欧洲肠外肠内营养学会痴呆营养指南

　　老年痴呆患者往往处于营养不良高风险，而且面临各种营养问题，欧洲肠外肠内营养学会（ESPEN）在循证基础上制定本指南。

　　对诊断为痴呆的老年患者，推荐进行营养风险筛查，常见的筛查工具为微型营养评定简表（MNA-SF）。对营养风险筛查阳性的患者，应该进行营养评定，对评定阳性的患者，应进行恰当的营养干预。

　　应密切监测老年痴呆患者的体重变化，并做好记录。同时要关注患者的疾病应激状况与摄食状况。尽可能排除潜在的营养不良因素。要对老年痴呆患者的看护着进行系统培训，是他们掌握营养相关知识。

　　不推荐对老年痴呆患者应用促进食欲的药物，尽量避免限制饮食的行为。根据患者的个人喜好与需求来推荐合适的食物摄入，推荐在愉快的家庭氛围中进食。

　　在没有证据证明老年痴呆患者存在营养缺乏时，不推荐靠补充营养素和营养补充剂来预防认知功能的进一步恶化。这些营养素包括：n-3多不饱和脂肪酸、维生素B1、B6、B12、D、E、叶酸、硒、铜。营养补充剂包括：α-亚麻酸、N-乙酰-半胱氨酸、乙酰基-L肉碱。

　　对患者进行人工营养决策时，应考虑患者的个人状态、预后情况与患者的喜好。不推荐通过口服营养补充（ONS）和特殊医学用途食品来预防痴呆患者认识功能的恶化，但推荐通过ONS来提高患者营养状态。对轻中度痴呆患者，为了克服口服摄入不足引起的潜在、可逆性营养不良，建议管饲喂养。如果管饲喂养不能耐受或者营养支持不能达到目标量时，建议肠外营养。然而，对重度痴呆患者反对管饲喂养。疾病危重期肠外营养应限制液量。疾病终末期治疗反对任何形式的人工营养。

　　上述是对26条推荐意见的总结，26条推荐意见的推荐等级大部分较低。对合理进行老年痴呆患者的营养支持仍需要进一步研究数据来提供更可靠的临床证据。

表1　获得适宜食物摄入的干预措施

疾病早期

  • 购买食物有困难：帮助购物

  • 准备食物和规律饮食有困难：家庭帮助、按规律进食、按个人准备食物

  • 忘记吃饭：监督吃饭

  • 记住吃饭、辨认食物和独立吃饭的能力下降：口头督促鼓励、喂养助手、增加进食时间、增加饭的密度

疾病晚期

行为问题：情感支持

  • 漫游癖：特殊行为与交流策略

  • 吞咽困难：结构调整

表2　引起老年痴呆患者营养不良的常见原因与干预措施

  • 咀嚼问题：口腔护理，牙齿治疗，结构调整

  • 吞咽问题：吞咽功能评估，吞咽锻炼，组织功能调整

  • 口腔干燥：核实药物副作用、停药或换药，确保合适的液体摄入，使用口腔清洗液和明胶

  • 活动受限：心理治疗，群体锻炼，阻力训练，帮助购物与烹调，规律饮食

  • 精神疾病（抑郁症、焦虑症）：合适的医学治疗，与他人一起进餐、分享，愉快的进餐氛围

  • 急性疾病、慢性疼痛：群体活动、专业治疗、适宜的医学处理

  • 药物的副作用（口腔干燥、恶心、淡漠）：核对药物、减药或停药

  • 社会问题（缺乏支持、家庭冲突）：帮助购物、烹调、进食，缓解冲突

翻译：天津医科大学第二医院营养科（曹婧然，郭玉文）

Clin Nutr. 2015 Dec;34(6):1052-1073.

ESPEN guidelines on nutrition in dementia.

Volkert D, Chourdakis M, Faxen-Irving G, Frühwald T, Landi F, Suominen MH, Vandewoude M, Wirth R, Schneider SM.

Friedrich-Alexander-Universitat (FAU) Erlangen-Nürnberg, Nuremberg, Germany; Aristotle University of Thessaloniki (AUTH), Greece; Karolinska Institutet, Stockholm, Sweden; Krankenhaus Hietzing, Vienna, Austria; Catholic University of the Sacred Heart, Rome, Italy; Helsinki University Central Hospital, Helsinki, Finland; Medical School, University of Antwerp, Belgium; St. Marien-Hospital Borken, Borken, Germany; Centre Hospitalier Universitaire de Nice, Nice, France.

BACKGROUND: Older people suffering from dementia are at increased risk of malnutrition due to various nutritional problems, and the question arises which interventions are effective in maintaining adequate nutritional intake and nutritional status in the course of the disease. It is of further interest whether supplementation of energy and/or specific nutrients is able to prevent further cognitive decline or even correct cognitive impairment, and in which situations artificial nutritional support is justified.

OBJECTIVE: It is the purpose of these guidelines to cover these issues with evidence-based recommendations.

METHODS: The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds and accepted in an online survey among ESPEN members.

RESULTS: 26 recommendations for nutritional care of older persons with dementia are given. In every person with dementia, screening for malnutrition and close monitoring of body weight are recommended. In all stages of the disease, oral nutrition may be supported by provision of adequate, attractive food in a pleasant environment, by adequate support and elimination of potential causes of malnutrition. Supplementation of single nutrients is not recommended unless there is a sign of deficiency. Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Artificial nutrition is suggested in patients with mild or moderate dementia for a limited period of time to overcome a crisis situation with markedly insufficient oral intake, if low nutritional intake is predominantly caused by a potentially reversible condition, but not in patients with severe dementia or in the terminal phase of life.

CONCLUSION: Nutritional care and support should be an integral part of dementia management. In all stages of the disease, the decision for or against nutritional interventions should be made on an individual basis after carefully balancing expected benefit and potential burden, taking the (assumed) patient will and general prognosis into account.

PMID: 26522922

PII: S0261-5614(15)00237-X

DOI: 10.1016/j.clnu.2015.09.004

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