- Email: [email protected]
The refeeding syndrome in geriatric patients
G Model
EURGER-646; No. of Pages 2 European Geriatric Medicine xxx (2015) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
EGM clinical case
The refeeding syndrome in geriatric patients M. Sparre-Sørensen *, M. Midttun Copenhagen University Hospital Herlev, Geriatric Section, Denmark
A R T I C L E I N F O
Article history: Received 21 May 2015 Accepted 25 May 2015 Available online xxx Keywords: Refeeding syndrome Geriatric Malnourishment
1. Introduction Malnourishment is a common complication in geriatric patients because diseases, medical side effects, depression, and poor dental status reduce appetite [1,2]. Because earlier studies have shown that malnutrition increases the risk of morbidity and mortality during hospitalization [3], all geriatric patients are screened for malnutrition when admitted to geriatric sections. If diagnosed with malnutrition the patient is offered energy and protein rich supplements to quickly improve nutritional status. During periods of catabolic metabolism, where the intake of calories is lower than needed, the body reduces energy usage by loosening the strict control of electrolyte movement over cell membranes. This results in a flow of potassium, phosphate, calcium, magnesium, and zinc from the intracellular liquid to the extracellular liquid. The excess electrolytes in the extracellular liquid are excreted through the kidneys, keeping serum levels stable. When the intake of calories increases, for instance during hospitalization, and corresponds to or exceeds the patient’s needs, the flow of electrolytes shifts from the extracellular liquid to the intracellular liquid, and hypopotassemia, hypophosphatemia, hypocalcemia, hypomagnesemia, and hypozincemia can occur. This can lead to respiratory distress, edemas, cardiac failure and arrhythmia, universal cramps, delirium, and death [4–7]. The condition is called the refeeding syndrome and is generally
* Corresponding author. Copenhagen University Hospital Herlev, Geriatric Section, Denmark. E-mail address: [email protected] (M. Sparre-Sørensen).
considered a rare condition. However, from November 2012 through June 2013, seven cases of refeeding syndrome were diagnosed at the geriatric section, University Hospital Herlev. One case is described below. 2. Case presentation Case 1: a 68-year-old woman was admitted to the geriatric section, after having lost 20 kilograms and function of living over a period of six months, due to nausea and vomiting. Six months prior to admittance she had suffered an osteoporotic compression fracture in her lower back, and had been prescribed two types of morphine-containing analgesics, tramadol and mandolgin. During hospitalization, painkillers were gradually phased out, without discomfort to the patient, and quickly she regained her appetite and mobility. The patient’s blood pressure gradually fell from an average of 135/75 mmHg to 85/60 mmHg. Despite potassium supplements of up to 9 grams per day her serum potassium level stayed around 2.0 mmol/L. She became confused, and one night she developed universal cramps. An acute brain CT, a lumbar puncture, and blood tests were performed, all normal. She was loaded with levetiracetam (keppra) to stop cramping. Next morning additional blood tests showed:
magnesium 0.13 mmol/L (ref 0.71–0.94 mmol/L); calcium (ionized) 0.87 mmol/L (ref 1.18–1.23 mmol/L); phosphate 0.34 mmol/L (ref 0.76–1.41 mmol/L), potassium 2.8 mmol/L (ref 3.5–4.5 mmol/L); zinc 8 mmol/L (ref 10–19 mmol/L).
http://dx.doi.org/10.1016/j.eurger.2015.05.011 1878-7649/ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Please cite this article in press as: Sparre-Sørensen M, Midttun M. The refeeding syndrome in geriatric patients. Eur Geriatr Med (2015), http://dx.doi.org/10.1016/j.eurger.2015.05.011
G Model
EURGER-646; No. of Pages 2 M. Sparre-Sørensen, M. Midttun / European Geriatric Medicine xxx (2015) xxx–xxx
2
She was transferred to the department of cardiology for telemetry and IV magnesium, calcium, potassium, and phosphate treatment. After returning to the geriatric section, she was loaded with zinc, thiamin, vitamin B supplements and started on a restricted diet. Blood tests were performed daily until she was stabilized.
3. Discussion Over the past few years, there has been an increasing awareness of the effects of malnutrition, resulting in more screening and dietary initiatives [8–10]. Screening for malnourishment is routine in all Danish geriatric departments, but not screening for refeeding syndrome or thiamin deficiency. The seven cases suggest that the refeeding syndrome may be more common among geriatric patients than we are aware of. We may be exposing our patients to serious risk when we start protein and energy supplements, if the electrolyte status is not monitored closely.
4. Conclusion The refeeding syndrome is a potentially life-threatening condition that may be more common in geriatric patients than we are aware of. Additional research is needed to confirm this theory.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] McMinn J, Steel C, Bowman A. Investigation and management of unintentional weight loss in older adults. BMJ 2011;342:d1732. [2] Bamia C, Halkjaer J, Lagiou P, et al. Weight change in later life and risk of death amongst the elderly: the European prospective investigation into cancer and nutrition-elderly network on ageing and health study. J Intern Med 2010; 268(2):133–44. [3] Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 2003;22(3):235–9. [4] Mehanna H, Nankivell PC, Moledina J, Travis J. Refeeding syndrome – awareness, prevention and magagement. Head Neck Oncol 2009;1:4. http:// dx.doi.org/10.1186/1758-3284-1-4. [5] Kraft MD, Btaiche IF, Sacks GS. Review of the refeeding syndrome. Nutr Clin Pract 2005;20:625–33. [6] Caplan JP, Chang G. Refeeding syndrome as an iatrogenic cause of delirium: a retrospective pilot study. Psychosomatics 2010;51(5):419–24. [7] Gaasbeek A, Meinders AE. Hypophosphatemia: an update on its etiology and treatment. Am J Med 2005;118:1094–101. [8] Frongillo EA, Wolfe WS. Impact of participation in home-delivered meals on nutrient intake, dietary patterns, and food insecurity of older persons in New York State. J Nutr Elder 2010;29:293–310. [9] Mowe M, Bosaeus I, Rasmussen HH, et al. Insufficient nutritional knowledge among health care workers? Clin Nutr 2008;27:196–202. [10] Lindorff-Larsen K, Rasmussen HH, Kondrup J, Staun M, Ladefoged K, Scandinavian Nutrition Group. Management and perception of hospital under nutrition – a positive change among Danish doctors and nurses. Clin Nutr 2007;26:371–8.
Please cite this article in press as: Sparre-Sørensen M, Midttun M. The refeeding syndrome in geriatric patients. Eur Geriatr Med (2015), http://dx.doi.org/10.1016/j.eurger.2015.05.011
EURGER-646; No. of Pages 2 European Geriatric Medicine xxx (2015) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
EGM clinical case
The refeeding syndrome in geriatric patients M. Sparre-Sørensen *, M. Midttun Copenhagen University Hospital Herlev, Geriatric Section, Denmark
A R T I C L E I N F O
Article history: Received 21 May 2015 Accepted 25 May 2015 Available online xxx Keywords: Refeeding syndrome Geriatric Malnourishment
1. Introduction Malnourishment is a common complication in geriatric patients because diseases, medical side effects, depression, and poor dental status reduce appetite [1,2]. Because earlier studies have shown that malnutrition increases the risk of morbidity and mortality during hospitalization [3], all geriatric patients are screened for malnutrition when admitted to geriatric sections. If diagnosed with malnutrition the patient is offered energy and protein rich supplements to quickly improve nutritional status. During periods of catabolic metabolism, where the intake of calories is lower than needed, the body reduces energy usage by loosening the strict control of electrolyte movement over cell membranes. This results in a flow of potassium, phosphate, calcium, magnesium, and zinc from the intracellular liquid to the extracellular liquid. The excess electrolytes in the extracellular liquid are excreted through the kidneys, keeping serum levels stable. When the intake of calories increases, for instance during hospitalization, and corresponds to or exceeds the patient’s needs, the flow of electrolytes shifts from the extracellular liquid to the intracellular liquid, and hypopotassemia, hypophosphatemia, hypocalcemia, hypomagnesemia, and hypozincemia can occur. This can lead to respiratory distress, edemas, cardiac failure and arrhythmia, universal cramps, delirium, and death [4–7]. The condition is called the refeeding syndrome and is generally
* Corresponding author. Copenhagen University Hospital Herlev, Geriatric Section, Denmark. E-mail address: [email protected] (M. Sparre-Sørensen).
considered a rare condition. However, from November 2012 through June 2013, seven cases of refeeding syndrome were diagnosed at the geriatric section, University Hospital Herlev. One case is described below. 2. Case presentation Case 1: a 68-year-old woman was admitted to the geriatric section, after having lost 20 kilograms and function of living over a period of six months, due to nausea and vomiting. Six months prior to admittance she had suffered an osteoporotic compression fracture in her lower back, and had been prescribed two types of morphine-containing analgesics, tramadol and mandolgin. During hospitalization, painkillers were gradually phased out, without discomfort to the patient, and quickly she regained her appetite and mobility. The patient’s blood pressure gradually fell from an average of 135/75 mmHg to 85/60 mmHg. Despite potassium supplements of up to 9 grams per day her serum potassium level stayed around 2.0 mmol/L. She became confused, and one night she developed universal cramps. An acute brain CT, a lumbar puncture, and blood tests were performed, all normal. She was loaded with levetiracetam (keppra) to stop cramping. Next morning additional blood tests showed:
magnesium 0.13 mmol/L (ref 0.71–0.94 mmol/L); calcium (ionized) 0.87 mmol/L (ref 1.18–1.23 mmol/L); phosphate 0.34 mmol/L (ref 0.76–1.41 mmol/L), potassium 2.8 mmol/L (ref 3.5–4.5 mmol/L); zinc 8 mmol/L (ref 10–19 mmol/L).
http://dx.doi.org/10.1016/j.eurger.2015.05.011 1878-7649/ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Please cite this article in press as: Sparre-Sørensen M, Midttun M. The refeeding syndrome in geriatric patients. Eur Geriatr Med (2015), http://dx.doi.org/10.1016/j.eurger.2015.05.011
G Model
EURGER-646; No. of Pages 2 M. Sparre-Sørensen, M. Midttun / European Geriatric Medicine xxx (2015) xxx–xxx
2
She was transferred to the department of cardiology for telemetry and IV magnesium, calcium, potassium, and phosphate treatment. After returning to the geriatric section, she was loaded with zinc, thiamin, vitamin B supplements and started on a restricted diet. Blood tests were performed daily until she was stabilized.
3. Discussion Over the past few years, there has been an increasing awareness of the effects of malnutrition, resulting in more screening and dietary initiatives [8–10]. Screening for malnourishment is routine in all Danish geriatric departments, but not screening for refeeding syndrome or thiamin deficiency. The seven cases suggest that the refeeding syndrome may be more common among geriatric patients than we are aware of. We may be exposing our patients to serious risk when we start protein and energy supplements, if the electrolyte status is not monitored closely.
4. Conclusion The refeeding syndrome is a potentially life-threatening condition that may be more common in geriatric patients than we are aware of. Additional research is needed to confirm this theory.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] McMinn J, Steel C, Bowman A. Investigation and management of unintentional weight loss in older adults. BMJ 2011;342:d1732. [2] Bamia C, Halkjaer J, Lagiou P, et al. Weight change in later life and risk of death amongst the elderly: the European prospective investigation into cancer and nutrition-elderly network on ageing and health study. J Intern Med 2010; 268(2):133–44. [3] Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 2003;22(3):235–9. [4] Mehanna H, Nankivell PC, Moledina J, Travis J. Refeeding syndrome – awareness, prevention and magagement. Head Neck Oncol 2009;1:4. http:// dx.doi.org/10.1186/1758-3284-1-4. [5] Kraft MD, Btaiche IF, Sacks GS. Review of the refeeding syndrome. Nutr Clin Pract 2005;20:625–33. [6] Caplan JP, Chang G. Refeeding syndrome as an iatrogenic cause of delirium: a retrospective pilot study. Psychosomatics 2010;51(5):419–24. [7] Gaasbeek A, Meinders AE. Hypophosphatemia: an update on its etiology and treatment. Am J Med 2005;118:1094–101. [8] Frongillo EA, Wolfe WS. Impact of participation in home-delivered meals on nutrient intake, dietary patterns, and food insecurity of older persons in New York State. J Nutr Elder 2010;29:293–310. [9] Mowe M, Bosaeus I, Rasmussen HH, et al. Insufficient nutritional knowledge among health care workers? Clin Nutr 2008;27:196–202. [10] Lindorff-Larsen K, Rasmussen HH, Kondrup J, Staun M, Ladefoged K, Scandinavian Nutrition Group. Management and perception of hospital under nutrition – a positive change among Danish doctors and nurses. Clin Nutr 2007;26:371–8.
Please cite this article in press as: Sparre-Sørensen M, Midttun M. The refeeding syndrome in geriatric patients. Eur Geriatr Med (2015), http://dx.doi.org/10.1016/j.eurger.2015.05.011