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)

[Delirium]. / Delir.

Delirium in older patients is also associated with persistent functional and cognitive impairment. Nevertheless, it frequently remains unrecognized or misinterpreted by treating physicians and this is particularly true in cases of hypoactive delirium. Screening and assessment instruments are helpful in the identification of patients with delirium. A multifactorial model of a combination of predisposing and precipitating factors best explains the etiology of delirium and avoidance is crucial for its prevention. Whenever delirium is suspected, immediate diagnosis and therapy of the precipitating condition are of primary importance. Non-pharmacological interventions, for example environmental modifications, play an important role in managing behavioral symptoms of delirium. Pharmacological interventions are merely symptomatic and should be limited to patients with severe symptoms when non-pharmacological means fail.

[Delirium: an interdisciplinary challenge]. / Delir : Eine interdisziplinäre Herausforderung.

Delirium, the acute deterioration of cognitive function and attention, is the most frequent mental disorder in elderly. Its correct diagnosis and adequate management are of crucial importance for the patient's health and functional outcome. First of all, one has to be aware of the possibilities of preventing this complex, potentially life-threatening problem, which means recognizing the patient at risk, avoiding environmental stress and causal factors (i.e., anticholinergic medication) in cognitively impaired patients, and timely reaction to prodromal symptoms. Causal therapy (i.e., treatment of the causal condition and/or eliminating the precipitating situation) is imperative. It must be accompanied by nursing and environmental measures and, if necessary, by antipsychotic and/or sedating symptomatic treatment.

[Ethics in geriatrics]. / Ethik in der Geriatrie.

Ethics is a fundamental part of geriatric medicine. Ethical questions are important in all fields of medicine but in geriatrics they are of particular importance. This branch of medicine is concerned with the care and health problems of mostly very old people close to the end of life. They are physically, mentally and socially vulnerable, frail individuals with a high risk for progressive deficits in physical and cognitive functions and are thus progressively dependent on help and care. Decisions about medical interventions are easier when the patients concerned have an intact decisional capacity and is more complex and difficult when dealing with multimorbid, frequently cognitively impaired very old individuals. Ethics is about systematically asking the right questions. This process should be logically structured but questions may remain unanswered. It is about questioning prejudices and modes of action, it means explaining terminology, requesting the best facts possible, formulating definitions and helping to logically reflect on a problem. Good ethics begins with good facts, not with groundless assumptions.

[Consensus statement "Dementia 2010" of the Austrian Alzheimer Society]. / Konsensusstatement "Demenz 2010" der Osterreichischen Alzheimer Gesellschaft.

The Austrian Alzheimer Society developed evidence-based guidelines based on a systematic literature search and criteria-guided assessment with subsequent transparent determination of grades of clinical recommendation. The authors evaluated currently available therapeutic approaches for the most common forms of dementia and focused on diagnosis and pharmacological intervention, taking into consideration the situation in Austria. The purpose of these guidelines is the rational and cost-effective use of diagnostic and therapeutic measures in dementing illnesses. Users are physicians and all other providers of care for patients with dementia in Austria.

[Geriatric medicine at European universities]. / Die universitäre Geriatrie in Europa.

The demographic data of industrialised nations predict an unavoidable shift towards an increase of the ratio of old people to total population. Thus, senescence presents a challenge to sociology, psychology and medicine. The latter responds by the holistic approach of geriatrics and medical gerontology. The diversity of European nations and their medical schools lead us to assess the respective incentives in the field of geriatric medicine. By means of a questionnaire with a response rate of 41%, by direct contact and personal communication and by consulting published and unpublished papers we obtained a survey of current geriatric activities in European universities. The results of this investigation are summarized.

Reactivating occupational therapy: a method to improve cognitive performance in geriatric patients.

In this prospective treatment study, the effects of two different occupational therapy strategies were compared in two samples of long-term geriatric inpatients (n = 22 in each group) with slight to moderate dementia according to DSM-III-R. Psychometric ratings after 12 weeks and 24 weeks of treatment have demonstrated that the application of a reactivating occupational therapy programme in addition to functional rehabilitation is significantly more efficient than the application of functional rehabilitation alone on levels of cognitive performance, psychosocial functioning, and the degree of contentedness with life. These results support the assumption that geriatric patients, if stimulated for a longer time, are able to mobilize latent resources of cognitive and psychosocial performance. Reactivating occupational therapy has a place in the treatment of long-term geriatric patients.

[Gliclazide in the non-insulin-dependent diabetic patient in geriatrics]. / Gliclazid beim nichtinsulinpflichtigen Diabetiker in der Geriatrie.

In the present open clinical pilot study of 12 months duration we tested the metabolic and hemato-biological efficacy as well as the clinical tolerance of the oral antidiabetic agent gliclazide, a second-generation sulfonylurea derivate, on a group of 20 hospitalized geriatric patients (mean age 80.5 +/- 10.2 years). Gliclazide was proven to be a reliable blood-sugar lowering agent with a generally good subjective tolerance. There were no undesired side-effects on the renal, hepatic and hematopoietic systems.

[Ergotherapy within the scope of rehabilitation in geriatrics]. / Die Ergotherapie im Rahmen der Rehabilitation in der Geriatrie.

Occupational therapy in geriatric rehabilitation must take into account the multimorbidity of the patients. Thus a more complex treatment is called for that takes into consideration the affective disturbances accompanying the organic lesions.