Enteral and Parenteral Nutrition

  • Manie Juneja
  • Stephen J. D. O’Keefe


Malnutrition is more common in geriatric population because of higher incidence of chronic disability and disease, but the principles of nutritional support are the same as those for any adult. Nutrition support should be implemented in a step-wise fashion, starting with dietary consultation with a nutritionist with recommendations for dietary change or supplementation. If this fails, nasogastric feeding should be considered. In the presence of anatomic changes in the upper gastrointestinal tract, a more distal postpyloric feeding tube should be considered. Intestinal failure is the only absolute indication for parenteral feeding, but initial PN supplementation may be necessary in the critically ill depleted patient while awaiting enteral feeding (EN). In the vast majority of patients, a simple low-cost polymeric formula will meet EN requirements. Extra care should be taken in the elderly terminal patient to avoid long-term “forced feeding,” whether it be EN, PN, or via gastrostomy, as these interventions are associated with poor outcomes and may actually impair the remaining quality of life.


Parenteral Nutrition Enteral Nutrition Percutaneous Endoscopic Gastrostomy Enteral Feeding Thiamine Deficiency 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Rolls BJ. Do chemosensory changes influence food intake in the elderly? Physiol Behav. 1999;66(2):193–7.PubMedCrossRefGoogle Scholar
  2. 2.
    Parker BA, Chapman IM. Food intake and ageing—the role of the gut. Mech Ageing Dev. 2004;125(12):859–66.PubMedCrossRefGoogle Scholar
  3. 3.
    Horowitz M, Maddern GJ, Chatterton BE, et al. Changes in gastric emptying rates with age. Clin Sci (Lond). 1984;67(2):213–8.Google Scholar
  4. 4.
    Silver AJ, Morley JE, Strome LS, et al. Nutritional status in an academic nursing home. J Am Geriatr Soc. 1988;36(6):487–91.PubMedGoogle Scholar
  5. 5.
    Bernstein LH, Shaw-Stiffel TA, Schorow M, et al. Financial implications of malnutrition. Clin Lab Med. 1993;13(2):491–507.PubMedGoogle Scholar
  6. 6.
    Ferguson RP, O’Connor P, Crabtree B, et al. Serum albumin and prealbumin as predictors of clinical outcomes of hospitalized elderly nursing home residents. J Am Geriatr Soc. 1993;41(5):545–9.PubMedGoogle Scholar
  7. 7.
    Abbasi AA, Rudman D. Undernutrition in the nursing home: prevalence, consequences, causes and prevention. Nutr Rev. 1994;52(4):113–22.PubMedCrossRefGoogle Scholar
  8. 8.
    Edington J, Kon P. Prevalence of malnutrition in the community. Nutrition. 1997;13(3):238–40.PubMedCrossRefGoogle Scholar
  9. 9.
    Marton KI, Sox Jr HC, Krupp JR. Involuntary weight loss: diagnostic and prognostic significance. Ann Intern Med. 1981;95(5):568–74.PubMedGoogle Scholar
  10. 10.
    Rabinovitz M, Pitlik SD, Leifer M, et al. Unintentional weight loss. A retrospective analysis of 154 cases. Arch Intern Med. 1986;146(1):186–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Bilbao-Garay J, Barba R, Losa-Garcia JE, et al. Assessing clinical probability of organic disease in patients with involuntary weight loss: a simple score. Eur J Intern Med. 2002;13(4):240–5.PubMedCrossRefGoogle Scholar
  12. 12.
    Thompson MP, Morris LK. Unexplained weight loss in the ambulatory elderly. J Am Geriatr Soc. 1991;39(5):497–500.PubMedGoogle Scholar
  13. 13.
    Lankisch P, Gerzmann M, Gerzmann JF, et al. Unintentional weight loss: diagnosis and prognosis. The first prospective follow-up study from a secondary referral centre. J Intern Med. 2001;249(1):41–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Huffman GB. Evaluating and treating unintentional weight loss in the elderly. Am Fam Physician. 2002;65(4):640–50.PubMedGoogle Scholar
  15. 15.
    Lin HW, Li CM, Lee YC, et al. Differences in diagnostic approach between family physicians and other specialists in patients with unintentional body weight loss. Fam Pract. 1999;16(6):586–90.PubMedCrossRefGoogle Scholar
  16. 16.
    Morley JE, Kraenzle D. Causes of weight loss in a community nursing home. J Am Geriatr Soc. 1994;42(6):583–5.PubMedGoogle Scholar
  17. 17.
    Brozek J. Effects of generalized malnutrition on personality. Nutrition. 1990;6(5):389–95.PubMedGoogle Scholar
  18. 18.
    Marcus EL, Berry EM. Refusal to eat in the elderly. Nutr Rev. 1998;56(6):163–71.PubMedCrossRefGoogle Scholar
  19. 19.
    Mueller C, Compher C, Ellen DM. A.S.P.E.N. clinical guidelines: nutrition screening, assessment, and intervention in adults. JPEN J Parenter Enteral Nutr. 2011;35(1):16–24.PubMedCrossRefGoogle Scholar
  20. 20.
    Kirby DF, Delegge MH, Fleming CR. American Gastroenterological Association technical review on tube feeding for enteral nutrition. Gastroenterology. 1995;108(4):1282–301.PubMedCrossRefGoogle Scholar
  21. 21.
    Horton WL, Colwell DL, Burlon DT. Experience with percutaneous endoscopic gastrotomy in a community hospital. Am J Gastroenterol. 1991;86(2):168–70.PubMedGoogle Scholar
  22. 22.
    Finucane P, Aslan SM, Duncan D. Percutaneous endoscopic gastrostomy in elderly patients. Postgrad Med J. 1991;67(786):371–3.PubMedCrossRefGoogle Scholar
  23. 23.
    Debaveye Y, Van den Berghe G. Risks and benefits of nutritional support during critical illness. Annu Rev Nutr. 2006;26:513–38.PubMedCrossRefGoogle Scholar
  24. 24.
    Nyswonger GD, Helmchen RH. Early enteral nutrition and length of stay in stroke patients. J Neurosci Nurs. 1992;24(4):220–3.PubMedCrossRefGoogle Scholar
  25. 25.
    Broadley S, Croser D, Cottrell J, et al. Predictors of prolonged dysphagia following acute stroke. J Clin Neurosci. 2003;10(3):300–5.PubMedCrossRefGoogle Scholar
  26. 26.
    Angus F, Burakoff R. The percutaneous endoscopic gastrostomy tube. Medical and ethical issues in placement. Am J Gastroenterol. 2003;98(2):272–7.PubMedGoogle Scholar
  27. 27.
    Sanders DS, Carter MJ, D’Silva J, et al. Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia. Am J Gastroenterol. 2000;95(6):1472–5.PubMedCrossRefGoogle Scholar
  28. 28.
    Braunschweig CL, Levy P, Sheean PM, et al. Enteral compared with parenteral nutrition: a meta-analysis. Am J Clin Nutr. 2001;74(4):534–42.PubMedGoogle Scholar
  29. 29.
    Heyland DK, MacDonald S, Keefe L, et al. Total parenteral nutrition in the critically ill patient: a meta-analysis. JAMA. 1998;280(23):2013–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Jeejeebhoy KN. Enteral nutrition versus parenteral nutrition—the risks and benefits. Nat Clin Pract Gastroenterol Hepatol. 2007;4(5):260–5.PubMedCrossRefGoogle Scholar
  31. 31.
    Zaloga GP. Parenteral nutrition in adult inpatients with functioning gastrointestinal tracts: assessment of outcomes. Lancet. 2006;367(9516):1101–11.PubMedCrossRefGoogle Scholar
  32. 32.
    Hebuterne X, Schneider S, Peroux JL, et al. Effects of refeeding by cyclic enteral nutrition on body composition: comparative study of elderly and younger patients. Clin Nutr. 1997;16(6):283–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Schneider SM, Al-Jaouni R, Pivot X, et al. Lack of adaptation to severe malnutrition in elderly patients. Clin Nutr. 2002;21(6):499–504.PubMedCrossRefGoogle Scholar
  34. 34.
    American Gastroenterological Association medical position statement: guidelines for the use of enteral nutrition. Gastroenterology. 1995;108(4):1280–1.Google Scholar
  35. 35.
    O’Keefe SJ. A guide to enteral access procedures and enteral nutrition. Nat Rev Gastroenterol Hepatol. 2009;6(4):207–15.PubMedCrossRefGoogle Scholar
  36. 36.
    Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med. 2001;29(12):2264–70.PubMedCrossRefGoogle Scholar
  37. 37.
    Gray R, Tynan C, Reed L, et al. Bedside electromagnetic-guided feeding tube placement: an improvement over traditional placement technique? Nutr Clin Pract. 2007;22(4):436–44.PubMedCrossRefGoogle Scholar
  38. 38.
    O’Keefe SJ, Foody W, Gill S. Transnasal endoscopic placement of feeding tubes in the intensive care unit. JPEN J Parenter Enteral Nutr. 2003;27(5):349–54.PubMedCrossRefGoogle Scholar
  39. 39.
    Lewis SJ, Franco S, Young G, et al. Altered bowel function and duodenal bacterial overgrowth in patients treated with omeprazole. Aliment Pharmacol Ther. 1996;10(4):557–61.PubMedCrossRefGoogle Scholar
  40. 40.
    Malone AM. Specialized enteral formulas in acute and chronic pulmonary disease. Nutr Clin Pract. 2009;24(6):666–74.PubMedCrossRefGoogle Scholar
  41. 41.
    Ceriello A, Lansink M, Rouws CH, et al. Administration of a new diabetes-specific enteral formula results in an improved 24 h glucose profile in type 2 diabetic patients. Diabetes Res Clin Pract. 2009;84(3):259–66.PubMedCrossRefGoogle Scholar
  42. 42.
    Rushdi TA, Pichard C, Khater YH. Control of diarrhea by fiber-enriched diet in ICU patients on enteral nutrition: a prospective randomized controlled trial. Clin Nutr. 2004;23(6):1344–52.PubMedCrossRefGoogle Scholar
  43. 43.
    Lewis S, Burmeister S, Brazier J. Effect of the prebiotic oligofructose on relapse of Clostridium difficile-associated diarrhea: a randomized, controlled study. Clin Gastroenterol Hepatol. 2005;3(5):442–8.PubMedCrossRefGoogle Scholar
  44. 44.
    Heyland DK, Novak F, Drover JW, et al. Should immunonutrition become routine in critically ill patients? A systematic review of the evidence. JAMA. 2001;286(8):944–53.PubMedCrossRefGoogle Scholar
  45. 45.
    Marik PE, Zaloga GP. Immunonutrition in critically ill patients: a systematic review and analysis of the literature. Intensive Care Med. 2008;34(11):1980–90.PubMedCrossRefGoogle Scholar
  46. 46.
    Druml W, Mitch W. Enteral and tube feeding. Philadelphia: WB Saunders; 1997.Google Scholar
  47. 47.
    Abras E, Walser M. Nitrogen utilization in uremic patients fed by continuous nasogastric infusion. Kidney Int. 1982;22(4):392–7.PubMedCrossRefGoogle Scholar
  48. 48.
    Frankfort JD, Fischer CE, Stansbury DW, et al. Effects of high- and low-carbohydrate meals on maximum exercise performance in chronic airflow obstruction. Chest. 1991;100(3):792–5.PubMedCrossRefGoogle Scholar
  49. 49.
    Vermeeren MA, Wouters EF, Nelissen LH, et al. Acute effects of different nutritional supplements on symptoms and functional capacity in patients with chronic obstructive pulmonary disease. Am J Clin Nutr. 2001;73(2):295–301.PubMedGoogle Scholar
  50. 50.
    O’Keefe SJ, Ogden J, Ramjee G, et al. Short-term effects of an intravenous infusion of a nutrient solution containing amino acids, glucose and insulin on leucine turnover and amino acid metabolism in patients with liver failure. J Hepatol. 1988;6(1):101–8.PubMedCrossRefGoogle Scholar
  51. 51.
    Blackburn GL, O’Keefe SJ. Nutrition in liver failure. Gastroenterology. 1989;97(4):1049–51.PubMedGoogle Scholar
  52. 52.
    Le Cornu KA, McKiernan FJ, Kapadia SA, et al. A prospective randomized study of preoperative nutritional supplementation in patients awaiting elective orthotopic liver transplantation. Transplantation. 2000;69(7):1364–9.PubMedCrossRefGoogle Scholar
  53. 53.
    Kearns PJ, Young H, Garcia G, et al. Accelerated improvement of alcoholic liver disease with enteral nutrition. Gastroenterology. 1992;102(1):200–5.PubMedGoogle Scholar
  54. 54.
    Dasgupta M, Binns MA, Rochon PA. Subcutaneous fluid infusion in a long-term care setting. J Am Geriatr Soc. 2000;48(7):795–9.PubMedGoogle Scholar
  55. 55.
    Remington R, Hultman T. Hypodermoclysis to treat dehydration: a review of the evidence. J Am Geriatr Soc. 2007;55(12):2051–5.PubMedCrossRefGoogle Scholar
  56. 56.
    Hearnshaw SA, Thompson NP. Use of parenteral nutrition in hospitals in the North of England. J Hum Nutr Diet. 2007;20(1):14–23; quiz 24–6.Google Scholar
  57. 57.
    American Gastroenterological Association medical position statement: parenterul nutrition. Gastroenterology. 2001;121(4):966–9.Google Scholar
  58. 58.
    Anderson AD, Palmer D, MacFie J. Peripheral parenteral nutrition. Br J Surg. 2003;90(9):1048–54.PubMedCrossRefGoogle Scholar
  59. 59.
    Howard L, Malone M. Clinical outcome of geriatric patients in the United States receiving home parenteral and enteral nutrition. Am J Clin Nutr. 1997;66(6):1364–70.PubMedGoogle Scholar
  60. 60.
    O’Keefe SJ, Burnes JU, Thompson RL. Recurrent sepsis in home parenteral nutrition patients: an analysis of risk factors. JPEN J Parenter Enteral Nutr. 1994;18(3):256–63.PubMedCrossRefGoogle Scholar
  61. 61.
    Burnes JU, O’Keefe SJ, Fleming CR, et al. Home parenteral nutrition—a 3-year analysis of clinical and laboratory monitoring. JPEN J Parenter Enteral Nutr. 1992;16(4):327–32.PubMedCrossRefGoogle Scholar
  62. 62.
    Heyland DK, Dhaliwal R, Drover JW, et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr. 2003;27(5):355–73.PubMedCrossRefGoogle Scholar
  63. 63.
    Cangelosi MJ, Auerbach HR, Cohen JT. A clinical and economic evaluation of enteral nutrition. Curr Med Res Opin. 2011;27(2):413–22.PubMedCrossRefGoogle Scholar
  64. 64.
    Hitchings H, Best C, Steed I. Home enteral tube feeding in older people: consideration of the issues. Br J Nurs. 2010;19(18):1150–4.PubMedGoogle Scholar
  65. 65.
    Tkatch L, Rapin CH, Rizzoli R, et al. Benefits of oral protein supplementation in elderly patients with fracture of the proximal femur. J Am Coll Nutr. 1992;11(5):519–25.PubMedGoogle Scholar
  66. 66.
    Lawson RM, Doshi MK, Barton JR, et al. The effect of unselected post-operative nutritional supplementation on nutritional status and clinical outcome of orthopaedic patients. Clin Nutr. 2003;22(1):39–46.PubMedCrossRefGoogle Scholar
  67. 67.
    Stratton RJ, Ek AC, Engfer M, et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev. 2005;4(3):422–50.PubMedCrossRefGoogle Scholar
  68. 68.
    Wouters-Wesseling W, Van Hooijdonk C, Wagenaar L, et al. The effect of a liquid nutrition supplement on body composition and physical functioning in elderly people. Clin Nutr. 2003;22(4):371–7.PubMedCrossRefGoogle Scholar
  69. 69.
    Faxen-Irving G, Andren-Olsson B, af Geijerstam A, et al. The effect of nutritional intervention in elderly subjects residing in group-living for the demented. Eur J Clin Nutr. 2002;56(3):221–7.PubMedCrossRefGoogle Scholar
  70. 70.
    Milne AC, Potter J, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev. 2005;(2):CD003288.Google Scholar
  71. 71.
    Avenell A, Handoll HH. Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev. 2005;(2):CD001880.Google Scholar
  72. 72.
    Gray-Donald K, Payette H, Boutier V. Randomized clinical trial of nutritional supplementation shows little effect on functional status among free-living frail elderly. J Nutr. 1995;125(12):2965–71.PubMedGoogle Scholar
  73. 73.
    Wouters-Wesseling W, Wouters AE, Kleijer CN, et al. Study of the effect of a liquid nutrition supplement on the nutritional status of psycho-geriatric nursing home patients. Eur J Clin Nutr. 2002;56(3):245–51.PubMedCrossRefGoogle Scholar
  74. 74.
    Espaulella J, Guyer H, Diaz-Escriu F, et al. Nutritional supplementation of elderly hip fracture patients. A randomized, double-blind, placebo-controlled trial. Age Ageing. 2000;29(5):425–31.PubMedCrossRefGoogle Scholar
  75. 75.
    Patel PH, Thomas E. Risk factors for pneumonia after percutaneous endoscopic gastrostomy. J Clin Gastroenterol. 1990;12(4):389–92.PubMedCrossRefGoogle Scholar
  76. 76.
    Abitbol V, Selinger-Leneman H, Gallais Y, et al. [Percutaneous endoscopic gastrostomy in elderly patients. A prospective study in a geriatric hospital]. Gastroenterol Clin Biol. 2002;26(5):448–53.PubMedGoogle Scholar
  77. 77.
    Norton B, Homer-Ward M, Donnelly MT, et al. A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. BMJ. 1996;312(7022):13–6.PubMedCrossRefGoogle Scholar
  78. 78.
    Dwolatzky T, Berezovski S, Friedmann R, et al. A prospective comparison of the use of nasogastric and percutaneous endoscopic gastrostomy tubes for long-term enteral feeding in older people. Clin Nutr. 2001;20(6):535–40.PubMedCrossRefGoogle Scholar
  79. 79.
    Lee JS, Frongillo Jr EA. Nutritional and health consequences are associated with food insecurity among U.S. elderly persons. J Nutr. 2001;131(5):1503–9.PubMedGoogle Scholar
  80. 80.
    Shizgal HM, Martin MF, Gimmon Z. The effect of age on the caloric requirement of malnourished individuals. Am J Clin Nutr. 1992;55(4):783–9.PubMedGoogle Scholar
  81. 81.
    Morley JE. Nutrition in the elderly. Curr Opin Gastroenterol. 2002;18(2):240–5.PubMedCrossRefGoogle Scholar
  82. 82.
    Sarkisian S, Fenton TR, Shaheen AA, et al. Parenteral nutrition-associated hyperglycemia in noncritically ill inpatients is associated with higher mortality. Can J Gastroenterol. 2010;24(7):453–7.PubMedGoogle Scholar
  83. 83.
    Matsushima K, Cook A, Tyner T, et al. Parenteral nutrition: a clear and present danger unabated by tight glucose control. Am J Surg. 2010;200(3):386–90.PubMedCrossRefGoogle Scholar
  84. 84.
    Allison SP, Lobo DN. Fluid and electrolytes in the elderly. Curr Opin Clin Nutr Metab Care. 2004;7(1):27–33.PubMedCrossRefGoogle Scholar
  85. 85.
    Kagansky N, Levy S, Koren-Morag N, et al. Hypophosphataemia in old patients is associated with the refeeding syndrome and reduced survival. J Intern Med. 2005;257(5):461–8.PubMedCrossRefGoogle Scholar
  86. 86.
    Al-Jaouni R, Schneider SM, Rampal P, et al. Effect of age on substrate oxidation during total parenteral nutrition. Nutrition. 2002;18(1):20–5.PubMedCrossRefGoogle Scholar
  87. 87.
    Aberg W, Thorne A, Olivecrona T, et al. Fat oxidation and plasma removal capacity of an intravenous fat emulsion in elderly and young men. Nutrition. 2006;22(7–8):738–43.PubMedCrossRefGoogle Scholar
  88. 88.
    Walshe C, Phelan D, Bourke J, et al. Vascular erosion by central venous catheters used for total parenteral nutrition. Intensive Care Med. 2007;33(3):534–7.PubMedCrossRefGoogle Scholar
  89. 89.
    Oz V, Theilla M, Singer P. Eating habits and quality of life of patients receiving home parenteral nutrition in Israel. Clin Nutr. 2008;27(1):95–9.PubMedCrossRefGoogle Scholar
  90. 90.
    Huerta G, Viniegra L. [Involuntary weight loss as a clinical problem]. Rev Invest Clin. 1989;41(1):5–9.PubMedGoogle Scholar
  91. 91.
    Bistrian BR, Driscoll DF. Enteral and parenteral nutrition therapy, vol. 17e. New York: McGraw-Hill; 2008.Google Scholar

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© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Department of Internal MedicineGeorgetown University HospitalWashingtonUSA
  2. 2.Department of Gastroenterology, Hepatology and NutritionUniversity of Pittsburgh Medical CenterPittsburghUSA

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