Chapter 18 Nutrition Support

nutrition support in older adults. These include the per- son’s desires, estimated duration of nutrition support, expected benefits, prognosis, and effect on quality and quantity of life. Older adults with advance directives or those who have made their wishes known to family members may help outline the decisions for implement- ing or discontinuing nutrition support, especially if it is expected to be long-term or will require institutionaliza- tion for administration (14). Refer to Chapter 19 for end- of-life care.

HOME ENTERAL AND PARENTERAL NUTRITION

The older adult may be a candidate for enteral or par- enteral home nutrition support. As is the case whenever home nutrition support is being considered, it is neces- sary to thoroughly assess the person’s medical condi- tion, level of independence, and ability to learn home nutrition support procedures, as well as the psychologi- cal and social life aspects and reimbursement (insur- ance coverage). The evaluation process is best accomplished by an interdisciplinary team (IDT), including the physician, nurse, dietitian, social worker, and case manager/discharge planner. Home nutrition support will impact the older adult’s and the caregiv- er’s lifestyle. Sleep, travel, and social life are signifi- cantly affected by home nutrition support therapies (15). One of the most important aspects for successful home nutrition support is the availability, commitment, and support of the person’s family or caregiver. In situ- ations where a caregiver is not available or is incapable of managing home EN or PN, the older adult may not be a good candidate for home nutrition support but may be a candidate for nutrition support in a rehabilita- tion or nursing facility. Nutrition support in a nursing facility may be permanent or temporary while the older adult undergoes rehabilitation, wound management, or training for home EN or PN procedures before dis- charge to home. Benefit versus burden and risks should be evaluated prior to starting PN or EN in the home or alternate site facility.

ENTERAL NUTRITION SUPPORT Older adults who are unable to meet their nutritional requirements orally may be candidates for EN. This is appropriate when the GI tract is functional and safely accessible. Clinicians and support staff, or family in the case of home care, will require specific training on management of an enteral feeding, including access management, how to feed, and how to manage compli- cations. The scope of this chapter is not adequate to provide this information or to ensure proficiency in these areas.

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Enteral nutrition can be used to provide full nutri- tion needs or as a supplement to oral intake or paren- teral nutrition. Box 18.2 lists indications for tube feeding in older persons.

BOX 18.2 Indications for Tube Feeding in Older Persons

Oncological Disease Neoplasm Chemotherapy Radiation therapy

Inability to Swallow Cerebrovascular accident Dysphagia Head trauma or comatose state Advanced dementia

Degenerative or Debilitating Disease Huntington’s chorea Advanced Parkinson’s disease Demyelinating disease

Hypermetabolism or Inadequate Oral Intake > 7 Days Sepsis Surgery Severe malnutrition Burns Organ failure

Other Depression

The decision to proceed with EN should involve the older adult, caregiver, or support person(s); the physician; and the health care team. The older adult’s medical status, comorbidities, quality of life, and prog- nosis should be taken into consideration. A comprehen- sive guideline compilation for EN therapy is available through the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) (16). Recent studies have suggested that older adults with cognitive impair- ment have outcomes similar to other populations receiving home EN (17); however, for certain sub- groups of older adults, particularly those who have dementia, the risks may outweigh the benefits of EN