Delivery of Enteral

Nutrition Support

for Elderly Patients

Admitted to

General Wards

Noraishah Mohamed

Nor

IIUM

Introduction

• Many research have shown that the elderly are at high risk of malnutrition (Adil et al. 1994; Jensen et al. 2001), especially it is common among elderly who are hospitalized (Suzana et al. 2002; Patel & Martin 2008; Oliveira et al. 2009)

• The tube feeding is the best choice for hospitalized elderly with insufficient oral feeding.

• There is much less information in the literature regarding formula delivery to patients receiving ENS in general hospital wards, especially in Malaysia.

• The available data about ENS in Malaysia mostly refers to ICU patient (Kao 2007).

• Only three studies have been identified so far regarding the ENS for elderly in general wards and two of them reported formula delivery to be 70% and 88% of the prescribed volume, all these studies were done at overseas. (Robertson 1990; Abernathy et al. 1989).

The importance of the Study

• To the best of our knowledge, data on enteral feeding

delivery practices for elderly in Malaysia have not yet

been reported.

• This information is important to identify any barriers

to delivering adequate enteral nutritional support and

to subsequently identify strategies for improving

enteral nutritional support provisions to elderly in

general wards.

Study Aim

To determine the delivery of enteral

nutrition support to elderly patients in

General wards of General Hospital Kuala

Lumpur.

Methodology • Subject selection was through convenience sampling

method.

• All elderly patients on Ryle’s tube bolus feeding that meet inclusion and exclusion criteria were chosen for the study.

• Inclusion Criteria were: – Age 60-90 years

– Requiring tube feeding at least 5 days

– On bolus tube feeding

– On nasogastric tube feeding

– Absence of any oral intake during the period of tube feeding

– Requiring and able to consume a standard polymeric enteral formula .

• Exclusion Criteria

– Patient not receiving tube feeding

– On total parenteral nutrition or given continuous tube

feeding.

– Patient on EN through other than nasogastric tube.

– Patients receiving diet orally or both en and oral (mix

feeding)

• The flowchart for patients recruitment is as follow:

• Sample size calculation is based on the equation from Kish L, 1965 (Azmi,

2008). The equation is as follow:

– n = (Z1- α) 2 [P (1- P) / D2]

– Where:

n = sample size

Z1- α = alpha value for 95% confident Interval (Z0.95) is 1.96

P = Prevalence of patient on tube feeding in general ward is 5%

(0.05) (Bowling TE, 1995)

D = Degree of accuracy (5% = 0.05)

• Form the available data, the sample size calculation is as follow:

n = 1.962 x [0.05 (1 – 0.05)/ 0.052]

= 73 subjects

= 73 + 10% Dropout

= 80 subjects (Therefore, sample size for the study was 80 subjects)

Results • Total subjects recruited were 73 subjects after the dropouts

were excluded.

• Demographic profile for subjects:

VARIABLE Mean±SD FREQUENCY

(%)

Age (years) 70.9±7.7

GENDER

Male 36 (49.3)

Female 37 (50.7)

RACE

Malay 31 (42.5)

Chinese 21 (28.8)

Indian 18 (24.7)

Others 3 (4.1)

• Anthropometry profile and nutritional status of

subjects:

Variables Median (IQR) Frequency (%)

Body Weight, kg 48.1 (19.3 – 111.5)

SGA Score

Well Nourished (A) 9 (12.3)

Moderately Malnourished (B) 32 (43.8)

Severely Malnourished (C) 32 (43.8)

• Administration of Enteral Nutritional Support:

Variables Median (IQR) Frequency

(%)

Enteral Nutritional Initiation time 14.0 (0.0 – 140.0)

Referral to dietitian

Yes 46 (63.0)

No 27 (37.0)

Starting Formula

Clear Fluid 68 (93.2)

Enteral Formula 5 (6.8)

Initiation Time

< 24 hours 60 (82)

24 – 48 hours 8 (11)

> 48 hours 5 (7)

• Association between nutrition with clinical

data and ENS initiation time:

Variables Initiation Time <24

hours

n (%)

Initiation Time >24

hours

n (%)

p Value CI (95%)

SGA

Well Nourished

Moderately Malnourished

Severely Malnourished

7 (9.6)

25 (34.2)

28 (38.4)

2 (2.7)

7 (9.6)

4 (5.5)

0.578

NA

% Mean of Calorie Achievements c 90.2 ±38.9 73.1 ± 40.1 0.129 - 7.7 – 42.1

% Mean of Protein Achievement c 85.1 ± 40.7 70.2 ± 45.7 0.364 - 10.4 – 40.2

% Calorie Achievement according to days of

ENS initiation

% Protein Achievement according to days of

ENS initiation

• Feeding Interruptions:

– In this study approximately about 21 subjects

(29%) experienced interruptions throughout five

days administration of enteral nutrition support.

– Types of interruptions experienced by patients

were:

• Medical procedures (52%)

• mechanical complication (19%)

• non- gastro complication (19%)

• gastro complications (10%)

• Comparison of interruptions with nutritional

and clinical outcome:

Variables Subjects with feeding

interruptions

(n=21)

Subjects without

feeding interruptions

(n=52)

p value

Mean % of calorie achievement b 56.0±45.4 101±59.7 0.624

Mean % of protein achievement b

46.6±39.2 98.8±51.4 0.864

Subjective Global Assessment a

Score A, n (%)

Score B, n (%)

Score C, n (%)

3 (4.1)

10 (16.4)

8 (11.0)

6 (8.2)

22 (27.4)

24 (32.5)

0.556

Total Protein level a

Low, n (%)

Normal, n (%)

10 (15.1)

11 (31.5)

28 (37.0)

24 (16.4)

0.003

Albumin level a

Low, n (%)

Normal, n (%)

16 (24.7)

5 (6.8)

41 (54.8)

11 (13.7)

0.037

N = 73, a Chi- square test, b Independent t-test

Discussion • In this study, referring to the SGA score, more than three quarter of

the subjects (87.6%) were either moderately malnourished or severely malnourished, only about 12% were well nourished.

• This figure was higher than the prevalence of malnutrition among elderly patients admitted to a tertiary care hospital (40- 50%) (McWhirter & Pennington 1995).

• Current guideline on initiation time of ENS has recommended that patients in stable condition and resuscitated should be fed within 24 to 48 hours after admission (Heyland et al. 2003).

• In line with this guideline, majority of the subjects in this study (93%) started with ENS less than 48 hour after admission. Early initiation of ENS is very, early enteral nutrition (EN) was associated with significantly lower incidence of infections and reduced length of hospital stay crucial (Marik and Zaloga 2001).

• According to Heyland (1998), the enteral nutrition support should reach 100% of the requirement within seven days of admission, and optimally by the third to fifth day.

• In this study showed that, subjects in general wards achieved around 84% of the calorie requirement and around 87% of the protein requirement after five days of feeding administration, indicating good enteral nutrition progress.

• This findings are similar to the previous study reported 70-80% for calorie achievement (Rice et al. 2005; Abernathy et al. 1989) and Whelan et al. (2006) concluded that formula delivery was slightly not optimal in patients receiving enteral nutrition in general wards, with only 88% of calorie achieved compared to the requirement.

• Interruptions are common in enteral nutrition

delivery, however in general wards the

interruptions are not as often as in ICU due to

severity of the patients.

• In this study only 29% of the subjects

experienced interruptions, lower than a study

carried out in Malaysian ICU patients (82%)

underwent interruptions (Kao 2007).

• In this study, the types of interruptions mostly due

to procedure,high GRV and non- gastro

complications.

• Similar finding was reported by O’Leary-Kelley and

colleagues (2005), of which enteral feeding was delayed

mostly due to procedures.

• Additionally, McClave et al (1999) found 35% patients

experienced interruptions due to procedures.

• A study carried out by Kao (2007) also concluded that most of

the enteral feeding interruptions were due to procedure (54%).

• However, a study carried out by Whelan et al. (2006) in

general ward; found that nasogastric extubation was the most

common interruption.

Summary & Conclusion

• Most of the elderly admitted to general wards were either severely malnourished or moderately malnourished that need enough calorie and protein to improve nutritional status and clinical outcome.

• The mean percentage achievement of calorie and protein were approximately 80% from the requirement within five days of feeding administration.

• The interruptions in feeding were not as common as in ICU and from this study, most frequent interruption were due to procedures.

• In conclusion, the delivery of ENS was suboptimal in

general wards as not all subjects received ENS

according to the requirements. Minority of subjects

experienced interruptions, however interruptions did

not cause in lower calorie and protein achievements.

Acknowledgements

• To Supervisors:

– Dr Zahara Abdul Manaf (UKM)

– Dr Suzana Sahar (UKM)

• To Dr. Lee Fatt Soon and the Head of

Department for General Medicine; Dato’ Dr.

Jeyaindran a/l Tan Sri Sinnadura, and all staffs

at geriatric and general wards at HKL.

Thank You…