COMMON GERIATRIC PROBLEMS: NUTRITION Thierry Pepersack on behalf of the Belgian College for Geriatrics USA –Be same problems-different solutions March 22, 2006

Malnutrition

Definition of the “geriatric patient” 1. Decreased homeostasis 2. Atypical presentations of the diseases 3. Multiple pathologies and functional dependence 4. Combination of somatic, psychological and social factors 5. Altered pharmacokinetics

Definition of the “geriatric patient” 1. Decreased homeostasis 2. Atypical presentations of the diseases 3. Multiple pathologies and functional dependence ? 4. Combination of somatic, psychological and social factors 5. Altered pharmacokinetics 6. malnutrition

Busby et al. N Engl J Med 1991 Malnutrition  % on admission  «under-diagnosed»  Nutritional deficit, diseases (liver, digestive, cancers, chronic)  increase mortality, morbidity  Increase length of stay

Prevalence of Malnutrition in Hospitalized Patients

Energy % recommended needs Protein % recommended needs patients 399 patients 557 patients 417 patients Dupertuis YM. Clin Nutr 2003, 22: Food intake in 1707 hospitalized patients: a prospective comprehensive hospital survey

Energy % recommended needs Protein % recommended needs patients 399 patients 557 patients 417 patients Dupertuis YM. Clin Nutr 2003, 22: Food intake in 1707 hospitalized patients: a prospective comprehensive hospital survey

> 4 / 6 patients underfed ! Prominant influence of the disease on food intake : Only 1/4 patient !!! Food intake in 1707 hospitalised patients: a prospective comprehensive hospital survey Dupertuis YM. Clin Nutr 2003, 22:

ECONOMIC IMPACT of MALNUTRITION in 771 HOSPITALIZED PATIENTS Reilly J.J. et al. J Parent Enteral Nutr 12(4), , 1988 Protein-depletedWell-nourishedp (<80% normal) All ± ± Medecine ± ± Surgery ± ± in US$

Prevalence of Malnutrition in Hopitalized Geriatric Patients *60% at risk and 30% presenting overt malnutrition ** >60 y: 50; > 70 y: 53, > 80 y: 77 %

Prevalence of Malnutrition in Institutions Pepersack T. Nutritional approach in long term geriatric institution. Rev Med Brux 2001

History of malnutrition weight Time Acute problem (hospitalization)

Age (years) Women 95th 90th 75th 50th 25th 10th 5th Women % % Percentiles Percent Fat Mass in 5225 Volunteers ( years, kg/m2 ) Aging : The gain of fat mass masks the loss of lean mass Kyle U. et al. Nutrition 2001, 17:

Weight lossProtein loss *(%) * in vivo neutron analysis. Hill G.L. J Parent Enteral Nutr 16, , 1992

sarcopenia

 Low Body Water  reduced vol. of dist. for polar drugs eg. Aminoglycosides, Digoxin  High Fat Stores  increased vol. of dist. for lipid soluble drugs eg. Phenytoin, Diazepam, Flurazepam Body composition and aging

growth retardation bronchopneumonia bed sores urinary infection death anemia too weak to walk % healthy body weight" healing impairment time too weak to sit Heymsfield S. B. Ann. Intern. Med. 1979, 90: 63-71

growth retardation bronchopneumonia bed sores urinary infection death anemia too weak to walk % healthy body weight" healing impairment time too weak to sit Heymsfield S. B. Ann. Intern. Med. 1979, 90: 63-71

ADL dependence of outpatients (Katz) N=2588, age:78(9)yr Pepersack T, Beyer I et al. Facts Res Gerontology 1998

ADL dependence of outpatients (Katz) N=2588, age:78(9)yr Pepersack T, Beyer I et al. Facts Res Gerontology 1998 <30% of the patients need help to eat

ADL dependence of hospitalized patients N=655, age: 83(7) yrs Pepersack T, CUMG. Arch Public Health 1999

ADL dependence of hospitalized patients N=655, age: 83(7) yrs Pepersack T, CUMG. Arch Public Health % of the patients able to eat alone

2005 College’s project: Dependence for ADL (Katz) Pepersack on behalf of the College for Geriatrics % of the patients able to eat alone

2005 College’s project: IADL (Lawton) from lowest (0) to highest dependence (4) Pepersack on behalf of the College for Geriatrics % of the patients able to prepare their meals

Total comorbidity Pepersack on behalf of the College for Geriatrics 2005

Malnutrition screening  Anthropometric measurements  Risk assessment scales Nutritional Screening questionnaire MNA MUST  Biology: Prealbumine

Malnutrition screening  Anthropometric measurements  Risk assessment scales Nutritional Screening questionnaire MNA MUST  Biology: Prealbumine

Categories of BMI for identifying risk of chronic PEM in adults

Anthropometric cut-off values that include body mass index for detecting underweight or undernutrition in adults

Malnutrition screening  Anthropometric measurements  Risk assessment scales Nutritional Screening questionnaire MNA MUST  Biology: Prealbumine

Malnutrition screening  Anthropometric measurements  Risk assessment scales Nutritional Screening questionnaire MNA MUST  Biology: Prealbumine

Malnutrition screening  Anthropometric measurements  Risk assessment scales Nutritional Screening questionnaire MNA MUST  Biology: Prealbumine

Pepersack T on behalf of the College for Geriatrics. Outcomes of continuous process improvement of nutritional care program among geriatric units. J Gerontol A Biol Sci Med Sci : College’s project 2001

Pepersack T on behalf of the College for Geriatrics. Outcomes of continuous process improvement of nutritional care program among geriatric units. J Gerontol A Biol Sci Med Sci : MNA <23,5: 60% of patients at risk College’s project 2001

Malnutrition screening  Anthropometric measurements  Risk assessment scales Nutritional Screening questionnaire Nursing Nutritional checklist MNA MUST  Biology: Prealbumine

The Malnutrition Universal Screening Tool (MUST) (BAPEN)

Risk of malnutrition (MUST) Pepersack on behalf of the College for Geriatrics 2005

Risk of malnutrition (MUST) MUST: 65% of patient at risk Pepersack on behalf of the College for Geriatrics 2005

Histogram of frequencies of the values of TPP TK effects Pepersack et al. Gerontology 1999:45; % of inpatients presenting TPP TK>15%

Pepersack et al. Arch Gerontol Geriatrics 2001;33: % of patients presenting Zn<10.7 µM Histogram of frequencies of the values of serum Zinc concentrations

Factors involved in the pathogenesis of the physiological anorexia of aging and energy expenditure. Wilson MG, Morley JE. Aging and energy balance. J Appl Physiol 2003; 95: 1728–1736, 2003.

Social complexity (SOCIOS) 45% of patients at risk of social complexity Pepersack on behalf of the College for Geriatrics 2005

Morley 1994 The « meals-on-wheels approach »  Medicaments  Emotions  Anorexia  Late life paranoia  Swallowing  Oral problems  No money  Wandering  Hyperthyroidism,HPT1  Entry (malabsorption)  Eating problems  Low salts, low chol diets  Shopping

Polypharmacy Pepersack on behalf of the College for Geriatrics 2005

depression Pepersack T, Bastan M. Prévalence de la dépression et caractéristiques du patient gériatrique déprimé. In: L'Année Gérontologique 2001, vol. 15 p Serdi Edition, Paris. 45% of patients at risk of depression

« Frigotherapy… »

Definition of the “geriatric patient” 1. Decreased homeostasis 2. Atypical presentations of the diseases 3. Multiple pathologies and functional dependence ? 4. Combination of somatic, psychological and social factors 5. Altered pharmacokinetics 6. malnutrition

The concept of “comprehensive geriatric assessment”  Holistic approach of medical psycho-social functional Environmental problems Stuck AE et al. Lancet 1993;342:

Randomized Trial of a Hospital Geriatric Evaluation & Management Unit Rubenstein et al. N Engl J Med 1984; 311:1664  Mortality (24% vs 48% at 1 yr)  NH Use (27% vs 47%; 26 vs 56 days)  Rehosps (35% vs 50%; 17 vs 23 days)  Costs ($22,000 vs $28,000 /yr surv)  ADL (42% vs 24% improved at 1 yr)  Morale(42% vs 24% improved at 1 yr) The Sepulveda GEM Study:

The concept of “comprehensive geriatric assessment”  Holistic approach of medical psycho-social functional Environmental problems Stuck AE et al. Lancet 1993;342:

The concept of “comprehensive geriatric assessment”  Holistic approach of medical psycho-social functional Environmental Nutritional problems Stuck AE et al. Lancet 1993;342:

Is nutritional intervention effective ?

postOP (orthopedic) recovery (nursing home) 6 mths later % FAVORABLE EVOLUTION p<0.07 p<0.05 p<0.02 N = 60, age ≥ 80 yr Control Dietary supplementation in elderly patients with fractured neck of the femur kcal, 20 g protein Delmi M et al. Lancet 335, 42-46, 1990

So… 1. High prevalence of malnutrition 2. Nutritional intervention is effective  What can we do to do better ?

« cycle of quality» What is quality?

« cycle of quality» 1.First, you have to say what you intend to do; 2.Then, you have to do what you said; 3.And finally you have to write what you have done

OUTCOMES OF CONTINUOUS PROCESS IMPROVEMENT OF NUTRITIONAL CARE PROGRAM AMONG GERIATRIC UNITS IN BELGIUM Pepersack et al College’s project  Aims to assess the quality of care concerning nutrition among Belgian geriatric units to include more routinely nutritional assessments and interventions into comprehensive geriatric assessment to assess the impact of nutritional recommendations on nutritional status an on the length of hospitalisation

Methodology: 2 phases Observation  Comprehensive geriatric assessment and MNA  Routine nutrition Intervention  Comprehensive geriatric assessment and MNA  « Flow Chart»  « Meals on Wheels » approach months

FLOW CHART SUGGESTING A RATIONAL APPROACH TO THE MANAGEMENT OF MALNUTRITION  MNA <23.5 points and/or PAB<0.2 g/l  START CALORIC SUPPLEMENTATION  RULE OUT TREATABLE CAUSES/ UTILIZE MEALS- ON-WHEELS APPROACH  IF PAB FAILS TO RAISE  CONSIDER ENTERAL (or parenteral) NUTRITION  CHECK PAB AT DISCHARGE

Morley 1994 The « meals-on-wheels approach »  Medicaments  Emotions  Anorexia  Late life paranoia  Swallowing  Oral problems  No money  Wandering  Hyperthyroidism,HPT1  Entry (malabsorption)  Eating problems  Low salts, low chol diets  Shopping

Results 12 centers presented evaluable data N=1140 admissions

Pepersack T on behalf of the College for Geriatrics. Outcomes of continuous process improvement of nutritional care program among geriatric units. J Gerontol A Biol Sci Med Sci :

Characteristics of the patients according to period. Phase I: observational period; phase II: interventional period.

Determinants of hospitalisation stay:

Hospital comparisons

Discharge parameters

Conclusions  High prevalence of malnutrition among geriatric hospitalized patients  Significant decreased hospitalization stay during 2 nd phase (Confounding factor?)  Significant decreased PAB concentrations at discharge during the first phase whereas PAB did not decrease during the 2 nd phase

Conclusions  By multiple regression analysis, hospitalization stay is determined by Mini- MNA  Quite homogeneous hospital data distribution  Data comparable with those of medical literature

Conviviality & eating behavior  immediate environmental, psychological, social, and cultural stimuli exert powerful but short-lived effects on intake Women  intake (+13%) when their husband is present Old subjects  intake (+23%) in presence of their family. De Castro JM. How can eating behavior be regulated in the complex environments of free-living humans? Neurosci Biobehav Rev 1996;20:

Conviviality  Intake increased 44% when the meals are given in groups, people eat more during the week-end and at the end of the day  Convivial, calm and well-lighted environment, increase dietary intake  When meals are brought home, when the person who brought the meals stays during the meals, the risk of malnutrition decreases Morley JE. Anorexia, sarcopenia, and aging. Nutrition 2001;17:

hedonic

Acknowledgments  the geriatric patients and other participants who volunteered in the studies.  members of the College for Geriatrics, the Belgian Society for Gerontology and Geriatrics who participated and encouraged the quality programs

Acknowledgments  the geriatric patients and other participants who volunteered in the studies.  members of the College for Geriatrics, the Belgian Society for Gerontology and Geriatrics who participated and encouraged the quality programs  And you for your attention !

« the most fruitful lesson is the conquest of one’s own error. Who ever refuses to admit error may be a great scholar, but he is not a great learner » Johan Wolfgang von Goethe Maxims & Reflexions