高齢者リハビリテーション栄養

今日のカイ書林メールマガジンで、12月刊行予定の新著が紹介されました。現在最終校正中です。皆様よろしくお願い申し上げます。

若林秀隆著「高齢者リハビリテーション栄養」、カイ書林

本書は「臨床高齢者医学シリーズ」の第1作です。高齢者リハの科学的根拠も交えて，卒前教育の不十分さもカバーしています．脳卒中，大腿骨近位部骨折，転倒，認知症，廃用，虚弱，老年症候群，栄養について，リサーチ・ベーストの記述が展開されています。高齢社会ではリハはキーなので，本書を通して「リハなくして総合診療なし」というメッセージが伝わればと願っています．

NHKラジオ：ラジオあさいちばん

12月2日～6日までNHKのラジオあさいちばんの健康ライフに「要注意！サルコペニア（筋肉減少）のやせ・肥満」というテーマで出演します。朝5時37分～44分頃です。早起きできないという方は、番組HPからのポッドキャストも可能です。よかったら聞いてくださいね。

https://pid.nhk.or.jp/pid04/ProgramIntro/Show.do?pkey=702-20131202-05-70108

脳卒中は急性期病院入院中に栄養状態悪化

この論文も、急性期脳卒中患者の栄養状態が、入院後10日間で悪化することを示した報告です。

Mosselman MJ, Kruitwagen CL, Schuurmans MJ, Hafsteinsdóttir TB.　Malnutrition and risk of malnutrition in patients with stroke: prevalence during hospital stay.　J Neurosci Nurs. 2013 Aug;45(4):194-204. doi: 10.1097/JNN.0b013e31829863cb.

対象は73人の脳卒中患者で、10日間フォローできたのは23人のみです。23人の栄養状態は入院時、91％栄養状態良好、9％低栄養のおそれあり、0％低栄養でした。10日後は35％栄養状態良好、39％低栄養のおそれあり、26％低栄養でした。

以上より急性期病院入院後10日間で、急性期脳卒中患者の栄養状態が悪化することが示唆され、入院時だけでなく入院期間中の栄養スクリーニングが重要といえます。

急性期病院での栄養評価の推移に関する研究は難しい、と個人的に思っていました。しかし、このような形の研究であれば日本でも実現できますね。より多くの対象者数や他の疾患でも同様な研究をすることで、急性期病院での栄養評価と栄養管理の重要性を訴えたいですね。

Abstract

BACKGROUND:

Although various studies have shown high prevalence of malnutrition in hospitalized patients with stroke, recent studies on how the nutritional status of patients with acute stroke develops during the first weeks of hospital stay are scarce. Information is lacking concerning the identification of patients with stroke who are at risk of malnutrition during an acute hospital stay, because these patients may have a significant chance to improve their nutritional status.

PURPOSE:

This study aimed to investigate the prevalence of malnutrition and risk of malnutrition of patients with acute stroke during the first 10 days of hospitalization.

METHODS:

A prospective, descriptive study was conducted in a neurological department of a university hospital in The Netherlands. Seventy-three patients with acute stroke were included, of which 23 patients could be followed up after 10 days. The nutritional status was determined with the Mini Nutritional Assessment at admission and after 10 days.

RESULTS:

At admission, 5% of the patients (n = 73) were malnourished, 14% were at risk of malnutrition, and 81% were well nourished. Of the patients who could be followed up (n = 23), at admission, no patients were malnourished, 9% were at risk of malnutrition, and 91% were well nourished; whereas 10 days later, 26% of these patients were malnourished, 39% were at risk of malnutrition, and 35% were well nourished. This means that, within the followed-up group, the proportion of patients with malnutrition or risk of malnutrition increased significantly during hospital stay from 9% to 65%.

CONCLUSIONS:

Our study shows that the prevalence of malnutrition and risk of malnutrition in patients with acute stroke increases strongly during the first 10 days of admission. Therefore, screening of the nutritional status of these patients throughout this period is highly recommended to enable timely nutritional intervention and nutritional management of these patients.

10日間の入院で脳疾患の低栄養2倍

10日間の入院で、神経疾患患者（約半数が脳卒中）の低栄養の割合が約2倍になるという報告です。MNAで調査して良好、At risk、低栄養が入院時59％、34％、7％だったものが、10日後に21％、57％、22％になっています。急性期病院で栄養状態が悪化するという1つのエビデンスです。

Hafsteinsdóttir TB, Mosselman M, Schoneveld C, Riedstra YD, Kruitwagen CL. Malnutrition in hospitalised neurological patients approximately doubles in 10 days of hospitalisation. J Clin Nurs. 2010 Mar;19(5-6):639-48. doi: 10.1111/j.1365-2702.2009.03142.x.

急性期病院で栄養状態が悪化する理由として、①神経疾患・手術による侵襲、②不適切な栄養管理による飢餓が考えられます。急性期病院で低栄養になり、この状態で回復期リハ病院に転院するので、回復期でも低栄養が多いことになります。

Abstract

AIMS AND OBJECTIVES:

To measure the nutritional status of neurological patients during admission and after 10 days, with a special focus on those with malnutrition and those at risk of malnutrition, and to measure the association of clinical variables and nutritional status, which may be important for the early detection of patients at risk of malnutrition.

BACKGROUND:

Studies have shown high prevalence of malnutrition in hospitalised patients and recommend structured screening and nutritional intervention for these patients. There is a lack of information concerning the nutritional status of neurological patients.

DESIGN:

A prospective descriptive study.

METHOD:

Neurological patients (n = 196) were included from departments of neurology and neurosurgery in Dutch university hospital. Nutritional status was measured with the Mini Nutritional Assessment and functional status with the Barthel Index and the Rankin Scale at admission to the hospital and after 10 days.

RESULT:

Of the patients, 34% were at risk of malnutrition, 7% were malnourished, whereas 59% of the patients were well nourished according to the MNA. After 10 days, 57% were at risk of malnutrition, 22% were malnourished and 21% were well nourished. The total group of patients malnourished and at risk of malnutrition was 41% at admission, which had grown to 79% in 10 days. Significant association was found between various clinical variables and nutritional status.

CONCLUSIONS:

A large group of neurological patients is malnourished and at risk of malnutrition during hospital admission, and the nutritional status of most patients worsens in 10 days. Various clinical variables may be of importance in detecting malnourished patients.

RELEVANCE TO CLINICAL PRACTICE:

Nurses need to observe the symptoms of malnutrition and provide evidence-based nutritional interventions to these patients. Improved education of nurses and good collaboration between the professionals and the facilitation of hospital management is essential to improve nutritional care of neurological patients.

亜急性期高齢脳卒中の低栄養と予後

亜急性期の高齢脳卒中患者では、栄養状態が悪いと入院期間が長く、18カ月後の機能予後が悪く、死亡率が高いという報告です。MNAで30％が低栄養、53％が低栄養のおそれありです。回復期のリハ栄養的に重要な論文だと思います。

Charlton K, Nichols C, Bowden S, Milosavljevic M, Lambert K, Barone L, Mason M, Batterham M.　Poor nutritional status of older subacute patients predicts clinical outcomes and mortality at 18 months of follow-up.　Eur J Clin Nutr. 2012 Nov;66(11):1224-8.

Abstract

BACKGROUND/OBJECTIVES:

Older malnourished patients experience increased surgical complications and greater morbidity compared with their well-nourished counterparts. This study aimed to assess whether nutritional status at hospital admission predicted clinical outcomes at 18 months follow-up.

SUBJECTS/METHODS:

A retrospective analysis of N=2076 patient admissions (65+ years) from two subacute hospitals, New South Wales, Australia. Analysis of outcomes at 18 months, according to nutritional status at index admission, was performed in a subsample of n = 476. Nutritional status was determined within 72 h of admission using the Mini Nutritional Assessment (MNA). Outcomes, obtained from electronic patient records, included hospital readmission rate, total Length of Stay (LOS), change in level of care at discharge and mortality. Survival analysis, using a Cox proportional hazards model, included age, sex, Major Disease Classification, mobility and LOS at index admission as covariates.

RESULTS:

At baseline, 30% of patients were malnourished and 53% were at risk of malnutrition. LOS was higher in malnourished and at risk, compared with well-nourished patients (median (interquartile range): 34 (21, 58); 26 (15, 41); 20 (14, 26) days, respectively; P<0 .001="" 0.001="" 1.07-10.87="" 16.9="" 3.41="" 33.1="" 4.9="" a="" and="" at-risk="" care="" confidence="" death="" discharge="" for="" group.="" group="" hazard="" higher="" in="" interval:="" is="" level="" malnourished="" of="" p="" patients="" rate="" residential="" respectively="" the="" times="" to="" was="" well-nourished="">

CONCLUSION:

Malnutrition in elderly subacute patients predicts adverse clinical outcomes and identifies a need to target this population for nutritional intervention following hospital discharge.

MNA-SFとリハのアウトカム

MNA-SFが高齢リハ患者の臨床的なアウトカムを予測できるかを調査した論文です。オーストラリアの栄養士の論文です。

Andrew Slattery, et al. Does the Mini Nutrition Assessment—Short Form predict clinical outcomes at six months in older rehabilitation patients? Nutrition & Dietetics, DOI: 10.1111/1747-0080.12094

対象はリハ目的で入院した65歳以上の高齢者181人で、後ろ向きコホートのようです。アウトカムは入院期間、入院中の合併症、リハ活動への参加、入院中の機能変化、退院6ヶ月間の急性期病院への再入院と死亡です。

結果ですが、MNA-SFで栄養状態良好は22％、低栄養のおそれありは54％、低栄養は24％でした。低栄養のおそれあり・低栄養群では、入院期間が長く、リハ活動への参加が少なかったです。低栄養群は入院時機能が最も低く、入院中に最も改善しました。

以上より3/4の高齢リハ患者が低栄養のおそれあり・低栄養で、入院時の昨日低下、入院期間、リハ活動への参加と関連していました。低栄養はリハのアウトカムに影響を与えるため、さらなる研究と入院中の栄養状態への注意が必要という結論です。

まさにリハ栄養の論文ですし、後ろ向き研究ですから日本でも十分実現可能な研研究ですし、管理栄養士に行ってほしいです。日本で同じような調査を行えばMNA-SFで低栄養のおそれあり・低栄養の方はより多く、低栄養はリハのアウトカムに影響するでしょう。

Abstract

Aims

This study aimed to determine if nutritional status as assessed by the revised Mini Nutritional Assessment—Short Form is predictive of relevant clinical outcomes within six months in older rehabilitation patients, and to investigate the relationship between admission diagnosis and nutritional status.

Methods

A consecutive retrospective case note audit of 181 patients ≥ 65 years admitted to rehabilitation between May and November 2010 at the Repatriation General Hospital was performed. Nutritional status was assessed using the revised Mini Nutritional Assessment—Short Form. Outcomes measured included length of stay in rehabilitation, complications during admission, participation in rehabilitation activities and change in function during admission. Acute readmissions and mortality were assessed at six months post discharge from rehabilitation.

Results

Thirty-nine (22%) patients had normal nutritional status, 98 (54%) were at risk of malnutrition and 43 (24%) were malnourished. Patients at risk of malnutrition/malnourished had a longer length of stay (P = 0.008) and were more likely to be poor participators in rehabilitation activities (P = 0.006). Malnourished patients had poor function on admission to rehabilitation (P < 0.001) and had the greatest improvement in function during the rehabilitation admission (P = 0.012).

Conclusions

Over three-quarters of older rehabilitation patients were identified as malnourished or at risk of malnutrition, and this was associated with poorer function on admission, increased length of stay and poorer participation in rehabilitation activities. Thus, the issue of malnutrition is a concern as it impacts on clinical outcomes of rehabilitation and therefore, further investigation and attention to nutritional status during admission is required.

プレハビリテーションのメタ解析

プレハビリテーションのメタ解析の論文を紹介します。

D. Santa Mina, et al. Effect of total-body prehabilitation on postoperative outcomes: a systematic review and meta-analysis. Physiotherapy, http://dx.doi.org/10.1016/j.physio.2013.08.008

成人外科患者に対するプレハビリテーションの系統的レビューとメタ解析です。結果ですが、系統的レビューではプレハビリテーションで術後疼痛、入院期間、身体機能は改善しましたが、健康関連QOL、生命予後、有酸素能力は一貫した結果ではありませんでした。

メタ解析では、術後の入院期間が有意に短縮しました。これよりプレハビリテーションは入院期間短縮と術後の身体機能改善に有用な可能性がありますが、論文の質が中～低いためバイアスの可能性があるという結論です。

整形外科領域でのプレハビリテーションは賛否両論のところがありますが、外科領域でのプレハビリテーションは有用なようです。今後はどのようなプレハビリテーション介入（例えば運動＋栄養＋心理）がより有用かの検証が重要と思われます。

Abstract

Objective

To systematically review the evidence of pre-operative exercise, known as ‘prehabilitation’, on peri- and postoperative outcomes in adult surgical populations.

Design

Systematic review and meta-analysis.

Data sources

CENTRAL, Medline, EMBASE, CINAHL, PsycINFO and PEDro were searched from 1950 to 2011.

Methods

Two reviewers independently examined relevant, English-language articles that examined the effects of pre-operative total-body exercise with peri- and postoperative outcome analysis. Given the nascence of this field, controlled and uncontrolled trials were included. Risk of bias was assessed using the Cochrane Risk of Bias Assessment tool. Only data on length of stay were considered eligible for meta-analysis due to the heterogeneity of measures and methodologies for assessing other outcomes.

Results

In total, 4597 citations were identified by the search strategy, of which 21 studies were included. Trials were generally small (median = 54 participants) and of moderate to poor methodological quality. Compared with standard care, the majority of studies found that total-body prehabilitation improved postoperative pain, length of stay and physical function, but it was not consistently effective in improving health-related quality of life or aerobic fitness in the studies that examined these outcomes. The meta-analysis indicated that prehabilitation reduced postoperative length of stay with a small to moderate effect size (Hedges’ g = -0.39, P = 0.033). Intervention-related adverse events were reported in two of 669 exercising participants.

Conclusion

The literature provides early evidence that prehabilitation may reduce length of stay and possibly provide postoperative physical benefits. Cautious interpretation of these findings is warranted given modest methodological quality and significant risk of bias.

Yahooニュース掲載

高齢入院患者の廃用症候群の低栄養について調査したJ Rehabil Medの論文が、Yahooニュースに紹介されました。リハ栄養やサルコペニアへの関心が高まるきっかけになれば嬉しいです。

http://headlines.yahoo.co.jp/hl?a=20131113-00000001-cbn-soci

以下、上記HPからの引用です。

入院中に廃用症候群となった65歳以上の169人に対する調査で、88%にあたる148人が低栄養で残りの21人は低栄養のリスクがあり、栄養状態に問題がない人はいないことが分かった。横浜市立大附属市民総合医療センターリハビリテーション科助教の若林秀隆氏ら研究グループによる、入院中に起きた廃用症候群と栄養状態の関連性を調べた前向きコホート研究の中で明らかになった。リハ分野の学術誌「Journal of Rehabilitation Medicine」への掲載が決まっており、同誌のウェブサイトで概要が公開されている。【香西杏子】

Malnutrition is associated with poor rehabilitation outcome in elderly inpatients with hospital-associated deconditioning a prospective cohort study

J Rehabil Medに投稿していた高齢の廃用症候群の低栄養とリハの予後に関する論文が、ようやくEpub ahead of printになりました。まだオープンアクセスではないはずですが、下記のHPで全文見れます。

Wakabayashi H, Sashika H. Malnutrition is associated with poor rehabilitation outcome in elderly inpatients with hospital-associated deconditioning a prospective cohort study. J Rehabil Med, DOI: 10.2340/16501977-1258, Epub ahead of print

http://www.medicaljournals.se/jrm/content/?doi=10.2340%2F16501977-1258&preview=1

この研究をする中で、廃用症候群における廃用性筋萎縮は、サルコペニアを考慮したリハ栄養の視点で考えて対応しないといけないことを確信しました。その点でリハ栄養の考え方を生みだすきっかけとなった研究といえます。

今まできちんとした研究をしないで学会発表、講演、依頼原稿執筆ばかりしてきました。ようやくImpact Factorが2.134でリハのTop journalの1つであるJ Rehabil Medに論文を掲載できて、ほっとしています。

リハ栄養という言葉や考え方は3-4年前に比べればいくらか普及したと思いますが、リハ栄養の土台（エビデンス）作り（IFのある英語雑誌への原著論文掲載）は遅れていました。でもようやく土台作りの第一歩を踏み出すことができました。

今後は一発屋で終わらないように自分がリハ栄養のエビデンスを発信し続けることと、リハ栄養のエビデンスを発信できる仲間を増やすことが、当面の私の使命です。とはいえ研究だけでなくリハ栄養の臨床、教育、管理面でも頑張ります。

Abstract:

Objective: To investigate the association between nutritional status and rehabilitation outcome in elderly inpatients with hospital-associated deconditioning. Design: A prospective cohort study. Subjects/patients: One hundred sixty-nine consecutive elderly inpatients diagnosed with hospital-associated deconditioning. Methods: Nutritional status at referral was assessed by the Mini Nutritional Assessment Short Form at the University Medical Center. Body mass index, haemoglobin, albumin, total lymphocyte count, C-reactive protein, cause of malnutrition, and feeding route were also investigated. Primary outcome was Barthel Index score at discharge. Results: A total of 148 patients (87.6%) were malnourished, and 21 were at risk for malnutrition. There were no patients with normal nutritional status. Malnourished patients had a lower Barthel Index score at discharge than those at risk for malnutrition. Chronic disease-related malnutrition, oral intake, and parenteral nutrition were associated with the Barthel Index score at discharge. There were significant correlations between the Barthel Index score at discharge and nutritional score, albumin, and total lymphocyte count. In multiple regression analysis, Mini Nutritional Assessment Short Form, albumin, and chronic disease-related malnutrition were significantly associated with the Barthel Index score at discharge. Conclusion: Most elderly inpatients with hospital-associated deconditioning are malnourished. Nutritional status, albumin, and chronic disease-related malnutrition are associated with poor rehabilitation outcome in hospital-associated deconditioning.

7th Cachexia Conference抄録

12月9-11日に神戸で7th Cachexia Conferenceが開催されます。

http://www.lms-events.com/19/

その抄録がJ Cachexia Sarcopenia Muscleに掲載されていました。下記HPで抄録集を全文見ることができます。

http://download.springer.com/static/pdf/941/art%253A10.1007%252Fs13539-013-0123-9.pdf?auth66=1383947904_2ac3d168a46b5f6c5797c045b5fcd7b9&ext=.pdf

全部で演題は100弱程度です。口腔・嚥下関連の発表は、熊本リハ病院の吉村先生（番号1-22）と私（番号1-21）だけのようです。ポスターも隣になっていました。吉村先生のような美しいポスターは作れませんが、頑張ります。

Presbyphagia and sarcopenic dysphagia

Journal of Frailty and AgingのCurrent Issueに知らぬ間に(笑)、自分の論文が出ていました。

http://www.jfrailtyaging.com/current-issue.html

Wakabayashi H. Presbyphagia and sarcopenic dysphagia: association between aging, sarcopenia, and deglutition disorders.

http://www.jfrailtyaging.com/all-issues.html?article=149

Summaryだけは上記のHPで見れますが、ここにも記載しておきます。本文では先日の第19回日本摂食・嚥下リハ学会のシンポジウム「サルコペニアと摂食嚥下リハ」で発表した診断基準案も紹介させていただきました。

Summary
Presbyphagia refers to age-related changes in the swallowing mechanism in the elderly associated with a frailty in swallowing. Presbyphagia is different from dysphagia. Sarcopenic dysphagia is difficulty swallowing due to sarcopenia of generalized skeletal muscles and swallowing muscles. Age-related loss of swallowing muscle mass becomes evident in the geniohyoid muscle and tongue. Elderly subjects with both sarcopenia and dysphagia may have not only disease-related dysphagia but also sarcopenic dysphagia. In cases of aspiration pneumonia, deterioration in activity-, disease-, and nutrition-related sarcopenia of generalized skeletal muscles and swallowing muscles may develop into sarcopenic dysphagia. Assessment of sarcopenic dysphagia includes evaluation of both dysphagia and sarcopenia. The 10-item Eating Assessment Tool (EAT-10) and a water test combined with pulse oximetry are useful for dysphagia screening. Assessment of the multi-factorial causes of sarcopenia including nutritional review is important, because rehabilitation of sarcopenic dysphagia differs depending on its etiology. Consensus diagnostic criteria for sarcopenic dysphagia were proposed at the 19th Annual Meeting of the Japanese Society of Dysphagia Rehabilitation. Rehabilitation for sarcopenic dysphagia includes treatment of both dysphagia and sarcopenia. The core components of dysphagia rehabilitation are oral health care, rehabilitative techniques, and food modification. The causes of adult malnutrition may also contribute to the etiology of secondary sarcopenia and sarcopenic dysphagia. Therefore, nutrition management is indispensable for sarcopenic dysphagia rehabilitation. In cases of sarcopenia with numerous complicating causes, treatment should include pharmaceutical therapies for age-related sarcopenia and comorbid chronic diseases, resistance training, early ambulation, nutrition management, protein and amino acid supplementation, and non-smoking.