J Nutr Health Aging
THE JOURNAL OF NUTRITION, HEALTH & AGING©
THE NUTRITIONAL STATUS OF DUTCH ELDERLY PATIENTS WITH PARKINSON’S DISEASE J. VAN STEIJN1, B. VAN HARTEN2, E. FLAPPER1, E. DROOGSMA1, P. VAN WALDERVEEN1, M. BLAAUW1, D. VAN ASSELT1 1. Medical Centre Leeuwarden , department of Geriatrics; 2. Medical Centre Leeuwarden , department of Neurology. Corresponding author: Jolanda van Steijn, Medical Centre Leeuwarden, Department of Geriatrics, PO Box 888, 8901 BR Leeuwarden, The Netherlands, +31 58 2863067, [email protected]
Abstract: Objectives: To assess the prevalence of (risk of) undernutrition in Dutch elder Parkinson’s disease patients as well as it’s risk factors. Design: Observational cross-sectional study. Setting: An outpatient clinic at the department Neurology of Medical Centre Leeuwarden, a large teaching hospital. Participants: 102 outpatients with Parkinson’s disease aged 65 years and older were recruited. Measurements: Data regarding various aspects of undernutrition including socio-demographic aspect, disease characterisitics, nutritional status, appetite and overall-physical and psychological functioning were collected. Results: Undernutrition was diagnosed in 2.0% and 20.5% of the patients were categorized as being at risk of undernutrition. Care dependency and appetite were the two risk factors with the highest predictive value for an unfavorable nutritional status. Conclusion: Of Dutch elderly patients with Parkinson’s Disease 22.5% had an unfavourable nutritional status. Dependency and appetite were the two risk factors with the highest predictive value fort his outcome. Because undernutrition can be regarded as a geriatric syndrome a comprehensive nutritional assessment should be done followed by nutritional interventions next to interventions focused on the risk factors. Further studies are needed to evaluate these interventions. Key words: Under nutrition, Parkinson disease, nutritional status, weight loss.
Introduction
Neurodegenerative diseases (Parkinson’s disease, motor neuron disease, and dementia) are projected to surpass cancer as the second most common cause of death among the elderly by the year 2040 (6).
Parkinson’s disease Parkinson’s disease (PD), as first described by James Parkinson in 1817, is characterised by the presence of severe pars-compacta nigral-cell loss, and accumulation of aggregated α-synucleinin specific brain stem, spinal cord, and cortical regions. PD is the most common neurodegenerative disorder after Alzheimer’s disease with a worldwide prevalence of 0.2% (1). It’s aetiology is unclear. Only symptomatic treatment like dopamine agonists and levodopa is available, next to treatment of non-motor symptoms (2, 3). PD is historically regarded as primarily a motor disorder with bradykinesia, rigidity, tremor and postural instability. However multiple non-motor symptoms like neuropsychiatric symptoms such as, dementia, depression, psychosis, anxiety and apathy, autonomic disturbances like bowel dysfunction, dysphagia, weight loss, salivation, bladder dysfunction, sexual dysfunction, postural hypotension and excessive sweating - and pain due to dystonia can occur (1). These symptoms contribute to increased disease burden and decreased quality of live (4). Age is the single most important risk factor. Therefore, PD is mainly a disease of the elderly. The average age of a patient with Parkinson’s disease is 70,5 year (5). In America PD is estimated to afflict1% of those aged over 60 years and 4% of those aged over 80 years (3, 4). With increasing age of the general population, the prevalence will rise in future. PD causes substantial morbidity and results in a shortened life span (6). After dementia and oesophageal carcinoma PD is the most common cause of loss of quality of live (7). Received June 17, 2013 Accepted for publication October 9, 2013
Undernutrition in the elderly Undernutrition and weight loss are much common in the elderly (8, 9). Prevalence’s worldwide for in hospital geriatric patients vary between 23–61%. For community-dwelling elderly who receive homecare the prevalence varies between 6–15% (10-13). The most important cause for undernutrition in the elderly is multi-morbidity. Other causes can be classified in the four domains used in clinical geriatrics (somatic, functional, psychiatric, social) (14). Undernutrition can be regarded as a geriatric syndrome (14). This term is used by geriatricians to highlight the unique features of common health conditions in older people. Geriatric syndromes, such as delirium, falls, incontinence, and frailty, are highly prevalent, multifactorial, and associated with substantial morbidity and poor outcomes (15). Undernutrition has important consequences like, muscle loss, reduce of immunity, falls, fractures, increase of complications after surgery, longer hospital stay, increase of nursing home admissions, increased mortality, decreased quality of live, increased use of medication and considerable economic consequences. In the Netherlands €1,7 billion a year is spent on undernutrition (16). Prevention, early recognition and treatment of undernutrition are useful. Nevertheless, nutritional assessment is still not 1
J Nutr Health Aging
THE NUTRITIONAL STATUS OF DUTCH ELDERLY PATIENTS WITH PARKINSON’S DISEASE common in the work-up of elderly patients. Besides, a gold standard for diagnosing undernutrition in the elderly is still lacking (14). Undernutrition and Parkinson’s disease PD patients have a higher risk of undernutrition compared with the same age group without PD (17). Weight loss is common in PD: 19–73% of the patients have unintentional weight loss (18-21). There are many assumptions regarding why PD patients lose weight. Increased energy expenditure at rest, metabolic dysfunction, insufficient nutrient intake, the neurodegenerative process itself, and l-dopa treatment have been mentioned (1625). However, the exact mechanism is still not known (26). The consequences of undernutrition for elderly mentioned above are the same for PD patients. The motor symptoms can increase (20, 27, 28). Nutritional assessment followed by nutritional treatment in PD patients could contribute to the amelioration of symptoms. Daily Practice Little is known about the prevalence of undernutrition in PD patients and their contributing factors. Recently a comprehensive Dutch guideline for Parkinson’s disease was presented (26). However, only a few lines addressed undernutrition. It’s therefore, that we assessed the prevalence of (risk of) undernutrition in the elderly PD patients as well as their risk factors. Because undernutrition can be regarded as a geriatric syndrome we investigated risk factors from the four domains used in clinical geriatrics: somatic, functional, psychiatric and social. Methods Subjects Between November 2010 and February 2011, a total of 140 PD patients aged 65 years and older were consecutively recruited from the outpatient clinic of the department Neurology of Medical Centre Leeuwarden, a large teaching hospital in the North of the Netherlands. Patients were selected according to the UK Parkinson’s Disease Society Brain Bank diagnostic criteria for the diagnosis of PD. Patients with known malignancy, gastrointestinal or endocrine disease were excluded, just like tube fed patients, patients after pallidotomy and patients who were unable to give informed consent. Each patient gave their written informed consent to participate in the study. The study was approved by the Research Ethics Committee. Study design Observational cross-sectional study.
2
Data collection Data regarding various aspects of undernutrition including socio-demographic aspects, disease characteristics, nutritional status, appetite and overall - physical and psychological functioning were collected with questionnaires. All the questionnaire assessment were performed during face-to-face interviews with the patient by one and the same investigator. In addition information was also retrieved from patients records. Mini Nutritional Assessment (MNA) The MNA is a international validated nutrition-assessment tool used as a part of standard evaluation of elderly patients. MNA was specifically designed for the elderly, and is it is used to identify elderly at risk who may benefit from early intervention (29). The MNA consists of 18 items grouped in 4 subheadings. The maximum score is 30 points. A score less than 17 is indicative for undernutrition. A score of 24 points or more indicate a good nutrition status, while a score equal to or higher than 17 but equal to or less than 23.5 is indicative of risk of undernutrition. Cumulative Illness Rating Scale (CIRS) The CIRS has been developed to meet the need for a short, yet comprehensive and reliable instrument for assessing physical impairment in the elderly (30). The scale format provides for 14 body systems. Ratings are made per body system on a 5-point ‘degree of severity’ scale, ranging from ‘none’ to ‘extremely severe’ .The maximum score is 56 points. Zero points is indicative of no comorbidity while a score of 56 indicate serious multi organ failure. Council of Nutrition Appetite Questionnaire (CNAQ) The CNAQ is an 8-item single-domain questionnaire used to evaluate appetite (31). The total score is the sum of scores on the 8 items, with lower scores indicating deterioration in appetite. The maximum score is 40 points. The CNAQ is validated for use in older adults and has been shown to identify persons at risk of significant weight loss. A CNAQ score 5 may identify persons at risk of depression.
The Spearman correlation was used to assess the correlation between continuous variables. We employed the Pearson Chisquare to assess the correlation between categorical variables. Multiple logistic regression analysis was performed to assess the predictive value of variables for the nutritional status. The MNA was used as a dependent variable. Variables that differed between well-nourished patients and patients who were undernourished or at risk of undernutrition (comorbidity (CIRS), loneliness, disease stage (H&Y), appetite (CNAQ), dependency (KATZ 15), total hours assistance, swallowing disorders, falls, chewing disorders, nausea, depressive symptoms (GDS) and cognitive disturbances (PDD-QS) ) were included in the regression analysis as independent variables. Hypotheses were two-tailed tested. A probability (p) value of less than 0.05 was considered significant. We used the Shapiro-Wilk test to establish the distribution of the variables.
Motor symptoms Parkinson Disease In this study the following items were assessed for mapping of the motor symptoms: rigidity, tremor, swallowing, speech, dribbling of saliva, dyskinesia, off-periods and falls. It was only noted if these symptoms were present or absent according to the opinion of the patient. Non-Motor-Symptoms-quest (NMS-quest) The NMS-quest is a 30-item self-completed questionnaire that provides a comprehensive assessment of the range of NMS that occur in PD (35). It consist of 6 domains that cover symptoms ranging from gastrointestinal symptoms to sensory symptoms. Each question can be answered with “yes” or “no”. In this study 5 questions were used: nausea, obstipation, olfactory ability, visual hallucinations and sleeping disorders.
Results A total of 140 consecutive patients were asked to participate, 35 patients refused due to personal circumstances and 3 were excluded because of a malignancy. 102 patients were included (52.9% male and 48.1% female), with a mean age of 76.4 ± 6.0 years and mean disease duration of 6.4 ± 5.1 years (table 1). Undernutrition (MNA score
THE JOURNAL OF NUTRITION, HEALTH & AGING©
THE NUTRITIONAL STATUS OF DUTCH ELDERLY PATIENTS WITH PARKINSON’S DISEASE J. VAN STEIJN1, B. VAN HARTEN2, E. FLAPPER1, E. DROOGSMA1, P. VAN WALDERVEEN1, M. BLAAUW1, D. VAN ASSELT1 1. Medical Centre Leeuwarden , department of Geriatrics; 2. Medical Centre Leeuwarden , department of Neurology. Corresponding author: Jolanda van Steijn, Medical Centre Leeuwarden, Department of Geriatrics, PO Box 888, 8901 BR Leeuwarden, The Netherlands, +31 58 2863067, [email protected]
Abstract: Objectives: To assess the prevalence of (risk of) undernutrition in Dutch elder Parkinson’s disease patients as well as it’s risk factors. Design: Observational cross-sectional study. Setting: An outpatient clinic at the department Neurology of Medical Centre Leeuwarden, a large teaching hospital. Participants: 102 outpatients with Parkinson’s disease aged 65 years and older were recruited. Measurements: Data regarding various aspects of undernutrition including socio-demographic aspect, disease characterisitics, nutritional status, appetite and overall-physical and psychological functioning were collected. Results: Undernutrition was diagnosed in 2.0% and 20.5% of the patients were categorized as being at risk of undernutrition. Care dependency and appetite were the two risk factors with the highest predictive value for an unfavorable nutritional status. Conclusion: Of Dutch elderly patients with Parkinson’s Disease 22.5% had an unfavourable nutritional status. Dependency and appetite were the two risk factors with the highest predictive value fort his outcome. Because undernutrition can be regarded as a geriatric syndrome a comprehensive nutritional assessment should be done followed by nutritional interventions next to interventions focused on the risk factors. Further studies are needed to evaluate these interventions. Key words: Under nutrition, Parkinson disease, nutritional status, weight loss.
Introduction
Neurodegenerative diseases (Parkinson’s disease, motor neuron disease, and dementia) are projected to surpass cancer as the second most common cause of death among the elderly by the year 2040 (6).
Parkinson’s disease Parkinson’s disease (PD), as first described by James Parkinson in 1817, is characterised by the presence of severe pars-compacta nigral-cell loss, and accumulation of aggregated α-synucleinin specific brain stem, spinal cord, and cortical regions. PD is the most common neurodegenerative disorder after Alzheimer’s disease with a worldwide prevalence of 0.2% (1). It’s aetiology is unclear. Only symptomatic treatment like dopamine agonists and levodopa is available, next to treatment of non-motor symptoms (2, 3). PD is historically regarded as primarily a motor disorder with bradykinesia, rigidity, tremor and postural instability. However multiple non-motor symptoms like neuropsychiatric symptoms such as, dementia, depression, psychosis, anxiety and apathy, autonomic disturbances like bowel dysfunction, dysphagia, weight loss, salivation, bladder dysfunction, sexual dysfunction, postural hypotension and excessive sweating - and pain due to dystonia can occur (1). These symptoms contribute to increased disease burden and decreased quality of live (4). Age is the single most important risk factor. Therefore, PD is mainly a disease of the elderly. The average age of a patient with Parkinson’s disease is 70,5 year (5). In America PD is estimated to afflict1% of those aged over 60 years and 4% of those aged over 80 years (3, 4). With increasing age of the general population, the prevalence will rise in future. PD causes substantial morbidity and results in a shortened life span (6). After dementia and oesophageal carcinoma PD is the most common cause of loss of quality of live (7). Received June 17, 2013 Accepted for publication October 9, 2013
Undernutrition in the elderly Undernutrition and weight loss are much common in the elderly (8, 9). Prevalence’s worldwide for in hospital geriatric patients vary between 23–61%. For community-dwelling elderly who receive homecare the prevalence varies between 6–15% (10-13). The most important cause for undernutrition in the elderly is multi-morbidity. Other causes can be classified in the four domains used in clinical geriatrics (somatic, functional, psychiatric, social) (14). Undernutrition can be regarded as a geriatric syndrome (14). This term is used by geriatricians to highlight the unique features of common health conditions in older people. Geriatric syndromes, such as delirium, falls, incontinence, and frailty, are highly prevalent, multifactorial, and associated with substantial morbidity and poor outcomes (15). Undernutrition has important consequences like, muscle loss, reduce of immunity, falls, fractures, increase of complications after surgery, longer hospital stay, increase of nursing home admissions, increased mortality, decreased quality of live, increased use of medication and considerable economic consequences. In the Netherlands €1,7 billion a year is spent on undernutrition (16). Prevention, early recognition and treatment of undernutrition are useful. Nevertheless, nutritional assessment is still not 1
J Nutr Health Aging
THE NUTRITIONAL STATUS OF DUTCH ELDERLY PATIENTS WITH PARKINSON’S DISEASE common in the work-up of elderly patients. Besides, a gold standard for diagnosing undernutrition in the elderly is still lacking (14). Undernutrition and Parkinson’s disease PD patients have a higher risk of undernutrition compared with the same age group without PD (17). Weight loss is common in PD: 19–73% of the patients have unintentional weight loss (18-21). There are many assumptions regarding why PD patients lose weight. Increased energy expenditure at rest, metabolic dysfunction, insufficient nutrient intake, the neurodegenerative process itself, and l-dopa treatment have been mentioned (1625). However, the exact mechanism is still not known (26). The consequences of undernutrition for elderly mentioned above are the same for PD patients. The motor symptoms can increase (20, 27, 28). Nutritional assessment followed by nutritional treatment in PD patients could contribute to the amelioration of symptoms. Daily Practice Little is known about the prevalence of undernutrition in PD patients and their contributing factors. Recently a comprehensive Dutch guideline for Parkinson’s disease was presented (26). However, only a few lines addressed undernutrition. It’s therefore, that we assessed the prevalence of (risk of) undernutrition in the elderly PD patients as well as their risk factors. Because undernutrition can be regarded as a geriatric syndrome we investigated risk factors from the four domains used in clinical geriatrics: somatic, functional, psychiatric and social. Methods Subjects Between November 2010 and February 2011, a total of 140 PD patients aged 65 years and older were consecutively recruited from the outpatient clinic of the department Neurology of Medical Centre Leeuwarden, a large teaching hospital in the North of the Netherlands. Patients were selected according to the UK Parkinson’s Disease Society Brain Bank diagnostic criteria for the diagnosis of PD. Patients with known malignancy, gastrointestinal or endocrine disease were excluded, just like tube fed patients, patients after pallidotomy and patients who were unable to give informed consent. Each patient gave their written informed consent to participate in the study. The study was approved by the Research Ethics Committee. Study design Observational cross-sectional study.
2
Data collection Data regarding various aspects of undernutrition including socio-demographic aspects, disease characteristics, nutritional status, appetite and overall - physical and psychological functioning were collected with questionnaires. All the questionnaire assessment were performed during face-to-face interviews with the patient by one and the same investigator. In addition information was also retrieved from patients records. Mini Nutritional Assessment (MNA) The MNA is a international validated nutrition-assessment tool used as a part of standard evaluation of elderly patients. MNA was specifically designed for the elderly, and is it is used to identify elderly at risk who may benefit from early intervention (29). The MNA consists of 18 items grouped in 4 subheadings. The maximum score is 30 points. A score less than 17 is indicative for undernutrition. A score of 24 points or more indicate a good nutrition status, while a score equal to or higher than 17 but equal to or less than 23.5 is indicative of risk of undernutrition. Cumulative Illness Rating Scale (CIRS) The CIRS has been developed to meet the need for a short, yet comprehensive and reliable instrument for assessing physical impairment in the elderly (30). The scale format provides for 14 body systems. Ratings are made per body system on a 5-point ‘degree of severity’ scale, ranging from ‘none’ to ‘extremely severe’ .The maximum score is 56 points. Zero points is indicative of no comorbidity while a score of 56 indicate serious multi organ failure. Council of Nutrition Appetite Questionnaire (CNAQ) The CNAQ is an 8-item single-domain questionnaire used to evaluate appetite (31). The total score is the sum of scores on the 8 items, with lower scores indicating deterioration in appetite. The maximum score is 40 points. The CNAQ is validated for use in older adults and has been shown to identify persons at risk of significant weight loss. A CNAQ score 5 may identify persons at risk of depression.
The Spearman correlation was used to assess the correlation between continuous variables. We employed the Pearson Chisquare to assess the correlation between categorical variables. Multiple logistic regression analysis was performed to assess the predictive value of variables for the nutritional status. The MNA was used as a dependent variable. Variables that differed between well-nourished patients and patients who were undernourished or at risk of undernutrition (comorbidity (CIRS), loneliness, disease stage (H&Y), appetite (CNAQ), dependency (KATZ 15), total hours assistance, swallowing disorders, falls, chewing disorders, nausea, depressive symptoms (GDS) and cognitive disturbances (PDD-QS) ) were included in the regression analysis as independent variables. Hypotheses were two-tailed tested. A probability (p) value of less than 0.05 was considered significant. We used the Shapiro-Wilk test to establish the distribution of the variables.
Motor symptoms Parkinson Disease In this study the following items were assessed for mapping of the motor symptoms: rigidity, tremor, swallowing, speech, dribbling of saliva, dyskinesia, off-periods and falls. It was only noted if these symptoms were present or absent according to the opinion of the patient. Non-Motor-Symptoms-quest (NMS-quest) The NMS-quest is a 30-item self-completed questionnaire that provides a comprehensive assessment of the range of NMS that occur in PD (35). It consist of 6 domains that cover symptoms ranging from gastrointestinal symptoms to sensory symptoms. Each question can be answered with “yes” or “no”. In this study 5 questions were used: nausea, obstipation, olfactory ability, visual hallucinations and sleeping disorders.
Results A total of 140 consecutive patients were asked to participate, 35 patients refused due to personal circumstances and 3 were excluded because of a malignancy. 102 patients were included (52.9% male and 48.1% female), with a mean age of 76.4 ± 6.0 years and mean disease duration of 6.4 ± 5.1 years (table 1). Undernutrition (MNA score
