DEFINING THE GERIATRIC POPULATION
Nowadays nutrition for elderly patient is a serious issue to deal with. As per international guidelines, Geriatric is when an individual is 65 yrs and above. But in developing countries of Asia and South America, it is noted that from the 6th decade of life the capacity of ‘self care star’ starts declining.
This can be attributed to factors of ergonomy which grossly starts affecting the lifestyle.
This leads to the 5 Giants of Geriatric being
- Intellectual Impairment
These ‘giants’ have changed over the past 50 years. The understanding of ‘modern geriatric giants’ has evolved to encompass the four new syndromes of
- The anorexia of ageing
- Cognitive impairment.
These syndromes are the harbingers of falls, hip fractures, affective disorders and delirium with their associated increase in morbidity and mortality.
ORTHOPEDIC TRAUMA AND MALNUTRITION
The prevalence of poor nutritional status among older adults with hip fracture ranges from 18 to 63%.
It has been reported that the nutritional status of these patients deteriorates further during admission for intervention procedure and that being undernourished has an adverse impact on recovery.
Factors influencing decline in nutritional status in this patient group are likely to be numerous including
- Lack of recognition
- Ignored treatment of undernutrition
- Increased dietary requirements
In addition poor appetite and oral dietary intake are likely to be significant contributing factors, with studies consistently reporting dietary energy intakes below requirements.
This becomes a serious concern during rehabilitation procedure.
MALNUTRITION AND SARCOPENIA
The prevalence of malnutrition and sarcopenia in older patients undergoing rehabilitation is 49–67 % and 40–46.5 %, respectively.
Malnutrition and sarcopenia are associated with poorer rehabilitation outcome and physical function.
Therefore, a combination of both rehabilitation and nutrition care management may improve outcome in disabled elderly with malnutrition and sarcopenia.
The concept of rehabilitation nutrition as a combination of both rehabilitation and nutrition care management and the International Classification of Functioning, Disability and Health guidelines are used to evaluate nutrition status and to maximize functionality in the elderly and other people with disability.
Primary and secondary sarcopenia often coexist in people with disability, the concept of rehabilitation nutrition is useful for their treatment.
A multidisciplinary approach in the management of orthopeadic rehabilitations especially post hip/knee arthroplasty and spine surgery is generally adopted these days.
However, much misperception persists on the founding concepts of rapid-recovery approaches, and most of the programs in orthopedics lacks nutritional support.
Despite the complexities of nutritional parameters prognostic potentials, associated interventions mainly focused on using dietary supplements.
CORRECTIVE NUTRITIONAL INTERVENTIONS ASSOCIATED WITH BETTER PROGNOSIS DURING REHABILITATION
|NUTRITIONAL PARAMETERS ASSOCIATED WITH WORSE OUTCOMES||WORSE OUTCOMES ASSOCIATED WITH NUTRITIONAL PARAMETERS||NUTRITIONAL INTERVENTIONS ASSOCIATED WITH BETTER PROGNOSIS||BETTER PROGNOSES ASSOCIATED WITH NUTRITIONAL INTERVENTIONS|
|Low levels of pre-albumin, albumin, total protein, and total lymphocyte count||Higher wound complications, prolonged recovery time, higher resource consumption and operative time||Protein supplementation, immuno-nutrition||Suggested improvement of frailty and mobility, decreased length of hospital stay, reduced C-reactive protein|
|Low levels of hemoglobin, transferrin, ferritin, and iron||Higher 90-day readmissions, transfusions, and wound complications||Iron supplementation||Reduced transfusion rates, decreased length of hospital stay|
|Low vitamin D||Longer hospitalization, acute periprosthetic infections, lower handgrip strength and physical performance, higher 90-day complications||Vitamin D supplementation||Gain of cardiac function, suggested improvement of frailty and mobility, promotion of spinal fusion|
|High body mass index||Higher 30-day complications, increased risk for mechanical implant failure, component malposition, and prosthesis dislocation, slower gain of function||Planned weight loss program||Suggested improvement of knee symptoms and no delays of knee replacement, improved physical health scores after surgery|
|ALTERED FAT MASS/MUSCLE MASS RATIO||Higher complications and adverse events||Exercise and dietary supplements||Suggested improvement of frailty and mobility|
|Faulty diet, unhealthy eating behaviors||Suggested nutritional deficiencies and risk for joint degeneration and subchondral bone deterioration||Nutritional counseling or ad hoc diet||Decreased length of hospital stay, suggested improvement of frailty and mobility|
|Fasting||Metabolically ‘fed’ state with more nitrogen and protein loss||Carbohydrate or mixed nutrient loading||Decreased length of hospital stay, reduced C-reactive protein|
|Short-term weight loss and reduced food intake||Suggested increased hospital stay and reduced gain of muscle performance||Supplementation with a combination of carbohydrates, proteins, amino acids, β-hydroxy β-methylbutyrate, vitamin D||Decreased length of hospital stay, maintenance of lower limbs strength, preservation of quadriceps muscle volume, acceleration of wound healing|
|Unhealthy eating behaviors||Suggested overeating and alteration of the nutritional status||General nutritional counseling or ad hoc diet||Expected healthy eating behaviors and adherence to nutritional prescriptions|
AMINO ACIDS AND REHABILITATION
“Hypoaminoacidemia is less pronounced in geriatric trauma”: This is often a false negative finding mainly because of a larger decrease in nonessential amino acids in young trauma victims.
Significant decreases in arginine and methionine and increases in ornithine and citrulline concentrations were seen in geriatric trauma.
These results suggest a sluggish protein metabolic response to trauma in elderly individuals, which should be considered in their nutritional management.
L-arginine is metabolized to L-ornithine, which can be processed to polyamines or to proline.
Polyamines are important mediators of cell growth and proline is a precursor in collagen synthesis.
Hence , supplementation with arginine may be attributed to
- Increased collagen synthesis.
- All calcium-dependent processes like collagen recruitment for Haversian system formation better bone matrix, and cortical repair
- Moreover, the oral administration of arginine in pharmacological doses also induces growth hormone (GH) and IGF-I responses.
NITRIC OXIDE (NO), THE ANTIOXIDANT
Another such factor is nitric oxide (NO), which is derived from the basic amino acid arginine.
NO is formed from arginine in the presence of enzyme nitric oxide synthase (NOS).
There are three types of NOS: iNOS (inducible NOS), eNOS (endothelial NOS), and neuronal (bNOS).
iNOS is inducible and calcium independent while eNOS and bNOS are calcium dependent and are constitutive.
It was seen that healing is better at 3 weeks postoperatively mainly because of increased vascularity and better angiogenesis which had occurred due to increased NO synthesis from arginine supplementation.
NO is expressed during fracture healing, and suppression of NOS impairs fracture healing.
Similar results by Corbett et al.6 show that NO-mediated vasoreactivity is maximal in early phases of fracture healing, before returning to basal levels, as healing progresses.
This is compatible with an initial restoration of blood flow at the fracture site by NO-dependent vasodilation of pre-existing vessels followed by growth of less NO-dependent angiogenic vessels during later stages of healing.
(However, vascularity was not a determinant of better fracture healing in the later stages of healing.)
l-lysine has an equally important role to play;
In vitro studies demonstrated that the addition of a lysine-rich 18 kDA protein to osteoblast-like cells resulted in a 1.6- to 2-fold increase in the activity of alkaline phosphatase and a slight increase in the DNA content.
Clinical experiments showed that l-lysine significantly increases intestinal calcium absorption and renal conservation of absorbed calcium.
Hydroxylysine is derived from lysine and is essential for the formation of bone matrix.
Lysine and arginine treated rabbits have significant radiographical, morphological, and histological differences in fracture healing at 3, 8, and 12 weeks.
Probiotic supplements may have a positive effect on bowel movements among orthopedic rehabilitation elderly patients.
NUTRIENTS IN REHABILITATION
- HABITUAL DIET is the first choice of nutrition supportive therapy. However, when EN cannot provide 60% of the total energy intake of the patient, supplementation should be applied .
- Generally, a daily non-protein energy supply of 20-30 kcal/kg and a daily protein energy supply of 1.0-1.2 g/kg are recommended (B). 3. Double energy resources from carbohydrate and lipid are recommended for dietary prescription, with an increase in the proportion of lipid (no more than 50% of nonprotein calories)
- Pharmacological doses of fish oil lipid emulsion are suitable for postoperative rehab patients, improving the clinical outcome .
- Fish oil lipid emulsion should be considered as an ingredient for patients with CVD. Attention to the supply of micronutrients is also needed .
- Gutamine supplementation with RNA and immunoglobulins for a period of ^ weeks post op often speeds the rehab process.
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