Practicalities of Integrating Nutrition into Geriatric Care

• Dysphagia and malnutrition are modifiable conditions that diminish patient quality of life and heighten morbidity, mortality, and costs.
• Call for systematic validated screening to enable early nutrition intervention 
• Multi-disciplinary teams are best positioned to support patients  

 
Vevey, Switzerland, October 2011 – The Nestlé Nutrition Institute  organised  several complimentary
educational sessions at the 7th European Union Geriatric Medicine Society (EUGMS) Annual Congress
in Malaga, Spain.
 
At the Nestlé Nutrition Institute Satellite Symposium,  keynote speakers highlighted  the benefits of
integrated management of dysphagia and malnutrition. A multidisciplinary panel of experts, chaired by
Professor Maurits Vandewoude, Head of the Geriatrics Dept, University of Antwerp (Belgium), outlined
the magnitude of the problem for the patient as well as for health care systems. The pathophysiologic
mechanisms leading to the development of oropharyngeal dysphagia along with the available methods
for screening, identifying and treating this under-diagnosed condition were also discussed. Professor
Vandewoude commented, “Earlier  nutrition  intervention coupled with systematic screening will allow
multi-disciplinary teams to more effectively manage these under-diagnosed conditions and reduce the
economic and societal burden of these treatable life-threatening conditions.” 
 

Oropharyngeal dysphagia: A growing concern in health care 

Professor Rebecca Leonard, Clinical Director of the Voice and Swallowing  Centre, University of
California-Davis (USA), highlighted that unmanaged dysphagia can have severe health consequences
including malnutrition,  dehydration, and aspiration pneumonia which is associated with increased
mortality¹.  She discussed how the swallowing mechanism changes with age and how otherwise
healthy older individuals can suffer from dysphagia due to acute illness or certain medications.
Professor Leonard noted, “Our studies have shown that older adults need longer swallowing  time (25-
30%) and experience a reduced upper oesophageal opening”. Epidemiologic studies^{2, 3} suggest that 22% of over 50 year olds suffer from dysphagia, rising to nearly 40% in those over 60. In the US alone, of 77 million hospitalisations in 2004/5 the mortality rate associated with dysphagia was 13.7%. In addition, hospital stays were twice as long at an estimated cost of $547 million per year⁴.  
 

Pathophysiology of oropharyngeal dysphagia in the older adult

Dr. Helena Bascuñana Ambrós, Director of Physical Medicine and Rehabilitation Dept, Sant Pau
University Hospital, Barcelona (Spain), further explored the pathophysiology of dysphagia among older
adults. She emphasised the nature of the oropharyngeal musculature; most of the muscle fibres being
Type II which are powerful but tire quickly, and she  illustrated the positive effect that exercise can have
on reducing or reversing the atrophy in these muscles. Dr  Bascuñana  commented, “The optimal
intervention for older people with dysphagia is compensatory, rehabilitative, or a combination of both.”
She reported how her team has established a telemedicine rehabilitation program that makes use of the
internet to provide guided therapy to patients in their homes, to improve the cost-effectiveness of follow-
up care, and to avoid readmissions when their condition is not well-managed. 
 

Dysphagia and malnutrition: From screening to treatment 

Early identification of those at risk for dysphagia and malnutrition requires suitable screening tools for
these highly prevalent conditions among older people. Dr Rosa Burgos Peláez, Chief of the Nutritional
Support Unit, University Hospital Vall d’Hebron, Barcelona (Spain), focused on the need to consider the 2 of 2 sensitivity and specificity, and the ease of use when selecting a screening method.  She presented the protocol used in her region for early screening and management of dysphagia and malnutrition among patients  at-risk  of these conditions.  She reviewed in detail the screening tool for dysphagia,  Eating Assessment Tool  (EAT-10)⁵, an easy to perform test that is fast for patients to complete⁶, and how her team recently validated the Spanish version of this tool.  The group found that the EAT-10 was easy to understand  by over 95% of patients, quickly completed in less than 4 minutes, and useful to
differentiate those patients with dysphagia risk vs. a normal swallow⁷. Dr Burgos also discussed  the use of the Mini Nutritional Assessment short form (MNA®-SF)⁸, a highly sensitive and specific method to screen for malnutrition in  older adults. Both of these tools are provided by the  Nestlé Nutrition Institute as part of their on-going support of clinicians to improve patient quality of life through science-based nutrition  interventions. “These  screening methods are easy to perform and enable initiation of nutritional intervention that improves clinical  outcomes of malnourished patients and reduces costs associated with the condition, such as decreasing hospital stay (average reductions of 2 days or more) and readmissions (a 28% reduction)”, commented Dr Burgos^{9, 10}. 

Hands-on application of science-based nutrition solutions in geriatric care: A multi-disciplinary effort

The Nestlé Nutrition Institute¹¹ also organised a workshop, which used a patient case study approach to illustrate the practicalities of integrating nutrition into geriatric care. Prof Frederico Cuesta Triana, geriatrician at Hospital Clinico San Carlo, Madrid (Spain), and Prof Stéphane M Schneider, Head of the Nutritional Support Unit in the Digestive Dept, Nice University Hospital  (France), delivered a fully interactive session.  The case showed the integration of nutrition screening and evidence-based decision making to determine the appropriate nutrition intervention. The participants’ knowledge of the ESPEN guidelines on enteral nutrition amongst older adults was tested alongside their awareness of the importance of protein and  the effects of Vitamin D on  the  reduction of  falls and  fractures¹². Data shows that a Vitamin D dose of >400 IU/d results in a 20% risk reduction of non-vertebral fractures¹³ and 700 IU/d results in a 23% reduction in fall risk¹⁴. Also discussed was data from a 2009 Cochrane review which demonstrated a 21% decrease in mortality in undernourished older adults when they are supplemented with Oral Nutritional supplements¹⁵.  The workshop closed  with  consensus that  early nutritional intervention can  help prevent the downward spiral towards dependence which, associated with other co-morbidities, leads to a rapid decline in health, the need for institutionalisation and the associated economic and social burden.  
 
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Nestlé Health Science Marie-Françoise Rütimeyer Head of Communications marie-francoise.ruetimeyer@nestle.com +41 21 924 40 92

College Hill Lynne Trowbridge nestle@collegehill.com +44 20 7457 2020

                                          
References:
1   Clave et al. Clin Nutr. 2008; 27(6):806-15.
2  Ney et al. Nutr Clin Pract. 2009; 24(3):395-413.
3  Lind. Gastroenterol Clin North Am. 2003;32:553–575.
4  Altman et al. Arch Otolaryngol Head Neck Surg. 2010;136:784-789.
5  More information on: http://www.nestlenutrition-institute.org/PracticalTools/Documents/test1.pdf 
6  Belafsky et al. Annals of Otology Rhinology Laryngology. 2008;117(12):919-24.
7   Burgos et al. (2011, September). Translation and validation of the Spanish version of the Eating Assessment Tool-10(EAT-10) for the screening of Dysphagia. Poster session presented at the 33rd European Society for Clinical Nutrition and Metabolism (ESPEN) Congress, Gothenburg, Sweden.
8  More information on: www.mna-elderly.com 
9   Edited by Rebecca J Stratton, Ceri J Green, and Marinos Elia, 2003, Disease-Related Malnutrition: An Evidence-Based Approach To Treatment. Wallingford, United Kingdom. CABI Publishing.
10   Gariballa et al. Am J Med. 2006;119(8):693-9.
11  More information on: www.nestlenutrition-institute.org
12  Volkert et al. Clin Nutr. 2006;25(2):330-60.
13  Bischoff-Ferrari HA, et al. Arch Intern Med 2009;169:551-561.
14  Bischoff-Ferrari HA, et al. BMJ 2009;339:b3692.
15   Milne, AC et al. Cochrane Database of Systematic Reviews. 2, 2009.

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