NUTRITION IN GERIATRIC WITH COPD

HARUN ALRASYID DAMANIK

FAC.OF MEDICINE UNIVERSITY OF SUMATERA UTARA

/GENERAL HOSPITAL H.ADAM MALIK MEDAN

OBJECTIVES

TO RAISE THE AWARENESS OF MEDICAL NUTRITION WITH RESPIRATORY HEALTHCARE AND GERIATRIC PATIENTS

TO PROVIDE A SIMPLE TOOL TO AID FIRST LINE

MEDICAL NUTRITIONAL THERAPY

TO IMPROVE THE NUTRITIONAL STATUS OF THE GERIATRIC PATIENTS (NUTR.CARE PLAN & MONITOR)

TO UNDERSTAND POSSIBLE, FUTURE, NUTRITION STRATEGY

Epid. & Pathophysiology

Pathophysiology: chronic lung inflammation in response to noxious particles,gases; the 4th cause of death in the world

Taking less O2, retaining CO2

Emphysema,chronic bronchitis,ashmatic bronchitis (irreversible)

“Pink Puffers:significant weight loss,”Blue Bloaters”: normal-overweight

Protein energy malnutrition as a consequence of disease progression

Not apparent until damage is done (underdiagnosed/treatment)

COPD theories & discoveries

1968: rare geneticmarker, defic. α-one-antitrypsin

2006: autoimmune disease

2008:systemic inflammation ↑ plasma leptinRise global mortality (3rd leading cause worldwide,2020)

National Health Education Program

Tayde P,kumar S .COPD in the elderly.Asian J Gerontol Geriatrn2013: 8:90-7

Body Weight in COPD patients

25-40% (FEV1< 50%): significant weight loss

(> 5 % in past 3 months,or >10% in the past 6 month)

Frequently underweight (30-50% by different studies)

Normal BMI with ↓FFM : MR with low BMI and depletion of FFM

17-21 % with Very low BMI (<20 kg/m2),38-45 % with lean body mass depletion

Vestbo et al.Copenhagen City Heart Study.Am J. Resp Crit Care Med 2006,173

Effect of COPD on nutrition

A catabolic wasting disease (19%-74% malnutrition)

Dyspnea & coughing dietary intake <

Fatigue: buying and preparing food ?

Chronic mouth breathingtaste of food ?

Headaches,mental status changes cause by hypercapnia

Pharmacologic agents

Benson et al,Nutr.Clin Prac 5,1990 Antonione R.Basic in Clinical Nutrition 4th ed.ESPEN 2011

COPD....

Low grade inflammatory condition ↑proinflammatory cytokines liver need muscular amino acid to maintain acute phase mediator.

Cytokine direct action on muscle tissue ↓FFM

↑Energy demand during ventilation & systemic inflammationREE >

Systemic inflammatory condition insulin resistance & hyperglycaemia metabolic ?

COPD.............

Mortality by malnutrition (BMI in BODE index)

Respiratory muscle strength <<

Aerobic metabolism <<

Surfactant synthesis & elastic fibre in lung parenchyme <<

↑dyspnea & ventilatory drive

Prolonged ventilators weaning QOL & MR

Impaired immune function (undernutrition) systemic & pulmonal defenceinfection & mortality >

Nutritional Screening

A. S G A

History

Weight Change

Dietary Intake Change Relative to Normal

GI Symptoms (Persisting more than 2 weeks)

Functional Capacity

Disease and its relationship to nutritional requirements

Physical Examination

Loss of subcutaneous fat (triceps, chest)

Muscle wasting (quadriceps, deltoids)

Ankle edema, Sacral Edema

For Each Specify: 0= normal, 1+= Mild, 2+ = Moderate, 3+ = Severe

SGA Rating

Well nourished

Moderately (or suspected of being) malnourished

Severely malnourished

B. Regularly screening (elderly with COPD) using a tool like MNA:

a.Food decline d.Psychological/acute disease

b.Weight loss e.Neuropsychologic problem

c.Mobility f.BMI

>12 point not at risk/no need complement assessment

<11 point possible malnutrition continue assessment

(subtotal screening score 14)

MNA vs SGA in geriatic COPD

patients

Identified more patient as malnutritioned than SGA

Early diagnosis & early administration of MNT

SGA correlated with frequent hospital admissionsbad prognostic markers in COPD

Yuceege MB et al.The Evaluation Of Nutrition in Male COPD using SGA and MNA.International Journal of Internal Medicine 2013,2(1):1-5

Assessment

FFM relates closely to muscle mass gold standard for nutritional evaluation for respiratory failure

Estimated by:

- Anthropometric (skinfold determination)

- Bioimpendance analysis (BIA)

- Dual energy x-ray absorptiometry (DEXA)

FFM depleted FFM index (kg FFM –m2) < 16(♂) and < 15 (♀)

Simple Steps:

1.Review weight history (BW < ?)

2.Calculate BMI

3.Current Nutritional Status

4.Identify for new guideline

5.Appropiate action

6.Review and monitor: quick check about poor quality diet,BW and nutrition every appointment

Nici et al.ATS/ERS Statement on Pulmonary Rehab.Am J Respir Crit Care Med 2006,173:1390-1413

Open question

1.How is your appetite?

2.Are you managing to eat?

3.Any changes in your weight?

4.Any changes to your body shape(muscle strength)?

5.Do you have any concerns about your food intake and diet?

Specific Nutrition Concerns

Shortness of breath/swallowing air

Bloating or gas

Thick mucus

Dental problem

Fatigue

Reliance on oxygen

Constipation

Chronic Disease Network and Access Program 2009

• Intercurrent Illness• Hypercytokinemia

in response to disease

• Increased effort in breathing

Weight Loss

Muscle Waisting

Abnormal diaphragmatic function

Abdominal Distension

and GI Congestion

Difficulty in Eating

Hypoxemia Acidosis

Increased Metabolic

Rate

Metabolic and

Hormonal Aterations

Insulin Resistance, reduced IGF-1,

Reduced Testosterone

Reduced Respiratory

function

Increased Morbidity and

Mortality, Decreased

Quality of Life Modified from R. Antonione in Basics in Clinical Nutrition, Fourth Ed. 2011

Patophysiology &

Consequences of malnutritionUndernutrition ↓glycoytic & oxidative enzyme impaired skeletal muscle aerobic metabolism phosphocreatine & glycogen enzyme <<

↑ respiratory muscle burden by ↑ lactic acidosis (ventilatory demand)

Chronic hypoxia calcium dependent proteolysis muscle metabolism> , ↑reactive oxygen & cytokine conc.

Protein synthesis & protein breakdown imbalance

Excess in EE,energy intake << muscle wasting

Skeletal muscle impairement & dysfunction + atrophy & structural modification+ global weight loss ↓phsyical activity (FFM <<)

Wasted COPD (↓ plasma glutamine/glutamate/

BCAA) amino acids modification

Glucocorticoid protein & muscle degradation

Beta agonist & hormonal modification unclear

Nutrition Support

A. Energy

Calorie (involuntary weight loss, mechanical efficiency <<), small meal frequent; 35-45 kcal/kg

MNT ( BMI < underweight, 10 % involuntary weight loss in 6 mth, 5% in past, FFM depletion)

Malnourished high energy & protein diet

CH (40%) CO2 production during metabolism, complex CH

High fat diet early satiety, diaphragma movement & thoracic dynamics

Increased meal OxyHB desaturation resp.?

B.Protein

(0,8 g)1-1,5 g/kg/day (1,2-2,0) protein synthesis

Amino- acid supplementation (Glutamine) before exercise benefit for resp.muscle &reduced infective complication; Leucine (60-120 g) also

CKD avoid excess protein

C. Fat: 35% - 55% (20% MCT)

C. Fluid

6 – 8 cup/non carbonated

Water, milk, 100 % juice, tea,soup etc.

Caution : COPD with CHF

D. Sodium (salt)

Recommended 2300 mg sodium or less (1 cth)

Salt subsitutes may not be for everyone

E.Micronutrients: vit.K, Ca, vit.D, P, Mg ?

(osteoporosis: 1200 mg Ca, 700-1000 IU vit.D); analog Vit.D (alphacalcidol/

calcitriol muscle strenght

ESPEN guidelines

Enteral nutrition with excercise and anabolic pharmacotheraphy

Frequent small oral nutr.suppl.

Anker SD et al.ESPEN Guidelines on Enteral Nutrition.Clin Nutr 2006,25:311-8

GHRELIN

Novel GH-releasing peptide

-↓ fat utility & stimulating feeding - positive energy balance Decrease in COPD

repeated administration improves body composition and functional capacity, reduced muscle wasting,

↑ symphatetic in cachectic COPD patient

Nagaya N, et al.Treatment of cachexia with ghrelin in patients with COPD.Chest 2005, 128: 1187-93

Medical Foods

To prevent hypercapniaApproaches to prevent hypercapnia

1.Reduce feeding rate 2.Change to a formula with higher proportion

of fat vs carbohydrateStable COPD : oral nutrition with standard high- protein/high energy

Voss AC,E.Mayer K.Role of Liquid Dietary Supplement in Nutrition in the Prevention & Treatment of Disease,2001,235-6

Zadak Z.et al. Commercially prepared diet for enteral nutrition. Basics in Clinical Nutrition 4rd ed.ESPEN 2011

FOOD Access

Enteral Diet/Formula:

Calorie –dense Diet,limited CH high lipid

Calorie-dense,complet oral supplement,high

Vitamin & mineral; very cold/small sip

(avoid stomach ache/diarrhea)

Conclusion for succesful eating Prepare meals early

Rest & medicated before eating

Oral care before meal

Appetite stimulans

Liquify foods to reduced chewing

Eat small and frequent

Adequate water intake

THANK YOU