espen_guidelines_geriatrics nutrition 200625330-60.pdf
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Clinical Nutrition (2006) 25, 330360
ESPEN GUIDELINES
ESPEN Guidelines on Enteral Nutrition: Geriatrics$
D. Volkerta,,1, Y.N. Bernerb, E. Berryc, T. Cederholmd, P. Coti Bertrande,A. Milnef, J. Palmbladg, St. Schneiderh, L. Sobotkai, Z. Stangaj,DGEM:$$ R. Lenzen-Grossimlinghaus, U. Krys, M. Pirlich, B. Herbst,T. Schutz, W. Schroer, W. Weinrebe, J. Ockenga, H. Lochs
aHead Medical Science Division, Pfrimmer-Nutricia, Erlangen, GermanybHead Geriatric Department, Meir Hospital, Kfar Saba, IsraelcDepartment of Human Nutrition & Metabolism, Hebrew University, Hadassah Med School,
Jerusalem, IsraeldDepartment of Public Health and Caring Science, Uppsala University, Uppsala, SwedeneUnite de Nutrition Clinique, CHUV, Lausanne, SwitzerlandfHealth Services Research Unit, University of Aberdeen, Aberdeen, UKgDepartment of Medicine, Karolinska Institute, Huddinge University Hospital, Huddinge, SwedenhGastroenterologie et Nutrition Clinique, Hopital de lArchet, Nice, FranceiMetabolic Care Unit, Department of Gerontology and Metabolic Care, Charles University,Faculty of Medicine, Hradec Kralove, Czech RepublicjInternal Medicine and Clinical Nutrition, Inselspital/University Hospital, Bern, Switzerland
Received 18 January 2006; accepted 19 January 2006
KEYWORDSGuideline;Clinical practice;Evidence-based;Recommendations;
Summary Nutritional intake is often compromised in elderly, multimorbidpatients. Enteral nutrition (EN) by means of oral nutritional supplements (ONS)and tube feeding (TF) offers the possibility to increase or to insure nutrient intake incase of insufficient oral food intake.
The present guideline is intended to give evidence-based recommendations forthe use of ONS and TF in geriatric patients. It was developed by an interdisciplinaryexpert group in accordance with officially accepted standards and is based on all
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0261-5614/$ - see front matter & 2006 European Society for Clinical Nutrition and Metabolism. All rights reserved.doi:10.1016/j.clnu.2006.01.012
Abbreviations: ADL, activities of daily living; BCM, body cell mass; BMI, body-mass index; CI, confidence interval; EN, enteralnutrition; FFM, fat-free mass; IADL, instrumental activities of daily living; MAC, mid-arm circumference; MAMC, mid-arm musclecircumference; NGT, nasogastric tube; ONS, oral nutritional supplement; OR, odds ratio; PEG, percutaneous endoscopic gastrostomy;RR, relative risk; SD, standard deviation; TF, tube feeding; TSF, triceps skin fold$For further information on methodology see Schutz et al.173 For further information on definition of terms see Lochs et al.174Corresponding author. Tel.: +499131 7782 31; fax: +499131 7782 86.
E-mail address: [email protected] (D. Volkert).1Dorothee 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.
http://intl.elsevierhealth.com/journals/clnuhttp://localhost/var/www/apps/conversion/tmp/scratch_10/dx.doi.org/10.1016/j.clnu.2006.01.012mailto:[email protected]:[email protected]://localhost/var/www/apps/conversion/tmp/scratch_10/dx.doi.org/10.1016/j.clnu.2006.01.012http://intl.elsevierhealth.com/journals/clnuhttp://intl.elsevierhealth.com/journals/clnu -
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Enteral nutrition;Oral nutritionalsupplements;Tube feeding;Geriatric patients;Undernutrition;Malnutrition;Elderly;Aged-80-and-over
relevant publications since 1985. The guideline was discussed and accepted in aconsensus conference.
EN by means of ONS is recommended for geriatric patients at nutritional risk, incase of multimorbidity and frailty, and following orthopaedic-surgical procedures. Inelderly people at risk of undernutrition ONS improve nutritional status and reducemortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearlyindicated in patients with neurologic dysphagia. In contrast, TF is not indicated infinal disease states, including final dementia, and in order to facilitate patient care.
Altogether, it is strongly recommended not to wait until severe undernutrition hasdeveloped, but to start EN therapy early, as soon as a nutritional risk becomesapparent.
The full version of this article is available at www.espen.org.& 2006 European Society for Clinical Nutrition and Metabolism. All rights reserved.
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Summary of statements: Geriatrics
Subject Recommendations Grade173 Number
Indications In patients who are undernourished or at risk of
undernutrition use oral nutritional supplementation toincrease energy, protein and micronutrient intake,maintain or improve nutritional status, and improvesurvival.
A 2.1
In frail elderly use oral nutritional supplements (ONS) toimprove or maintain nutritional status.
A 2.2
Frail elderlymay benefit from TF as long as their generalcondition is stable (not in terminal phases of illness).
B 2.2
In geriatric patients with severe neurological dysphagiause enteral nutrition (EN) to ensure energy and nutrientsupply and, thus, to maintain or improve nutritional
status.
A 2.3
In geriatric patients after hip fracture and orthopaedicsurgery use ONS to reduce complications.
A 2.4
In depression use EN to overcome the phase of severeanorexia and loss of motivation.
C 2.6
In demented patients ONS or tube feeding (TF) may leadto an improvement of nutritional status.
2.7
In early and moderate dementia consider ONSandoccasionally TFto ensure adequate energy and nutrientsupply and to prevent undernutrition.
C 2.7
In patients with terminal dementia, tube feeding is notrecommended.
C 2.7
In patients with dysphagia the prevention of aspirationpneumonia with TF is not proven.
2.9
ONS, particularly with high protein content, can reducethe risk of developing pressure ulcers.
A 2.10
Based on positive clinical experience, EN is alsorecommended in order to improve healing of pressureulcers.
C 2.10
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Application In case of nutritional risk (e.g. insufficient nutritionalintake, unintended weight loss 45% in 3 months or 410%in 6 months, body-mass index (BMI) o20 kg/m2) initiateoral nutritional supplementation and/or TF early.
B 2.1
In geriatric patients with severe neurological dysphagiaEN has to be initiated as soon as possible.
C 2.3
In geriatric patients with neurological dysphagiaaccompany EN by intensive swallowing therapy until safeand sufficient oral intake is possible.
C 2.3
Initiate enteral nutrition 3hours after PEG placement. A 3.2
Route In geriatric patients with neurological dysphagia preferpercutaneous endoscopic gastrostomy (PEG) tonasogastric tubes (NGT) for long-term nutritional support,since it is associated with less treatment failures andbetter nutritional status.
A 2.3
Use a PEG tube if EN is anticipated for longer than 4weeks.
A 3.1
Type of
formulaDietary fibre can contribute to the normalisation of bowelfunctions in tube-fed elderly subjects.
A 3.4
Grade: Grade of recommendation; Number: refers to statement number within the text.
Terminology
Geriatric patienta biologically elderly patient who is at acute risk of loss of independence due to acuteand/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 arejeopardised, diminished or lost. The person is in increased need of rehabilitative, physical, psychologicaland/or social care to avoid partial or complete loss of independence.
Elderlya term used to describe a particular age group, i.e. over 65 years.Very old or very elderlya term to describe those over 85 years of age.Frail elderlyFrail elderly are limited in their activities of daily living due to physical, mental,
psychological and/or social impairments as well as recurrent disease. They suffer from multiple pathologieswhich seriously impair their independence. They are therefore in particular need of help and/or care and arevulnerable to complications.
Reduced capacity for rehabilitationThis means that the older the patient, the more difficult it is torehabilitate that patient back to normal or to his/her previous state. Specifically, the restoration ofmuscle mass after illness requires much greater effort in terms of exercise and nutrition in the elderly
compared with the younger patient. It is also implicit that other functions, including mental, are similarlymore resistant to rehabilitation.Functional statusThis term is being used in a general sense to describe global function, e.g. the ability
to perform activities of daily living (ADL), or specific function, e.g. muscle strength or immune function.
Introduction
The risk of undernutrition is increased in elderlypatients due to their decreased lean body mass andto many other factors that may compromisenutrient and fluid intake. Consequently, an ade-quate intake of energy, protein and micronutrients
has to be ensured in each patient independently ofhis/her previous nutritional status. Since restorationof body cell mass (BCM) is more difficult than inyounger persons, preventive nutritional support hasto be considered.
Nutritional care should be integrated appropri-ately into the overall care plan, which takes into
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account all aspects of the patient, personal, social,physical and psychological. A complete assessment ofthe patient should include that of nutritional status orrisk, followed by a nutritional programme reflectingethical as well as clinical considerations. In designingthe programme, it should be remembered that themajority of sick elderly patients require at least 1 g
protein/kg/day and around 30 kcal/kg/day of energy,depending on their activity. Many elderly people alsosuffer from specific micronutrient deficiencies, whichshould be corrected by supplementation.
Oral nutritional therapy via assisted feeding anddietary supplements is often difficult, time-con-suming and demanding in elderly patients (due tomultimorbidity and slow responses). However,assisted oral feeding and supplements are able tosupport the physical and psychological rehabilita-tion of most elderly patients. Therefore, even intimes of declining financial and human resources, it
is unacceptable to initiate tube feeding (TF) merelyin order to facilitate care or save time.Decision making concerning TF in the elderly is
often difficult, and in many cases ethical questionsarise (see Guidelines Ethical and legal aspectsin enteral nutrition). In each case, the followingquestions should be asked:
Does the patient suffer from a condition that islikely to benefit from enteral nutrition (EN)?
Will nutritional support improve outcome and/oraccelerate recovery?
Does the patient suffer from an incurable
disease, but one in which quality of life andwellbeing can be maintained or improved by EN?
Does the anticipated benefit outweigh thepotential risks?
Does EN accord with the expressed or presumedwill of the patient, or in the case of incompetentpatients, of his/her legal representative?
Are there sufficient resources available to manageEN properly? If long-term EN implies a differentliving situation (e.g. institution vs. home), will thechange benefit the patient overall?
Sedation of the patient for acceptance of thenutritional treatment is not justified.
The present guidelines are based on studies inelderly subjects or in those in whom the averageage of the study participants is 65 years or more.
1. What are the aims of EN therapy ingeriatrics?
Provision of sufficient amounts of energy,protein and micronutrients.
Maintenance or improvement of nutritionalstatus.
Maintenance or improvement of function,activity and capacity for rehabilitation.
Maintenance or improvement of quality oflife.
Reduction in morbidity and mortality.
Therapeutic aims for geriatric patients do notgenerally differ from those in younger patientsexcept in emphasis. While reducing morbidity andmortality is a priority in younger patients, ingeriatric patients maintenance of function andquality of life is often the most important aim.Considering the reduced adaptive and regenerativecapacity of the elderly, EN may be indicated earlierand for longer periods than in younger patients.
1.1. Can EN improve energy and nutrient intake
in geriatric patients?
EN (oral nutritional supplement (ONS) and/or TF)increases energy and nutrient intake in geriatric
patients (Ia). Percutaneous endoscopic gastro-stomy (PEG) feeding is superior to nasogastric
feeding in this respect (Ia).
Comment: In a recent Cochrane analysis, ONS ledto an increase in energy and nutrient intake in 29out of the 33 analysed trials which had reportedintake. In three studies no difference in total intakewas found, since patients reduced their voluntaryfood consumption1 (Ia). The success of ONS issometimes limited by poor compliance due to lowpalatability, side effects such as nausea anddiarrhoea, and by cost.210 Variety and alterationin taste (different flavours, temperature andconsistency), encouragement and support by staff,as well as administration between the meals (andnot at meal times) are all important in order toachieve increased energy and nutrient intake.
Randomised controlled trials of TF in patientswith neurological dysphagia that compared naso-gastric (NG) with PEG feeding have shown that93100% of the prescription was administered via
the PEG, versus 55
70% via a NG tube.11,12 In threestudies with supplemental overnight NG TF, be-tween 1000 and 1500 kcal were administered pernight in addition to daily food intake. Total energyand nutrient intake was, therefore, markedlyimproved.1315
1.2. Can EN maintain or improve the nutritional
status of elderly patients?
ONS can maintain or improve nutritional status(Ia). Several studies have shown that TF also
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maintains or improves nutritional paramentersirrespective of the underlying diagnosis. Themetabolic consequences of ageing which can leadto sarcopenia and a severely reduced nutritionalstatus at the time of tube placement can impair oreven prevent successful nutritional therapy (III).
Comment: The administration of ONS has beenreported to have positive effects on nutritionalstatus irrespective of the main diagnosis. Weightloss, during acute illness and hospitalisation, can beprevented by the provision of food of high energyand protein density, combined with between mealsnacks, and by the use of ONS, when normal intakeis insufficient. Sometimes weight gain can even beachieved. Milne et al.1 analysed the percentageweight change in 34 randomised controlled trialswith 2484 elderly patients and showed a meanweight increase of 2.3% (pooled weighted meandifference; 95% confidence interval (CI) 1.92.7%)1
(Ia). Changes to anthropometric parameters areless consistent, but may reflect improvement ofnutritional status in general1 (Ia). Effects on bodycomposition have only occasionally been investi-gated. Increases in fat-free mass (FFM) (Ib)16,17
(IIa)18 and BCM (Ib)19 in supplemented patientshave been reported by some investigators whereasothers could not detect any change (Ib)2022 (IIa)23.
Several observational studies exploring the ef-fect of TF in multimorbid geriatric patients haveshown improvements in nutritional status, e.g.maintenance of body weight2427 (III) and either
maintenance25,27 (III) or increase in albuminlevels24,26,28 (III). It should be emphasised, how-ever, that changes in albumin more usually reflectchanges in disease rather than nutritional sta-tus.29,30 In two studies of frail, mainly dementednursing home residents, weight gain has beenreported.31,32 Improvements in nutritional statushave also been described in patients with neurolo-gical dysphagia, in whom PEG feeding provedsuperior to nasogastric feeding (NGT)11,12 (Ib).The effects of nocturnal TF supplementary to dailyfood intake in elderly patients with hip fracture or
fractured neck of femur, are inconsistent.
1315
Bastow et al.13 have reported the greatest benefitin undernourished patients (Compare 2.4).
The effectiveness of TF on nutritional status maybe limited by compliance with the tubes, and byside effects. The nutritional status of the frailelderly is often very reduced at the time of tubeplacement,2426,3338 and is accompanied by sarco-penia which is more difficult to reverse in the oldcompared with the young.3941 Resistance training,if tolerated, may add to the effectiveness ofnutritional support.9,42 Many tube fed patients are
bedridden, and consequent immobility furtherenhances muscle wasting and prevents gain in leanmass. Weighing is also problematic in thesepatients.
1.3. Does EN maintain or improve functional
status or rehabilitative capacity?
Adequate nutrition is a prerequisite for anyfunctional improvement, although studies aretoo few and diverse to allow a general state-ment. Some studies have been positive and somenegative in this respect.
Comment: Available data concerning the effect ofONS on the functional capacity of elderly patientsare inconsistent, although several studies reportfunctional improvements. Thus, Gray-Donald et al.7
(Ib), observed a significantly lower frequency offalls in supplemented free-living frail elderly
compared with non-supplemented and Unossonet al.43 (Ib) describe a higher activity level inlong-term care residents after 8 weeks of ONS.Improvements in the ability to perform basicactivities of daily living (ADL) are reported in agroup of female patients after hip fracture byTidermark et al.44 (Ib), in a subgroup of severelyundernourished geriatric patients by Potter45 (Ib)and in a subgroup of patients with good acceptanceof a 6 months supplementation by Volkert et al.2
(Ib). Woo et al.46 (Ib) describe a significantlyimproved ADL status in patients during recoveryfrom chest infection after 3-months intervention
compared with the control group. Several studies,however, detected no difference between inter-vention and control groups with respect to inde-pendence in ADL (Ib)19,20,4749 (IIa)6,50. Mobilitywasalso unchanged in several studies (Ib)3,43,47 (IIa)6.Similarly, hand grip strength was unaltered in moststudies (Ib)3,6,7,17,21,5153 (IIa)18 but this may be oflimited relevance as it only tests muscle function ofthe upper body. One randomised trial54 (IIa) as wellas two non-randomised23,55 and one uncontrolledtrial56 (IIb) report an improved hand grip strength insupplemented patients. In four trials, the effects
on mental capacity were assessed and again nochanges were observed (Ib)20,43,52 (IIa)50.At the time of tube placement, geriatric patients
are often in a significantly compromised generalcondition as well as severely functionally im-paired.24,27,36,5759 Trials in nursing homes alsodescribe a high degree of frailty and dependencein PEG-fed residents32,36,6063 (III).
Apart from the fractured femur studies withsupplementary overnight TF (Compare 2.4) onlya few, uncontrolled trials have reported theeffects of TF on either functional status or
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rehabilitative capacity in other groups of elderlypatients.24,33,36,64,65 Callahan et al.24 evaluated 72PEG-fed patients with severe physical and mentalimpairments before and after PEG placement usingseveral ADL scales. Improvements in functionalstatus were only rarely observed (improvement ofinstrumental activities of daily living (IADL) in 6%,
ADL 10%, upper body functions 18%, lower bodyfunctions 29%) (IIb). Kaw and Sekas,36 using theFunctional Independence Measure Scale (FIM), alsofailed to show significant improvements after 18months in functional status in tube-fed nursinghome residents who were in reduced generalcondition (52% demented, 48% completely ADLdependent) (III). Weaver et al.65 used a Quality ofLife Scale adapted from Spitzer, in which orienta-tion, communicative capacity, ability to self-care,and continence were assessed. In a mixed popula-tion of PEG-fed patients (median age 76 years), no
significant change was detected after long-termEN. Relatives of the patients with the lowest valueon the scale tended to answer no to the questionwhether they would wish TF in a similar situationfor themselves (IIb). Nair et al.33 observed nochanges in function measured by the KarnovskyPerformance Scale after 6 months of PEG feeding in31 surviving patients aged 8478 years (IIa). OnlySanders et al.64 describe an improvement in ADL in25 stroke patients (mean age 80 years) with EN viaPEG. At the time of PEG placement 84% of thepatients had a Barthel index (0100 points) of 0points (completely dependent; mean 0.5 points).
After 6 months of EN a mean increase of 4.8 pointswas observed. Six patients (24%) showed a clearimprovement (Barthel index increase from 0.5 to 9points), in 10 patients (40%), however, no or only aminimal improvement was observed (IIa).
1.4. Does EN reduce length of hospital stay?
In geriatric patients, length of hospital stay isdetermined not only by nutritional status butalso by other factors. Available results concern-ing the effect of EN on length of hospital stay areconflicting.
Comment: Undernutrition increases the risk ofcomplications thereby increasing the length ofhospital stay in geriatric patients.6669 Consequently,improvement in nutritional status using EN shouldresult in a reduced length of hospital stay. In geriatricpatients, however, length of hospital stay is not onlydetermined by nutritional status but also by otherfactors, e.g. the assurance of adequate care afterdischarge. In addition, in times of declining financialresources, length of hospital stay is only a poorreflection of the effects of EN.
Available study results about the impact of EN onlength of stay are conflicting. In 2002 Milne et al.70
analysed seven studies with 658 participants andreported a statistically significant benefit of ONSwith respect to hospital stay. Mean length of staywas 3.4 days shorter in the supplemented com-pared with the unsupplemented group (95% CI
6.1
0.7 days) (Ia). The addition of three new trialsto the meta-analysis, however, shifted the resultsto non-significant effects.1 If patients with hip orfemoral neck fracture are regarded separately,several studies report significantly shorter length ofstay in supplemented patients7174; this could nothowever be confirmed by others75 (Compare 2.4)
The effects of TF on length of hospital stay haveonly occasionally been measured11,13,15 and requirefurther study.
1.5. Does EN improve quality of life?
The effect of ONS and TF on quality of life isuncertain.
Comment: Although quality of life is crucial in theevaluation of therapeutic benefit in geriatrics, onlya few studies have examined the effect of EN uponit. Studies investigating the effect of ONS haveemployed different parameters, e.g: general well-being, subjective health, SF 36, EQ-5D, HospitalAnxiety and Depression Scale (HADS). Some reportimprovements (IIa)3,54,76, whereas others observeno changes7,22,51 (IIa). These few available data donot allow any firm conclusion about the effects of
ONS on quality of life.In patients requiring TF, impairments of cogni-
tion, vigilance and speech can make assessingquality of life difficult. About 60% of the patientsin the trial of Callahan et al.24 were unable tocommunicate at the time of PEG placement, andthe majority of patients with preserved ability tocommunicate were cognitively impaired (IIb). Inthe cohort of 215 patients investigated by Banner-man et al.77 data on quality of life could only begathered in 30 patients (IIb). Verhoef and vanRosendaal78 used semi-structured interviews (with
either patients or their relatives), the KarnovskyPerformance Scale as well as the Quality of LifeIndex, in order to measure subjective quality of lifein patients after PEG placement (mean age 66718years). About 85% of the patients who were stillalive after one year and still fed via PEG (n 23)were not able to run a household, 67% weredependent in personal care and 19% were feelingvery ill. However, the majority of patients andcaregivers felt that it had been the right decision toagree to the PEG. All 10 patients who were aliveafter one year and could be asked, stated that they
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would decide in favour of PEG again. The Karnovskyindex deteriorated in three of these 10 survivingpatients and improved in six (IIb). According to theauthors, these results do not necessarily imply aclear improvement in quality of life.78 Weaver etal.65 evaluated subjective quality of life by inter-view and observed a correlation between subjec-
tive and objective quality of life (Compare 1.3).Significant changes in subjective quality of lifewere not detected (IIb). Abitbol et al.26 used both abehaviour scale and a depression scale in order toassess quality of life in 59 institutionalised patients(mean age 85 years) who received EN via a PEG.The patients were bedridden, their health statuswas reduced, and infections were present in 25%.After 3 months of EN via a PEG, quality of lifescores were unchanged, although the depressionscale tended to improve. However, 16 of thesurviving patients (27%) resumed full oral nutrition
and six patients (10%), returned to their own homewith a functioning PEG tube (IIb). In a cohort of 38long-term home EN patients, quality of life waspoorer in elderly than in younger patients.79
All in all, these studies do not allow for anygeneral conclusions about effects of EN on qualityof life. TF may also have side effects that mayadversely affect quality of life, e.g. gastrointest-inal symptoms, aspiration, the discomfort of thetube, or the need to use restraints.
1.6. Does EN improve survival in geriatric
patients?
ONS improve average survival (Ia). In patientswho need TF due to the severity of disease, anincrease in survival is not proven.
Comment: Meta-analysis of the data from 32randomised controlled trials with 3017 partici-pants revealed a lower mortality risk in supple-mented elderly subjects than in controls (relativerisk (RR) 0.74; 95% CI 0.590.92)1 (Ia). Participantswere supplemented for at least 1 week andobserved for at least 2 weeks. A further meta-analysis from 12 randomised controlled trials
(n
1146) and five non-randomised studies on theeffect of ONS in hospitalised geriatric patients withmixed diagnoses reached similar conclusions (RR0.58; 95% CI 0.40.83)80 (Ia). In contrast, a meta-analysis from five studies on the effect of proteinand energy supplementation, mainly in hip fracturepatients, showed no effect on mortality risk.75
Studies on supplementary overnight TF in hipfracture patients have produced similar results(Compare 2.4).
The effect of TF on the survival of elderlypatients without a hip fracture was investigated
in nine non-randomised controlled studies (non-randomised for ethical reasons) (Table 1) and sev-eral uncontrolled observational studies (Table 2).
Four ofthe controlled studieswere carried out inhospitals,33,81,82,84 five in nursing homes.6063,83
Two of the studies were prospective,33,81 and theothers were retrospective comparisons of EN vs. no
EN. In five studies, participants with advanceddementia were investigated.33,61,62,81,84 The mostrecent of these studies was retrospective anddescribes a mean survival of 59 and 60 days in 23severely demented dysphagic patients with PEGand in 18 patients without PEG.84 A databaseanalysis from Mitchell et al.62 in 1386 nursing homeresidents with severe cognitive impairmentwhere 135 were enterally fedshowed no increasein survival (III). Mortality rate after one year wassurprisingly low (15%). Meier et al.81 prospectivelystudied 99 acutely ill patients with advanced
dementia, seventeen of whom were already beingfed by PEG at the time of hospital admission, 51had a PEG inserted in hospital, and the remaining31 consumed regular food orally. Half of all patientsdied during the following 6 months irrespective ofthe nutritional regimen. Nair et al.33 observed ahigher mortality rate in 55 severely dementedpatients with PEG after 6 months compared with acontrol group without a PEG (44% vs. 26%).According to the authors, the groups were com-parable regarding age, gender and comorbidity.PEG patients, however, suffered more often fromsevere hypoalbuminaemia (mean albumin con-
centration 28.675 vs. 33.274g/l in the controlgroup) suggesting more severe underlying inflam-matory disease. The only trial that detecteda significantly reduced mortality in nursing homeresidents with severe cognitive impairment isthe data base analysis from Rudberg et al.61
After 30 days, 15% had died in the group ofenterally fed patients compared with 30% in thecontrol group. After 1 year, the difference wasless distinct, but still statistically significant (50%vs. 61%). The control group was comparableregarding dementia, comorbidity, functional status
and BMI (III).Two further non-randomised controlled studies innursing home patients with various diagnoses and alow percentage of demented patients also failed toshow prolonged survival in the enterally fedpatients.60,63 In the databank analysis from Mitchellet al.63 mortality in 551 tube-fed nursing homeresidents with chewing and swallowing difficultieswas even higher than in 4715 residents withoutnutritional therapy (III). Approximately half of theparticipants showed severe cognitive impairments(66% of tube-fed patients vs. 46% of the control
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Table1
Mortalityintube-fe
delderlysubjects(controlled,
non-ra
ndomisedstudies).
Article
Study
Typeof
EN
Patients
Diagnosis
Mortality(%)
Firstauthor
Type
Place
n
Age(years)
Dementia
(%)
CVE
(%)
CA
(%)
Dysphagia
(%
)
Othercharacteristics
30
6
1
M7SD
Rang
e
day
mon
year
Mitchell62
R(database)
NH
TF
135
87(Md)
(65107)
100severe
47
6
63%instablecondition,
30%decubitus,
33%severe
ADL-dependent,
84%chewingor
swallowingproblems
o5
ca.
15
No
1251
87(Md)
(65107)
100severe
27
7
52%instablecondition,
15%decubitus,
45%severeADL-
dependent,
61%chewingor
swallowingproblems
o5
ca.
15
Meier8
1
P
H
68PEG,
31no
99
84.8
(63100)
100advanced
0
0
Allacutelyill,
56%decubitus,
62%infections
ca.
20
50
65
Nair33
P
H
PEG
55
83710
100advanced
0
0
NoCA,
CVE,
severe
disease,
ENduetoloworal
intake
44
No
33
8078
100advanced
0
0
NoCA,
CVE,
severedisease
26
Rudberg
61
R(database)
NH
NG
353
8577
X65
93cog.
imp.
(63severe)
10
0
100%dysphagia&eating
dependence,
96%dependentin6ADL
15
50
No
1192
8677
X65
93cog.
imp.
(64severe)
10
0
100%dysphagia&eating
dependence,
96%dependentin6ADL
30
61
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Table1(continued)
Article
Study
Typeof
EN
Patients
Diagnosis
Mortality(%)
Firstauthor
Type
Place
n
Age(years)
Dementia
(%)
CVE
(%)
CA
(%)
Dysphagia
(%
)
Othercharacteristics
30
6
1
M7SD
Rang
e
day
mon
year
Mitchell63
R(database)
NH
TF
551
87(Md)
X65
31(66severe
cog.
imp.)
59
7
100%chewingor
swallowingdifficulties,
47%instablecondition,
12%decubitus,
83%severely
ADL-dependent
22
No
4715
87(Md)
X65
50(46severe
cog.
imp.)
30
6
100%chewingor
swallowingdifficulties,
40%instablecondition,
9%decubitus,
46%severely
ADL-dependent
12
Bourdel-
Marchasson
60
R
NH
PEG
58
7479
n.a.
(NH55%)
n.a.
(NH
19%)
n.a.
53
36%anorexia,
10%unconscious,
allseverelydependent,
66%decubitus
14
No
50
8278
n.a.
(NH55%)
n.a.
(NH
19%)
n.a.
44
56%anorexia,
0%unconscious,
allseverelydependent,
14%decubitus
10
Cowen82
R
H
All
149
76712
20
56
0
100
Seriouscomorbidity,
42%hemiplegia,
32%CHF,20%decubitus,
70%alert,
85%urine-incontinent
27
62
PEG
80
60
Spontaneousimprovement
10
No
18
78
No/NG
51
Croghan
83
R
NH
All
40
69
(3196)
25
90
5
83
55%aspiration,
20%mobile
Tube
15
53
No
7
43
ADL
Activitiesofdailyliving,
CA
cancer,CHF
congestiveheartfailure
,cog.i
mp.
cognitiveimpairment,CVE
cerebrovascularevent,EN
enteralnutrition,
H
Hospital,
ONS:oralnutritionalsupplements,
TF
tubefeeding,
EN
enteralnutritio
n(
ONS&TF)Md
Median,
M7SDM
ean7standarddeviation,
mon
months,
n.a.
notavailable,
NG
nasogastrictube,
NH
nursinghome,
PEG
percutaneousendoscopicgastrostomy,P
prospective,
R
retrospective.
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Table2
Mortalityintube-fe
delderlysubjects(observationalstud
ieswithoutcontrolgroup).
Article
Study
type
Typeof
EN
Patients
Diagnosis
Mortality
Firstauthor
n
Age(yr)
(Range)
Dementia
CVE
CA
Dysphagia
Otherchara
cteristics
30day
3mon
6mon
1year
M7SD
(%)
(%)
(%)
(%)
(%)
(%)
(%)
(%)
Nursinghomeresidents
Golden32
R
PEG
102
8976
(71104)
89severe
20
0
100
Persistentd
ysphagia,
low
intake,
75%compl.
ADL-depend
ent,
stablecond
ition,
noterminalstage,
LEatleast
1mon
12
24
38
Abuksis57
R
PEG
47
84711
(44100)
87
49
0
94%desorie
nted,
96%bedridden
4
Kaw36
R
PEG
46
74
(1996)
52
24
7
48%comple
telyADL-
dependent,
only4%could
decideinfavourofPEG
themselves,
poorgeneral
condition
20
50
70%470
Geriatricpatients(all465yrormea
nage465yr)
Lindemann85
P
PEG
36
83
(X65)
100
0
0
11
84%lowint
ake(53%chron,
31%acute),
6%behaviouraldisorder
25
42
Sanders59
R
PEG
103
77
100
0
0
100
allseverely
ADL-dependent
(BI0-5
P)
54
78
81
90
Dwolatzky86
P
PEG
32
8576
(X65)
84
53
3
28
72%refusal
toeat
5
45
NG
90
8279
(X65)
68
43
2
37
63%refusal
toeat
20
80
Abuksis57
R
PEG
67
80716
(26103)
52
30
10
31
79%bedridden,
11%unconscious
29
Paillaud35
R
PEG
73
8379
(X65)
45
4
45
49%anorexia,
30%infection
44%reducedmobility,
44%decubitus
32
52
63
Fay27
R
PEG
80
70.2
32
52
23
79
31%decubitus,
91%inneed
ofassistancein
ADL,
76%fa
ecal-,
90%urine-incontinent
17
55
70
NG
29
69.8
13
41
28
41
21%decubitus,
86%inneed
ofassistancein
ADL,
66%fa
ecal-,
82%urine-incontinent
28
45
70
Callahan24
P
PEG
99
7979
(6098)
35
41
13
35%neuro-degenerative
disorder,se
verephysicaland
mentalimp
airment
22
50
Ciocon25
P
NG
70
82
(6595)
34
47
50%refusal
toeat,
3%oesopha
gus-obstruction,
multiple&
advanceddisease
5
41
Quill87
R
NG/G
55
470
(X70)
31
49
27
69%incomp
etent
Abitbol26
P
PEG
59
8377
50%485
30
2
42
31%MNwit
houtdys,
25%refusal
toeat
54%decubitus,49%pulmonary
infection
25
Bussone88
R
PEG
155
84
(7098)
24
3
35%neurol,
38%depression
16
Bussone89
P
PEG
101
83.6
(7098)
22
36
4
38%depression
14
Markgraf90
R/P
PEG
54
87
(6594)
24
72%neurol,
multimorbid
33
Raha91
?
PEG
161
79
(5399)
81
88
12%MN
20
39
Finucane92
P
PEG
28
82
(6899)
93
100
7%Parkinso
n;
NG-intolera
nt
8
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group) and 83% and 46%, respectively, wereseverely dependent in basic ADLs. The mortalityrate after one year was comparably low in bothgroups (22% and 12%, respectively). Bourdel-March-asson et al.60 (III) reported in a mixed population of108 severely dependent nursing home residents amortality rate of 14% in the PEG group vs. 10% in
the group without nutritional support. Gastroin-testinal and pulmonary complications were also notsignificantly different. The prevalence of dementiain the nursing home was reported to be 55% and ofstroke 19%. Specific prevalence data for the studygroup, however, are not given.
Two trials in dysphagic patients reach differentconclusions. Croghan et al.83 report no differencein mortality between 15 tube-fed and seven orallyfed nursing home residents suffering from aspira-tion, who underwent videofluoroscopic swallowingevaluation mainly because of stroke. Cowen et al.82
(III) recruited 149 severely ill hospital patients withdysphagia and compared the mortality of threesubgroups after one year: Death had occurred in60% of 80 patients who had received a PEG, in 10%of 18 patients who did not receive a PEG becausetheir clinical situation had improved in hospital,and in 78% of 51 patients who did not receive a PEGfor other reasons (28 had refused EN, 12 had diedbefore PEG placement, one patient was transferredto another hospital and 10 patients were fed via aNGT).
The study by Cowen et al.82 is an example of thedifficulty of all non-randomised controlled studies,
i.e. there is a lack of comparability between theintervention and control group. The enterally fedpatients from almost all studies described aboveare probably not comparable with the patients inthe control group. The only exception is the studyfrom Rudberg et al.61 In the studies from Meieret al.81 and Murphy and Lipman84 the groups are notproperly described. In the non-randomised studies,the enterally fed patients obviously differed fromthose patients who did not receive ENfor avariety of reasons. The decision not to use EN isprobably linked to the status of the patients in
some respects. Moreover, the heterogeneity ofgeriatric patient populations provides a multitudeof factors which may influence outcome, e.g. maindiagnosis, comorbidity, nutritional status and gen-eral condition, mood, various functional para-meters including cognition, vigilance, self-careability, mobility and continence which are presentat the same time in different combinations and to avarying extent.
Observational studies reporting mortality ofenterally fed elderly subjects focus on mortalityafter 30 days or after 1 year (Table 2). However,
comparisons between studies are generally difficultdue to the heterogeneous populations involved thatare often not properly characterised. In most of thestudies, between 10% and 30% of the participantsdied after 30 days. Lower mortality rates arereported by Abuksis et al.57 and Dwolatzkyet al.86 mainly in the demented elderly, by
Finucane et al.92 and Horton et al.98 in geriatricpatients with predominantly cerebrovascularevents, and by Ciocon et al.25 in a mixed populationof elderly patients. Extremely high 30 day mortalityrates of 46% and 54% are described by Schneideret al.115 and Sanders et al.59 in the dementedelderly. One year after initiation of EN, mortalityrates between 15% and 90% are reported (Table 2).The highest as well as the lowest mortality rate isreported in demented patients59,62 (Compare 2.7).
Mitchell et al. who performed a meta-analysis ofseven controlled studies on mortality with or
without PEG, draw the conclusion that the impactof TF on survival is not known because the level ofevidence is limited.116 Further studies are neededin groups in whom nutrition may further reasonablybe expected to influence mortality.
2. EN in specific diagnostic groups
2.1. Is EN indicated in patients with under-
nutrition?
Undernutrition and risk of undernutrition repre-
sent essential and independent indications forEN in geriatric patients. ONS is recommended inorder to increase energy, protein and micronu-trient intake, maintain or improve nutritionalstatus, and improve survival in patients who areundernourished or at risk of undernutrition (A).ONS and/or TF are recommended early in
patients at nutritional risk (e.g. insufficientnutritional intake, unintended weight loss 45%in 3 months or410% in 6 months, BMIo20 kg/m2) (B).
Comment: Undernutrition in geriatric patients is
associated with poor outcome. Essential signs ofundernutrition in the elderly are unintended weightloss 45% in 3 months or 410% in 6 months as wellas a BMI below 20 kg/m2. Risk of undernutrition isindicated by loss of appetite, reduced oral intakeand stress (physical as well as psychological).
In a Cochrane analysis of 49 studies including4790 randomised elderly patients with manifestundernutrition or risk of undernutrition, positiveeffects of ONS have been shown: there is increasein energy and nutrient intake, maintenance orimprovement of nutritional status and reduction of
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mortality risk1 (Ia) (Compare 1.1, 1.2 and 1.6).ONS are, therefore, clearly recommended (A).Effects on functionality and quality of life are,however, uncertain (Compare 1.3 and 1.5).
The effects of TF in undernourished elderlypatients are unclear due to limited data. Veryoften TF is not initiated until advanced under-
nutrition has developed, which is a clear impedi-ment to the success of nutritional therapy(Compare 1.2). Results from several studies how-ever, indicate maintenance or improvement ofnutritional parameters in undernourished elderlypatients after TF2426 (III). Effects on functionalstatus and quality of life are uncertain (Compare1.3 and 1.5).
It is highly recommended to initiate nutritionalsupport, not only in manifest undernutrition, but assoon as there are indications of nutritional risk, andas long as physical activity is possible, EN
together with rehabilitative exercise
can help tomaintain muscle mass (C). Early routine nutritionalscreening is mandatory. Several tools (e.g. ESPENguidelines,117 MNA118) are available for this pur-pose.
2.2. Is EN indicated in frail elderly?
In frail elderly, ONS are recommended in order toimprove or maintain nutritional status (A).
Frail elderly may benefit from TF as long as theirgeneral condition is stable (not in terminal
phases of illness). TF is therefore recommended
early in case of nutritional risk (B), wherenormal food intake is insufficient.
Comment: Frail elderly are limited in their ADL dueto physical, mental, psychological and/or socialimpairments a well as recurrent disease. Theysuffer from multiple pathology which seriouslyimpairs their independence. Therefore they are inparticular need of help and care and are vulnerableto complications. An inadequate intake of fluidsand nutrients is a common problem in thesesubjects. Frail elderly therefore are at high risk ofundernutrition and its serious consequences. Ex-
perience has shown that the ability to eat sufficientamounts orally is inversely associated with theextent of frailty. Decreasing oral intake maytherefore be an indication of the progress orseverity of disease or frailty.
ONS lead to a significant increase in energy andnutrient intake as well as to a stabilisation orimprovement of nutritional status in mixed samplesof multimorbid elderly with acute and/or chronicdiseases, at home as well as in nursing homes andhospitals (Table 3). Effects on functional status andquality of life are uncertain due to limited data.
Effects on length of hospital stay and mortalityhave been investigated only occasionally. Potter etal.127 found a reduced length of hospital stay onlyin a subgroup of patients with adequate initialnutritional status. Data on mortality are contro-versial in frail elderly.8,127
Clinical experience shows that frail elderly, at
nutritional risk, may benefit from TF as long as theirgeneral condition is stable. Observational studiesindicate a relatively good prognosis in tube-fed frailelderly nursing home residents with good healthstatus32,57 (III) (Table 2). Although data are scarce,it is recommended that nutritional support beinitiated early, as soon as there are indications ofnutritional risk and as long as physical activity ispossible since ENtogether with rehabilitativeexercisecan help to maintain muscle mass (C).Nutritional screening has to be implemented as amatter of routine for early detection of risk of
undernutrition. Several tools (e.g. ESPEN guide-lines,117 MNA118) are available for this purpose.TF is not recommended in frail elderly who have
progressed to an irreversible final stage, e.g. withextreme frailty and advanced disease (irreversiblydependent in ADL, immobile, unable to commu-nicate, as well as high risk of death) (IV).
2.3. Is EN indicated in geriatric patients with
neurological dysphagia?
In geriatric patients with severe neurologicaldysphagia, EN is recommended in order to
ensure energy and nutrient supply and, thus, tomaintain or improve nutritional status (A). Forlong-term nutritional support PEG should be
preferred to NGT, since it is associated with lesstreatment failures, better nutritional status (A),and it may also be more convenient for the
patient. In patients with severe neurologicaldysphagia TF has to be initiated as soon as
possible (C). EN should accompany intensiveswallowing therapy until safe and sufficient oralintake from a normal diet is possible (C).
Comment: In neurological dysphagia, nutritional
therapy depends on the type and extent of theswallowing disorder. Nutritional therapy may rangefrom normal food, to mushy meals (modifiedconsistency), thickened liquids of different consis-tencies or total EN delivered via NGT or PEG.Nutritional therapy and swallowing therapy have tobe closely coordinated. Typical complications ofneurological dysphagia are aspiration with bronch-opulmonary infections136139 and undernutrition,causing extended length of hospital stay andrecurrent hospitalisations.139141 Mortality due todysphagia is significantly enhanced.139 Patients
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Table3
Oralsupplementatio
ninmixedcohortsoffrailelderly.
Article
Study
type
Patients
Supplements
Results
Firstauthor
n
Age(yr)
Nutritional
Place
Energy
Protein
Duration
Intake
N
utritionalstatus
Functional
status
Quality
oflife
M7SD
(range)
status
(kcal/d)
(g/d)
E
Prot
Chandra
119
RCT
30
(7084)
MN
Athome
Individ.
n.a.
4wks
n.a.
n.a.
W
eight+
T
SF+
A
lb,
PA+
immuneresponse+
n.a.
n.a.
Gray-Donald7
RCT
50
78
BMI1973
Athome
500700
1726
12wks
(+)
n.a.
W
eight+
s
kinfolds
A
MC,
CC
Handgrip
falls+
Well-
being
subjective
health
(460)
Payette
3
RCT
83
8077
BMI2073
Athome
500700
1726
16wks
+
(+)
W
eight+
s
kinfolds
A
MC,
CC
Handgrip
mobility
daysinbed+
Emotional
role
functioning+
(465)
Volkert
2
RCT
46
85
MN
Athome
250
15.0
6mon
n.a.
n.a.
W
eight
ADL+(incompliant
subgroup)
n.a.
(7598)
BMI1972
Woo
46
RCT
81
73
BMI2075
Athome
500
17.0
1mon
+
+
W
eight+(m)
f
atmass+
F
FM+(m)
ADL+
activity+
mentalfunction
appetite
sleep+
n.a.
(465)
Wouters22
RCT
68
82
BMI2472
Nursing
home
250
8.8
6mon
+
+
w
eight+
F
FM,
FM,
CC
A
lb,
PA
Handgrip
ADL
mobility
sleep+
(X65)
Wouters120
RCT
55
83
BMI2472
Nursing
home
250
8.8
6mon
n.a.
n.a.
V
it.
C,
E,
Cysteine+
A
ntiox.
capacity+
n.a.
n.a.
(X65)
Banerjee
121,
122
RCT
63
81
n.a.
Nursing
home
265
18.6
14wks
+
T
SF+
A
lb,
Trf,
PA
%
T-Lymphocytes
C
omplementC3
Skinproblems+
n.a.
(6098)
Beck123
RCT
16
85
BMI20(M)
Nursing
home
380
5.0
2mon
n.a.
w
eight
n.a.
n.a.
(6596)
MNA1723,5
Ek124
RCT
482
80
28.5
%MN
Nursing
home
400
16.0
26wks
n.a.
n.a.
S
kintest+
n.a.
n.a.
Fiatarone
20
RCT
50
8871
BMI
25.5
(M)
Nursing
home
360
15.0
10wks
n.a.
W
eight+
F
FM
FM(+)
A
lb,
Fe,
HDL
V
it.
D,
E,
Folate
ADL
depression
mentalfunction
n.a.
(470)
Hankey
125
RCT
14
8172
weight
45kg,
Alb
33g/L
Nursing
home
680
n.a.
8wks
+
n.a.
w
eight(+)
T
SF,AMC
+
Albumin
n.a.
n.a.
(475)
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Table3(continued)
Article
Study
type
Patients
Supplements
Results
Firstauthor
n
Age(yr)
Nutritional
Place
Energy
P
rotein
Duration
Intake
N
utritionalstatus
Functional
status
Quality
oflife
M7SD
(range)
status
(kcal/d)
(g/d)
E
Prot
Larsson
8
RCT
435
80
29%MN
Nursing
home
400
1
6.0
26wks
n.a.
n.a.
n.a.
n.a.
Lauque
53
RCT
35
85
BMI2271
Nursing
home
300500
2
030
60days
+
+
W
eight+
Handgrip
MNA+
n.a.
(465)
MNA
17-2
3.5
Unosson
43
RCT
430
80
26%MN
Nursing
home
400
1
6.0
26wks
n.a.
n.a.
n.a.
Activity+,
mobility
mentalfunction
generalwell-being
n.a.
Hubsch19
RCT
72
86
MN
Hospital
500
3
0.0
3wks
+
+
W
eight
FFM
BCM+
A
lb,
Trf,
RBP
V
it.
B1,
C+
ADL(+)
n.a.
(7599)
McEvoy126
RCT
51
n.a.
MN
Hospital
644
3
6.4
4wks
n.a.
n.a.
W
eight+
T
SF+,
A
MC
A
lb
n.a.
n.a.
Potter127
RCT
381
83(Md)
Non-o
bese
hospital
540
2
2.5
Hospital
(Md17days)
+
n.a.
W
eight+
A
MC(+)
ADL+(MN)
n.a.
(6199)
Bunker1
28
NRT
58
80
BMI
24.4
(M);
Athome
200(in
under-
weight
patients
300)
2
0.0
12wks
n.a.
n.a.
A
lb,
PA
,RBP+
Fe,
Zn,
Se+
ly
mphocyte-populations
skintest(+)
n.a.
n.a.
(7085)
19%o20
Cederholm55
NRT
23
7471
MN
Athome
400
4
0.0
3mon
n.a.
n.a.
W
eight+
T
SF,
A
MC+
A
lb,
Orosomucoid
skintest+
Handgrip+
peakflow
n.a.
BMI17(M)
Bos1
8
NRT
23
79
MN
Hospital
400
3
0.0
10days
+
+
W
eight+
FFM+
A
lb,
Trf,
PA
C
RP,IGF-I
Im
munglobulin
C
omplementC3
Handgrip(+)
n.a.
(6990)
BMI
2173
Bourdel-M.1
29
NRT
672
83
Alb3275
Hospital
400
3
0.0
15days
+
+
n.a.
Decubitus(+)
n.a.
(465)
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Chandra
130
UCT
21
460
MN
Athome
500
17.5
8wks
n.a.
n.a.
A
lb,
PA,
Trf,
RBP+
Z
n+,
F
erritin
s
kintest+
lymphocyte
p
opulations+
n.a.
n.a.
Gray-Donald131
UCT
14
7976
MN
Athome
500
KA
12wks
+
+
A
lb(+),RBP,
H
b
lymphocyte
c
ount+
Handgrip
Well-
being+
(460)
Lipschitz132
UCT
12
75
Highrisk
Athome
1050
39.0
16wks
+
+
W
eight+
A
lb,
TIBC,
Vit.
+
H
b,
metals
lymphocytecount
s
kintest
n.a.
n.a.
Harrill133
UCT
18
89(Md)
n.a.
Nursing
home
355
13,0
30days
(+)
(+)
V
it.
A,
C,
B1,
B2+
A
lb,
Hb,
Ht,Fe
n.a.
n.a.
Welch134
UCT
15
81
Alb32g/L
Nursing
home
n.a.
n.a.
6mon
+
+
W
eight+
A
lb,
Hb,
Ht+
F
e,
TIBC,
Trf
Decubitus+
n.a.
Bourdel-M.2
3
UCT
11
87
MN
Hospital
400
30.0
4wks
W
eight+
m
usclemass
A
lb+
Handgrip+
n.a.
BMI1873
Joosten135
UCT
50
8376
BMI24.5
74
Hospital
600
19.0
1376days
+
n.a.
n
.a.
n.a.
n.a.
Alb3676g/
L
Katakity
56
UCT
12
(7184)
n.a.
n.a.
204
9.0
12wks
n.a.
n.a.
H
b
V
it.
C,
D,
B1
Handgrip+
mentalfunction
darkadaption
n.a.
ADL
activitiesofdailyliving,A
lb
albumin,
AMC
arm
muscle
circum
ference,
Antiox.
antioxidative,
BCM
bodycellmass,
BMI
body-massindex
[Kg/m
2],CC
calf
circumference,
CRP
C-reactivep
rotein,
E
energy,Fe
iron,
FFM
fatfreemass,
FM
fatmass,
Hb
hemoglobin
,Ht
hematocrit,n.a.
notavailable,M
Mean,
(m)
male
participants,
Md
median,
MN
malnutrition,
MNA
MiniNutritionalAsses
sment,mon
months,NRT
non-random
isedtrial,PA
prealbumin,
Prot
protei
n,
RCT
randomised
controlledtrial,RBP
Retinolbin
dingprotein,
Ref.
reference,
SD
standarddeviation,
Se
Selen,
TIBC
totali
ronbindingcapacity,TSF
Tricepsskinfo
ld,
Trf
Transferrin,
UCT
uncontrolledtrial,Vit.vi
tamin,
wks
weeks,Zn
Zinc.
+improvementinsupplementedgr
oup(SG)comparedtocontrolgroup(CG).
(+)trendtowardsimprovement,n
otsignificant;
nodifferenceSGCG.
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with acute stroke and dysphagia often alreadyexhibit a poor nutritional status on hospital admis-sion, which negatively impacts on outcome andcosts: length of hospital stay is extended, rehabi-litation is delayed and survival is reduced.141143
These results are confirmed by the current inter-national FOOD study.144
Controlled trials studying the effects of EN afterdysphagic stroke are not available, since controlgroups without nutritional support would be un-ethical. It is common sense, however, that energyand nutrient supply has to be ensured in thesepatients in order to maintain nutritional status andto avoid the development of undernutrition. Due tothe strong physiological plausibility based on thefact that patients with severe neurological dysphy-gia are not able to sustain their life withoutnutritional support, this recommendation wasrated at the highest level.
Nutritional status: In a Cochrane analysis ofinterventions for dysphagia in acute stroke ENdelivered via PEG was associated with a greaterimprovement of nutritional status when comparedto EN delivered via NGT.145 These results are basedon a randomised controlled trial conducted byNorton et al.11 (Ib) in 30 patients and on unpub-lished data from the authors of the Cochraneanalysis from 19 further patients. In anotherrandomised controlled trial in 40 patients withneurological dysphagia (mean age 60 years), thegroup receiving PEG also exhibited weight gain aswell as an increase in mean serum albumin and
transferrin. Due to a high drop out rate noevaluation was undertaken in the NGT group12 (Ib).
Functional status: Sanders et al.64 reported animprovement in ADL in 25 stroke patients (meanage 80 years) with EN via PEG (PEG placement onaverage 14 days after stroke). At the time of PEGplacement Barthel index was 0 points (completelydependent) in 84% of patients (mean 0.5 points).After 6 months of EN a mean increase of 4.8 pointswas observed. Six patients (24%) showed a clearimprovement (Barthel index increase from 0.5 to 9points). In 10 patients (40%), however, no or only a
minimal improvement was observed (IIa).Resuming oral nutrition: Dysphagia may bereversible in stroke patients.146 In various studiesbetween 4% and 29% of patients resumed full oralnutrition after 431 months11,92,93,95,112,115 (III)(Table 4). In the British Artificial Nutrition Survey(BANS) no difference between 65- and 75-year oldelderly people and younger adults (1664 years)was found, although resumption of oral nutritionwas slightly reduced in the elderly above the age of75 years112 (Table 4). Schneider et al.115 report therate of resuming oral nutrition in different diag-
nostic groups of tube-fed patients at home. Among148 neurological patients with dysphagia (mean age75 years), 24% regained the ability to eat sufficientamounts orally within the study period of 2427494days.
Mortality: Clear statements about the effect ofEN on overall mortality after dysphagic stroke are
not possible since the investigated groups are tooheterogeneous, and control groups without nutri-tional support would be unethical (Compare 1.6).In the study of Norton et al.11 mortality after 6weeks was significantly lower in the PEG group thanin the group fed by NGT (12% vs. 57%), due probablyto the lower percentage of the prescribed intakereached in the latter. In the recent multicentreFOOD trial147 no difference in 6-month mortalitywas found between 162 dysphagic stroke patientswith PEG and 159 patients with NGT. However,these results are of limited value since only those
patients were enrolled in whom the responsibleclinician was uncertain of the best feeding practice.Furthermore the duration of the intervention isunclear and there was a greater delay to first TF inthe PEG group than in the nasogastic group. Becauseof these methodological problems, results of theFOOD trial have to be interpreted with caution.
Timing of tube placement: In patients withsevere neurological dysphagia, TF has to beensured immediately unless there are compellingreasons against it. Studies investigating the role ofearly TF after acute cerebrovascular events in age-mixed samples have shown that early TF is feasible
also in elderly patients148,149 and has a positiveimpact on survival148 and length of hospital stay144
(III). In a retrospective analysis of stroke patients(19% of patients 465 years) by Nyswonger andHelmchen,149 the group receiving TF within 72 hafter the cerebrovascular event had a reducedhospital stay compared to patients that received TFafter 72 h (III). Taylor148 found that patients, whohad spent less than 5 days without nutrient supply,had a lower mortality than patients who had morethan 5 days without nutrition. Interestingly, thisdifference was statistically significant only in
patients aged 465 years and was less distinct inyounger patients. The authors conclude that olderpatients react more sensitively to food deprivationthan younger patients and that TF should beinitiated as early as possible in this group (III).
In the recent multicentre FOOD trial147 nodifference in outcome was found between dyspha-gic stroke patients who received EN via a PEGwithin 7 days of hospital admission and anothergroup in whom TF was avoided for at least 7 days.Again, these results are of limited value because ofmethodological problems (see above).
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Table4
Resumingoralnutritionafterenteralnutritioninelderly
patients.
Article
Study
Patients
TypeofEN
Proportion
resumingfull
oralnutrition(%)
Timeperiod
Firstauthor
Type
Place
n
Ag
e(yr)
Proportionof
elderly
M7SD
(Range)
Neurologicdysphagia
Finucane92
P
Hospital
28
82
(6899)
PEG
4%
6months
Elia112
P
Athome
2970
(X75)
EN
10%
12months
Elia112
P
Athome
1230
(6575)
EN
15%
12months
Norton11
P
Hospital
16
76
PEG
19%
6months
Schneider115
P
Athome
148
75
(Md)
(197)
EN
24%
4months(M)
Wijdicks95
R
Hospital
63
74
(Md)
(4198)
PEG
28%
236months
(Md4months)
James93
R
Hospital
126
80
(Md)
(5394)
PEG
29%
471months
Mixedcohorts
(Md31months)
Quill87
R
Hospital
55
470
(X70)
51%480y
r
NG
4%
Clarkston96
R
Hospital
42
71
.4
(3399)
PEG
7%
2months
Dwolatzky86
P
Hospital
122
(X65)
PEG/NG
8%
3months
Markgraf103
R
Hospital
84
69
714
(3598)
65%X65y
r
PEG
12%
14229days
(M108days)
Markgraf90
R/P
Hospital
54
87
(6594)
PEG
13%
14229days
(M133days)
Bussone88
R
Hospital
155
84
(7098)
PEG
14%
Larson100
R
Hospital
314
(392)
66%460y
r
PEG
14%
Skelly58
P
Hospital
74
69
(Md)
(2890)
PEG
15%
6months
Tan109
R
Hospital
44
65
(1494)
PEG
16%
144months
Howard113
R
Athome
887
79
78
(X65)
EN
17%
12months
Nicholson104
R
Hospital
168
70
(Md)
(1696)
PEG
21%
4months(Md)
Wolfsen111
R/P
Hospital
201
66
716
PEG/PEJ
21%
2757353days
(Md144days)
Sali107
R
Hospital
32
75
(3888)
PEG
22%
28months
Mitchell63
R
Athome
551
87
(Md)
(65107)
TF
25%
12months
Taylor110
P
Hospital
97
76
.5
(o197)
PEG
25%
1day7yr
(Md327days)
Abitbol26
P
Hospital
59
83
77
50%485y
r
PEG
27%
12months
Verhoef78
P
Hospital
71
66
718
(1789)
PEG
28%
12months
EN
enteralnutrition,
M
mean,
Md
Median,
NG
nasogastrictube,
P
prospective,
PEG
percutaneousendoscopicgastrostomy,PEJ
percutaneousend
oscopicjejunostomy,
R
retrospective,
SD
standarddeviation,
TF
tubefeeding,
yr
years.
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Table5
Supplementaryover
nighttubefeedinginelderlyfracture
patients.
Article
Patients
Supplement
Results
Firstauthor
n
Age
(yr)
Diagnosis
Energyand
protein/day
Duration
Intake
Nutritionalstatus
Clinicalcourse
Bastow13
58CG
80
Femurneck
+1000kcal
1639days
Tota
lintakem
Anthropometrym
ADL
64SG
81
fracture&
malnutrition
+28gprot
Md26days
Foodintake
Proteinsm
LORk
LOSk
Mo
rtality(k)
Hartgrink14
67CG
8378
Hipfracture&riskof
pressuresores
+1500kcal
7and14days,
resp.
mDespitelow
tole
rance
Intendedtofeed:
Alb,
TP
Pre
ssuresores
only40%tolerated
tub
e41wk
62SG
8477
+60gprot
Actuallyfed:
Albm
,TPm
Sullivan15
10CG
7776
Hipfracture&good
nutritionalstatus
+1383kcal
1676days
m
Alb,
transferrin
Complications
8SG
7572
+86gprot
ADL
LOS
In-hospital
mo
rtality
6-m
onthsmortalityk
ADL
activitiesofdailyliving,
Alb
albumin,
CG
controlgroup,
LORlengthofrehabilitation,
LOS
lengthofstay,Md
median,
prot
protein,
SGS
upplementedgroup,
TP
totalprotein,
yr
years.
m
increase,
k
decrease(orimprov
ementinthesupplmentedgroupcomparedtothecontrolgroup);
nodifference
betweenthegroups.
Meanormean7standarddevia
tion.
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In earlier studies, long periods of 4463 daysbetween the acute event and PEG placement arenoticeable.91,93,107 Three studies on the naturalcourse of dysphagia after stroke show that sponta-neous remission of the swallowing difficulty occurs714 days after the acute event in 7386%.150152
Based on clinical experience, prognosis of dyspha-
gia seems to be better in medial cerebral infarctthan in brain stem infarct (IV). If severe dysphagiapersists longer than 14 days after the acute event,a PEG should be placed immediately. Controlledtrials on the ideal timing and length of TF inneurological dysphagia, that also consider thevarying kinds and extents of swallowing disorders,are still not available.
2.4. Is EN indicated after orthopaedic surgery in
geriatric patients?
ONS are recommended in geriatric patients after
hip fracture and orthopaedic surgery in order toreduce complications (A).
Comment: Voluntary oral intake is often insuffi-cient to meet the enhanced requirements ofenergy, protein and micronutrients after orthopae-dic surgery. Rapid deterioration in nutritionalstatus, and impaired recovery and rehabilitationare common.
The results of several randomised studies of ENafter hip fracture are summarised in a Cochraneanalysis75 that includes eight trials testing supple-mentary overnight TF, five trials with ONS and three
studies regarding the effects of supplementary oralprotein. The quality of most of the studies and theavailability of outcome data were considered poorby the authors of the Cochrane analysis.75 Inaddition, a recent randomised controlled study153
and two non-randomised trials with ONS areavailable.4,6,154
Energy and nutrient intake: Administration ofONS leads to a significant increase in energy andnutrient intake.75 However, several trials71,74,155
have shown that the daily requirements for energyand protein are still not met. This may be due to
poor compliance of less than 20%,7
to intolerance ofsupplements by some patients,155 and to require-ments being markedly increased.
Supplementary overnight TF enables the admin-istration of larger amounts of enteral formu-lae,1315 but is of limited tolerance in practice. Inthe trial of Hartgrink et al.14 only 40% tolerated thisintervention longer than 1 week and only one-quarter for the whole study period of 2 weeks.
Nutritional status: Information about the effectsof ONS on nutritional status is sparse and incon-sistent. Delmi et al.71 observed a larger increase in
albumin and transferrin levels in supplementedpatients than in the unsupplemented control group(Ib), whereas Lawson et al.154 and Williams et al.6
detected no difference with respect to serumalbumin (IIa). In the study of Lawson et al.154 BMIand mid-arm muscle circumference (MAMC) werealso unaffected, however transferrin and haemo-
globin decreased less than in the unsupplementedgroup. Williams et al.6 reported a positive effect ontriceps skinfold thickness (TSF) and MAMC in thesupplemented group. In contrast Tidermark et al.44
registered weight loss, and Brown and Seabrock74
observed decreases in body weight, mid-armcircumference (MAC) and TSF in the supplementedas well as in the control group.
Positive effects of protein supplementation onbone density and parameters of bone metabolismwere described by Tkatch et al.72 and Schurchet al.73 (Ib). A 6-month administration of protein-
enriched supplements led to a significant attenua-tion of loss of bone mineral density when comparedto the control group. Even short-term supplemen-tation (o40 days) was accompanied by a smallerdecrease in proximal femur bone mineral densitythan in the unsupplemented group. However, otherskeletal sites were unaffected. Moreover, proteinrepletion was shown to be associated with anincrease in serum osteocalcin72 and insulin-likegrowth factor-I,73 both of which are importantmediators of bone metabolism.
The effect of supplementary overnight TF onnutritional status of elderly patients with either
hip or femoral neck fracture was investigated inthree randomised controlled studies1315 (Ia)(Table 5). Initial nutritional status as well as resultswere inconsistent. Clear improvements were re-ported by Bastow et al.13 who divided theirpatients into thin and very thin according toanthropometric measurements. In both interven-tion groups (thin and very thin), anthropo-metric parameters (body weight, TSF, MAC)and postoperative prealbumin increased during1639 days. Very thin patients had the greatestbenefit from the nutritional therapy. No change in
serum albumin was observed in the study ofHartgrink et al.14 in 62 patients intended to receivesupplementary TF. An evaluation of the actuallytube-fed patients however (n 25 after 1 week,n 16 after 2 weeks), revealed increased serumconcentrations of albumin and total protein. Noeffects on plasma proteins were reported in thestudy of Sullivan et al.15 who examined patientswith a relatively good nutritional status (BMI24.1kg/m2, albumin 32 and 35 g/l, respectively),with respect to albumin, transferrin and cholester-ol values.
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Length of hospital stay: Data concerning thelength of hospital stay are inconsistent. Delmi etal.71 found a significantly shorter length of hospitalstay (including rehabilitation) in patients receivingONS (median 24 days) compared to control patients(median 40 days) (Ib). Protein administration in thetrials of Tkatch et al.72 and Schurch et al.73 was
also associated with a significantly reduced lengthof stay (30 and 21 days, respectively). In five otherstudies, however, the observed differences werenot significant.44,75
A positive impact ofsupplementary overnight TFon the length of hospital stay of geriatric patientsafter hip or femur neck fracture cannot be firmlyconcluded from the data available.1315
Functional status: Data regarding functionalstatus are heterogeneous and unsatisfactory. TheCochrane analysis of Avenell and Handoll75 refers tofour studies investigating this aspect. Only one of
them showed positive effects of ONS on ADL-functions after 6 months.44 The non-randomisedtrial of Williams et al.6 showed a trend towardsimproved mobility and greater independence athospital discharge in supplemented patients. Oralsupplementation of calcium, protein and vitaminsin the study of Espaulella et al.47 showed nosignificant changes in mobilisation, ADL status anduse of walking aids when compared to the controlgroup receiving an isocaloric placebo as well.
Bastow et al.13 assessed the time between thepatient0s operation and the achievement of phy-siotherapy goals (e.g. recovering independent mobi-
lity). Thin patients (according to anthropometricmeasurements; see above) receiving supplementaryovernight TF, achieved independent mobility in 10days, while thin control patients did so in 12 days.Very thin patients from the intervention groupreached this goal after 16 days whereas very thincontrol patients needed 23 days to regain indepen-dent mobility (Po0:05) (IIa). ADL status at discharge,however, was not affected by the intervention.13
Postoperative complications and mortality: ONShave a positive impact on the rate of postoperativecomplications. Thus, Lawson et al.154 in their
recent non-randomised study found a significantlylower rate of complications in post-operativelysupplemented orthopaedic patients than in thoseunsupplemented (IIa). In the study of Tkatch etal.72 the complication rate in protein supplementedpatients was significantly lower during hospitalstay, as well as 7 months later, compared to thecontrol group with isocaloric placebo. The pooledanalysis of five randomised studies in the meta-analysis of Avenell and Handoll75 revealed aborderline reduction of the risk of complicationsin supplemented patients (RR 0.61, 95% CI
0.361.03). When risks for mortality and complica-tions were combined in these five studies, thechances of an unfavourable outcome were reducedin supplemented patients (RR 0.52, 95% CI0.320.84)72 (Ia).
If mortality was considered separately in themeta-analysis of five studies with ONS, no reduction
in mortality risk was found.75 The same was true inthe study of Espaulella et al.47 Combining mortalityoutcome of all the studies with supplementaryovernight TF did not produce a significant riskreduction either (RR 0.99; 95% CI 0.51.97).75 Thepooled analysis of studies using ONS or overnight TFin geriatric patients with either hip or femoral neckfracture also did not show a significant reduction ofmortality risk in the enterally fed patients whencompared to controls (RR 0.94; 95% CI 0.591.50).75
2.5. Is EN indicated in the perioperative phase of
major surgery in geriatric patients?There is no evidence that nutritional therapy inelderly patients undergoing major surgery (e.g.
pancreatic surgery, head and neck surgery)should be different from that in younger pa-tients. We therefore refer to the Guidelines.Surgery and transplantation.
It is generally recognised, however, that elderlyare at higher risk of being undernourished thanyounger patients and restoration of BCM is moredifficult. Therefore, preventive nutritional supporthas to be considered.
2.6. Is EN indicated in elderly patients with
depression?
EN is recommended in depression in order toovercome the phase of severe anorexia and lossof motivation (C).
Comment: Depression is common in elderly pa-tients, but often not recognised due to thedifficulty of discriminating it from other symptomsof old age. Anorexia and refusal to eat are integralsymptoms of this disease, and depression is there-
fore regarded as a major cause of undernutrition inthe elderly.156 Undernutrition may itself contributeto the depressive states often seen in theelderly.157 Depression can be treated by severalmethods, especially by drugs, although this maytake some time to be effective. Based on positiveclinical experience and expert opinion, EN isrecommended in the elderly suffering from depres-sion in order to support the patient during the earlyphase of severe anorexia and loss of motivation,thereby preventing the development of under-nutrition with its serious consequences (C).
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Table6
Prevalenceofaspira
tionpneumoniaintube-fedelderlyp
atients.
Firstauthor
Stud
ytype
Patients
Aspi
rationpneumonia(AP)
n
Age
(years)
Diagnos
es
Befo
re
After
Timeperiod
Patel160
P
24
72
CVE,
CA,
dementia
58%
14/24(58%)(all)
UntilAPordeath
12/14(86%)(withAP)
Paillaud35
R
73
8379
Mixed
15%
53%
2,
6,
12months
Sali107
P
32
75
Mixed
9%
3/5(60%)deathsduetoAP
2488days
Abitbol26
P
59
8377
Nursing
homeresidents
49%
51%
30days
Baeten161
P
90
72
CA,
neu
rologicaldisease
6%
12months
Wijdicks95
P
63
74
Apoplex
16%
Hospitalstay
Peschl151
P
33
76
Cerebraldysfunctions
18%
236months
Kaw36
R
46
74
Neurolo
gicaldisease,
dementia
22%
6months
Stuart108
R
125
70
CA,
dem
entia,
cachexia
28%
12,
18months
Bourdel-Marchasson60
R
46
8179
Mixed
39%
30days
Fay27
R
80
70
Apoplex,
dementia,
PEG
6%/32%
14/192days
29
70
Parkinson
NG
24%/46%
14/141days
Golden32
R
102
8976
dementia
51%
6months
AP
aspirationpneumonia,
CA
carcinoma,
CVE
cerebrovascularevent,
NG
nasogastrictube,
P
prospective,R
retrospective.
Meanormean7standarddevia
tion.
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2.7. Is EN indicated in dementia?
ONS or TF may lead to an improvement innutritional status in demented patients. In earlyand moderate dementia ONSand occasionallyTFmay contribute to ensuring an adequateenergy and nutrient supply and to preventingundernutrition from developing; they are there-
fore recommended (C). In those with terminaldementia, TF is not recommended (C). Thedecision in each case must be made on anindividual basis.
Comment: An indequate intake of energy andnutrients is a common problem in dementedpatients. Undernutrition may be caused by severalfactors including anorexia (common cause: poly-pharmaco-therapy), insufficient oral intake (for-getting to eat), depression, apraxia of eating or,less often, enhanced energy requirement due tohyperactivity (constant pacing).158 In advancedstages of dementia, dysphagia may develop andmight be an indication for EN in a few cases.
Some studies with ONS have shown improve-ments in body weight (Ib)49,159 (IIa)50. In tube-feddemented elderly patients, two studies reportedweight gain31,32 (III), but two others reported nochange (III)24 (IIb)86. Available trials regarding theeffects of ONS (Ib)49 (IIa)50 or TF24,33,36 onfunctional status, report no improvement (Com-
pare 1.5). In terms of survival most studies show nobenefit.33,81,84,94 On the other hand, Rudberg etal.61 described lower mortality, compared to con-
trols, at 30 days and 1 year in enterally fed patientswith severe cognitive impairment (IIb). Very lowmortality rates have been reported in PEG-feddemented nursing home residents.32,57,62 On theother hand, in one retrospective study comparingmortality rates in different diagnostic groups,outcome was worst among the demented59 (III).
In conclusion, tube-fed demented patients varyconsiderably with respect to their prognosis. Out-come and also the success of nutritional therapy indemented patients are strongly influenced by theseverity of disease, the kind and extent of
comorbidities and by their general condition. It istherefore recommended that adequate and highquality nutrition is ensured, especially in the earlyand middle stages of dementia, in order to preventundernutrition developing and to help maintain astable general condition (C).
TF may be useful in some demented patients.The following aspects have to be considered indecision-making:
presumed or previously expressed wishes of thepatient with respect to TF;
severity of the disease; the individual prognosis and life expectancy of
the demented patient; the anticipated quality of life of the patient with
or without TF; the anticipated complications and impairments
due to TF;
the mobility of the patient.
The decision for or against TF has always to bemade individually and together with relativesand care givers, legal custodian, family doctorand therapists, and in case of doubt, with legaladvice.
For patients with terminal dementia (irreversi-ble, immobile, unable to communicate, completelydependent, lack of physical resources) TF is notrecommended (C).
2.8. Is EN indicated in geriatric patients withcancer?
In principal, nutritional therapy in geriatricpatients with cancer does not differ from young-er cancer patients (see Guidelines on Non-surgical oncology).
Comment: It is generally recognised, however, thatelderly are at higher risk of being undernourishedthan younger patients and restoration of BCM ismore difficult. Therefore, preventive nutritionalsupport has to be considered.
2.9. In patients with dysphagia does TF preventaspiration pneumonia by improving functional
status?
Due to the heterogeneity of the studies, and lackof data on prevalence before the TF, firmconclusions can not be drawn.
Comment: Dysphagia may enhance aspiration frompharyngeal contents, but, on the other hand, TFmay enhance reflux and aspiration of gastriccontents. Several studies have reported the pre-valence of aspiration pneumonia in tube-fed
elderly patients (Table 6). Due to the heterogeneityof patient groups and lack of data on theprevalence of aspirat