Indications for percutaneous endoscopic gastrostomy and survival in old adults

Background : Many diseases striking old adults result in eating difficulties. Indications for selecting individuals for percutaneous endoscopic gastrostomy (PEG) are unclear and everybody may not benefit from the procedure. Objective : The aim of this study was to evaluate indications for and survival after PEG insertion in patients older than 65 years. Design and Methods : A retrospective analysis including age, gender, diagnosis, indication, and date of death was made in 201 consecutive individuals, 94 male, mean age 79±7 years, who received a nutritional gastrostomy. Results: Dysphagia was present in 86% of the patients and stroke was the most common diagnosis (49%). Overall median survival was 123 days and 30-day mortality was 22%. Patients with dementia and Mb Parkinson had the longest survival (i.e. 244 and 233 days), while those with other neurological diseases, and head and neck malignancy had the shortest (i.e. 75 and 106 days). There was no difference in mortality in patients older or younger than 80 years, except in patients with dementia. Conclusions: Old age should not be a contraindication for PEG. A high 30-day mortality indicates that there is a need of better criteria for selection and timing of PEG insertion in the elderly

Urinary phosphate is associated with cardiovascular disease incidence

Elevated phosphate (P) in urine may reflect a high intake of inorganic P salts from food additives. Elevated P in plasma is linked to vascular dysfunction and calcification. Objective, To explore associations between P in urine as well as in plasma and questionnaire-estimated P intake, and incidence of cardiovascular disease (CVD). Methods, We used the Swedish Mammography Cohort-Clinical, a population-based cohort study. At baseline (2004–2009), P was measured in urine and plasma in 1625 women. Dietary P was estimated via a food-frequency questionnaire. Incident CVD was ascertained via register-linkage. Associations were assessed using Cox proportional hazards regression. Results, After a median follow-up of 9.4 years, 164 composite CVD cases occurred (63 myocardial infarctions [MIs] and 101 strokes). Median P (percentiles 5–95) in urine and plasma were 2.4 (1.40–3.79) mmol/mmol creatinine and 1.13 (0.92–1.36) mmol/L, respectively, whereas dietary P intake was 1510 (1148–1918) mg/day. No correlations were observed between urinary and plasma P (r = −0.07) or dietary P (r = 0.10). Urinary P was associated with composite CVD and MI. The hazard ratio of CVD comparing extreme tertiles was 1.57 (95% confidence interval 1.05, 2.35; P trend 0.037)—independently of sodium excretion, the estimated glomerular filtration rate, both P and calcium in plasma, and diuretic use. Association with CVD for plasma P was 1.41 (0.96, 2.07; P trend 0.077). Conclusion, Higher level of urinary P, likely reflecting a high consumption of highly processed foods, was linked to CVD. Further investigation is needed to evaluate the potential cardiovascular toxicity associated with excessive intake of P beyond nutritional requirement

Physical activity and energy expenditure in haemodialysis patients: an international survey

Background. The assessment of physical activity and energy expenditure is relevant to the care of maintenance haemodialysis (MHD) patients. In the current study, we aimed to evaluate measurements of physical activity and energy expenditure in MHD patients from different centres and countries and explored the predictors of physical activity in these patients. Methods. In this cross-sectional multicentre study, 134 MHD patients from four countries (France, Switzerland, Sweden and Brazil) were included. The physical activity was evaluated for 5.0 ± 1.4 days (mean ± SD) by a multisensory device (SenseWear Armband) and comprised the assessment of number of steps per day, activity-related energy expenditure (activity-related EE) and physical activity level (PAL). Results. The number of steps per day, activity-related EE and PAL from the MHD patients were compatible with a sedentary lifestyle. In addition, all parameters were significantly lower in dialysis days when compared to non-dialysis days (P < 0.001). The multivariate regression analysis revealed that diabetes and higher body mass index (BMI) predicted a lower PAL and older age and diabetes predicted a reduced number of steps. Conclusions. The physical activity parameters of MHD patients were compatible with a sedentary lifestyle. This inactivity was worsened by aging, diabetes and higher BMI. Our results indicate that MHD patients should be encouraged by the health care team to increase their physical activit

Prevalence and risk of protein-energy wasting assessed by subjective global assessment in older adults with advanced chronic kidney disease:results from the EQUAL study

Prevalence and risk factors for protein-energy wasting (PEW) are poorly studied in the nondialysis, older population with advanced chronic kidney disease (CKD). Our aim was to evaluate the prevalence of PEW in advanced stage CKD patients aged greater than 65 years. Furthermore, we aimed to describe risk factors for PEW in the overall study population and among obese individuals. Prospective observational cohort study. 2not on dialysis attending nephrology care. PEW was assessed by 7-point Subjective Global Assessment (7-p SGA). 2), 25% were diagnosed with protein wasting. Risk factors for SGA ≤5 in obese people were similar to those for the overall study population. This European multicenter study shows that the prevalence of PEW is high in patients with advanced CKD aged >65 years. The risk of PEW increases substantially with age and is commonly characterized by muscle wasting. Our study suggests that focus on nutrition should start early in the follow-up of older adults with CK

Effects of DHA- Rich n-3 Fatty Acid Supplementation on Gene Expression in Blood Mononuclear Leukocytes: The OmegAD Study

Background: Dietary fish oil, rich in n-3 fatty acids (n-3 FAs), e. g. docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), regulate inflammatory reactions by various mechanisms, e. g. gene activation. However, the effects of long-term treatment with DHA and EPA in humans, using genome wide techniques, are poorly described. Hence, our aim was to determine the effects of 6 mo of dietary supplementation with an n-3 FA preparation rich in DHA on global gene expression in peripheral blood mononuclear cells. Methods and Findings: In the present study, blood samples were obtained from a subgroup of 16 patients originating from the randomized double-blind, placebo-controlled OmegAD study, where 174 Alzheimer disease (AD) patients received daily either 1.7 g of DHA and 0.6 g EPA or placebo for 6 months. In blood samples obtained from 11 patients receiving n-3 FA and five placebo, expressions of approximately 8000 genes were assessed by gene array. Significant changes were confirmed by real-time PCR. At 6 months, the n-3 FAs group displayed significant rises of DHA and EPA plasma concentrations, as well as up-and down-regulation of nine and ten genes, respectively, was noticed. Many of these genes are involved in inflammation regulation and neurodegeneration, e. g. CD63, MAN2A1, CASP4, LOC399491, NAIP, and SORL1 and in ubiqutination processes, e. g. ANAPC5 and UBE2V1. Down-regulations of ANAPC5 and RHOB correlated to increases of plasma DHA and EPA levels. Conclusions: We suggest that 6 months of dietary n-3 FA supplementatio

Matens betydelse vid demenssjukdom

Studier har visat att äldre med demenssjukdom väger mindre än äldre utan demenssjukdom. Viktminskning är vanligast hos dem, som drabbas av Alzheimer's sjukdom och den verkar öka med sjukdomens svårighetsgrad. Förmodligen är det olika faktorer, som samverkar vid denna viktnedgång. Sjukdomen påverkar t. ex. vår inlärda och reflexmässiga förmåga att handla mat, laga mat, komma ihåg att äta och komma ihåg hur man äter. Oro, rastlöshet och ångest bidrar till att det kan vara svårt att äta i lugn och ro. Vid Alzheimer's sjukdom finns även en inflammatorisk aktivitet, som kan inverka negativt på aptiten och därmed matintaget. För att försöka påverka sjukdomen, och därigenom förbättra livskvaliteten hos personer med demenssjukdom, måste man undersöka och förstå sambanden mellan näringsintag och fysisk funktionsförmåga. Kostbehandling kan bidra till viktuppgång vid lätt till medelsvår demenssjukdom. Om man kan påverka minnesfunktionen med kostfaktorer kvarstår att bevisa. Den kost, som ofta rekommenderas allmänt idag den s.k. Medelhavskosten d.v.s. mycket frukt och grönsaker, måttligt med vin samt mycket fisk verkar ha en skyddande effekt även när det gäller Alzheimer's sjukdom. Mat som skyddar hjärtat verkar också skydda hjärnan

Nutritional status and cognitive function in frail elderly subjects

Longevity, frailty and chronic disease are often associated with protein energy-malnutrition (PEM). Subjects with dementia are at particular risk for PEM. The overall aims of this thesis were to evaluate relationships between nutrition, cognition and functional capacity and to assess interventional means of developing the nutritional care of elderly. In study I and 11, the nutritional status and the cognitive function were examined in 28 and 80 service flat (SF) residents. Furthermore, the effect of a nutrition education programme to SF care staff was evaluated. In study 111, 22 and 14 subjects living in two group living units for demented (GLD) participated and the effects of nutritional supplementation and education to care personnel were evaluated. In study IV, possible relationships between weight, weight change and cognitive function were studied in 231 patients, admitted to a geriatric ward for examination of cognitive dysfunction. Seven-year mortality in relation to dementia diagnosis and nutritional status was also studied (IV). The nutritional status was assessed by Body mass index (BMI=kg/M2), triceps skin fold (TSF), and arm muscle circumference (AMC). Study I and 11 included a modified Subjective Global Assessment (SGA). Muscle strength was measured with a Harpenden Grip Strength Dynamo-Meter@ (1, 11). As biochemical nutritional markers in serum, albumin, transferrin, haemoglobin, C-reactive protein (CRP), vitamin B 12, folic acid and insulin-like growth factor-1 (Igf-1) (I-III) were analysed. Cognitive and functional status was assessed by the Mini Mental State Examination (MMSE) (0-30p, I-IV), Clinical Dementia Rating Scale (CDR) (0-3, 111) and Katz' ADL-index (1-111). Care personnel at the SF (I-III) complexes attended 12-hour nutritional education program. The care personnel answered a questionnaire before and after the education that reflected their knowledge and attitudes about nutrition in elderly (I, II). Oral supplements (410 kcal/1720 kJ) were given daily during 5 months to residents in one of the two GLD units and the personnel attended a nutritional education programme (III). Mortality data (IV) were obtained from Swedish population records. Up to one third of the SF residents were assessed as malnourished or at risk for PEM according to SGA (1-11). The education program tended to improve the knowledge of the care personnel in study 1. In study 11 there was no significant difference in improvement between the staff at the two SF complexes. Objective measures of nutritional status and cognitive function in the residents was not changed at 5and 6-months follow-ups, whereas SGA appeared to improve after the educational intervention (11). The combined intervention in study III resulted in a weight gain of 3.4 ±11.2 kg (p=0.00 1) 6 months later, that was not seen in the control group. The weight gain was not related to an improvement in ADLcapacity or cognitive function (MMSE). A BMI <23 was noticed in more than half of 231 patients admitted for diagnostic evaluation of cognitive function (IV). The weight increased by 0.5 kg (p<0.001) during a 3-week hospital stay. Concurrently, an increase in MMSE by 1 point was noticed (p=0.0001). The changes in weight and MMSE did not correlate. BMI <23 seemed to predict shorter survival (OR 3, 95% Cl 1.3-6.7), even after adjustment for age, gender and comorbidity, whereas type and degree of dementia were not related to 7-year mortality. In conclusion, a limited nutrition education programme to care personnel did not affect the nutritional status of SF residents 5-6 months later. No overt improvements in the knowledge of the care staff were observed. Nutritional status was related to cognitive function. Care staff education and oral supplementation resulted in weight gain in GLD residents. A BMI <23 seemed to predict mortality in individuals with cognitive failure. More studies are needed to settle the relationships between nutrition and cognition in elderly individuals

The Relation between Masticatory Function and Nutrition in Older Individuals, Dependent on Supportive Care for Daily Living

Introduction: Associations between masticatory function and nutritional status have been suggested. Masticatory function can be divided into two subdomains, the objective capacity of an individual to mix solid food and the individual's subjectively assessed ability to masticate solid food. Aim: The aims of this study were to assess the relationship between these subdomains and nutritional variables in older, care-dependent individuals. Materials and methods: From a group of 355 individuals with care dependency and functional limitations, individuals aged 60 and older were selected. By home visits, the subjects underwent an oral examination and answered chewing related questions. Nutritional status was assessed using the Mini Nutritional Assessment. A total of 196 individuals met the age requirement of 60 years or older. Of these, 86 subjects were able to answer the questions. Results: We could not find any concluding significant associations between the subdomains of masticatory function or the nutritional variables. Conclusions: The absence of associations could be explained by the lack of standardized and validated methods to assess masticatory function and they possibly reflect varying underlying constructs. Self-reported questionnaires seem less useful among older and care-dependent individuals, while an objective clinical measurement will be needed when evaluating masticatory function

Nutritional assessment and post-procedural complications in older stroke patients after insertion of percutaneous endoscopic gastrostomy – a retrospective study

Background: Oropharyngeal dysphagia is one of the major complications of stroke and a risk factor for malnutrition and prolonged in-hospital stay. Objective: The overall aim was to describe to what extent nutritional assessments (i.e. BMI kg/m2, eating problem, and weight loss) were performed and documented in the records of older stroke patients treated with enteral nutrition by percutaneous endoscopic gastrostomy (PEG). A secondary aim was to identify documented post-procedural complications after PEG insertion during hospital stay. Design: The study is retrospective. Data were collected from records of 161 stroke patients ≥65 years, who received PEG, admitted to three stroke units during a 4-year period. Results: Mean age of the patients was 82.2 (±7) years, and 86% of the patients were ≥75 years old. On admission, body weight was documented in 50% of the patients and at discharge in 38% of the patients. BMI data were not documented at all at discharge in one of the units. Almost 80% of the patients fulfilled the European Network criteria for multimorbidity. Morbidity and multimorbidity correlated to the length of stay (p<0.0005). Complications were reported in 111 (69%) of the patient records. In 53 patients (33%) more than one complication was reported. A total of 116 pressure ulcers were reported and 30 patients had more than one pressure ulcer. The number of complications was related to weight loss (p=0.046) and BMI change (p=0.018). Conclusions: Essential information of the patient's nutritional status was poorly recorded which could affect the patient's nutritional treatment during the hospital stay. This study indicates that implementation of guidelines in patients with stroke is needed. The high number of pressure ulcers was an unexpected finding

The Nordic Prudent Diet Reduces Risk of Cognitive Decline in the Swedish Older Adults: A Population-Based Cohort Study

Appropriate dietary pattern for preserving cognitive function in northern Europe remains unknown. We aimed to identify a Nordic dietary pattern index associated with slower cognitive decline compared to the Mediterranean-DASH Intervention for Neurodegenerative Delay, Mediterranean Diet, Dietary Approaches to Stop Hypertension, and Baltic Sea Diet indices. A total of 2223 dementia-free adults aged ≥60 were followed for 6 years. Mini-Mental State Examination was administrated at baseline and follow-ups. Dietary intake was assessed by 98-item food frequency questionnaire, and the Nordic Prudent Dietary Pattern (NPDP) was identified. Data were analysed using mixed-effects and parametric survival models and receiver operating characteristic curves with adjustment for potential confounders. Moderate (β = 0.139, 95% CI 0.077−0.201) and high adherence (β = 0.238, 95% CI 0.175−0.300) to NPDP were associated with less cognitive decline compared to other four indices. High adherence to NPDP was also associated with the lowest risk of MMSE decline to ≤24 (HR = 0.176, 95% CI 0.080−0.386) and had the greatest ability to predict such decline (area under the curve = 0.70). Moderate-to-high adherence to the NPDP may predict a better-preserved cognitive function among older adults in Nordic countries. Regional dietary habits should be considered in developing dietary guidelines for the prevention of cognitive impairment and dementia