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Clinical Nutrition 28 (2009) 461–466
Contents lists available at ScienceDirect
Clinical Nutrition
journal homepage: http://www.elsevier.com/locate/clnu
ESPEN Guidelines on Parenteral Nutrition: Geriatrics
a b c d e f g
L. Sobotka , S.M. Schneider , Y.N. Berner , T. Cederholm , Z. Krznaric , A. Shenkin , Z. Stanga ,
G. Toigoh, M. Vandewoudei, D. Volkertj
a ´ ´
Department of Metabolic Care and Gerontology, Medical Faculty, Charles University, Hradec Kralove, Czech Republic
bNutritional Support and Intestinal Transplant Unit, Archet University Hospital, University of Nice Sophia-Antipolis, Nice, France
cMeir Medical Centre, Tel Aviv University, Sackler Medical School, Tel Aviv, Israel
dDepartment of Public Health and Caring Sciences/Clinical Nutrition and Metabolism, Uppsala University, Uppsala Science Park, Uppsala, Sweden
eDepartment of Gastroenterology & Clinical Nutrition, Clinical Hospital Center and School of Medicine Zagreb, Zagreb, Croatia
f Department of Clinical Chemistry, University of Liverpool, Liverpool, UK
gDivision of Endocrinology, Diabetes and Clinical Nutrition, Department of General Internal Medicine, University Hospital, Bern, Switzerland
hGeriatric Unit, Division of Internal Medicine, Department of Clinical Morphological Technological Sciences, University of Trieste, Trieste, Italy
i Department of Geriatrics, University of Antwerp, Ziekenhuisnetwerk Antwerpen (ZNA), Antwerp, Belgium
j Departments of Nutrition and Food Science, University of Bonn and Pfrimmer Nutricia, Erlangen, Germany
articleinfo summary
Article history: Older subjects are at increased risk of partial or complete loss of independence due to acute and/or
Received 4 February 2009 chronic disease and often of concomitant protein caloric malnutrition. Nutritional care and support
Accepted 1 April 2009 should be an indispensable part of their management. Enteral nutrition is always the first choice for
nutrition support. However, when patients cannot meet their nutritional requirements adequately via
Keywords: the enteral route, parenteral nutrition (PN) is indicated.
Nutritional support in the elderly PN is a safe and effective therapeutic procedure and age per se is not a reason to exclude patients from
Enteral nutrition in the elderly this treatment. The use of PN should always be balanced against a realistic chance of improvement in the
Parenteral nutrition in the elderly general condition of the patient. Lower glucose tolerance, electrolyte and micronutrient deficiencies and
Malnutrition in the elderly
Subcutaneous fluid administration lower fluid tolerance should be assumed in older patients treated by PN. Parenteral nutrition can be
administered either via peripheral or central veins. Subcutaneous administration is also a possible
solution for basic hydration of moderately dehydrated subjects. In the terminal, demented or dying
patient the use of PN or hydration should only be given in accordance with other palliative treatments.
2009European Society for Clinical Nutrition and Metabolism. All rights reserved.
Preliminary remarks pressure ulcers), length of stay in hospital and duration of conva-
lescence after acute illness in geriatric patients.
An elderly subject is usually defined, in western countries, as A reduced capacity for rehabilitation is characteristic of older
a person over the age of 65 (WHO). A geriatric patient is an older patients, making it more difficult to rehabilitate and to return the
adult seeking medical care. He or she may be independent and patient to normal or to his/her previous condition. Muscle mass
generally healthy needing mainly preventive care, but is often restoration is more complicated in terms of exercise and nutrition
someone who has a loss of independence caused by acute and/or 1
than in younger patients.
chronicdiseases(oftenmultiplepathology)withrelatedlimitations Manyfactorsthatcompromisenutrientandfluidintakeincrease
inphysical,psychological,mental,cognitiveand/orsocialfunctions. theriskofundernutritionwithaprogressivelossofleanbodymass.
The ability to perform the basic activities of independent daily Since restoration of body cell mass is more difficult in older
1 preventative nutritional support with adequate intake of
living maythenbejeopardisedorlost.Suchapersonisinincreased persons,
need of rehabilitative, physical, psychological and social care to energy, protein and micronutrients should be considered in every
avoid partial or complete loss of independence. Moreover muscle elderly patient.
mass deficit, i.e. sarcopenia, is a frequent comorbid situation. Nutritional care should be an integral part of the overall care
Studies haveshownaninverserelationshipbetweennutritional plan, which takes into account all aspects of the patient. A
status and complication rates (e.g. mortality, infections, and comprehensive assessment should include nutritional status and
risk. A nutritional programmetakingintoaccountethicalaswellas
clinical considerations should be implemented.2 Appropriately
E-mail address: espenjournals@espen.org. minimisingtheneedforparenteralnutrition,lessphysiologicaland
0261-5614/$ – see front matter 2009 European Society for Clinical Nutrition and Metabolism. All rights reserved.
doi:10.1016/j.clnu.2009.04.004
462 L. Sobotka et al. / Clinical Nutrition 28 (2009) 461–466
Summaryofstatements: Geriatrics
Subject Recommendations Grade Number
Indications Age per se is not a reason to exclude patients from PN. C [IV] 1.1.
PNisindicatedandmayallowadequatenutritioninpatientswhocannotmeettheirnutritionalrequirements C [IV] 1.1.
via the enteral route.
PNsupport should be instituted in the older person facing a period of starvation of more than 3 days or if C [IV] 1.1.
intake is likely to be insufficient for more than 7–10 days, and when oral or enteral nutrition is impossible.
Pharmacological sedation or physical restraining to make PN possible is not justified. C [IV] 1.1.
PNis a useful and effective method of nutritional support in older persons but compared to EN and oral B [III] 1.2.
nutritional supplements are much less often justified.
Metabolic/physiological Insulin resistance and hyperglycaemia together with impairment of cardiac and renal function are the C [IV] 2
features in older subjects most relevant features. They may warrant the use of formulae with higher lipid content.
Deficiencies in vitamins, trace elements and minerals should be suspected in older subjects. B [IIb] 2
The effect of nutritional support on restoration of depleted body cell mass is lower in elderly patients than B [IIa] 2
in younger subjects. The oxidation capacity for lipid emulsions is not negatively influenced by age.
Peripheral PN Both central and peripheral nutrition can be used in geriatric patients. C [IV] 3
Osmolarity of peripheral parenteral nutrition should not be higher than 850 mOsmol/l. B [III] 3
Subcutaneous fluid The subcutaneous route is possible for fluid administration in order to correct mild to moderate A[Ia] 4
administration dehydration but not to meet other nutrient requirements.
PNandnutritional status PNcanimprovenutritional status in older as well as in younger adults. However, active physical B [IIb] 5
rehabilitation is essential for muscle gain.
Functional status PNcansupport improvement of functional status, but the margin of improvement is lower than in C [IV] 6
younger patients.
Morbidity and mortality PNcanreducemortality and morbidity in older as well as in middle-aged subjects. C [IV] 7
Length of hospital stay Nostudies have assessed length of hospital stay in older patients on PN. 8
Quality of life Long-term parenteral nutrition does not influence quality of life of older patients more negatively than it C [IV] 9
does in younger subjects.
Specific complications There are no specific complications of PN in geriatric patients compared to other ages, but complications C [IV] 10
tend to be more frequent due to associated comorbidities.
Specific situations Indications for PN are similar in younger and older adults in the hospital and at home. B [III] 11
Ethical problems PNorparenteral hydration should be considered as medical treatments rather than as basic care. Therefore C [IV] 12
their use should be balanced against a realistic chance of improvement in the general condition.
more invasive than the enteral route, demands that frailty be – Does PN accord with the expressed or presumed will of the
detected and characterised in a timely and precise manner. This patient, or in the case of incompetent patients, of his/her legal
assessmentisthusacrucialstepinthediagnosticwork-upofthese representative?
3 and the methodological approach should be multidi- – AretheresufficientresourcesavailabletomanagePNproperly?
patients
mensional such as those proposed by national societies of geriat- – If long-term PN implies a different living situation (e.g. insti-
rics; even in this context it is important that the action of the tution vs. home), will the patient derive benefit from it?
clinical nutritionist is integrated with that of the geriatrician and
other medical specialists (in particular, the neurologist, psychia-
trist, and rehabilitation specialist). 1. Indications for PN in older persons
In designing the programme, it should be remembered that the
majorityofsickelderlypatientsrequireatleast1.0–1.2gprotein/kg 1.1. Is PN indicated in geriatric patients?
per day and 20–30kcal/kg per day of non-protein energy,4,5
depending on the severity of the disease, the degree of current PN is a safe and effective therapeutic procedure, on the
inflammation/catabolism, the physical activity level and the need conditionthatitisprovidedbyanexperiencedteam.Ageperseis
and time course of rehabilitation. Although, current literature not a reason to exclude patients from PN (C).
review suggests that slightly higher protein amounts (1.5 g/kg per PNisindicated and may allow adequate nutrition in patients
day) should be warranted in the malnourished elderly to improve whocannot meet their nutritional requirements via the enteral
4 studies specifically
nitrogen balance and restore lean body mass, route, and should be limited to situations when EN is contra-
addressing protein supply by parenteral route are still lacking. indicated or poorly tolerated (C).
Nevertheless,inacutelyhospitalisedolderpatientsenergyintakeis PN support should be instituted in the older person facing
rarelysufficienttocoverthebasalenergyexpenditure(BEE).5Many a period of starvation of more than 3 days when oral or enteral
older people also suffer from specific micronutrient deficiencies, nutrition is impossible, and when oral or enteral nutrition has
which should be corrected by supplementation. been or is likely to be insufficient for more than 7–10 days (C).
Institution of PN in older subjects generates the same medical Pharmacological sedation or physical restraining of the
and ethical problems as EN and therefore the same questions patient to make PN possible is not justified (C).
should be asked6:
Comments: Malnutrition is widespread in older people and is
– Doesthepatientsufferfromaconditionthatislikelytobenefit reported in more than half of geriatric patients at the time of
from PN? hospital admission (III).7 In nursing homes and long-term care
– Will PN improve outcome and/or accelerate recovery? institutions even moresubjects maybeaffected.Howeverreported
– Does the patient suffer from an incurable disease, but never- prevalenceratesvaryaccordingtothemethodsusedfornutritional
theless quality of life and wellbeing can be maintained or assessmentandthespecificcharacteristicsofthepopulationunder
8 Nutritional care should beanintegralpartof theoverall
improved by PN? study(III).
– Does the anticipated benefit outweigh the potential risks? care plan. Nutritional support is indicated when patients are at
L. Sobotka et al. / Clinical Nutrition 28 (2009) 461–466 463
risk of developing malnutrition-related complications or when nutritional support. Onlyafewmalnourishedoldersubjectscannot
adequate nutrition is impossible and should be started in a timely be enterally fed. Another reason might be that, at present, malnu-
6
fashion. trition is often overlooked and left untreated. In addition PN might
Enteral nutrition (EN, including oral and enteral routes) should beunderutilisedbecauseitisoftennotconsideredasapossibleand
6
always be the first choice. In patients who cannot meet their practical wayofnutrientdelivery.However,arecentqualitycontrol
nutritional requirements via the enteral route, parenteral nutrition study in the Geneva University Hospital highlighted that, even
(PN)mayallowadequatenutrition.PNisasafeandeffectivemethod when highly justified, PN is frequently inadequate in terms of
of nutrition support for most patients – including older patients. energy, protein, vitamins or trace elements administration and
However, it remains an invasive and costly method potentially 14
further optimisation of current practice is needed.
causing numerous complications, and potentially requiring inten- As a consequence of demographic changes with an increase in
sive nursing care. Therefore it should be restricted to patients who life expectancy the number of older people requiring (home) PN
cannotreceiveadequatenutritionbytheenteralroute. will rise in the future. This is particularly true for the oldest old
This may be the case in patients who are unable to receive EN patients (>90years old), a group in whom artificial nutrition is
(gut failure, high-output fistulas, uncontrollable diarrhoea) or in poorly studied. For these patients there is no exhaustive literature
whom EN alone cannot meet the energy and nutritional require- on any form of artificial nutrition, even though clinical experience
ments, e.g. when tube feeding is poorly tolerated. Many geriatric suggests that adequate and timely nutritional treatment is
patients have cognitive deficits or other mental impairments that fundamental.
may enhance the risk of temporary confusional states during
somatic illnesses. Under such conditions naso-gastric tubes are 2. Are there any metabolic/physiological features in older
likely to be removedbythepatient.Alongwiththis,age-associated subjects that may affect their response to PN?
changes in the physiology of the gastrointestinal tract should be
considered in regard to the effectiveness of nutrient absorption, Insulin resistance, leading to a lower glucose utilisation and
9 Thus, oral/enteral and paren-
particularly during critical illness. hyperglycaemia together with impairment of cardiac and renal
teral nutrition are not mutuallyexclusive but maycomplementone function are the most relevant features. They may warrant the
another. use of formulae with higher lipid content – up to 50% of total
Subjects, whoreceivegeriatric care at home, including PN, need energy intake (C).
considerablesupportfromfamilymembers.Theappropriatenessof Deficienciesinvitamins,traceelementsandmineralsshouldbe
this kind of specialised nutritional support should be considered suspected in older subjects (B). The effect of nutritional support
with caution, taking into account the patients particular circum- on restoration of depleted body cell mass is lower in elderly
stances such as probable survival, rehabilitation potential and patients than in younger subjects; however, the oxidation
complication risk. capacity for lipid emulsions is not negatively influenced by
age (B).
1.2. Is PN a useful method in older malnourished patients? Comments: Insulin resistance and the prevalence of diabetes
PN is a useful method of nutritional support in older mellitus increase with age. Therefore impaired glucose tolerance
15
malnourished patients; however, compared to EN and oral should be looked for in the elderly.
nutritional supplements PN is much less often justified in geri- Vitamin and mineral deficiencies are more prevalent than in
atric patients (B). younger subjects. Many older patients will already have impaired
status of trace elements and vitamins at the time they commence
Comments: Several studies have documented that PN is nutritional support. There is good evidence from the United
a feasible and successful method of nutritional support in older Kingdom and from the United States that up to 40% of individuals
people. In a British survey on PN in 15 hospitals in Northern aged65ormorehaveaninadequateintakeofoneormorevitamins
England,themedianageofPNpatientswas67years(range20–90). or minerals (ascorbate, folate, B12, thiamine, riboflavin, magne-
Thus, more than one half of adult patients on PN are older than sium, iron and zinc) with associated low blood concentrations16,17
10 (IIb). Such abnormalities occur in free living as well as institu-
65 (III).
Similarly, the mean age of 159 parenterally nourished outpa- tionalised individuals, especially in those regarded as food inse-
tientsfromtheClinicalNutritionUnitforHomePNoftheFedericoII cure. Abnormalities are also common in patients admitted to
University Hospital in Naples, Italy (referred from oncology, hospital, probably as a result of recently reduced intake despite the
neurology or surgery units) was 60.1 14.2years with a median increased demands of illness, as well as a poor underlying nutri-
11 Along with this, 18 All essential vitamins and trace elements should
value of 63 and a maximum of 93years (III). tional state.
a further recent Italian survey, investigating the negative outcome therefore be given from the beginning of the course of PN;19 this
of artificial nutrition (cases: EN, 57%; total PN, 30%; mixed, 13%), can be considered an effective way to achieve micronutrient
1
demonstratedthatdeathorinterruption(duetoworseningclinical repletion and correction. In addition, mild (<0.77 mmol l )to
1
conditions within the initial 10 days of treatment) were meaning- severe (<0.45mmol l ) hypophosphataemia is frequently found
fully higher in those aged >80 years and unrelated to the route of on admission, and particularly commonly develops, in older
12 malnourished patients (w5 and 14.1% respectively according to
administration when corrected for the indications.
Reported prevalence rates of PN are, however, very low. In 20).
Kagansky et al.
a prospective study of adjunctive peripheral PN in subacute care Cardiac and renal functions are more likely to be impaired in
patients, Thomas et al. screened 1140 consecutive admissions for olderpersons.Thereforefluidandsodiumintakeshouldbelimited,
patients receiving inadequate EN. By using stringent criteria (e.g. and especially so during periods of mobilisation of extracellular
signs of malnutrition, low intake, no EN, no end stage disease) they water that has accumulated due to inflammatory processes or
21–23
identified only 19 patients (1.7%; mean age 83years) who were during an earlier stage of refeeding (III).
considered eligible for peripheral PN and finally consented to this A study in 325 patients on PN has shown that with a similar
13 The low prevalence of PN may be explained by the fact that nutritional intake, depleted body cell mass was restored more
(III).
oral and enteral interventions are generally the first choice for slowlyinolderpatients.Agewasasignificantindependentvariable
464 L. Sobotka et al. / Clinical Nutrition 28 (2009) 461–466
1
affecting the response to nutritional support (IIb). Probably, given mild to moderate dehydration, especially in chronic care settings
the effect of both aging and related insulin resistance on body cell 33,34 In addi-
where the intravenous route is particularly difficult.
massturnover,4 more protein calories should be delivered but this tion, this technique is less invasive for drug administration in
hypothesis still need to be explored. palliative management where opioid and antiemetic therapy is
35,36 Fluid replacement by hypodermoclysis is
A study in twenty healthy volunteers submitted to a hyper- frequently necessary.
triglyceridaemic clamp showed a similar capacity in young and relatively safe and easy to initiate, demands less nursing time,
oldersubjectstooxidiseahighintravenoustriglycerideload(IIa).24 is more cost effective than intravenous treatment, causes less
However, another study in 24 patients with intestinal failure discomfort, minimises the risk of intravascular infection, does not
showed a markedly higher lipid oxidation along with a lower immobilisealimb,andhasbeenfoundtobelessdistressingforthe
glucose oxidation, which may contribute to the frequent hyper- patients. The technique can be used in the nursing home and home
25 37–40 The
glycaemia seen in older PN patients (IIa). setting and, thus, can prevent the stress of hospitalisation.
use of hyaluronidase in the infused solution augments the rate of
3. Is peripheral PN feasible in geriatric patients? fluid uptake, and volumes up to 3000ml have been delivered over
24h.41
Both central and peripheral nutrition can be used in geriatric Hypodermoclysis is, however, not appropriate when large fluid
patients (C). volumes are needed in short time periods or for infusing electro-
Osmolarity of peripheral parenteral nutrition should not be lyte-free or hypertonic solutions in emergency situations. Most
higher than 850mOsmol/l (B). units limit daily volumes to no more than 1 l.
The principal procedural disadvantages of subcutaneous fluid
Comments: Administration of parenteral nutrition via periph- treatment are local oedema and infection at the infusion site, but
42
eral veins is a method which can be used safely in an older patient. the reported incidence of the latter is extremely low.
Moreover, this approach allows early infusion of nutritional In a recent systematic review Remington & Hultman found two
substrates during acute illness without the need to insert a central RCTs and six cohort studies on the use of HDC to treat dehydration
34 They concluded that HDC is as effective as IV
venous catheter. There are no consistent studies, which compare in older adults.
different osmolarities during peripheral PN in geriatric patients. rehydration of older adults with mild to moderate dehydration.
However in adult subjects it was found that using very fine bore Several advantages of HDC over IV hydration are described: lower
silicon or polyurethane catheters and infusion pump-controlled complicationrate,lowercosts,greaterpatientcomfort,lessnursing
35 However, it should be
continuous administration, the osmolality of intravenous periph- time to start and maintain the infusion.
eral nutritioncanbetoleratedupto1000mOsmol/l.Thisallowsthe kept in mind that HDC is onlya method for hydration and does not
administrationofasufficientamountofmacro-andmicronutrients meetother nutrient requirements.
via peripheral veins over periods of 2–3 weeks. Peripheral PN can
cover nutrition needs in older patients who may receive regimens 5. Can PN maintain or improve nutritional status
incorporatingupto1700kcal,60gofaminoacids,60–80goflipids
and 150–180g of carbohydrates per day in a typical volume of PN can improve nutritional status in older as well as in
2400ml.Thisisdeemedpossiblein50%ofpatients(Ib).26However, younger adults. However, active physical rehabilitation is essen-
other published guidelines for peripheral PN suggest that osmo- tial for muscle gain (B).
larity of nutritional solutions should be limited to no more than
27 Comments: There is no high quality trial which compares the
900mOsmol/l. effect of PN with EN in a group of older patients. It is apparent from
In the UK, utilisation of peripheral PN rose from 9% of adult experimental stable isotope studies that intravenous nutrition
patients on PN in 1988 to 18.3% in 1994. This was due to improved (especially amino acid administration) could increase fraction
peripheral catheters (fine bore silicone or polyurethane catheters) 43
28 The synthesis rate in old as well as in younger malnourished patients
andbetterdeliverysystems(allinonebags,infusionpumps). (IIb), particularly in hypercatabolic cancer patients when tight
recent availability of peripherally inserted catheters for both glucose control is achieved.44 It should be stressed that physical
peripheral (midline catheters) and central (PICC) PN might help in activity is a necessary condition for significant muscle gain in both
controlling the incidence of infectious or thrombotic complications 45
29,30 It was demonstrated that up to 70% of groups (IIb).
in parenteral nutrition.
the patients were suitable for peripheral PN, and that 50% 6. Can PN maintain or improve functional status?
completed a full course. However, the peripheral route should be
limited to those with an anticipated duration of feeding of no more
than 10–14days.31,32 PN can support improvement of functional status, but the
margin of improvement is lower than in younger patients (C).
4. Is there a role for subcutaneous fluid administration in Comments: Howard and Malone found that 38% of older
geriatric patients? (>65years) patients receiving home PN reached full rehabilitation
capacity in comparisonwith62%inmiddle-aged(35–55years)and
Peripheral or central venous access for fluid and electrolyte 63% in paediatric (0–18 years) subjects (III).46
replacement is mandatory in emergencies and in situations
where strict fluid balance is required. The subcutaneous route is 7. Can PN reduce morbidity and mortality?
possible for fluid administration in order to correct mild to
moderate dehydration but not to meet other nutrient require- PNcanreduce mortality and morbidity in older as well as in
ments (A). middle-aged subjects. However, as PN has more complications
Comments: Hypodermoclysis (HDC), the method of correcting than EN, the oral and enteral route should be used whenever
fluid deficits by subcutaneous infusion may be an alternative to possible (C).
intravenous cannulation in older patients (IIa). Isotonic fluids are Comments: Mortality is higher in older patients on PN than in
introduced into subcutaneous tissues seeking the correction of youngerones. In Howard and Malones study,1year mortality was
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