Artificial Nutrition

Transcription

1 Nutrition in the Elderly 36.4 Artificial Nutrition Stéphane M. Schneider, MD, PhD Nutritional Support Unit, Nice University Hospital, France

2 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

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4 Enteral vs Parenteral? When the gut works use it! Even though using the gut can sometimes be a pain in the ***

5 Benefits of Enteral vs Parenteral Nutrition Maintains morphologic, functional integrity of GI tract Avoids mechanical, metabolic complications of TPN Decreases cost Use of line for other purposes

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7 Hypodermoclysis Subcutaneous infusion < 700 mosm/l et 500 ml/j Water, glucose, minerals, vitamins, trace elements Pros Easy No DVT Freearms Little monitoring Cons Infection, pain, œdema Proofs?

8 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

9 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

10 Requirements Water 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

11 Energy Requirements kcal/kg/day Maintenance 25 Minor infection 30 Major surgery, sepsis 35 Burns 40

12 Protein Requirements g/kg/day Maintenance 1.0 Moderate stress or repletion 1.5 Severe stress 2.0 Renal failure without dialysis Renal failure with dialysis 1.0

13 Indications Hospital Secondary anorexia+++ Home Howard and Malone AJCN 1997

14 Outcome in EN patients Schneider et al. JPEN 2001

15 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

16 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

17 Good indications for EN Undernutrition Depression Neurological dysphagia Hip fracture Depression Early/moderate dementia

18 Survival in HEN H&N cancer Neurol. Dementia Number Age 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

19 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

20 Net improvement of nutritional parameters during cyclic enteral nutrition in young and elderly malnourished patients kg g/l P<0.01 D15 D28 Body weight NS D15 P<0.001 P<0.05 D28 Serum prealbumin g/l g/l P<0.05 D15 NS D28 Serum transferrin NS D15 Serum albumin P<0.05 D28 <65 years 65 years Hébuterne et al. JAMA 1995

21 Estimation of energy excess for the gain of 1 kg in young and elderly malnourished patients Young Elderly Body weight Fat-free mass Body cell mass Hébuterne et al. Personal data

22 Effects of age on energy needs during TPN Correlation between daily BCM changes and energy provided during a 2-wk TPN in 325 mildly malnourished patients aged Body cell mass gain (g/d) yr 40 yr 60 yr 80 yr Energy provided (kcal/kg/d) Shizgal et al. Am J Clin Nutr 1992

23 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