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

2. Malnutrition

3. 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

4. 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

5. Busby et al. N Engl J Med 1991 Malnutrition  35 - 40% on admission  «under-diagnosed»  Nutritional deficit, diseases (liver, digestive, cancers, chronic)  increase mortality, morbidity  Increase length of stay

6. Prevalence of Malnutrition in Hospitalized Patients

7. Energy % recommended needs Protein % recommended needs 0100200300 0 100 200 300 19 patients 399 patients 557 patients 417 patients Dupertuis YM. Clin Nutr 2003, 22: 115-23 Food intake in 1707 hospitalized patients: a prospective comprehensive hospital survey

8. Energy % recommended needs Protein % recommended needs 0100200300 0 100 200 300 19 patients 399 patients 557 patients 417 patients Dupertuis YM. Clin Nutr 2003, 22: 115-23 Food intake in 1707 hospitalized patients: a prospective comprehensive hospital survey

9. > 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: 115-23

10. ECONOMIC IMPACT of MALNUTRITION in 771 HOSPITALIZED PATIENTS Reilly J.J. et al. J Parent Enteral Nutr 12(4), 371-376, 1988 Protein-depletedWell-nourishedp (<80% normal) All7715519 ± 3003372 ± 1380.001 Medecine3652945 ± 2421783 ± 1240.0001 Surgery4067335 ± 5134579 ± 1820.001 in US$

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

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

13. History of malnutrition weight Time Acute problem (hospitalization)

14. Age (years) Women 95th 90th 75th 50th 25th 10th 5th Women % % Percentiles Percent Fat Mass in 5225 Volunteers (15 - 98 years, 16.0 - 47.1 kg/m2 ) Aging : The gain of fat mass masks the loss of lean mass Kyle U. et al. Nutrition 2001, 17:534-541

15. Weight lossProtein loss *(%) 511.2 - 16.8 1015.2 - 20.8 1519.2 - 24.8 2023.0 - 29.0 2526.8 - 33.2 * in vivo neutron analysis. Hill G.L. J Parent Enteral Nutr 16, 197-218, 1992

16. sarcopenia

17.  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

18. 100 90 80 70 50 60 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

19. 100 90 80 70 50 60 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

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

21. 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

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

23. ADL dependence of hospitalized patients N=655, age: 83(7) yrs Pepersack T, CUMG. Arch Public Health 1999 30% of the patients able to eat alone

24. 2005 College’s project: Dependence for ADL (Katz) Pepersack on behalf of the College for Geriatrics 2005 30% of the patients able to eat alone

25. 2005 College’s project: IADL (Lawton) from lowest (0) to highest dependence (4) Pepersack on behalf of the College for Geriatrics 2005 40% of the patients able to prepare their meals

26. Total comorbidity Pepersack on behalf of the College for Geriatrics 2005

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

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

29. Categories of BMI for identifying risk of chronic PEM in adults

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

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

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

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

40. 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 2005 60: 787-792. College’s project 2001

41. 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 2005 60: 787-792. MNA <23,5: 60% of patients at risk College’s project 2001

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

43. The Malnutrition Universal Screening Tool (MUST) (BAPEN)

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

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

47. Histogram of frequencies of the values of TPP TK effects Pepersack et al. Gerontology 1999:45; 96-101 30% of inpatients presenting TPP TK>15%

48. Pepersack et al. Arch Gerontol Geriatrics 2001;33:243-253. 30% of patients presenting Zn<10.7 µM Histogram of frequencies of the values of serum Zinc concentrations

49. 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.

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

51. 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

52. Polypharmacy Pepersack on behalf of the College for Geriatrics 2005

53. depression Pepersack T, Bastan M. Prévalence de la dépression et caractéristiques du patient gériatrique déprimé. In: L'Année Gérontologique 2001, vol. 15 p. 103-114.Serdi Edition, Paris. 45% of patients at risk of depression

54. « Frigotherapy… »

55. 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

56. The concept of “comprehensive geriatric assessment”  Holistic approach of medical psycho-social functional Environmental problems Stuck AE et al. Lancet 1993;342:1032-36

57. 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:

58. The concept of “comprehensive geriatric assessment”  Holistic approach of medical psycho-social functional Environmental problems Stuck AE et al. Lancet 1993;342:1032-36

59. The concept of “comprehensive geriatric assessment”  Holistic approach of medical psycho-social functional Environmental Nutritional problems Stuck AE et al. Lancet 1993;342:1032-36

60. Is nutritional intervention effective ?

61. postOP (orthopedic) recovery (nursing home) 6 mths later % FAVORABLE EVOLUTION 70 50 30 10 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 + 250 kcal, 20 g protein Delmi M et al. Lancet 335, 42-46, 1990

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

64. « cycle of quality» What is quality?

65. « 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

66. OUTCOMES OF CONTINUOUS PROCESS IMPROVEMENT OF NUTRITIONAL CARE PROGRAM AMONG GERIATRIC UNITS IN BELGIUM Pepersack et al. 2001 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

67. Methodology: 2 phases Observation  Comprehensive geriatric assessment and MNA  Routine nutrition Intervention  Comprehensive geriatric assessment and MNA  « Flow Chart»  « Meals on Wheels » approach 0 3 6 months

68. 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

69. 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

70. Results 12 centers presented evaluable data N=1140 admissions

71. 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 2005 60: 787-792.

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

75. Determinants of hospitalisation stay:

76. Hospital comparisons

79. Discharge parameters

81. 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

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

83. 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;20:119-131

84. 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;17:660-663

85. hedonic

86. 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

87. 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 !

88. « 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