1 NÖROLOJİK HASTALIKLARDA BESLENME BOZUKLUKLARI Epidemiyoloji, Sorunun Boyutu Prof. Dr. Ayşe Sağduyu Kocaman
4 Dünyada hastaneye kabulde malnütrisyon prevalansı*: % 28 % 76 Malnütrisyonun sonuçları Yara iyileşmesinde gecikme Bağışıklık sisteminde bozulma Yaşam kalitesinin düşmesi % 28 % 76 Hastanede yatma süresinde uzama, mortalite ve morbidite artışı *Thomas, 2003 Correia et al, 2003; Covinsky, 2002; Middleton et al, 2001; Ferguson et al, 1998 % Barker LA et al. Int J Environ Res Public Health 2011; 8: Ahmed T et al. Clin IntervenIons in Aging 2010; 5:
5 ESPEN- LLL-2007
7 TÜRKİYE DE MALNÜTRİSYON Türkiye de hastanın katılımıyla gerçekleştirilen bir çalışmada kliniklere göre malnütrisyon Korfalı G et al. Clin Nutr 2009; 28:
8 Nöroloji ve Nöroşirürji Hastalarında Malnütrisyon / Malnütrisyon Riski 2 % % 79 % 79 Hastaneye yatışta 10 günlük yatış sonrasında Hafsteinsdo1r TB et al. J Clin Nurs 2010 Mar; 19(5-6):
9 Hastayı N/G ile besleyelim mi Dr Bey? Biraz daha bekleyelim, durumu komplike etmeyelim Bu gün de aç kalsın, yapılacak tetkikleri var AÇIMMMM
10 NÖROLOJİK HASTALIKLARDA BESLENME BOZUKLUKLARI İLERLEYİCİ FONKSİYONEL BOZUKLUK DİSFAJİ Kronik psikiyatrik ve nörolojik hastalığı olanların % 60 ından fazlasında VKİ < 20 kg /m 2 Planas M. ESPEN 2007
11 Yutma Bozukluğu (Disfaji) Yetersiz Yutma Beslenme ve sıvı alımında yetersizlik Boğulma, orofaringeal aspirasyon MALNÜTRİSYON DEHİDRATASYON Pnömoni Solunum yetmezliği Robbins J J Rehab Research and Dev 2002
12 Beyin Damar Hastalıkları % 30 ALS (başlangıç semptomu) % (terminal dönem) % 100 Guillain Barre Sendromu % Myastenia Gravis % 40 Multipl Skleroz % 3-43 Parkinson Hastalığı % Alzheimer Hastalığı % 84 Clave P et al Rev Esp Enform Dig 2004;96:
13 Levodopa ve Dopa agonistleri Propofol Barbitüratlar Piridostigmin, Donapezil ve diğer kolinerjikler Fenitoin Diüretikler Mannitol Proteinle birlikte alınması emilimini bozar, Bulantı, kusmaya neden olabilir, Domperidon kullanımı ile GİS yan etkileri Lipit içeriğiyle kaloriyi arttırır Kalori gereksiniminde azalma, konstipasyon Diyare ve motilite artışı Enteral nütrisyonda emilim bozuklukları, Folat malabsorbsiyonu Hipokalemi, hipomagnezemi, hiponatremi Hipokalemi, hipomagnezemi, dehidratasyon
14 Ekstremite ve solunum kaslarında atrofi Solunum kaslarının güçsüzlüğü sonucu pnömoni riskinde Bağışıklık sisteminde yetersizlik ve enfeksiyonlara yatkınlık Tip II kas lifi atrofisi sonucunda yutma kaslarında yetersizlik Bası yarası oluşma riskinde artış Osteoporoza eğilim Sağ kalım oranlarında düşmeye neden olur
15 Depresyon Kendine bakımın bozulması Yutma ve yeme güçlükleri Gıda reddi Yemek hazırlayamama Yemeği ağzına götürememe Ataksi, apraksi, görme bozuklukları Yemek yeme ve yutma süresinin uzaması Çiğneyememe, yutamama Diğer Gıdaların emilimini etkileyen ilaçlar Konstipasyon, diyare
16 Protein enerji malnütrisyonu Hastaneye kabulde % 7-15 İkinci haftada % Gariballa et al JPEN 1998, 22:315 Dennis MS (FOOD) Lancet 2005;365: Uzun süre rehabilitasyon gerektiren hastalarda % 50 Finestone HM Arch Phys Med Rehabil 1995; 76:
17 Orofaringeal disfaji unilateral hemisferik inmelerin % 50 sinde görülmekte Martine R et al Stroke 2005;36: Üçüncü ayın sonunda disfaji % 1-15 Mann G Stroke 1999;30:
18 Premorbid nutrition and short term outcome of stroke: a multicentre study from India. Pandian JD, Jyotsna R, Singh R, Sylaja PN, Vijaya P, Padma MV, Venkateswaralu K, Sukumaran S, Radhakrishnan K, Sarma PS, Mathew R, Singh Y. Source Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India. Abstract J Neurol Neurosurg Psychiatry Oct;82(10): Epub 2011 Mar 22 BACKGROUND: Little is known about the impact of premorbid undernutrition on stroke outcome in developing countries. AIM: PREMORBİD BESLENME BOZUKLUĞU To study the impact of premorbid undernutrition status, measured by the Subjective Global Assessment (SGA) tool, on short term stroke outcome. METHODS: First ever stroke patients admitted to six major hospitals in North and South India participated in this study from 1 March 2008 to 30 September The SGA tool was administered within 48 h of stroke onset, and 6 months premorbid nutritional status was rated as well nourished (A rating) and undernourished (B and C ratings) using this tool. Stroke outcome was assessed after 30 days using the modified Rankin scale (mrs), and a mrs score >3 was defined as a poor outcome. Statistical analyses were performed using SPSS Statistics V RESULTS: Of 477 patients enrolled, 448 patients were included in the analyses. Mean age was 58.1±13.7 years (range 16-96) and 281 (62.7%) patients were men. At admission, premorbid undernutrition was found in 121 (27.2%) patients. Older age (OR 4.99, CI 1.26 to 19.64, p=0.021), hypertension (OR 1.99, CI 1.04 to 3.79, p=0.037) and patients from Andhra Pradesh State (OR 1.87, CI 1.05 to 3.32, p=0.032) were predictors of undernutrition in multiple logistic KÖTÜ İNME PROGNOZU regression analysis. Premorbid undernutrition (OR 1.99, CI 1.20 to 3.31, p=0.007) and length of hospital stay (OR 3.41, CI 1.91 to 6.06, p<0.0001) were the independent predictors of poor outcome in the multiple logistic regression model. CONCLUSIONS: High rates of premorbid undernutrition in stroke patients were found. Age, hypertension and patients from Andhra Pradesh State were predictors of premorbid undernutrition. Premorbid undernutrition was associated with poor stroke outcome. The results provide opportunities for primary prevention and improving stroke outcome.
19 Oropharyngeal dysphagia after stroke: incidence, diagnosis, and clinical predictors in patients admitted to a neurorehabilitation unit. Falsetti P, Acciai C, Palilla R, Bosi M, Carpinteri F, Zingarelli A, Pedace C, Lenzi L. Source Neurorehabilitation, Local Health Unit 8, S. Donato Hospital, Arezzo, Italy. Abstract OBJECTIVE: Disfaji oranı % 41 J Stroke Cerebrovasc Dis Sep-Oct;18(5): We analyzed patients with stroke in a neurorehabilitation unit to define incidence of dysphagia, compare clinical bedside assessment and videofluoroscopy (VFS), and define any correlation between dysphagia and clinical characteristic of patients. METHODS: Klinik bulgular videofloroskopi ile korele In all, 151 consecutive inpatients with recent ischemic or hemorrhagic stroke were enrolled. RESULTS: Dysphagia was clinically diagnosed in 62 of 151 patients (41%). A total of 49 patients (79% of clinically dysphagic patients) underwent VFS. Six patients clinically suggested to be dysphagic had a normal VFS finding. The correlation Hastaların % 25 inde gizli aspirasyon with VFS-proved dysphagia). between clinical and VFS diagnosis of dysphagia was significant (r = ). Penetrations and aspirations were observed, respectively, in 42.8% and 26.5% of patients with dysphagia, with 12.2% classified as silent. Lower respiratory tract infections were observed in 5.9%, more frequently in patients with dysphagia (30%). Dysphagia was not influenced by type of stroke. Cortical stroke of nondominant side was associated with dysphagia (P =.0322) and Disfaji inme tipi ile ilişkisiz subcortical nondominant stroke showed a reduced frequency of dysphagia (P =.0008). Previous cerebrovascular disease resulted associated to dysphagia (P =.0399). Patients with dysphagia had significantly lower functional independence measurement (FIM) and level of cognitive functioning on admission and lower FIM on discharge, longer hospital stay, and more frequent malnutrition, and they were more frequently aphasic and dysarthric. Disfajik olgularda hastanede kalım süresi uzun, Percutaneous endoscopic gastrostomy was used in 18 of 151 patients (11.9%) (41.8% of patients with VFS-proved dysphagia). malnütrisyon riski yüksek CONCLUSIONS: Dysphagia occurs in more than a third of patients with stroke admitted to rehabilitation. Clinical assessment demonstrates good correlation with VFS. The grade of dysphagia correlates with dysarthria, aphasia, low FIM, and level of cognitive functioning. Large cortical strokes of nondominant side are associated with dysphagia.
20 The Lancet Neurology, Volume 11, Issue 1, Pages 66-81, January 2012 doi: /s (11) Nutrition and the risk of stroke Prof Graeme J Hankey AŞIRI BESLENME Summary Poor nutrition in the first year of a mother's life and undernutrition in utero, infancy, childhood, and adulthood predispose individuals to stroke in later life, but the mechanism of increased stroke risk is unclear. Overnutrition also increases the risk of stroke, probably by accelerating the development of obesity, hypertension, hyperlipidaemia, and diabetes. Reliable evidence suggests that dietary supplementation with antioxidant vitamins, B vitamins, and calcium does not reduce the risk of stroke. Less reliable evidence DİABETES suggests MELLİTUS that stroke HİPERTANSİYON can be prevented by HİPERLİPİDEMİ diets that are prudent, aligned to the Mediterranean or DASH (Dietary Approaches to Stop Hypertension) diets, low in salt and added sugars, high in potassium, and meet, but do not exceed, energy requirements. Trials in progress are examining the effects of vitamin D and marine omega-3 fatty acid supplementation on incidence of stroke. Future challenges include the need to improve the quality of evidence linking many nutrients, foods, and dietary patterns to the risk of stroke. İNME RİSK ARTIŞI
21 Nöromusküler Nedenli Disfaji Motor nöron ALS Akson GBS Nöromusküler bileşke Presnaptik Postsnaptik Kas MG
22 Ciddi disfajik hastaların % 30 u gastrostomi tüpüyle beslenmekte, Disfaji ve malnütrisyon aspirasyon pnömonisi riskini arttırmakta, Sağkalım süresi kısalmaktadır.
24 Malnutrition at the time of diagnosis is associated with a shorter disease duration in ALS Limousin N, Blasco H, Corcia P, Gordon PH, De Toffol B, Andres C, Praline J. Source Centre SLA, Service de Neurologie et de Neurophysiologie Clinique, CHRU, Tours, France. AbstractJ Neurol Sci Oct 15;297(1-2):36-9. Epub 2010 Jul 31. BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease. During the course of the illness, malnutrition can occur and may shorten survival. The aim of our study was to determine whether clinical nutritional parameters that are used in daily practice are ERKEN DÖNEMDE MALNÜTRİSYON associated with prognosis and whether they can help guide therapeutic decisions. METHODS: We retrospectively reviewed a cohort of ALS patients in our institution between January 2002 and January Clinical and demographic outcomes were compiled. To evaluate predictors of survival, we analyzed several clinical nutritional parameters available in daily practice (body mass index, weight loss exceeding 10% of premorbid weight at the time of diagnosis and during the course of the disease and the use of technical supports such as percutaneous endoscopic gastrostomy (PEG) and non-invasive ventilation). RESULTS: Sixty-three patients were retrospectively studied. Thirteen patients had weight loss exceeding 10% of premorbid weight at the time of diagnosis and thirty patients had weight loss meeting this criterion at final examination. Weight loss exceeding 10% at the time of diagnosis was associated with a shorter duration of disease (17±6months versus 35±26months; p=0.002). A linear correlation was KÖTÜ PROGNOZ found between mean disease duration and time between onset and diagnosis (p<0.0001). The subgroup of patients with a PEG had a longer survival time than the other subgroup of patients (p=0.02). CONCLUSIONS: In ALS patients, early and marked weight loss significantly predicts a worse prognosis. The percentage of premorbid weight loss is a suitable and useful measure that can be used in daily practice to identify patients with a poor prognosis.
25 Alteration of nutritional status at diagnosis is a prognostic factor for survival of amyotrophic lateral sclerosis patients. Marin B, Desport JC, Kajeu P, Jesus P, Nicolaud B, Nicol M, Preux PM, Couratier P. Source Université de Limoges, IFR 145 GEIST, Institut d'epidémiologie Neurologique et de Neurologie Tropicale, EA 3174 NeuroEpidémiologie Tropicale et Comparée, Limoges, France. Abstract J Neurol Neurosurg Psychiatry Jun;82(6): Epub 2010 Nov 19. OBJECTIVES: The aims were to analyse changes in nutritional parameters from diagnosis of amyotrophic lateral ERKEN sclerosis DÖNEMDE (ALS) to death and MALNÜTRİSYON to assess their relationships with survival at the time of diagnosis and during follow-up. METHODS: 92 ALS patients were included and clinically assessed every 3 months (ALS functional rating scale, manual muscular testing, forced vital capacity, weight, BMI, percentage weight loss). Bioimpedance was performed to evaluate body composition (fat-free mass, fat mass and hydration status) and phase angle. Survival analyses were performed from diagnosis to death or censoring date using a Cox model. RESULTS: The evolution of nutritional parameters in ALS patients was marked by significant decreases in weight, BMI, fat-free mass and phase angle, and increased fat mass. The authors identified an adjusted 30% increased risk of death for a 5% decrease from usual weight at time of diagnosis (RR 1.30; 95% CI 1.08 to 1.56). During follow-up, the authors identified adjusted 34% (95% CI 18% to 51%) and YÜKSEK MORTALİTE 24% (95% CI 13% to 36%) increased risks of death associated with each 5% decrease in usual weight and each unit decrease in usual BMI, respectively (p<0.0001). Malnutrition during the course was related to a shorter survival (p=0.01), and fat mass level was associated with a better outcome (RR 0.90 for each 2.5 kg fat mass increment). CONCLUSIONS: Nutritional parameters of ALS patients worsened during evolution of the disease, and worse nutritional status (at time of diagnosis or during the course) was associated with a higher mortality. This study offers some justification for studying the use of therapeutic nutritional intervention to modify the survival of ALS patients.
26 Vücut ağırlığı takibi Disfaji değerlendirmesi ORAL BESLENME DESTEĞİ! ALS tanısı Üç ayda bir kontrol Disfajinin erken saptanması Beslenme konusunda bilgilendirme Zorlu vital kapasite (FVC) veya vital kapasite izlemi Üç ayda bir kontrola devam Semptomlarda progresyon FVC> % 50 FVC % FVC < % 30 GÜVENSİZ YUTMA VE / VEYA MALNÜTRİSYON PEG riskli PEG orta riskli PEG riskli PEG kabul edildi Tolere edebildiği kadar oral gerektiğinde PEG ile enteral Anestezi kons PEG PEG reddedildi Tolere edebildiği kadar oral, Gerektiğinde IV / NG destek
27 İnflamatuvar demyelinizan/ aksonal Poliradikülonöropati Ventilatör gereksinimi Var Yok N=60 n=54 Yaş (yıl) 58,5 ( 4-87) 55,5 ( 7,5-84 ) Bulber disfonksiyon 49 ( 91 ) 20 ( 37 ) Maksimum defisite erişme zamanı (gün) 7 ( ) 10 ( 0-53 ) Mayo Clinic GBS Study Group Hipermetabolik- Hiperkatabolik Süreç Enerji tüketimi ; kcal/kg Protein gereksinimi; g/kg Aksonal formlarda uzun süreli enteral nütrisyon desteği gerekebilir! Roubenoff et al JPEN 1992, 16:464
28 Miyastenia Gravis ve Miyastenik Kriz Solunum yetmezliğine neden olan solunum kaslarında zayıflık Bulbar kaslarda zayıflık, yutma çiğneme güçlüğü MG in en şiddetli komplikasyonu Yoğun bakım gerektirir Krizler dışında miyastenik olgularda disfaji çok enderdir. Bulber başlangıçlı olgularda tanı gecikmesi halinde çiğneme kaslarındaki güçsüzlük yetersiz beslenmeye ve malnütrisyona neden olabilir!!
29 MS in seyrinde disfaji çok enderdir Hastalığın çok ilerlemiş evrelerinde ortaya çıkabilir Devic Sendromunda bulber bölge tutulumunda disfaji görülebilir
30 Hastalığın orta ve ileri evrelerinde % olguda yutma güçlüğü Dopaminerjik ilaçların neden olduğu bulantı kusma, % 30 olguda depresyon ve buna bağlı gıda reddi MALNÜTRİSYON
31 MALNÜTRİSYONA YOL AÇAN TEMEL SORUNLAR Yeme ve yutma süresinde uzama Gastrointestinal yavaşlama Protein-ilaç etkileşimi
35 65 yaş ve üstü popülasyonun çok önemli sağlık sorunu!! Tip 2 Diabet ve obesite ile risk İnsülin direncinde artış, amiloid plak birikimini arttırır. Orta evrede ve ileri evrede malnütrisyon riski İleri evrede disfaji % 85
39 Malnutrition in the elderly and its relationship with other geriatric syndromes. Saka B, Kaya O, Ozturk GB, Erten N, Karan MA. Source Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Millet Cad., Capa, Fatih, Istanbul 34093, Turkey. Abstract Clin Nutr Dec;29(6): Epub 2010 Jun 2 BACKGROUND & AIMS: Age related decline in food intake is associated with various physiological, psychological and social factors. Our aim was to assess the nutritional status of our elderly patients and its association with other geriatric syndromes. METHODS: In this cross-sectional population based study, Mini Nutritional Assessment (MNA) test was used to evaluate nutritional status of 413 elderly patients who were admitted to our outpatient clinic in the last 12 months. MNA test results were compared with the laboratory findings and established geriatric syndromes. RESULTS: Poor nutritional status was found in 44% of the patients (n=181: 13% malnutrition, 31% malnutrition risk). Malnutrition rate was higher among those with subsequent hospitalization (n=122, 25% vs 8%). Patients with poor nutritional status had lower blood haemoglobin, serum total protein and albumin, and revealed more chronic diseases and geriatric syndromes (6 ± 2 vs 3 ± 2, p<0.0001). Patients with depression, fecal incontinence, decreased cognitive function and functional dependence showed poor nutritional status according to MNA test results. CONCLUSIONS: Malnutrition rate of our patients was comparable with the previous data. Malnutrition risk showed positive correlation with the number of existing geriatric syndromes. Depression, dementia, functional dependence and multiple co-morbidities were associated with poor nutritional status.
40 Prevalence of sarcopenia and its association with functional and nutritional status among male residents in a nursing home in Turkey. Bahat G, Saka B, Tufan F, Akin S, Sivrikaya S, Yucel N, Erten N, Karan MA. Source Department of Internal Medicine, Istanbul University, Turkey. Abstract Aging Male Sep;13(3): The prevalence of sarcopenia differs between different populations, ages, gender and between settings such as the community and nursing homes. Studies on the association of sarcopenia with functional status revealed conflicting results whereas its association with nutritional status is well documented. We aimed at investigating the prevalence of sarcopenia and its association with functional and nutritional status among male residents in a nursing home in Turkey. Fat free mass (FFM) was detected by bioelectric impedance analysis. Functional status was evaluated with Katz activities of daily living (ADL) and Lawton Instrumental activities of daily living (IADL). Nutritional assessment was performed by Mini Nutritional Assessment Test (MNA(R)). One hundred fifty-seven male residents composed the study cohort. Mean age was /- 6.7 years. The prevalence of sarcopenia was 85.4%. No significant correlation was found between sarcopenia and ADL or IADL. There was a weak but significant correlation between IADL score and FFM (r = 0.18; p = 0.02). Sarcopenic residents had lower MNA score than non-sarcopenic residents (18.1 +/- 3.2 vs /- 0.8, p = 0.02). FFM was significantly lower in the residents with malnutrition compared to well-nourished residents (26.8 +/- 1 kg/body surface area vs /- 1.8 kg/body surface area, p < 0.05). In conclusion, the prevalence of sarcopenia was very high among male nursing home residents in Turkey. Sarcopenia was associated with low nutritional status but not with functional status.
41 Özet KRONİK NÖROLOJİK HASTALIKLARDA MALNUTRİSYON RİSKİ ÇOK YÜKSEKTİR! POLİKLİNİK İZLEMLERİNDE MALNUTRİSYONA DİKKAT EDİLMELİDİR! ORAL / ENTERAL BESLENME DESTEĞİ HASTALIK MORTALİTESİ VE MORBİDİTESİ YÖNÜNDEN ÇOK ÖNEMLİDİR!!!
42 Katılımınız için teşekkürler
43 NÜTRİSYONEL DURUMUN DEĞERLENDİRİLMESİ Öykü Fizik Bakı Kan Biyokimyası Tarama ve Değerlendirme Ölçekleri
44 BESLENME DURUMUNUN DEĞERLENDİRİLMESİ Durum değerlendirilmesi yapılırken, aşağıdaki yöntemlerin biri veya birkaçı kullanılabilir. 1. Besin tüketiminin saptanması 2. Antropometrik ölçümler 3. Biyokimyasal testler 4. Biyofizik testler 5. Klinik bulgular ve sağlık öyküsü 6. Psikososyal veriler Pekcan G et al. Beslenme Durumunun Saptanması 2008
45 MALNÜTRİSYON TARAMA VE DEĞERLENDİRME ÖLÇEKLERİ Malnütrisyon Tarama Testi Subjektif Global Değerlendirme Ölçeği
46 (MST) Malnütrisyon Tarama Testi Son zamanlarda istemeden kilo kaybınız var mı? Hayır 0 Evet / emin değilim 2 Yanıtınız evet ise ne kadar kilo kaybettiniz? > 15 4 Emin değilim 2 İştahsızlık nedeniyle daha mı az yiyorsunuz? Hayır 0 Evet 1
47 (MST) Malnütrisyon Tarama Testi SKORLAMA 0-1 Malnütriyon riski yok 2-3 Malnitrisyon riski orta 4-5 Malnütrisyon riski yüksek
48 Subjektif Global Değerlendirme Ölçeği Tıbbi hikayenin ve fiziksel muayene bulgularının da göz önünde bulundurulduğu, ve bu amaçla en yaygın olarak kullanılan yöntemdir. 1 Beslenme durumu; Hastanın beslenme durumu iyi ise A Orta derecede beslenme bozukluğu varsa B Ciddi derecede beslenme bozukluğu varca C olarak değerlendirilir Bauer J et al. Asia Pacific J Clin Nutr 2003; 12(3): Uygun A, Mendana S. Güncel Gastroenteroloji 2005; 9(2):
49 Subjektif Global Değerlendirme Ölçeği 1. Kilo değişikliği 2. Diyet değişikliği 3. Gastrointestinal semptomlar 4. Fonksiyonel kapasite 5. Beslenme gereksinimi hastalık ilişkisi 6. Beslenme bozukluğu yönünden fizik muayene