ESPEN Guidelines on Parenteral Nutrition: Geriatrics

SummaryOlder subjects are at increased risk of partial or complete loss of independence due to acute and/or chronic disease and often of concomitant protein caloric malnutrition. Nutritional care and support 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 the enteral route, parenteral nutrition (PN) is indicated.PN is a safe and effective therapeutic procedure and age per se is not a reason to exclude patients from this treatment. The use of PN should always be balanced against a realistic chance of improvement in the general condition of the patient. Lower glucose tolerance, electrolyte and micronutrient deficiencies and 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.Summary of statements: GeriatricsSubjectRecommendationsGradeNumberIndicationsAge per se is not a reason to exclude patients from PN.C [IV]1.1.PN is indicated and may allow adequate nutrition in patients who cannot meet their nutritional requirements via the enteral route.C [IV]1.1.PN support should be instituted in the older person facing a period of starvation of more than 3 days or if intake is likely to be insufficient for more than 7–10 days, and when oral or enteral nutrition is impossible.C [IV]1.1.Pharmacological sedation or physical restraining to make PN possible is not justified.C [IV]1.1.PN is a useful and effective method of nutritional support in older persons but compared to EN and oral nutritional supplements are much less often justified.B [III]1.2.Metabolic/physiological features in older subjectsInsulin resistance and hyperglycaemia together with impairment of cardiac and renal function are the most relevant features. They may warrant the use of formulae with higher lipid content.C [IV]2Deficiencies in vitamins, trace elements and minerals should be suspected in older subjects.B [IIb]2The effect of nutritional support on restoration of depleted body cell mass is lower in elderly patients than in younger subjects. The oxidation capacity for lipid emulsions is not negatively influenced by age.B [IIa]2Peripheral PNBoth central and peripheral nutrition can be used in geriatric patients.C [IV]3Osmolarity of peripheral parenteral nutrition should not be higher than 850 mOsmol/l.B [III]3Subcutaneous fluid administrationThe subcutaneous route is possible for fluid administration in order to correct mild to moderate dehydration but not to meet other nutrient requirements.A [Ia]4PN and nutritional statusPN can improve nutritional status in older as well as in younger adults. However, active physical rehabilitation is essential for muscle gain.B [IIb]5Functional statusPN can support improvement of functional status, but the margin of improvement is lower than in younger patients.C [IV]6Morbidity and mortalityPN can reduce mortality and morbidity in older as well as in middle-aged subjects.C [IV]7Length of hospital stayNo studies have assessed length of hospital stay in older patients on PN.8Quality of lifeLong-term parenteral nutrition does not influence quality of life of older patients more negatively than it does in younger subjects.C [IV]9Specific complicationsThere are no specific complications of PN in geriatric patients compared to other ages, but complications tend to be more frequent due to associated comorbidities.C [IV]10Specific situationsIndications for PN are similar in younger and older adults in the hospital and at home.B [III]11Ethical problemsPN or parenteral hydration should be considered as medical treatments rather than as basic care. Therefore their use should be balanced against a realistic chance of improvement in the general condition.C [IV]12Full-size tableTable optionsView in workspaceDownload as CSV