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Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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10
Nutrition Support

Nutrition support, defined as the provision of enteral or parenteral nutrition, has made great strides over the past three decades. Enteral nutrition includes oral ingestion of foods or supplements as well as the non-volitional administration of nutrients by tube into the gastrointestinal tract. Parenteral nutrition is the intravenous administration of nutrients into the bloodstream, by either peripheral or central venous access routes. Nutrition administered by the peripheral route is termed peripheral parenteral nutrition, and by the central route total parenteral nutrition (TPN). Improvements in enteral and parenteral techniques, equipment, nutrient formulations, and gastrointestinal and venous access devices have enabled the provision of nutrients to many patients who might otherwise have received inadequate or inappropriate nutrition. Reflecting shifting health care demographics in America, Medicare beneficiaries comprise a substantial proportion of all adult patients who receive parenteral or enteral nutrition in hospitals.

Although it is generally accepted that adequate nutrition plays an important role in maintaining optimal health, many hospitalized patients have compromised nutrient intakes for extended periods (Sullivan et al., 1999). Studies document a prevalence of protein–energy undernutrition among hospitalized older persons that exceeds one-third of all admissions (Constans et al., 1992; Mowé and Bøhmer, 1991; Sullivan et al., 1989). Many elderly are undernourished prior to hospitalization (Mowé et al., 1994). The nutritional status of older patients at hospital discharge is

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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also predictive of the need for early nonelective readmission to the hospital (Friedmann et al., 1997; Sullivan, 1992).

The indications for providing nutrients by the enteral or parenteral route have not been well defined, and the efficacy of nutrition support is unproven in many circumstances. Nutrition support is most frequently used as short-term therapy for hospitalized patients with protein–energy undernutrition. The consequences of protein–energy undernutrition include depletion of body cell mass and decline of vital tissue and organ functions (see chapter 4). Compromise in host defense and wound-healing functions can result in suboptimal response to medical and surgical therapies. Complications may include hospital-acquired infections and wound breakdown. Adverse outcomes that may result include increased morbidity and mortality with associated increased length of hospital stay and increased use of health care resources (Friedmann et al., 1997; Incalzi et al., 1998; Jensen et al., 1997; Marinella and Markert, 1998; Sullivan et al., 1999).

The rationale for the provision of nutrition support includes (1) to mitigate the effects of semi-starvation, and (2) to favorably alter the natural history or response to treatment for a disease. Nutrition support is clearly indicated when food intake or nutrient assimilation will be compromised for an extended period, since starvation and death will otherwise result. Such patients may include those with inadequate gastrointestinal function (e.g., short-bowel syndrome or chronic intestinal obstruction), as well as those with severe oropharyngeal dysfunction or permanent neurological impairment.

Enteral and parenteral nutrition support of shorter duration can also prevent and treat protein–energy undernutrition among other selected Medicare beneficiaries in the hospital setting. Complications can be reduced among patients who are either undernourished or at high risk of becoming undernourished. Such patients may include those who have suffered major abdominal trauma or who undergo major elective abdominal surgery (Heyland, 1998; Kudsk et al., 1992; Moore et al., 1992; Müller et al., 1982; Senkal et al., 1997; VA TPN Cooperative Study Group, 1991). Reported benefits have included decreased rates of septic and wound complications, with resulting reductions in number of hospital days and cost.

There are also risks associated with enteral and parenteral nutrition support that must be taken into consideration. Serious complications include aspiration of enteral feedings and infectious and thrombotic events related to parenteral venous access (Cataldi-Betcher et al., 1983; Ryan et al., 1974). Appreciable under- or overfeeding can result in adverse metabolic consequences (Dark et al., 1985; Keys et al., 1950). Feeding intolerance, derangement of fluid balance, and laboratory abnormalities may be

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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observed with refeeding of the undernourished patient (Solomon and Kirby, 1990; Weinsier and Krumdieck, 1981). Such complications can also be associated with increased lengths of hospital stay and health care expenditures.

LITERATURE REVIEW

The Committee on Nutrition Services for Medicare Beneficiaries sought to critically review the available nutrition support literature according to the guidelines of the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research). The committee was greatly assisted in this process by the availability of several recent review articles of this literature that served as a strong foundation (ASPEN, 1993; Heyland et al., 1998; Klein et al., 1997; Pillar and Perry, 1990; Souba, 1997). In addition to systematic examination of the literature used to support these reviews, relevant new material was examined from the past 5 years, corresponding to more than 1,500 parenteral and 2,000 enteral citations from Medline in both the English and the non-English scientific literature. The general approach taken by the committee was to clarify the type of evidence available and to specifically highlight evidence in relation to persons 65 years of age or older. When there was no specific evidence available in relation to older persons, the committee attempted to ascertain what might reasonably be generalized from studies of middle-aged adults. Both the types of evidence and any relevant assumptions are clearly highlighted for each section. The limitations of current data and future research needs and recommendations are summarized for each indication for nutrition support.

INDICATIONS FOR THE USE OF NUTRITION SUPPORT

GASTROINTESTINAL DISEASES

Short-Bowel Syndrome

Extensive resection of the small intestine can result in inadequate intestinal length and/or function to maintain normal fluid, electrolyte, and nutritional homeostasis. Short-bowel syndrome is characterized by severe malabsorption and resulting dehydration, electrolyte losses, metabolic abnormalities, and undernutrition (Purdum and Kirby, 1991). Since clinical experience has demonstrated the clear efficacy of nutrition support in this setting, prospective randomized trials that include nonintervention arms have not been and are unlikely to be conducted. No studies have focused specifically on older persons with short-bowel syndrome,

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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but many of the patients who have benefited from nutrition support intervention for this condition are Medicare eligible. Indeed 21 percent of all registrants in the North American Home Parenteral and Enteral Nutrition Patient Registry with a diagnosis of motility disorder were Medicare beneficiaries (Howard and Malone, 1997).

Patients with substantial intestinal resection will often require TPN temporarily until adequate adaptation of the remaining intestine occurs to facilitate transition to enteral feedings by tube or mouth. The use of TPN in these patients hastens rehabilitation and transition to the home care setting. Some patients with profound malabsorption require indefinite parenteral support for survival. The degree of impairment of nutrient assimilation is determined by the remaining bowel anatomy and function.

The least favorable anatomical alteration is to have combined resections of both the small and the large intestines and resulting decreased function (Gouttebel et al., 1986; Nightingale et al., 1990). Nonetheless, even in the setting of long-term TPN dependence, it is sometimes possible with aggressive enteral nutritional supplementation and rehydration therapies, in combination with pharmacologic interventions, to modulate gut secretions and transit in order to obviate the need for parenteral support (Cosnes et al., 1985; Lennard-Jones, 1990). The applications of specific hormonal and nutrient growth factors to increase intestinal mass and absorptive function are being tested in active research and may offer important therapeutic opportunities (Byrne et al., 1995).

Enterocutaneous Fistulas

Case series demonstrate a high prevalence of undernutrition among fistula patients and suggest that the most undernourished patients have the worst clinical outcomes (Chapman et al., 1964; Dudrick et al., 1999; Rose et al., 1986; Soeters et al., 1979). Prior to the use of nutrition support, many of these patients suffered severe dehydration, electrolyte derangements, and undernutrition. The role of nutrition intervention is primarily supportive care to prevent further deterioration.

Retrospective analysis of clinical experience with patients having small-bowel fistulas found that those patients who received nutrition support had lower mortality rates, higher rates of spontaneous fistula closure, and superior surgical closure outcomes (Himal et al., 1974). Prospective randomized trials have not been conducted that rigorously evaluate the role of nutrition support in the treatment of enterocutaneous fistulas, and older patients have not been specifically investigated. Such studies are unlikely to be undertaken because it appears likely that medical therapy that includes TPN in conjunction with bowel rest and pharmaco-

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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logic intervention (i.e., octreotide and histamine receptor antagonists) favors spontaneous fistula closure and improved clinical outcomes (di Costanzo et al., 1987; Dudrick et al., 1999; Meguid and Campos, 1996). Spontaneous closure will occur within 5 weeks in 40 to 60 percent of patients treated with this approach, and if surgical intervention to close the fistula proves necessary then nutritional status will be maintained. Although elemental diets have been successfully used for enteral feeding in patients with fistulas, there are no randomized prospective studies that contrast this approach with TPN (Dudrick et al., 1999; Meguid and Campos, 1996).

Inflammatory Bowel Disease

Protein–energy undernutrition and specific nutrient deficiencies are common among patients with inflammatory bowel disease. Even patients with long-standing Crohn’s disease in remission demonstrate a variety of nutritional deficiencies (Geerling et al., 1998). Sequelae of inflammatory bowel disease and related treatment interventions can result in decreased nutrient intake, malabsorption, enteropathy, and drug–nutrient interactions. Although nutrition therapy is often part of the overall management plan, its role in primary therapy remains controversial. However, in those patients who suffer inadequate intestinal length or function as a result of surgery or complications associated with inflammatory bowel disease (short-bowel syndrome or enterocutaneous fistula), nutrition support clearly will be efficacious.

A number of randomized prospective trials have examined the roles of bowel rest and TPN in inducing remission in patients with active Crohn’s disease (Greenberg et al., 1988; Lochs et al., 1984; Wright and Adler, 1990). None of these studies focused specifically on older persons. Bowel rest alone, independent of nutritional support, did not appear necessary to achieve clinical remission, and long-term outcome was not affected. There was also no apparent role for TPN as primary therapy in the specific treatment of Crohn’s disease or ulcerative colitis (Dickinson et al., 1980; McIntyre et al., 1986). Patients randomized to bowel rest and TPN had no better outcomes than those assigned to enteral feedings (González-Huix et al., 1993).

Enteral diets using elemental formula1 have been suggested to be as effective as glucocorticoid therapy in inducing remission of Crohn’s disease, but the majority of randomized prospective trials suffer from small size, heterogeneous participants, variable diet composition and intake,

1  

A liquid formula designed for easy digestion and absorption and leaves minimal residue in the bowel.

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

and disproportionate withdrawals among the enteral treatment arm (Bernstein and Shanahan, 1996). Again no studies focus specifically on older persons. Meta-analysis of prospective randomized trials suggests that enteral nutrition may not be as effective as corticosteroids (Fernández-Bañares et al., 1995; Griffiths et al., 1995; Trallori et al., 1996). Since there are no studies that randomize to enteral feedings versus placebo, it is not possible to discern the therapeutic benefit of enteral feeding alone.

Pancreatitis

No studies of nutrition support in pancreatitis have focused specifically on older persons. The potential benefits of nutrition support for patients with acute pancreatitis may be best determined by the severity of the disease. The majority of patients with acute pancreatitis have mild or moderate disease. Prospective randomized trials indicate that the provision of enteral or parenteral nutrition does not alter the natural history of pancreatitis in this setting (Sax et al., 1987). Indeed, the administration of TPN to patients with pancreatitis resulted in greater insulin requirements and higher prevalence of catheter-related sepsis than that observed in a control group who received only intravenous fluids (Sax et al., 1987). McClave and coworkers (1997) found that enteral feedings were well tolerated in such patients and that clinical outcomes were comparable to TPN. Beneficial effects of aggressive nutrition support on morbidity or mortality have not been realized and hospital costs are elevated in those who receive TPN.

Although most patients with mild or moderate pancreatitis require only routine supportive measures, it is not clear how long such patients will tolerate semistarvation. If the course is protracted, severe, or complicated, nutrition support may be indicated (Baron and Morgan, 1999; Wyncoll, 1999). Recent prospective trials have randomized patients with severe pancreatitis to enteral feeding versus TPN (Kalfarentzos et al., 1997; Windsor et al., 1998). The enteral feedings were well tolerated and had no adverse clinical effects. There were fewer total and infectious complications, and the acute-phase response and disease severity scores were favorably attenuated with enteral nutrition.

Liver Disease

Although many patients with chronic liver disease suffer protein– energy undernutrition (Lautz et al., 1992; Mendenhall et al., 1984), the efficacy of nutrition support for these patients is not yet established. Older persons with liver disease have not been specifically evaluated in this

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

regard. Whereas some laboratory measures of liver function appear to be improved with the provision of enteral or parenteral nutrition to patients with chronic alcoholic liver diseases, other outcomes are less clear (Mizock, 1999). Some prospective randomized trials have observed improved survival among patients with chronic alcoholic liver diseases who receive enteral or parenteral nutrition (Cerra et al., 1985), while others have not (Nasrallah and Galambos, 1980; Naveau et al., 1986; Naylor et al., 1989).

Meta-analysis of prospective randomized trials that evaluated TPN formulations enriched with branched-chain amino acids suggests that recovery from acute hepatic encephalopathy may be hastened (Naylor et al., 1989). The follow-up for these studies was, however, of short duration, and many of the control subjects received TPN that contained no amino acids. In a prospective randomized trial that included control patients who received TPN with a standard amino acid formulation, a beneficial effect of branched-chain amino acids was not observed (Michel et al., 1985).

Enteral nutrition is well-tolerated by many patients with liver diseases (Cabré et al., 1990; Hirsch et al., 1993; Kearns et al., 1992) and clinical trials suggest that simple casein-based enteral feeding may be efficacious in promoting recovery from acute hepatic encephalopathy (Christie et al., 1985; Horst et al., 1984; Kearns et al., 1992).

Gastrointestinal Disease Summary

Short-Bowel Syndrome. Provision of enteral and parenteral nutrition support has established efficacy in the prevention of life-threatening undernutrition for patients with inadequate intestinal length and/or function.

Enterocutaneous Fistulas. Parenteral nutrition in combination with bowel rest and pharmacologic intervention to diminish gastrointestinal secretions appears likely to improve the opportunity for spontaneous fistula closure and more favorable clinical outcomes. Studies are insufficient to address the role of enteral nutrition in fistula management.

Inflammatory Bowel Disease. Enteral and parenteral nutrition support is likely to be indicated for inflammatory bowel disease patients who suffer undernutrition related to compromised intestinal length and/or function. Although enteral nutrition may have a therapeutic role in the treatment of Crohn’s disease, it appears that corticosteroids are more effective. In addition, the use of TPN is not supported as primary therapy.

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

Pancreatitis. The routine use of enteral and parenteral nutrition is not indicated in patients with mild or moderate pancreatitis. If the course is protracted or severe, nutrition support may be considered. Studies are inadequate to clarify the optimal timing, feeding route, or formulation for this indication. Enteral feedings may be well tolerated in selected patients.

Liver Disease. Enteral and parenteral nutrition may improve some laboratory measures of liver function in patients with chronic alcoholic liver diseases. Studies are conflicting with regard to whether there are associated improvements in survival. It is also unclear whether branchedchain amino acid-enriched formulations offer advantage in accelerated recovery from acute hepatic encephalopathy.

Gastrointestinal Disease Recommendations
  • There is a need for well-designed clinical trials of nutrition support interventions for gastrointestinal disease. Studies should include older persons. Indications for nutrition support require further clarification for inflammatory bowel disease, pancreatitis, and liver diseases. The use of specific nutrients, growth factors, and modified nutrient formulations warrants further investigation.

  • The use of enteral and parenteral nutrition is recommended as life-sustaining and supportive therapy for patients with short-bowel syndrome and enterocutaneous fistula.

HUMAN IMMUNODEFICIENCY VIRUS AND ACQUIRED IMMUNE DEFICIENCY SYNDROME

Even though the incidence of acquired immune deficiency syndrome (AIDS) is higher among younger age groups, persons aged 50 years or older accounted for 11 percent of all AIDS cases in the United States in 1996 (CDC, 1998). The Centers for Disease Control and Prevention (CDC) estimated that newly reported AIDS cases among persons ages 50 years and older increased by 12.6 percent (from 55,819 to 62,874) from mid-1996 to mid-1997 (CDC, 1997). This increase is alarming since the number of new AIDS cases reported annually is declining among younger persons. Because many older persons do not perceive themselves to be at risk for human immunodeficiency virus (HIV)/AIDS, they may delay testing and be diagnosed at a later stage of disease, placing them at increased risk of malnutrition associated with AIDS. AIDS-related malnutrition is associated with loss of lean body mass, which in turn can lead to reduced functional capacity and diminished quality of life (Grinspoon et al., 1999;

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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Wilson and Cleary, 1997). In two studies (Turner et al., 1994; Wilson and Cleary, 1997), loss of lean body mass, resulting in fatigue and weakness, was closely associated with functional status, an important aspect of quality of life. Although wasting is less common, significant loss of lean body mass occurs even in patients who are receiving highly active antiretroviral therapy (Grinspoon et al., 1997). Moreover, highly active antiretroviral therapy may contribute to deleterious fat redistribution, as well as the premature development of cardiovascular disease and diabetes mellitus in some patients (Carr et al., 1998; Dubé et al., 1997; Henry et al., 1998). Other studies have documented a correlation between weight loss and more rapid disease progression, increased risk for hospitalization and opportunistic infections, and reduced tolerance of and response to treatments (Rivera et al., 1998; Wheeler et al., 1998; Wilson and Cleary, 1997).

A growing body of evidence suggests that nutrition counseling and/ or nutrition support may improve nutritional status in persons with HIV/ AIDS. In a 6-week randomized, controlled trial, Rabeneck and colleagues (1998) found that nutrition counseling, with or without oral supplementation, achieved a substantial increase in energy intake in nearly half of their malnourished HIV-infected patients. Compared to the counseling-only group, the supplement group had greater increases in fat-free mass and grip strength. A study by Stack and colleagues (1996) found that HIV-infected patients without secondary infections were able to maintain or gain weight with a high-energy, high-protein supplement used in conjunction with nutrition counseling. Studies of omega-3 fatty acid supplementation have shown that fish oil may be efficacious in lowering hypertriglyceridemia and increasing lean body mass (Bell et al., 1996; Hellerstein et al., 1996). Studies of oral and enteral supplements designed especially for HIV/AIDS indicate that these products are associated with greater weight gain when compared to standard supplements (Pichard et al., 1998; Süttmann et al., 1996). The majority of weight gain in these studies was fat, however, as opposed to lean body mass. In a randomized study comparing total parenteral nutrition to dietary counseling in severely malnourished men (loss of more than 10 percent usual body weight and concomitant diarrhea), weight increased by a mean of 8 kg in the parenteral nutrition group and decreased by a mean of 3 kg in the dietary counseling group (Melchior et al., 1996). The administration of TPN increased body cell mass in men with AIDS wasting and malabsorption and gastrointestinal disease, but those with secondary infections continued to lose body cell mass despite TPN administration. A recent study by Kotler et al. (1998) compared TPN to a semielemental diet given to AIDS patients with malabsorption syndrome. Patients receiving TPN consumed more calories and gained more weight than patients receiving the oral formula; however, weight gain was a function of total calorie intake. As in other

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

studies, the composition of weight gained was predominantly fat. In this study, the semielemental diet was less costly than TPN and associated with improvement in quality of life, specifically functional status.

In summary, there are limited but consistent data that nutrition counseling and support in HIV/AIDS are associated with greater calorie intake and weight gain. Because the weight gain was due to fat deposition as opposed to lean body mass accrual in some of the studies, exercise and pharmacologic agents may be indicated as adjuncts to nutrition interventions to produce an increase in lean body mass. Further research is needed to identify optimum combinations of nutrition interventions, pharmacologic approaches, and exercise that will maximize nutritional status and clinical outcomes in HIV/AIDS in a cost-effective manner, particularly in persons aged 50 years and older. Methodological problems of the studies discussed in this section include the short-term nature of the nutrition interventions, the lack of inclusion of clinical outcome measures (e.g., functional status, quality of life) that may respond to nutrition therapy, and the homogeneity of the study populations which consist of mostly younger, homosexual white males.

HIV/AIDS Summary

Weight loss in patients with AIDS is correlated with more rapid disease progression, increased risk of hospitalization and opportunistic infections, and reduced tolerance of and response to treatments. Loss of lean body mass is correlated with diminished functional status, a component of quality of life. There are limited, but consistent, data that nutrition counseling and oral, enteral, and parenteral nutrition promote calorie intake and weight gain in AIDS patients who have experienced significant weight loss or have malabsorption, but who do not have secondary infections. There are limited data which indicate that total parenteral nutrition may be more costly and associated with lower quality of life than either oral or enteral nutrition.

HIV/AIDS Recommendations
  • Nutrition therapy to improve caloric intake and weight gain in persons with AIDS is recommended using a multidisciplinary team of nutrition support professionals. Parenteral nutrition is costly and may therefore be indicated only in select cases.

  • Further research should focus on the development of the most effective combinations of nutrition and adjunctive (e.g., exercise) therapies which increase lean body mass, especially in persons with AIDS who are aged 50 years and older.

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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CANCER AND BONE MARROW TRANSPLANTATION

Chemotherapy and Radiation Therapy

The CDC (1999) estimated that there were 1,374,000 cancer-related hospital discharges in 1996, with an average length of stay of 7 days. More than two-thirds of cancer patients lose weight during their disease course (Rowan Chlebowski, Harbor-UCLA Medical Center, personal communication, 1999). Since 60 percent of all cancers occur in older adults who may already have preexisting special nutritional needs, this is a significant problem. Studies of nutrition support during cancer chemotherapy, radiation therapy, and bone marrow transplantation report mixed results. Three meta-analyses that examined the use of TPN in cancer patients undergoing chemotherapy or radiation therapy reported no benefit of TPN in terms of tumor response, treatment tolerance, or survival. Moreover, TPN administration in these patient populations was associated with higher rates of pneumonia and sepsis (ACP, 1989; Klein et al., 1986; McGeer et al., 1990). Systematic reviews have also indicated that enteral and parenteral nutrition may not be efficacious for cancer patients undergoing these particular treatments (Klein and Koretz, 1994; Klein et al., 1997). However, the reviews point out that serious shortcomings in study design and methods make it difficult to draw definitive conclusions from the data.

Since these reviews (Klein and Koretz, 1994; Klein et al., 1997), a few studies have evaluated the use of nutrition support in cancer patients treated with chemotherapy. In one clinical trial, malnourished gastrointestinal cancer patients who received both parenteral nutrition and chemotherapy preoperatively had fewer complications and more tumor sensitivity to chemotherapy than patients without nutrition support (Jin et al., 1999). In another trial involving metastatic cancer patients treated with high doses of interleukin-2, a brief course of TPN during treatment corrected calorie and protein undernutrition, improved control of serum electrolytes, and was well tolerated (Samlowski et al., 1998). A prospective study of nutrition support in patients receiving antineoplastic therapy indicated that parenteral nutrition successfully maintained the body weight of patients who were unable to receive enteral nutrition (Lees, 1997). A retrospective study of chemotherapy and TPN for advanced ovarian cancer patients with bowel obstruction found that median survival was 17 days longer (p < 0.05) for patients who received chemotherapy with TPN than for patients who received chemotherapy alone (Abu-Rustum et al., 1997). In a retrospective study of nutrition support during chemoradiation therapy in esophageal cancer, parenteral nutrition facili-

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

tated the administration of complete chemoradiation doses (Sikora et al., 1998).

Bone Marrow Transplantation

With increasing frequency, bone marrow transplantation (BMT) is used in treating patients with hematologic malignancies who are over the age of 65 years. Due to the severe gastrointestinal side effects of total body irradiation and chemotherapy, BMT patients are frequently unable to eat for 2 or more weeks following transplantation. TPN traditionally has been used to meet the nutritional needs of the BMT patient population (Aker et al., 1982). In a systematic review of studies involving bone marrow transplant patients, the use of standard TPN was generally not found to be associated with improved clinical outcomes (Klein et al., 1997). One exception occurred in a prospective study of 137 patients (age greater than 1 year) who were randomized to either a TPN or a no-TPN group (Weisdorf et al., 1987). They found that patients receiving short-term TPN had increased long-term survival (more than 6 months), decreased rate of tumor relapse, and increased energy intake when compared to the no-TPN control group. More recently, the effects of a lipid-based versus a glucose-based TPN solution on 66 randomly assigned bone marrow transplant patients were evaluated (Muscaritoli et al., 1998). The results suggest that the use of a lipid-based TPN solution was associated with a lower incidence of acute graft-versus-host disease and hyperglycemia. However, the lack of a control group makes the study findings difficult to interpret.

Szeluga and colleagues (1987) randomized patients to TPN versus an enteral-oral feeding program and found that the nutritional needs of 23 of 30 patients could be met with the enteral feeding program. The safety of enteral feeding in bone marrow transplant patients was also documented in a small group of patients undergoing autologous BMT (Mulder et al., 1989).

A few studies have focused on the benefit of oral or parenteral feedings supplemented with the amino acid glutamine. Forty-five patients (aged 20 to 49) were randomly assigned to a double-blind, controlled trial of glutamine-supplemented versus standard TPN (Ziegler et al., 1992). They found that patients whose TPN was supplemented with glutamine had significantly greater nitrogen balance, fewer infections, less bacterial colonization, and shortened hospital stay compared to patients who received standard TPN. A significantly reduced hospital stay, as well as significantly less fluid retention, was reported in 29 patients (average age 35 years) who were randomly assigned to a similar TPN protocol with or without glutamine (Schloerb and Amare, 1993). MacBurney and colleagues (1994) calculated hospital charges for patients

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

in the 1992 Ziegler et al. study and found significantly lower charges ($51,484 versus $61,591, p = 0.02) in the group of patients receiving the glutamine-supplemented formula. However, Schloreb and Skikne (1999) randomly assigned 48 patients (aged 26 to 56) to oral and parenteral glutamine or isocaloric and isonitrogenous oral and parenteral therapy without glutamine. They concluded that glutamine is of limited benefit to bone marrow transplant patients.

Cancer and Bone Marrow Transplantation Summary

There is insufficient evidence to suggest that nutrition support has been shown to be efficacious in cancer patients undergoing chemotherapy or radiation therapy. The limitations of the available data, however, do not rule out the possible utility of nutrition support in older cancer patients undergoing chemotherapy or radiation therapy. In bone marrow transplantation, enteral nutrition is safe and can be used to meet energy needs. In addition to various methodological flaws, none of the studies explicitly studied older persons. Many of the cancer trials are conducted with younger subjects even though older persons comprise the majority of cancer patients.

Cancer and Bone Marrow Transplantation Recommendations
  • Until additional data, including data specific to the elderly, become available, nutrition support should be used selectively in malnourished cancer patients undergoing radiation therapy and/or chemotherapy.

  • Enteral nutrition may be considered for bone marrow transplantation patients who are unable to eat due to the side effects of chemoradiation. TPN is recommended for those who have protracted gastrointestinal dysfunction.

  • More prospective, randomized clinical trials of older cancer patients are necessary to determine whether a relationship exists between nutrition support and clinical outcomes. Additional studies are needed before recommendations can be made concerning the efficacy of specific amino acid formulations in bone marrow transplant patients.

ACUTE RENAL FAILURE

Hospitalized patients with acute renal failure will often have serious underlying comorbid disease and may be critically ill and in a catabolic state (Ikizler and Himmelfarb, 1997). Protein–energy undernutrition is highly prevalent among acute renal failure patients and is associated with

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

increased likelihood of death, complications, and use of health care resources (Fiaccadori et al., 1999). Since anorexia, nausea, vomiting, and metabolic derangement are common, these patients may suffer compromised nutritional intakes for extended periods. When clinically indicated, the initiation of acute hemodialysis or ultrafiltration facilitates the provision of adequate amino acids or protein but also promotes nutrient losses (Ikizler et al., 1994; Mehta, 1994; Wolfson et al., 1982).

There have been no prospective randomized trials of enteral nutrition in the setting of acute renal failure. A number of studies with modest subject numbers and variable control groups have examined the use of TPN. None of these investigations have explicitly studied older persons. Only one well-designed randomized trial with 53 subjects has detected a significant improvement in recovery from acute renal failure among patients treated with parenteral glucose and essential amino acids in comparison to glucose alone (Abel et al., 1973). Two smaller studies of similar design did not observe an accelerated recovery of renal function with essential amino acid treatment (Feinstein et al., 1981; Leonard et al., 1975). Improved survival rates have also been described for patients who received essential amino acids in TPN in comparison to glucose alone, but these did not achieve statistical significance (Abel et al., 1973; Feinstein et al., 1981). Other randomized studies of TPN with small numbers of subjects have tested formulations enriched in essential amino acids in comparison to formulations containing both essential and nonessential amino acids (Feinstein et al., 1981, 1983; Mirtallo et al., 1982). While recovery and survival rates favored the essential amino acid formulations, statistically significant differences were not observed.

Acute Renal Failure Summary

Although parenteral formulations enriched in essential amino acids may improve patient outcomes in acute renal failure, data are insufficient to make conclusions regarding clinical efficacy. The limited data from younger adults are insufficient to make any generalizations about specific nutrition support therapy to be used in the older person with acute renal failure.

Acute Renal Failure Recommendations
  • Well-conceived clinical trials of nutrition support interventions are needed in patients with acute renal failure.

  • Studies should include older persons.

  • The role of specific nutrient supplementation must be clarified in studies with adequate control groups and methodology.

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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For a discussion of the efficacy of nutrition therapy for chronic renal failure, see chapter 7.

CRITICAL ILLNESS

Nutrition support is often used in patients with critical illness, although benefit has been difficult to demonstrate given the great diversity of patient conditions and variable severity of illness. Studies have suffered from the inability to acquire adequate samples of homogeneous patients, inadequately controlled designs, concurrent treatments, and illdefined outcome measures. Older persons have been excluded from many of the clinical trials that have examined the role of nutrition support in critical illness. Heyland and colleagues (1998) recently presented a metaanalysis of 26 randomized trials comparing the use of TPN with standard care (usual oral diet and intravenous dextrose) in 2,211 pooled patients with critical illness or surgery. It was concluded that TPN does not influence overall mortality rate or major complication rates in critically ill patients. Post-hoc subgroup analyses suggested that TPN might reduce the complication rate in malnourished patients. Unfortunately, this benefit was limited to studies published prior to 1989, studies that did not use intravenous lipids, and studies of surgical patients. These findings are likely confounded by the unsound methodology used in the older studies and the general limitations of studies of critical illness described above.

There has been a growing emphasis on enteral feeding when feasible for patients with critical illness because the provision of nutrients via the gastrointestinal lumen appears to help maintain mucosal structure and function of the intestine (Buchman et al., 1995; Hadfield et al., 1995; Hernandez et al., 1999). The “gut injury” hypothesis suggests that a breakdown in mucosal barrier function associated with the lack of luminal nutrients when giving TPN may facilitate the translocation of intestinal flora and their associated endotoxin, thereby fueling inflammatory pathways (Deitch, 1990). Enteral feeding of critically ill patients has numerous proponents but remains controversial (Lipman, 1998; Minard and Kudsk, 1998; Moore and Moore, 1996). Unfortunately there are so few studies that directly contrast carefully matched enteral and parenteral nutrition that a meta-analysis comparing these interventions across the spectrum of critical illness is not feasible.

Patients with major trauma, including major blunt or penetrating trauma, head injury, or burn, are at high risk of proteinenergy undernutrition. These patients are often hypermetabolic with ongoing injury response. They may be unable to eat for extended periods and may have compromise to intestinal function. They may also have complex wounds that require repeated surgical interventions. Clinical trials of nutrition

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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support in trauma patients have not included appreciable numbers of older persons. Nonintervention controls are also lacking. A number of trials have found enteral nutrition to be superior to parenteral nutrition in reducing septic complications in abdominal trauma patients (Kudsk et al., 1992; Moore and Jones, 1986; Moore et al., 1989, 1992). It is not evident whether there is a specific benefit to enteral nutrition or alternatively whether TPN is associated with increased risk of infections. Thus, the benefits of nutrition support in trauma have not been clearly established.

Nutrition support should offer benefit for patients with severe head injury since they will otherwise be subject to protracted semistarvation. While early studies (Rapp et al., 1983) suggested that parenteral nutrition had more favorable outcomes when head-injured patients received greater parenteral than enteral nutrition, more recent clinical trials have observed equivalent outcomes with enteral or parenteral nutrition when nutrient intakes are comparable (Borzotta et al., 1994; Grahm et al., 1989; Norton et al., 1988).

A number of small prospective randomized trials have examined assorted nutrition support interventions in patients with burns (Alexander et al., 1980; Brown et al., 1990; Chiarelli et al., 1990; Herndon et al., 1987; Liljedahl et al., 1982), but in the absence of rigorous clinical trials, the guidelines for intervention are largely empiric. Enteral feedings have been shown to be well tolerated by burn patients and modified nutrient formulations have been shown to diminish the rate of infection (Garrel et al., 1995; Gottschlich et al., 1990).

New strategies are being tested to modulate immune functions in critical illness using modified enteral formulations that have been enriched in nutrients which may have immune-enhancing or preserving functions. Nutrients tested include arginine, nucleotides, glutamine, and omega-3 fatty acids. Prospective randomized trials have suggested potential benefits such as reductions in infectious complications and hospital length of stay when such modified enteral formulas are compared to standard enteral feedings (Bower et al., 1995; Brown et al., 1994; Daly et al., 1992; Moore et al., 1994). These studies, however, have been questioned as to their conclusions because of the inclusion of multiple nutrients that may impact immune functions, the mismatching of control feedings for nitrogen and/or energy, and the extensive use of post-hoc subgroup analysis. More recent trials have attempted to address these concerns, and have found benefit to groups receiving the modified formulas (Atkinson et al., 1998; Daly et al., 1995; Houdijk et al., 1998; Kudsk et al., 1996; Senkal et al., 1997). An evidence-based review by Zaloga (1998) found that 12 of 13 prospective randomized clinical trials attributed beneficial outcomes to immune-enhancing enteral formulas and that evidence for their use among critically ill patients would meet level I

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

recommendation criteria. A meta-analysis by Heys and colleagues (1999) examined 11 prospective randomized trials of enteral nutritional supplementation with formulations containing key nutrients felt to favor immune function. The control subjects received standard enteral formulas. There were a total of 1,009 evaluable subjects who were critically ill patients with trauma or burn or were patients who had surgery for gastrointestinal cancer. Findings suggested that enteral feeding with formulas with a combination of possible immune-enhancing nutrients added resulted in a significant reduction in the risk of infectious complications and reduced the length of overall hospital stay in patients with critical illness and patients with gastrointestinal cancer. There was, however, no effect on mortality. Although older persons are subject to relative decline in immunocompetence with aging and might accrue benefit from such modified feeding formulations, these feedings have not yet been rigorously evaluated for efficacy among older, critically ill patients.

Critical Illness Summary

The benefits of enteral versus parenteral nutrition support have not been clearly established for patients with critical illness. The preponderance of recent research suggests that trauma patients fed enteral nutrition have fewer complications than those given TPN. Nutrient formulations modified with specific nutrients which may preserve or promote immune or other vital functions have shown promise in preliminary trials with critically ill patients, but studies among older persons are inadequate to draw definitive conclusions for the Medicare population at this time.

Critical Illness Recommendations
  • There is a need for prospective randomized trials of enteral versus parenteral nutrition in well-characterized subgroups of critically ill patients. Older persons should be included and, when safe and appropriate, nonintervention controls should be considered.

  • The efficacy of supplementation with specific nutrients in regard to immune or other vital functions in the critically ill warrants further investigation with well-designed prospective randomized trials that focus on single nutrients and include appropriate controls.

PERIOPERATIVE NUTRITION SUPPORT

The effect of perioperative nutritional support—that is, nutrition support given before and/or after surgery—has been evaluated in a number of prospective randomized clinical trials, in meta-analyses, and by expert

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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groups. These evaluations indicate that perioperative nutrition support is efficacious in selected surgical populations such as gastrointestinal cancer surgery patients and elderly hip fracture patients. In addition, there is current evidence and expert opinion supporting the use of nutritional support in severely malnourished patients undergoing major elective surgery and in surgical patients unable to eat for more than 1 to 2 weeks pre-and/or postoperatively.

Gastrointestinal Surgery
Enteral Nutrition

A meta-analysis of six randomized, controlled clinical trials of gastrointestinal cancer surgery patients treated postoperatively with enteral supplements enriched with selected nutrients (Heys et al., 1999) revealed a significant reduction in the risk of developing infectious complications and in length of stay in the treatment patients compared to patients receiving standard enteral nutrition. The enriched enteral nutrition formulas had no effect on incidence of pneumonia or death.

One large study included in the meta-analysis was a multicenter trial conducted in Germany (Senkal et al., 1997). Within 12 hours of upper gastrointestinal cancer surgery, patients were randomized to receive an enteral formula enriched with arginine, dietary nucleotides, and omega-3 fatty acids (n = 77, mean age 65 years) or a standard formula with identical calorie and protein content (n = 77, mean age 66 years). Early feeding was well tolerated by both patient groups. Patients who received the enriched formula experienced significantly fewer late (more than 5 days after surgery) infectious and wound-healing complications compared with the standard enteral group. The costs for treating the complications were substantially less in the enriched-formula group compared to the standard-formula group.

Another large study included in the meta-analysis reported similar findings (Braga et al., 1998). Gastrointestinal surgery patients (n = 166, mean age 62 years) were randomized into one of three groups: a standard-formula group, an enriched-formula group, or a TPN group. In all three groups, nutrition support was initiated 12 hours after surgery. Early enteral feeding was well tolerated by both groups given enteral formulas. In a subgroup of malnourished and transfused patients, the enriched-formula group had significantly less severe infectious complications and a shorter hospital stay compared to the TPN group.

In a related study, the effects of three different nutrition support techniques on 260 patients following major abdominal surgery were evaluated (Gianotti et al., 1997). Patients were randomly assigned to receive a

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

standard enteral formula; an enteral formula enriched with arginine, omega-3 fatty acids, and RNA; or TPN. All of the nutritional support regimens contained equal amounts of calories and protein and were started 6 hours after surgery. Compared with patients who received either standard enteral nutrition or TPN, patients who received the enriched enteral formula had significantly better immune measures, fewer complications, and a shorter length of hospital stay.

Recent trials have also examined the efficacy of standard enteral formulas versus placebo formulas or regular oral diets. A two-phase clinical trial evaluated the effects of oral dietary supplements versus a regular diet in 100 marginally nutritionally depleted gastrointestinal surgery patients (Keele et al., 1997). Patients were randomly assigned to either a control group (mean age 60 years) or an oral supplement group (mean age 64 years). In phase 1, the inpatient phase, the treatment group had significantly better nutritional intake, fewer complications, less fatigue, and less weight loss when compared to the control group. In the outpatient phase, phase 2, patients in the treatment group continued to have better nutritional intakes, but measures of nutritional status and well-being were not significantly different from the control group. An earlier study (Beier-Holgersen and Boesby, 1996) had similar results. After major abdominal surgery, patients (n = 30) were randomly assigned to receive either enteral feeding or a placebo (flavored water) through a nasoduodenal feeding tube. Patients in the enteral feeding group had a significantly lower rate (p < 0.001) of infectious complications than patients in the placebo group. Considering the substantial costs associated with treating infectious complications and of administering TPN, coupled with the costs of longer hospital stays, the use of early enteral nutrition has implications for reducing overall hospital costs.

Total Parenteral Nutrition

Estimates from a pooled analysis of 13 prospective randomized clinical trials have indicated that TPN given to “malnourished” gastrointestinal cancer patients, as defined by weight loss, plasma proteins, or prognostic indices, for 7 to 10 days before surgery reduced the overall risk of postoperative complications by approximately 10 percent. In contrast, a pooled analysis of nine prospective randomized clinical trials in a similar population indicated that postoperative TPN increased the overall risk of postoperative complications by approximately 10 percent (Klein et al., 1997).

A key study in the pooled analysis, the Veterans Affairs Total Parenteral Nutrition Cooperative Study Group (VA TPN Cooperative Study Group, 1991) evaluated the use of TPN in 395 patients (mean age 63

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

years) undergoing thoracoabdominal surgery. Patients were randomly assigned either to receive TPN for 7 to 15 days before surgery and 3 days after surgery or to a regular diet. Patients who were randomized to TPN and who were identified as severely malnourished (weight loss >10 percent, albumin <2.8g/dL, nutrition risk index <83.5) had fewer noninfectious complications compared to similar malnourished patients randomly assigned to a regular diet. Patients who were mildly malnourished and received TPN had more infectious complications than patients who received a regular diet.

A second study in the pooled analysis had a comparable design and findings. Gastrointestinal cancer surgery patients (n = 125) who received preoperative parenteral nutrition had fewer postoperative complications, better serum protein and immune parameters, and a lower mortality rate than patients who received a regular diet (Müller et al., 1982). Similarly, Fan and colleagues (1994) reported significantly less postoperative pneumonia and diuretic use in a group of surgical patients with hepatic cancer who received perioperative parenteral nutrition versus patients who received a regular diet.

Five to 7 days of postoperative parenteral nutrition was compared to feeding with 5 percent glucose infusion in a large number of patients (n = 678) undergoing major elective abdominal surgery (Doglietto et al., 1996). They concluded that the two groups of patients did not significantly differ in terms of complications or mortality rates. In another study of postoperative parenteral nutrition, patients (n = 300) who received parenteral nutrition for 14 days after surgery had higher complication and mortality rates compared to patients who received glucose infusions (Sandström et al., 1993).

Several investigations have tested the effects of enriched TPN solutions in patients following major abdominal surgery. TPN enriched with omega-3 fatty acids improved selected immune status parameters in 40 gastrointestinal surgery patients (Wachtler et al., 1997). While these findings were not associated with significant changes in the rate of postoperative complications, they provide evidence that enriched TPN solutions can modulate immune function. Twenty-eight elective abdominal surgery patients (mean age 68 years) were randomly assigned to either standard TPN or TPN supplemented with glutamine dipeptide (Morlion et al., 1998). The use of supplemented TPN resulted in improved nitrogen balance, improved immune parameters, and shortened hospital stay.

Taken together, these results suggest that (1) TPN should be reserved for severely malnourished patients, (2) short-term therapy with glucose infusions does not complicate recovery from surgery, (3) early enteral nutrition is preferable to TPN in the postoperative period, and (4) enriched parenteral solutions may have beneficial effects.

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×
Hip Surgery

Studies that have evaluated the use of oral and enteral nutritional supplementation after surgical repair of hip fracture in frail elderly patients consistently report beneficial effects. In two studies, supplemental nutrition following surgery reduced postoperative complications and shortened rehabilitation time and hospital stay (Bastow et al., 1983; Delmi et al., 1990). Elderly women (n = 744) who had undergone hip fracture surgery were divided into three groups based on nutritional status: well nourished, thin, and very thin (Bastow et al., 1983). Patients who were thin or very thin were randomly assigned to receive overnight tube feedings in addition to a regular diet. Enteral supplementation was associated with improvements in nutritional and serum protein status in both groups. In addition, patients in the very thin group had shorter rehabilitation times and hospital stays compared to those who did not get the nightly tube feedings.

Similar results with oral supplemental feeding in elderly patients (mean age 82 years) with femoral neck fracture were reported (Delmi et al., 1990). Patients who were randomly assigned to receive a daily oral nutrition supplement had significantly lower rates of complications and shorter hospital stays compared to nonsupplemented patients. These findings are also similar to a clinical trial in elderly subjects (mean age 81 years) (Schürch et al., 1998). In a 6-month randomized, double-blind trial, 82 patients with recent hip fractures were randomly assigned to receive protein supplementation (20 g per day) or an isocaloric placebo. Patients who were given supplemental protein had significantly shorter hospital stays and attenuated proximal femur bone loss. In another study, 18 elderly male hip fracture patients who received supplemental nightly enteral nutrition (mean age 76.5 years) during hospitalization had lower mortality rates within 6 months of surgery compared to control patients (mean age 74.5 years) (Sullivan et al., 1998). No differences between supplemented patients and control patients were found in relation to postoperative complications and in-hospital mortality.

Perioperative Nutrition Support Summary

Consistent data show that enriched enteral nutrition administered in the postoperative period reduces the incidence of infectious complications and length of hospital stay in gastrointestinal cancer surgery patients. There are extensive data to suggest that preoperative TPN administered for 7 to 10 days decreases postoperative complications in these patients.

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

There are limited, but consistent data to suggest that postoperative oral and enteral supplementation decreases complications and length of stay and speeds rehabilitation in elderly hip fracture patients.

Perioperative Nutrition Support Recommendations
  • Enriched enteral nutrition may be considered for older patients following gastrointestinal cancer surgery.

  • Postoperative enteral nutrition is recommended for undernourished hip fracture patients.

  • Further studies are needed to evaluate the safety and benefits of enteral and parenteral nutrition, including the use of early enteral nutrition and modified enteral formulas, in well-characterized groups of older surgical patients.

LIMITATIONS OF NUTRITION SUPPORT EVIDENCE

Table 10.1 summarizes available studies on the role of nutrition support. As can be seen, there have been few clinical trials of nutrition support with elderly subjects. Some observations may be reasonably generalized from studies of middle-aged adults, but limitations in design, inadequate sample size, the inclusion of heterogeneous subjects of variable nutritional risk, and inappropriate clinical outcome measures often preclude this possibility. Information is therefore insufficient to draw specific conclusions regarding some of the possible indications for use of enteral and parenteral nutrition for Medicare beneficiaries. The absence of broad-based evidence that nutrition support favorably impacts diverse outcomes for older persons does not, however, condemn its use.

Although most patients do not appear to require enteral or parenteral nutrition support interventions, clear benefits have been established for selected subgroups of patients. Those individuals with inadequate intestinal length or function or those with severe oropharyngeal dysfunction or permanent neurological impairment are striking examples. In order to avoid complications of semistarvation, it also appears prudent to consider nutrition support in selected patients who will otherwise be unable to eat or to assimilate adequate nutrition for more than 7 to 10 days. Patients who are undernourished at baseline and/or highly stressed may not, however, tolerate this duration of starvation. Such patients may include those with major trauma or severely undernourished patients who undergo major elective surgical procedures. The frail older person with hip fracture is an example of an appropriate candidate for nutrition support intervention.

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

The need for skilled nutrition professionals to oversee the safe and appropriate administration of enteral and parenteral nutrition in the hospital has been repeatedly emphasized in the nutrition literature. The requirement for skilled nutrition personnel is supported by three observations: (1) the need for appropriate patient selection to accrue benefit and justify risk, (2) the potential for serious complications that require close surveillance, and (3) the appreciable costs that can be associated with these interventions and their related complications.

DELIVERY OF NUTRITION SUPPORT

Parenteral and enteral nutrition support are complex medical nutrition therapies that may result in significant morbidity or mortality if administered inappropriately. Parenteral and enteral nutrition support have traditionally been administered by a multidisciplinary team consisting of a physician, registered nurse, registered dietitian, and registered pharmacist. Several models exist for the organization of a nutrition support service. In one model, a free-standing department operates with a physician-, dietitian-, pharmacist-, or nurse-director, and an appropriate number of employees. In another more common model, clinicians retain appointments in their primary departments and consult as needed with other team members. Institutions with fewer resources or fewer patients receiving enteral or parenteral nutrition may function with a nutrition support committee. The model in place in any institution depends upon available resources, local practice patterns, and institutional tradition. Many clinicians express strong opinions about the preferred model, but there is little documentation that one model is superior to another.

In some institutions, nutrition support teams have been established to reduce inappropriate resource utilization, increase revenue, and/or improve patient care. Initially, teams were supported by revenue generated from the provision of parenteral nutrition. As revenue from parenteral nutrition has declined, nutrition support teams have been under pressure to or have already downsized. Some institutions have eliminated nutrition support teams based on the rationale that the work they perform can be done by less specialized staff. However, most of the work performed by the nutrition support team members (assessment of nutritional status, implementation of enteral and parenteral nutrition therapy, monitoring response to therapy, patient education, and quality assurance monitoring) is a necessary part of quality patient care. Thus, the true cost of a nutrition support team is probably limited to the expenses needed for coordination of team activities. Most regulatory agencies and many hospitals accept the multidisciplinary nutrition support team as the standard of care for provision of enteral and parenteral nutrition.

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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TABLE 10.1 Hospital Settings: Evaluation of Nutrition Support Interventions

 

Observational Studiesa

Consensus Document

Systematic Review

Intervention

GPb

Elderly

GP

Elderly

GP

Elderly

Gastrointestinal

Short bowel

Enteral

Parenteral

Fistulas

Enteral

Parenteral

Inflammatory bowel disease

Enteral

Parenteral

Pancreatitis

Enteral

Parenteral

Liver disease

Enteral

Parenteral

HIV/AIDS

Enteral

Parenteral

Cancer Therapy

Chemotherapy

Enteral

Parenteral

Radiation Therapy

Enteral

Parenteral

Renal Failure

Acute

Enteral

Parenteral

Chronic

Enteral

Parenteral

Critical Illness

Enteral

Parenteral

Perioperative

Abdominal

Enteral

Parenteral

Hip fracture

Enteral

Parenteral

a This category includes case series, case-control studies, cohort studies and nonrandomized trials of nutrition-based therapies including nonhuman studies.

b GP = general population.

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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Some Clinical Trial Evidence

Extensive Clinical Trial Evidence

 

GP

Elderly

GP

Elderly

Overall Strength of Evidence Supporting Nutrition Therapy for Elderly Persons

Efficacious

Efficacious

Insufficient data

Efficacious

Insufficient data

Not primary therapy

Insufficient data

Insufficient data

Insufficient data

Insufficient data

Insufficient data

Insufficient data

Not supported

Not supported

Not supported

Not supported

Insufficient data

Insufficient data

Insufficient data

Not supported

Insufficient data

Insufficient data

Selected efficacy

Selected efficacy

Efficacious

Insufficient data

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

In instances where nutrition support teams have been eliminated, the work formerly performed by dietitians, pharmacists, and nurses must then be performed by physicians, which may actually increase costs. The literature suggests that without the aid of a nutrition support team, patients receiving nutrition support are subjected to increased complications and increased costs in the form of unnecessary therapy. A discussion of these studies follows.

Early studies justified nutrition support teams based on their role in reducing catheter sepsis during parenteral nutrition (Dalton et al., 1984; Faubion et al., 1986; Hickey et al., 1979; Jacobs et al., 1984; Nehme, 1980; Sanders and Sheldon, 1976; Traeger et al., 1986). Several of these studies attributed positive results to trained nursing staff who used standard protocols for dressing changes and catheter care. However, none of these trials were randomized, only two were prospective, and results are difficult to aggregate due to inconsistent definitions of catheter sepsis.

Several studies have looked at the role of the nutrition support team in reducing electrolyte abnormalities in patients receiving TPN. In an early study of 382 patients, Nehme (1980) found fewer electrolyte abnormalities in patients whose parenteral nutrition was managed by a team.

However, in a retrospective review of 31 patients prior to team formation and a prospective review of 9 patients following team formation, no significant difference was found in the number of electrolyte abnormalities (Hickey et al., 1979). Jacobs and coworkers (1984) reported similar findings in a retrospective review of 78 patients. In both of these studies, the team functioned by team members making recommendations to the referring physician who managed his/her own patients, which could have inhibited team effectiveness.

These two studies (Hickey et al., 1979; Jacobs et al., 1984) described the method of practice during the initiation phase of a nutrition support team and may not represent the practice of an established team. In a later study of 206 patients (mean age 53 years, range 18–88 years) significantly less hypokalemia (12 percent versus 3 percent, p < 0.05) and hyperglycemia (47 percent versus 22 percent, p < 0.01) were found when cohorts of team-managed patients from 1992 and 1979 were compared (ChrisAnderson et al., 1996). The authors attributed this improvement in practice over time to established protocols as well as educational efforts. A significant reduction in metabolic complications of TPN (34 percent versus 66 percent, p < 0.005) was reported in a study (n = 209) when teammanaged patients were compared with non-team-managed patients (Trujillo et al., 1999).

Team management of enteral nutrition has also resulted in significantly fewer metabolic abnormalities (Brown et al., 1987; Hassell et al., 1994; Powers et al., 1986). In a prospective study of 101 patients (mean age

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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64 years, ± 16 years) 513 metabolic abnormalities in non-team-managed patients were documented compared to 131 in team-managed patients (p < 0.05) (Powers et al., 1986) Formula modifications to correct abnormalities were made significantly more often (30 percent versus 9.8 percent, p < 0.05) by the nutrition support team. In a similar study of 102 patients, 49 percent of enterally fed patients managed by a nutrition support team had metabolic abnormalities compared to 72 percent of the non-team-managed patients (p < 0.01) (Brown et al., 1987). Thus, it appears that nutrition support team management has resulted in fewer metabolic abnormalities, particularly for patients receiving enteral feeding.

Nutrition support teams are also more effective with respect to nutrition outcomes. Team-managed patients received more nutritional assessments (Traeger et al., 1986), and significantly more patients achieved nutrition goals (Powers et al., 1986; Traeger et al., 1986). Hassell and colleagues (1994) found that team-managed enteral patients had significantly fewer metabolic, pulmonary, and gastrointestinal complications despite significantly higher acuity. In general, patients followed by nutrition support teams were monitored more frequently for laboratory abnormalities. More frequent monitoring was probably the reason that one team identified a higher incidence of hypomagnesemia as the team gained experience (ChrisAnderson et al., 1996).

Many nutrition support teams have a role in cost reduction by identifying and implementing the most cost-effective therapy. For example, a retrospective study of 31 patients compared costs of nutrition therapy for patients when nutrition support team recommendations were followed versus when they were not (O’Brien et al., 1986). In 14 cases, the referring physician did not comply with the recommendations of the nutrition support team. In 12 of these cases, a less expensive form of therapy (enteral nutrition) was recommended. Cost comparisons were based on 1984 patient charges which included overhead. Differences in the cost of therapy received and the cost of the therapy recommended by the nutrition support team were calculated and a potential cost saving of $72,270 was identified.

A prospective review of 50 patients (average age 63 ± 4 years) who received parenteral nutrition identified inappropriate or avoidable days of parenteral nutrition (Maurer et al., 1996). Independent review by two clinicians followed by a quality assurance subcommittee was used to determine inappropriate and avoidable TPN. Of 469 days of parenteral nutrition, 22 percent were inappropriate and half of the days were avoidable. Most avoidable days of TPN (184) were due to failure to access the gastrointestinal tract. Based on estimated costs to the hospital to provide TPN, the authors projected a savings of approximately $220,000 annually if a multidisciplinary oversight group had eliminated the use of avoidable

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

or inappropriate TPN. Costs of monitoring and alternate therapy were not included in the study, and overhead was not calculated for anything other than the TPN preparation.

In a similar study, 209 patients who were started on TPN over a 4-month period were prospectively followed (Trujillo et at., 1999). Of the 209 starts, 62 percent were indicated, 23 percent were preventable, and 15 percent were not indicated. Standards established by the American Society for Parenteral and Enteral Nutrition were used to determine whether TPN was “indicated” or “not indicated.” TPN was considered to be preventable when the gastrointestinal tract was functioning. For patients followed by the nutrition support team, 82 percent of the starts were indicated. For patients not followed by the nutrition support team, 56 percent of the starts were not indicated (p < 0.005). Avoidable charges were calculated based on a charge of $301 per day for parenteral nutrition. Avoidable charges per parenteral nutrition day averaged $20.57 for nutrition support team-managed patients versus $94.57 per day for non-nutrition support team patients. Reduced charges of approximately $430,000 annually could be projected based on the above data. These charges do not take into consideration the cost of overhead, costs of substitute therapy, or team management of patients. However, these data point to the role of a multidisciplinary nutrition support team in reducing charges to the patient.

Perhaps the most impressive economic data are those of Hassell et al. (1994) who studied 136 elderly patients (mean age 72 years) receiving enteral nutrition support for more than 24 hours. Cost calculations included salaries for clinicians and support personnel to provide care using a team or non-team model. Benefit was calculated based on dollar savings resulting from reduced length of hospital stay applied to the deficit shown between hospital costs and expected reimbursement. Of the surviving patients, 41 received care provided by the nutrition support team and 53 received care from non-team staff members. Mean patient acuity score assigned by the Pittsburgh Research Institute Patient Management Category System was 3.02 for the nutrition support team group and 1.83 for the non-team group (p < 0.001) with the average score of a hospitalized patient being 1.00. Patients managed by the nutrition support team had a hospital stay 2.43 days shorter than non-team patients, which was not statistically significant. However, the net savings (reduction in length-of-stay personnel costs associated with care) was $1,174 per patient which translated into a benefit of $4.20 for every $1 invested in salaries of nutrition support team personnel.

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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Role of the Dietitian

The role of the dietitian in parenteral and enteral nutrition has been widely expanded beyond the early descriptions of Wade (1977). Initially, dietitians focused only on the assessment of nutritional status, selection of enteral feedings, and transition to oral intake. Dietitians today measure body composition, perform indirect calorimetry, monitor the metabolic response to enteral and parenteral nutrition therapy, and in some cases order parenteral and enteral nutrition. In a 1996 survey by Olree and Skipper (1997), dietitians were found to have increased their role in parenteral nutrition and in monitoring drug–nutrient interactions when compared to a similar study conducted by Jones et al. (1986) a decade earlier.

Significantly improved enteral feeding tolerance (p < 0.05) was demonstrated in patients for whom dietitian recommendations for enteral feeding were implemented (Braunschweig et al., 1988). The same study showed that the goal rate of enteral formula delivery was achieved sooner (4 versus 7 days) when recommendations by the dietitian were implemented. Another study found that 56 percent of dietitian recommendations for parenteral nutrition were implemented (Skipper et al., 1994), which is comparable to the data of O’Brien and colleagues (1986) previously cited for recommendations made by a multidisciplinary team.

Specialty credentials based on role delineation studies are available for dietitians involved with parenteral and enteral nutrition. While the number of credentialed dietitians is increasing, surveys indicate that nutrition support positions for dietitians have declined often disproportionately to other workers (Compher and Colaizzo, 1992; Compher et al., 1989). The effect of these declines has not been measured. However, the requirements for nutrition assessment are increasing, and with decreasing hospitalizations, the percentage of malnourished patients would logically remain the same or increase. Therefore, regulatory agencies should be encouraged to ensure that sufficient qualified staff are available to monitor patients receiving enteral and parenteral nutrition.

Delivery of Nutrition Support Recommendations
  • A multidisciplinary team approach to the provision of nutrition support is recommended for Medicare beneficiaries in the hospital setting. A variety of team models may fulfill this need and the approach chosen by an individual acute care hospital may be best determined by institutional resources and policy.

  • The dietitian should be a key member of the multidisciplinary team. Optimally it would also include a physician, pharmacist, and nurse, irrespective of the model chosen.

Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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  • Medicare reimbursement to hospitals for nutrition support-related activities should be continued and periodically re-evaluated for adequacy.

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Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

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Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

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Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
×

Wyncoll DL. 1999. The management of severe acute necrotising pancreatitis: An evidence-based review of the literature. Intensive Care Med 25:146–156.


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Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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Suggested Citation:"10 Nutrition Support." Institute of Medicine. 2000. The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population. Washington, DC: The National Academies Press. doi: 10.17226/9741.
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Malnutrition and obesity are both common among Americans over age 65. There are also a host of other medical conditions from which older people and other Medicare beneficiaries suffer that could be improved with appropriate nutritional intervention. Despite that, access to a nutrition professional is very limited.

  • Do nutrition services benefit older people in terms of morbidity, mortality, or quality of life?
  • Which health professionals are best qualified to provide such services?
  • What would be the cost to Medicare of such services? Would the cost be offset by reduced illness in this population?

This book addresses these questions, provides recommendations for nutrition services for the elderly, and considers how the coverage policy should be approached and practiced. The book discusses the role of nutrition therapy in the management of a number of diseases. It also examines what the elderly receive in the way of nutrition services along the continuum of care settings and addresses the areas of expertise needed by health professionals to provide appropriate nutrition services and therapy.

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