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      Management of Malnutrition in Older Patients—Current Approaches, Evidence and Open Questions

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          Abstract

          Malnutrition is widespread in older people and represents a major geriatric syndrome with multifactorial etiology and severe consequences for health outcomes and quality of life. The aim of the present paper is to describe current approaches and evidence regarding malnutrition treatment and to highlight relevant knowledge gaps that need to be addressed. Recently published guidelines of the European Society for Clinical Nutrition and Metabolism (ESPEN) provide a summary of the available evidence and highlight the wide range of different measures that can be taken—from the identification and elimination of potential causes to enteral and parenteral nutrition—depending on the patient’s abilities and needs. However, more than half of the recommendations therein are based on expert consensus because of a lack of evidence, and only three are concern patient-centred outcomes. Future research should further clarify the etiology of malnutrition and identify the most relevant causes in order to prevent malnutrition. Based on limited and partly conflicting evidence and the limitations of existing studies, it remains unclear which interventions are most effective in which patient groups, and if specific situations, diseases or etiologies of malnutrition require specific approaches. Patient-relevant outcomes such as functionality and quality of life need more attention, and research methodology should be harmonised to allow for the comparability of studies.

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          Most cited references40

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          Opposing Effects of Fasting Metabolism on Tissue Tolerance in Bacterial and Viral Inflammation.

          Acute infections are associated with a set of stereotypic behavioral responses, including anorexia, lethargy, and social withdrawal. Although these so-called sickness behaviors are the most common and familiar symptoms of infections, their roles in host defense are largely unknown. Here, we investigated the role of anorexia in models of bacterial and viral infections. We found that anorexia was protective while nutritional supplementation was detrimental in bacterial sepsis. Furthermore, glucose was necessary and sufficient for these effects. In contrast, nutritional supplementation protected against mortality from influenza infection and viral sepsis, whereas blocking glucose utilization was lethal. In both bacterial and viral models, these effects were largely independent of pathogen load and magnitude of inflammation. Instead, we identify opposing metabolic requirements tied to cellular stress adaptations critical for tolerance of differential inflammatory states. VIDEO ABSTRACT.
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            Oropharyngeal dysphagia in older persons – from pathophysiology to adequate intervention: a review and summary of an international expert meeting

            Oropharyngeal dysphagia (OD) is a highly prevalent and growing condition in the older population. Although OD may cause very severe complications, it is often not detected, explored, and treated. Older patients are frequently unaware of their swallowing dysfunction which is one of the reasons why the consequences of OD, ie, aspiration, dehydration, and malnutrition, are regularly not attributed to dysphagia. Older patients are particularly vulnerable to dysphagia because multiple age-related changes increase the risk of dysphagia. Physicians in charge of older patients should be aware that malnutrition, dehydration, and pneumonia are frequently caused by (unrecognized) dysphagia. The diagnosis is particularly difficult in the case of silent aspiration. In addition to numerous screening tools, videofluoroscopy was the traditional gold standard of diagnosing OD. Recently, the fiberoptic endoscopic evaluation of swallowing is increasingly utilized because it has several advantages. Besides making a diagnosis, fiberoptic endoscopic evaluation of swallowing is applied to evaluate the effectiveness of therapeutic maneuvers and texture modification of food and liquids. In addition to swallowing training and nutritional interventions, newer rehabilitation approaches of stimulation techniques are showing promise and may significantly impact future treatment strategies.
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              ESPEN Guidelines on Enteral Nutrition: Geriatrics.

              Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.
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                Author and article information

                Journal
                J Clin Med
                J Clin Med
                jcm
                Journal of Clinical Medicine
                MDPI
                2077-0383
                04 July 2019
                July 2019
                : 8
                : 7
                Affiliations
                [1 ]Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, 90408 Nuremberg, Germany
                [2 ]Department Nutrition and Health, University College Copenhagen, 2200 Copenhagen, Denmark
                [3 ]Herlev and Gentofte University Hospital, 2703 Herlev, Denmark
                [4 ]Clinical Nutrition and Metabolism, Department of Public Health and Caring Sciences, Uppsala University, 701 05 Uppsala, Sweden
                [5 ]Theme Ageing, Karolinska University Hospital, 171 76 Stockholm, Sweden
                [6 ]Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
                [7 ]Servicio de Geriatría, Hospital Universitario Ramón y Cajal (IRYCIS), 28034 Madrid, Spain
                [8 ]Heidelberg University Centre for Geriatric Medicine and Network Aging Research (NAR), University of Heidelberg, 69126 Heidelberg, Germany
                [9 ]Division of Human Nutrition, Wageningen University, 6708 WE Wageningen, The Netherlands
                [10 ]German Institute for Human Nutrition Potsdam-Rehbrücke, Department of Nutrition and Gerontology, 14558 Nuthetal, Germany
                [11 ]Research Group on Geriatrics, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, 10117 Berlin, Germany
                [12 ]Institute of Nutritional Science, University of Potsdam, 14558 Nuthetal, Germany
                [13 ]Department for Geriatric Medicine, Marien Hospital Herne—University Hospital, Ruhr-Universität Bochum, 44625 Herne, Germany
                [14 ]Department of Health Sciences, Faculty of Science, and Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
                [15 ]Southampton NIHR Biomedical Research Centre, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK
                [16 ]Gérontopôle, Centre Hospitalo-Universitaire de Toulouse, 31059 Toulouse, France
                [17 ]Nutritional Support Unit, Centre Hospitalier Universitaire de Nice, Université Côte d’Azur, 06200 Nice, France
                [18 ]Department of Medicine, Kantonsspital Winterthur, 8401 Winterthur, Switzerland
                [19 ]Centre of Geriatrics and Gerontology, Albertinen-Haus, Hamburg, and Chair of Geriatrics and Gerontology, University Medical Centre Eppendorf, 20246 Hamburg, Germany
                Author notes
                [* ]Correspondence: dorothee.volkert@ 123456fau.de ; Tel.: +49-911-5302-96168
                Article
                jcm-08-00974
                10.3390/jcm8070974
                6678789
                31277488
                8a89ba73-b19b-4b5c-887d-8bd755aa16e7
                © 2019 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                Categories
                Review

                geriatric patients,older persons,malnutrition,therapy,interventions

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