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