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.(AU)

[Measuring the handgrip strength of geriatric patients]. / Het meten van handgreepsterkte bij geriatrische patiënten.

The handgrip strength of geriatric patients can be measured when the patient is hospitalized. This article elaborates on the intrinsic and extrinsic factors which have a direct or indirect influence on handgrip strength. For the best results the tests need to be taken in the best circumstances with attention to individual differences and the age of the patient. Handgrip strength as determination of biological vitality is a key concept. Besides the physical characteristics there are many psychological factors (cognition, psyching-up, test attitude…) influencing the results. These are barely mentioned or not mentioned at all in the usual procedures. Research of handgrip strength testing theories is mostly focused on young, healthy adults and less on elderly patients. The main goal of this article is stimulating experimental research on the measurement of handgrip strength with elderly people and involving them more actively with the procedure. It is not enough to acquire insight in function and predicting characteristics of handgrip strength. Next to the aiming for the best test performance is 'working interactively with elderly patients' a goal on itself in the modern vision of health care.

Frailty indexes, screening instruments and their application in Belgian primary care.

OBJECTIVES: The complex and expensive medical care for a rising number of older patients presents a significant challenge to the health care system. Identifying cost-effective preventive interventions and systematically applying them in the elderly population could help address this challenge. Frailty assessments could prove to be valuable tools by identifying at-risk individuals to which these interventions would be offered. This review seeks to provide the reader with an overview of frailty and explain how frailty assessments could contribute to daily practice. METHODS: PubMed was searched for articles concerning frailty assessment (July 2013). Articles discussing prominent frailty models and articles primarily focused on comparing frailty assessments in the home-dwelling population were used for this article. Domus Medica was searched for guidelines concerning the use of frailty in Belgian primary care. RESULTS: Several notable models of frailty are summarized and discussed to provide the reader with an overview of available frailty assessments. Frailty screening modalities in primary care are discussed, as well as the current recommendations for the use of frailty assessments in Belgian primary care. The advantages of a systematic frailty assessment in primary care and other settings are highlighted. CONCLUSION: This article recommends the assessment of frailty status as a screening tool for the evaluation of the older person in primary care. An overview of available frailty models is offered for this purpose. A consensus should be reached on which model is most appropriate. The screening for frailty promotes early intervention and timely involvement of specialists with the purpose of avoiding unfavourable outcomes, such as death or disability.

Rationale and clinical data supporting nutritional intervention in Alzheimer's disease.

Adequate nutrition plays an important role in the maintenance of cognitive function, particularly during aging. Malnutrition is amongst the risk factors for developing mild cognitive impairment (MCI) and Alzheimer's disease (AD). Epidemiological studies have associated deficiencies in some nutrients with a higher risk of cognitive dysfunction and/or AD. Cognitive decline in AD is correlated with synaptic loss and many of the components required to maintain optimal synaptic function are derived from dietary sources. As synapses are part of the neuronal membrane and are continuously being remodelled, the availability of sufficient levels of nutritional precursors (mainly uridine monophosphate, choline and omega-3 fatty acids) to make the phospholipids required to build neuronal membranes may have beneficial effects on synaptic degeneration in AD. In addition, B-vitamins, phospholipids and other micronutrients act as cofactors to enhance the supply of precursors required to make neuronal membranes and synapses. Despite this, no randomized controlled trial has hitherto provided evidence that any single nutrient has a beneficial effect on cognition or lowers the risk for AD. However, a multi-target approach using combinations of (micro)nutrients might have beneficial effects on cognitive function in neurodegenerative brain disorders like AD leading to synaptic degeneration. Here we review the clinical evidence for supplementation, based on a multi-target approach with a focus on key nutrients with a proposed role in synaptic dysfunction. Based on preclinical evidence, a nutrient mixture, Souvenaid(®) (Nutricia N.V., Zoetermeer, The Netherlands) was developed. Clinical trials with Souvenaid(®) have shown improved memory performance in patients with mild AD. Further clinical trials to evaluate the effects of nutritional intervention in MCI and early dementia due to AD are on-going.

Nutritional screening strategy in nonagenarians: the value of the MNA-SF (mini nutritional assessment short form) in NutriAction.

OBJECTIVES: To identify older subjects at risk of malnutrition using the most appropriate tool available for the specific setting and to evaluate the Mini Nutritional Assessment short form (MNA-SF) in a sample of nonagenarians. DESIGN: Questionnaire based national screening week for the risk and prevalence of malnutrition in older people (NutriAction). SETTING: Older people in the community (CD) and in nursing homes (NH). PARTICIPANTS: General practices (n=70) and Nursing Homes (n=70). MEASUREMENTS: Questionnaire based on items from validated screening instruments: the MNA-SF, the Short Nutritional Assessment Questionnaire (SNAQ) and additional clinically relevant parameters (mobility, independence, social isolation and co-morbidities). RESULTS: In total 5,334 people were screened of which 16% were aged over 90 years. In this age group, 66% of the screened individuals were at risk of malnutrition (MNA ≤ 11), and women were affected significantly more than men (p<0.001). Actual malnutrition was present in 22% (BMI <20), 20% (SNAQ) and 25% (clinical evaluation). The MNA appeared to be very sensitive but had a low specificity as well in the nonagenarians (98% and 44%) as in the younger old (97% and 52%). The SNAQ was not a sensitive tool for detecting malnutrition in this study population (25%). Although clinical impression had a low sensitivity (60-61%) it has a good specificity (86% in 90+ and 91% below 90yr). CONCLUSION: The overall risk of and the prevalence of malnutrition is common in older people. The prevalence is higher in women, in nursing homes and in older age groups. The MNA-SF followed by a clinical subjective evaluation seems to be the preferred strategy for detecting malnutrition in nonagenarians.

Rare cause of gastric outlet obstruction: incarcerated pylorus within an inguinal hernia.

We present the case of a 79-year-old man admitted to the emergency room. Having anorexia and vomiting as main complaints, combined with abdominal distension and discomfort, diagnostic examination revealed a giant left inguinal hernia containing the antrum and pylorus of a dilated stomach, creating an outlet obstruction. This was complicated with free peritoneal air, gastric emphysema and air in the portal system due to ischaemia.

[Nutritional assessment in oncogeriatrics]. / Nutritionele screening bij de oncogeriatrische patient.

Geriatric patients are not defined by their age but by their general profile. Ageing is characterized by loss of organ function together with a reduced capability for adapting to changes in the environment (loss of homeostatic mechanisms) leading to frailty. In the older patient with cancer, there can be problems of dietary intake next to the effects of ageing per se. On top of this situation, the deleterious effects of the inflammatory processes induced by the tumour are superimposed. When these changes are translated into nutritional concepts, it is clear that, in the older cancer patient, there is a strong overlap of starvation, sarcopenia, and cachexia. Nutritional assessment should be part of the routine preliminary evaluation of the older oncology patient. Difference should be made between assessment of risk and actual nutritional status, which should be assessed with specific malnutrition indices. Body weight assessment with specific attention to unintended weight loss is essential in this evaluation. One should recognise the fact that body mass index (BMI) should be interpreted with caution, but that a low value for BMI still heralds an increased malnutrition risk. This increased alertness for nutritional problems has a lot to offer in the willingness for early intervention. The nutritional assessment, however, must be framed in a larger comprehensive geriatric assessment addressing several functional domains.

Liver diseases in the older adult.

Although there are no liver diseases specific to advanced age, the clinical course and management of liver disease in the older adult may differ from those in younger people. Changes in hepatic morphology with aging may lead to changes in liver function. Disturbances in laboratory liver function tests are similar as in younger people and should lead to the same vigilance in investigating for liver disease. Changes in immune function lead to more symptomatic acute hepatitis A, more progression to chronicity in hepatitis B and more fibrosis progression in chronic hepatitis C, especially after liver transplantation with livers from older donors. Treatment for chronic hepatitis C or autoimmune hepatitis is similar for younger or older adults, but side effects may be more prominent in older people. Comprehensive geriatric assessment should be part of the preliminary evaluation of the older patient with liver disease.

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.

Donepezil-related toxic hepatitis.

Alzheimer's disease (AD) is the leading cause of dementia. It is characterized by the presence of senile plaques and neurofibrillary tangles in the brain, and impairment of the central cholinergic system, which contribute to memory loss and cognitive dysfunction. Cholinesterase inhibitors prevent the hydrolysis of acetylcholine and are currently approved for the symptomatic treatment of Alzheimer's disease. Donepezil, a piperidine-based, reversible and specific inhibitor of acetylcholinesterase, has been demonstrated to be clinically effective in the treatment of patients with mild to moderate AD. To date, clinical trials have not reported an association between treatment with donepezil and hepatotoxicity. We describe a case of toxic hepatitis, documented by liver biopsy, in a patient treated with donepezil.

[A screening tool to identify older people at risk of adverse health outcomes at the time of hospital admission]. / Een screeningsinstrument om de geriatrische liaison in het ziekenhuis op te starten: de Voorlopige indicator voor Plaatsing (VIP).

The proportional increase of the ageing population results in an ever growing percentage of elderly among hospitalised patients. Older patients have complex medical, social and psychological problems that could benefit from coordinated care or case management. Identification of high-risk older adults is mandatory to initiate a liaison geriatric management program. A simple screening tool is presented to identify older people at the time of admission who are at increased risk of adverse health outcomes. The instrument was validated during a period of 6 months when all (n = 618) older adults (> 70 year) hospitalised in non-geriatric departments of a general hospital were screened. This "Variable Indicative of Placement risk" (VIP) shows a good sensitivity (81%) and specificity (86%) and has a high Negative Predictive Value (97%). Furthermore, it shows a significant positive correlation with the length of stay (p < 0.001). The questionnaire turned out to be a very useful tool in the emergency department as well as in other wards because it probes premorbid frailty components with three simple questions. Due to its simplicity a nurse without geriatric training can complete it. Patients who are not at risk of an adverse outcome are easily recognised. A positive score indicates loss of functional independence and a risk of increased length of stay. Further geriatric assessment and intervention seem then appropriate.

(18)FDG-PET-scan in staging of primary malignant melanoma of the oesophagus: a case report.

Primary malignant melanoma of the oesophagus is a rare disease, only 262 cases being reported up to June 2005. In general, the prognosis is dismal because of its tendency to present as an advanced neoplasm with aggressive biological behaviour. (18)FDG-PET-scan is a useful tool for evaluation of metastatic disease and locoregional lymph node metastasis. We present herein a case of a young adult with primary malignant melanoma of the oesophagus, followed by a literature review on the subject.

Alterations in immune functions during normal aging and Alzheimer's disease.

It is thought that aging induces immune changes, which are related to the pathophysiology of Alzheimer's disease (DAT). In this study, the total number of leukocytes, white blood cell differentiation, mitogen-induced lymphocytic proliferation, neutrophil phagocytosis and superoxide release, and prostaglandin E2 (PGE2) production by mitogen-stimulated whole blood cultures were comparatively investigated between healthy adults (range 22-45 years) and healthy elderly volunteers (range 70-91 years), and between DAT patients (range 56-94 years) and age-matched control subjects. Healthy elderly volunteers showed significantly lower phytohemagglutinin (PHA)-induced lymphocyte proliferation and percentage and absolute number of basophils than young volunteers. In normal volunteers, there were significant and negative correlations between age and the number of basophils. Patients with DAT showed a trend toward significantly higher PHA-induced lymphocyte proliferation and significantly decreased percentage and absolute number of large unstained cells than healthy volunteers. In DAT patients, the total number of leukocytes and the percentage and number of neutrophils were positively correlated with age. All other immune-inflammatory variables were not significantly altered either by the aging process or DAT. The present study suggests that aging and DAT may differently affect some immune variables.

Serotonin-immune interactions in elderly volunteers and in patients with Alzheimer's disease (DAT): lower plasma tryptophan availability to the brain in the elderly and increased serum interleukin-6 in DAT.

The aims of this study were to examine the plasma availability of tryptophan, the precursor of 5-hydroxytryptamine (5-HT), and serum cytokines, such as interleukin-6 (IL-6) and IL-8, in normal elderly volunteers and in patients with Alzheimer's disease (DAT). Elderly normal volunteers (mean age = 78.3 +/- 5.7 years) had a significantly lower tryptophan/competing amino acids (valine + leucine + isoleucine + phenylalanine + tyrosine) ratio than younger subjects (mean age = 32.9 +/- 8.1 years). In normal volunteers, there were significant and inverse relationships between age and either plasma tryptophan or the tryptophan/competing amino acids ratio, and between the availability of tryptophan to the brain and serum IL-6 or IL-8. DAT patients had significantly higher serum IL-6, but not IL-8, than age-matched normal volunteers. There were no significant differences in the availability of tryptophan to the brain between DAT patients and age-matched normal volunteers. The results suggest that: 1) in normal humans, the availability of plasma tryptophan to the brain decreases with age, and with activation of the immune system; and 2) increased production of IL-6 may play a role in the pathogenesis of DAT.