Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2929_Библиотеки_им_академика_М_И_Перельмана

production of vitamin D is limited where sunshine is depleted, such as in northern Europe and northern North America, particularly during wintertime. The capacity to produce vitamin D decreases in older age by four times, resulting in lower levels [22]. To achieve the recommended amount of Vitamin D it is advised that the hands, arms, and face should be exposed to sunlight for approximately 5–25min per day [23]. At the same time, age, geographic latitude, air pollution, and other factors inuence the appropriate production of Vitamin D in the skin. The blood level of Vitamin D should be checked regularly and, if necessary, supplemented as part of a comprehensive therapy plan. The recommendation for adequate supplementation of vitamin D intake for older people is 800–1000IU per day [24]. With the reduction of the risk of hip fracture and other fractures in mind, older patients benet from a combination of Vitamin D and calcium if the level of Vitamin D is low and the intake of calcium is poor [25, 26].

Although nutrition is important in preventing fragility fractures, it is also essential for maintaining the positive effects of weight-bearing activity and exercise training on bone density [27]. Regular physical activity of 30min per day promotes calcium resorption and supports muscle growth and bone density [28]. Following hip fracture, patients should be encouraged to participate in daily activity as part of their discharge plan, supported by inpatient or outpatient rehabilitation programmes. If patients are independent in activities of daily liv­ing and do not suffer from other health problems or disabilities which limit physical activity, additional information about specic exercises and activities should also be provided (see Chap. 8).

at least 1 x Yes

> 10 %

months

week, or any reduction

for > 2 weeks, or any

disease-related

The prevalence of malnutrition in care facilities differs widely depending on loca­tion, for example, in geriatric wards the prevalence is higher than on coronary wards [32]. The estimated number of patients admitted to acute hospitals being at risk of malnutrition is approximately 35% with 20–50% [33].

Other factors like frailty or multimorbidity may progressively worsen the nutri­tional status of older adults. The symptoms of malnutrition vary and may manifest as weight loss, low energy levels, lethargy, low mood, depression, cognitive decline [35], delayed wound healing, diarrhoea, limited/reduced muscle tone (sarcopenia), and/or lack of interest in, or aversion to, eating/drinking [36].

Screening and assessment for malnutrition should be conducted with a validated instrument. Examples of validated instruments are [39, 40]:

2. Assess all those identied as at risk to provide a comprehensive understanding

of the problem to enable planning of appropriate interventions.

If a patient is at risk of malnutrition, or already malnourished, the information obtained from screening and assessment should be used to achieve a comprehensive understanding of the individual issues as part of the Comprehensive Geriatric Assessment (CGA) process (see Chap. 6) to facilitate an individualised plan for avoiding or treating malnutrition.

Regarding Michael’s situation, the following steps should be undertaken (see case study Box 11.1):

• Involvement of his wife and other carers to understand and assess his nutritional

status and needs.

• Collaboration with members of the interdisciplinary team such as dieticians,

• Ensure continuity of nutritional care throughout hospital, rehabilitation, and

Malnutrition, or risk of malnutrition, should be approached as a multifactorial prob­lem. It is important that interventions to prevent malnutrition begins with recording a nutrition history and monitoring the patient’s food intake during the rst days after admission. The ESPEN guideline for clinical nutrition and hydration in older per­sons provides evidence-based recommendations for preventing and/or treating mal­nutrition and dehydration [17]. The treatment of malnutrition involves several specic aspects:

should be provided with the use of appropriate aids (e.g. large handles on

cutlery, coloured glasses for visually impaired patients) to help increase

independence.

• Where there are specic problems such as difculty swallowing or poor denti-

dentists to address the problem [41].

multi-nutrition supplements with at least 400kcal/day including 30g or more of

protein/day [17].

nutritional intake [42]. This is particularly important in frail older people in the

• Patients should be informed about the reason for supplementation and be asked

particularly about the requirement for minerals and vitamin D, is essential during

discharge management.

important that enough help is available at mealtimes to support eating and that

families are encouraged to be involved.

impersonal. Mealtimes are important human interaction opportunities normally

and carers in eating well. Information needs to be individualised and can be pro-

vided in a variety of ways. Some people prefer written information (e.g. leaets,

• The medical doctor should regularly check the medical management of condi-

tions adversely inuence nutrition, for example, nausea, vomiting (see Chap.

6, CGA).

validated screening tools, so nurses need to use their knowledge and skills to make individualised assessments by:

1. Screening all patients within 24 h of admission to identify risk factors for

output such as vomiting or wound drainage.

• Involvement of the patient and family/carers in the assessment and plan of care,

and food) if not contraindicated.

• Ensure the problem is included within the discharge plan.

Patients’ oral uid intake is often inadequate, especially early in the patient pathway while fasting and undergoing perioperative preparation. It is essential to closely monitor and document uid intake and output and to supplement intake, where necessary, with intravenous uids.

Prevention aims to ensure the availability of drinks that are pleasant to drink and that patients and families understand the necessity to drink. Support and help are needed to facilitate adequate intake of oral uids with the following advice in mind [49]:

Offering individualised support to patients to help them to drink can encourage adequate uid intake. This should be done in a friendly, unhurried, and calm manner using appropriate drinking aids such as straws and special cups or with bottle­clipped systems. Families often feel helpless but may be able to help with drinking so that they feel involved and useful. Family members can be offered information including how to recognise dehydration and how to help with drinking.