PREVALENCE AND COSTS OF MALNUTRITION IN HOSPITALIZED DYSPHAGIC PATIENTS: A SUBANALYSIS OF THE PREDYCES STUDY.

INTRODUCTION: dysphagia and malnutrition are conditions that frequently appear together in hospitalized patients. OBJECTIVES: the main purpose of this study was to analyze the prevalence of malnutrition in patients with dysphagia included in the PREDyCES study as well as to determine its clinical and economic consequences. METHODS: this is a substudy of an observational, cross-sectional study conducted in 31 sites all over Spain. RESULTS: 352 dysphagic patients were included. 45.7% of patients presented with malnutrition (NRS-2002 ≥ 3) at admission and 42.2% at discharge. In elderly patients (≥ 70 years old) prevalence of malnutrition was even higher: 54.6% at admission and 57.5% at discharge. Also, prevalence of malnutrition was higher in urgent admissions versus those scheduled (45.7% vs 33.3%; p < 0.05) and when admitted to small hospitals vs. large hospitals (62.8% vs 43.9%; p < 0.001). In-hospital length of stay was higher in malnourished patients compared to those well-nourished (11.5 ± 7.1 days vs. 8.8 ± 6.05 days; p < 0.001), and in malnourished patients a tendency towards increase related-costs was also observed, even though it was not statistically significant (8 004 ± 5 854 € vs. 6 967 ± 5 630 €; p = 0.11). Length of stay was also higher in elderly patients (≥ 70 y/o) vs adults (< 70 y/o). 25% of dysphagic patients and 34.6% of malnourished patients with dysphagia received nutritional support during hospitalization. DISCUSSION: these results confirm that in patients with dysphagia, malnutrition is a prevalent and under recognized condition, that also relates to prolonged hospitalizations.

Introducción: la disfagia y la desnutrición son condiciones que con frecuencia aparecen juntas en los pacientes hospitalizados. Objetivos: el objetivo principal de este estudio fue analizar la prevalencia de desnutrición en pacientes con disfagia incluidos en el estudio PREDyCES®, así como para determinar sus consecuencias clínicas y económicas. Métodos: se trata de un subestudio de un estudio observacional, transversal realizado en 31 hospitales de toda España. Resultados: se incluyeron 352 pacientes con disfagia. El 45,7% de los pacientes presentaron desnutrición (NRS®-2002 ≥ 3) al ingreso y el 42,2% al alta. En pacientes de edad avanzada (≥ 70 años) la prevalencia de la desnutrición fue aún mayor: 54,6% al ingreso y el 57,5% al alta. Además, la prevalencia de la desnutrición fue mayor en los ingresos urgentes frente a las programados (45,7% vs 33,3%; p.

Prevalence and costs of malnutrition in hospitalized dysphagic patients: a subanalysis of the PREDyCES® study / Prevalencia y costes de la desnutrición en pacientes hospitalizados con disfagia: un subanálisis del estudio Predyces®

Introduction: dysphagia and malnutrition are conditions that frequently appear together in hospitalized patients. Objectives: the main purpose of this study was to analyze the prevalence of malnutrition in patients with dysphagia included in the PREDyCES® study as well as to determine its clinical and economic consequences. Methods: this is a substudy of an observational, cross-sectional study conducted in 31 sites all over Spain. Results: 352 dysphagic patients were included. 45.7% of patients presented with malnutrition (NRS®-2002 ≥ 3) at admission and 42.2% at discharge. In elderly patients (≥ 70 years old) prevalence of malnutrition was even higher: 54.6% at admission and 57.5% at discharge. Also, prevalence of malnutrition was higher in urgent admissions versus those scheduled (45.7% vs 33.3%; p < 0.05) and when admitted to small hospitals vs. large hospitals (62.8% vs 43.9%; p < 0.001). In-hospital length of stay was higher in malnourished patients compared to those well-nourished (11.5 ± 7.1 days vs. 8.8 ± 6.05 days; p < 0.001), and in malnourished patients a tendency towards increase related-costs was also observed, even though it was not statistically significant (8 004 ± 5 854 Euros vs. 6 967 ± 5 630 Euros; p = 0.11). Length of stay was also higher in elderly patients (≥ 70 y/o) vs adults (< 70 y/o). 25% of dysphagic patients and 34.6% of malnourished patients with dysphagia received nutritional support during hospitalization. Discussion: these results confirm that in patients with dysphagia, malnutrition is a prevalent and under recognized condition, that also relates to prolonged hospitalizations (AU)

Introducción: la disfagia y la desnutrición son condiciones que con frecuencia aparecen juntas en los pacientes hospitalizados. Objetivos: el objetivo principal de este estudio fue analizar la prevalencia de desnutrición en pacientes con disfagia incluidos en el estudio PREDyCES®, así como para determinar sus consecuencias clínicas y económicas. Métodos: se trata de un subestudio de un estudio observacional, transversal realizado en 31 hospitales de toda España. Resultados: se incluyeron 352 pacientes con disfagia. El 45,7% de los pacientes presentaron desnutrición (NRS®-2002 ≥ 3) al ingreso y el 42,2% al alta. En pacientes de edad avanzada (≥ 70 años) la prevalencia de la desnutrición fue aún mayor: 54,6% al ingreso y el 57,5% al alta. Además, la prevalencia de la desnutrición fue mayor en los ingresos urgentes frente a las programados (45,7% vs 33,3%; p <0,05) y en los ingresados en hospitales pequeños frente a los hospitales grandes (62,8% vs 43,9%; p <0,001). La estancia hospitalaria fue mayor en los pacientes desnutridos en comparación con los bien nutridos (11,5 ± 7,1 días frente a 8,8 ± 6,05 días, p <0,001). En pacientes con desnutrición también se observó una tendencia al incremento de costes relacionados, aunque no fue estadísticamente significativa (8 004 ± 5 854 Euros frente a 6 967 ± 5 630 Euros; p = 0,11). La duración de la estancia también fue más prologada en los pacientes de edad avanzada (≥ 70 y / o) vs adultos (<70 y / o). El 25% de los pacientes con disfagia y el 34,6% de los pacientes desnutridos con disfagia recibieron soporte nutricional durante la hospitalización. Conclusión: estos resultados confirman que en los pacientes con disfagia, la desnutrición es una condición frecuente y poco reconocida, que también está relacionada con la prolongación de la hospitalización (AU)

[Nutritional and metabolic aspects of neurological diseases]. / Aspectos metabólico-nutricionales en las enfermedades neurológicas.

The central nervous system regulates food intake, homoeostasis of glucose and electrolytes, and starts the sensations of hunger and satiety. Different nutritional factors are involved in the pathogenesis of several neurological diseases. Patients with acute neurological diseases (traumatic brain injury, cerebral vascular accident hemorrhagic or ischemic, spinal cord injuries, and cancer) and chronic neurological diseases (Alzheimer's Disease and other dementias, amyotrophic lateral sclerosis, Parkinson's Disease) increase the risk of malnutrition by multiple factors related to nutrient ingestion, abnormalities in the energy expenditure, changes in eating behavior, gastrointestinal changes, and by side effects of drugs administered. Patients with acute neurological diseases have in common the presence of hyper metabolism and hyper catabolism both associated to a period of prolonged fasting mainly for the frequent gastrointestinal complications, many times as a side effect of drugs administered. During the acute phase, spinal cord injuries presented a reduction in the energy expenditure but an increase in the nitrogen elimination. In order to correct the negative nitrogen balance increase intakes is performed with the result of a hyper alimentation that should be avoided due to the complications resulting. In patients with chronic neurological diseases and in the acute phase of cerebrovascular accident, dysphagia could be present which also affects intakes. Several chronic neurological diseases have also dementia, which lead to alterations in the eating behavior. The presence of malnutrition complicates the clinical evolution, increases muscular atrophy with higher incidence of respiratory failure and less capacity to disphagia recuperation, alters the immune response with higher rate of infections, increases the likelihood of fractures and of pressure ulcers, increases the incapacity degree and is an independent factor to increase mortality. The periodic nutritional evaluation due to the evolutionary changes should be part of the treatment. At the same time to know the metabolic and nutritional characteristics is important to be able to prevent and treat early the possible side effects. If nutritional support is indicated, the enteral route is the route of choice although some times, mainly in critical patients, parentral nutrition is necessary to ensure the administration of the required nutrients.

Aspectos metabólico-nutricionales en las enfermedades neurológicas / Nutritional and metabolic aspects of neurological diseases

El sistema nervioso central regula la ingesta de nutrientes, la homeostasis de la glucosa y de los electrolitos y pone en marcha las sensaciones de hambre y sed. Diversos factores nutritivos participan en la patogénesis de muchas enfermedades neurológicas. Los pacientes con enfermedades neurológicas agudas (traumatismo craneoencefálico, accidente cerebrovascular hemorrágico o isquémico, lesiones medulares o tumorales) y crónicas (enfermedad de Alzheimer y otras demencias, esclerosis lateral amiotrófica, esclerosis múltiple o enfermedad de Parkinson), incrementan el riesgo de desnutrición por factores múltiples relacionados con ingesta de nutrientes, anormalidades en el gasto energético, trastornos de la conducta alimentaria, cambios gastrointestinales y efectos secundarios de la medicación. Los pacientes con lesión neurológica aguda tienen en común la presencia de un hipermetabolismo e hipercatabolismo que se asocia a un periodo de ayuno prolongado por las frecuentes complicaciones gastrointestinales muchas veces secundarias a los tratamientos administrados. En la fase aguda, las lesiones medulares presentan una reducción del gasto energético asociado a un aumento en la excreción de nitrógeno, para intentar corregir el balance nitrogenado negativo se intente incrementar las ingestas con el resultado de una sobrealimentación que debe evitarse por las complicaciones que comporta. En los pacientes crónicos (y en el ictus en fase aguda) la disfagia es un síntoma que aparece a lo largo de la enfermedad y que condiciona las ingestas. Muchas patologías neurológicas crónicas cursan con demencia que se acompaña de trastornos en la conducta alimentaria. La presencia de desnutrición complica la evolución de estos pacientes, aumenta la atrofia muscular con mayor incidencia de insuficiencia respiratoria y menor capacidad de recuperación de la disfagia, altera el sistema inmunitario con mayor susceptibilidad a infecciones, incrementa la posibilidad de fracturas y de úlceras de presión, aumenta el riesgo de discapacidad y es un factor independiente de mortalidad. No sólo es importante que la valoración nutricional periódica, dadas las múltiples modificaciones a lo largo de su evolución, forme parte de la rutina asistencial de estos pacientes sino deben conocerse las características metabólico-nutricionales observadas en cada situación lo que permitirá prevenir y tratar precozmente las consecuencias clínicas de ello derivadas y así evitar las consecuencias evolutivas de las mismas. Si el soporte nutricional específico está indicado la vía preferencial es la vía digestiva aunque en muchas ocasiones, especialmente en los pacientes críticos, debe optarse por la vía parenteral para asegurar la administración de los nutrientes requeridos (AU)

The central nervous system regulates food intake, homoeostasis of glucose and electrolytes, and starts the sensations of hunger and satiety. Different nutritional factors are involved in the pathogenesis of several neurological diseases. Patients with acute neurological diseases (traumatic brain injury, cerebral vascular accident hemorrhagic or ischemic, spinal cord injuries, and cancer) and chronic neurological diseases (Alzheimer’s Disease and other dementias, amyotrophic lateral sclerosis, Parkinson’s Disease) increase the risk of malnutrition by multiple factors related to nutrient ingestion, abnormalities in the energy expenditure, changes in eating behavior, gastrointestinal changes, and by side effects of drugs administered. Patients with acute neurological diseases have in common the presence of hyper metabolism and hyper catabolism both associated to a period of prolonged fasting mainly for the frequent gastrointestinal complications, many times as a side effect of drugs administered. During the acute phase, spinal cord injuries presented a reduction in the energy expenditure but an increase in the nitrogen elimination. In order to correct the negative nitrogen balance increase intakes is performed with the result of a hyper alimentation that should be avoided due to the complications resulting. In patients with chronic neurological diseases and in the acute phase of cerebrovascular accident, dysphagia could be present which also affects intakes. Several chronic neurological diseases have also dementia, which lead to alterations in the eating behavior. The presence of malnutrition complicates the clinical evolution, increases muscular atrophy with higher incidence of respiratory failure and less capacity to disphagia recuperation, alters the immune response with higher rate of infections, increases the likelihood of fractures and of pressure ulcers, increases the incapacity degree and is an independent factor to increase mortality. The periodic nutritional evaluation due to the evolutionary changes should be part of the treatment. At the same time to know the metabolic and nutritional characteristics is important to be able to prevent and treat early the possible side effects. If nutritional support is indicated, the enteral route is the route of choice although some times, mainly in critical patients, parentral nutrition is necessary to ensure the administration of the required nutrients (AU)

[Artificial nutrition in respiratory failure]. / Nutrición artificial en la insuficiencia respiratoria.

Patients with chronic respiratory failure frequently have nutritional impairments that prompt nutritional support. This is more important during acute exacerbation episodes since, in this situation, the risk for hyponutrition is increased and recovery may be compromised. In order to prevent ventilatory overload, nutritional support should be normocaloric or mildly hypocaloric (using indirect calorimetry, if possible) with a fat content ratio of around 50% of the caloric intake. Micronutrients supply should be considered due to the effects of some of them (P, Mg, Se) on respiratory function. The aim of nutritional support in patients with acute respiratory failure (ARDS) is the requirements provision meanwhile the inflammatory response is modulated and repair mechanisms against acute damage are stimulated. Qualitative modification of lipids supply (by decreasing the intake of linoleic acid and increasing other eicosanoids-precursor lipids with a lesser inflammatory capability) and the use of antioxidants seem to be the most important mechanisms in this regard.

Nutrición artificial en la insuficiencia respiratoria / Artificial nutrition in respiratory failure

Los pacientes con insuficiencia respiratoria crónica presentan con frecuencia alteraciones nutricionales que hacen necesario el soporte nutricional. Ello es más importante en presencia de episodios de descompensación aguda, dado que en esta situación se incrementa el riesgo de desnutrición y puede comprometerse la recuperación. Con el fin de evitar la sobrecarga ventilatoria, el soporte nutricional debe ser normocalórico o discretamente hipocalórico (recurriendo a la calorimetría indirecta, si es posible) y contener una proporción de grasa cercana al 50% del aporte calórico. El aporte de micronutrientes debe ser considerado debido a los efectos de algunos de ellos (P, Mg, Se) sobre la función ventilatoria. El objetivo del soporte nutricional en los pacientes con insuficiencia respiratoria aguda (SDRA) es el de aportar los requerimientos al mismo tiempo que se procede a la modulación de la respuesta inflamatoria y a la estimulación de los mecanismos de recuperación ante la agresión aguda. La modificación cualitativa del aporte lipídico (disminuyendo el aporte de ácido linoleico e incrementando el de otros lípidos precursores de eicosanoides con menor capacidad proinflamatoria) y el empleo de antioxidantes, parecen ser los mecanismos más importantes en este sentido (AU)

Patients with chronic respiratory failure frequently have nutritional impairments that prompt nutritional support. This is more important during acute exacerbation episodes since, in this situation, the risk for hyponutrition is increased and recovery may be compromised. In order to prevent ventilatory overload, nutritional support should be normocaloric or mildly hypocaloric (using indirect calorimetry, if possible) with a fat content ratio of around 50% of the caloric intake. Micronutrients supply should be considered due to the effects of some of them (P, Mg, Se) on respiratory function. The aim of nutritional support in patients with acute respiratory failure (ARDS) is the requirements provision meanwhile the inflammatory response is modulated and repair mechanisms against acute damage are stimulated. Qualitative modification of lipids supply (by decreasing the intake of linoleic acid and increasing other eicosanoids-precursor lipids with a lesser inflammatory capability) and the use of antioxidants seem to be the most important mechanisms in this regard (AU)