RISCHIO CLINICO ED IMPATTO ECONOMICO DI MALNUTRIZIONE,

DISFAGIA E SARCOPENIA

Dario GregoriUnit of Biostatistics, Epidemiology and Public Health

University of Padova

Malnutrition definitionMalnutrition = “a state resulting from lack of intake or uptake of nutrition that leads to altered body composition (decreased fat free mass) and body cell mass leading to diminished physical and mental function and impaired clinical outcome from disease” (Sobotka, 2012)

Diagnostic criteria for malnutritionAlternative 1:- BMI <18.5 kg/m2

Alternative 2:- Weight loss (unintentional) > 10% indefinite of time, or >5% over the last 3

months combined with either

- BMI <20 kg/m2 if <70 years of age, or <22 kg/m2 if ≥70 years of age or

- FFMI <15 and 17 kg/m2 in women and men, respectively

(Cederholm et al., 2015)

Sarcopenia definition

• «Sarcopenia progressive and generalized skeletal muscle disorder that is associated with increased likelihood of adverse outcomes including falls, fractures, physical disability and mortality» (Cruz-Jentoft et al., 2019)

• Diagnostic criteria are based on measurement of muscle mass and strenght through a specific algorithm

Dysphagia

• Dysphagia is a condition in which swallowing function is impaired:• Primary (presbyphagia), determined only by modifications typical of the aging

process;

• Secondary, when derived by specific diseases (neurological conditions, stroke, and infections) (de Lima Alvarenga et al., 2018)

• Assessed through simple test such as EAT-10 test

Wirth et al., 2016

The role of dysphagia in the development of malnutrition and dehydration in older persons.

(ESPEN guideline, 2017)

Nutrition disorders and nutrition-related conditions

Factors that cause and worsen muscle quantity and quality, sarcopenia

Cruz-Jentoft et al., 2018

Algorithm for sarcopeniadetection

Cruz-Jentoft et al., 2018

Malnutrition prevalence (1)

• It ranges from 38% to 78% in ICU and is associated with worse clinical outcomes (Lew et al., 2017)

• In community-dwelling elderly, using GLIM criteria, the prevalence is about 17.6% (Beaudart et al., 2019)

• In the Italian context prevalence of malnutrition and risk of malnutrition are respectively 14.1% (CI95% 10.2-18.0) and 48.6% (CI95%43.4-53.8) in elderly patients in residing home (Tominz et al., 2012)

• In patients hospitalized in a medical area in Italy the prevalence is 21.4% (Bonetti et al., 2017)

• The prevalence of malnutrition is higher in patients older than 85 years old, with impaired autonomy, pressure ulcers or taking more than three drugs (Bonetti et al., 2017)

Malnutrition prevalence (2)

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Sarcopenia prevalence

• In community-dwelling elderly, it has been shown to have an incidence of 21.4% (7.7% severe sarcopenia) (Lew et al., 2017)

• Prevalence in long-term care populations ranges from 14% to 33% (Marty et al., 2017)

• In hospitalized patients in Italian ICU prevalence is various, from 10% (Gariballa et al., 2013) to 21.4% (Cerri et al., 2015) and 26% (Rossi et al., 2014)

Dysphagia prevalence

• The prevalence of dysphagia has been estimated to be from 13% to 35% in elderly living independently (Roy et al., 2007; Madhavan et al., 2016)

• 86.6% among community-dwelling older patients with dementia (Michel et al., 2018)

• Dysphagia prevalence in the overall US population is reported to be about 3.3% in 2013 (Patel et al., 2017)

• Presbyphagya may predispose do dysphagia and nutritional deficits. Exact prevalence is not estimated yet.

Relationship among malnutrition, sarcopenia and dysphagia (1)

Aging

Sarcopenia MalnutritionPresbyphagia/dysphagia

Sarcopenicpresbyphagia/dysphagia

malnutrition-sarcopenia syndrome (MSS)”

Relationship among malnutrition, sarcopenia and dysphagia (2)• Sarcopenia is associated with malnutrition regardless of the origin of the

malnourishment (Cederholm et al., 2017). Low muscle mass, a peculiarity of sarcopenia, was recently introduced among the criteria for the diagnosis of malnutrition (Jensen et al., 2019).

• The co-existance of malnutrition and sarcopenia has been defined as “malnutrition-sarcopenia syndrome (MSS)” (Vandewoude et al., 2012).

• Sarcopenia is positively associated with dysphagia: the general loss of muscle mass also reduces the ability to swallow correctly. Patients that are dysphagic due to sarcopenia are called “sarcopenic dysphagic” (Azzolino et al., 2019).

• Swallowing disorders can be responsible for malnutrition: they work as triggers for reduced/altered intake of food and liquids (Serra-Prat et al., 2012).

Effects of malnutrition on healthcare (1)

• Malnutrition is associated with reduced functional status, increased mortality, risk for infections and length of hospital stay, especially in the elderly population (Cederholm et al., 2015)

• Unintentional weight loss is associated with an increased likelihood of institutionalization after hospital stay and with poor rehabilitation outcomes (Elia et al., 2016).

Effects of malnutritionon healthcare(2)

Prevalence of risk factors and association with odds ratio for death in hospital within 30 days after nutritionDay in medical patients. Prevalence is indicated by dots. Each dot represents 1% of the total population. All risk indicators are collected on one single day, the nutritionDay 2006–2015. Odds ratio are indicated with 95% confidence intervals and colours according to risk indicator categories Graph of Community–Hospital–Continuum (Hiesmayr et al., 2019)

Malnutrition costs (1)

• Malnutrition has a significant impact on healthcare costs (both direct and indirect)

• In the United States, costs related to malnutrition in community-based disease-associated malnutrition for a year have been estimated being around $150 billion, and 10% of these costs represents direct medical costs (Snider et al., 2009)

• Insufficient food intake led to an increase of in-hospital costs in 2003 from 36% to 67% (USA), and an increase of 40% of hospital costs and of 10% of the cost of hospitalized patients over 65 years old (UK) (Elia et al., 2009)

Malnutrition costs (2)

• In English context, health expenditure attributable to malnutrition of adult and child patients in a two-year period (2011-2012) is 19,6 billion pounds

• In UK it is estimated an avoidable cost for oral Nutritional Support between 324,000 and 432,000 pounds per 100,000 inhabitants, against an investment required by the implementation of the NICE guidelines between 119,000 and 145,000 pounds per 100,000 inhabitants.(Elia 2016)

• Italian context (Bolzano)• total costs incurred as a result of cases of iatrogenic malnutrition in hospital:

two million euros per year with the possibility of saving between eight hundred thousand and one million euros net of the increase in spending on increased use of Oral Nutritional Support in hospital (Cereda et al., 2010)

• Preventing malnutrition vs treating ulcers: saving of 39,4 Euro/patient (Cereda et al, 2017)

Malnutrition costs (3)

Effects of sarcopenia on healthcare

• Untreated sarcopenia is related to recurrent falling (Schaap et al., 2018), impaired ability in functional status (Mijnarends et al., 2018), loss of independence (dos Santos et al., 2017), higher length of stay and mortality (De Buyser et al., 2017) both in the outpatinet and in-hospital settings (Cerri et al., 2015).

Sarcopenia costs (1)

• Poor grip strength and slow gait speed (peculiar of sarcopenia) increased both direct and indirect health-care costs (Sánchez-Rodríguez et al., 2017).

• In United States, direct cost of sarcopenia in 2000 was estimated to be $18.5 billion ($10.8 billion for men), which was 1.5% of the total expenditure of the US for that year (Janssen et al., 2004).

Sarcopenia costs (2)

• In Portugal, a state where the system of reimbursement is similar to the one in Italy, hospitalized patients with sarcopenia have 5.7 times higher odds of costing the hospitals (Antunes et al., 2017

• hospital costs of €1240 (95% CI: €596–

1887) in patients younger than 65 years

old (58.5%)

• hospital costs of €721 (95% CI: €13–

1429) for patients aged ⩾65 (34%)

Sousa et al., 2016

Effects of dysphagia on health care• Dysphagia could cause aspiration pneumonia,

infections, malnutrition and dehydration (Azzolino et al., 2019) and also reduced life expectancy and quality of life (Christmas et al., 2019).

• Dysphagia is associated with longer length of stay, increased safe-discharge, complications, and higher total costs (Cohen et al., 2019) especially in post-stroke patients (Muehlemann et al., 2019).

Dysphagia costs (1)

• In a review of eleven studies in the United States, the mean attributable cost of dysphagia is about $12715 which means an increase in terms of cost of 40.36%. More, in general, it means that dysphagia increases the annual hospital cost between $4.3 to $7.1 billion (Attrill et al., 2018).

• Another study estimates that dysphagia higher the costs from a minimum of $1,599.86 to a maximum of $5147.19. Patients older than 80 years old bring a higher increase in cost between NZD$1,976 and NZD$2,206 (Allen et al., 2019)

Dysphagia costs (2)

“Graph demonstrating that increasing number of comorbidities is associated with increasing age, that at age 80 years there isa sharp increase in the rate of dysphagia, and that this is associated with increased aspiration. Diagnosis Related Group (a grouping of ICD‐10 codes).” Allen et al., 2019.

Impact of improving nutrient availability

Number of cardiovascular

events avoided under different

supplementation regimes

(estimates for the population

with hypertension). The first

chart (A) refers to CHD cases,

the second chart (B) refers to

stroke cases, the third chart (C) refers to HF cases.

monItoring Nutritional sTatus of Elderly people in a Residential Care faciliTYINTERCITY project

• Prospective Multicenter Longitudinal Study on RCF in Italy

• Aims• Estimate incidence, prevalence of malnutrition, dysphagia and sarcopenia in

RCF

• Determine major risk factors associated with such diseases