Malnutrition in elderly individuals in nursing homes has been well-documented (Nelson, Coulston, Sucher, & Tseng, 1993; Position of The American Dietetic Association, 1998), and so have the effects of malnutrition and benefits of nutritional support (Dougherty, Bankhead, Kushner, Mirtallo, & Winkler, 1995; Gallagher- Allred, Voss, Finn, & McCamish, 1996) (Tables 1 and 2). It is easy for a fragile elderly individual to become malnourished. Therefore, nurses must take every measure to avoid malnutrition and its consequences.
Two extremes exist predominately in medical nutrition practice. The first practice is encouraging the patient to eat and consume supplements to boost nutritional intake. This is usually the method of choice, but it is rarely successful when a patient is sick and has a depressed appetite. The opposite is providing aggressive nutritional support via total parenteral nutrition (TPN) or tube feeding (TF). Both forms of therapy have their indications, but because they are extremes on the therapy continuum, cannot satisfy the nutritional delivery needs for every situation. Therefore, another therapy is needed to bridge this gap.
The gap widens even more if one considers only intravenous (IV) methods of support. In some practices, only hydration therapy is used (e.g., dextrose 5% in water [D5W], saline solutions) and assumed to be providing the needed nutrition. One liter of D5W provides only 170 calories and 0 grams of protein, and saline solutions provide neither energy nor protein. Again, on the aggressive side, TPN provides large amounts of calories and protein, but is designed for longer term, more invasive care. At times, neither of these choices is appropriate. The following are some examples of difficult situations.
EFFECTS OF MALNUTRITION ON THE ELDERLY
A man is having elective surgery and is to remain without oral intake (NPO) prior to surgery. He must he put on clear liquids for a day or two after the operation. If he is already borderline malnourished, a few days of suboptimal intake will delay the recovery and healing process (Heys & Gardner, 1999). Feeding the stomach is not possible, and putting in a central line for only a few days of TPN would not he desirable. How would the patient be nourished?
A patient has a pressure ulcer on his right leg and needs extra protein to heal the ulcer (Thomas, 1997). If his appetite is failing, protein intake is minimal. Even though he refuses all supplements and is losing weight, the family does not want him to be encumbered by a nasogastric feeding tube. Again, placing a central line for TPN may he too aggressive. How does one nourish this patient and heal the wound?
A woman was given an enteral TF after a hip replacement when her health care providers found her albumin was below normal at 2g/dL. She has been refusing all meals, not tolerating the feeding well, and experiencing diarrhea (Heimhurger, Sockwell, & Geeb, 1994; Hwang, Lue, Nee, Jan, & Chen, 1994). The feeding has been kept at a low rate, so she is only receiving 50% of her nutritional needs. She does not have insurance to cover the costs of TPN. At this rate, how will her visceral protein status improve so she may heal from surgery?
Many other situations exist in which conventional therapies do not deliver the needed nutritional support. What can be done to bridge the gap in nutritional care? Peripheral parenteral nutrition (PPN) is one option. This is an IV nutritional therapy that provides energy and protein needs noninvasively and more economically than TPN. Because it is delivered peripherally, the risks and costs of central line placement are avoided. Careful selection of the right PPN solution also minimizes problems of poor vein tolerance. See Table 3 for indications for PPN.
The following case studies are from two different nursing homes and demonstrate this mode of therapy with a PPN solution. The clinical outcomes are positive: enhanced wound healing, restored alertness, and improved quality of life.
CASE STUDY I: PROGRESSING WITH CAUTION
JK was an 89-year-old man diagnosed with malnutrition and dementia. He had suffered a 20-lb (9.07 kg) weight loss in 3 months, weighing 102 lb (46.27 kg) at the time of evaluation. Weight loss was attributed to depression, progressive confusion, and decreased appetite. At 5 ft 5 in. (1.65 m) tall, JK had a body mass index (BMI) of 17 kg/m2, severely below normal range. His visceral protein status was slightly below normal with an albumin of 3.4 g/dL.
Nutritional goals for weight gain were set at 1,400 calories, 68 gm of protein, and 1,790 cc of fluid per day. Because JK could not achieve these goals through diet alone, PPN was initiated with a regimen of 2,000 cc (3% amino acid and 3% glycerol with electrolytes solution is sold as ProcalAmine [B. Braun, Germany]) admixed with 500 cc 10% lipids for 10 days. Delivery was via a size 3 French midline catheter. This PPN regimen provided an additional 1,040 calories and 58 g of protein per day to his dietary intake, which was not recorded.
BENEFITS OF NUTRITION SUPPORT
Monitoring and Follow-Up
The PPN regimen was easy to deliver without any difficulties with laboratory values within normal limits. The IV site was changed every 72 hours and as needed because JK pulled out the line or pulled the tubing apart in the initial stages of the therapy.
Outcome of Initial Problem
JK stopped pulling out the IV line and showed marked improvement in alertness as the therapy progressed. Visceral protein status improved to 3.8 g/dL and a 7-lb (3.18 kg) weight gain was noted.
PERIPHERAL PARENTERAL NUTRITION (PPN) BRIDGES THE GAP FOR PATIENTS
Even with a history of dementia, the care center staff did not attribute all of JK's confusion to his dementia. Malnutrition and dehydration contribute heavily to symptoms of lethargy, confusion, and lack of alertness. Also, thiamin, folate, and vitamin B12 deficiencies in elderly individuals all have been associated with symptoms of the previously mentioned clinical findings (LaRue et al., 1997; Lipschitz, 1990).
The conservative calorie goal set by the center's dietitian was also a wise choice. With such a significant weight loss and low BMI, some clinicians might treat more aggressively to reverse the status more quickly. However, older (i.e., > 60 years), malnourished individuals are particularly susceptible to the refeeding syndrome (Gonzalez, 1996) - a dangerous imbalance in fluid and electrolyte status caused by overfeeding (Brooks & Melnik, 1995). Nutrition support initiates a shift of the electrolytes, potassium, magnesium, and phosphate into the cell, which may cause adverse effects. Refeeding syndrome is characterized by the intracellular shift of phosphate (< 2.5 mmol/L) with neuromuscular clinical manifestations.
Other symptoms have been documented in chronic starvation cases, such as in victims of prisoner of war camps. Keneally (1982) reports the mistaken diagnosis of typhus in hundreds of skeleton-like Jews who had been delivered by Oskar Schindler from the Nazi prison camps of World War II. Existing on fewer than 1,000 calories a day for months in the prison camps, their diets had been increased to more than 2,000 calories a day when they were freed and moved to a recovery clinic. Symptoms of headache, fever, malaise, general pains, and dysentery appeared shortly after they arrived, similar to those seen in typhus epidemics.
By using JK's actual weight of 102 lb (46.27 kg), versus ideal body weight (Ireton-Jones, 1998), goals were set aggressively enough for good tolerance, at 30 kcal/kg and 1 .5g protein/kg. Thus, JK showed improvement in alertness and returned to his normal state of health by way of a gradual and welltolerated recovery.
CASE STUDY II: THE HEALING POWER OF PROTEIN
MN was a 72-year-old man recovering from a colonectomy performed to correct uncontrollable rectal bleeding. Dementia was noted in his medical history. With a decreased oral intake and extremely poor visceral protein status (i.e., depressed albumin and pre-albumin of 2.2g/dL and 13mg/dL respectively), the 18 cm dehisced abdominal wound held together with retention sutures was healing poorly (Heys & Gardner, 1999). MN's BMI of 21kg/m2 was at the low end of normal range. He was 6 ft (1.83 m) tall and weighed 154 lb (69.85 kg).
Based on his body weight and protein status, and the increased demands placed on his body by surgery and the need for wound healing, the nutritional goals were set at 2,280 calories, 74 g protein and 2,780 cc fluid per day. Because these goals were impossible to meet by oral means in MN's condition, PPN was chosen to supplement his nutritional intake. The PPN was initiated for a 10-day course at 2,000 cc per day. Five hundred cc of 10% lipid was piggybacked into the line for additional calories. This regimen provided an additional 1,040 calories and 58 g protein to his oral intake.
After the 10-day course of PPN, MN received hydration therapy for 3 days, and then the PPN regimen was restarted for another 10 days. The PPN was delivered via a midline catheter initially, and then peripherally via a 22-gauge protective catheter. The PPN therapy was in conjunction with some oral intake, however a calorie count was not available to compare the combined oral and parenteral intake to the assessed goals set for MN.
Monitoring and Follow-Up
Vein tolerance was good when using the midline catheter. However, MN's veins hardened with the peripheral catheter. MN had to be restrained because he was pulling out the IVs daily because of his dementia. Otherwise, the PPN regimen was easy to deliver and monitor and was well-tolerated.
Outcome of Initial Problem
Eighteen days after the PPN support regimen was initiated, the abdominal wound closed. MN's physician was surprised with the quicker-than-expected healing of the wound. The company's IV Clinical Supervisor said, "I personally never expected it to close. I thought he would die with the wound."
MN's weight increased by 2 lb (0.91 kg) to 156 lb (70.76 kg), and his oral intake resumed. He ate between 75% to 100% of his meals. Additional laboratory results were not available to compare visceral protein status improvement. However, proof of improvement was evidenced by clinical observation of the wound healing.
MN remained in total isolation on hydration therapy because of a methicillin-resistant staph aureus infection. He is currently out of isolation with complete wound healing. He is reported to be much more responsive and wheeling himself around the nursing home.
Amino acids, which make up protein, can be found in every cell of the body and are necessary for dozens of functions and chemical reactions. Despite research documenting the importance of protein in promoting adequate collagen synthesis for wound healing (Heys & Gardner, 1999; Winkler & Mandry, 1992), an overall prevalence of protein and energy under-nutrition in nursing homes has been cited (Morley & Silver, 1995).
For optimal wound healing, studies suggest a higher-than-normal protein intake of between 1.5 g and 2 g protein/kg per day (Thomas, 1997). The need for nutritional support to meet this increased protein demand is therefore heightened, often when the ability to consume additional protein is most difficult. Healing of MN's abdominal wound was aided by the boost in protein intake provided by the PPN regimen (1.05 g protein/kg per day) in addition to that of his improving oral intake. Calories also appeared to be adequate to spare protein, which allowed for optimal wound healing.
Peripheral parenteral nutrition is an effective bridge in the gap of existing nutritional support therapies. In the continuum of IV support, PPN delivers nutrition to those for whom TPN is too invasive, too expensive, or for other reasons is undesirable. Peripheral parenteral nutrition also provides much more than IY hydration can supply.
In the continuum of enteral nutrition, PPN bridges the gap for tubefed patients who are not tolerating TF because of hypoalbuminemia. Albumin levels less than 2.2 interfere with normal gastrointestinal (GI) absorption, producing diarrhea and preventing a patient from receiving the proper nutrition. Peripheral parenteral nutrition delivers protein in a well -tolerated, noninvasive manner that may be a better way to boost the visceral proteins (e.g., albumin, pre-albumin). With a satisfactory visceral protein level, the gastrointestinal tract can function more normally, and TF tolerance is increased with normal GI absorption.
The PPN solutions using glycerol instead of dextrose as their non-protein calorie source may be more easily tolerated in the elderly population. Glycerol is reported to be better tolerated by a patient's veins. Thus, there is generally less vein irritation and phlebitis (Rypins, Johnson, Reder, Sarfeh, Shimoda, 1990; Waxman et al., 1992) than with a PPN solution using dextrose.
Glycerol metabolism requires less insulin than dextrose, which may make it a better choice for patients with diabetes or glucose intolerance caused by other etiologies (Lev-Ran et al., 1987). This is especially important considering there is a higher percentage of patients with diabetes mellitus in the older population.
IMPLICATIONS FOR NURSING
Nurses have a critical role to alert other team members to nutritional problems. Gilmore et al. (2000) outline the nurse's role in initiating and conducting specified therapies; monitoring the patient's progress; and providing information to the primary care physician, dietitian, pharmacist, and physical therapist.
Providing the appropriate PPN therapy makes the nurse's job easier in three ways when compared to other nutritional choices that may be less effective for the patient. First, because the solution used in these case studies is generally well tolerated by the vein, IV Unes do not need to be changed as often as with other solutions. Second, PPN is much simpler to administer and less invasive than TPN, making it an easier IV therapy to deliver and monitor. Last, in patients with severe hypoalbuminemia, TF often results in diarrhea, whereas PPN does not. Although enteral nutrition is always the feeding method of choice, when not feasible, feeding parenterally provides a readily absorbable and usable form of protein to boost albumin and eliminate the need to continually change bedding and clean the patient.
- Brooks, MJ., & Melnik, G. (1995). The refeeding syndrome: An approach to understanding its complications and preventing its occurrence. Pharmacotherapy, 15, 713-726.
- Dougherty, D., Bankhead, R., Kushner, R., Mirtallo, J., & Winkler, M. (1995). Nutrition care given new importance in JCAHO standards. Nutrition in Clinical Practice, 10(1), 26-31.
- Gallagher- Allred, C.R., Voss, A.C., Finn, S.C., & McCamish, M.A. (1996). Malnutrition and clinical outcomes: The case for medical nutrition therapy. Journal of the American Dietetics Association, 96(4), 361-363, 369.
- Gilmore, L.R., Escobedo, J., Elliot, L., Spiller, K., Strickland, J., Jones, J., & Allen, P. (20CX)). Practical uses of peripheral intravenous nutrition. Journal of Gerontological Nursing, 26(1), 41-46.
- Gonzalez, A. (1996). The incidence of the refeeding syndrome in cancer patients who receive artificial nutritional treatment. Nutrición HospitaUria, 11(2), 98-101.
- Heimburger, D.C., Sockwell, D.G., & Geels, WJ. (1994). Diarrhea with enteral feeding: Prospective reappraisal of putative causes. Nutrition, /0(5), 392-3%.
- Heys, S.D., & Gardner, E. (1999). Nutrients and the surgical patient: Current and potential therapeutic applications to clinical practice. The Journal of the Royal College of Surgeons of Edinburgh, 44(5), 283-293.
- Hwang, TL., Lue, M.C., Nee, YJ., Jan, Y. Y., & Chen, M.F. (1994). The incidence of diarrhea in patients with hypoalbuminemia due to acute or chronic malnutrition during enteral feeding. American Journal of Gastroenterology, 89(3), 376-378.
- Ireton-Jones, C. (1998). Fine tuning nutrition support· Does it work? Workshop conducted at the American Society of Parenteral and Enteral Nutrition, 22nd Clinical Congress, Orlando, FL.
- Ireton-Jones, CS., & Robinson N. (1995). Peripheral parenteral nutrition: Indication and guidelines. Support Line, 17(5), 11-13.
- Keneally, T (1982). Schindlers list. New York: Simon & Schuster.
- LaRue, A., Koehler, K.M., Wayne, S.J., Chiulli, SJ., Haaland, K.Y., & Garry, PJ. (1997). Nutritional status and cognitive functioning in a normally aging sample: A 6-yr reassessment. American Journal of Clinical Nutrition, 65, 20-29.
- Lev-Ran, A., Johnson, M., Hwang, D.L., Askanazi, J., Weissman, G, & Gersovitz, M. (1987). Double-blind study of glycerol vs glucose in parenteral nutrition of postsurgical insulin-treated diabetic patients. Journal of Parenteral and Enteral Nutrition, 11(3), 271-27 '4.
- Lipschitz, D. A. (1990). Principles of geriatric medicine and gerontology. In WR. Hazzard, R. Andres, E.I. Bierman, J.P. Blass (Eds.), Anemia in the elderly (pp.662-668). New York: McGraw Hill.
- Morley, J.E., & Silver, AJ. (1995). Nutritional issues in nursing home care. Annals of Internal Medicine, 123(1 1), 850-859.
- Nelson, K.J., Coulston, A.M., Sucher, K.P., & Tseng, R.Y. (1993). Prevalence of malnutrition in the elderly admitted to long-termcare facilities. Journal of the American Dietetics Association, 93(A), 459-461.
- Position of The American Dietetic Association. (1998). Liberalized diets for older adults in long-term care. Journal of the American Dietetics Association, 98(2), 201-204.
- Thomas, D.R. (1997). The role of nutrition in prevention and healing of pressure ulcers. Clinical Geriatric Medicine, 13(3), 497-511.
- Rypins, E.B., Johnson, B. H., Reder, B., Sarfeh, IJ., & Shimoda, K. (1990). Threephase study of phlebitis in patients receiving peripheral intravenous hyperalimentation. The American Journal of Surgery, 159, 222-225.
- Waxman, K., Day, A.T., Stellin, G, Tominaga, T., Gazzaniga, A.B., & Bradford, R.R. (1992). Safety and efficacy of glycerol and amino acids in combination with lipid emulsion for peripheral parenteral nutrition support Journal of Parenteral and Enteral Nutrition, 16(A), 374-376.
- Winkler, M.F., & Mandry, M.K. (1992). Nutrition and wound healing. Support Line, 14(3), 1-4.
EFFECTS OF MALNUTRITION ON THE ELDERLY
BENEFITS OF NUTRITION SUPPORT
PERIPHERAL PARENTERAL NUTRITION (PPN) BRIDGES THE GAP FOR PATIENTS