Nutrition in Older Adults Topic 36

Module 36.3
Artificial Nutrition in Older Adults

Stphane M. Schneider, MD, PhD

Nutritional Support Unit, Archet University Hospital
CS 23079, 06202 Nice Cedex 3, France

Learning Objectives

To know the most frequent indications for artificial nutrition;

To know the techniques and outcome;
To know the indications and results in specific clinical situations;
To understand the need for ethical elements alongside the medical ones in deciding
upon starting an older patient on artificial nutrition.

Contents

1. Introduction
2. Choice of nutritional support technique
2.1 General considerations
2.2 Decision on percutaneous endoscopic gastrostomy
3. Age-related issues
3.1 Route
3.2 Outcomes
3.2.1 Complications
3.2.2 Survival
3.2.3 Nutritional status
3.2.4 Function and quality of life
3.3 A specific formula for older patients?
3.4 Disease
3.4.1 Hip fracture
3.4.2 Neurological dysphagia
3.4.3 Dementia
3.4.4 Pressure sores
4. Ethical issues
5. Summary
6. References

Key Messages

Most indications are ideally addressed with enteral nutrition, rarely parenteral
nutrition;
Indications, products and techniques do not differ from younger adults, but the
outcome is worse;
Prolonged artificial nutrition can be performed at home or in an institution;
Most demented patients will not benefit from artificial nutrition.

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1. Introduction

The mean age of patients receiving artificial nutrition is steadily increasing along with 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 nutrition
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 younger adult patients
(see LLL Topics 8 and 9). However, there are some marked differences, including the
metabolic response to refeeding, specific indications or contra-indications and outcomes.
Anorexia in the older adult will also lead to longer refeeding periods, along with more
frequent institutionalization.
While reducing morbidity and mortality is a priority in younger patients, artificial nutrition
in the older patient 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
condition.
Last, the anticipated benefits need to outweigh the potential risks.

2. Choice of Nutritional Support Technique

2.1 General Considerations

Artificial nutrition should be considered after oral supplements have failed (due to
insufficient intake) (see LLL Module 36.2) or in a severely malnourished patient in
whom there is a need for fast weight gain. The flow chart in older patients is the same as
the one we refer to in younger 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, thus preventing patients from meeting their nutritional requirements. Enteral
nutrition will be started during a hospital stay of at least a few days, in order to place the
feeding tube, evaluate tolerance and to train the patient and/or relatives. It will then be
continued at home or in an institution.

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 Fig. 1 Flow chart for artificial nutrition in the older patient

2.2 Decision on 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 older patient. Three groups of patients can be identified (Fig.
2):
Those who will need prolonged home EN, probably due to persistent dysphagia
after a resolving disease. Prolonged nutritional support may ensure a prolonged
survival;
Those who will get a short-term benefit before resuming oral nutrition, such as
those 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 then to improve
their quality of life.

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Fig. 2 Flow chart for percutaneous endoscopic gastrostomy decision-making in the older
patient with dysphagia. Adapted from (4).

3. Age-related Issues

3.1 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 access devices,
namely PEG buttons and implantable venous access ports. These may not be needed in
house-bound or institutionalized older patients.
Hypodermoclysis is a method of infusing fluid into subcutaneous tissue that requires only
minimal equipment. It can be helpful in older 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 these patients (6). Table 1 shows the main indications and contra-indications for this
method.

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Table 1
Indications and contra-indications for hypodermoclysis

Indications Contra-indications
Prevention / treatment of moderate Shock, severe dehydration
dehydration (NaCl glucose) (Na > 150 mmol/L)
Dysphagia for liquids Major coagulation disorders
Confusion, dementia Severe heart failure
Fever, heat-wave Severe malnutrition
Difficulties in enteral/venous access
Prevention of malnutrition worsening
(amino acids)
Transient insufficient oral intake
Contra-indication to enteral nutrition
Terminal patients
Prevention of dehydration
Infusion of analgesic/anti-anxiety
drugs

EN may be delivered continuously or cyclically, with similar nutritional results (7, 8).
However, only cyclical nocturnal nutrition allows the patient to have physical activity in
the daytime and to eat normally at meal times.
PN can be administered both centrally and peripherally, with in the latter case an
osmolarity not exceeding 850 mOsm/L (9).

3.2 Outcomes

3.2.1 Complications

Complications of HEN and HPN are similar to those observed in other age groups. They
include tube complications (obstruction, removal) and diarrhoea/constipation for
enterally fed patients and catheter-related complications (infections, thrombosis,
obstruction) for parenterally fed patients. Specifically, advanced age has been associated
with a higher risk for hyperglycaemia and central catheter vascular erosion, but not for
bloodstream infections (10).

3.2.2 Survival

As would be expected, life expectancy on nutritional support is lower in older patients

than in younger ones (11). 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 (12). However,
an Italian study of 482 nursing home residents receiving EN reported a median survival
of 13.7 months, with a median duration of EN of 296 days, and 6% having resumed oral
nutrition and able to stop EN because of this improvement (13). For obvious ethical
reasons, no study has been designed in order to show a benefit of artificial nutrition
versus 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 (14).

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Fig. 3 Outcome of home enteral nutrition patients according to age. Adapted from (5).

3.2.3 Nutritional Status

There is resistance to refeeding in older patients. Namely, for the same amount of
nitrogen and energy provided by EN, the increase in weight, fat-free mass and chronic
phase proteins is lower in older patients than in younger adults (7, 15). When an extra
7,500 kcal are needed to gain one kilogram of body weight in young malnourished
patients, 8,800 to 22,600 kcal are needed in older ones (16). The same is true for PN
(Fig. 4) (17). Chronic inflammation (18), insulin resistance (9) as well as a higher
splanchnic extraction of proteins (19) 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 adjuvants that may be used to counteract this resistance to
refeeding, exercise performed during artificial nutrition is probably the most important
(20).

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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 20-80.
Adapted from (17).

3.2.4 Function and Quality of Life

Health-related quality of life is lower in older home EN patients compared with younger
ones (21). 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 in a questionnaire themselves because of cognitive
impairment. Some studies have shown a positive impact of EN on functionality and
others a negative impact. Older patients on home EN and PN achieve lesser levels of
rehabilitation than their younger counterparts (9, 22).

3.3 A Specific Nutrition Formula for Older Patients?

There is no evidence in favour of a specific formula in EN or PN in the older adult. Rees et

al. have proved high-energy high-protein EN diets to be able to help reach a positive
nitrogen balance faster, which may be helpful in stressed older patients (23). As a higher
protein intake is recommended in these patients, possibly to counteract the higher
splanchnic extraction, high-protein formulae may be helpful. As diet-induced
thermogenesis is similar to that in younger adults (24) the use of high-energy formulae
is not warranted, and the energy load of the formula will be considered concomitantly
with the hydration needs. Sodium reabsorption is lower and the threshold for thirst
higher in older adults, which highlights the needs for water intake (30 ml/kg/d) which
should be taken into account in the prescription of EN/PN formulae. Semi-elemental EN
formulae do not have any age-specific benefit over polymeric ones. Last, fibre
supplementation is able to improve bowel function with reduced stool frequency and
more solid stool consistency, without affecting the nutritional efficiency of enteral feeding
in hospitalised older patients (25). For PN, lipid oxidation is not impaired by age, unlike
carbohydrate oxidation, which may warrant the use of formulae with higher lipid contents
(grade B) (9).

3.4 Disease

Even though the same diseases leading to a need for nutritional support can be found
throughout the lifespan, there are differences in indications in older patients (Fig. 5)
(22). Patients outcomes differ, with age being an important factor (Table 2).

Table 2
Outcome of patients on home enteral nutrition (5)

Head and neck Neurological Dementia

cancer diseases
Number of patients 76 148 54
Age 65 75 85
Body mass index 19.9 19.9 17.4
30-d survival 88% 83% 54%
1-yr survival 37% 41% 20%
5-yr survival 24% 21% 3%

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Fig. 5 Proportions of young and older adult patients starting home enteral and parenteral
nutrition in the USA (1985-92) according to the major diagnostic groups. Adapted from
(22). HEN: home enteral nutrition; HPN: home parenteral nutrition.

3.4.1 Hip Fracture

Hip fracture is a common condition in the older patient. A Cochrane analysis that includes
four trials testing supplementary overnight EN failed to show benefits on survival, but
these studies were heterogeneous (26). Bastow et al. have showed a benefit of EN on
anthropometric measurements, with reductions in rehabilitation time and hospital stay in
the most malnourished patients (27). On balance, oral nutritional supplements should be
prescribed at least temporarily in all patients (grade B) (28).

3.4.2 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 texture), 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 (29). 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) (30). The better post-
procedural prognosis if PEG is placed more than one month after the stroke leads to
advice PEG placement if dysphagia persists after one month (31).

3.4.3 Dementia

An inadequate intake of energy and nutrients is a common problem in demented

patients. Malnutrition may be caused by several factors including anorexia (common
cause: polypharmacy), insufficient oral intake (forgetting to eat), depression, apraxia of
eating or, less often, enhanced energy requirement due to hyperactivity (constant
pacing) (14). In advanced stages of dementia, dysphagia may develop and might be an
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indication for EN in a few cases. Most studies, with a low level of evidence, have shown 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 (12, 32). EN may be recommended at
early stages of the disease, or after an acute weight loss in patients with Alzheimers
disease (33). However, for patients with terminal dementia (irreversible, immobile,
unable to communicate, completely dependent, lack of physical resources) EN is not
recommended (grade of recommendation C) (14).

3.4.4 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 (34).
The importance of protein in pressure sore healing was suggested in an 8 week non-
randomised study in 28 malnourished nursing home residents with decubitus ulcers (35).
The administration of a formula with 61 g protein per litre (24% of the total energy) was
more successful in decreasing total pressure ulcer surface area than a formula with 37 g
protein per litre (14% of energy). A high energy intake is also important. If oral
nutritional support fails, enteral nutrition should be proposed, provided that the expected
benefit is thought to outweigh the risks of the technique (28).

4. Ethical Issues

Ethical issues are crucial in deciding upon starting an older patient on artificial nutrition.
Public controversy about life-sustaining technologies for older persons 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 (36). In most countries, nutritional support is considered a medical
treatment and not comfort care. The patients informed consent needs to be obtained,
with family or a caregiver as possible surrogates (where legislation permits this).
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 medical evidence. The justification
for nutritional support should be critically reviewed at regular intervals, to determine
whether the treatment is mainly prolonging the patients life or his/her suffering.
Although artificial nutrition may be withheld, there is a general consensus that once
initiated, it may not be withdrawn, unless the patients circumstances change
substantially (37).

5. Summary

Enteral and parenteral nutrition are valid options in the malnourished older patient, both
in the hospital and at home. Older patients share most indications and complications with
younger adult patients, even though more focus needs to be put on function and quality
of life than on mortality.

6. References

1. Hbuterne X, Bozzetti F, Moreno Villares JM, et al. Home enteral nutrition in adults: a
European multicentre survey. Clin Nutr. 2003;22:261-6.
2. Van Gossum A, Bakker H, Bozzetti F, et al. Home parenteral nutrition in adults: a
European multicentre survey in 1997. Clin Nutr. 1999;18:135-40.

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3. Zaloga GP. Parenteral nutrition in adult inpatients with functioning gastrointestinal
tracts: assessment of outcomes. Lancet. 2006;367:1101-11.
4. Hbuterne X, Messing B, Rampal P. A quels malades faut-il poser une gastrostomie
percutane endoscopique ? Gastroenterol Clin Biol. 1998;22:1065-70.
5. Schneider SM, Raina C, Pugliese P, Pouget I, Rampal P, Hebuterne X. Outcome of
patients treated with home enteral nutrition. J Parenter Enteral Nutr. 2001;25:203-9.
6. 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;45:857-60.
7. Hbuterne X, Broussard JF, Rampal P. Acute renutrition by cyclic enteral nutrition in
elderly and younger patients. JAMA. 1995;273:638-43.
8. Ciocon JO, Galindo-Ciocon DJ, Tiessen C, Galindo D. Continuous compared with
intermittent tube feeding in the elderly. JPEN. 1992;16:525-8.
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Geriatrics. Clin Nutr. 2009;28:461-6.
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placement in older persons. J Gerontol A Biol Sci Med Sci. 2000;55:M735-9.
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gastrostomy: the role of dementia. J Nutr Health Aging. 2005;9:255-9.
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nutrition on body composition: comparative study of elderly and younger patients.
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malnutrition, re-nutrition, and physical exercise. Curr Opin Clin Nutr Metab Care.
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malnourished individuals. Am J Clin Nutr. 1992;55:783-9.
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cytokine production in an elderly population: effect of age and inflammation. J
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and elderly men. Am J Clin Nutr. 1997;65:489-95.
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energy malnutrition in older adults: effects of a short-term aerobic program. Clin
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term home enteral nutrition patients. Clin Nutr. 2000;19:23-8.
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receiving home parenteral and enteral nutrition. Am J Clin Nutr. 1997;66:1364-70.
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contents of enteral diets on nitrogen balance: a double blind prospective controlled
clinical trial. Gut. 1989;30:123-9.
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oxidation during total parenteral nutrition. Nutrition. 2002;18:20-5.
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tube feeding in the hospitalised elderly. Age Ageing. 2005;34:120-4.
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patients on prescribing costs in general practice. J Clin Pharm Ther. 1999;24:357-63.
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fractured neck of femur: a randomised controlled trial. Br Med J (Clin Res Ed).
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28. Raynaud-Simon A, Revel-Delhom C, Hbuterne X. Clinical practice guidelines from the
French health high authority: Nutritional support strategy in protein-energy
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acute dysphagic stroke. J Nutr Health Aging. 2000;4:58-60.
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evaluating feeding policies in patients admitted to hospital with a recent stroke.
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tube placement in nursing home residents with severe cognitive impairment. Arch
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33. Gurin 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;82:435-41.
34. 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;4:422-50.
35. Breslow RA, Hallfrisch J, Guy DG, Crawley B, Goldberg AP. The importance of dietary
protein in healing pressure ulcers. J Am Geriatr Soc. 1993;41:357-62.
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an OTA study. JPEN J Parenter Enteral Nutr. 1988;12:425-32.
37. Schostak RZ. Jewish ethical guidelines for resuscitation and artificial nutrition and
hydration of the dying elderly. J Med Ethics. 1994;20:93-100.

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