Évaluation de l’état nutritionnel péri-opératoire

In surgical patients, malnutrition is associated with an increase in morbidity, mortality, length of stay and health care costs, and has an impact on quality of life. Before surgery, the risk of malnutrition is depending on patient-related factors (age, associated diseases, on-going symptoms, duration of pre-operative hospital stay), surgical procedure, and medical treatment (radiotherapy, chemotherapy, corticoid treatment). The early screening and management of malnutrition are mandatory during the peri-operative period, with the aim to improve post-operative prognosis and clinical outcome. The nutritional assessment is based on the research of weight loss, the calculation of body mass index and the research of an hypoalbuminemia, all of them having a negative impact on postoperative prognosis. The Nutritional Risk Index (NRI) is also of strong prognostic value. We propose a stratification of the nutritional risk indicating several levels of surgical risk. The organization, the planning and the traceability in the medical record of the nutritional assessment should allow optimizing the management and the clinical outcome of surgical patients. The pre-operative consultation of anaesthesia could be the privileged time to perform the screening of malnutrition and to plan its management, if they were not previously performed by the medico-surgical team.     

Nutrition périopératoire chez la personne âgée. Cas particulier de la fracture de l’extrémité supérieure du col du fémur

Emergency surgery is associated with an increase in the risk of malnutrition in the elderly. Thirty to fifty percent of elderly persons admitted to in surgery are malnourished. In patients for which nutritional status is threatened by both the aging process and comorbidities, the surgical intervention represents an additional stress that will induce or worsen malnutrition. Nutritional care must no be delayed. First choice is the oral route, including protein and energy rich nutritional supplements, and must be a part of multidimensional perioperative care It is recommended to reach 30 to 40 kcal tot/kg/day and 1.2 to 1.5 g of proteins/kg/day. It is recommended to prescribe, during the stay in rehabilitation wards after surgery, oral nutritional supplements. This oral supplementation has been shown to be efficacious in malnourished elderly patients: there is weight gain, a lower risk for complications and a lower mortality rate. However, compliance may be reduced in elderly patients with low appetite, especially in case of dementia, or early medical complications. In order to prevent other falls and fractures, it is recommended to look for vitamin D deficiency and to prescribe vitamin D 800–1200 UI/day.     

Évaluation de l'état nutritionnel et des besoins de l'enfant et de l'adolescent

Ten to fifteen percent of hospitalized children suffer from malnutrition. Children suffering from chronic diseases are at particularly high risk for malnutrition. A systematic screening for malnutrition and nutritional risk can improve nutritional care in this population. Simple measures (weight and height at admission) can be used to calculate nutritional indices (weight for height ratio or body mass index). Nutritional risk depends on: 1) the severety of the principal diagnosis, 2) the ability to feed oneself, and 3) the pain intensity. The oral or enteral route is preferred when the gut is functional. In all cases nutritional status must be followed throughout hospitalisation. Furthermore, it is preferable to begin nutritional care before malnutrition sets in. Nutritional care can improve the outcome and well-being of hospitalized children.     

Nutritional status and oxidative stress in an elderly Sardinian population

Weight loss and overweight/obesity-frequent consequences of malnutrition-may impair functional status and worsen concomitant morbidities in the elderly, often through changes in oxidative balance. In order to verify the relationships between these factors, a group of elderly people living on the island of Sardinia (Italy) underwent health and nutritional status assessment and oxidative balance evaluation. The elderly subjects had significantly higher d-ROMs test and body mass index (BMI) values than controls (d-ROMs 325.4 ± 66.3 vs. 295.4 vs 58-9 CARR U, p = 0.006; BMI 28.0 ± 4.6 vs. 21.7 ± 1.4 kg/m², p < 0.0001). The risk of malnutrition in the elderly subjects was evaluated with the Mini Nutritional Assessment (MNA), which showed that 32 of the 111 elderly subjects (28.8%) were at risk of malnutrition, of whom 11 (34%) were overweight and 10 (31-2%) obese. Oxidative stress was negatively and significantly correlated with nutritional status. Oxidative stress may precede malnutrition, even in the absence of weight loss. Routine evaluation of nutritional status and oxidative balance in the elderly may help identify an early risk of malnutrition so that treatment can be personalized.     

Place de l'impédancemétrie dans le dépistage de la dénutrition à l'hôpitalBio-impedance analysis: Screening of denutrition in hospitalized patients

The prevalence of malnutrition is high in patients and tends to worsen during the hospital stay. In the absence of one reliable method to evaluate patients, the assessment of nutritional status is based on a global approach. Body composition measurement by bio-impedance analysis (BIA) is one of these approaches. Body composition measurements can detect malnutrition or abnormal hydration. Fat free mass, fat mass, and total body water are the main body compartments that are evaluated. Determination of abnormal body composition can then guide nutritional support. The reliability of BIA depends on the equation used to predict body composition and the parameters included in the formula (weight, height, sex, age, race, etc.). These parameters allow to minimize measurement errors. Thus, formula developed for specific populations allow to evaluate the nutritional status with reasonable error rates. BIA has been found to be inaccurate with abnormal distribution of body compartments (ascites, dialysis, lypodystrophy, etc.) or extreme weights (cachexia, obesity). Multi-frequency or segmental BIA was developed to overcome hydration abnormalities and variations in body geometry. However, these techniques require further validation. The BIA seems to have some limitations. This review aims to assess the reliability of BIA to detect protein-calorie malnutrition at hospital admission or during nutritional follow-up of patients.     

Prise en charge nutritionnelle périopératoire du patient obèse

Recommendations for perioperative nutrition in obese subjects require considering the following evidences. Obesity has long been falsely considered a risk factor for poor outcomes from a variety of surgical procedures, yet recent studies of critically and chronically ill patients suggest that overweight and obese patients may paradoxically have better outcomes than normal weight patients. Preoperative weight loss should be considered as a risk factor of postoperative complications in obese subjects as in normal weight patients. Obese patients could be malnourished because of vitamin deficiencies and of sarcopenia. The prevalence of vitamin deficiencies in the morbidly obese population prior to surgery is high, especially for vitamins B1, B12, B9, A, C, D and E. Standard of care should include perioperative thiamine replacement, especially in case of prolonged vomiting. Vitamin B12 deficiency could appear fast after gastric or ileal surgery, and iron deficiency is more frequent. Low caloric diet is not recommended in obese subjects before surgery, especially for the elderly, because of the frequent sarcopenia in this population. Energy and protein recommendations are not easy to be determined in obese subjects. Recommended allowance for protein should be defined according of the fat free mass, which is not easy to evaluate in clinical practice. So it is recommended to use a normalized weigh for a theoretic BMI between 25 and 30 kg/m². The loss of muscle mass can be very fast in the postoperative period in these subjects. The nutritional objective of care is to preserve skeletal muscle mass and to enhance the protein balance.     

Malnutrition in Older Adults—Recent Advances and Remaining Challenges

Malnutrition in older adults has been recognised as a challenging health concern associated with not only increased mortality and morbidity, but also with physical decline, which has wide ranging acute implications for activities of daily living and quality of life in general. Malnutrition is common and may also contribute to the development of the geriatric syndromes in older adults. Malnutrition in the old is reflected by either involuntary weight loss or low body mass index, but hidden deficiencies such as micronutrient deficiencies are more difficult to assess and therefore frequently overlooked in the community-dwelling old. In developed countries, the most cited cause of malnutrition is disease, as both acute and chronic disorders have the potential to result in or aggravate malnutrition. Therefore, as higher age is one risk factor for developing disease, older adults have the highest risk of being at nutritional risk or becoming malnourished. However, the aetiology of malnutrition is complex and multifactorial, and the development of malnutrition in the old is most likely also facilitated by ageing processes. This comprehensive narrative review summarizes current evidence on the prevalence and determinants of malnutrition in old adults spanning from age-related changes to disease-associated risk factors, and outlines remaining challenges in the understanding, identification as well as treatment of malnutrition, which in some cases may include targeted supplementation of macro- and/or micronutrients, when diet alone is not sufficient to meet age-specific requirements.     

État nutritionnel des patients avec maladies du foie : épidémiologie et pronostic

Malnutrition is generally defined as protein-energy malnutrition (PEM) in patients with chronic liver disease, because the depletion of muscle mass and body fat is associated with protein depletion. Deficiencies of vitamins and minerals often coexist. PEM represents a common complication of advanced liver disease, both of alcoholic and nonalcoholic etiology. It is related to the severity of the liver disease more than to its etiology.Malnutrition negatively affects liver function, complications of the liver disease, and survival. Malnourished patients have an increased surgical risk and decreased survival after liver transplantation. The assessment of nutritional status in patients with chronic liver disease may be helpful in providing better prognostic information and more precise targeting of potential nutrition intervention.     

Nutritional risk and body composition in free-living elderly participating in congregate meal-site programs

Early detection of nutritional risk in free-living elderly is critical in healthcare, yet comprehensive measurements are time consuming and can be frustrating to both health professionals and elderly. In addition, body composition measurements provide information regarding fat and fat-free mass that have been linked to morbidity and mortality in elderly. In this study, nutritional risk was assessed in 69 elderly, aged 50-90 years, attending congregate meal-site programs, using Mini Nutritional Assessment, and body composition was assessed by bioelectric impedance. Analysis revealed that 31.9% of the elderly were at risk for malnutrition and 2.9% were malnourished. Males had significantly greater body weight, height and fat-free mass, and females had significantly greater body fat as percentage of body weight, but there was no gender difference in nutritional risk. Of elderly, 36.2% had body mass index > 85th percentile and 8.7% < 15th percentile using national population reference standards. Age-related decline in fat-free mass was an early indicator of changes in body composition.     

Evaluation of the efficacy of nutritional screening tools to predict malnutrition in the elderly at a geriatric care hospital

BACKGROUND/OBJECTIVESMalnutrition in the elderly is a serious problem, prevalent in both hospitals and care homes. Due to the absence of a gold standard for malnutrition, herein we evaluate the efficacy of five nutritional screening tools developed or used for the elderly.SUBJECTS/METHODSElected medical records of 141 elderly patients (86 men and 55 women, aged 73.5 ± 5.2 years) hospitalized at a geriatric care hospital were analyzed. Nutritional screening was performed using the following tools: Mini Nutrition Assessment (MNA), Mini Nutrition Assessment-Short Form (MNA-SF), Geriatric Nutritional Risk Index (GNRI), Malnutrition Universal Screening Tool (MUST) and Nutritional Risk Screening 2002 (NRS 2002). A combined index for malnutrition was also calculated as a reference tool. Each patient evaluated as malnourished to any degree or at risk of malnutrition according to at least four out of five of the aforementioned tools was categorized as malnourished in the combined index classification.RESULTSAccording to the combined index, 44.0% of the patients were at risk of malnutrition to some degree. While the nutritional risk and/or malnutrition varied greatly depending on the tool applied, ranging from 36.2% (MUST) to 72.3% (MNA-SF). MUST showed good validity (sensitivity 80.6%, specificity 98.7%) and almost perfect agreement (k = 0.81) with the combined index. In contrast, MNA-SF showed poor validity (sensitivity 100%, specificity 49.4%) and only moderate agreement (k = 0.46) with the combined index.CONCLUSIONSMNA-SF was found to overestimate the nutritional risk in the elderly. MUST appeared to be the most valid and useful screening tool to predict malnutrition in the elderly at a geriatric care hospital.     

Malnutrition in elderly ambulatory medical patients.

Elderly ambulatory persons may be especially susceptible to malnutrition, particularly those who are poor and socially isolated or have comorbid chronic medical diseases. We found that 98 of 2,986 persons aged 60 years or older attending a hospital-based medical practice between 1979 and 1989 weighed less than 45.4 kg (100 lbs). All but 1 of these subjects met criteria for malnutrition as judged against age-specific norms for weight. Thus the prevalence of malnutrition in this sample was 3.25% (95% CI 2.61, 3.89%). Interviews and physical examinations of a subsample (n = 16) revealed that all 16 subjects either met anthropometric-based criteria for malnutrition or were being treated for malnutrition. Of the 98 subjects who weighed less than 45.4 kg, 62 (63.3%; 95% CI 53.8, 72.8%) had comorbid conditions that could have contributed to malnutrition. Physicians did not record a diagnosis of malnutrition or weight loss in 47.9% of subjects (95% CI 38.0, 57.8%) and did not prescribe a nutrition supplement for 76.5% of subjects (95% CI 68.1, 84.9%). Subjects treated with nutrition supplement were more likely to have cancer. These findings suggest that malnutrition, both with and without concomitant major comorbid disease, is relatively frequent among elderly ambulatory patients and that a specific nutritional diagnosis is not made in many cases. We suggest that weight under 45.4 kg in an elderly person is a useful criterion for identifying elderly patients at nutritional risk.     

La nutrition dans le parcours de soins des personnes âgées

Among the structured care plans published by the High Authority of Health, the course dedicated specifically to the elderly aims at preventing the loss of autonomy. The approach promotes an action upstream to the risk of loss of autonomy, including the prevention of malnutrition. The personalized care plan concerns the elderly affected by one or several chronic diseases and/or frail. Frailty involves most of the time weight loss and a decrease of muscular function. “Key points and solutions” deal with the identification of and multimodal intervention in fragility syndrome and with the prevention of the avoidable hospital readmissions. The strategies of action include nutritional care and physical activity. Besides, the elderly may be concerned by several of the care plans developed for the chronic diseases. Some of these disease lead at any age to a risk of malnutrition (renal disease, Parkinson's disease, chronic bronchitis, cancer…). Others are more often associated with obesity in adults (diabetes, coronary disease, cardiac insufficiency…), but may be associated with malnutrition in the elderly. The specificities of the nutritional evaluation in the elderly and the efficacy of nutritional care would maybe deserve to appear more clearly in the courses of care concerning chronic diseases, which are increasingly prevalent in aging people; the objective is to maintain at best and as long as possible the quality of life for the aging people.     

Nutrition du patient cancéreux : la pratique clinique

Malnutrition is common in patients with cancer and must be actively treated at the different steps of management, given its prognostic value. Several mechanisms are involved in the onset of malnutrition: food intake reduction (anorexia), metabolic disorders, therapies side effects. Consequences concern both the energetic balance disorder and the decrease of protein reserves, leading to a proteino-energetic malnutrition. The assessment of malnutrition must be systematically realised as soon as the diagnostic is done, and regularly repeated. The evaluation is performed with the loss of weight measure, the clinical examination and the serum levels of albumin and prealbumin, which are sufficient most of the time. The body mass index, the subjective global assessment scale and the Buzby's nutritional risk index can also be useful. In perioperative time, a patient exhibiting a severe malnutrition (loss of weight > 10 % or albumin < 30 g/l) must receive a perioperative renutrition, preferentially by the enteral route. The development of the enteral immunonutrition and of the glutamine supplementation in parenteral nutrition are clearly more efficient than standard solutions. During chemoradiotherapy, parenteral nutrition must remain uncommon, as its beneficial effect is not demonstrated. Enteral renutrition must be reserved to severely malnourished patients, in whom malnutrition can compromise the treatment course. In patients with cachexia, indications of artificial nutrition are very limited. Nutritional management, especially by oral or enteral route, takes place in a multidisciplinary approach of palliative care. New solutions targeted on the cancerous cachexia are now being developed and assessed.     

Low serum leptin serves as a biomarker of malnutrition in elderly patients

Anthropometric and classical biologic markers of malnutrition, such as serum albumin, are limited because they are influenced by nonnutritional factors. We propose that a biologic parameter that both predicts nutritional status and is unaffected by nonnutritional factors would facilitate the diagnosis of malnutrition in the elderly. This cross-sectional study included 179 randomized elderly patients. Nutritional status was assessed by the Mini-Nutritional Assessment (MNA) instrument; other end points included anthropometric measures and biologic parameters. Subjects were divided into 3 groups based on MNA-defined nutritional status, and end point means were compared using 2-way analyses of variance adjusted by sex. Correlations between the most accurate biologic marker in predicting malnutrition and other biologic and clinical variables were assessed using Pearson correlation test. Multiple linear regressions were then performed to relate the best biomarker of malnutrition to specific parameters. Finally, leptin levels that predict malnutrition were determined using receiver operating characteristic curve cutoff values. The well-nourished group had significantly higher leptin (P = .001), weight, body mass index, mid-arm circumference, and calf circumference (all, P < .001) compared with the malnourished group and the at risk of malnutrition group. Serum leptin was the optimal biomarker of MNA-defined malnutrition and had significant positive correlations with weight (P = .003) and with all anthropometric values (all P < .001), but no significant correlation with C-reactive protein. Sex, weight, and triglyceride were the best predictors of serum leptin (all P < .001). The optimal cutoff value of serum leptin to detect malnutrition was 4.3 ng/mL in men and 25.7 ng/mL in women. Serum leptin may be a good predictor of nutritional status in elderly patients.     

Prevalence of malnutrition in Parkinson's disease: a systematic review

Parkinson's disease (PD) patients may be at higher risk of malnutrition because of the symptoms associated with the disease and the side effects of the medication used to manage it. A decline in nutritional status is associated with many adverse outcomes related to health and quality of life. It is not clear, however, to what extent this population is currently affected by malnutrition. The objective of this review was to systematically assess the methodology and outcomes of studies reporting the prevalence of malnutrition in PD patients. Studies that attempted to classify participants with PD into nutritional risk and/or malnutrition categories using body mass index, weight change, anthropometric measures, and nutritional screening and assessment scores were included. The prevalence of malnutrition ranged from 0% to 24% in PD patients, while 3-60% of PD patients were reported to be at risk of malnutrition. There was a large degree of variation among studies in the methods chosen, the definition of malnutrition using those methods, and the detail in which the methodological protocols were reported. The true extent of malnutrition in the PD population has yet to be accurately quantified. It is important, however, to screen for malnutrition at the time of PD diagnosis.     

Hospital length of stay and nutritional status

PURPOSE OF REVIEW: This review looks at the recent medical literature on the association between hospital length of stay and nutritional status. RECENT FINDINGS: Simple anthropometric parameters underestimate the nutritional risk in hospitalized patients. The Malnutrition Universal Screening Tool and Nutritional Risk Screening are simple screening tools that identify patients who require further monitoring. Recent weight loss appears to be the most important single indicator of nutritional status. Body composition measurements identify patients with muscle mass depletion and excess body fat, both of which are significantly associated with increased length of stay. The Subjective Global Assessment is useful at detecting patients with established malnutrition and the Mini Nutritional Assessment for the elderly is useful at detecting patients who need preventive nutritional measures. The Nutritional Risk Index, which incorporates albumin and weight loss, appears to capture both nutritional risk and poor clinical outcome. SUMMARY: Nutritional risk is associated with the length of stay in hospital. The choice of nutritional screening and assessment tools depends on the type of institution (university hospital versus community hospital), the patient populations (acute care versus intermediary care; general hospital versus elderly population) and the resources available.     

Vieillissement humain : évolution démographique et implications médicales

French population ageing is constant since 1960. Even if elderly people quality of life keeps on improvement, population ageing leads to increasing consumption of care. Dementia, dependencies, are more frequent, and lead to many diseases, especially through malnutrition. This phenomenon have to be anticipate with global and coordinated agreement of sanitary, medical and psycho-social organization.     

Assessment of nutritional status on hospital admission: nutritional scores

Malnutrition is still a largely unrecognized problem in hospitals. Malnutrition in hospitalized patients is generally related to increasing morbidity and mortality, and costs and length of stay. The aim of this study was to assess the nutritional status of patients on admission to a general hospital using different nutritional scores and to test the sensitivity and specificity of these scores. Sample population included 60 patients (55% male; 45% female) selected (aged 65.6+/-15.9 y) at random by using a computer software program. The nutritional state assessment was performed within 48 h of admission, using different nutritional indices (Subjective Global Assessment (SGA), Nutritional Risk Index (NRI), Gassull classification, Instant Nutritional Assessment (INA) and a combined index). About 78.3% of patients were found to be malnourished on admission. The frequency of malnutrition degree varied from 63.3% as assessed by the SGA to 90% with the NRI. Malnutrition severity was not related to the diagnosis. However, an elderly population was associated with a higher prevalence of malnutrition. INA was the best single score to identify patients who are malnourished or at risk of malnutrition and who may benefit from nutrition support.     

The Prediction of Deterioration of Nutritional Status during Chemoradiation Therapy in Patients with Esophageal Cancer

Patients with esophageal cancer are at high risk of developing malnutrition during neoadjuvant chemoradiation therapy (CRT), which in turn is associated with postoperative morbidity. The aim of the study is to explore whether parameters of a complete pre-treatment nutritional status may predict deterioration of nutritional status during CRT in patients with esophageal cancer. In this prospective cohort study, 101 patients with esophageal cancer treated with CRT were included. Data of patient characteristics, tumor classification, performance score, %weight change, body mass index, fat (free) mass index, phase angle, handgrip strength, energy- and protein intake, and use of (additional) dietary supplements were collected. A prediction model was constructed to identify predictive parameters for deterioration in nutritional status (defined as weight loss of >5% and/or decline in fat free mass of ≥1.4 kg) during CRT. Nutritional status deteriorated in 49 patients (49%) during CRT. The only predictor for deterioration in nutritional status was fat free mass index (OR 1.21 (90% CI: 1.03 – 1.42)). Patients with a higher fat free mass index are at increased risk of deterioration in nutrition status during CRT. Results suggest that all patients should be carefully supervised during CRT, regardless of their nutritional status before start of CRT.