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ESPEN 2014: “On the move against frailty”: Tested nutritional and social activity interventions support mobility and recovery

  • Frailty is a growing problem in our ageing society; nutritional supplementation for the elderly has a Grade A recommendation by ESPEN1
  • Pairing supplemental protein and exercise interventions can improve the muscle health and mobility of pre-frail and very frail older people
  • Offering a variety of nutritional supplements multiple times per day between meals combined with assistance and encouragement to promote consumption is an effective strategy to improve nutritional status in the frail, elderly population

Vevey, Switzerland, September 2014 – Frailty syndrome is a growing concern in our ageing society, but with better management it is not inevitable and may be reversible to a degree. New studies presented at a compelling satellite symposium at the European Society of Clinical Nutrition and Metabolism (ESPEN) congress show that specialized nutrition, when combined with physical activity, can help optimize mobility and recovery in older adults. For those who are frail, use of oral nutritional supplements is supported by a Grade A recommendation from ESPEN1. Professor Matteo Cesari from the University of Toulouse, France, moderating the Nestlé Nutrition Institute-sponsored symposium named three important areas to be addressed: “the key aspects of frailty for sharing best practice are the role of nutrition and exercise for the frail and the institutionalized elderly, and practical solutions to the challenges of effective supplementation in care settings”.

Specialized nutrition with a high daily intake of protein is a vital fuel for muscle in older age

Professor Reto W. Kressig, Chair of Geriatrics at the University of Basel, explained the new ESPEN expert group recommendations2, calling for older adults to have higher daily protein intake, at least 1-1.5 g per kilogram body weight for optimal muscle function. Emphasis was placed on the importance of combining this with regular exercise, especially resistance training for maintaining healthy muscle with ageing. However, older people are prone to have inadequate protein intake due to age-related appetite loss and elevated needs from medical conditions. Recent research has shown that supplements high in whey protein, naturally rich in the amino acid leucine, are particularly protective and effective for the elderly3. Prof Kressig explained that whey protein is a ‘fast’ protein that is swiftly integrated into muscle: “20 minutes after you drink a glass of whey you can measure the arriving amino acids in the muscle, so they are available for muscle protein synthesis”4.

Increase the practice of exercise in older adults by making it fun

In the pre-frail, combining a diet enriched in protein with resistance training has been shown to enhance muscle mass and muscle strength5. But according to Professor Kressig, there is a practical problem in this population of muscle performance on demand (muscle motor control), that is needed to prevent a fall. He stressed that exercise programmes should therefore not only address muscle strength but also cognitive components for body coordination and balance control. Furthermore, older people often have little interest in taking regular exercise, leading to reluctance6. A new study has recently demonstrated that a method called Dalcroze eurhythmics in pre-frail people can effectively reduce the rate of falls7 and give high attendance over a prolonged period. This is a music-based exercise program, initially developed for music education in Switzerland. Movement is performed to the rhythm of improvised piano playing, demanding balance, attention and coordination. In the study, 134 eurhythmics-naïve, pre-frail older adults living in the community participated in Dalcroze eurhythmics for 45 minutes once weekly, for 6 months7. Coffee and socialising were offered after each session to make the whole experience an enjoyable event. The results, said Prof Kressig, were striking: “what we were able to show in those participants was a decrease in fall rate by over 50%, and importantly they also improved their gait safety including dual-tasking, which means walking while concentrating on other things at the same time”7.

Summarizing, Prof Kressig said that promoting enjoyable exercise and good daily intake of high quality protein are important for healthy ageing and good functional mobility and quality of life in pre-frail people.

Together, protein supplementation and exercise help improve functional capacity even in very frail older adults

Frailty is a problem not only in community-dwelling older people but also for those in long-term care settings where up to 69% of individuals are frail8. A structured program of nutrition and exercise co-therapy can also have health and mobility benefits in frail older adults explained Professor Pedro Abizanda, Chief of the Geriatrics Department, Complejo Hospitalario Universitario de Albacete, Spain. He presented the results of a new multicenter study conducted in Spain. The ACTIVNES study was designed to look at the effects of a combined intervention using a high protein, high calorie oral nutritional supplement plus standardized physical exercise training in frail nursing home residents9. Those who participicated in the study were at least 70 years old and able to walk 50 metres. They received two daily servings of a supplement for 90 days and undertook physical exercise at least 5 days a week. The 91 participants were very frail according to Prof Abizanda: “33% presented four of the established Fried frailty criteria and almost 40% of our participants presented all five criteria” he said. In addition, at the start of the study, 15% were malnourished and 43% were at risk of malnourishment, and only 9% had adequate levels of vitamin D.

The main outcome measure was change in the short physical performance battery (SPPB)9, a questionnaire based on three dimensions: balance, walking speed and time to stand up from a chair five times, scored from 0 to 12 (best performance possible). The effects of the combined intervention were very encouraging said Prof Abizanda: “52% of our population improved by at least 1 point in SPPB at 6 weeks, and 48% showed improvement at 12 weeks”. This degree of change is both statistically (p<0.05 for both timepoints) and clinically relevant, helped by good (60% or more) adherence to oral nutritional supplementation and exercise: 84% and 98%, respectively. Importantly, almost all participants showed improvements in nutritional measures: an average weight gain at 12 weeks of 1.7kg, an increase in BMI of 0.9 kg/m2, and a significant increase in blood vitamin D levels of 8 ng/mL.

Prof Abizanda concluded that nutritional and exercise interventions led to real benefits in the functional capacity of frail adults in residential care settings9. “The extent of functional improvement was related to their individual functionality at the start of the intervention” explained Prof Abizanda; “the most frail individuals, those with higher Fried frailty criteria, had greater probability of improving their function”.

Modifiable issues with the provision of meals, supplements and snacks contribute to suboptimal intake among frail individuals

In the long-term care setting, unintentional weight loss, under-nutrition and dehydration are common problems for the elderly and linked to poor clinical outcomes including increased hospitalization rates, morbidities such as skin breakdown and delayed wound healing, and increased mortality. Using data from studies in the United States, Dr Sandra Simmons, Associate Professor of Medicine at Vanderbilt University, USA, presented new solutions for raising total daily caloric intake among older adults in long-term care. As many as 50-70% of long-term care residents have inadequate daily food and fluid intake10, and oral nutritional supplements are the most common nutritional intervention. However, observational studies of usual care practices have revealed issues with staff provision of supplements. While written orders called for individuals to receive supplements two to four times daily, supplements were offered an average of just once daily, or less10. When given, a large quantity (6-8 oz) is offered, although older adults manage to drink only about 4 oz at any one time. Thus, there is a significant amount of waste. Also, supplements are often given during meals instead of between meals10. This is a problem, Dr Simmons explained: “supplements are being used as a substitute for the served meal, instead of a true supplement to their total daily intake”. Giving small, manageable amounts (up to 4 oz) combined with assistance to promote consumption several times daily during routine medication passes and/or between regularly-scheduled mealtimes is recommended, along with offering a variety of supplement types and flavours to enhance intake11.

Simple caregiver strategies, offering a variety of supplements and providing assistance and verbal encouragement, can enhance nutrient intake and improve nutritional status

In the long-term care setting, residents are often not given adequate assistance with opening containers and the necessary encouragement to promote consumption of supplements. A lack of variety in supplement type and flavour may also be a barrier. Emerging evidence suggests similar issues are present in other care settings. Dr Simmons presented a series of intervention studies showing that improvements in the amount and quality of mealtime assistance results in increased food and fluid intake for nearly 50% of residents who eat poorly10. Varying the supplements is also very important for increasing uptake10: “consistently offering a variety of supplements and snack items between meals, combined with adequate assistance and encouragement, will result in increased intake for up to 80% of residents” said Dr Simmons.

Cognitive impairment is very common in the long-term care setting, so, in addition to physical assistance, verbal cuing and reminders are necessary to keep the person’s attention on the meal and/or supplement or snack item(s). Ultimately, care-givers can help to enhance intake by offering supplements more frequently between meals, providing a greater variety, and giving more attention and positive cues during consumption. Combining supplements and snacks with other enjoyable routine daily activities is key to optimising caloric intake advised Dr Simmons: “every time there’s a social activity or any kind of gathering, add food and/or fluids. We need to take every opportunity to put foods and fluids in front of this population. Due to a small appetite, older adults often consume only a small amount at any one point in time, so offering supplements and snacks multiple times per day between meals, coupled with verbal cueing and encouragement, increases their opportunity for caloric intake”.

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Key references
1. Volkert D et al. Clin Nutr. 2006;25:330-60.
2. Deutz NE et al. Clin Nutr. 2014. pii:S0261-5614(14)00111-3. doi: 10.1016/j.clnu.2014.04.007.(Epub ahead of print)
3. Barillaro C et al. Aging Clin Exp Res. 2013;25(2):119-27.
4. Katsanos CS et al. Nutr Res. 2008;28(10):651-8.
5. Daly RM et al. Clin Nutr. 2014 ;99 :899-910.
6. Crombie IK et al. Age Ageing. 2004 ;33 :287-92.
7. Trombetti A et al. Arch Intern Med. 2011 ;171(6) :525-33.
8. González-Vaca J et al. Maturitas. 2014;77(1):78-84.
9. Abizanda P et al. Eu Geriatr Med. 2014 :5(S1):S78.
10. Simmons SF et al. J Nutr Health Aging. 2010;14(5):367-72.
11. American Medical Directors Association. Altered Nutritional Status in the Long-Term Care Setting. Clinical Practice Guideline. Columbia (MD): AMDA 2010.

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