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编者按 2018年6月，欧洲临床营养和代谢学会(ESPEN)发布了老年患者临床营养和水化指南，营养不良和脱水在老年人群中普遍存在。本指南的主要目的是介绍老年人临床营养和水化预防和/或治疗营养不良和脱水的相关治疗推荐意见。通过提供一系列有效的干预措施来支持老年人的营养和水化，提高他们的生活质量。 正如上一期韦军民教授所介绍的，本次指南也对ONS的使用进行了多项推荐，包括：“在膳食咨询指导、膳食营养不足以增加饮食摄入量并达到营养目标的情况下，对有营养不良或具有营养不良风险合并慢性疾病的老年人应当给予ONS；应向营养不良或有营养不良风险的住院老年人提供ONS，以改善饮食摄取量、增加体重，并降低并发症和重新入院的风险；向有营养不良或有营养不良风险的老年人提供口服营养品时，应提供至少400千卡/天的能量，其中包括每天30g或以上的蛋白质；对营养不良或有营养不良风险的老年人，ONS应继续至少一个月，ONS的效果和预期获益应每月评估一次；为营养不良或有营养不良风险的老年人提供膳食时，应当定期评估ONS的完成情况。”因此，特节选本指南中有关ONS及肠内肠外营养治疗的内容以供参考学习。 1.2018 ESPEN指南：老年患者临床营养和水化 Volkert D, Beck AM, Cederholm T,et al. Clin Nutr. 2018 Jun 18. pii: S0261-5614(18)30210-3. 摘要 背景：在老年人中，营养不良与脱水非常普遍，而且肥胖也是一个日益严重的问题。在临床实践中，往往不清楚哪些策略是适合的并且可以有效地抵消上述关键的健康威胁。 目的：为老年人的临床营养与水化提供循证建议，从而防止和/或治疗营养不良与脱水。此外，讨论减重干预是否适合于超重或肥胖的老年人。 方法：本指南是遵照ESPEN指南及共识文件的标准操作程序而形成的。根据33个PICO形式的临床问题，进行了系统的文献检索与初步的研究。 按照SIGN分级系统，对现有的证据进行了分级。推荐意见是经由一个多阶段的共识过程形成并达成一致的。 结果：我们为老年人的营养治疗提供了82条循证的推荐意见，其涵盖了主要的四个主题：基本问题与一般原则，对于营养不良或存在营养不良风险的老年人的推荐意见，对于罹患特定疾病的老年患者的推荐意见，以及对于脱水的预防、识别及治疗的推荐意见。总体而言，我们推荐对所有的老年人进行常规筛查，以早期识别已存在的危险。经口营养支持可以通过护理干预、教育、营养咨询、食品改良以及口服营养补充剂进行。如果肠内营养不足或不可能实施时，则应开始肠外营养，其总体预后完全是良好的。通常，应当避免饮食限制，减重膳食应仅在肥胖、有与体重相关的健康问题且进行体育锻炼的老年人中加以考虑。应当认为所有的老年人都存在摄入不足导致的脱水风险，从而鼓励老年人摄入足够的水分。通常，干预措施应当是个体化的、综合性的，并作为一种多模式与多学科团队策略的一部分。 结论：可以通过提供一系列有效的干预措施来支持老年人的充分营养与水化，从而维持或改善老年人的营养状况并促进其临床病程与生活质量的提高。上述干预措施应当在临床实践中实施并常规采用。 节选指南中老年患者临床营养的推荐如下： 1.ESPEN guideline on clinical nutrition and hydration in geriatrics Volkert D, Beck AM, Cederholm T,et al. Clin Nutr. 2018 Jun 18. pii: S0261-5614(18)30210-3. Abstract Background: Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats. Aim:To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons. Methods:This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process. Results:We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counseling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach. Conclusions:A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used. Recommendations: 仅供学习参考
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