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PREVIEW
The aging of the US population has meant that more people than ever have physical limitations or dementia that curtails their ability to eat Independently. As a result, tube feeding is increasingly used to deliver nutrition. In this article, the authors review the indications, clinical aspects, and possible complications of tube feeding. Long-term outcome and ethical aspects also are discussed.
Persons older than 65 years make up 13% of the US population.1 Common characteristics of this age-group include frailty and comorbidity, particularly dementia, which in its advanced stages often leads to the inability to eat independently.2 Dysphagia precludes oral intake in many others. Up to 15% of the elderly in the community and up to 60% of older adults in hospitals and long-term care facilities are malnourished and require supplemental nutrition.1 3
Malnutrition is associated with altered immune function, delayed wound healing, susceptibility to infection, reduced quality of life, increased caregiver burden, and mortality.56 Weight loss may occur even in the absence of a significant cause, a phenomenon associated with anorexia of aging. Deglutition may be impaired in persons with neurodegenerative or cerebrovascular disease.1
The ability to feed usually is the last activity of daily living to be lost. When persons are no longer able to independently maintain an acceptable caloric or fluid intake, enteral supplementation becomes a consideration. As long as the gastrointestinal tract is functional, the enteral route is preferred to the parenteral route and is accomplished through the use of a feeding tube.79 Enteric feeding resembles normal nutrient delivery and maintains villous structure and mucosal immune function.10 The new soft, pliable, and nonirritating tubes have minimized the contraindications to tube feeding.
The decision to tube-feed
All patients who are being considered for tube feeding should undergo a nutritional assessment.3,8 The assessment involves measuring biologic parameters such as total protein, serum albumin, prealbumin, transferrin, and cholesterol; obtaining a total lymphocyte count; performing anthropometrics (eg, serial weight, body mass index, skinfold thickness); and evaluating immune function through anergy testing.1'411
The presence of dysphagia warrants evaluation for reversible causes, gastrointestinal malignancy, thyroid disease, and problems with dentition.3'4" Other issues to consider are the presence of depression and an inability to afford food.1 A speech and swallow assessment and a modified barium swallow...