Ernæringsproblemer hos svækkede ældre

Anne Marie Beck, klinisk diætist, seniorforskerambe@food.dtu.dk

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’………clinical interventions for weight loss have been used with modest succes’.

Bales CW, Ritchie CS. Sarcopenia, weight loss, and nutritional frailty in the elderly. Annu Rev Nutr 2002; 22: 309-23

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Hvor er problemet?

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Hvor er problemet?• På sygehuse• På plejehjem• I hjemmepleje

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Hvor er problemet?• Poulsen et al. J Nutr Health

Aging 2006; 10:84-90• Geriatric admission• 44 % BMI<22• Poor appetite, oral cavity

problems associated with undernutrition

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Hvor er problemet? (Beck et al. Ugeskr Læger 2008; 170:749-52) (16 % BMI<18.5)

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Hvorfor er problemet her? (Ernæringsrådet. Ernæring og aldring 2002)

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10

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30

40

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21-30 31-40 41-50 51-60 61-70 70+

Alder (År)

Pct.

af s

amle

t kro

psvæ

gt

muskelmasse fedtmasse

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Hvorfor er problemet her? (Ernæringsrådet. Ernæring og aldring 2002)

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Hvorfor er problemet her? (Ernæringsrådet. Ernæring og aldring 2002)

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Hvorfor er problemet her? (Ernæringsrådet. Ernæring og aldring 2002)

• RisikofaktorerSygehusopholdKroniske sygdommeBivirkninger til medicinTygge- og synkeproblemerNedsat fysisk funktionsevneDiæter med lavt fedtindholdOsv.

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OBS!

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OBS!

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OBS!

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OBS! (Janssen & Mark. Obes Rev 2007; 8: 41-59)

BMI 25-30 and mortality• All studies 1.00 (0.97-1.03)• No disease at baseline 1.04 (1.01-1.07)• Measured height and weight 0.89 (0.84-0.95)• Self-reported height and weight 1.03 (1.00-1.06)• Very old (75+) age ?

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OBS! (Janssen & Mark. Obes Rev 2007; 8: 41-59)

BMI 30+ and mortality• All studies 1.10 (1.06-1.13)• No disease at baseline 1.30 (1.24-1.37)• Measured height and weight 0.90 (0.84-0.95)• Self-reported height and weight 1.22 (1.16-1.27)• Very old (75+) age ?

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OBS! (Beck & Ovesen. Clin Nutr 1998; 17: 195-8) (Sygehus)

< 65 ÅR ≥

65 ÅR

Undervægt < 18.5 < 24.0

Normalvægt 18.5-24.9 24.0-29

Overvægt ≥

25 > 29.0

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OBS! (Beck & Damkjær. J Nutr Health Aging 2008; 12: 675-8) (Plejehjem)

BMI<24 BMI 24-29 BMI>29

Lav socialt engagement

74% 62% 46% ***

Hjælp til - Spisning- Personlig hygiejne- Toiletbesøg

34%73%56%

25%67%54%

18% *67% *48%

Engageret i livet 44% 54% 67% ***

Trives ikke med andre 9% 15% 6%

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OBS! (Beck & Damkjær. J Nutr Health Aging 2008; 12: 675-8) (Plejehjem)

BMI<24 BMI 24-29 BMI>29

> 1 livsstilssygdom 46% 48% 78% ***Indlagt - t=0-6- t=6-12

13%10%

10%8%

10%11%

Død t=6- >85 år- Øvrige

18%11%

10%7%

11%5%

Død t=12- >85 år- Øvrige

33%29%

24%13%

28%9% **

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OBS!

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OBS!

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’………clinical interventions for weight loss have been used with modest succes’.

Bales CW, Ritchie CS. Sarcopenia, weight loss, and nutritional frailty in the elderly. Annu Rev Nutr 2002; 22: 309-23

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Andres konklusioner vedr. ernæring til ældre (Milne et al. Cochrane Library 2005, Ann Intern Med 2006; 144: 37-48)

• For geriatric patients who were given oral nutritional supplements (ONS), evidence suggested fewer complications (0.72 (CI 0.53 to 0.97) and reduced mortality (0.66 (CI 0.49 to 0.90))

• A reduction in mortality for older people in long-term care was almost statistical significant (0,65 (CI 0.41 to 1.02))

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Andres konklusioner vedr. ernæring til ældre (Volkert et al. ESPEN guidelines. Clin Nutr 2006; 25: 330-60)

• In geriatric patients who are undernourished or at risk of undernutrition use ONS to improve survival (A)

• In geriatric patients with severe neurological dysphagia use enteral nutrition (A)

• In geriatric patients after hip fracture and orthopaedic surgery use ONS to reduce complications (A)

• In frail elderly use ONS to improve or maintain nutritional status (A)

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Andres konklusioner vedr. ernæring til ældre (Sundhedsstyrelsen. Screening og behandling af patienter i ernæringsmæssig risiko)

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Andres konklusioner vedr. ernæring til ældre (Sundhedsstyrelsen. Medicinske patienters ernæringspleje. MTV 2005)

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Andres konklusioner vedr. ernæring (til ældre) (Europarådet. Resolution 2003)

• ’Proper nutrition is a human right’

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OBS!

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OBS! Følg ordentligt hjem

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’………clinical interventions for weight loss have been used with modest succes’.

Bales CW, Ritchie CS. Sarcopenia, weight loss, and nutritional frailty in the elderly. Annu Rev Nutr 2002; 22: 309-23

’Because nutritional frailty rarely has only one cause, treatment requires a plan that includes several simultaneous interventions’.

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Andres konklusioner vedr. ernæring til ældre (Milne et al. Cochrane Library 2005, Ann Intern Med 2006; 144: 37-48) (plejehjem)

• Change in functional status ?• Change in quality of life ?• Some problems with compliance with ONS• A minority (none ?) energy dense foods• A minority training• None focus on oral health or other risk factors

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OBS ny viden (plejehjem)

• Nijs et al. BMJ 2006; 332: 1180-4 (family-style meals) OK• Rosendahl et al. Aust J Physiother 2006; 52: 105-13 (ONS +

exercise) OK• Beck et al. Nutrition 2008; 24: 1073-80 (energy dense food,

exercise, oral care) OK• Smoliner et al. Nutrition 2008; 24: 1139-44 (energy dense

food)• Rydwik et al. Aging Clin Exp Res 2008;20:159-70 (dietician

+ exercise) OK• Zak et al. BMC Public Health 2009; 9: 39 (ONS + exercise)

OK

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OBS ny viden (plejehjem)

• Beck AM, Ovesen L, Schroll M. Homemade oral supplement as nutritional support of old nursing home residents, who are undernourished or at risk of undernutrition based on the MNA. A pilot trial. Aging Clin Exp Res 2002;14:212-5.

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OBS ny viden Esmarck et al. 2001 *)• ”Early intake of an oral protein supplement after resistance

training is important for the development of hypertrophy in skeletal muscle of elderly (un-trained) men”

*) J Physiol 2001;535:301-11

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OBS ny viden (plejehjem)

Rydwik et al. 2004 *) (16 trials)• Improved muscle strength,

mobility• Improved range of motion ?• Gait, ADL, balance, endurance ?*) Age Ageing 2004;33:13-23

Rydwik et al. 2005 *)• Strength (moderate), mobility,

balance, endurance• Twice a week, 45-60 min., team,

10 w• Improved balance, mobility*) Arch Gerontol Geriatr 2005;40:29-

44

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OBS ny viden (plejehjem)

• Ekstrand et al. plejehjemsbeboere *)• 31 deltagere → 16 (fra 2 til alle tænder) 81,6 år• Plaque fjernelse m.m. hver 14. dag v. tandplejer• I 8 måneder• Effekt på forekomst af plaque og tandsten *) Tandlægebladet 1998

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OBS ny viden (plejehjem)

- 25 g chokolade/dag, - 450 ml varm chokolade/uge,

600 ml energidrik/uge, - 150 ml træningsdrik x 2/uge,

holdtræning x2/uge, - tandpleje x 1-2/uge)- 11 uger- Randomiseret, kontrolleret

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OBS ny viden (plejehjem)

• Oldest participant

• N=200 invited• N=121 (61%) participants - 86 y (CI 85-88) - BMI 23.4 (CI 22.2-24.3)• N=62 in intervention group- 8 dead, 6 drop-outs (t=11)

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OBS ny viden (plejehjem)

Chocolate 68%

Homemade oral supplement

70%

Training 70%

Homemade ”training” supplement

69%

Oral health care

67%

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OBS ny viden (plejehjem)

Intervention Control P-value

Weight change (t=0-11 w)

1,3% -0,6% 0.005

Weight change (t=0-27 w)

-0,5% -3,1% 0.019

Weight change(t=11-27 w)

-2,5% -3.1% 0.908

Energy intake change(t=0-11 w)

0,7 MJ -0,3 MJ 0.084

Habitual energy intake change (t=0-11 w)

0,5 - 0.066

Protein intake change(t=0-11 w)

5 g -2 g 0.012

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OBS ny viden (plejehjem)

Intervention Control P-value

30-second chair stand 39 20 0.04

30-second arm curl 57 30 0.009

2-minute step 41 17 0.012

8-foot-up-and-go 39 15 0.01

Berg balance scale 53 19 0.001

Hand grip strenght 55 39 0.119

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OBS ny viden (plejehjem)

Konklusion• Det er muligt at gøre noget

ved ernæringsproblemer, som således ikke skal accepteres som en naturlig del af det, at blive beboere på et plejehjem

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OBS ny viden (plejehjem)

• VELUX FONDENE• Helsefonden• TOMS• Arla• Tandex• Findus

Samt ikke mindst: Alle medvirkende

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Ernæringsproblemer hos svækkede ældre ’………clinical interventions for weight loss have been used with modest succes’. IKKE OK!