nutrition in the elderly 36.4 artificial nutrition stéphane m. schneider, md, phd nutritional...
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Nutrition in the Elderly36.4
Artificial Nutrition
Stéphane M. Schneider, MD, PhDStéphane M. Schneider, MD, PhDNutritional Support Unit, Nice University Nutritional Support Unit, Nice University
Hospital, FranceHospital, France
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
In which of the following patients is nutritional support NOT warranted?
• 77 year old previously healthy female with severe dysphagia two weeks after a CVA
• 69 year male with COPD and esophageal cancer who has lost 10 kilos
• 65 year old newly edentulous patient who can’t chew a regular diet
Enteral vs Parenteral?
• When the gut works use it!
• Even though using the gut
can sometimes be a pain in
the ***
Benefits of Enteralvs Parenteral Nutrition
• Maintains morphologic, functional integrity of GI tract
• Avoids mechanical, metabolic complications of TPN
• Decreases cost
• Use of line for other purposes
Hypodermoclysis
• Subcutaneous infusion
• < 700 mOsm/L et 500 mL/j
• Water, glucose, minerals, vitamins, trace elements
• Pros– Easy– No DVT– Free arms– Little monitoring
• Cons– Infection, pain,
œdema– Proofs ?
Feeding route (1)
• Duration– Less than a month– More than a month
• Risk of aspiration– Standard– Increased
• Previous aspiration, decreased consciousness, dysphagia, endotracheal intubation, vomiting, supine position
• Need for digestive surgery
Feeding route (2)
Short-term Long-term
Risk of aspiration
Std High Std High
EN NGT NJT G tube (G)J tube
PN Standard line Tunnelled line / PAC
• Water– 30-40 mL/kg/day– Beware heart failure
• Electrolytes– Add Na to EN formulas– Ca: 1,2 g/day in the elderly
• Energy– Formulas such as Harris-Benedict– kcal/kg method– Indirect calorimetry
Requirements
Energy Requirements
kcal/kg/day
Maintenance 25
Minor infection 30
Major surgery, sepsis 35
Burns 40
Protein Requirements
g/kg/day
Maintenance 1.0
Moderate stress or repletion 1.5
Severe stress 2.0
Renal failure without dialysis 0.3-0.5
Renal failure with dialysis 1.0
Indications
Howard and Malone AJCN 1997
• Hospital– Secondary anorexia+++
• Home
Outcome in EN patients
Schneider et al. JPEN 2001
EN in Geriatrics (1)
• What are the aims of EN therapy in geriatrics?– Provision of sufficient energy, protein and
micronutrients (quality and quantity) – Maintenance or improvement of nutritional status– Maintenance or improvement of function, activity and
capacity for rehabilitation– Maintenance or improvement of quality of life– Reduction in morbidity and mortality
Volkert et al. Clin Nutr 2006
EN in Geriatrics (2)
• EN increases energy and nutrient intake in geriatric patients (Ia). PEG feeding is superior to nasogastric feeding in this respect (Ia).
• EN also maintains or improves nutritional parameters irrespective of the underlying diagnosis.
• Adequate nutrition is a prerequisite for any functional improvement, although studies are too few and diverse to allow a general statement.
• The effect of EN on quality of life is uncertain.
Volkert et al. Clin Nutr 2006
Good indications for EN
• Undernutrition
• Depression
• Neurological dysphagia
• Hip fracture
• Depression
• Early/moderate dementia
Survival in HENH&N cancer Neurol. Dementia
Number 76 148 54
Age 65 75 85
BMI 19,9 19,9 17,4
Reason for HEN Dysphagia (100%) Dysphagia (97%) Anorexia (100%)
1-mo survival 88% 83% 54%
1-yr survival 37% 41% 20%
5-yr survival 24% 21% 3%
Schneider et al. JPEN 2001
Bad indications for EN
• Terminal illness
• Late-stage dementia– Whether Alzheimer’s or not– « Refuses to eat »– « Pulls out his/her NGT »
• Do not harm: ethical aspects– Patient, family, caregivers, nursing team– Ethics committee
Net improvement of nutritional parameters
during cyclic enteral nutrition in young and
elderly malnourished patientskg
0.0
0.2
0.4
0.6
0.8
1.0
P<0.05
Serum transferrin
g/L NS
D15 D28
<65 years
≥65 years P<0.05
Serum albumin
g/L
NS
D15 D28
1.0
3.0
4.0
2.0
0.0
kg
P<0.01
P<0.001
Body weightD15 D28
0.01.02.03.04.05.06.07.0
0.00
0.02
0.04
0.06
0.08
0.10
P<0.05
Serum prealbumin
NS
D15 D28
g/L
Hébuterne et al. JAMA 1995
Estimation of energy excess for the gain of 1 kg in young and elderly
malnourished patients
0
5000
10000
15000
20000
25000
Body weight Fat-free mass Body cell mass
Young
Elderly
Hébuterne et al. Personal data
Effects of age on energy needs during TPN
-50
0
50
100
150
200
250
10 20 30 40 50 60 70 80
20 yr
40 yr
60 yr
80 yr
Energy provided (kcal/kg/d)
Correlation between daily BCM changes and energy provided during a 2-wk TPN in 325 mildly malnourished patients aged 20-80.
Bod
y c
ell m
ass g
ain
(g
/d)
Shizgal et al. Am J Clin Nutr 1992
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 from artificial nutrition