Abstract
Enteral nutrition support among elderly residents of long-term care facilites is a common health care intervention. The literature investigating the effectiveness of enteral nutrition in the same population is somewhat controversial. This article reviews the literature on the effectiveness of enteral nutrition in elderly residents of long-term care facilities and presents the results of a recent outcome investigation on the same topic. Further, the article sets forth a practical approach in the form of a decision tree to selecting appropriate candidates for enteral nutrition among elderly residents on the basis of the literature, the recent investigation, and the published professional guidelines on the use of enteral nutrition in elderly residents of long-term care facilities.
SINCE THE early 1990s, anecdotal reports suggest that the use of enteral nutrition in elderly residents of long-term care facilities has increased dramatically because of advances in feeding-device technology. Formerly, tubes were inserted through the nose into the esophagus to the stomach (nasogastric tubes); newer methods permit tubes to be placed directly into the stomach by guiding a feeding tube with an endoscope through an incision in abdominal and gastric wall (percutaneous endoscopic gastrostomy or PEG). PEG is the feeding device of choice for residents requiring long-term enteral nutrition because general anesthesia is not required for placement, and resident comfort and tolerance for PEGs is much improved over nasogastric tubes. In 1995, approximately 121000 PEGs were placed in elderly patients for use in both acute- and long-term care settings. 1 PEG is the preferred long-term (longer than 1 month) enteral nutrition device used for elderly residents of long-term care facilities, hereafter referred to as elderly residents. PEGs are more durable and comfortable than nasogastric tubes and are well tolerated by elderly residents. 2-4
The elderly population in the United States, defined as adults over the age of 65, comprises 12% of the total population. By the year 2030, 24% of the total population will be over 65; of this group, a significant percentage will be older than 75 because of increased longevity. 5 The number of elderly residents is likely to increase, and so too will candidates for enteral nutrition increase in long-term care facilities.
Published reports in the 1980s indicated that enteral nutrition was associated with decreased morbidity and mortality when employed as adjunctive therapy for elderly acute-care patients admitted to long-term care facilities for rehabilitation. 6,7 However, these results have not been consistently duplicated in elderly residents who are long-term recipients of enteral nutrition. 8-14 Such residents are among the oldest of elderly residents and usually have a diagnosis of severe dementia. Three commentaries by geriatric experts discourage the use of enteral nutrition in elderly residents with dementia because of the lack of published evidence that supports its use. 15-17
The purpose of this article is to review the published literature on the effectiveness of enteral nutrition in elderly residents, and discuss the findings of a recent retrospective investigation on the outcomes of enteral nutrition in the same population. Our objective is to give practical guidance on the selection of appropriate candidates for enteral nutrition by dietitians and other health care givers in long-term care facilities on the basis of current data, and legal and ethical considerations. In addition, we suggest future direction for outcome investigations on the effectiveness of enteral nutrition in elderly residents.