Escarres en gériatrie : place de la prise en charge nutritionnelle

A simple remote nutritional screening tool and practical guidance for nutritional care in primary practice during the COVID-19 pandemic

Challenging periods like the COVID-19 pandemic require fast and efficient adaptations of the healthcare system. It is vital that every patient has access to nutritional care as a part of primary healthcare services, even if social distancing measures are adopted. Therefore, we propose a simple remote nutritional screening tool and practical guidance for nutritional care in primary practice, and their implementation into telemedicine processes and digital platforms suitable for healthcare providers. The acronym for the tool is R-MAPP, as for Remote – Malnutrition APP, while the tool will be available also as an app. This protocol consists of two simple validated clinical tools for identifying nutritional risk and loss of muscle mass and function –Malnutrition Universal Screening Tool (‘MUST’) and SARC-F (5-item questionnaire: Strength, Assistance with walking, Rise from a chair, Climb stairs and Falls) - and additional practical guidance on nutritional interventions for family physicians.

[Undernutrition of the elderly]

Malnutrition remains a particularly important issue in elderly. Physiological ageing induces many changes but ageing cannot entirely explain a Protein-Energy Malnutrition (PEM). Nutritionnal screening is indicated once a year in community medicine or in the first 48hours in case of an acute disease or of hospitalization. The Mini Nutritional Assessment is recommended for screening and for the diagnostic of malnutrition. Possible aetiologies are large and must be investigated in order to be careful not to dismiss curable disease and to be able to take corrective actions. PEM is associated to functional decline, length of stay in hospital and to morbi-mortality. Recommendations for dietary intakes in healthy old subjects are about 30 kcal/kg/day and 1 g/kg/day of protein and are strongly enhanced in case of acute or chronic diseases. The nutritional strategy depends on spontaneous food intake, medical situation, patient profile and opinion. Appropriate nutritional care could reduce morbidity-mortality and prevent functional decline in various disease contexts.

Improving nutritional care quality in the orthopedic ward of a Septic Surgery Center by implementing a preventive nutritional policy using the Nutritional Risk Score: a pilot study

BACKGROUND/OBJECTIVES

Septic Surgery Center (SSC) patients are at a particularly high risk of protein-energy malnutrition (PEM), with a prevalence of 35-85% found in various studies. Previous collaboration between our hospital's SSC and its Clinical Nutrition Team (CNT) only focussed on patients with severe PEM. This study aimed to determine whether it was possible to improve the quality of nutritional care in septic surgery patients with help of a nutritional policy using the Nutritional Risk Score (NRS).

SUBJECTS/METHODS

Nutritional practices in the SSC were observed over three separate periods: in the 3 months leading up to the implementation baseline, 6 months after implementation of preventive nutritional practices, and at 3 years. The nutritional care quality indicator was the percentage of patients whose nutritional care, as prescribed by the SSC, was adapted to their specific requirements. We determined the septic surgery team's NRS completion rate and calculated the nutritional policy's impact on SSC length of stay. Data before (T₀) and after (T₁ + T₂) implementation of the nutritional policy were compared.

RESULTS

Ninety-eight patients were included. The nutritional care-quality indicator improved from 26 to 81% between T₀ and T₂. During the T₁ and T₂ audits, septic surgery nurses calculated NRS for 100% and 97% of patients, respectively. Excluding patients with severe PEM, SSC length of stay was significantly reduced by 23 days (p = 0.005).

CONCLUSIONS

These findings showed that implementing a nutritional policy in an SSC is possible with the help of an algorithm including an easy-to-use tool like the NRS.

25-Hydroxyvitamin D [25(OH)D] levels and diabetic foot ulcer: is there any relationship?

AIMS

In recent years, there has been an effort to understand possible roles of 25(OH)D, including its role in the immune system particularly on T cell medicated immunity, pancreatic insulin secretion and insulin action. 25(OH)D stimulates the cell differentiation and reduces cell proliferation, which is essential for cell growth and wound healing. However, data on the association between low level of plasma 25(OH)D and diabetic foot syndrome are scarce.

MATERIALS AND METHODS

Circulating plasma levels of 25(OH)D were measured in diabetic patients with ulcer (n=162) and without ulcer (n=162) in a prospective cohort hospital based study.

RESULTS

Of these patients, 85.1% had type 2 diabetes. Subjects with diabetic foot ulcer showed lower median plasma level of 25(OH)D [6.3(4.2-11.1) vs 28.0(21.4-37.0)] ng/ml after adjusting the age and BMI. Regardless of the low levels of 25(OH)D in cases and controls, it was associated with neuropathy, sex (female), duration of ulcer healing, and smoking status and independent of confounding factors, including BMI (kg/m²), A1c (%), hypertension, nephropathy, foot ulcer, retinopathy, CAD, PAD, HDL-C (mg/dl) and LDL-C (mg/dl). The factors which predict the risk of developing ulcer independent of 25(OH)D status were A1c (>6.9%) [OR 4.37; RR 1.77], HDL-C (<40mg/dl) [OR 1.16; RR 1.07], LDL-C (>100mg/dl) [OR 1.07; RR 1.03], triglycerides (>200mg/dl) [OR 1.40; RR 1.19], neuropathy [OR 6.88; RR 3.12], retinopathy [OR 3.34; RR 1.91], hypertension [OR 1.64; RR 1.28], nephropathy [OR 3.12; RR 1.87] and smoking [OR 4.53; RR 2.99] using odds and risk ratios.

CONCLUSION

It is not clear whether the suppression of delayed wound healing seen during 25(OH)D deficiency is due to the secondary effect or is a direct action of vitamin D on certain components of the immune system. Long-term randomized trials are needed to see the impact of vitamin D supplementation on the outcome of diabetic foot patients.

Prevalence and incidence rates of pressure ulcers in an Emergency Department

Older patients represent an increasing population in emergency department (ED) with underlying diseases and longer ED length of stay, which are potential risk factors of pressure ulcers (PUs). The aim of the study was to determine the prevalence and incidence rates of PUs in an Emergency Department and to analyse variables related to PUs occurrence. The study was carried out in the Emergency Department of Bordeaux (France), and included 602 patients from 1 to 15 June 2010. All the potential body sites of pressure were examined at admission and discharge for all the patients by trained nurses. Comorbidity score, list of treatment, length of stay (hours), PUs (including stage I) and C-reactive protein (CRP) level were systematically recorded. A total of 47 (7·8%) patients had prevalent PUs at admission and 74 (12·3%) at discharge. The cumulative incidence was 4·9% and the incidence density was 5·4 per 1000 patients per hour. In multivariate analysis, higher comorbidities (OR 1·3; P = 0·014) and CRP levels (OR 1·005; P = 0·017) were both independent risk factors for developing PU. In conclusion, these data show that even a very short stay to the ED is sufficient to induce PUs especially stage I.

Association between vitamin D and pressure ulcers in older ambulatory adults: results of a matched case-control study

Background

Pressure ulcers are common among older adults, but knowledge about nutritional risk factors is still developing. Vitamin D deficiency is common in the elderly population and is required for normal skin proliferation. The role of vitamin D in pressure ulceration and wound healing is not known. The purpose of this case–control study was to determine the association between vitamin D levels and pressure ulceration in an older community-dwelling cohort.

Methods

All cases and controls were community-dwelling elderly older than 60 years in a primary care panel in Olmsted County, MN. Pressure ulcer cases were defined clinically. The controls were age-matched and gender-matched to controls without pressure ulceration. The main exposure variable was 25-hydroxyvitamin D levels in both groups. The other exposure variable was the Charlson Comorbidity Index used to measure medical comorbidity. The analysis included univariate and conditional logistic regression for 25-hydroxyvitamin D levels.

Results

The average (standard deviation) age of the study participants with a pressure ulcer was 80.46 years (±8.67), and the average vitamin D level was 30.92 ng/mL (±12.46). In univariate analysis, Vitamin D deficiency (levels < 25 ng/mL) was associated with pressure ulcers (odds ratio: 1.871, P = 0.0154). Comorbidities of the subjects calculated using the Charlson Comorbidity Index were also associated with pressure ulcers (odds ratio: 1.136, P < 0.001). In the final conditional logistical regression model, the association of Vitamin D and pressure ulcers became nonsignificant after adjustment for comorbid illness.

Conclusion

Medical comorbidities increased the risk of pressure ulceration. Vitamin D deficiency was not an independent risk factor for pressure ulceration, and may be a marker of comorbid illness.