme, sowie der Sprechverständlichkeit und der kommunikativen Leistungen. Es wurden ein Ernährungsplan bei Dysphagie mit fünf Viskositätsstufen und angedickte Getränke eingesetzt. Zusätzlich gingen der Zeitpunkt der PEG-Versorgung, Krankenhausverweildauer, die Anzahl der Komplikationen und die Mortalität in die Untersuchung ein.Die Ergebnisse zeigten, dass beide Untersuchungsgruppen (mit oder ohne PEG) von der funktionellen Dysphagietherapie profitierten. Die Nahrungsaufnahme der Gruppe 2 konnte im Verlauf der Therapie signifikant verbessert werden. Es zeigten sich Steigerungen der Koststufe von breiiger Konsistenz bis zu festen Speisen. Die Schluckleistung der Gruppe 2 war damit bei Entlassung deutlich besser als bei den schwer gestörten Patienten der Gruppe 1. Die Patienten der Gruppe 1 konnten bei Entlassung zwar weitgehend oral ernährt (in Kombination mit der PEG) werden, waren aber in der Regel auf diätetische Maßnahmen (z. B. Breikost, Andicken von Getränken) angewiesen. Die Therapieverläufe zeigen aber, dass auch die schwer gestörten Dysphagiepatienten (Gruppe 1) trotz eines geringeren Rehapotentials signifikant von der Schlucktherapie profitierten.Die Patienten der Gruppe 2 zeigten zusätzlich im Bereich der kommunikativen Leistungen und der Sprechverständlichkeit signifikant höhere Verbesserungswerte als die schwer gestörten Dysphagiepatienten (Gruppe 1).Darüber hinaus konnte nachgewiesen werden, dass je früher eine PEG angelegt wurde, desto stärker die Schluckfunktion (FOIS) der Patienten gesteigert wurde. Die Ergebnisse einer multiplen Regressionsanalyse zeigten bei Gruppe 1 geringe aber dennoch signifikante Zusammenhänge zwischen einer frühzeitigen Versorgung mit PEG und den Verbesserungen der oralen Nahrungsaufnahme durch die funktionelle Dysphagietherapie.Die Gruppe 1 wies signifikant mehr Komplikationen und eine signifikant höhere Mortalität auf als die Patienten der Gruppe 2, die nicht mit PEG versorgt war.Die Ergebnisse belegen, wie wichtig eine präzise Schluckdiagnostik ist, um eine frühzeitige PEG-Versorgung gezielt bei persistierenden Dysphagien einzuleiten. Die Behandlung der Dysphagie in der Geriatrie erfordert einen multidisziplinären Ansatz, ein differenziertes Assessment und eine auf die spezifische Störung angepasste logopädische Übungsbehandlung.AbstractObjectives Patients with dysphagia whose food intake is inadequate and who may compromise their airways need to receive nasogastric (NG) or gastrostomic (PEG) feeding. There are controversial discussions about the best time for intervention and the best method. Each approach has its advantages and disadvantages. Further research is required to assess the optimum method of treating patients with dysphagia. A retrospective study was undertaken to investigate the influence of functional dysphagia therapy with or without PEG feeding.Methods A total of 164 patients with dysphagia were investigated in a center for geriatric medicine (EGZB) within one year. Patients were divided into two groups: those with PEG (group 1, n=59) and those without (group 2, n=105). Both groups received functional training (training of oral motor skills and sensation, compensatory swallowing techniques) by speech-language therapists.Geriatric basic assessment was used. Speech-language therapists also evaluated language, speech and swallowing disorders pre- and post-training. Diet modification for oral intake altering viscosity and texture of foods and liquids was used. Additional data on the time between being admitted to hospital and receiving a PEG tube, the hospitalization period, the number of complications and mortality were collected.Results Both groups benefited from functional dysphagia therapy. The patients of group 2 showed a significant improvement in functional oral intake post-treatment. In most of the cases, diet modification improved from pasty consistency to firm meals. Swallowing abilities were much better than those of the more severely disabled patients of group 1. Group 1 still needed PEG feeding post-treatment but could also take in some food orally. However even the patients of group 1 showed a significant increase in functional oral intake.Group 2 also showed significantly stronger improvements in communication abilities and speech intelligibility after training compared to the severely disabled patients of group 1.In terms of the clinical outcome of group 1 it was demonstrated that the sooner a PEG was placed, the more significantly functional oral intake improved. The results of a multiple regression analysis showed a small but nevertheless significant association between an early supply of PEG and improvement of functional oral intake which had been achieved by functional dysphagia therapy.Significantly more complications and significantly higher mortality occurred in group 1 (PEG feeding) compared to group 2 (exclusively oral feeding).Conclusion The treatment of dysphagia in the elderly requires a multi-professional setting, differentiated assessment and functional training of oral motor skills and sensation and swallowing techniques. Compared to patients with severe dysphagia, however, patients with mild to moderate dysphagia benefit most from functional training. The results reveal the importance of precise and early diagnosis of swallowing disorders in order to introduce PEG supply early in cases of persistent dysphagia.