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Part II Nutrition Assessment, Consequences, and Implications

complications of enteral nutrition and can lead to pneu- monia and death in a debilitated, older adult. Elevating the head of the bed at least 30 degrees consistently and for at least one hour after the feeding, using aggressive oral hygiene, regularly assessing feeding-tube tip loca- tion, and using narcotics minimally are measures to prevent aspiration during tube feeding. Additional measures to prevent aspiration include using small- bore feeding tubes and placing the feeding tube beyond the pyloric sphincter. The use of continuous feeding regimens is recommended for individuals at high risk of aspiration along with the measures suggested above. Leakage of feeding-tube contents can be second- ary to several different problems. Although rare, leakage around the exit site of a feeding tube may be due to infection or trauma from the tube itself. To prevent or treat infection around the exit site, antibiotic therapy, debridement, and/or feeding tube removal may be indicated.

Contamination of any tube-feeding system may originate from nonsterile ingredients, unsanitary equip- ment, and failure of the client or caretaker to maintain a clean technique when preparing the feeding. The risk of contamination may be minimized by proper hand washing, clean preparation methods, and use of ready- to-hang/closed system formulas and adherence to formula hang time, usually no more than eight hours per feeding period if an open system or 24 hours for a closed system.

Gastrointestinal Complications

GI complications may result from the administration of tube feeding. One of the most common complications is diarrhea, which occurs in up to 66% of tube-fed older adults (28). Causes such as antibiotic therapy, osmotically active medications, infection (eg, Clostridium difficile [C. diff]), hypoalbuminemia, and microbial contamination of the tube-feeding formula should be ruled out before the tube-feeding formula is considered as the source of diarrhea (28). If the formula is the suspected cause, changing from a hyper- tonic to an isotonic formula or changing a standard formula to one containing fiber or adding fiber (eg, banana flakes or psyllium) may help to alleviate diar- rhea. Some types of fiber can also exacerbate diarrhea if the fiber in the formula contains fructooligosaccha- rides or inulin (29). Finally, use of antidiarrheal agents may be of benefit but should be carefully monitored for response and then discontinued. Additional GI compli- cations include nausea, vomiting, abdominal disten- tion, and pain. Often the older adult’s medical status and medications are the primary cause of such symp- toms. When GI dysmotility is an underlying cause, provision of tube feeding at a slow, continuous

infusion or use of prokinetic agents may ease symp- toms. Antiemetic medications may also relieve nausea and vomiting.

Metabolic Complications

Dehydration, electrolyte disturbances, and azotemia (retention of excessive amounts of nitrogenous com- pounds in the blood) may occur in an unconscious or debilitated older adult who is unable to communicate or alleviate thirst. These complications may be reduced by the delivery of adequate amounts of free water, especially to clients who have an elevated temperature or who have additional fluid losses from ostomies, fis- tulas, or drains. Overhydration may also occur if the older adult is receiving excessive amounts of fluid. Accurate daily assessment of fluid intake/output and frequent monitoring of weights and laboratory values are needed to help minimize these complications and to ensure that the client is receiving the prescribed amount of tube feeding.

PARENTERAL NUTRITION SUPPORT PN is the provision of macronutrients, vitamins, miner- als, and electrolytes via a central or peripheral vein. Contraindications for PN include a functioning GI tract, hemodynamic instability (which would also pre- clude home management of PN), or when the risks out- weigh benefits. Once the need for PN is established, the route of administration depends on the length of the anticipated therapy, nutritional requirements, available intravenous (IV) access, and fluid status. The indica- tions for nutrition support are the same for older adults as for their younger counterparts. Age alone should not be a contraindication to nutrition support. Box 18.4 shows indications for parenteral nutrition support.

BOX 18.4 Indications for Parenteral Nutrition Support

●● ●● ●● ●● ●● ●● ●● ●● ●● ●● ●●

Nonfunctioning GI tract Severe malabsorption Short bowel syndrome Obstruction

Intractable diarrhea or vomiting GI bleeding

Radiation enteritis Bowel ischemia

High-output fistula (> 200 mL) Bowel rest (eg, severe pancreatitis)

GI tract not accessible or is unsafe for enteral nutrition support