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fondamenti di nutrizione umana

Fondamenti di nutrizione umana (III Edizione) a cura di Lorenzo M. Donini, Anna Maria Giusti, Alessandro Pinto, Valeria del Balzo.

Malnutrizione per difetto

Malnutrition and distribution of food resources


The chronically undernourished or maInourished people in the world are about 800 million. This is an alarmingfigure that should be hailled in 2015 following the actions springing from the decisions o[the First World Food Summit. promoted by FAO in Rome in 1996. Anyway, during the time following this meeting, the reduction registered of about 8 million undernourished or malnourished people every year showed to be insufficient to grant the achievement of the goal, that would require an average decrease of about 20 mil­lions per year. Thus the Second Summit, held in June 2002 with the aim of promoting or renewing the polit­ical will to fight against hunger and to mobilize the necessary economical resources. could only ascertain the current inadequacy o[ the countermeasures undertaken. An important concept that emerges from the statistics, is that, at a world level, the food resources are enough to grant an adequate nutritional status to everybody.
Nevertheless excessive assumptions of nutrients are observed in the industrialized countries to the detriment of the largely inadequate intake for the developing countries. Starting from the latest decades the technological and cognitive progress of food technologies proposed considerable potential with regards to qualify and food safety. The increase o[ crop yield through varied selections and new agrarian technologies; the preparation, transformation, conservation and commercialisation of food, showed to have such an evolution which made available more and more attractive, heaIthy foods with a higher added value. This a!so affected a certain evo­lution of the approach to feeding: food is not only the source o[ subsistence but a!so the fulfillment of social needs - nutritional aspects apart. The interventions to reduce poverty must not be limited to increasing the technical knowledge and the Iogistic infrastructures, but must operate a revision of the support politics and of international trade, in order to promote a free market that is effectively accessible to everybody. In a wider view, the fight against hunger and misery passes through economical and political systems, through education, freedom of thought and of the press.

 

Carlo Cannella, Giovanni Costa J Anthropological Sciences 2005, 83, 119-125


Effect of nutritional status on clinical outcome in a population of geriatric rehabilitation patients


In a geriatric patient, nutritional status (NS), particularly in the case of malnutrition, may influence not only clinical results but also achievement of targets expected by Geriatric Rehabilitation, i.e. to restore maximum autonomy, allowing subjects to return to their previous functional status or, alternatively, to improve or at least maintain their residual functions (1).
The complexity of clinical status is a peculiarity in patients at geriatric age, since they usually suffer polypathologies and have a high degree of comorbidity and frailty (2-5).
NS is one of the conditions causing frailty and may influence functional recovery in elderly people. As reported in many studies, malnutrition is related to a higher incidence of complications such as immunodeficiency, frequent appearance of pressure sores, and respiratory diseases,thus affecting organs and apparatuses with a consequent increase in mortality (6-9).
The objective of this research was to evaluate retrospectively the influence of NSon the occurrence of Adverse Clinical Events (ACE) and on mortality in a sample of geriatric patients hospitalized in a rehabilitation setting.

Methods: We retrospectively examined the clinical records of 278 elderly subjects (154 women, 124 men), admitted to a geriatric hospital between September 2000 and December 2001 and evaluated for clinical, functional, cognitive and NS within the first 48 hours of admission. Clinical outcomes (ACE, mortality) were recorded during follow-up. Logistic regression analysis estimated models having mortality or the occurrence of ACE as outcome variables.

Results: Malnutrition was detected upon admission in 56.1% of the sample population. Incidence of ACE in malnourished subjects was higher than that in well-nourished patients was (28.2 vs 13.1%). Equally, mortality among malnourished subjects was higher than among those whose NS was normal (23.1 vs 9.8%).
The logistic regression models were able to predict: (1) mortality from comorbidity (OR 1.43; 95% CI 1.16-1.78; p = 0.001) andNS (OR 2.64; 95% CI 1.29-5.4; p = 0.008), and (2) occurrence of ACE from comorbidity (OR 1.69; 95% CI 1.36-2.1; p = 0.000), cognitive (OR 1.22; 95% CI 1.11-1.35; p = 0.000) and nutritional status (OR 2.38; 95% CI 1.19-4.8; p = 0.015).

Conclusion: The data presented here confirm what has already been stated in the pertaining literature. Nutritional assessment is a key component of multidimensional assessment aimed at identifying geriatric subjects at risk of morbidity and death.Targeting elderly subjects at risk of death and adverse clinical events must be a prerequisite for establishing both prevention and treatment strategies, for optimal allocation of the limited resources available for the care of chronic diseases.
Malnutrition was detected upon admission in 56.1% of our sample population. This prevalence is similar to that described in other studies and is probably explained by the general characteristics of the sample.Severe comorbidity, mildly or severely impaired cognitive functions, functional impairment, including immobility and eating dependenceall with high prevalence in this sample are considered to be risk factors for malnutrition. Although the majority of patients fell into the category of mild/moderate (energy) malnutrition, a mild deterioration of NS, for instance a reduction in TSF, seems to be sufficient to cause an increase in ACE incidence and in mortality.

 

1. L De Bernardini, L.M. Donini, A Tagliaccica, MR De Felice, A Palazzotto, L Girvasi: Un'esperienza di Riabilitazione Geriatrica.Giorn Gerontol 2002, 50, 95-107
2. L.M. Donini, C. Savina, A. Rosano, M.R. De Felice, L. Tassi, L De Bernardini, A. Pinto, A.M. Giusti, C. Cannella MNA predictive value in the follow-up of geriatric patients. J Nutr Health & Aging2003, 5, 282-293
3. LM Donini, L De Bernardini,MR De Felice, C Savina, C Coletti, C Cannella: Effect of nutritional status on clinical outcome in a population of geriatric rehabilitation patients. Aging Clin Exper Res 2004, 16, 132-8

 

Nutritional Status, Comorbidity, Frailty and Evolution of Pressure Sores in Geriatric Patients


The prevalence of pressure sores (PS) ranges from 1 to 18% of in-patients and from 3 to 28% of those admitted to long-term settings.
The aim of our study was to verify, a posteriori, how nutritional status, comorbidity and frailty influenced the evolution of PS in a population of elderly subjects hospitalised in a long-term care setting.

Materials and Methods: The charts of 125 patients with ulcerative or necrotic pressure ulcers were evaluated retrospectively.For each subject we took note of: PS characteristics (stage, ulcer surface, evolution),clinical characteristics (comorbidity,adverse clinical events,cognitive, functional and nutritional status).

Results: In 58 patients (46.4%) there was overall healing of the lesions while in 39 patients (31.2%) we had however an “improvement” of PS.
The course of PS was not significantly influenced by the patient's physiological characteristics, by cognitive status or by initial characteristics of PS. Instead, we noticed a significant difference in the course of PS as a function of the level of autonomy, clinical status and nutritional status.
The course of PS, and in particular the Healing Index, were influenced by the Nutritional Status and, above all, by its course during the treatment period.There was no correlation between frailty score or initial stage and the course of PU. During the observation period, instead, we noticed statistically significant differences concerning the frailty scores: 87.2% of those who had an improvement in the score had resolution or improvement in PU, while this occurred in only 27.3% of those who had a worsening in the level of frailty (p= 0.000).

Conclusions: The development of PS is multifactorial. Whereas, it is clear that factors other than nutrition influence the risk of developing PS, an important role for nutrition in the development and resolution of PS is suggested. We maintain that the integration between the multidimensional assessment upon admission, with special attention to comorbidity status and to frailty (particularly, the level of autonomy andnutritional status), and the different approaches may allow an optimal healing of the PU.
Our data certainly confirm the “Quality indicators for prevention and management of pressure ulcers in vulnerable elders”, especially were they say “if a vulnerable elder is identified as at risk for pressure ulcer development and has malnutrition, then nutritional intervention or dietary consultation should be instituted because poor diet, particularly low dietary protein intake, is an independent predictor of pressure ulcer development”.

 

1. L.M. Donini, M.R. De Felice, A Tagliaccica, L. De Bernardini, C. Cannella: Nutritional Status and Evolution of Pressure Sores in Geriatric Patients. In stampa su J Nutr Health & Aging
2. DoniniLM, De Felice MR, Tagliaccica A, De Bernardini L, Cannella C: Comorbidity, frailty and evolution of pressure ulcers in Geriatric Age Med Sci Monit. 2005 Jul;11(7):CR326-36.
3. LM Donini, MR De Felice, A Tagliaccica, L De Bernardini, C Cannella: Comorbidity, frailty, and evolution of pressare ulcers in geriatrics. Med sci Monit 2005, 11 (7), CR 326-336
4. LM Donini, MR De Felice, A Tagliaccica, L De Bernardini, C Cannella: I fattori determinanti l’evoluzione delle lesioni da decubito in età geriatrica. ADI Magazine 2005, 2, 173-183 
5. LM Donini, MR De Felice, A Tagliaccica, L De Bernardini, C Cannella: Nutritional status and evolution of pressure sores in geriatric patients. J Nutr Health Aging 2005, 9, 6, 446-454

 

Nutrizione Artificiale in età geriatrica


Il concetto di terminale o di inguaribile (paziente con aspettativa di vita non superiore a sei mesi) in ambito geriatrico deve essere opportunamente integrato con quello di anziano “biologico (AB). Questi, a differenza dell’anziano anagrafico (soggetto che ha superato l’artificiosa barriera “previdenziale” dei 65 anni e che di fatto spesso in nulla si distingue da un soggetto di 50-60 anni), è un soggetto, spesso oltre i 75 anni di età, affetto da multipatologie con grave livello di comorbilità, deterioramento cognitivo e perdita dei livelli di autonomia. Tutto ciò si manifesta con una “fragilità” intesa come facile perdita del compenso clinico e difficile recupero del compenso stesso, anche di fronte a patologie di lieve entità. Questa fragilità è spesso accompagnata ed aggravata da una malnutrizione per difetto, endogena o esogena, (la prevalenza di malnutrizione nella popolazione ricoverata in età geriatrica oscilla dal 50 all’80% a seconda delle casistiche) ed un conseguente più frequente ricorso alla nutrizione artificiale.
Le discipline che si occupano del paziente in fase terminale (geriatria e medicina palliativa in particolare) hanno molto in comune non avendo come riferimento la cura di una patologia d’organo, ma la fase finale della vita caratterizzata dariduzione del performance status, astenia, malnutrizione, … Ciò ha fatto sì che queste discipline, non potendo incidere in maniera determinante sull’età biologica o sulla patologia di base, si ponessero come obbiettivo principale quello di migliorare la qualità di vita (domanda di autonomia, di libertà di scelta, di salvaguardia della dignità della persona anche all’avvicinarsi della morte). L’approccio al paziente è inevitabilmente diventato, con le dovute differenze legate ai diversi ambiti in cui ogni disciplina opera, un approccio multidimensionale e multidisciplinare in grado di valutare anche dimensioni tradizionalmente non strettamente di competenza medica.
Il progresso delle procedure diagnostiche, terapeutiche ed assistenziali, ha provocato tra gli altri un miglioramento della sopravvivenza ed il conseguente aumento di pazienti in fase terminale (pazienti oncologici “inguaribili”, anziani “fragili” affetti da polipatologie e frequentemente malnutriti, soggetti in stato vegetativo permanente, …). Parallelamente è avvenuta la messa a punto di efficaci procedure di alimentazione per via artificiale (NA), facilmente disponibili, con costi relativamente contenuti ed una migliore conoscenza degli effetti deleteri della malnutrizione calorico-proteica unitamente alla conferma degli effetti benefici della rialimentazione per via naturale o artificiale
La decisione se intraprendere, continuare o sospendere la nutrizione artificiale nel anziano “biologico” è quindi diventata una delle controversie più frequenti in nutrizione clinica.
Sulla base della loro esperienza, gli autori analizzano le problematiche cliniche e nutrizionali relative a tale decisione, la qualità di vita dei paziento sottoposti a nutrizione artificiale, le tematiche relative ad una corretta allocazione delle risorse.
Infine analizzano la decisione in un contesto bioetico caratterizzato dal rispetto dell’autonomia decisionale del pazienti e dai principi di beneficenza-non maleficienza e di giustizia.

 

1. L.M. Donini, C. Moretti, C. Giardina, L. De Bernardini: Alimentazione artificiale nel paziente geriatrico. Comunicazione al “VII Congresso Nazionale della Società Italiana di Nutrizione Parenterale ed Enterale – SINPE”- Sorrento, novembre 1994 - Atti del Congresso, pag. 173
2. F. Vetta, W Gianni, S. Ronzoni, L.M. Donini, L. Palleschi, T. Peppe, PFA Lato, M Migliori, M. Cacciafesta, V. Marigliano : Role of aging in malnutrition and in restitution of nutritional parameters by tube feeding. Arch Gerontol Geriatr. 1996, suppl 5, 599-604
3. L.M. Donini, L. De Bernardini, MR De Felice, C. Cannella: L’adeguatezza della nutrizione artificiale nell’anziano “biologico” in fase terminale. Rivista Italiana di Nutrizione Parenterale ed Enterale 2003, 21, 4-15 
4. M.L. Ricciardi, C Savina, C Coletti, L. Scavone, M. Paolini, L.M. Donini,C. Cannella:Elementi clinici funzionaliin grado di determinare l’esito della nutrizione artificiale. Atti XXXIV Congresso Soc Italiana Nutrizione Umana – Riccione, 8-10 novembre 2006 – p.104

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