07 Kressig RW, Ernährung bei Demenz 2011

7/28/2019 07 Kressig RW, Ernhrung bei Demenz 2011

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Ernhrung bei Demenz

16. WorkshopModerne klinische Ernhrung

Fokus Geriatrie27. April 2011, Inselspital Bern

Prof. Dr. med. Reto W. Kressig

[email protected]

Extraordinarius f. GeriatrieChefarzt

AkutgeriatrieAkutgeriatrische Uniklinik - Memory Clinic Mobility Center


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Introduction

Body Weight, Nutritional Status, and Dementia

Nutritional interventions in patients with dementia

Tube feeding

Summary

Outline


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0

10

20

30

40 Alzheimer (Bachmann et al., 1992)

Alter (Jahre)

Prvalen

z(%)

85-9380-8475-7970-7465-6961-64

Demenz (Jorm et al., 1987)

0.90.4

3.6

10.5

23.8

1.8

18

59

3

36

Prvalenz der Demenz

Jorm et al. Acta Psychiatr Scand 1987;76(5):465-79.Bachman et al. Neurology 1992;42(1):115-9.


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Kraft E et al. Cost of Dementia in Switzerland. Swiss Med Wkly 2010;140:w13093

Prevalence of Dementia in Switzerland


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Kraft E et al. Cost of Dementia in Switzerland. Swiss Med Wkly 2010;140:w13093

Cost of Dementia in Switzerland


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Role of symptomatic AD treatments in delay of

Nursing Home Admission

Lopez OL et al. Long-term effects of the concomitant use of memantine with cholinesterase

inhibition in Alzheimer disease. J Neurol Neurosurg Psychiatry 2009;80:600-7.


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Course of the Alzheimers disease (State of the Art 2011)

Dynamic biomarkers of the Alzheimers pathological cascade

Jack CR Jr et al. Hypothetical model of dynamic biomarkers of the Alzheimer's pathological cascade.

Lancet Neurol 2010 Jan;9(1):119-28.

Treatment


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Relationship between

Body Weight and Dementia


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Weight loss precedes

mild to moderate dementiaN = 299, community-dwellingFollow-up: 20 years (1970 1990)

Result:Significant weight decrease after baseline in participants withdiagnosis of dementia in 1990 (n=50)

No significant weight loss in cognitively stable participants

Barrett-Connor E et al. Weight loss precedes dementia in community-dwelling older adults.J Am Geriatr Soc 1996;44:1147-52.


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Accelerated weight loss

preceding diagnosis of

Alzheimer disease

Johnson DK et al. Accelerated weight loss mayprecede diagnosis in Alzheimer disease.

Arch Neurol 2006;63:1312-7.


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Weight loss in preclinical Alzheimers Disease

Responsible mechanisms unknown.

Psychosocial (..forget to eat)?

Caregiver burden?Depression?Reduced appetite?Changes in taste and smell?

Ongoing pathophysiologic changes (inflammation?)in preclinicial AD are related to weight loss.

Weight loss = early manifestation of AD ( AD risk factor)

Johnson DK et al. Accelerated weight loss may precede diagnosis in Alzheimer disease.Arch Neurol 2006;63:1312-7.


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Total lean mass reduced in early AD

Burns JM et al. Reduced lean mass in early Alzheimer Disease and its association with

brain atrophy. Arch Neurol 2010;67:428-433.


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Burns JM et al. Reduced lean mass in early Alzheimer Disease and its association with

brain atrophy. Arch Neurol 2010;67:428-433.

Predictors of lean mass


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Fitzpatrick AL et al. Midlife and late-life obesity

and their risk of dementia: cardiovascular healthStudy. Arch Neurol 2009;66:336-42

Overweight at midlife:

Risk for dementia increased

Risk of dementia by BMI at midlife (age 50 years)


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Fitzpatrick AL et al. Midlife and late-life obesity

and their risk of dementia: cardiovascular healthStudy. Arch Neurol 2009;66:336-42

Risk of dementia by BMI at late life ( 65 years)

Overweight at late life:Risk for dementia decreased


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Overweight and obesity:Protective against cognitive impairment and dementia?

Higher BMI was associated with poorer cognitive functionin women with normal WHR (< 0.78)

Kerwin RD et al. The cross-sectional relationship between body mass index, waist-hip ratio, and cognitivePerformance in postmenopausal women enrolled in the womens health initiative. J Am Geriatr Soc 2010;58:1427-32.
http://www.google.ch/imgres?imgurl=http://www.vallys.nl/vallyfun/funpics2/0576,-wespentaille.jpg&imgrefurl=http://www.vallys.nl/vallyfun/funpics2/taille2.htm&usg=__B2-OhZPJBoCJuMZIQjTC31suEcg=&h=434&w=300&sz=18&hl=de&start=5&zoom=1&tbnid=JnDIfuSAmc2SQM:&tbnh=126&tbnw=87&ei=1vmvTcj_LIat8gPzycXpCw&prev=/images%3Fq%3DWespentaille%26hl%3Dde%26gbv%3D2%26tbm%3Disch&itbs=1


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xx x

x x

x

x

Higher waist-hip ratio (central fat mass )

was associated with higher cognitive function

Kerwin RD et al. The cross-sectional relationship between body mass index, waist-hip ratio, and cognitivePerformance in postmenopausal women enrolled in the womens health initiative. J Am Geriatr Soc 2010;58:1427-32.
http://nadelundfaden.beate-zaech.de/wp-content/nadelundfaden_uploads/2008/12/img_4410.jpg


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Women Health Initiative Study of Cognitive Aging

Association between weight changes

and global cognitive function

Driscoll I et al. Weight Change and Cognitive Function: Findings From the Women's Health Initiative

Study of Cognitive Aging. Obesity (Silver Spring). 2011 Mar 10. [Epub ahead of print]

No association between weight and cognition if weight stable or increased

Only found association was between cognition and weight loss!


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Ousset PJ et al. Nutritional status is associated with disease progression in veryMild Alzheimer disease. Alzheimer Dis Assoc Diord 2008;22:66-71.

Lower nutritional status by MNA:

predictor of dementia progression in MCI

160 AD patients (CDR 0.5), follow-up 1 year

52.5% stable47.5% progressive

A baseline lower nutritional status (MNA) and a lowercognitive performance (AdasCog) : predictors of progression


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Massive weight loss in Alzheimers disease

Rapid weight loss ( 5kg/6 months) during a 6.5 year follow-up

N = 395 AD-patients

Independently associated with rapid weight loss:

BPSD (behavioral & psychological symptoms of dementia)(HR 1.05)

Death at 6 months (HR 3.01)

Cholinesterase-inhibitors appeared as protective (HR 0.33)

Gurin O et al. Characteristics of Alzheimers disease patients with a rapid weight loss during a

six-year follow-up. Clinical Nutrition 2009;28:141-6


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Improving the nutritional status

of people with dementia


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Caregiver burden as a short-term predictor

of weight loss in older Alzheimer Patients

Bilotta C et al. Caregiver burden as a short-term predictor of weight loss in older outpatients suffering from

mild to moderate Alzheimer's disease: a three months follow-up study. Aging Ment Health 2010;14:481-8.

N = 150, Age 70 y., mild to moderate AD, community-dwelling,at least one informal care giver, follow-up of 3 months

Weight loss: 3% of baseline weight

Care giver burden inventory scale in the highest tertile (36+ out of 96)

Results:23% of patients with weight lossCare giver burden of 36+ predicted weight loss

OR 13.93 (CI 1.91-101.33, p=0.009)


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Schulungsmanahmen ber die Ernhrung

von Alzheimer-Patienten fr Betreuungspersonen

ErgebnisseAnstieg des Gewichtes in der Interventionsgruppe(0,7 3,6 kg) gegenber Kontrollen (-0,7 5,4 kg) n.s.

Weniger Patienten mit signifikantem Gewichtsverlust(> 4 %) in der Interventionsgruppe

MNA in der Interventionsgruppe konstant, in derKontrollgruppe signifikanter Abfall

Abfall des MMSE in der Interventionsgruppe signifikant

niedriger als unter den Kontrollen

Riviere S et al, J Nutr Health Aging 2001; 5: 295 - 299


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Lauque S et al, Am J Geriatr Soc 2004;52:1 6.

Increase of weight and lean body mass in AD patientsSetting: nursing home and day hospital

With oral supplements: weight +1,9 kg 2,33(duration: 3 months) lean body mass +0,78 kg 1,4

No changes for cognition or physical function


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Dementia and Nutrition

1-year intervention study in AD nursing home patients

25 patients with nutritional supplements,

74 controls

Results (intervention group):Higher values: Alb, Pre-Alb, BMI, MNA, triceps skinfold

No significant mortality differenceLower infection rate (47 vs. 66 %) p = 0,05

No difference: cognition, functional dependence

Gregorio PG et al, J Nutr Health Aging 2004;7:304 8.


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Young KWH et al. Providing nutrition supplements to institutionalized seniors with probable Alzheimers

disease is least beneficial to those with low body weight status. J Am Geriatr Soc 2004;52:1305-12.

Nutrition Supplements in AD Patients

N = 34 institutionalized AD patients who ate independently

Intervention: nutrition supplement (between breakfast and lunch)for 21 consecutive days (control: 21 days of habitual intake)

Results: 24h energy intake only increased in 21 of 31 subjectsCompensation at lunch in subjects with lower BMI, aberrant motorbehavior, poorer attention, and increased confusion.

Those likely to benefit: higher BMI, less aberrant motorproblems, less mental confusion, increased attention


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Improving the nutritional status

of people with dementia

Food thickener for patients with swallowing disorders

Finger Food

Snacks between traditional meals Less importance of three traditional meels

Less healthy food, give what patients know and like

Increase of body weight over 6 years of follow-up

Biernacki C et al. Br J Nursing 2001; 10: 1104 - 1114


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Effekt von Aquarien in den Speiserumen auf

Nahrungsaufnahme und Gewichtsentwicklung

62 Bewohner eines Seniorenheimes

Aquarien mit lebenden Fischen in den Speiserumen

fr die Interventionsgruppe

Fototapete mit Seeblick fr die KontrollgruppeBeobachtungszeitraum 16 Wochen

Ergebnis

Signifikante Gewichtszunahme (p 0,005) in derInterventionsgruppeAbnahme der Supplementzufuhr um 25 %

Edwards NE et al. West J Nursing Res 2002; 24: 697 - 712


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Artificial Nutrition

Steps of nutrition therapy

Oral supplements

Oral nutrition

+

EnteralTube Feeding

Parenteral

?


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Enterale Sondenernhrung und DemenzLeitlinie Enterale Ernhrung Geriatrie und geriatrisch-neurologischeRehabilitation, Aktuel Ernaehr Med 2004

Mortalitt

4 Studien bei geriatrischen dementen Patienten ohneReduktion der Mortalitt

Nair S et al. Am J Gastroenterol 2000: 95: 133 136Mitchell SL et al. Arch Intern Med 1997; 157: 327 332Meier DE et al. Arch Intern Med 2001: 161: 594 599Murphy LM et al. Arch Intern Med 2003; 1351 1353

1 Studie mit Nachweis eines berlebensvorteilsRudberg MA et al. J Parent Ent Nutr 2000; 24: 97 102

Nachweis einer erhhten Mortalitt von dementen PEG-Patienten im Vergleich zu anderen Populationen


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Enterale Sondenernhrung und DemenzLeitlinie Enterale Ernhrung Geriatrie und geriatrisch-neurologischeRehabilitation, Aktuel Ernaehr Med 2004

Orale Supplemente und Sondenernhrung fhren zueiner Verbesserung des Ernhrungszustands.

Sie werden in f rhen und m itt leren Krankheits-stadienempfohlen (C).

Die Entscheidung fr Sondenernhrung bei for t -gesch ri t tener Demenzbleibt eine Einzelfall-

entscheidung (C).

Bei f inal dementen Pat ientenwird eine Sonden-

ernhrung nicht empfohlen (C).


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PEG und Demenz

Grundlagen der Entscheidung zur Sonden-ernhrung bei Demenz

der (mutmaliche) Wille des Patienten

die Schwere der Erkrankung

die individuelle Prognose

die Lebensqualitt mit und ohne enterale Ernhrung

mgliche Komplikationen und Beeintrchtigungen imRahmen der enteralen Ernhrung

Sozio-kultureller Kontext


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Basismanahmen in der Ernhrung von

Patienten mit Demenz

Gewhrleistung

eines ausreichenden Angebots an Getrnken

einer Auswahl an Speisen

von genug Zeit zur Nahrungsaufnahme

von Hilfe bei der Nahrungsaufnahme

von Spezialwissen zum Problem derErnhrung bei Demenzkranken


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Voraussetzungen einer erfolgreichen Therapie

von Ernhrungsproblemen bei Demenz

Interdisziplinrer Ansatz Pflegefachvertreter

Ernhrungsberater/in

Logopde/in

Kche/Caterer

Ergotherapie

Arzt Bereitstellung ausreichender personeller und

finanzieller Ressourcen


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Ernhrung bei Demenz

Zusammenfassung

Gewichtsverlust u. Malnutrition = Folge einer Demenz

Rascher Gewichtsverlust = rasch progrediente Demenz Ernhrungsmassnahmen mglich u. eher erfolgreich, wenn

frh eingeleitet

Antidementiva: protektiv!

Wichtigkeit v. Sensibilisierung, Schulung, Interdisziplinaritt Antizipation von Sondenernhrung mittels Patientenverfgung

Einbezug v. ethischen u. soziokulturellen Aspekten

Documents

07 Kressig RW, Ernährung bei Demenz 2011