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clinical nutrition 28 2009 461 466 contents lists available at sciencedirect clinical nutrition journal homepage http www elsevier com locate clnu espen guidelines on parenteral nutrition geriatrics a b c ...

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                                                                         Clinical Nutrition 28 (2009) 461–466
                                                                   Contents lists available at ScienceDirect
                                                                         Clinical Nutrition
                                                    journal homepage: http://www.elsevier.com/locate/clnu
             ESPEN Guidelines on Parenteral Nutrition: Geriatrics
                             a                        b                   c                      d                   e                   f               g
             L. Sobotka , S.M. Schneider , Y.N. Berner , T. Cederholm , Z. Krznaric , A. Shenkin , Z. Stanga ,
             G. Toigoh, M. Vandewoudei, D. Volkertj
             a                                                                                  ´  ´
              Department of Metabolic Care and Gerontology, Medical Faculty, Charles University, Hradec Kralove, Czech Republic
             bNutritional Support and Intestinal Transplant Unit, Archet University Hospital, University of Nice Sophia-Antipolis, Nice, France
             cMeir Medical Centre, Tel Aviv University, Sackler Medical School, Tel Aviv, Israel
             dDepartment of Public Health and Caring Sciences/Clinical Nutrition and Metabolism, Uppsala University, Uppsala Science Park, Uppsala, Sweden
             eDepartment of Gastroenterology & Clinical Nutrition, Clinical Hospital Center and School of Medicine Zagreb, Zagreb, Croatia
             f Department of Clinical Chemistry, University of Liverpool, Liverpool, UK
             gDivision of Endocrinology, Diabetes and Clinical Nutrition, Department of General Internal Medicine, University Hospital, Bern, Switzerland
             hGeriatric Unit, Division of Internal Medicine, Department of Clinical Morphological Technological Sciences, University of Trieste, Trieste, Italy
             i Department of Geriatrics, University of Antwerp, Ziekenhuisnetwerk Antwerpen (ZNA), Antwerp, Belgium
             j Departments of Nutrition and Food Science, University of Bonn and Pfrimmer Nutricia, Erlangen, Germany
             articleinfo                                     summary
             Article history:                                Older subjects are at increased risk of partial or complete loss of independence due to acute and/or
             Received 4 February 2009                        chronic disease and often of concomitant protein caloric malnutrition. Nutritional care and support
             Accepted 1 April 2009                           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
             Keywords:                                       the enteral route, parenteral nutrition (PN) is indicated.
             Nutritional support in the elderly              PN is a safe and effective therapeutic procedure and age per se is not a reason to exclude patients from
             Enteral nutrition in the elderly                this treatment. The use of PN should always be balanced against a realistic chance of improvement in the
             Parenteral nutrition in the elderly             general condition of the patient. Lower glucose tolerance, electrolyte and micronutrient deficiencies and
             Malnutrition in the elderly
             Subcutaneous fluid administration                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.
                                                                                 2009European Society for Clinical Nutrition and Metabolism. All rights reserved.
             Preliminary remarks                                                            pressure ulcers), length of stay in hospital and duration of conva-
                                                                                            lescence after acute illness in geriatric patients.
                 An elderly subject is usually defined, in western countries, as                 A reduced capacity for rehabilitation is characteristic of older
             a person over the age of 65 (WHO). A geriatric patient is an older             patients, making it more difficult to rehabilitate and to return the
             adult seeking medical care. He or she may be independent and                   patient to normal or to his/her previous condition. Muscle mass
             generally healthy needing mainly preventive care, but is often                 restoration is more complicated in terms of exercise and nutrition
             someone who has a loss of independence caused by acute and/or                                              1
                                                                                            than in younger patients.
             chronicdiseases(oftenmultiplepathology)withrelatedlimitations                      Manyfactorsthatcompromisenutrientandfluidintakeincrease
             inphysical,psychological,mental,cognitiveand/orsocialfunctions.                theriskofundernutritionwithaprogressivelossofleanbodymass.
             The ability to perform the basic activities of independent daily               Since restoration of body cell mass is more difficult in older
                                                                                                     1 preventative nutritional support with adequate intake of
             living maythenbejeopardisedorlost.Suchapersonisinincreased                     persons,
             need of rehabilitative, physical, psychological and social care to             energy, protein and micronutrients should be considered in every
             avoid partial or complete loss of independence. Moreover muscle                elderly patient.
             mass deficit, i.e. sarcopenia, is a frequent comorbid situation.                    Nutritional care should be an integral part of the overall care
                 Studies haveshownaninverserelationshipbetweennutritional                   plan, which takes into account all aspects of the patient. A
             status and complication rates (e.g. mortality, infections, and                 comprehensive assessment should include nutritional status and
                                                                                            risk. A nutritional programmetakingintoaccountethicalaswellas
                                                                                            clinical considerations should be implemented.2 Appropriately
                 E-mail address: espenjournals@espen.org.                                   minimisingtheneedforparenteralnutrition,lessphysiologicaland
             0261-5614/$ – see front matter  2009 European Society for Clinical Nutrition and Metabolism. All rights reserved.
             doi:10.1016/j.clnu.2009.04.004
           462                                                          L. Sobotka et al. / Clinical Nutrition 28 (2009) 461–466
           Summaryofstatements: Geriatrics
           Subject                            Recommendations                                                                                                 Grade           Number
           Indications                        Age per se is not a reason to exclude patients from PN.                                                         C [IV]           1.1.
                                              PNisindicatedandmayallowadequatenutritioninpatientswhocannotmeettheirnutritionalrequirements                    C [IV]           1.1.
                                              via the enteral route.
                                              PNsupport should be instituted in the older person facing a period of starvation of more than 3 days or if      C [IV]           1.1.
                                              intake is likely to be insufficient for more than 7–10 days, and when oral or enteral nutrition is impossible.
                                              Pharmacological sedation or physical restraining to make PN possible is not justified.                           C [IV]           1.1.
                                              PNis a useful and effective method of nutritional support in older persons but compared to EN and oral          B [III]          1.2.
                                              nutritional supplements are much less often justified.
           Metabolic/physiological            Insulin resistance and hyperglycaemia together with impairment of cardiac and renal function are the            C [IV]           2
              features in older subjects      most relevant features. They may warrant the use of formulae with higher lipid content.
                                              Deficiencies in vitamins, trace elements and minerals should be suspected in older subjects.                     B [IIb]          2
                                              The effect of nutritional support on restoration of depleted body cell mass is lower in elderly patients than   B [IIa]          2
                                              in younger subjects. The oxidation capacity for lipid emulsions is not negatively influenced by age.
           Peripheral PN                      Both central and peripheral nutrition can be used in geriatric patients.                                        C [IV]           3
                                              Osmolarity of peripheral parenteral nutrition should not be higher than 850 mOsmol/l.                           B [III]          3
           Subcutaneous fluid                  The subcutaneous route is possible for fluid administration in order to correct mild to moderate                 A[Ia]            4
              administration                  dehydration but not to meet other nutrient requirements.
           PNandnutritional status            PNcanimprovenutritional status in older as well as in younger adults. However, active physical                  B [IIb]          5
                                              rehabilitation is essential for muscle gain.
           Functional status                  PNcansupport improvement of functional status, but the margin of improvement is lower than in                   C [IV]           6
                                              younger patients.
           Morbidity and mortality            PNcanreducemortality and morbidity in older as well as in middle-aged subjects.                                 C [IV]           7
           Length of hospital stay            Nostudies have assessed length of hospital stay in older patients on PN.                                                         8
           Quality of life                    Long-term parenteral nutrition does not influence quality of life of older patients more negatively than it      C [IV]           9
                                              does in younger subjects.
           Specific complications              There are no specific complications of PN in geriatric patients compared to other ages, but complications        C [IV]          10
                                              tend to be more frequent due to associated comorbidities.
           Specific situations                 Indications for PN are similar in younger and older adults in the hospital and at home.                         B [III]         11
           Ethical problems                   PNorparenteral hydration should be considered as medical treatments rather than as basic care. Therefore        C [IV]          12
                                              their use should be balanced against a realistic chance of improvement in the general condition.
           more invasive than the enteral route, demands that frailty be                               – Does PN accord with the expressed or presumed will of the
           detected and characterised in a timely and precise manner. This                                patient, or in the case of incompetent patients, of his/her legal
           assessmentisthusacrucialstepinthediagnosticwork-upofthese                                      representative?
                     3 and the methodological approach should be multidi-                              – AretheresufficientresourcesavailabletomanagePNproperly?
           patients
           mensional such as those proposed by national societies of geriat-                           – If long-term PN implies a different living situation (e.g. insti-
           rics; even in this context it is important that the action of the                              tution vs. home), will the patient derive benefit from it?
           clinical nutritionist is integrated with that of the geriatrician and
           other medical specialists (in particular, the neurologist, psychia-
           trist, and rehabilitation specialist).                                                   1. Indications for PN in older persons
               In designing the programme, it should be remembered that the
           majorityofsickelderlypatientsrequireatleast1.0–1.2gprotein/kg                            1.1. Is PN indicated in geriatric patients?
           per day and 20–30kcal/kg per day of non-protein energy,4,5
           depending on the severity of the disease, the degree of current                              PN is a safe and effective therapeutic procedure, on the
           inflammation/catabolism, the physical activity level and the need                         conditionthatitisprovidedbyanexperiencedteam.Ageperseis
           and time course of rehabilitation. Although, current literature                          not a reason to exclude patients from PN (C).
           review suggests that slightly higher protein amounts (1.5 g/kg per                           PNisindicated and may allow adequate nutrition in patients
           day) should be warranted in the malnourished elderly to improve                          whocannot meet their nutritional requirements via the enteral
                                                                     4 studies specifically
           nitrogen balance and restore lean body mass,                                             route, and should be limited to situations when EN is contra-
           addressing protein supply by parenteral route are still lacking.                         indicated or poorly tolerated (C).
           Nevertheless,inacutelyhospitalisedolderpatientsenergyintakeis                                PN support should be instituted in the older person facing
           rarelysufficienttocoverthebasalenergyexpenditure(BEE).5Many                               a period of starvation of more than 3 days when oral or enteral
           older people also suffer from specific micronutrient deficiencies,                         nutrition is impossible, and when oral or enteral nutrition has
           which should be corrected by supplementation.                                            been or is likely to be insufficient for more than 7–10 days (C).
               Institution of PN in older subjects generates the same medical                           Pharmacological sedation or physical restraining of the
           and ethical problems as EN and therefore the same questions                              patient to make PN possible is not justified (C).
           should be asked6:
                                                                                                        Comments: Malnutrition is widespread in older people and is
              – Doesthepatientsufferfromaconditionthatislikelytobenefit                              reported in more than half of geriatric patients at the time of
                 from PN?                                                                           hospital admission (III).7 In nursing homes and long-term care
              – Will PN improve outcome and/or accelerate recovery?                                 institutions even moresubjects maybeaffected.Howeverreported
              – Does the patient suffer from an incurable disease, but never-                       prevalenceratesvaryaccordingtothemethodsusedfornutritional
                 theless quality of life and wellbeing can be maintained or                         assessmentandthespecificcharacteristicsofthepopulationunder
                                                                                                                 8 Nutritional care should beanintegralpartof theoverall
                 improved by PN?                                                                    study(III).
              – Does the anticipated benefit outweigh the potential risks?                           care plan. Nutritional support is indicated when patients are at
                                                                                 L. Sobotka et al. / Clinical Nutrition 28 (2009) 461–466                                                              463
                risk of developing malnutrition-related complications or when                                    nutritional support. Onlyafewmalnourishedoldersubjectscannot
                adequate nutrition is impossible and should be started in a timely                               be enterally fed. Another reason might be that, at present, malnu-
                          6
                fashion.                                                                                         trition is often overlooked and left untreated. In addition PN might
                    Enteral nutrition (EN, including oral and enteral routes) should                             beunderutilisedbecauseitisoftennotconsideredasapossibleand
                                                      6
                always be the first choice. In patients who cannot meet their                                     practical wayofnutrientdelivery.However,arecentqualitycontrol
                nutritional requirements via the enteral route, parenteral nutrition                             study in the Geneva University Hospital highlighted that, even
                (PN)mayallowadequatenutrition.PNisasafeandeffectivemethod                                        when highly justified, PN is frequently inadequate in terms of
                of nutrition support for most patients – including older patients.                               energy, protein, vitamins or trace elements administration and
                However, it remains an invasive and costly method potentially                                                                                                        14
                                                                                                                 further optimisation of current practice is needed.
                causing numerous complications, and potentially requiring inten-                                     As a consequence of demographic changes with an increase in
                sive nursing care. Therefore it should be restricted to patients who                             life expectancy the number of older people requiring (home) PN
                cannotreceiveadequatenutritionbytheenteralroute.                                                 will rise in the future. This is particularly true for the oldest old
                    This may be the case in patients who are unable to receive EN                                patients (>90years old), a group in whom artificial nutrition is
                (gut failure, high-output fistulas, uncontrollable diarrhoea) or in                               poorly studied. For these patients there is no exhaustive literature
                whom EN alone cannot meet the energy and nutritional require-                                    on any form of artificial nutrition, even though clinical experience
                ments, e.g. when tube feeding is poorly tolerated. Many geriatric                                suggests that adequate and timely nutritional treatment is
                patients have cognitive deficits or other mental impairments that                                 fundamental.
                may enhance the risk of temporary confusional states during
                somatic illnesses. Under such conditions naso-gastric tubes are                                  2. Are there any metabolic/physiological features in older
                likely to be removedbythepatient.Alongwiththis,age-associated                                    subjects that may affect their response to PN?
                changes in the physiology of the gastrointestinal tract should be
                considered in regard to the effectiveness of nutrient absorption,                                    Insulin resistance, leading to a lower glucose utilisation and
                                                               9 Thus, oral/enteral and paren-
                particularly during critical illness.                                                            hyperglycaemia together with impairment of cardiac and renal
                teral nutrition are not mutuallyexclusive but maycomplementone                                   function are the most relevant features. They may warrant the
                another.                                                                                         use of formulae with higher lipid content – up to 50% of total
                    Subjects, whoreceivegeriatric care at home, including PN, need                               energy intake (C).
                considerablesupportfromfamilymembers.Theappropriatenessof                                            Deficienciesinvitamins,traceelementsandmineralsshouldbe
                this kind of specialised nutritional support should be considered                                suspected in older subjects (B). The effect of nutritional support
                with caution, taking into account the patients particular circum-                               on restoration of depleted body cell mass is lower in elderly
                stances such as probable survival, rehabilitation potential and                                  patients than in younger subjects; however, the oxidation
                complication risk.                                                                               capacity for lipid emulsions is not negatively influenced by
                                                                                                                 age (B).
                1.2. Is PN a useful method in older malnourished patients?                                           Comments: Insulin resistance and the prevalence of diabetes
                    PN is a useful method of nutritional support in older                                        mellitus increase with age. Therefore impaired glucose tolerance
                                                                                                                                                                15
                malnourished patients; however, compared to EN and oral                                          should be looked for in the elderly.
                nutritional supplements PN is much less often justified in geri-                                      Vitamin and mineral deficiencies are more prevalent than in
                atric patients (B).                                                                              younger subjects. Many older patients will already have impaired
                                                                                                                 status of trace elements and vitamins at the time they commence
                    Comments: Several studies have documented that PN is                                         nutritional support. There is good evidence from the United
                a feasible and successful method of nutritional support in older                                 Kingdom and from the United States that up to 40% of individuals
                people. In a British survey on PN in 15 hospitals in Northern                                    aged65ormorehaveaninadequateintakeofoneormorevitamins
                England,themedianageofPNpatientswas67years(range20–90).                                          or minerals (ascorbate, folate, B12, thiamine, riboflavin, magne-
                Thus, more than one half of adult patients on PN are older than                                  sium, iron and zinc) with associated low blood concentrations16,17
                         10                                                                                      (IIb). Such abnormalities occur in free living as well as institu-
                65 (III).
                    Similarly, the mean age of 159 parenterally nourished outpa-                                 tionalised individuals, especially in those regarded as food inse-
                tientsfromtheClinicalNutritionUnitforHomePNoftheFedericoII                                       cure. Abnormalities are also common in patients admitted to
                University Hospital in Naples, Italy (referred from oncology,                                    hospital, probably as a result of recently reduced intake despite the
                neurology or surgery units) was 60.1 14.2years with a median                                    increased demands of illness, as well as a poor underlying nutri-
                                                                                11 Along with this,                              18 All essential vitamins and trace elements should
                value of 63 and a maximum of 93years (III).                                                      tional state.
                a further recent Italian survey, investigating the negative outcome                              therefore be given from the beginning of the course of PN;19 this
                of artificial nutrition (cases: EN, 57%; total PN, 30%; mixed, 13%),                          can be considered an effective way to achieve micronutrient
                                                                                                                                                                                                   1
                demonstratedthatdeathorinterruption(duetoworseningclinical                                       repletion and correction. In addition, mild (<0.77 mmol l                            )to
                                                                                                                                              1
                conditions within the initial 10 days of treatment) were meaning-                                severe (<0.45mmol l ) hypophosphataemia is frequently found
                fully higher in those aged >80 years and unrelated to the route of                               on admission, and particularly commonly develops, in older
                                                                                    12                           malnourished patients (w5 and 14.1% respectively according to
                administration when corrected for the indications.
                    Reported prevalence rates of PN are, however, very low. In                                                       20).
                                                                                                                 Kagansky et al.
                a prospective study of adjunctive peripheral PN in subacute care                                     Cardiac and renal functions are more likely to be impaired in
                patients, Thomas et al. screened 1140 consecutive admissions for                                 olderpersons.Thereforefluidandsodiumintakeshouldbelimited,
                patients receiving inadequate EN. By using stringent criteria (e.g.                              and especially so during periods of mobilisation of extracellular
                signs of malnutrition, low intake, no EN, no end stage disease) they                             water that has accumulated due to inflammatory processes or
                                                                                                                                                                       21–23
                identified only 19 patients (1.7%; mean age 83years) who were                                     during an earlier stage of refeeding (III).
                considered eligible for peripheral PN and finally consented to this                                   A study in 325 patients on PN has shown that with a similar
                     13 The low prevalence of PN may be explained by the fact that                               nutritional intake, depleted body cell mass was restored more
                (III).
                oral and enteral interventions are generally the first choice for                                 slowlyinolderpatients.Agewasasignificantindependentvariable
         464                                               L. Sobotka et al. / Clinical Nutrition 28 (2009) 461–466
                                                             1
         affecting the response to nutritional support (IIb). Probably, given      mild to moderate dehydration, especially in chronic care settings
         the effect of both aging and related insulin resistance on body cell                                                             33,34 In addi-
                                                                                   where the intravenous route is particularly difficult.
         massturnover,4 more protein calories should be delivered but this         tion, this technique is less invasive for drug administration in
         hypothesis still need to be explored.                                     palliative management where opioid and antiemetic therapy is
                                                                                                        35,36 Fluid replacement by hypodermoclysis is
             A study in twenty healthy volunteers submitted to a hyper-            frequently necessary.
         triglyceridaemic clamp showed a similar capacity in young and             relatively safe and easy to initiate, demands less nursing time,
         oldersubjectstooxidiseahighintravenoustriglycerideload(IIa).24            is more cost effective than intravenous treatment, causes less
         However, another study in 24 patients with intestinal failure             discomfort, minimises the risk of intravascular infection, does not
         showed a markedly higher lipid oxidation along with a lower               immobilisealimb,andhasbeenfoundtobelessdistressingforthe
         glucose oxidation, which may contribute to the frequent hyper-            patients. The technique can be used in the nursing home and home
                                                    25                                                                                        37–40 The
         glycaemia seen in older PN patients (IIa).                                setting and, thus, can prevent the stress of hospitalisation.
                                                                                   use of hyaluronidase in the infused solution augments the rate of
         3. Is peripheral PN feasible in geriatric patients?                       fluid uptake, and volumes up to 3000ml have been delivered over
                                                                                   24h.41
             Both central and peripheral nutrition can be used in geriatric           Hypodermoclysis is, however, not appropriate when large fluid
         patients (C).                                                             volumes are needed in short time periods or for infusing electro-
             Osmolarity of peripheral parenteral nutrition should not be           lyte-free or hypertonic solutions in emergency situations. Most
         higher than 850mOsmol/l (B).                                              units limit daily volumes to no more than 1 l.
                                                                                      The principal procedural disadvantages of subcutaneous fluid
             Comments: Administration of parenteral nutrition via periph-          treatment are local oedema and infection at the infusion site, but
                                                                                                                                         42
         eral veins is a method which can be used safely in an older patient.      the reported incidence of the latter is extremely low.
         Moreover, this approach allows early infusion of nutritional                 In a recent systematic review Remington & Hultman found two
         substrates during acute illness without the need to insert a central      RCTs and six cohort studies on the use of HDC to treat dehydration
                                                                                                   34 They concluded that HDC is as effective as IV
         venous catheter. There are no consistent studies, which compare           in older adults.
         different osmolarities during peripheral PN in geriatric patients.        rehydration of older adults with mild to moderate dehydration.
         However in adult subjects it was found that using very fine bore           Several advantages of HDC over IV hydration are described: lower
         silicon or polyurethane catheters and infusion pump-controlled            complicationrate,lowercosts,greaterpatientcomfort,lessnursing
                                                                                                                             35 However, it should be
         continuous administration, the osmolality of intravenous periph-          time to start and maintain the infusion.
         eral nutritioncanbetoleratedupto1000mOsmol/l.Thisallowsthe                kept in mind that HDC is onlya method for hydration and does not
         administrationofasufficientamountofmacro-andmicronutrients                 meetother nutrient requirements.
         via peripheral veins over periods of 2–3 weeks. Peripheral PN can
         cover nutrition needs in older patients who may receive regimens          5. Can PN maintain or improve nutritional status
         incorporatingupto1700kcal,60gofaminoacids,60–80goflipids
         and 150–180g of carbohydrates per day in a typical volume of                 PN can improve nutritional status in older as well as in
         2400ml.Thisisdeemedpossiblein50%ofpatients(Ib).26However,                 younger adults. However, active physical rehabilitation is essen-
         other published guidelines for peripheral PN suggest that osmo-           tial for muscle gain (B).
         larity of nutritional solutions should be limited to no more than
                         27                                                           Comments: There is no high quality trial which compares the
         900mOsmol/l.                                                              effect of PN with EN in a group of older patients. It is apparent from
             In the UK, utilisation of peripheral PN rose from 9% of adult         experimental stable isotope studies that intravenous nutrition
         patients on PN in 1988 to 18.3% in 1994. This was due to improved         (especially amino acid administration) could increase fraction
         peripheral catheters (fine bore silicone or polyurethane catheters)                                                                          43
                                                                        28 The     synthesis rate in old as well as in younger malnourished patients
         andbetterdeliverysystems(allinonebags,infusionpumps).                     (IIb), particularly in hypercatabolic cancer patients when tight
         recent availability of peripherally inserted catheters for both           glucose control is achieved.44 It should be stressed that physical
         peripheral (midline catheters) and central (PICC) PN might help in        activity is a necessary condition for significant muscle gain in both
         controlling the incidence of infectious or thrombotic complications              45
                                 29,30 It was demonstrated that up to 70% of       groups   (IIb).
         in parenteral nutrition.
         the patients were suitable for peripheral PN, and that 50%                6. Can PN maintain or improve functional status?
         completed a full course. However, the peripheral route should be
         limited to those with an anticipated duration of feeding of no more
         than 10–14days.31,32                                                         PN can support improvement of functional status, but the
                                                                                   margin of improvement is lower than in younger patients (C).
         4. Is there a role for subcutaneous fluid administration in                   Comments: Howard and Malone found that 38% of older
         geriatric patients?                                                       (>65years) patients receiving home PN reached full rehabilitation
                                                                                   capacity in comparisonwith62%inmiddle-aged(35–55years)and
             Peripheral or central venous access for fluid and electrolyte          63% in paediatric (0–18 years) subjects (III).46
         replacement is mandatory in emergencies and in situations
         where strict fluid balance is required. The subcutaneous route is          7. Can PN reduce morbidity and mortality?
         possible for fluid administration in order to correct mild to
         moderate dehydration but not to meet other nutrient require-                 PNcanreduce mortality and morbidity in older as well as in
         ments (A).                                                                middle-aged subjects. However, as PN has more complications
             Comments: Hypodermoclysis (HDC), the method of correcting             than EN, the oral and enteral route should be used whenever
         fluid deficits by subcutaneous infusion may be an alternative to            possible (C).
         intravenous cannulation in older patients (IIa). Isotonic fluids are          Comments: Mortality is higher in older patients on PN than in
         introduced into subcutaneous tissues seeking the correction of            youngerones. In Howard and Malones study,1year mortality was
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...Clinical nutrition contents lists available at sciencedirect journal homepage http www elsevier com locate clnu espen guidelines on parenteral geriatrics a b c d e f g l sobotka s m schneider y n berner t cederholm z krznaric shenkin stanga toigoh vandewoudei volkertj department of metabolic care and gerontology medical faculty charles university hradec kralove czech republic bnutritional support intestinal transplant unit archet hospital nice sophia antipolis france cmeir centre tel aviv sackler school israel ddepartment public health caring sciences metabolism uppsala science park sweden edepartment gastroenterology center medicine zagreb croatia chemistry liverpool uk gdivision endocrinology diabetes general internal bern switzerland hgeriatric division morphological technological trieste italy i antwerp ziekenhuisnetwerk antwerpen zna belgium j departments food bonn pfrimmer nutricia erlangen germany articleinfo summary article history older subjects are increased risk partial or c...

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