About the Author.
md，phd
Chief physician, doctoral supervisor.
Department of Geriatrics, Peking Union Medical College, Director of the Department of Geriatrics.
He has published more than 190 articles and edited the national planning textbook "Geriatrics" (3rd Edition) for medical graduate students in colleges and universities across the country
Member of the Standing Committee of the Geriatrics Branch of the Chinese Medical Association, and the leader of the Geriatric Malnutrition and Sarcopenia Group.
Chairman of the Palliative Care Branch of the Chinese Geriatric Health Care Medical Research Association.
President of the Geriatric Specialist Branch of Beijing Medical Doctor Association.
Vice Chairman of Geriatrics Branch of Beijing Medical Association.
Member of the Internal Medicine Professional Committee of the Beijing Resident Standardized Training Committee (the 2nd).
Older people are at high risk of malnutrition, and malnutrition is closely associated with many adverse outcomes. Combating malnutrition is a key part of maintaining the intrinsic capacity of older persons. We will share our insights on the latest developments in geriatric clinical nutrition in 2023 and share them with our readers.
a) Guidelines and consensus.
1.Lancet: Malnutrition in older people.
In January 2023, The Lancet published a blockbuster review of malnutrition in older adults, discussing the current evidence on the identification and ** of malnutrition in older adults, analysing the gaps between evidence and practice in medical profiles of malnourished older adults, and providing practical and public health strategies for translating evidence-based data into improved nutritional care. Key takeaways: Malnutrition increases the risk of adverse clinical outcomes, such as frailty, osteoporosis, sarcopenia, and death. Malnutrition is divided into three subtypes: inflammatory disease-related malnutrition, non-inflammatory disease-related malnutrition, and non-disease-associated malnutrition. Key to the management of malnutrition are routine malnutrition screening and assessment, individualized nutritional supplementation programs, nutritional food fortification, medical education, nutritional counselling, and oral nutritional supplementation. Clinical practice recommendations for the management of malnutrition in older adults are suggested: All older adults should be screened for malnutrition on a regular basis, and effective assessment tools should be used during the screening process. Patients with positive malnutrition screening should be systematically evaluated. Serum albumin is strongly influenced by inflammation in older adults and is not recommended as a biomarker of malnutrition in older adults. Nutritional interventions should be individualized. Nutrition interventions should incorporate a multimodal and multidisciplinary team approach. Older adults who are at risk of malnutrition should receive nutrition-related education and counseling. Malnourished older adults should be provided with oral nutritional supplements (ONS) if they do not eat enough, both during hospitalization and after discharge, and ONS should be continued for at least 1 month after discharge, and their nutritional status should be reviewed. Oral nutrition can be supported through food modification. Provide supportive interventions to all residents living in nursing homes or receiving home care services for malnourished (at-risk), including the provision of assisted meals, the provision of a home-style dining environment, etc.
2.ESPEN Guidelines for Nutrition in Geriatric Comorbid Hospitalized Patients** (2023).
The guide offers 32 practical suggestions. RECOMMENDATION: In older hospitalized patients with comorbidities, validated tools such as NRS-2002 and mNA-SF should be used to identify malnutrition risk using rapid and simple screening. Patients at risk of malnutrition should be evaluated in more detail and a plan should be developed for adequate nutrition as early as possible. Individualized nutritional support through ONS is recommended for malnourished hospitalized patients with comorbid conditions or those at high risk of malnutrition who are able to receive oral feeding. Enteral nutrition may be preferred over parenteral nutrition in comorbid hospitalized patients whose nutritional needs cannot be met orally. The energy requirements of hospitalized patients with comorbidities can be determined by indirect calorimetry;In the absence of indirect calorimetry, the total energy expenditure of a 65-year-old elderly patient with comorbid disease was estimated to be about 27 kcal kg d, and that of severely underweight patients was estimated to be 30 kcal kg dReplenishment should begin slowly to prevent refeeding syndrome. Daily protein requirement12g-1.5 g kg d, impaired renal function (EGFR< 30 ml min 173 m2) and did not receive renal replacement** with a protein requirement of 08 g/kg/d。Comorbid hospitalized patients with reduced food intake and poor nutritional status should be at least 75% of the calculated energy and protein requirements to reduce the risk of adverse events. Adequate intake of micronutrients (vitamins and trace elements) should be ensured to meet daily requirements. In older hospitalized patients with comorbidities who require enteral nutrition, enteral nutrition preparations containing soluble and insoluble dietary fiber may improve bowel function;In hospitalized patients with comorbid conditions with pressure ulcers, specific amino acids (arginine and glutamine) may be added to enteral nutrition to promote wound healing. Comorbid hospitalized patients who are malnourished or at risk of malnutrition should continue to provide nutritional support after discharge to maintain or improve functional status and quality of life;Nutritional indicators and functional parameters should be monitored simultaneously to assess the effect of nutritional support, but functional parameters may be more appropriate to assess clinical outcomes in hospitalized patients with comorbidities. In hospitalized patients with comorbidities, drug-drug or drug-nutrient interactions need to be considered, and therefore, pharmacists are required to be involved in the management of nutrition plans.
3.ESPEN Practice Guidelines for Home Parenteral Nutrition (2023).
Starting from clinical practicability, the guidelines have reduced the 2020 version of the ESPEN home parenteral nutrition guidelines to a total of 76 recommendations, and added 6 flow charts, which are more convenient for clinicians, dietitians and ** to use in clinical practice.
4.Based on the evidence-based medical evidence at home and abroad and the diagnosis and treatment experience of experts in various fields, Ma Lina et al. put forward a Chinese expert consensus on the multidisciplinary decision-making model of "screening-multiple intervention-joint management" for malnutrition in the elderly.
5.Nutritional support** is essential for maintaining and improving the functional status, quality of life and prognosis of critically ill elderly patients, and is an important part of the comprehensive treatment and prognosis of elderly patients. The Geriatrics Branch of the Chinese Medical Association and the Geriatrician Branch of the Chinese Medical Doctor Association jointly released the Guidelines for Nutritional Support for Elderly Critically Ill Patients in China (2023), focusing on the principles of nutritional management of elderly critically ill patients, the timing and approach of nutritional support, nutritional needs, blood glucose management, nutritional intervention after discharge, and the clinical monitoring of nutritional support.
6.Nutrition experts from the China Geriatric Care Alliance, the National Geriatrics Center, and the National Clinical Research Center for Geriatric Diseases, focusing on enteral nutrition for malnourished older adults who can eat by mouth**. Through literature search and analysis, the clinical practice guidelines for non-pharmacological intervention in malnourished elderly were formulated using the recommendation evaluation, formulation and evaluation (GRADE) grading system, and 9 recommendations were put forward for non-pharmacological intervention in malnourished elderly.
References: 1] Dent E, Wright Orl, Woo J, Hoogendijk Eo malnutrition in older adults. lancet. 2023;401(10380):951-966.
2] wunderle c, gomes f, schuetz p, et al. espen guideline on nutritional support for polymorbid medical inpatients. clin nutr. 2023;42(9):1545-1568.
3] pironi l, boeykens k, bozzetti f, et al. espen practical guideline: home parenteral nutrition. clin nutr. 2023;42(3):411- 430.
4] Ma Lina, Ji Tong, Li Hailong, et al. Chinese expert consensus on a multidisciplinary decision-making model for malnutrition in the elderly (2023)[J].Chinese Journal of Clinical Health Care, 2023, 26(4): 433-445
5] Geriatrics Branch of Chinese Medical Association, Geriatrician Branch of Chinese Medical Doctor Association, Editorial Board of Chinese Journal of Geriatrics. Guidelines for Nutritional Support for Elderly Critically Ill Patients in China (2023)[J].Chin J Geriatrics,2023,42(9):1009-1028
6] China Geriatric Nursing Alliance, Xiangya School of Nursing, Central South University (Xiangya Oceanwide Health Management Research Institute, Central South University), Xiangya Hospital of Central South University (National Clinical Research Center for Geriatric Diseases), etc. Clinical practice guidelines for non-pharmacological interventions in malnourished older adults[J].Chinese Journal of General Practice,2023,26(17):2055-2069
2) Clinical nutrition research.
a) Nutrition and disease.
1.The association between dietary fiber intake and the risk of cognitive decline in older adults is affected by apolipoprotein E.
Spanish scholars included 848 cases of elderly people in the community (740±7.0 years old), the effect of dietary fiber on cognitive function was evaluated by dietary questionnaires, MMSE, etc. After 15 years of follow-up, 549 of them developed cognitive decline, and energy-corrected fiber intake was not associated with cognitive decline. However, dietary fiber intake and apolipoprotein E (APOE) haplotype showed a significant interaction in cognitive decline: in participants with APOE-4 haplotype, a 5g increase in fiber intake per day was associated with a 30% reduction in the risk of cognitive decline.
2.Nutritional status was assessed using mNA, and 1768 elderly hospitalized patients in Sweden (781±7.8 years old) were followed up for 10 years after discharge. Older patients at risk of malnutrition have been shown to have a higher risk of early all-cause mortality compared with well-nourished older patients (p<0.)05）。
3.Older Japanese (n=141, 735±6.3 years old) were followed up for 2 years after receiving assessment of the number of teeth, oral function (bite force, tongue pressure, swallowing function, etc.) and nutritional status assessment. The results showed that oral condition (number of teeth and swallowing function) was positively correlated with nutritional status.
4.A Canadian study of 3457 elderly patients (74.)2±6.5 years of age), retrospective studies have shown that malnutrition (risk) increases the risk of adverse outcomes after surgery in older adults. Preoperative nutritional screening90% were at risk of malnutrition, and the risk of malnutrition was associated with an increased risk of adverse outcomes after surgery (OR = 1.).74，95% ci:1.25-2.39), higher hospitalization costs (relative cost = 1.).84，95% ci:1.59-2.13), prolonged hospital stay (hr=0.).67，95% ci:0.59-0.77) Relevant. The conclusion is.
References: 1] Unión-Caballero A, Mero o T, Andrés-Lacueva C, et al apolipoprotein e gene variants shape the association between dietary fibre intake and cognitive decline risk in community-dwelling older adults. age ageing. 2023;52(1):afac329.
2] söderström l, rosenblad a. long-term association between malnutrition and all-cause mortality among older adults: a 10-years follow-up study. clin nutr. 2023;42(12):2554-2561.
3] sawada n, takeuchi n, ekuni d, morita m. effect of oral health status and oral function on malnutrition in community-dwelling older adult dental patients: a two-year prospective cohort study. gerodontology. 2023.
4] le b, flier s, madill j, et al. malnutrition risk, outcomes, and costs among older adults undergoing elective surgical procedures: a retrospective cohort study. nutr clin pract. 2023;38(5):1045-1062.
2) Effect of malnutrition interventions.
1-2.In the European Homefood study, Blondal BS et al., a nutritional intervention in elderly patients in Iceland after hospital discharge was observed for the effects on readmissions, length of hospital stay, mortality, and admission to long-term care facilities [7,8]. Elderly patients discharged from the hospital were randomly divided into intervention groups (n=53, 83.).3±6.7 years) and the control group (n=53, 818±6.0 years old), the intervention group received nutritional interventions within half a year of discharge, including home visits, **free provision of energy- and protein-rich foods and nutritional supplements. The results showed that both weight and Mini-Physical Status Scale (SPPB) scores were increased in the intervention group compared to the control group (B=5.).12，95%ci：−6.38-−3.86，p＜0.001；b=−0.91，95%ci：−1.79-−0.29，p=0.024）；and the rate of readmission in the intervention group was reduced (1 month: 19% vs 15.8%，p=0.033；6 months: 250% vs 46.2%，p=0.021；12 months: 385% vs 55.8%，p=0.051；18 months: 519% vs 65.4%，p=0.107), the length of hospital stay is shortened;However, there were no significant differences in emergency department rates, mortality, and long-term care facility admission compared with the control group.
3.A study of elderly Chinese community with an MNA-SF score of 11 (n=101, 747±7.1 year old), ONS (400 kcal d) and family-based nutrition education (Q2W) were administered, and the control group (n=100, 75.)8±7.7 years old) received nutrition education only, and the follow-up was 12w. The results showed that the weight of the elderly in the intervention group (536±8.4kg vs.48.7±9.4kg) and grip strength (272±9.8kg vs.23.5±7.4kg) (P 005）。
4.In an Australian hospital, frail and pre-frail elderly inpatients were randomly assigned to the intervention group (n=16, 800±7.6 years) and the control group (n=16, 783±5.8 years old), the intervention group received a personalized exercise nutrition plan developed by a dietitian and a ** physician during hospitalization, and continued to implement and self-administer for 6 months after discharge, and the control group received routine care. The degree of frailty was assessed using the Edmonton Frail Scale. The intervention group improved in frailty, SPPB, gait speed, and grip strength.
References: 1] Blondal BS, Geirsdottir og, Halldorsson TI, et al homefood randomised trial - six-month nutrition therapy in discharged older adults reduces hospital readmissions and length of stay at hospital up to 18 months of follow-up. j nutr health aging. 2023;27(8):632-640.
2] blondal bs, geirsdottir og, beck am, et al. homefood randomized trial-beneficial effects of 6-month nutrition therapy on body weight and physical function in older adults at risk for malnutrition after hospital discharge. eur j clin nutr. 2023;77(1):45-54.
3] xie h, qiao lh, zhao y, et al. nutrition education with or without oral nutrition supplements has contrasting effects on nutrition status in older adults: a randomized controlled study. nutr clin pract. 2023;38(1):138-147.
4] han cy, sharma y, yaxley a,et al. individualized hospital to home, exercise-nutrition self-managed intervention for pre-frail and frail hospitalized older adults: the independence randomized controlled pilot trial. clin interv aging. 2023;18:809-825.
This article was originally published on "Healthy Aging Network" on December 7, 2023, authors: Lu Fei, Zhou Yaru, Liu Xiaohong, Department of Geriatrics, Peking Union Medical College, Chinese Academy of Medical Sciences and Peking Union Medical College.