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home - Nutrition - Clinical Conditions and Nutrition - Elderly Written by Dr Sebastian Zeki
Knowledge
Assessment
Methods GMP
Knows the role of nutrition as therapy for active IBD SCE 1
Knows the role of dietary alteration in treatment of symptoms of IBD
e.g. low residue diet for stricturing disease
SCE, CbD 1
Knows the mechanism of nutritional deficiency in IBD, the importance
of gut preservation, and the role of nutritional support in IBD
SCE, CbD 1
Understands the circumstances when nutritional support should be
provided by enteral or parenteral routes, and to know the various
methods of delivery
SCE, CbD 1
Understands the possible methods of maximising bowel preservation
including appropriate medical therapy, endoscopic therapy and bowel
preserving surgery
SCE, CbD 1,3
Skills
Uses enteral feed as therapy for active disease in appropriate
patients, and to alter diets as appropriate to improve symptoms
SCE, mini-CEX, CbD 1
Can use enteral and parenteral nutrition appropriately to support
patients with active IBD and to prevent substantial malnutrition
mini-CEX, CbD 1
Can perform colonoscopic balloon dilatation to prevent the
requirement for resection, and to understand when to refer for
enteroscopic dilatation or for a surgical opinion
DOPS, CbD 1
Behaviours
Explains to patients and relatives the importance of nutrition as
treatment and support
mini-CEX, PS 1,3,4
Can work with the MDT to ensure all treatment decisions maximise
bowel length
CbD 1,3
Liaises with dieticians and other healthcare professionals to ensure
that all patients have appropriate nutritional support
Also...

Knowledge


Appreciates that preserving bowel length is important
Knows how to use immunomodulating or biological drugs to treat IBD
so as to maintain a maximum bowel length and avoid resections that
may result in a short bowel

Knows endoscopic and surgical techniques that avoid bowel being
resected (e g balloon dilatation and sphincteroplasty)

Knows the dietary therapies available to reduce disease and
symptoms (e g for intermittent obstruction l giving a liquid or low fibre
diet)

Skills
Appreciates that preserving bowel length is important
Can use immunomodulating or biological drugs to treat IBD so as to
maintain a maximum bowel length and avoid resections that may
result in a short bowel

Behaviours
Can empathise with and appreciate the needs of patients with IBD
Works within the multidisciplinary NST and also with the IBD nurses
and surgeons

Discuss any issue relating the disease honestly with the patient
carers friends and family

Also
Knowledge


Knows the causes of small bowel infarction
Knows the difference between arterial and venous gut infarction
Understands the problems and timing of anastomosing the small
bowel onto the colon

Knows the different methods of imaging the vascular supply to the gut
(e g CT angiography digital subtraction angiography angiograms
etc)

Skills
Is able to investigate the causes of a small bowel arterial or venous
infarction

Can identify other co-existing vascular problems
Can choose the appropriate route for nutritional support (EN or PN)
Be able to feed into defunctioned gut (fistuloclysis) when appropriate
Behaviours
Works within the multidisciplinary NST and with the vascular
surgeons and Haematologists
Appreciates there may be other co-morbidities that limit treatment
Can discuss disease-related issues honestly with the patient carers
friends and family

Also...

Knowledge


Knws the principles of normal post operative care including early fluid
management (avoiding excessive saline) and having a knowledge of
when to start nutritional support

Appreciates the reasons why surgical wounds and anastomoses can
break down

Knows the stages of development of an enterocutaneous fistula and
thus the appropriate fluid/nutritional management at each stage

Understands how complex abdominal wounds are dressed (e g
wound manager bags)

Understands what is meant by a frozen abdomen and sclerosing
peritonitis

Knows why intestinal obstruction occurs and the ways in which it can
be managed

Knows why abdominal surgery is best avoided 0- 00 days after the
last abdominal operation

Knows the principles of enhanced recovery after surgery (ERAS)
(including reducing insulin resistance and saline excess)

Skills
Can institute an appropriate investigation plan for occult sepsis
Can assess whether an enterocutaneous fistula is likely to close
spontaneously

Is able to prescribe appropriate pain relief (often with the pain team)
Can assess fluid losses and thus give appropriate fluid replacement
Appreciates the principle of later restorative surgery
Is able to arrange the appropriate tests for mapping the remaining gut
(both that is in and out of circuit)

Gives appropriate psychological care with the psychological medicine
team

Helps a patient to be physically and emotionally well so they are able
to tolerate more surgery if necessary or be able to cope at home

Can feed into defunctioned gut (fistuloclysis) when appropriate
Behaviours
Understands role of tissue viability nurses and can integrate care with
them

Explains to patients their anatomy the principles of intended
treatment and any procedures

Also...

Elderly

Undernutrition SyndromesInvestigation: Whole body CT/ OGD if early satietyColonoscopy is not indicated Appetite stimulantsMegestrol acetate — Better QOL but only slight increase in weight and increased risk of DVT’s, CCF and Addison’sDronabinol — Good in AIDS but significant CNS side effects The Simplified Nutrition Assessment Questionnaire (SNAQ),THis has a sensitiv-ity and specificity of 88.2 and 83.5 % for 10 % weight loss in elderly. SCREEN II (Seniors in the Community: Risk Evaluation for Eating and Nutrition)This assesses nutritional risk by evaluating food intake, physiological barri-ers to eating (difficulty with chewing or swallowing), weight change, and social/functional barriers to eating.It has excellent sensitivity and specificity. The Malnutrition Universal Screening Tool (MUST) This consists of BMI, weight loss in 3-6 months, and anorexia for 5 days due to disease.It is food for ecognition of protein energy undernutrition in hospi-talized patients. DETERMINE This is a 10 item checklist.It is not validated.It is used in the USA The Mini Nutritional Assessment (MNA) This is a global assess-ment and subjective perception of health, as well as questions specific to diet, and a series of anthropomor-phic measurements.It is validated and is predic-tive of poor outcomes. Nutrition In the ElderlyUnintentional weight loss of >5 % of weight over 3 years assoc with increased mortality Involuntary weight loss is driven by:Increased likelihood of isolation at mealtimes-(50% of > 85 live alone)- social eaters eat morePoverty-Older people are poorer.Medical and psychiatric factors — Malignancy (accounts for 15% of LOW) and depression(around 15%).Physiologic factors — a) Age-related decrease in taste and smell sensitivity b) Delayed gastric emptying c )Early satiety, and impairment in the regulation of food intake.Anorexia (decrease in appetite) — Due to decreased energy needs due to reduced physical activity, decreased resting energy expenditure (REE), and/or loss of lean body mass.Cachexia — Loss of muscle with or without loss of fat mass" - is usually cytokine mediated response.Sarcopenia — Sarcopenia is the loss of muscle mass and strength that occurs with aging. Micronutrient Deficiencies:-Vitamin B12 deficiencyThe prevalence of B12 deficiency is 15%- probably as have atrophic gastritis-Vitamin D deficiencyRecommend 25 mcg or 1000 IU (1 mcg = 40 IU) of vitamin D/ dayInadequate intake of calcium — Elder people absorb 1/3rd of amount younger absorb Written by Dr Sebastian Zeki

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