e-spen, the European e-journal of Clinical Nutrition and Metabolism

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1 e-spen, the European e-journal of Clinical Nutrition and Metabolism 4 (2009) e81 e85 Contents lists available at ScienceDirect e-spen, the European e-journal of Clinical Nutrition and Metabolism journal homepage: Educational Paper Virtual Clinical Nutrition University: Nutrition in the elderly-artificial nutrition Stephane M. Schneider UAMS, Center for Translational Research in Aging & Longevity, Little Rock, AR 72205, USA article info summary Article history: Received 31 October 2008 Accepted 3 November 2008 Keywords: Artificial nutrition Percutaneous endoscopic gastrostomy Neurological dysphagia Dementia Enteral and parenteral nutrition are valid options in the malnourished elderly, both in the hospital and at home. Elderly patients share most indications and complications with adult patients, even though more focus needs to be put on function and quality of life than on mortality. Ó 2008 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved. 1. Learning objectives - Know the most frequent indications for artificial nutrition; - Know the techniques and outcome; - Know the indications and results in specific clinical situations; - Understand the need for ethical elements alongside the medical ones in deciding upon starting an elderly patient on artificial nutrition. 2. Key messages - Most indications are ideally addressed with enteral nutrition, rarely parenteral nutrition; - Indications, products and techniques do not differ from adults, but the outcome is worse; - Prolonged artificial nutrition will be performed at home or in an institution; - Most demented patients will not benefit form artificial nutrition. 3. Introduction The mean age of patients receiving artificial nutrition is steadily increasing along with the life expectancy; patients over the age of 65 already represent 34.5% of home enteral nutrition patients 1 and those over 60 account for 28% of home parenteral patients 2 in Europe. Consequently, some aspects of artificial nutrition (such as the span of its complications) do not differ from what is described in adult patients (see EDU T8 and EDU T9). However, there are some address: espenjournals@gmail.com (Editorial Office). marked differences, including metabolic response to refeeding, specific indications or contra-indications and outcome. Anorexia in the elderly will also lead to longer refeeding periods, along with more frequent institutionalizations. While reducing morbidity and mortality is a priority in younger patients, artificial nutrition in the elderly aims more at improving function, wellbeing and/or quality of life, taking into account the change in living situation (e.g. institution vs. home) that it may imply, along with improving outcome and/or accelerating recovery from a given. Last, the anticipated benefits need to outweigh the potential risks. 4. Choice of nutritional support technique 4.1. General considerations Artificial nutrition should be considered after oral supplements have failed (due to insufficient intake) (see EDU T36 M36.3) or in a severely malnourished patient in whom there is a need for a fast weight gain. The flow chart in elderly patients is the same as the one we refer to in adults (Fig. 1). Namely, enteral nutrition (EN) should always be considered first in a patient with a functioning gastrointestinal tract, 3 and parenteral nutrition (PN) should only be considered when PN is contra-indicated or not tolerated Decision of percutaneous endoscopic gastrostomy As EN is preferred to PN and EN is often prolonged due to persistent anorexia or dysphagia, percutaneous endoscopic gastrostomy (PEG) will often be the route of choice for artificial nutrition in the elderly. Three groups of patients can be identified (Fig. 2): /$ - see front matter Ó 2008 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved. doi: /j.eclnm

2 e82 S.M. Schneider / e-spen, the European e-journal of Clinical Nutrition and Metabolism 4 (2009) e81 e85 may allow the patient to have a physical activity at daytime and to eat normally at meal times Outcomes Survival As could be expected, life expectancy under nutritional support is lower in elderly patients compared to younger ones. 9 This is true for survival in home EN patients (Fig. 3). 5 This is also true after procedures such as percutaneous endoscopic gastrostomy (PEG), where age is an independent factor associated with complications and mortality. 10 For obvious ethical reasons, no study has been designed in order to show a benefit of artificial nutrition vs. the absence of nutritional support in comparable groups and the only studies available, with conflicting results, are either observational or with non-comparable groups; therefore, in patients who need tube feeding due to the severity of disease, an increase in survival is not proven Nutritional status There is a resistance to refeeding in the elderly. Namely, for a same amount of nitrogen and energy provided by EN, the increase in weight, fat-free mass and chronic phase proteins is lower in elderly patients compared to adults. 7,12 When an extra 7500 kcal are needed to gain one kg of body weight in young malnourished patients, ,600 kcal are needed in elderly patients. 13 The same is true for PN (Fig. 4). 14 Chronic inflammation 15 as well as a higher splanchnic extraction 16 of proteins might be responsible. Many tube fed patients are bedridden, and the consequent immobility further enhances muscle wasting and prevents gain in lean mass. Weighing is also problematic in these patients. Among the therapeutic adjuvant that may be used to counteract this resistance to refeeding, exercise performed during artificial nutrition may play an important role. 17 Those who will need prolonged home EN, probably due to persistent dysphagia after a resolute disease. Prolonged nutritional support may ensure a prolonged survival; Those who will get a short-term benefit before resuming oral nutrition, such as with secondary anorexia after stress; survival is better in these patients than in those dependent on home EN 5 ; Those who will die while on home EN, due to their primary disease; in these patients, EN can be considered as palliative care and it needs to improve their quality of life Age-related issues Fig. 1. Flow chart of artificial nutrition in the elderly Route Long-term EN and PN in adult patients who are involved in sports (e.g. swimming) will often be provided through convenient motion-friendly gut/venous accesses, namely PEG buttons and implantable venous access ports. These may not be needed in house-ridden or institutionalized elderly patients. Hypodermoclysis is a method of infusing fluid into subcutaneous tissue that requires only minimal equipment. It can be helpful in elderly patients when the indication of artificial nutrition is mostly based on hydration needs; it may also be a convenient way to administer amino acids, with the aim of not worsening (rather than healing) malnutrition in the elderly. 6 Table 1 shows the main indications and contra-indications of this method. EN may be delivered as continuous or cyclical, with similar nutritional results. 7,8 However, only cyclical nocturnal nutrition 4.6. Function and quality of life Health-related quality of life is lower in elderly home EN patients compared with younger patients. 18 There again, there are few studies on the effects of artificial nutrition on functional status and health-related quality of life. This may be due to the fact that most studies have included patients from nursing homes with an impaired physical functioning beyond improvement and unable to fill a self-questionnaire. Some studies have showed a positive impact of EN on functionality and others a negative impact. Geriatric home EN and PN patients achieve a lower rehabilitation than their younger counterparts A specific nutrition formula for elderly patients There is no evidence in favour of a specific formula in EN or PN in the elderly. Rees et al. have proved high energy high protein EN diets to be able to reach faster a positive nitrogen balance, which may be helpful in stressed elderly patients. 20 As a higher protein intake is recommended in elderly patients, possibly to counteract the higher splanchnic extraction, high-protein formulas may be helpful. A diet-induced thermogenesis similar to that in adults 21 does not warrant the use of high-energy formulas, and the energy load of the formula will depend on the need for hydration. Sodium reabsorption is lower and the threshold for thirst higher in elderly subjects, which highlights the needs for water intake (30 ml/kg/d) which should be taken into account in the prescription of EN/PN formulas. Semi-elemental EN formulas are not preferable to polymeric ones. Last, fibre supplementation is able to improve bowel function with reduced stool frequency and more solid stool

3 S.M. Schneider / e-spen, the European e-journal of Clinical Nutrition and Metabolism 4 (2009) e81 e85 e83 Fig. 2. Flow chart of percutaneous endoscopic gastrostomy decision in the elderly patient with dysphagia. Adapted from. 4 consistency, without affecting the nutritional efficiency of enteral feeding in hospitalised geriatric patients Disease Even though the same diseases leading to nutritional support can be found throughout the lifespan, there are differences in indications in elderly patients (Fig. 5). 19 Also, some common diseases are most frequently encountered in elderly patients. Patients outcome differs, with age being an important factor (Table 2) Hip fracture Hip fracture is a common disease in the elderly. A Cochrane analysis that includes four trials testing supplementary overnight EN failed to show benefits on survival, but these studies were heterogeneous. 23 Bastow et al. have showed a benefit of EN on anthropometric measurements and on a reduction of rehabilitation time and hospital stay in the most malnourished patients Neurological dysphagia In neurological dysphagia, nutritional therapy depends on the type and extent of the swallowing disorder. Nutritional therapy may range from normal food, to mushy meals (modified Table 1 Indications and contra-indications of hypodermoclysis. Indications Contra-indications Prevention/treatment of moderate dehydration (NaCl glucose serum) Dysphagia for liquids Shock, severe dehydration (Na > 150 Confusion, dementia mmol/l) Fever, heat wave Difficulties in enteral/venous access Prevention of malnutrition worsening (amino acids) Transient insufficient oral intake Major coagulation disorders Contra-indication of enteral nutrition Terminal patients Severe heart failure Prevention of dehydration Infusion of analgesic/anti-anxiety Severe malnutrition drugs Fig. 3. Outcome of home enteral nutrition patients according to age. Adapted from. 5

4 e84 S.M. Schneider / e-spen, the European e-journal of Clinical Nutrition and Metabolism 4 (2009) e81 e85 Table 2 Outcome of home enteral nutrition patients. 5 Head and neck cancer Neurological diseases Dementia Number of patients Age Body mass index d survival 88% 83% 54% 1-yr survival 37% 41% 20% 5-yr survival 24% 21% 3% patients with terminal dementia (irreversible, immobile, unable to communicate, completely dependent, lack of physical resources) EN is not recommended (grade of recommendation C). 11 Fig. 4. Correlation between daily changes in body cell mass and energy provided during a 2-week parenteral nutrition course in 325 mildly malnourished patients aged Adapted from. 14 consistency), thickened liquids of different consistencies or total EN delivered via nasogastric tube or PEG. In a Cochrane analysis of interventions for dysphagia in acute stroke, EN delivered via PEG was associated with a greater improvement of nutritional status when compared to EN delivered via nasogastric tube. 25 Sanders et al. reported an improvement in activities of daily living in 25 stroke patients (mean age 80 years) with EN via PEG (PEG placement on average 14 days after stroke). 26 As dysphagia will rarely improve after two weeks, if severe dysphagia persists longer than 14 days after the acute event, a PEG should be placed immediately Dementia An inadequate intake of energy and nutrients is a common problem in demented patients. Undernutrition may be caused by several factors including anorexia (common cause: polypharmacotherapy), insufficient oral intake (forgetting to eat), depression, apraxia of eating or, less often, enhanced energy requirement due to hyperactivity (constant pacing). 11 In advanced stages of dementia, dysphagia may develop and might be an indication for EN in a few cases. Most studies, with of course a small level of evidence, have showed a worse outcome in enterally-fed demented patients and/or demented patients receiving PEG, compared to either the absence of intervention in demented patients 5 or the same interventions in non-demented patients. 10,27 EN may be recommended at early stages of the disease, or after an acute weight loss in patients with Alzheimer s disease. 28 However, for Pressure sores Pressure ulcers are associated with an increased risk of morbidity and mortality. A systematic review by Stratton et al. shows that enteral nutritional support, particularly high protein supplements, can significantly reduce the risk of developing pressure ulcers (by 25%). However, available studies on the effect of EN do not show improved healing of decubitus ulcers. 29 The importance of protein in pressure sore healing was suggested in an 8 week non-30 randomised study in 28 undernourished nursing home residents with decubitus ulcers. 30 The administration of a formula with 61 g protein per litre (24 energy percent) was more successful in decreasing total pressure ulcer surface area than a TF formula with 37 g protein per litre (14 energy percent) Ethical issues Ethical issues are crucial in deciding upon starting an elderly patient on artificial nutrition. Public controversy about lifesustaining technologies for elderly people now focuses on decisions about withholding or withdrawal of tube feeding, but debate about the legal and ethical issues involved in these decisions tends to obscure the relevant clinical considerations. 31 The patient s informed consent needs to be obtained, with family or a caregiver as possible surrogates. Sedation of the patient for acceptance of the nutritional treatment is never justified. Proposing PEG because the patient takes too long to feed is also unacceptable. The decision must always if possible be based on evidence, or if unavailable on the patient s (or his/her family s) desire and on a therapeutic project; if artificial nutrition may be withheld, there is a general consensus that once initiated, it may not be withdrawn. 32 Conflict of interest There is no conflict of interest. References Fig. 5. Proportions of adult and geriatric patients starting home enteral and parenteral nutrition in the USA ( ) according to the major diagnostic groups. Adapted from. 19 HEN: home enteral nutrition; HPN: home parenteral nutrition. 1. Hébuterne X, Bozzetti F, Moreno Villares JM, et al. Home enteral nutrition in adults: a European multicentre survey. Clin Nutr 2003;22: Van Gossum A, Bakker H, Bozzetti F, et al. Home parenteral nutrition in adults: a European multicentre survey in Clin Nutr 1999;18: Zaloga GP. Parenteral nutrition in adult inpatients with functioning gastrointestinal tracts: assessment of outcomes. Lancet 2006;367: Hébuterne X, Messing B, Rampal P. A quels malades faut-il poser une gastrostomie percutanée endoscopique? Gastroenterol Clin Biol 1998;22: Schneider SM, Raina C, Pugliese P, Pouget I, Rampal P, Hebuterne X. Outcome of patients treated with home enteral nutrition. JPEN J Parenter Enteral Nutr 2001;25: Ferry M, Leverve X, Constans T. Comparison of subcutaneous and intravenous administration of a solution of amino acids in older patients. J Am Geriatr Soc 1997;45: Hébuterne X, Broussard JF, Rampal P. Acute renutrition by cyclic enteral nutrition in elderly and younger patients. JAMA 1995;273:

5 S.M. Schneider / e-spen, the European e-journal of Clinical Nutrition and Metabolism 4 (2009) e81 e85 e85 8. Ciocon JO, Galindo-Ciocon DJ, Tiessen C, Galindo D. Continuous compared with intermittent tube feeding in the elderly. JPEN J Parenter Enteral Nutr 1992;16: Mitchell SL, Tetroe JM. Survival after percutaneous endoscopic gastrostomy placement in older persons. J Gerontol A Biol Sci Med Sci 2000;55:M Shah PM, Sen S, Perlmuter LC, Feller A. Survival after percutaneous endoscopic gastrostomy: the role of dementia. J Nutr Health Aging 2005;9: Volkert D, Berner YN, Berry E, et al. ESPEN guidelines on enteral nutrition: geriatrics. Clin Nutr; Hébuterne X, Schneider S, Péroux J, Rampal P. Effects of refeeding by cyclic enteral nutrition on body composition: comparative study of elderly and younger patients. Clin Nutr 1997;16: Hébuterne X, Bermon S, Schneider SM. Ageing and muscle: the effects of malnutrition, re-nutrition, and physical exercise. Curr Opin Clin Nutr Metab Care 2001;4: Shizgal HM, Martin MF, Gimmon Z. The effect of age on the caloric requirement of malnourished individuals. Am J Clin Nutr 1992;55: Roubenoff R, Harris TB, Abad LW, Wilson PW, Dallal GE, Dinarello CA. Monocyte cytokine production in an elderly population: effect of age and inflammation. J Gerontol A Biol Sci Med Sci 1998;53:M Boirie Y, Gachon P, Beaufrere B. Splanchnic and whole-body leucine kinetics in young and elderly men. Am J Clin Nutr 1997;65: Bermon S, Hébuterne X, Péroux J, Marconnet P, Rampal P. Correction of proteinenergy malnutrition in older adults: effects of a short-term aerobic program. Clin Nutr 1997;16: Schneider SM, Pouget I, Staccini P, Rampal P, Hébuterne X. Quality of life in long-term home enteral nutrition patients. Clin Nutr 2000;19: Howard L, Malone M. Clinical outcome of geriatric patients in the United States receiving home parenteral and enteral nutrition. Am J Clin Nutr 1997;66: Rees RG, Cooper TM, Beetham R, Frost PG, Silk DB. Influence of energy and nitrogen contents of enteral diets on nitrogen balance: a double blind prospective controlled clinical trial. Gut 1989;30: Al-Jaouni R, Schneider SM, Rampal P, Hebuterne X. Effect of age on substrate oxidation during total parenteral nutrition. Nutrition 2002;18: Vandewoude MF, Paridaens KM, Suy RA, Boone MA, Strobbe H. Fibresupplemented tube feeding in the hospitalised elderly. Age Ageing 2005;34: Avery AJ, Groom LM, Brown KP, Thornhill K, Boot D. The impact of nursing home patients on prescribing costs in general practice. J Clin Pharm Ther 1999;24: Bastow MD, Rawlings J, Allison SP. Benefits of supplementary tube feeding after fractured neck of femur: a randomised controlled trial. Br Med J (Clin Res Ed) 1983;287: Bath PM, Bath FJ, Smithard DG. Interventions for dysphagia in acute stroke. Cochrane Database Syst Rev; 2000::CD Sanders H, Newall S, Norton B, Holmes GT. Gastrostomy feeding in the elderly after acute dysphagic stroke. J Nutr Health Aging 2000;4: Mitchell SL, Kiely DK, Lipsitz LA. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Arch Intern Med 1997;157: Guérin O, Andrieu S, Schneider SM, et al. Different modes of weight loss in Alzheimer disease: a prospective study of 395 patients. Am J Clin Nutr 2005;82: Stratton RJ, Ek AC, Engfer M, et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev 2005;4: Breslow RA, Hallfrisch J, Guy DG, Crawley B, Goldberg AP. The importance of dietary protein in healing pressure ulcers. J Am Geriatr Soc 1993;41: Maslow K. Total parenteral nutrition and tube feeding for elderly patients: findings of an OTA study. JPEN J Parenter Enteral Nutr 1988;12: Schostak RZ. Jewish ethical guidelines for resuscitation and artificial nutrition and hydration of the dying elderly. J Med Ethics 1994;20: