Elsevier

Clinical Nutrition

Volume 25, Issue 2, April 2006, Pages 330-360
Clinical Nutrition

ESPEN GUIDELINES
ESPEN Guidelines on Enteral Nutrition: Geriatrics

https://doi.org/10.1016/j.clnu.2006.01.012Get rights and content

Summary

Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake.

The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference.

EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

The full version of this article is available at www.espen.org.

Section snippets

Terminology

Geriatric patient—a biologically elderly patient who is at acute risk of loss of independence due to acute and/or chronic diseases (multiple pathology) with related limitations in physical, psychological, mental and/or social functions. The abilities to perform the basic activities of independent daily living are jeopardised, diminished or lost. The person is in increased need of rehabilitative, physical, psychological and/or social care to avoid partial or complete loss of independence.

Elderly

What are the aims of EN therapy in geriatrics?

  • Provision of sufficient amounts of energy, protein and micronutrients.

  • 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.

Therapeutic aims for geriatric patients do not generally differ from those in younger patients except in emphasis. While reducing morbidity and mortality is a priority in younger patients, in geriatric patients

EN in specific diagnostic groups

2.1. Is EN indicated in patients with undernutrition?

Undernutrition and risk of undernutrition represent essential and independent indications for EN in geriatric patients. ONS is recommended in order to increase energy, protein and micronutrient intake, maintain or improve nutritional status, and improve survival in patients who are undernourished or at risk of undernutrition (A). ONS and/or TF are recommended early in patients at nutritional risk (e.g. insufficient nutritional intake,

Special practical aspects of EN in geriatric patients

3.1. How should EN be delivered: by PEG or by NGT?

In elderly patients in whom EN is anticipated for longer than 4 weeks, placement of a PEG tube is recommended (A).

Comment: Five studies (four prospective, three randomised) comparing PEG with NGT, show the superiority of PEG (Table 7) in allowing the administration of greater amounts of energy and nutrients over longer periods, resulting in better nutritional status (Ib)11, 12 (IIa)86 The use of NGT is associated with more tube displacements86

References (174)

  • F. Vetta et al.

    Role of aging in malnutrition and in restitution of nutritional parameters by tube feeding

    Arch Gerontol Geriatr

    (1996)
  • G. Franch-Arcas

    The meaning of hypoalbuminaemia in clinical practice

    Clin Nutr

    (2001)
  • S. Nair et al.

    Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia

    Am J Gastroenterol

    (2000)
  • X. Hébuterne et al.

    Effects of refeeding by cyclic enteral nutrition on body composition: comparative study of elderly and younger patients

    Clin Nutr

    (1997)
  • S.M. Schneider et al.

    Lack of adaptation to severe malnutrition in elderly patients

    Clin Nutr

    (2002)
  • H.M. Shizgal et al.

    The effect of age on the caloric requirement of malnourished individuals

    Am J Clin Nutr

    (1992)
  • M. Unosson et al.

    Effects of dietry supplement on functional condition and clinical outcome measured with a modified Norton scale

    Clin Nutr

    (1992)
  • J. Tidermark et al.

    Effects of protein-rich supplementation and nandrolone in lean elderly women with femoral neck fractures

    Clin Nutr

    (2004)
  • T.E. Cederholm et al.

    Reversibiliy of protein-energy malnutrition in a group of chronically ill elderly outpatients

    Clin Nutr

    (1995)
  • G. Abuksis et al.

    Percutaneous endoscopic gastrostomy: high mortality rates in hospitalized patients

    Am J Gastroenterol

    (2000)
  • R.H. Skelly et al.

    Percutaneous endoscopic gastrostomy (PEG): change in practice since 1988

    Clin Nutr

    (2002)
  • D.S. Sanders et al.

    Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia

    Am J Gastroenterol

    (2000)
  • M. Lumbers et al.

    Nutritional status and clinical outcome in elderly female surgical orthopaedic patients

    Clin Nutr

    (1996)
  • M. Delmi et al.

    Dietary supplementation in elderly patients with fractured neck of femur

    Lancet

    (1990)
  • M. Krondl et al.

    Subjectively healthy elderly consuming a a liquid nutrition supplement maintained body mass index and improved some nutritional parameters and perceived well-being

    J Am Diet Assoc

    (1999)
  • S.M. Schneider et al.

    Quality of life in long-term home enteral nutrition patients

    Clin Nutr

    (2000)
  • T. Dwolatzky et al.

    A prospective comparison of the use of nasogastric and percutaneous endoscopic gastrostomy tubes for long-term enteral feeding in older people

    Clin Nutr

    (2001)
  • D.E. Larson et al.

    Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients

    Gastroenterology

    (1987)
  • Milne AC, Potter J, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane...
  • D. Volkert et al.

    Nutritional support and functional status in undernourished geriatric patients during hospitalization and 6-month follow-up

    Aging Clin Exp Res

    (1996)
  • B.V. Roebothan et al.

    Relationship between nutritional status and immune function of elderly people

    Age Ageing

    (1994)
  • C.M. Williams et al.

    A controlled trial of sip-feed supplements in elderly orthopaedic patients

    Eur J Clin Nutr

    (1989)
  • M.A. Fiatarone et al.

    Exercise training and nutritional supplementation for physical frailty in very elderly people

    N Engl J Med

    (1994)
  • B. Norton et al.

    A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke

    Br Med J

    (1996)
  • R.H. Park et al.

    Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia

    Br Med J

    (1992)
  • M.D. Bastow et al.

    Benefits of supplementary tube feeding after fractured neck of femur: a randomised controlled trial

    Br Med J

    (1983)
  • D.H. Sullivan et al.

    Nightly enteral nutrition support of elderly hip fracture patients: a phase I trial

    J Am Coll Nutr

    (1998)
  • O. Norregaard et al.

    Effects of oral supplements to adults with chronic obstructive pulmonary disease (abstract)

    Clin Resp Physiol

    (1987)
  • S. Hübsch et al.

    Möglichkeiten und Grenzen der Anwendung flüssiger Nährstoffkonzentrate in der Therapie der Mangelernährung geriatrischer Patienten

    Akt Ernähr -Med

    (1994)
  • M.A. Fiatarone Singh et al.

    The effect of oral nutritional supplements on habitual dietary quality and quantity in frail elders

    J Nutr Health Aging

    (2000)
  • C.N. Meredith et al.

    Body composition in elderly men: Effect of dietary modification during strength training

    J Am Geriatr Soc

    (1992)
  • C.M. Callahan et al.

    Outcomes of percutaneous endoscopic gastrostomy among older adults in a community setting

    J Am Geriatr Soc

    (2000)
  • J.O. Ciocon et al.

    Tube feedings in elderly patients. Indications, benefits, and complications

    Arch Intern Med

    (1988)
  • V. Abitbol et al.

    Percutaneous endoscopic gastrostomy in elderly patients. A prospective study in a geriatric hospital

    Gastroenterol Clin Biol

    (2002)
  • D.E. Fay et al.

    Long-term enteral feeding: a retrospective comparison of delivery via percutaneous endoscopic gastrostomy and nasoenteric tubes

    Am J Gastroenterol

    (1991)
  • P.J. Friedman et al.

    Hypoalbuminemia in the elderly is due to disease not malnutrition

    J Clin Exp Gerontol

    (1985)
  • A. Peck et al.

    Long-term enteral feeding of aged demented nursing home patients

    J Am Geriatr Soc

    (1990)
  • A. Golden et al.

    Long-term survival of elderly nursing home residents after percutaneous endoscopic gastrostomy for nutritional support

    Nurs Home Med

    (1997)
  • K. Okada et al.

    The nutritional status of elderly bed-ridden patients receiving tube feeding

    J Nutr Sci Vitaminol

    (2001)
  • E. Paillaud et al.

    Prognosis factors of short and long-term survival in elderly hospitalized patients after percutaneous endoscopic gastrostomy

    Gastroenterol Clin Biol

    (2002)
  • Cited by (468)

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    For further information on methodology see Schütz et al.173 For further information on definition of terms see Lochs et al.174

    1

    Dorothee Volkert had been employed at the Department of Nutrition Science, University of Bonn, until May 31, 2005; she was not industry employed during the development of the guidelines.

    ☆☆

    The authors of the DGEM (German Society for Nutritional Medicine) guidelines on enteral nutrition in geriatrics are acknowledged for their contribution to this article.

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