Agathe Raynaud-SimonService de Gériatrie, Hôpital Bichat APHP, Paris

Faculté de Médecine Denis Diderot, Paris 7

Laboratoire de Biologie de la Nutrition, EA4466, Faculté de Pharmacie, Paris 5

Evaluation of

malnutrition

Malnutrition

Malnutrition and mortality

• EURONUT-SENECA STUDY– I (1988 - 1989) 2600 subjects, aged 70-75 years

– II (1993 - 1994) 1221 subjects aged 75-80 years

• Weight loss > 5 kg : 16 % (men and women)

Mortality X 2 in the next 5 years

Assessment of malnutrition

Risk factors

Appetite and food intake

Nutritional criteria

Risk factors for malnutrition

Psychologic, social and environement

Acute conditions, Worsening of a chronic condition

Drugs

•Alone•Grieving•Financial problms•Hospitalization•Admission to a nursing home

•Pain•infection•Fracture with limitation of mobility•Surgery•Severe constipation•Pressure sores

•Multiple drugs•Dryness of the mouth, abdominal complaints, nausea•Corticosteroids

Mouth and teeth Restrictive diets Neurologic

•Poor dental health•Ill adapted dentures•Mycosis of the mouth•Loss of taste

•Low salt •Weight reducing•diabetic•Low fat•Low fibers

•Alzheimer’s disease•Other dementia•Parkinson’s disease

Swallowing disorders Disability Psychiatric disorders

•Head and neck •Neurologic or vascular disease

•For eating•For mobility

•Depression•Troubles du comportement

Cancer

CardiacRespiratoryLiverRenal

Chronic infectionsChronic inflammation

MalabsorptionMaldigestion

Failure

Risk factors for malnutrition

Psychologic, social and environement

Acute conditions, Worsening of a chronic condition

Drugs

•Alone•Grieving•Financial problms•Hospitalization•Admission to a nursing home

•Pain•infection•Fracture with limitation of mobility•Surgery•Severe constipation•Pressure sores

•Multiple drugs•Dryness of the mouth, abdominal complaints, nausea•Corticosteroids

Mouth and teeth Restrictive diets Neurologic

•Poor dental health•Ill adapted dentures•Mycosis of the mouth•Loss of taste

•Low salt •Weight reducing•diabetic•Low fat•Low fibers

•Dementia•Alzheimer’s disease•Other dementia•Parkinson’s disease

Swallowing disorders Disability Psychiatric disorders

•Head and neck •Neurologic or vascular disease

•For eating•For mobility

•Depression•Troubles du comportement

Cancer

CardiacRespiratoryLiverRenal

Chronic infectionsChronic inflammation

MalabsorptionMaldigestion

Failure

Etiquette Patient

Date

Consommation _ _ _ _ _ _ _ _CAFE ou THE

LAIT

BISCOTTE BEURREE

BOUILLIE

Identification

du soignant P T P T P T Pour l'évaluation de la

SUPPLEMENT consommation, cocher

BOISSON les cases correspondantes

Identification

du soignant P T P T P T

ENTREE

VIANDES

LEGUMES

FROMAGE/LAITAGE

DESSERT

BOISSON Rien

Identification < moitié

du soignant P T P T P T > moitié

Tout

Identification (uniquement

du soignant P T P T P T partie consommée)

POTAGE

VIANDES REMARQUES

LEGUMES

FROMAGE/LAITAGE

DESSERT

BOISSON

Identification

du soignant P T P T P T

Identification du soignant :

P = aide Partielle Installation du patient, ouvrir les conditionnement, couper la viande..., stimulation pendant le repasT = aide Totale Installation du patient et le faire mangerIdentification du soignant (initiales Nom Prénom)

Acte effectué _ _Acte effectué renvoyant à une cible _ _ _

SURVEILLANCE ALIMENTAIRE Dépistage et suivi

DI

NE

R

PT

D

EJ

EU

NE

R

D

EJ

EU

NE

R

CO

LL

GOUTER

Evaluation of food intake

Nutritional parameters and life-threatening complications in geriatric patients

Parameter Complication rate P-Wert

MAC < 286 mm 13,8% <0,001

286 – 323 mm 2,4%

> 323 mm 3,2%

Weight loss > 5 % yes 19% <0,001

no 4,5%

Albumin < 30 g/L 13,3% 0,018

≥ 30 g/L 5,3%

Transthyretin < 18 mg/dL 10,5% 0,046

≥ 18 mg/dL 4,6%

BMI < 22 kg/m² 15,4% 0,008

≥ 22 kg/m² 4,0%Sullivan DH et al, J Gen Intern Med 2002; 17: 923 - 932

MalnutritionMalnutrition« Marasmus »

Progressiv weight lossProtein and energy deficiencyMuscle and fat lossNormal albuminemiaNo edema

« Kwashiorkor »

Rapid weight lossProtein deficiencyMuscle mass loss

HypoalbuminemiaEdema

BMI author patients n age prevalence< 16 Maffuli (1999) hip fracture 119 80 9 11 %

< 18 Volkert (1992) acute care, mixt 215 82 5 9 %

Maffuli (1999) hip fracture 119 80 9 31 %

< 18,5 DaCunha (2001) acute care, mixt 127 65 17 %

< 20 Volkert (1992) acute care, mixt 215 82 5 21 %

Markus (1993) Parkinson 95 62 26 %

Gariballa (1998) stroke 201 78 9 31 %

Ponzer (1999) hip fracture 42 80 7 36 %

20 Flodin (2000) acute care, mixt 337 81 1 36 %

< 21 Dardaine (2001) ICU (respirator) 116 > 70 8 %

Dormenval (1999) acute care, mixt 99 83 4 35 %

Ponzer (1999) hip fracture 42 80 7 52 %

< 22 Incalzi (1996) acute care, mixt 302 79 6 22 %

Sullivan (1994) rehabilitation 110 79 6 33 %

Volkert (1992) acute care, mixt 215 82 5 40 %

Volkert D et al. Aktuel Ernaehr Med 2004; 29: 190-197

Malnutrition criteria

• Malnutrition: one or more of the following criteria– Weight loss ≥ 5 % in 1 month ou ≥ 10% in 6 months – BMI ≤ 21 – Albuminemia < 35 g/L – MNA < 17

• Severe malnutrition: one or more of the following criteria– Weight loss ≥ 10 % in 1 month or ≥ 15% in 6 months – BMI < 18 – Albuminemia < 30 g/L

Mini- MNA

- risk factors- appetite

- nutritional criteria

NEW !

Kaiser, JNHA 2009

• GNRI = (1,489 x albumin g/L) + 41,7 x actual weight

ideal weight Ideal weight with Lorentz formulae

Geriatric Nutritional Risk Index

Bouillanne et al, Am J Clin Nut, 2005

Assessment of nutritional status

Body storage

Weight, BMI

How much fat?

How much muscle?

Metabolic homeostasis

Albuminemia?

Glycemia?Ca? P?

…