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Enteral and parenteral nutrition support are therapies that provide nutrients for maintenance or restoration of nutritional status for persons who are unable or unwill- ing to consume an adequate diet orally. Technological advances and the proliferation of home care providers have made nutrition support outside the traditional acute-care hospital setting a common therapeutic option. Oral nutrition is usually the first method used for older adults to supplement poor oral intake to treat or avoid malnutrition (1). Enteral nutrition (EN) support is most often used for older adults to provide total nutrition in the presence of stroke or other dis- eases or injuries that cause dysphagia. Two-thirds of nursing home residents receiving enteral feeding had their feeding tubes placed during a hospital admission (2). Parenteral nutrition (PN) is used when the gastro- intestinal (GI) tract is nonfunctional or unavailable for nutrition. Figure 18.1 (see page 252) provides a nutri- tion support decision algorithm.

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The basic indications for and principles of nutri- tion support are similar for older and younger adults. However, there are physiological and sociological factors unique to older adults that must be evaluated. These factors can affect timing and route of nutrition support and the type and amount of substrates adminis- tered. Changes in body composition and function that occur with aging leave older adults with diminished reserves and impaired compensatory mechanisms. It may be difficult, at times, to distinguish between these age-related physiological changes and abnormalities that occur due to malnutrition. Older adults are more likely to take multiple medications that can affect the absorption, metabolism, or excretion of nutrients. Ethical issues, such as those related to length of life, invasive therapy, and quality of life, must be consid- ered prior to the initiation of nutrition support (3). The role of the registered dietitian nutritionist (RDN) includes the following:

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Nutrition Support

recognizing the incidence of nutritional compro- mise through nutrition screening;

assessing nutrition status;

identifying appropriate candidates for nutrition support;

determining the type of nutrition support;

scheduling a meeting with the older adult and legal representative to discuss risks and benefits of tube feeding and possible financial concerns;

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monitoring the client if the older adult determines to use nutrition support; and

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documenting the nutrition care plan and providing options consistent with the older adult’s advance directives.

NUTRITION SCREENING

Nutrition screening tools have been developed to query individuals about dietary habits, functional status, social environment, and anthropometric data to iden- tify those at risk for malnutrition (4,5). A nutrition screening tool should provide a quick, reliable, and applicable evaluation of nutritional risk. The Mini Nutrition Assessment (MNA) is a short, concise, and well-validated tool to identify the presence of or risk for malnutrition in individuals 65 or older. The tool contains six questions on food intake, weight loss, mobility, body mass index (BMI), and dementia (5). It is available on mobile devices or paper and can be used for incorporation in medical records. The Subjective Global Assessment (SGA) is a screening and assess- ment tool that incorporates elements of the client’s weight and intake history, disease status, and physical findings. From these data, clients are categorized as well nourished, moderately malnourished, or severely malnourished. SGA has demonstrated superior predic- tive value for nutrition-related complications and mor- tality in older adult residents of a nursing facility over