Ernhrung bei Demenz

16. Workshop

Moderne klinische Ernhrung

Fokus Geriatrie
27. April 2011, Inselspital Bern

Prof. Dr. med. Reto W. Kressig

rkressig@uhbs.ch Extraordinarius f. Geriatrie Chefarzt

Akutgeriatrie
Akutgeriatrische Uniklinik - Memory Clinic Mobility Center

Outline
Introduction
Body Weight, Nutritional Status, and Dementia Nutritional interventions in patients with dementia Tube feeding Summary

Prvalenz der Demenz

40
Demenz (Jorm et al., 1987) Alzheimer (Bachmann et al., 1992) 36

Prvalenz (%)

30
23.8

20
10 0
0.4 0.9 61-64 3 9 5 1.8 3.6

18 10.5

65-69 70-74 75-79 80-84

85-93

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

Prevalence of Dementia in Switzerland

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

Cost of Dementia in Switzerland

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

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.

Course of the Alzheimers disease (State of the Art 2011) Dynamic biomarkers of the Alzheimers pathological cascade

Treatment

Jack CR Jr et al. Hypothetical model of dynamic biomarkers of the Alzheimer's pathological cascade. Lancet Neurol 2010 Jan;9(1):119-28.

Relationship between

Body Weight and Dementia

Weight loss precedes mild to moderate dementia

N = 299, community-dwelling Follow-up: 20 years (1970 1990) Result: Significant weight decrease after baseline in participants with diagnosis 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.

Accelerated weight loss preceding diagnosis of Alzheimer disease

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

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.

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.

Predictors of lean mass

Burns JM et al. Reduced lean mass in early Alzheimer Disease and its association with brain atrophy. Arch Neurol 2010;67:428-433.

Overweight in midlife: increased risk for dementia in later life

Hassing LB et al. Overweight in midlife and risk of dementia: a 40-year follow-up study. Int J Obes (Lond) 2009;33:893-8.

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

Overweight at midlife: Risk for dementia increased

Fitzpatrick AL et al. Midlife and late-life obesity and their risk of dementia: cardiovascular health Study. Arch Neurol 2009;66:336-42

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

Overweight at late life: Risk for dementia decreased

Fitzpatrick AL et al. Midlife and late-life obesity and their risk of dementia: cardiovascular health Study. Arch Neurol 2009;66:336-42

Overweight and obesity:

Protective against cognitive impairment and dementia?
Higher BMI was associated with poorer cognitive function in women with normal WHR (< 0.78)

Kerwin RD et al. The cross-sectional relationship between body mass index, waist-hip ratio, and cognitive Performance in postmenopausal women enrolled in the womens health initiative. J Am Geriatr Soc 2010;58:1427-32.

Higher waist-hip ratio (central fat mass ) was associated with higher cognitive function

x
x

Kerwin RD et al. The cross-sectional relationship between body mass index, waist-hip ratio, and cognitive Performance in postmenopausal women enrolled in the womens health initiative. J Am Geriatr Soc 2010;58:1427-32.

Women Health Initiative Study of Cognitive Aging

Association between weight changes and global cognitive function

No association between weight and cognition if weight stable or increased Only found association was between cognition and weight loss!
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]

Lower nutritional status by MNA: predictor of dementia progression in MCI

160 AD patients (CDR 0.5), follow-up 1 year 52.5% stable 47.5% progressive A baseline lower nutritional status (MNA) and a lower cognitive performance (AdasCog) : predictors of progression

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

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

Improving the nutritional status of people with dementia

Caregiver burden as a short-term predictor of weight loss in older Alzheimer Patients

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 loss Care giver burden of 36+ predicted weight loss

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

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.

Schulungsmanahmen ber die Ernhrung von Alzheimer-Patienten fr Betreuungspersonen

Ergebnisse Anstieg 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 der Kontrollgruppe 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

Increase of weight and lean body mass in AD patients

Setting: nursing home and day hospital

With oral supplements: (duration: 3 months)

weight lean body mass

+1,9 kg 2,33 +0,78 kg 1,4

No changes for cognition or physical function

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

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 difference Lower 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.

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 subjects Compensation at lunch in subjects with lower BMI, aberrant motor behavior, poorer attention, and increased confusion. Those likely to benefit: higher BMI, less aberrant motor problems, less mental confusion, increased attention
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.

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

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 Kontrollgruppe Beobachtungszeitraum 16 Wochen Ergebnis Signifikante Gewichtszunahme (p 0,005) in der Interventionsgruppe Abnahme der Supplementzufuhr um 25 %
Edwards NE et al. West J Nursing Res 2002; 24: 697 - 712

Steps of nutrition therapy

Artificial
Parenteral

Enteral Tube Feeding

?
+

Nutrition

Oral supplements

Oral nutrition

Enterale Sondenernhrung und Demenz

Leitlinie Enterale Ernhrung Geriatrie und geriatrisch-neurologische Rehabilitation, Aktuel Ernaehr Med 2004

Mortalitt
4 Studien bei geriatrischen dementen Patienten ohne Reduktion der Mortalitt
Nair S et al. Am J Gastroenterol 2000: 95: 133 136 Mitchell SL et al. Arch Intern Med 1997; 157: 327 332 Meier DE et al. Arch Intern Med 2001: 161: 594 599 Murphy LM et al. Arch Intern Med 2003; 1351 1353

1 Studie mit Nachweis eines berlebensvorteils

Rudberg MA et al. J Parent Ent Nutr 2000; 24: 97 102

Nachweis einer erhhten Mortalitt von dementen PEGPatienten im Vergleich zu anderen Populationen

Enterale Sondenernhrung und Demenz

Leitlinie Enterale Ernhrung Geriatrie und geriatrisch-neurologische Rehabilitation, Aktuel Ernaehr Med 2004

Orale Supplemente und Sondenernhrung fhren zu einer Verbesserung des Ernhrungszustands. Sie werden in frhen und mittleren Krankheitsstadien empfohlen (C).

Die Entscheidung fr Sondenernhrung bei fortgeschrittener Demenz bleibt eine Einzelfallentscheidung (C). Bei final dementen Patienten wird eine Sondenernhrung nicht empfohlen (C).

PEG und Demenz

Grundlagen der Entscheidung zur Sondenernhrung 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 im Rahmen der enteralen Ernhrung Sozio-kultureller Kontext

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 der Ernhrung bei Demenzkranken

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

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