A standardized approach to parenteral nutrition for the geriatric patient

Parenteral nutrition can be a useful therapeutic and prophylactic tool in managing some geriatric patients who present with nutritional deficiencies that accompany acute and chronic diseases. An outline is given of recommended procedures, e.g., solutions, dosages, indications, and contraindications. The techniques described permit a standardized approach to parenteral nutrition for most patients.     

Peripheral parenteral nutrition in protracted hyperemesis gravidarum--report of two cases and a literature review

Hyperemesis gravidarum is defined as severe nausea and vomiting during the first trimester of pregnancy. It is characterized by dehydration, electrolyte imbalance, ketonuria and weight loss of more than 5% of body weight and it usually requires hospitalization. Traditionally, total parenteral nutrition has been used when patients with hyperemesis gravidarum fail to respond to conservative measures, including dietary manipulation and antiemetics. Total parenteral nutrition has been shown to be an effective method of nutritional support during pregnancy but it is expensive and has potentially serious complications. Peripheral parenteral nutrition reduces the risk of complications, but caloric intake is limited. A small number of investigators have suggested using enteral nutrition as an alternative to total parenteral nutrition. Herein we report two cases of hyperemesis gravidarum successfully treated with an effective regimen of peripheral parenteral nutrition.     

Bacterial resistance to trimethoprim in geriatric medical wards

Urinary tract infections (UTI) caused by organisms resistant to trimethoprim (TMP), as well as their faecal carriage were studied in two geriatric wards. TMP-resistant UTI was common (26 and 50% of admission and ward-acquired infections, respectively) and was associated with male sex, recurrent and transferred admissions and length of stay. There was a strong relationship between faecal carriage and isolation of TMP-resistant organisms from urine. Antimicrobial exposure was the major determinant of TMP-resistant faecal carriage.     

Peripheral parenteral nutrition is no better than enteral nutrition in acute exacerbation of Crohn's disease: a prospective trial

The use of parenteral nutrition in patients with exacerbation of regional enteritis is controversial, the clinical dictum being bowel rest and nutritional repletion. In order to address this issue, on the short-term at least, a prospective randomized trial compared peripheral parenteral alimentation and elemental feedings for 2 weeks in patients hospitalized with regional enterities. Both groups had significant objective clinical improvement on their respective nutritional supplementation regimens pre- versus posttherapy as assessed by the Crohn's Disease Activity Index (CDAI) (p less than 0.05). However, there was no significant difference in improvement between parenteral versus enteral groups as assessed by the CDAI. Changes in nutritional assessment parameters, including retinol binding protein, nitrogen balance, total lymphocyte count, and transferrin, were related to the quantity of calories consumed rather than the mode of delivery. A positive nitrogen balance was obtained in all patients despite weight loss in the majority. The route of nutrient delivery in acute exacerbation of regional enteritis does not appear to have an impact on the short-term outcome.     

Overview of geriatric nutrition

Restoration and maintenance of optimal nutritional status in the long-term care setting may enhance the quality of life for geriatric patients. The elderly are at increased risk for poor nutrition due to age-related physiological and psychosocial changes, as well as the added toll of chronic disease. All of these may have a negative impact on adequate food intake. Health care providers must identify and address nutrition-related problems in a timely manner to correct nutrient imbalances and restore nutritional well-being in this population.     

Complications of parenteral nutrition

Parenteral nutrition plays a vital role for patients with intestinal failure and those who are unable to maintain oral or enteral nutrition alone. Parenteral nutrition has been shown to improve clinical outcome in patients with malnutrition and intestinal tract dysfunction. The use of parenteral nutrition is not without risk of serious complications. Parenteral nutrition complications can be divided into mechanical related to vascular access, septic, and metabolic. This article provides a review on the short- and long-term complications of parenteral nutrition and their management.     

Balance impairment not predictive of falls in geriatric rehabilitation wards

BACKGROUND: Falls are common among hospital inpatients, particularly in rehabilitation wards. Standing balance impairment is widely held to be a contributing factor to falls, is a component of several falls risk screening tools, and has motivated the development of balance retraining programs for the reduction of in-hospital falls. Little rigorous investigation of the link between standing balance impairment and in-hospital falls has been undertaken. METHODS: We identified optimal cut-off points of four commonly used balance measures (functional reach, Timed Up and Go, step test, and timed static stance) in a prospective multicenter cohort study. Admission data (n = 1373) were clustered and matched by center then randomly allocated to development and validation data sets. RESULTS: Optimal cut-off points for each test were identified from the development data set. The predictive accuracy of all four balance tests was poor when the optimal cut-off was applied to the validation data set (Youden Index scores ranged between 0.02 and 0.15). CONCLUSIONS: These findings do not support an association between admission standing balance and falls in a geriatric rehabilitation setting. This result has implications for content of falls risk screening tools and interventions to prevent falls in a geriatric rehabilitation population.     

Total parenteral nutrition in Crohn's disease

The effect of total parenteral nutrition on 19 patients suffering from severe active Crohn's disease was studied. Total parenteral nutrition was effective as primary therapy in 56 per cent. In the remaining patients, it was highly effective as supportive therapy, enabling them to undergo uneventful major surgery.     

Do-not-resuscitate policy on acute geriatric wards in Flanders, Belgium

OBJECTIVES: To describe the historical development and status of a do-not-resuscitate (DNR) policy on acute geriatric wards in Flanders, Belgium, and to compare it with the international situation. DESIGN: Structured mail questionnaires. SETTING: All 94 acute geriatric wards in hospitals in Flanders in 2002 (the year Belgium voted a law on euthanasia). PARTICIPANTS: Head geriatricians. MEASUREMENTS: A questionnaire was mailed about the existence, development, and implementation of the DNR policy (guidelines and order forms), with a request to return copies of existing DNR guidelines and DNR order forms. RESULTS: The response was 76.6%, with hospital characteristics not significantly different for responders and nonresponders. Development of DNR policy began in 1985, with a step-up in 1997 and 2001. In 2002, a DNR policy was available in 86.1% of geriatric wards, predominantly with institutional DNR guidelines and individual, patient-specific DNR order forms. Geriatric wards in private hospitals implemented their policy later (P=.01) and more often had order forms (P=.04) than those in public hospitals. The policy was initiated and developed predominantly from an institutional perspective by the hospital. The forms were not standardized and generally lacked room to document patient involvement in the decision making process. CONCLUSION: Implementation of institutional DNR guidelines and individual DNR order forms on geriatric wards in Flanders lagged behind that of other countries and was still incomplete in 2002. DNR policies varied in content and scope and were predominantly an expression of institutional defensive attitudes rather than a tool to promote patient involvement in DNR and other end-of-life decisions.     

Home parenteral and enteral nutrition

Home parenteral and enteral nutrition (HPEN) has evolved to become a very successful, lifesaving treatment in the management of patients with intestinal and oral failure, respectively. Nevertheless, the provision of HPEN remains intrusive, expensive, and continues to be associated with significant morbidity. The management of HPEN by a nutrition support team that optimally includes an experienced clinician, nurse specialist, dietitian, and pharmacist reduces HPEN-related morbidity and may reduce costs associated with its use. Because clinical expertise in the management of patients receiving HPEN is not widely available, the referral of these patients to experienced centers for periodic assessment should be encouraged.