Timely Tube Feeding

Because Life matters

Sarcopenia.jpg

Nutrition - the energy for life

The European society for clinical nutrition and metabolism (ESPEN) worked out guidelines1 especially for geriatric patients in 2018 to support a good nutritional status for these patients.

 

Nutrition delivers energy and nutrients for life. But especially elderly patients have a high risk of an insufficient energy and nutrient supply2,3. This risk increases in patients with an acute or chronic illness2,3. As a consequence, they can lose body weight resulting in a further deterioration of their health status4,5. And not all conditions allow patients to meet their nutritional needs orally6.


 

ESPEN Guidelines on Clinical Nutrition and Hydration in Geriatrics


Aim of the ESPEN Guidelines1:

Evidence-based recommendations for the nutritional management of older patients with or at risk of malnutrition to meet nutritional requirements and thus to maintain or improve nutritional status

Intention of the ESPEN Guidelines1:

Maintenance or improvement of function, activity, capacity for rehabilitation and quality of life, support of independence and a reduction of morbidity and mortality


 

The main statement: Early tube feeding matters

Early tube feeding is indicated in patients with reasonable prognosis with a defined timeline and justification to meet nutritional requirements and maintain or improve nutritional status.

 



Tube feeding: Why and when?

  • If oral intake is not possible or sufficient, tube feeding can help to give patients the energy and nutrients they need1
  • The guideline states EN shall start early to improve or maintain the patient’s condition and quality of life1
  • A close relation between malnutrition and poor outcome, e.g. increased rates of infections, pressure ulcers, length of hospital stay, duration of convalescence after acute illness and mortality is well-documented in older persons1


 

The ESPEN Guidelines on Clinical Nutrition and Hydration 2018 offer a clear and easy definition about the …

When?

  • If oral intake is expected to be impossible for more than 3 days (Rec. 29)
    OR oral intake is expected to be less than 50 % of energy requirements for more than 1 week (Rec. 29)
  • In older patients with malnutrition, EN shall start early; shall be gradually increased during the first 3 days in order to avoid refeeding syndrome (Rec. 39)
When-Tubefeeding?

How?

  • Older patients who require EN presumably for less than 4 weeks should receive a nasogastric tube (NGT)(Rec. 33)
  • Older patients expected to require EN for more than 4 weeks or who do not want or tolerate a nasogastric tube should receive a percutaneous gastrostomy tube (PEG) (Rec. 34)
  • Tube-fed patients shall be encouraged to maintain oral intake as far as safely possible (Rec. 35)
When-Tubefeeding?

What?

Increase nutrition support gradually during the first 3 days
  • Energy: With 30 kcal/kg/BW/day (Rec. 1)
  • Protein: At least 1 g/kg/BW/day (Rec. 2)
  • For EN, fibre-containing products should be used* (Rec. 3)

*unless contraindicated

When-Tubefeeding?


A good nutritional status in combination with physical activity can

  • Preserve muscle mass and maintain/improve functional status7
  • Improve wound healing8
  • Enhance Quality of Life through improving nutritional status, e.g. better progress in rehabilitation and recovery (possibly resulting in early hospital discharge), better ability to carry out activities of daily living9


 What‘s the problem?

…especially for patients with limited mobility

Prolonged bed rest and physical inactivity ⇒ deleterious effects across the bodily systems:

  • Loss of bone density and muscle
  • Loss of muscle strength and power (especially in the legs)
  • Reduced heart size and function
  • Blood vessel stiffening

⇒ Fatigue, low physical function, poor quality of life10  

Hospital admissions and spending long periods of time in bed are a major contributor to declining abilities in older people11  


More than half of people do not regain their previous level of function within a year12

What's the solution?

Promote early mobility of adults in hospital

  • Improved walking ability
  • Reduced length of stay
  • Reduction of medical complications (pulmonary embolism)13  
Proven in 13 studies with 2,703 people included

Exercise programmes during hospitalisation prevent functional and cognitive decline (e.g. memory, concentration) and can reduce overall length of stay14

Patient-led low-cost daily programme reverses the functional decline, improves balance, cognition and quality of life15




Motivate your patients to engage in physical activity

Weight loss is often accompanied by a considerable loss of muscle mass and strength. We have developed exercises for mobile and immobile patients to support their physical activity and enhance Quality of Life.

Thai Chi in sitting position

Excercise on a chair

Exercises suitable in bed



References:

1. Volkert D et al. Clin Nutr 2019;38(1):10-47.
2. Wells JL, Dumbrell AC. Clin Interv Aging 2006;1(1):67–79.
3. Stratton RJ et al. CABI Publishing 2003.
4. Volkert D et al. Clin Nutr 2006;25(2):330–360.
5. Morley JE et al. J Am Med Dir Assoc 2013;14(6):392–397.
6. Burgos R et al. Clin Nutr 2017;37(1):354-396.
7. Deutz NE et al. Clin Nutr 2014;33(6):929–936.
8. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.
9. Chidester JC, Spangler AA. J Am Diet Assoc 1997;97(1):23–28.
10. Kehler et al, 2019
11. Gill et al, 2015
12. Gill et al 2010
13. Cortes et al.2018
14. de Morton et al, 2007
15. Nicolás Martínez-Velilla  et al, 2019




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