1. Evaluation of Nutritional Status and Treatment Methods in Patients with Dementia
2. Urinary Incontinence and Treatment Approach
3. Pressure Sores
I. Evaluation of Nutritional Status and Treatment Methods in Patients with Dementia
1. Malnutrition and its causes in the elderly
According to 2010 data, all The number of elderly people (65 years and above) in the world constitutes approximately 8% of the population. While the rate is higher in developed countries, it is very low in underdeveloped countries (16% vs 3%) (2010 World Population Data Sheet). Thanks to the developing health facilities in our country, the number of elderly people is increasing day by day. While elderly individuals constituted 4.2% (2.2 million) of the entire society in 1985, today this rate is around 7.2% (5.3 million) (T.R. Başkabanlık Turkish Statistical Institute News Bulletin 28 January 2011). A significant portion of geriatric syndromes seen in the elderly consist of neurological diseases, metabolic disorders and malignancies. Another geriatric syndrome frequently encountered in old age is malnutrition. Malnutrition is pathological changes that occur in the body as a result of the deficiency of one or more nutrients. When there is inadequate intake of macronutrients (proteins, carbohydrates and lipids) and/or micronutrients (trace elements and vitamins), some physical and metabolic changes occur in the body. According to the European Society for Clinical Nutrition and Metabolism (ESPEN) and the British Association for Parenteral and Enteral Nutrition (BAPEN), malnutrition is defined as malnutrition, which causes noticeable adverse events in the body (body size and composition) and body functions as a result of inadequate or excessive intake of energy, protein and other nutrients, and However, they described it as a pathological condition that reduces survival (Lochs et al., 2006). In the declaration published in 2010 by the International Consensus Guideline Committee formed by the American Association for Parenteral and Enteral Nutrition (ASPEN) and ESPEN, malnutrition was redefined to highlight more causes. Accordingly, malnutrition is divided into two separate headings. made; “Malnutrition due to hunger” and “Malnutrition associated with chronic diseases” (Jensen et al., 2010). In critical diseases where a serious inflammatory response develops, the catabolic rate increases and in this case it is primarily associated with increased cytokine levels (Tumor necrosis factor, TNF). Based on this, cachexia is defined as an involuntary weight loss of more than 6% in the last 6 months due to increased catabolic rate and this situation resists food intake (Lochs et al., 2006).
37-40% of the elderly cannot eat enough to meet their daily energy needs, 2 out of three elderly people skip a meal, and this situation has been described as "Anorexia of aging" in recent years (Morley, 1997). Among the factors that negatively affect nutritional status, environmental factors such as physiological changes that occur with aging, acute and chronic diseases, dental and oral health problems, polypharmacy, economic problems, not being able to shop alone, and not being able to prepare and eat meals have an important place. In the 1-2.5 years following the onset of weight loss in old age for any reason, the mortality rate increases by 9-38% for this reason alone (Marton, 1981). In addition to the decrease in oral food intake, daily growth hormone secretion decreases by 29-70% with age, leading to sarcopenia (Corpas, 1993).
Istanbul Faculty of Medicine, Department of Internal Medicine, Geriatrics In a study in which the nutritional status of elderly patients followed up at the BD Polyclinic was screened with the Mini Nutritional Assessment Test, the malnutrition rate was found to be 13%, and the additional malnutrition risk rate was found to be 31%. An increase in the incidence of depression, stool incontinence, loss of cognitive function and physical addiction has been detected, especially in those with malnutrition (Saka et al., 2010). In two cross-sectional studies conducted by screening the elderly in a large-scale nursing home located within the borders of Istanbul Province in 2009 and 2010, the malnutrition rate was found to be 9.8% in 2009, and the malnutrition risk rate was found to be an additional 22.8%. A significant increase in the incidence of other geriatric syndromes has been detected in the elderly with malnutrition. In the screening conducted with 349 residents in 2010, the rate of malnutrition was 13.5%, and additional The risk of malnutrition was found to be 33.5%.
In a study conducted in 2010 on patients hospitalized in the Internal Medicine Geriatrics Clinic of Istanbul Faculty of Medicine, the rate of malnutrition at the time of hospitalization was found to be 45.5%. It was determined that the duration of hospital stay (18.9±19.1 vs 11.3±11.3 days, p<0.0001) and the rate of nosocomial infection (45% vs 7%, p<0.001, OR: 3.298) increased significantly in the group at risk of malnutrition.
In the study conducted at Hacettepe University Department of Internal Medicine Geriatrics Unit, the risk of malnutrition in the elderly followed up in the outpatient clinic was found to be 28%. The risk of malnutrition was found to be associated with the risk of depression, hematocrit, fasting plasma glucose, albumin, erythrocyte sedimentation rate, instrumental activities of daily living and bone mineral density (Ülger, 2010).
Around the world. The data in the literature on this subject are also similar. In the study conducted by Kaiser MJ et al., the malnutrition rate was found to be 5.8% in the elderly living in the community, 13.8% in those living in nursing homes, and 38.7% in those hospitalized. A significant relationship was observed between malnutrition and dementia and sarcopenia (Kaiser et al., 2010). The first of the studies (NutritionDay) to evaluate the nutritional status of hospitalized patients, carried out annually by ESPEN, was carried out in 2006 and a total of 74000 patients were scanned in 810 centres. According to geriatric age group data, 50-70% of the elderly are at risk of malnutrition while hospitalized. This condition is mostly associated with loss of appetite, gastrointestinal system diseases, chronic diseases and increased catabolic response (Hiesmayr et al., 2009).
The incidence increases with aging and Diseases associated with malnutrition include cancer, depression and social isolation caused by it, dementia, stroke, other neurological disorders leading to cognitive impairment, and gastrointestinal and endocrine system disorders. During all these diseases, muscle mass loss (sarcopenia), osteoporosis, physical dependence and self-care deficits occur, which indirectly further deteriorate the nutritional status (Morley, 1997; Saka et al., 2010; Claggett, 1989; Thompson and Morris, 1991; Cabr era et al., 2007; Wilson, 1998).
The most important causes of loss of appetite in the elderly are social isolation, dementia and depression, chronic diseases and medications. In fact, all of these factors occur in the presence of progressive cognitive impairment, and on the other hand, swallowing difficulties occur as the disease progresses. This facilitates the development of malnutrition (Hays and Roberts, 2006). As daily activities and instrumental daily activities decrease, patients become more dependent, depression develops, and the amount of food taken orally decreases (Claggett, 1989; Cabrera et al., 2007). In the study of Ülger et al., which included 2327 patients admitted to the geriatric clinic between 2002 and 2004, the risk of malnutrition was found to be 27% in patients without dementia, while this rate was reported to be 37.3% in patients with dementia (p < 0.001) (Ülger et al., 2010).
In early stage dementia, the causes of malnutrition are mostly due to co-morbidities (chronic diseases, oral and dental health disorders and depression), while in middle stage dementia, skipping meals and not being able to access food (increase in addiction) and, more rarely, swallowing problems begin to worsen. In advanced stage dementia, the most prominent problem is swallowing difficulties. Apart from this, in the terminal stage, they can no longer even comprehend eating. They do not know what to do when there is food in their mouth and do not chew it, they keep it in their mouth or take it out.
In the recommendations of ESPEN (European Society of Clinical Nutrition and Metabolism) published in 2002, all individuals over the age of 65 should be nutritionally aware. Routine screening is recommended. Similar recommendations are included in all ESPEN Guidelines published in subsequent years (Volkert et al., 2006). Within the framework of the decision taken by the European Parliament in 2007, obesity and malnutrition were accepted as the most important public health problems and the issue was included in the official political agenda of the European Union in 2008. The year 2009 has been declared the year of war against malnutrition by ESPEN.
2.Basic concepts in nutrition
2.1.Energy Balance
The energy consumed by the person for chemical events in the body at rest. The minimum amount of energy is called basal metabolic rate (resting energy consumption, BET). It varies with height, weight, gender and age. The age-related decrease in basal metabolic rate is due to the decrease in muscle mass and the replacement of muscle mass by fat tissue, which has a slower metabolic rate. IET increases with increasing metabolic stress in the presence of excessive cytokine response due to infection and inflammation. The total energy (TET) consumed by the individual during the day is equal to the sum of IET and activity-related energy consumption (AET). While the activity factor for an active person in bed is 15-20%, it is 20-25% for an ambulatory person and 30-40% for an active person.
Daily TET through food taken orally. A corresponding amount of calories must be taken. In addition to daily energy needs, the intake of essential nutrients required for intracellular metabolic functioning is also important. Insufficient food intake will lead to weight loss (malnutrition), and intake of more calories than TET will lead to excessive weight gain (obesity). Malnutrition and obesity can coexist because consumption of any nutrient less than the required amount can lead to malnutrition. In recent years, the incidence of "obese malnutrition" in the elderly has been increasing. Especially in the elderly who were previously obese and had an acute illness, as food intake decreases, rapid muscle breakdown occurs due to the catabolic process, and sarcopenia develops over time. This condition is called sarcopenic obesity (Li and Heber, 2012). Pressure sores may develop in patients hospitalized for long periods of time. Moreover, being obese is a risk factor in this respect.
Foods are used in the construction and repair of tissues as well as in the maintenance of body functions. A complete diet should consist of enough carbohydrates and fats to meet daily energy needs, as well as proteins, vitamins, trace elements and water necessary for tissues and metabolism.
2.2.Carbohydrates
Carbohydrates are found in three forms in foods; starch, sugar and cellulose (fiber). The major sources of energy (calories) for humans are starch and sugar. Cellulose is not absorbed in the gastrointestinal tract (GI). It adds volume to the GIS content and provides appropriate passage. texture
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