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.
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.
Summary 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. Summary of statements: Geriatrics Subject Recommendations Grade Number Indications Age per se is not a reason to exclude patients from PN. C IV 1.1. PN is indicated and may allow adequate nutrition in patients who cannot meet their nutritional requirements via the enteral route. C IV 1.1. PN support should be instituted in the older person facing a period of starvation of more than 3 days or if intake is likely to be insufficient for more than 7–10 days, and when oral or enteral nutrition is impossible. C IV 1.1. Pharmacological sedation or physical restraining to make PN possible is not justified. C IV 1.1. PN is a useful and effective method of nutritional support in older persons but compared to EN and oral nutritional supplements are much less often justified. B III 1.2. Metabolic/physiological features in older subjects Insulin resistance and hyperglycaemia together with impairment of cardiac and renal function are the most relevant features. They may warrant the use of formulae with higher lipid content. C IV 2 Deficiencies in vitamins, trace elements and minerals should be suspected in older subjects. B IIb 2 The effect of nutritional support on restoration of depleted body cell mass is lower in elderly patients than in younger subjects. The oxidation capacity for lipid emulsions is not negatively influenced by age. B IIa 2 Peripheral PN Both central and peripheral nutrition can be used in geriatric patients. C IV 3 Osmolarity of peripheral parenteral nutrition should not be higher than 850 mOsmol/l. B III 3 Subcutaneous fluid administration The subcutaneous route is possible for fluid administration in order to correct mild to moderate dehydration but not to meet other nutrient requirements. A Ia 4 PN and nutritional status PN can improve nutritional status in older as well as in younger adults. However, active physical rehabilitation is essential for muscle gain. B IIb 5 Functional status PN can support improvement of functional status, but the margin of improvement is lower than in younger patients. C IV 6 Morbidity and mortality PN can reduce mortality and morbidity in older as well as in middle-aged subjects. C IV 7 Length of hospital stay No studies have assessed length of hospital stay in older patients on PN. 8 Quality of life Long-term parenteral nutrition does not influence quality of life of older patients more negatively than it does in younger subjects. C IV 9 Specific complications There are no specific complications of PN in geriatric patients compared to other ages, but complications tend to be more frequent due to associated comorbidities. C IV 10 Specific situations Indications for PN are similar in younger and older adults in the hospital and at home. B III 11 Ethical problems PN or parenteral hydration should be considered as medical treatments rather than as basic care. Therefore their use should be balanced against a realistic chance of improvement in the general condition. C IV 12
Abstract In the ageing muscle, many changes occur. Some are on an architectural level, like alterations in muscle composition, or modifications in the characteristics of the muscle fiber itself, ...where muscle fiber length, orientation and type change. Other changes are neuronal, which occur on all levels, from the central activation over the spinal properties down to the level of the motor unit and the neuromuscular junction. There are also hormonal factors that undergo agerelated concentration variations. All these alterations in the muscle have an effect on both strength and function. In this matter, they contribute to the process of sarcopenia. Although many different components are identified, it is still unclear to what degree these components contribute to the loss of muscle mass, strength and function. This review summarizes the occurring physiological and anatomical changes within the ageing muscle and links them to outcomes such as strength and function.
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.
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