|Year : 2015 | Volume
| Issue : 1 | Page : 22-26
Current clinical aspects of parenteral nutrition in geriatric patients
Sukhminder Jit Singh Bajwa1, Ashish Kulshrestha2
1 Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
2 Department of Anaesthesiology and Intensive Care, Government Medical College and Hospital, Chandigarh, Punjab and Haryana, India
|Date of Web Publication||5-Dec-2014|
Sukhminder Jit Singh Bajwa
Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Patiala, Punjab
Source of Support: None, Conflict of Interest: None
Advancements in medicine, better diagnostics and zeal for a high quality of life have enabled many geriatric patients seeking medical attention for any type of illness. The elderly population is increasing globally and so does the number of such patients in hospital and critical care units. However, increased incidence of debilitating diseases in elderly makes them more prone to develop malnutrition and thus supplementation of nutrition plays an important role in care of these patients. The parenteral nutrition is usually given if enteral nutrition is inadequate or cannot be given. The causes of malnutrition in elderly can be manifold and may be due to weight loss, loss of fat free mass and due to muscle wasting. The special considerations when formulating parenteral nutrition in elderly population is increased content of lipids, early supplementation of trace elements, minerals and vitamins. The outcomes of parenteral nutrition in elderly population have been found to be similar to that in young patients, however overall prognosis in these patients remain guarded due to more severity and guarded prognosis of the diseases found in these patients. The complications due to parenteral nutrition in elderly patients are similar to that of the young patients and are mainly mechanical (catheter related), infectious and metabolic. It has been recommended that the parenteral nutrition should be started early, if indicated, in geriatric patients and should follow the same guidelines as in younger patients with some modifications.
Keywords: Geriatric, malnutrition, parenteral nutrition
|How to cite this article:|
Bajwa SS, Kulshrestha A. Current clinical aspects of parenteral nutrition in geriatric patients. J Med Nutr Nutraceut 2015;4:22-6
|How to cite this URL:|
Bajwa SS, Kulshrestha A. Current clinical aspects of parenteral nutrition in geriatric patients. J Med Nutr Nutraceut [serial online] 2015 [cited 2020 Oct 31];4:22-6. Available from: https://www.jmnn.org/text.asp?2015/4/1/22/146157
| Introduction|| |
With the increasing life expectancy due to better healthcare facilities and advancement in diagnosis and treatment of various diseases, the population seeking medical advice mainly comprise of older individuals. These geriatric patients usually seek medical advice due to various acute and/or chronic diseases with related limitations in physical, psychosocial, cognitive and social functions. These geriatric patients require more rehabilitative, psychosocial, physical and social care to prevent morbidity in such patient population. , These patients are often accompanied with significant muscle mass loss called sarcopenia due to under-nutrition. Nutrition plays an important role in preventing complications like morbidity, infections and pressure ulcers and hospital length of stay. Restoration of nutritional status is difficult in geriatric patients so adequate nutritional support with proper intake of protein, energy and micronutrients is essential and should be instituted early. A carefully instituted nutrition programme should include a comprehensive nutritional assessment and assessment of risk in a timely and precise manner with multidisciplinary approach. ,,
Aetiology of malnutrition in geriatric patients
The fat free mass which constitutes muscle, organ tissue, skin and bone decreases at an early age as compared to actual fat mass and with the background of much more fat free loss in elderly, these patients are more prone for depressed immunity and consequently more chances of infections.  The prevalence of malnutrition is high in these patients owing to high incidence of mental and cognitive impairment with high incidence of co-morbid diseases.  The etiology of weight loss in elderly can be divided into three main types. 
It is defined as involuntary loss of weight and is primarily due to inadequate intake of food that may be due to infection or psychosocial factors.
It is defined as involuntary loss of fat free mass or body cell mass and is mainly due to catabolism due to stress of diseases. It mainly results in increased metabolic rate and negative protein balance.
It is defined as involuntary loss of muscle mass and it may be due to complex interaction between hormonal and neural changes occurring during a normal ageing process and in chronic infections. 
The varied causes or risk factors for malnutrition in elderly population are depicted in [Table 1].
Assessment of nutritional status
Before starting any feeding formula, the assessment of degree of malnutrition is most important for success of feeding programme. Assessment takes into account various factors like severity of underlying illness, current medications and function of various organ systems. Emphasis has to be given to the patients with various debilitating diseases related to various organ dysfunctions and their current nutritional status. ,,, The various gross indicators of under-nutrition involve weight, body mass index (BMI) and anthropometric measurements of skin fold thickness and skeletal muscle mass. However, these do not carry much clinical significance.
Some of the biochemical parameters also can be used for malnutrition assessment like serum albumin, transferrin and prealbumin. The serum albumin may not carry much clinical significance as its production by liver may be decreased in presence of acute illnesses. 
An important tool described in literature for assessment of nutritional status in elderly patients is The Mini-Nutritional Assessment Short-Form (MNA-SF). It consists of questions on food intake, weight loss, mobility, psychological stress, presence of dementia or depression and BMI. It has a sensitivity of 89 and specificity of 82% and an important advantage is that no laboratory data is required for its interpretation. ,
Indications of parenteral nutrition in elderly
Historically, enteral and parenteral nutrition has seen gradual and progressive advancements.  Enteral or parenteral nutrition in the critically ill has long been a topic of great controversy.  Whatever is the case, supplementation of nutrition should be instituted early and promptly to reduce the risk of development of malnutrition related complications.  Enteral nutrition is considered to be the first choice for nutritional supplementation, while parenteral nutrition can be a safe and effective method mainly restricted to those who cannot receive adequate nutrition by enteral route. Parenteral nutrition is indicated in patients who cannot receive enteral nutrition or in those where enteral nutrition is inadequate to provide energy and nutritional requirements. The indications where enteral nutrition is not to be given are gut failure, high output fistulas, uncontrollable diarrhoea etc., In addition, other factors also should be considered like age related cognitive impairment and confusion and age related physiological changes in gastrointestinal tract, all of which can impair the enteral route. 
The prevalence rate of parenteral nutrition is still low and may be due to the fact that enteral nutrition is still the first choice and the malnutrition in elderly is still undertreated and often overlooked. ,
Calculation of nutritional requirements
The calculation of nutritional requirements starts from calculation of total fluid required in 24 h which is considered to be 30 to 40 ml/kg/day. The extra requirement of fluid can be done to compensate for any excessive overt or insensible losses. However, it should be noted that fluid restrictions may be required in elderly patients owing to the presence of significant comorbid conditions like heart failure or chronic kidney disease.
The caloric requirements of the patient can be calculated by the basal energy expenditure values and corrections should be made for specific diseases the patient might be suffering from like pyrexia, sepsis, burns etc., These caloric requirements are supplied in three main forms
- Carbohydrates: It should provide atleast 30 to 70% of the energy requirements. It should be noted that 1gm of carbohydrate provides about 3.75 kcal of energy. It is provided in the form of glucose that is the main substrate in various organ systems. Normoglycemia should be maintained by use of insulin as most of these elderly patients shoe insulin resistance in chronic illnesses Hypoglycaemia can be a fatal complication in this subset of population with overzealous treatment with insulin 
- Proteins: These should provide 15 to -20% of the energy requirements and are provided as soluble amino acids which should include equal proportions of essential and non-essential amino acids. The total daily requirement of proteins is estimated to be 1.5 to 2 gms/kg/day
- Fats: These should provide 20 to 50% of the total energy requirement and are provided in the form of 'intralipid' which is made from soya with chylomicron-sized particles. The essential fatty acids should also be provided. 1gm of fat yields around 9.3kcal of energy
- Electrolytes and Micronutrients: These may be included in the solution or can be provided separately. The various micronutrients required are magnesium, phosphorus, iron, copper, zinc and selenium. 
Special requirements in geriatric patients
There are few changes in the requirements of nutrients in elderly patients as compared to younger patients while prescribing parenteral nutrition. It has been found that deficiency of minerals and vitamins is more likely in elderly patients along with the deficiency of trace elements and these should be incorporated in the parenteral formulations from the beginning of the nutritional support.
High incidence of impaired renal and cardiac functions requires limited fluid and sodium intake in these patients to avoid development of fluid overload.  Due to similar capacities of young and older patients in oxidising a high intravenous triglyceride load, it is usually recommended to use formulations with higher lipid content i.e. more than 50% of total caloric requirement. 
Routes of parenteral nutrition
Parenteral nutrition can be given both by central venous and peripheral venous routes. The advantage of peripheral route is an early institution of nutritional support without the need of central venous cannulation. The main complication with peripheral route is thrombophlebitis of peripheral veins due to irritation by hyperosmolar parenteral preparations. Various studies have shown that the use of very fine bore silicon or polyurethane catheters and infusion pump controlled continuous infusions can increase the tolerance upto an osmolality of 900 to 1000 mOsm/l. , Based on various studies, it has been recommended that the peripheral route should be used for the preparations with osmolality upto 850 mOsm/l and if the anticipated duration of parenteral nutrition is not more than 10 to 14 days. 
Central venous lines used for parenteral nutrition should be inserted in a strict aseptic conditions and a dedicated port is used only for this purpose. The interruptions and disconnections should be done minimally and if done strict asepsis should be used.
Complications of parenteral nutrition in elderly
The types of complications and their corresponding rates are comparable to that in younger age population. The complications of parenteral nutrition can be divided into.
These are related to the central catheter insertion and include pneumothorax, hemothorax, arterial and nerve injury. These complications occur at almost the similar rates as in younger population.
The patients on parenteral nutrition have about 39% higher risk for development of blood stream infections irrespective of age. , However, the old age has been associated with a higher risk of central catheter vascular erosion and may have higher rates of blood stream infections. 
Hyperglycemia has been found to be more prevalent in elderly patients on parenteral nutrition which may be due to the insulin resistance and lower glucose oxidation often found in these patients.  The incidence of both hypo and hypervolemia is more in this population due to higher risk of cardiac failure, more frequent use of diuretics and altered water homeostasis.  Glucose infusion in parenteral nutrition can cause a rapid drop in plasma phosphorus levels causing acute psychosis and delirium.  The incidence of hypokalemia, hypomagnesemia and hypernatremia has been found to be more in elderly due to intracellular ion shift.
Due to high incidence of electrolyte disturbances, it is usually advised that in severely malnourished elderly patients the addition of substrates should be done in a stepwise manner with regular monitoring of electrolytes. 
Role of parenteral nutrition in elderly
The nutritional status of elderly patients improves to the same extent as in the younger patients which is mainly supported by experimental studies of effect of amino acid infusion on the rate of synthesis of proteins.  However, it has been found that active rehabilitation by muscle activity can improve the muscle mass.  The improvements in functional status of elderly patients have been found to be supported by parenteral nutrition but the degree of improvement is much smaller as compared to the younger patients. Mortality and morbidity is found to be more in elderly patients on parenteral nutrition due to poorer prognosis of various diseases in elderly patients. 
The reduction in length of hospital stay and improvement in quality of life have no direct relation with parenteral nutrition but are mainly influenced by the degree of pathological changes in body caused by the debilitating diseases in elderly patients. 
| Conclusion|| |
In conclusion, parenteral nutrition in geriatric population is an acceptable alternative if the enteral nutrition is inadequate or is contraindicated and should be instituted early if indicated. Few modifications should be done for elderly patients as difference exists between the pathological conditions in these patients. The incidence and types of complications remains same as in younger patients and it has been observed that parenteral nutrition definitely helps in improvement in the nutritional and functional status of these patients.
| References|| |
Bajwa SJ, Singh K, Bajwa SK, Singh A, Singh G, Panda A. Anesthesia considerations in a "very old" geriatric patient for major orthopedic surgery. Anesth Essays Res 2010;4:125-6.
Sehgal V, Bajwa SJ, Sehgal R, Bajaj A, Khaira U, Kresse V. Polypharmacy and potentially inappropriate medication use as the precipitating factor in readmissions to the hospital. J Family Med Prim Care 2013;2:194-9.
Arora VM, Johnson M, Olson J, Podrazik PM, Levine S, Dubeau CE, et al
. Using assessing care of vulnerable elders quality indicators to measure quality of hospital care for vulnerable elders. J Am Geriatr Soc 2007;55:1705-11.
Hogan DB, MacKnight C, Bergman H. The Canadian initiative on frailty and aging. Aging Clin Exp Res 2003;15:1-29.
Bajwa SJ, Kulshrestha A. Critical nutritional aspects in intensive care patients. J Med Nutr Nutraceut 2012;1:9-16.
Kyle UG, Genton L, Hans D, Karsegard VL, Michel JP, Slosman DO, et al
. Total body mass, fat mass, fat-free mass and skeletal muscle in older people: Cross-sectional differences in 60-year-old persons. J Am Geriatr Soc 2001;49:1633-40.
Feldblum I, German L, Castel H, Harman-Boehm I, Bilenko N, Eisinger M, et al
. Characteristics of undernourished older medical patients and the identification of predictors of undernutrition status. Nutr J 2007;6:37.
Roubenoff R. The pathophysiology of wasting in the elderly. J Nutr 1999;129 Suppl 1S:256S-9S.
Roubenoff R. Sarcopenia and its implications for the elderly. Eur J Clin Nutr 2000;54 Suppl 3:S40-7.
Bajwa SJ, Sethi E, Kaur R. Nutritional risk factors in endocrine diseases. J Med Nutr Nutraceut 2013;2:86-90.
Bajwa SJ, Kwatra IS. Nutritional needs and dietary modifications in patients on dialysis and chronic kidney disease. J Med Nutr Nutraceut 2013;2:46-51.
Bajwa SJ, Sehgal V, Bajwa SK. Clinical and critical care concerns in severely ill obese patient. Indian J Endocrinol Metab 2012;16:740-8.
Bajwa SJ, Bajwa SK, Kaur J. Care of terminally ill cancer patients: An intensivist's dilemma. Indian J Palliat Care 2010;16:83-9.
Klein S. The myth of serum albumin as a measure of nutritional status. Gastroenterology 1990;99:1845-6.
Kaiser MJ, Bauer JM, Uter W, Donini LM, Stange I, Volkert D, et al
. Prospective validation of the modified mini nutritional assessment short-forms in the community, nursing home, and rehabilitation setting. J Am Geriatr Soc 2011;59:2124-8.
Loreck E, Chimakurthi R, Steinle NI. Nutritional assessment of the geriatric patient: A comprehensive approach toward evaluating and managing nutrition. Clin Geriatr 2012;20:20-6.
Bajwa SJ. Nutritional facts in critically ill patients: The past, present and the future. J Med Nutr Nutraceut 2014;3:6-10.
Bajwa SJ, Gupta S. Controversies, principles and essentials of enteral and parenteral nutrition in critically ill-patients. J Med Nutr Nutraceut 2013;2:77-83.
Volkert D, Berner YN, Berry E, Cederholm T, Coti Bertrand P, Milne A, et al
. ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN guidelines on enteral nutrition: Geriatrics. Clin Nutr 2006;25:330-60.
Drozdowski L, Thomson AB. Aging and the intestine. World J Gastroenterol 2006;12:7578-84.
Thomas DR, Zdrodowski CD, Wilson MM, Conright KC, Diebold M, Morley JE. Aprospective, randomized clinical study of adjunctive peripheral parenteral nutrition in adult subacute care patients. J Nutr Health Aging 2005;9:321-5.
Nardo P, Dupertuis YM, Jetzer J, Kossovsky MP, Darmon P, Pichard C. Clinical relevance of parenteral nutrition prescription and administration in 200 hospitalized patients: A quality control study. Clin Nutr 2008;27:858-64.
Sehgal V, Bajwa SJ, Khaira U, Sehgal R, Bajaj A. Challenging aspects of and solutions to diagnosis, prevention, and management of hypoglycemia in critically ill geriatric patients. J Sci Soc 2013;40:128-34.
Bajwa SJ. The underestimated nutritional aspects of micronutrients supplementation in intensive care. J Med Nutr Nutraceut 2013;2:114-6.
Kinney JM, Allison SP. Food, fluids and pharmacy in the elderly. Curr Opin Clin Nutr Metab Care 2004;7:1-2.
Al-Jaouni R, Schneider SM, Rampal P, Hébuterne X. Effect of age on substrate oxidation during total parenteral nutrition. Nutrition 2002;18:20-5.
Anderson AD, Palmer D, MacFie J. Peripheral parenteral nutrition. Br J Surg 2003;90:1048-54.
Mirtallo J, Canada T, Johnson D, Kumpf V, Petersen C, Sacks G, et al
. Task force for the revision of safe practices for parenteral nutrition. Safe practices for parenteral nutrition. JPEN J Parenter Enteral Nutr 2004;28:S39-70.
Sobotka L, Schneider SM, Berner YN, Cederholm T, Krznaric Z, Shenkin A, et al
. ESPEN guidelines on parenteral nutrition: Geriatrics. Clin Nutr 2009;28:461-6.
Dissanaike S, Shelton M, Warner K, O'Keefe GE. The risk for bloodstream infections is associated with increased parenteral caloric intake in patients receiving parenteral nutrition. Crit Care 2007;11:R114.
Chen HS, Wang FD, Lin M, Lin YC, Huang LJ, Liu CY. Risk factors for central venous catheter-related infections in general surgery. J Microbiol Immunol Infect 2006;39:231-6.
Walshe C, Phelan D, Bourke J, Buggy D. Vascular erosion by central venous catheters used for total parenteral nutrition. Intensive Care Med 2007;33:534-7.
Al-Jaouni R, Schneider SM, Rampal P, Hébuterne X. Effect of age on substrate oxidation during total parenteral nutrition. Nutrition 2002;18:20-5.
Brandstrup B, Tønnesen H, Beier-Holgersen R, Hjortsø E, Ørding H, Lindorff-Larsen K, et al
. Danish Study Group on Perioperative Fluid Therapy. Effects of intravenous fluid restriction on postoperative complications: Comparison of two perioperative fluid regimens: A randomized assessor-blinded multicentre trial. Ann Surg 2003;238:641-8.
Kagansky N, Levy S, Koren-Morag N, Berger D, Knobler H. Hypophosphataemia in old patients is associated with the refeeding syndrome and reduced survival. J Intern Med 2005;257:461-8.
Stanga Z, Brunner A, Leuenberger M, Grimble RF, Shenkin A, Allison SP, et al
. Nutrition in clinical practice-the refeeding syndrome: Illustrative cases and guidelines for prevention and treatment. Eur J Clin Nutr 2008;62:687-94.
Volpi E, Ferrando AA, Yeckel CW, Tipton KD, Wolfe RR. Exogenous amino acids stimulate net muscle protein synthesis in the elderly. J Clin Invest 1998;101:2000-7.
Hasten DL, Pak-Loduca J, Obert KA, Yarasheski KE. Resistance exercise acutely increases MHC and mixed muscle protein synthesis rates in 78-84 and 23-32 yr olds. Am J Physiol Endocrinol Metab 2000;278:E620-6.
Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related malnutrition. Clin Nutr 2008;27:5-15.
Oz V, Theilla M, Singer P. Eating habits and quality of life of patients receiving home parenteral nutrition in Israel. Clin Nutr 2008;27:95-9.
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