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E. Fercot1, L. Marty2, C. Bouteloup3, Y. Lepley4, J. Bohatier1, M. Bonnefoy4, B. Lesourd5, Y. Boirie6, S. Dadet7


1. Gérontopôle, CHU Clermont-Ferrand, Clermont-Ferrand, France;
2. Anthropologue de la santé, Département de Médecine Générale, Université Clermont Ferrand Auvergne, Clermont-Ferrand, France; 3. Université Clermont Auvergne, INRA, UNH,Unité de Nutrition Humaine, CHU Clermont-Ferrand, Service de médecine digestive et hépatobiliaire, CRNH Auvergne, Clermont-Ferrand, France; 4.  Université Claude Bernard Lyon 1, Faculté Lyon-Sud, France, Inserm U1060, Université Lyon 1, France, Service de médecine gériatrique, Hospices civils de Lyon, France; 5. Université Clermont Auvergne, Clermont-Ferrand, France; 6. Université Clermont Auvergne, INRA, UNH, Unité de Nutrition Humaine, CHU Clermont-Ferrand, Service de Nutrition Clinique, CRNH Auvergne, Clermont-Ferrand, France; 7. Université Clermont Auvergne, INRA, UNH, Unité de Nutrition Humaine, CHU Clermont-Ferrand, CHU Clermont-Ferrand, Gérontopôle, CHU Clermont-Ferrand, France.

Corresponding Author: Elise Fercot, Gérontopôle, CHU Clermont-Ferrand, F-63000 Clermont-Ferrand, France, fercote@hotmail.fr

J Aging Res Clin Practice 2018;7:115-122
Published online October 15, 2018, http://dx.doi.org/10.14283/jarcp.2018.20



Introduction: Nasogastric tube feeding appears underused in acute geriatric care units. The objective of this study was to identify the knowledge, practice, fears or behaviors of care givers governing implementation. Material and Methods: Multicentric qualitative research study based on interviews with geriatricians and care staff. Coding of patterns and thematic analysis of the data were used to extract key concepts tied to the objective. Results: Ten geriatricians and eleven care staff were interviewed individually and in a focus-group setting. Undernutrition was perceived as a prognosis-worsening comorbidity, not a disease. Early screening for undernutrition appeared essential, but care management and monitoring was within the remit of downstream structures. A handful of indications are reported to justify moves to start nasogastric tube feeding, often as part of adjuvant care, when real benefit is expected, when the individualized feeding plan is part of a comprehensive care plan, with the patient consciously involved and after consulting with the family. Patients’ fear of complications, cognitive disorders, and uncertain life expectancy often fuel concerns of a form of unreasonable obstinacy. Finally, doctors and care staff alike think that decisions on nasogastric intubation in this patient population require a multidisciplinary-team process. Conclusion: Nasogastric tube feeding in acute geriatric care remains fraught with issues. It looks a viable option, but should be part of a comprehensive care plan, based on multidisciplinary decision-making by appropriately-trained teams, where the goals of care are the patient’s comfort and quality of life.

Key words: Enteral nutrition, frailty, care management, geriatrics, malnutrition, quality of life.



According to French health authorities (HAS-Haute Autorité de Santé) figures, the prevalence of hospital undernutrition in France approaches 30–70% in patients over 80 years (1, 2). Acute illnesses increase protein-energy needs, while intakes are often inadequate due to episodic loss of appetite, eating difficulties or malabsorption (1, 3). This deficit can lead to protein-energy undernutrition, which increases the risk of sarcopenia, frailty (4), loss of functional capabilities (5), infectious risk (6), length of stay at hospital (7) impair functional outcomes and recovery (8) and mortality (9, 10). Effective nutritional management is therefore  necessary, and various academic societies have proposed strategies that include artificial nutrition (1, 11, 12). These care decision strategies can be constructed as decision trees, such as that of the French society for clinical nutrition and metabolism (SFNEP), but are rarely adapted to very old patients (13). The HAS and the European society for clinical nutrition and metabolism (ESPEN) issued guidelines in 2006 and 2007 specifically addressing factors unique to geriatric care : patient life expectancy, functional capabilities, frailty, neurocognitive disorders and comorbidities (1, 12). In practice, while nasogastric tube (NGT) feeding for enteral nutrition (EN) may be recommended in acute-phase hospital care, it is a lot more problematic in the acute geriatric care unit (AGCU) (13) and reluctance for a enteral nutrition may exist because of lack of education, knowledge, communication, or team work (14). In an effort to improve nutrition management in these units, an improvement in a deeper understanding of the practices and of the difficulties among the clinicians and care staff teams is expected.
Therefore, the objective of the present study was to identify the knowledge and practices governing the implementation of NGT feeding in AGCU wards. The aim was to survey geriatric care professionals to capture their opinion on nutrition management, evaluate their knowledge of the issue, characterize their expectations and perceptions, and identify the reasons that frustrate or facilitate the process of prescribing NGT placement.


Matherials and methods

Description of the study

This multicentric qualitative research study was led in AGCU wards at different Main City Hospitals (MCH) in the Auvergne region, France.

Choice of method

Qualitative research explores complex phenomena, arising from the ‘human factor’ of care delivery, in their natural environment. It attempts to make sense of the participant experiences and interpret the meanings they attribute to them. The process of analysis is approached inductively, in contrast to deductive approaches that systematically verify a pre-determined hypothesis. The method of inquiry used is based on the 32-item COREQ 2007 criteria, spanning 3 domains: research team and reflexivity, study design, and analysis and findings (15). Data was collected through semi-structured interviews-either individual or in focus-group format. Individual interviews give interviewees the freedom to open up and express themselves, while focus groups enable interaction based on group-effect dynamics and dialogue, thus facilitating the emergence of knowledge, opinion and experience by bringing different personal perspectives together. The open-ended questions addressed topics defined in an interview guide. People interviewed were free to address other concepts not initially agendaed. The study secured approval from the local French ethics committee (‘CPP’ Sud-Est VI) for the protection of human subjects.


The sample of geriatric doctors and care staff (Registered Nurses (RN) and Registered Nursing Care Assistants (RNCA))-all of whom were volunteers-had to be heterogeneous in order to capture the broadest possible range of opinions, experiences and practices. Age, gender, place of practice, career path, time in the job, and further training and education had to be as varied as possible. We continued to include material until thematic saturation.

Interview guide

Two interview guides were developed and tested to fit each professional (one for doctors and one for care staff, both of which served for the individual interviews and the focus group) in order to explore the various themes exposed in the literature on enteral nutrition. The guides were modified after the early exploratory interviews, as the questions were not open-ended enough, which hinded in free-flowing conversation. Likewise, certain questions asking about the knowledge held by doctors and care staff were deleted to rule out any value judgment.

Process and flow of the interviews

The interviewers opened by explaining the aim of the interview or focus group and the objectives targeted. They then had the time to outline the interview process, guaranteeing that everything shared would be anonymous and confidential and in no way critical or judgemental. The interviewer then collected the credentials of the people interviewed and their consent to record the conversation.
a) Process and flow of a semi-structured individual interview:
The interview started with the interviewee telling their story of an experience-whether good or bad-with NGT feeding. The questions were then cued by the interview guide until all the themes had been addressed. The same interviewer, mainly at the participants’ place of work, conducted all the interviews.
b) Process and flow of a semi-structured focus group:
The focus group was asked to talk over one or more experiences concerning NGT feeding. Two investigators were mobilized to take part in the focus group-one as facilitator, the other as observer to collect expressions of nonverbal communication. The moderator used a set of questions to keep dialogue and discussion focused, making sure that all the focal topics in the interview guide were addressed.

Collection of the data material

All the interviews were recorded end-to-end on an OLYMPUS-brand digital dictaphone. All digital capture was transcribed in depersonalized format into a verbatim-record Microsoft Word document. No digital data records were kept.

Method of analysis

The process of thematic analysis based on verbatim accounts started right from the first interview. The content of the verbalized conversation was collapsed into themes that were then subcategorized. The interview transcripts were then re-read and reviewed a second time using this list.



Description of the people interviewed

The interviews were conducted from February to August 2015.

Interviews with doctors

Interviews were led in-hospital, in 5 different MCH including 4 AGCU, on the 10 geriatric doctors reported in Table 1, thus compiling 4h22 of recorded material. The sample was positively heterogeneous for age, gender, experience and place of practice. The focus of background training tended to be on palliative care and neurodegenerative diseases. Only one of the doctors had been university-trained on nutrition.

Table 1 Doctor characteristics

Table 1
Doctor characteristics


Interviews with care staff

Interviews were led in the same MCH hosting 3 different AGCU, on the 11 care staff reported in Table 2, thus compiling 4h04 of recorded material. Two participants were interviewed by phone and one at home. The sample was positively heterogeneous for age, gender, and professional experience. The most common focus of background training was palliative care and neurodegenerative diseases, and only two of the 11 care staff had been given training on nutrition.

Table 2 Care staff characteristics

Table 2
Care staff characteristics

RN¹ Registered Nurse, NCA² Nursing Care Assistant


Analysis of the main findings

Various major themes and concepts emerged.

Knowledge and training levels of the geriatric care professionals

Interviews with doctors

The geriatric doctors claim they are undertrained on nutrition. “You can’t say ‘trained’. You learn on the job.” (Doctor #5) “By our department heads and colleagues.” (Doctor #6)

Interviews with care staff

The RN feel undertrained on EN, especially on technical procedure. “I think the nurses in general don’t know enough about placing the NGT, because, it’s true, at nursing school you only get a brief look at it” (RN #1) “Er, the training goes back 15 years ago […] but the first one I got to place, that was later on, once I had started work” (RN #2).

Nutrition in hospital practice

Screening for undernutrition

Screening appears to be a routine phase, but with different approaches. “It’s a routine practice on the admission tests for all elderly subjects”. (Doctor #1) “Weight, height, body mass index chemistry panel-systematically” (Doctor #4). The geriatricians also think they are more undernutrition-aware than other speciality practitioners. “We screen them as soon as they come in […] We’re optimal on that, we’re in good shape”(Doctor #1). However, there is variability in the resources mobilized for the nutritional status assessment, and the doctors voiced their issues, given how exhaustive investigation is just not feasible. “It’s always made hard by the fact they already have some kind of inflammatory syndrome, so we struggle to quantify their baseline nutritional status” (Doctor #3) “It only really starts getting useful if you’ve got past weight figures”. (Doctor #3). Close monitoring of food intakes is voiced more by the care staff, who also feel they are screening-aware. “We generally do the 3-day food and drink record chart” (RN #3). “If they don’t eat anything, there are written messages, verbal messages, it gets flagged up.” (RNCA #1).

Management of undernutrition

For the doctors, oral nutrition remains the best care plan going forward. “So if oral intake is possible, then you put them straight on oral nutritional supplements (ONS) already […] you maintain oral feeding, which takes priority” (Doctor #1). “In most cases, elderly patients are undernourished. So what I sometimes do is, rather than wait to get low blood Proteins, I put them straight on refeeding protocol with two ONS/day.” (Doctor #1) Certain hypercatabolic-syndrome settings nevertheless prompt them to start thinking oral nutrition is not enough. “When pressure ulcers or cancers come back, these situations where you know you need far higher intakes-where you have no time to lose.” (Doctor #2)

Follow-up on undernutrition care throughout the hospital stay

Some geriatricians feel that undernutrition management should be pushed back to later. “In the AGCU, you assess: the hospital stay is too short to re-assess your NS-backed feeding programme […]. When you come to re-assess, they are often already be in Subacute Care and Rehabilitation (SCR)” (Doctor #2). However, they do feel that they could also push their engagement further to prepare the ground for enteral feeding when the nutritional management rolls over into SCR “Say, OK, this patient has a severe undernutrition, to be re-assessed in x amount of time and if not reversed, place the NGT.” (Doctor #2). The care staff, though, manifestly voice a disconnect between their routine nursing and the medical management process. “You do food record charts for people who are eating loads, and when you flag up that the person isn’t eating, you don’t do a food record chart […] there’s a gap there, and you tell yourself nothing gets done.” (RNCA #7)

Elements considered for medical decision

Indications for NGT placement

The doctors appear to share a consensus that it is essential to optimally feed patients admitted for pressure ulcer, dysphagia after a stroke, or to ready for surgery or chemotherapy. “After that, deep pressure ulcer might be an issue” (Doctor #3) “a lady who had a haemorrhagic stroke, there it’s undeniably a good indication […] there is hope for recovery once the hematoma resorbs” (Doctor #5) “It’s presurgery nutrition to support better tolerance.” (Doctor #9). Anorexia against a background of depression with decline in general status also emerges as a consensus indication. “We were clearly looking at a care plan including antidepressants, and it worked out that way.” (Doctor #7). There is no clear consensus for infection management, even though the geriatricians appeared to recognize this indication. “I think that one of the best indications is to get through an acute-phase flare of infection or inflammation when you know it is likely to resolve.” (Doctor #3) This was voiced in the focus group without any objection from the co-attendees, and again in individual interview. “It’s in situations of acute stress-where there are going to be difficulties over one week, difficulties getting enough intake during major hypercatabolism-may be situations like that where, from time to time, we could be proposing the patient artificial nutritional support, but we don’t.” (Doctor #10)

Patient information and consent

All the doctors interviewed uphold and respect the principle that the patient’s wishes come ahead of any medical rationale. “Me, I work to the principle that if they are against it, then I don’t fit it” (Doctor #10). Many doctors reported that even when patients are fully informed and give their consent, they will still rip their NGT out eventually. “He ripped the catheter out, we offered to re-place it, and as he answered a very clear ‘no’, we didn’t do it” (Doctor #2) Over and above consent, the decisive factor is ultimately active patient participation. “A patient who was really engaged in cooperation, active collaboration, which makes everything so much easier […] he really was a stakeholder in his own care plan”. (Doctor #5)

Relationship with the family

The family holds a central position as the primary caregivers to go through when communication or decision-making are out of the older patient’s reach, when no advance care directives to go on. “She didn’t want any artificial support, so we held off the enteral nutrition in accordance with the directive that the patient had-supposedly-left but that her two daughters had passed on” (Doctor #5). That said, the opinion of the caregivers can put the practitioner in a difficult position, under pressure from the family to provide an enteral nutrition that the practitioner sees as unreasonable. “The family is always all for it, because their perception is that the nutrition is what is going to save them” (Doctor #10) Conversely, at other times, the family may be against an enteral nutrition that the doctor wants to implement. “We were pretty much pushing-and this was against the family’s wishes-to keep the enteral feeding going, and what ultimately happened was that the patient almost completely recovered as she was able to resumed normal feeding.” (Doctor #5) Even if the family are a primary proxy in geriatrics, the patient remains the primary decision-maker. “He is cognitively healthy, so we don’t need to call the family in-it’s his decision.” (Doctor #1). There is a unanimous view that it is vital to inform the family to foster their acceptance and participation in care. “If you explain everything properly, there’s no reason the family won’t accept it. Information is actually the be-all and end-all.” (Doctor #3)

Care-team decision-making

A collegial forum is something that the doctors and especially the care staff want. “These are still tough decisions to make, so I do find that the staff meeting helps get a clear picture of the issues.” (Doctor #2) Care staff want to be involved in the decision process, to understand it, as their assessments sometimes diverge from those made by the doctors. “Us, the nurses and nursing care assistants, as a rule, it just gets done, no-one asks us for any input. You show up in the morning, NGTs have been placed without anyone asking us if it’s a good idea, a bad idea” (RNCA #6) “When you don’t get consulted, you don’t necessarily understand […] whereas if you’re involved, whether you agree with it or not, at least you can understand.” (RNCA #6)

Benefits expected

The doctors are unable to give a clear picture of the real benefit expected from NGT feeding as a nutrition support measure in this population. “What really clouds the issue is that we just can’t properly measure the impact” (Doctor #5) “My feeling would be that more often than not it’s a failure” (Doctor #3). There appears to be some kind of dichotomy between the confirmed need for a NGT and doubts over the benefit expected. “Is always reasoning in terms of the patient’s best interests, over and above any biological formula or loss of weight, really going to bring them something?” (Doctor #10).

Importance of the care plan

The comprehensive care plan approach is a mainstay of geriatric medicine. “Either way, more than any kind of across-the-board assessment, it’s really going to be typically geriatric, […] What do they want? Is it worth it?” (Doctor #7) The majority of geriatricians was for including nutrition management and NGT feeding into a coherent comprehensive care plan as one of the factors of the parameters of geriatric patient assessment-quality-of-life included. “Geriatrics is never all about a nutrition plan. For me, it’s always about a plan for the future, a plan to make it out of the acute-care period.” (Doctor #7) “What is the plan, what is the potential for recovery?” (Doctor #5).

Prescription practice influenced by geriatric-ward experience

Those practitioners most exposed to care dependency and pathological aging are quick to confide how it may colour their thinking. “Personally I think I have been also conditioned by my experience of long-term hospital care […] a dozen patients on enteral feeding for months, years sometimes, all spent fighting with the adverse effects […] I’ve seen all the negatives of extended enteral, the ethics conversations, the families who just want it all to stop”. (Doctor #5) “Often, with the patients we have here at the AGCU, it’s hard to really go for it when you know the complications” (Doctor #2).

Barriers to implementing EN

Factors connected to the geriatric care environment

Preconceptions and perceptions of geriatricians

The perception seems to be that undernutrition is a comorbidity rather than an independent disease, and the doctors anticipate how patients will react to a problem they often ignore. “The patient’s going to turn round and say ‘but I’ve got no complaint. All I want is to not be in pain, the infection is under control, and right now I don’t feel I’m suffering from undernutrition’ ” (Doctor #5) As a rule, the geriatricians feel that they do start thinking about EN, but often  too late on. “Let’s just say that if you start asking yourself whether you should be putting them on it, then it’s that things are already a bit desperate.” (Doctor #3) This delay may be explained by their doubts over the benefit expected and their overriding concern to put patient quality-of-life first. “I firmly believe that for someone extremely undernourished, trying desperately to refeed them is already a stupid idea-it just won’t work” (Doctor #3). The time factor thus emerges as essential, and for many geriatricians, as soon as the patient is taking even a little food on board, the decision to engage a nutritional intervention can be pushed back to later. “The crux of the issue in AGCU care is that even if you register severe undernutrition, regardless of the criteria you base it on, if food intakes are any good at all, then you can use up time to attempt to recorrect through oral feeding” (Doctor #2).

Preconceptions and perceptions of care staff

The care staff tend to consider that a drop in food intakes is a normal sign of the natural ageing process, culminating in a form of anorexia synonymous with refusal of care: “the person is in her early nineties, you can see that she’s tired of life and that the refusal to eat is her way of showing that she’s had enough” (RN 1). This means that nutrition management decisions-regardless of whether for or against intervention-are often misunderstood, and can sometimes even add a burden of distress to care staff teams who want to be kept informed and their voice heard. “Me, if there’s things I struggle to accept, I go and see the doctors, because if no-one tells me what’s happening, I can’t let it go” (RNCA #11) “sometimes, as care staff, we really struggle when we see someone for weeks, like the guy who died this morning, for weeks he wasn’t eating, and we kept telling them, telling them […] So you get the impression no-one listened to a word we say, nothing gets done about it, that you’re letting them starve to death”. (RNCA #9) That said, even in the situations where the care staff feel disarmed, there is still some ambivalence over the NGT. “I must say, I do find that at it’s still a procedure that is quite violent, in that it’s, after all, still an invasive procedure” (RN #1) The geriatric care teams remain underfamiliarized with using it, and they often experience placing the NGT as an assault on the patient. “I’m still not real comfortable with it, because-well, sure, I haven’t placed many, and as interventions go, it can’t be easy to live with” (RN #4). Today’s better hardware has nevertheless brought tangible progress, which the teams readily accept. “You have these special catheters now, with guidewires, that make procedure so much easier” (RN #2).

Fear of complications

Geriatrics, more than any other ward, seems to suffer the stigma of the incidence of complications. “It’s mainly inhaling stuff, yeah-I had the case of a patient who suffered a major aspiration pneumonia, which he never recovered from”(Doctor #10) “You’re often reluctant to place catheters-you can’t just place catheters and be done, without mulling it over” (Doctor #1).

Difficulties in practice

Interviewees raised several difficulties unique to geriatric care, such as tube feeding at night, the risk of prolonging the hospital stay and difficulties home-front continuation of care, although they also gave some positive feedback. “I’m personally not too happy with them being fed at night because there’s one nurse for 33 patients” (RN #2). “The NGT is not something you can go back home with-not unless you’re on in-home care” (Doctor #4) “I have already had two reports back from a care provider following her at home, and with that, she’s absolutely fine with her NGT” (Doctor #10).

The alternative-parenteral nutrition

Parenteral nutrition (PN) is not perceived as an alternative to NGT feeding, and appears to be rarely used in practice. “Personally I never put a patient on parenteral. Either I decide to talk about the nasogastric tube and then a Percutaneous Endoscopic Gastrostomy (PEG), or it’s a no.” (Doctor #2) Some doctors find that PN may be indicated when the care plan has not be clearly established or when it is difficult to gauge the patient’s acceptance. “Why not use parenteral nutrition more in acute cases when you’re not sure of where you’re going, rather than placing a NGT?”(Doctor #6).

Factors connected to the elderly population

Very old age and unreasonable obstinacy

Many doctors and care staff alike challenge the ethical soundness of starting this type of treatment in very old age, when patients are dependent on care and life expectancy is short, often to the point that it crosses the border into unreasonable obstinacy. “You have to admit that in paediatrics you are thinking about a life ahead, so there’s nothing distressing about putting a feeding tube on a baby in neonatal care because it’s just something you have to do to give them every chance of making it through, whereas in geriatrics you tend to hold back on it, because is NGT really worth it, is the patient consenting?” (Doctor #4) Practitioners regularly struggle with lingering doubts over the outcome of this type of care protocol. “Is it really going to bring the patient some kind of relief, because we’ve all had times when we’ve set up nutrition in patients who deceased shortly after.” (Doctor #10)

Cognitive disorders

The prevalence of cognitive disorders in the geriatric-care population emerges as a real barrier to the use of EN. “They’re just going to rip it out, because they just don’t understand what’s going on.” (Doctor #7) “When you have to fit wrist restraints just to keep the NGT in place, I consider that we’ve lost all sight of common sense and that we’re bordering on abuse to get someone feeding” (Doctor #10). The doctors remain well aware of the risk of under-evaluating the right indications for enteral nutrition. “You get so conditioned by all these patients who are very old or have cognitive disorders […] it prompts behaviours in patients who would likely benefit and we maybe end up overcompensating and excluding them.” (Doctor #5)

The long-term-care perspective

The geriatric doctors appear to fear the withdrawal of the NGT or the risk of having to move to a long-term PEG they feel is unreasonable. “You are withdrawing food, which in people’s minds means you are killing the patient […] Withdrawing it is a really tough call.” (Doctor #6) “Why didn’t we put him on PEG? You have to do something to stop short of overaggressive obstinacy […] there are situations where you have to know when it’s time to stop, because once you take the road of a nutrition management process, after there’s no turning back.” (Doctor #4)

Patient comfort and quality of life

The staff struggle to square integrating an invasive protocol like NGT feeding into a care plan where the goals are supposed to be the patient’s comfort and quality of life. “You feel like you’re creating them unnecessary hassle, given that in 10 days’ time, they’ll be back at home.” (Doctor #5)



Main findings

The objective of this study was to analyze the knowledge and practices governing implementation of nasogastric tube feeding as an enteral nutrition support measure in AGCU wards. Our findings highlight a number of factors that create a disconnection between real-life bedside care practices and guidelined medical nutrition management. Even though practitioners can lead on HAS and ESPEN guidelines, our study effectively shows that the issue remains fraught with complexity-a complexity that can be translated into several explanatory concepts to help better grasp the difficulties faced by geriatric health care teams.
Foremost, the geriatric health care teams are essentially trained in the management of cognitive disorders and end-of-life care, which revolves around a comprehensive care plan approach focused on the patient’s comfort and quality of life. Our results do show that undernutrition is perceived as a latent phenomenon, commonly emerging in elderly patients, and patterned perhaps more as a comorbidity to be dealt with than a disease to be treated.  The most common care consists in screening and oral nutrition, and geriatricians often think that Subacute Care and Rehabilitation is a better ward for nutrition care than AGCU. NGT feeding does not appear to be considered a solution to improve way to improved protein-energy intakes. It does feature in the therapeutic arsenal of geriatric medicine, but does not appear to get used unless to support adjuvant care for other diseases when framed within a comprehensive care plan (13). It is perceived as an invasive, aggressive therapeutic measure, which increases the risk of confusion, and often leads geriatric care teams to feel they are going against their primary goals of care, i.e. the patient’s comfort and quality of life.
Then, when its use seems needed, several concepts converge to influence medical decision-making in the AGCU ward, and thus determine certain preconditions. Information and consent are vital yet insufficient factors. Active patient participation, which goes further than a straight yes/no consent, is absolutely pivotal and will be dictated by how the NGT intervention plan is presented to the patient, how far the patient can trusts the doctor and how the patient can understand the information. Another concept is the role of the primary caregivers. Even though the medical decision has always been grounded in the wishes of the patient, it appears essential to have their collaborative involvement. The long-term-care perspectives can also prove problematic. Firstly, organizing EN at home for care-dependent patients can prove a real hurdle. Secondly, the uncertainty about the patient’s progress may lead to fear of a form of unreasonable medical care with the risk of becoming forced to look at a PEG. Last but not least, ethical factor remains a key factor being systematically addressed in this population where life expectancy is uncertain and prevalence of cognitive disorders is high. Consequently, the expected benefit of an NGT intervention seems uncertain for care teams and has to be more clear whereas they affraid over crossing the border into unreasonable obstinacy. Thus, the care staff teams-like the doctors-voice their need for a medical decision to be taken by multidisciplinary collegial consensus.
The circumspective position manifested by the geriatricians is probably legitimate given the potential consequences of an NGT in the most frail elderly (16). While the guidelines do not rule out NGT feeding as a very-short-term measure in patients with cognitive impairment, extended long-term delivery of EN via PEG is not advisable (1,12). The ESPEN prompts practitioners to think hard about the expected benefits of EN, and the HAS is equally prudent, advising EN only when expected benefit is considered to outweigh the procedure-related risks (1,12). Furthermore, the legal framework tends to improve comfort-only and support care first (17, 18). Even though the guidelines argue for enteral nutritional support to maintain normal intakes (1,11,12), the literature fails to confirm any real benefit in very old inpatients outside of certain indications for orthopedic surgery or as treatment for pressure ulcers (19-22).  Nutritional interventions studies seems effective but often concern younger patients, and few of them bring evidence that would encourage geriatricians to start a nutritional intervention in the oldest age-bracket patients (23-25). A recent review of the literature confirms the struggle to characterize the groups of elderly inpatients most likely to benefit from nutritional support (26). However, the geriatric care teams appear too undertrained on EN to be able to confidently assess this benefit–risk ratio and they have probably to expand their use of EN. Some of the concepts highlighted should be considered in order to initiate an EN as part of a global care project.
The qualitative approach adopted here enabled us to explore complex phenomena beyond the grasp of other scientific approaches. However, this method of inquiry does impose certain limitations, that we sought to minimize here using COREQ criteria (15).



Active nutrition management for undernourished elderly patients in the AGCU is problematic as a process when the goals of the care plan are the patient’s comfort and quality of life. Although various sets of recommendations have been released to help to guide clinicians in their decision-making, there is no solid data to confidently assert the benefit of EN in very-old-age patients and confirm the grounds for its indication. The good use of NGT in AGCU remains to be defined despite the guidelines of ESPEN and HAS.


Ethical standards: The study secured approval from a french committee for the protection of human subjects.

Conflict of Interest: The authors have no conflict of interest.



1.    Haute Autorité de Santé – Stratégie de prise en charge en cas de dénutrition protéino-énergétique chez la personne âgée. has-santé.fr. http://www.has.sante.fr/portail/jcms/fc_1249588/fr/accueil-2012
2.     Potter J, Klipstein K, Reilly JJ, Roberts M. The nutritional status and clinical course of acute admissions to a geriatric unit. Age Ageing. 1995;24(2):131-6.
3.     Patel MD, Martin FC. WHY DON’T ELDERLY HOSPITAL INPATIENTS EAT ADEQUATELY? J Nutr Health Aging. 2008;12(4):227-31.
4.     Bonnefoy M, Berrut G, Lesourd B, Ferry M, Gilbert T, Guérin O, et al. Frailty and nutrition: searching for evidence. J Nutr Health Aging. 2015;19(3):250-7.
5.     Galanos AN, Pieper CF, Cornoni-Huntley JC, Bales CW, Fillenbaum GG. Nutrition and function: is there a relationship between body mass index and the functional capabilities of community-dwelling elderly? J Am Geriatr Soc. 1994;42(4):368-73.
6.     Paillaud E, Herbaud S, Caillet P, Lejonc J-L, Campillo B, Bories P-N. Relations between undernutrition and nosocomial infections in elderly patients. Age Ageing. 2005;34(6):619-25.
7.     Herrmann FR, Safran C, Levkoff SE, Minaker KL. Serum albumin level on admission as a predictor of death, length of stay, and readmission. Arch Intern Med. 1992;152(1):125-30.
8.     Sullivan DH. The role of nutrition in increased morbidity and mortality. Clin Geriatr Med. 1995;11(4):661-74.
9.     Wallace JI, Schwartz RS, LaCroix AZ, Uhlmann RF, Pearlman RA. Involuntary weight loss in older outpatients: incidence and clinical significance. J Am Geriatr Soc. 1995;43(4):329-37.
10.     Payette H, Coulombe C, Boutier V, Gray-Donald K. Weight loss and mortality among free-living frail elders: a prospective study. J Gerontol A Biol Sci Med Sci. 1999;54(9):M440-5.
11.     Bouteloup C, Thibault R. Arbre décisionnel du soin nutritionnel. Nutr Clin Metabol 2014;28(1):52-6.
12.     Volkert D, Berner YN, Berry E, Cederholm T, Coti Bertrand P, Milne A, et al. ESPEN Guidelines on Enteral Nutrition: Geriatrics. Clin Nutr 2006; 25(2): 330-60.
13.     Bruhat A, Bos C, Sibony-Prat J, Bojic N. L’assistance nutritionnelle chez les malades âgés dénutris. Presse Med. 2000 ;29(39) :2191-201.
14.     Jaafar MH, Mahadeva S, Subramanian P, Tan MP. Perceptions of Healthcare Professionals on the Usage of Percutaneous Endoscopic Gastrostomy in a Teaching Hospital from a Middle-Income South East Asian Country. J Nutr Health Aging. 2017;21(4):473-479.
15.     Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349.
16.     Lubart E, Leibovitz A, Dror Y, Katz E, Segal R. Mortality after nasogastric tube feeding initiation in long-term care elderly with oropharyngeal dysphagia–the contribution of refeeding syndrome. Gerontology. Karger Publishers; 2009;55(4):393-7.
17.     Loi N. Loi: 303 du 4 mars 2002 relative aux droits des malades… – Google Scholar. Journal officiel; 2002. 1 p.
18.     Aubry R, Puybasset L, Devalois B, Morel V, Viallard M-L. Loi du 2 février 2016 créant de nouveaux droits en faveur des malades et des personnes en fin de vie : analyse et commentaires. Médecine Palliative : Soins de Support – Accompagnement – Éthique. 2016;15(3):165-70.
19.     Bastow MD, Rawlings J, Allison SP. Benefits of supplementary tube feeding after fractured neck of femur: a randomised controlled trial. Br Med J 1983;287(6405):1589-92.
20.     Beattie AH, Prach AT, Baxter JP, Pennington CR. A randomised controlled trial evaluating the use of enteral nutritional supplements postoperatively in malnourished surgical patients. Gut. 2000;46(6):813-8.
21.     Hartgrink HH, Wille J, König P, Hermans J, Breslau PJ. Pressure sores and tube feeding in patients with a fracture of the hip: a randomized clinical trial. Clin Nutr. 1998;17(6):287-92.
22.     Stratton RJ, Ek A-C, Engfer M, Moore Z, Rigby P, Wolfe R, 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.
23.     Milne AC, Avenell A, Potter J. Meta-analysis: protein and energy supplementation in older people. Ann Intern Med. 2006;144(1):37–48.
24.     Feldblum I, German L, Castel H, Harman-Boehm I, Shahar DR. Individualized nutritional intervention during and after hospitalization: the nutrition intervention study clinical trial. J Am Geriatr Soc. 2011;59(1):10-7.
25.     Hegerová P, Dědková Z, Sobotka L. Early nutritional support and physiotherapy improved long-term self-sufficiency in acutely ill older patients. Nutrition. 2015;31(1):166-70.
26.     de van der Schueren MAE, Wijnhoven HAH, Kruizenga HM, Visser M. A critical appraisal of nutritional intervention studies in malnourished, community dwelling older persons. Clin Nutr. 2016;35(5):1008-14.


Y. Hokotachi1,2, S. Ichimaru2, M. Hayashida2,3, T. Amagai2

1. Department of Clinical Nutrition, Takarazuka Dai-ichi Hospital; 2. Administration Food Sciences and Nutrition Major, Graduate School of Human Environmental Sciences, Mukogawa Women’s University, Japan; 3. Departmentof Clinical Nutrition, Kobe Adventist Hospital, Japan.

Corresponding Author: T. Amagai, Administration Food Sciences and Nutrition Major, Graduate School of Human Environmental Sciences, Mukogawa Women’s University, Japan, amagaipedteruyoshi@gmail.com


Aim: To examine the hypothesis that larger cumulative energy deficit and late initiation of enteral nutrition for older adult patients in non-acute setting is associated with poor outcome at 3 and 6 months later. Methods: This is retrospective study with chart review in a single institute. The consecutive older adult patients (>= 65 years-old) admitted to the institute were included. Dividing all subjects by two categories: take nutrients by mouth (PO) during hospital stay vs. non-PO group, and enteral nutrition (EN) during the first 7 and 14 days after admission vs. non-EN (NEN) group. Between these two groups, demographics, nutritional, and outcomes were compared. Results: 1, PO group showed significantly longer length of hospital stay (p=0.049). 2, NEN group showed significantly larger cumulative energy deficit, longer length of hospital stay, and higher mortality at 3 and 6 months later (p=0.000, p=0.000, p=0.044, and p=0.008, respectively). Conclusion: The larger cumulative energy more than 10, 000 kcal is considered to be associated with poor clinical outcomes, including longer LOS and higher mortality at 3 and 6 months later in the hospitalized older adults (>= 80 years-old). The cumulative energy deficit might be considered in nutritional support even for older adults admitted to non-acute setting to prevent poor outcomes.

Key words: Cumulative energy deficit, enteral nutrition, older adult, non-acute, outcome.



Clinical outcomes are predicted by multiple factors, including vital signs and immune function (1, 2) in patients in acute settings and sarcopenia status in community-dwelling older adults (3). These predictors might also help identify impairment in anti-bacterial capacity and mobility in older adults. However, the question of whether nutritional delivery for the first few days after hospital admission is a predictor of later outcomes in older patients remains unclear.

Here, we examined our working hypothesis that an early energy deficit in older adults admitted in non-acute settings impacts later outcomes, such as 3- or 6-month mortality after admission.


The study was conducted under a retrospective design with chart review at a single institution. All consecutive patients aged 65 years and older on admission to a single institution between November 2010 and October 2011 were eligible. Exclusion criteria were: (1) length of hospital stay (LOS) < 2 days, (2) duration of enteral nutrition (EN) ≥ 300 days, (3) daily amount of EN < 200 ml, and (4) EN starting earlier than 2 days after admission. These exclusion criteria were identified as inappropriate in examining the impact of enteral nutrition on clinical outcomes. Landmark days used in the study were defined as follows: D1 was the admission day, D2 was the day to initiate EN, and D3 was the day of discharge from hospital. Further, to compare the two groups by PO or EN status, D4 was defined as the first 7 or 14 days after admission, unless EN was initiated before D4, as described in methods 1 and 2, respectively (Fig.1).

Data collection

Data covering the total hospitalization period were collected from the clinical charts of subjects and divided into three domains, as follows:

(1) demographic data included age, sex, height, weight, primary diagnosis, and Charlson comorbidity index (CCI) score to evaluate the severity of the primary diagnosis. All were measured on admission cymbaltaonline-pharmacy day (D1).

(2) nutritional parameters included route of EN administration of enteral nutrition formulae by mouth or through a nasogastric (NG) or gastric (G) tube; energy density of EN formulae at D2 (kcal/ml); number of subjects who achieved an energy target; length of intestinal starvation defined as nil by mouth until D2 (days); and cumulative energy deficit between D1 and D3 calculated by the difference in energy amount between the energy target, set at 25 kcal/kg of actual body weight/day as proposed by the ESPEN guideline (7) and total energy amount delivered through all routes, including parenteral, enteral and oral routes. Cumulative protein deficit was calculated the same way, with a protein target set at 1.0 g/kg/day. Cumulative energy deficits delivered through both parenteral and enteral route was calculated every 7 days until the day of initiation of EN (D3), maximally until the first 28 days after admission, and are expressed in daily units, as the same was also conducted in cumulative protein deficit administered through parenteral route.

(3) outcome parameters have primary and secondary outcomes: primary outcomes included mortality rate (%) during hospitalization period (between D1 and D3) and death rate at 28 days, 3 months, and 6 months after admission, and secondary outcomes including the length of hospitalization (days, between D1 and D3, LOS), ; and discharge status by type of institution after discharge in the three categories of home, nursing home and rehabilitation hospital, occurrence of adverse events, including diarrhea, and constipation, vomiting, and comorbidities of pneumonia and pressure ulcer during periods of EN management between D2 and D4 (Table 2, 3), and utilization of antibiotics for treatment purpose (%), and CRP > 6.0 mg/dl during hospitalization, before D2, and after D2. Adverse events were defined as diarrhea, watery or loose stools three or more times per day; and constipation, no defecation for at least four consecutive days. Cause of death was analyzed for patients who died during hospitalization in the study period. Survival status was defined by survival during hospitalization at 3 or 6 months after admission

Comparisons of groups by two classifications, PO vs. NPO and EN vs. NEN

To examine our hypothesis that a cumulative nutritional deficit impacted outcomes, all subjects were divided into two groups in each of two categories, as follows: (1) the PO and non-PO (NPO) groups were classified by their ability or inability to start total energy and macronutrient intake by mouth during hospitalization, as detailed in method 1; and (2) the EN and non-EN (NEN) groups were classified by their ability or inability to initiate EN within the first 7 (D7) or 14 days (D14) after admission, as detailed in method 2.

All collected data of the three domains described above were then compared among groups in the two classifications (PO vs. NPO, and EN vs. NEN; Fig. 1).

Figure 1 Flow chart of the study with methods 1, 2, and 3: for each method, data shown in the bottom square were compared at the individual timings shown in the right columns

D1:admission day, D2:day to initiate enteral nutrition (EN), D3:day todischarge from hospital, D4:the first 7 or 14 day after admission, unlessEN was initiated before D4, D7:7th day after admission, D14:14th day after admission.

Method 1

Subjects were divided into two groups according to their ability to start energy and nutrient intake by mouth (Fig.1). PO group subjects were able to start oral intake between D1 and D3. NOP group subjects were not able to start oral intake on any hospitalization day.

Method 2

Subjects were divided into two groups according to their ability to initiate EN after D1 and after D3 (Fig. 1). EN group subjects were able to start EN between D1 and D3, while non-EN group subjects were not. All collected data for D7 and D14 were then compared among these two groups (Fig.1). Additionally, causes of death during hospitalization were compared between the two groups and odds ratios (ORs) were calculated and expressed as OR, 95% confidence interval (95% CI), and p value.

Statistical analysis

Groups in each category were compared using the Mann-Whitney U test for continuous variables and the chi-square or Fisher’s exact test for categorical variables. Multiple logistic regression analysis were conducted using death at discharge as the dependent variable, with oral nutrition, day of initiation of EN within 7 or 14 days after admission, diarrhea, constipation, vomiting, and pneumonia as the independent variables. The purpose of multivariable analyses was to reveal the impact of day of initiation of EN within 7 or 14 days after admission on outcome. All analyses were done using SPSS Statistics version 22 (IBM, Armonk, NY), with significance considered at the p < 0.05 level.


Sixty-six of 82 patients were enrolled in this study as subjects for analysis. Sixteen subjects were excluded due to length of hospital stay < 2 days (n=8), period of EN ≥ 300 days (n=2), EN amount < 200 ml/day (n=1), starting EN within 2 days after admission (n=4), and admission for gastrostomy (n=1) (Fig. 1).

Result 1 – Comparison PO and NPO groups

Subjects were classified by their ability to take nutrients by mouth. Contrary to expectations, we found that the PO and NPO groups did not statistically differ by demographics, except with regard to the primary diagnosis of pneumonia (Table 1). In contrast, the later the day of initiation of the first EN (days), the larger the cumulative energy deficit (p=0.000, p=0.005, respectively, Table 2). Moreover, LOS was significantly longer in the PO group than the NPO group (p=0.049, Table 2). These results may suggest that the delayed initiation of EN in the PO buy accutane online group and significantly longer LOS were due to the expectation that the patient would be started with EN with PO. In contrast, initiation was relatively earlier and more easily in the NPO group.

Table 1 Comparison of demographics, primary diagnosis, and Charlson Comorbidity Index (CCI) between the PO and NPO groups. No significant differences were seen between the two groups for any variable except the primary diagnosis of pneumonia, * values are median (25, 75 quartiles)

Table 2 Comparison of nutritional parameters and outcomes between the PO and NPO groups. No. of days to the initiation of EN in the PO group was significantly later and cumulative energy deficit during hospitalization (between D1 and D2) was significantly larger in the PO than in the NPO group (p=0.000, 0.005, respectively). Length of hospital stay (LOS) was significantly longer in the PO group (p=0.049), *values are median (25, 75% quartiles)

*D1: admission day, D2: day to initiate enteral nutrition (EN)

Indications for the use of gastrostomy as an enteral route are controversial. Early http://abilifygeneric-online.com/ EN using a gastrostomy (G-)tube may shorten LOS, as shown in the present study. However, the physical and economical burden of this approach and it labor burden on care-givers must be considered. A previous study (4) found no difference in mortality in older adult patients with gastrostomy regardless of the coexistence of cognitive impairment, but did identify several predictors, including subtotal gastrectomy, lower serum albumin

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< 2.8 g/dl, age > 80 years, chronic heart failure, and male gender (ORs = 2.617, 2.081, 1.721, and 1.541, respectively).

Although more than one-third of subjects in both our PO and NPO groups had cognitive impairment (Table 1), the NPO group did not show a survival benefit despite the higher incidence of gastrostomy as a comorbidity. A conclusive answer to the survival benefit of a G-tube awaits additional study.

Result 2 – Comparison EN and NEN groups

The EN and NEN groups did not statistically differ by demographics (data, not shown). In contrast, CCI scores were significantly greater in the EN group, which had a greater severity of co-morbidities on admission, than in the NEN group (Fig. 1). This means that the severity of comorbidities was lower in the NEN group. However, nutritional parameters were all significantly lower in the EN than NEN group, including oral nutritional intake with EN (%) on the day of initiation of EN (D2), length of intestinal starvation until D2 (days), cumulative deficit in energy intake by EN (kcal) and PN (kcal), and cumulative deficits in aminoacids delivered through PN (g) until D2 (p=0.000 for all) (Table 3). Similarly, when subjects were divided into EN and NEN groups on the first 7 days after admission, LOS was significantly shorter and survival rates at 3 and 6 months after admission were significantly higher in the EN than NEN group (p=0.000 p=0.0044, and p=0.008, respectively) (Table 3). Similarly to these observations, significantly fewer patients with CRP ≥ 6.0 mg/dl were seen in the EN than NEN group during the whole hospital stay, and before and after EN initiation (p = 0.000 for all) (Table 4). Moreover, the concurrence rate of diarrhea and vomiting as adverse events during hospitalization was significantly lower in the EN group (p=0.009, and p=0.044, respectively) (data, not shown). Considering these findings, we conclude that the early initiation of EN and lower cumulative energy deficit is associated with a shorter LOS and higher survival rates at 3 and 6 months after admission, and a lower concurrence rate of comorbidity for diarrhea and vomiting, although causes zoloft dosage of deaths did not differ between the two groups on the 14th day after admission (D14). Death by D7 could not be examined because no subjects died during the first 7 days (D7) (data, not shown). Consistent with this, OR for initiation of EN (D2) within the first 14 days showed significantly lower death rate (p=0.008) (Table 4).

Table 3 Comparison of nutritional parameters and outcomes between the EN and NEN groups on the 7th and 14th days after admission. On analysis of the EN and NEN groups as early as at the 7th day after admission, cumulative energy deficit until D2 and D3 was significantly lower in the EN than the NEN group. Similarly, the clinical outcome, namely length of hospital stay, was significantly shorter (p=0.000), survival rate during hospitalization was significantly higher (p=0.003), and rates of adverse events during hospitalization were lower in the EN group, particularly diarrhea and vomiting (p=0.009, 0.044, respectively), CRP levels during hospitalization (CRP ≥6.0mg/dl) and after D2 were lower (P=0.000, 0.000, 0.001, respectively), and death at 3 and 6 months after admission, *values are edian (25, 75% quartiles)

Comparisons between the two groups were done using the Mann-Whitney U test for continuous variables and the chi-square test or Fisher’s exact test for categorical variables; *D1: admission day, D2: day to initiate enteral nutrition (EN), D3: day to discharge from hospital; *Values are median (25, 75% quartiles).

Table 4 Multiple logistic regression analysis of associations between death at discharge and variants on the 7th or 14th day after admission. Odds ratio (OR) of death was 0.073 in the subjects with early EN initiation within 14 days after admission (p=0.008)




A study (4) in older adults admitted to the ICU with a BMI less than 20 kg/m2 reported better outcomes and a significantly lower need for respiratory assistance with lower energy administration during the first 7 days of admission, suggesting that BMI is an independent determinant of clinical outcome in these patients. In our present study, however, although mean BMI was similar to that in this previous report, our clinical setting was non-acute, versus acute in the previous study. Our hypothesis was that other factors might be associated with better outcomes in place of BMI, including energy deficit and route of nutritional delivery. The average age of all subjects admitted to the present single hospital was greater than 80 years (Table 1), suggesting that these subjects might mirror the super-aging society, in which the percentage of adults older than 65 years exceeds 21% of whole population. This demographic change is preceding similarly in most developed countries.

We focused on the route of nutritional delivery, and divided patients into two categories, a PO category for patients able to use oral intake and an EN category for when the enteral route could be used regardless of PO or NPO, on the basis that PO and EN should be considered different means of nutritional support, particularly for older adult patients.

Analysis of PO and NPO groups in Method 1

Subjects were classified by their ability to take nutrients by mouth. Contrary to expectations, we found that LOS was significantly longer in the PO than in the NPO group (p=0.049) and that cumulative energy deficit during the whole length of hospitalization was significantly greater in the PO group (p=0.005) (Table 2). These findings might mean that the PO group tended to have a larger cumulative energy deficient, despite the fact that the groups did not differ with regard to primary diagnosis on admission, severity of comorbidity as evaluated by CCI, or death rate as the primary outcome. Comparison clomid for men of primary diagnoses showed that significantly more subjects in the PO group had a primary diagnosis of pneumonia (p=0.003, Table 1). Further, these results might also suggest that older adults hospitalized with a primary diagnosis of pneumonia should be considered for early enteral nutrition through the gastrostomy route to shorten the length of stay in hospital (p=0.047) (Table 2).

Indications for gastrostomy for early enteral nutrition are controversial. Early gastrostomy may shorten LOS, as seen in the present study, but the physical burden for older adults and economic burden on medical society must also be considered. In a previous study, no difference in mortality was seen in older adult PEG patients with and without dementia (5). Predictors of poor survival were subtotal gastrectomy, lower serum albumin < 2.8 g/dl, age > 80 years, chronic heart failure, and male sex (ORs = 2.617, 2.081, 1.721, and 1.541, respectively) (5).

In the present study, although more than one-third of subjects in both the PO and NPO groups had cognitive impairment as comorbidity (Table 1), the NPO groups with a higher percentage of gastrostomy showed no survival benefit, as seen in the previous report (5). The clinical importance of gastrostomy in older adults with pneumonia and/or dementia warrants additional detailed study.

Analysis of the EN and NEN groups in Method 2

The first strength of this study is the observation of a cumulative energy deficit in the non-acute setting in older adult patients. To our knowledge, this is the first study to prove the influence of a short-term energy deficit on clinical outcomes in the non-acute setting in older adult patients. We set an energy target for the management of older adults admitted to a general ward of 25 kcal/kg actual body weight/day (7, 8), in accordance with the ESPEN guideline. A cumulative energy deficit was associated with outcomes at 3 and 6 months after admission in the older adult patients. The concept of energy deficit is frequently used in the acute setting (9, 10). Our results suggest that a cumulative energy deficit is associated with outcome in later periods even in non-acute settings. A conclusive result requires further investigations.

A second consideration is the extent to which a cumulative energy deficit is suitable during the early part of a short period of hospitalization. Our results may suggest that a cumulative energy deficit in the first 4 days after admission of 13000 kcal (mean, 12,735 kcal, 25, 75% quartiles: 6572, 25700 kcal: Table 3) seems to be a threshold in older adult patients in non-acute settings, and will act as an indicator of poor outcome (Table 4). In contrast, previous studies (6, 11) were conducted in acute settings, where an energy deficit of > 4,000 to 8,000 kcal or >100 kcal/kg of body weight lead to a higher frequency of infectious complications (9, 10, 12-15). The energy deficit shown in a non-acute setting seems larger than that in acute settings. One reason for this difference might be the difference in the number of days of observation for cumulative energy deficit. A second reason might be the late initiation of EN in the NEN group compared to the EN group (33 vs. 4 days to initiation of EN, respectively, p= 0.000) (Table 3). Even the less severely ill patients might have had a similar endocrine milieu, so immune modulation modulated by the timing and route of nutrition might have affected the outcome. This might be partly because older adults are likely more vulnerable to an energy deficit than younger adults, or because they tend to have multiple comorbidities. Although CCI score, used to evaluate the severity of comorbidities with EN, was worse in the EN than in the NEN group, the cumulative energy deficit in the EN group was less than that in the NEN group, and survival rate as a later outcome was significantly better (Table 3). The question of whether the relation between cumulative energy deficit and length of hospital stay is causal or an association awaits confirmation. Nevertheless, maintenance of a cumulative energy deficit with a threshold of 13000 kcal during the first 23 days after admission on average will prevent poor outcomes such as longer hospital stay and high mortality (Table 3).

Furthermore, optimum timing for the initiation of EN remains of concern. Unlike previous papers that argued for around 48 hours after admission to the ICU (6, 11), we focused on evaluation within 7 and 14 days after admission. This difference in time scale was because of the difference in subjects and ward characteristics, namely the acute setting in the 48-hour study versus the non-acute general ward setting in our study. In other words, instead of 48 hours for the ICU setting, we considered that the first 7 days after admission to a general ward was the proper time scale in which to examine timing for the initiation of enteral nutrition.

To our knowledge, this is the first study to report that the early initiation of EN in older adults admitted to non-acute wards impacted outcomes, namely that it was associated with a shorter LOS and a higher survival rate at 3 and 6 months later. The reason why early nutrition impacts outcomes long after admission warrants consideration. Although our study should be considered preliminary, it appears likely that the severity of the primary diagnosis is greatest in the first several days after admission, and that a cumulative energy deficit during this important period may impact the later outcome partly through immune deficiencies, as previously discussed (11). The causality or otherwise of an early energy deficit and later poor outcome in older patients in non-acute settings warrants further evaluation.

Of note, ORs for death were lower in patients with early EN initiation within the first 14 days after admission (Table 4). This finding suggests that an early start to EN within 14 days after admission will save lives among older adult patients admitted in non-acute settings. This better survival in older adult patients with the earlier initiation of EN may be due to the modulation of immune function (11). It might also be seen in non-acute settings in older adults in the area of clinical nutrition.

Several limitations of our study warrant mention. First, the study was conducted under a retrospective chart review. As frequently encountered in previous reports, many subjects did not meet the inclusion criteria. A prospective study design might prevent the loss of these patients. Second, the number of subjects was too small to allow any definitive conclusions, and additional larger studies are necessary. Third, the energy target of 25 kcal/kg/day requires validation, although indirect calorimetric evaluation as the gold standard measurement for resting energy expenditure is not available everywhere (9). Note that an energy target of 30 kcal/kg of actual body weight/day is recommended for patients managed in acute settings (14); clinical status in the non-acute settings in the present report undoubtedly differed from those in acute settings, and the target energy must be validated well.

While many studies have reported that early enteral nutrition is clinically beneficial, almost all subjects in these studies were under treatment in ICU settings (3, 5, 6). In contrast, our present subjects were less ill and were not hospitalized in the ICU. The CCI score for comorbidities showed that although our EN group had better survival at 3 and 6 months after admission, subjects had a more severe CCI score (p=0.044 and p=0.008, respectively) (data, not shown). In general, patients who are less critically ill are able to tolerate enteral nutrition, which modulates the immune response and provides a better outcome (6, 11). Indeed, even though the severity of comorbidity in the EN and NEN groups as evaluated by average CCI score (5 points representative of moderate severity (16) and 3 points representative of mild16, respectively; and moderate and mild severity (16), respectively) differed significantly, subjects in the EN group with a higher CCI score still tolerated enteral nutrition. This result might be interpreted to mean that the early initiation of EN is better indicator in older hospitalized adults admitted to non-acute wards than CCI score, regardless of the degree of comorbidity severity.


These findings in older adult patients suggest that a cumulative energy deficit over 13000kcal in the first 23 days of hospitalization in non-acute setting are associated with poor outcomes, including lower survival and longer length of hospital stay. This might be interpreted to mean that a cumulative energy deficit of less than 13000 kcal in 3 weeks after admission is associated with better clinical outcomes, including LOS and survival rate at 3 and 6 months, in hospitalized adults older than 80 years. Hospitalized older adult patients in non-acute settings should be followed for cumulative energy deficit.

Conflict of interest: The all authors have no conflict of interest to disclose.

Ethics Statement: This study was conductedaccording to the guidelines in the Declaration ofHelsinki, and all procedures were approved by theEthics Committee of Takarazuka Dai-ichi Hopital.


1. Koss CA, Jarlsberg LG, Den boon S, et al. A Clinical Predictor Score for 30-Day Mortality among HIV-Infected Adults Hospitalized with Pneumonia in Uganda. PLoS ONE. 2015;10:e0126591.

2. Hegazi RA, Dewitt T.

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Enteral nutrition and immune modulation of acute pancreatitis. World J Gastroenterol. 2014;20:16101-5.

3. Kim JH, Lim S, Choi SH, et al. Sarcopenia: an independent predictor of mortality in community-dwelling older Korean men. J Gerontol A Biol Sci Med Sci. 2014;69:1244-52.

4. Ichimaru S, Fujiwara H, Amagai T, Atsumi T. ) Low energy intake during the first week in an emergency intensive care unit is associated with reduced duration of mechanical ventilation in critically ill, underweight patients: a single-center retrospective chart review. Nutr Clin Pract. 2014;29:368-79.

5. Kumagai R, Kubokura M, Sano A, et al. Clinical evaluation of percutaneous endoscopic gastrostomy tube feeding in Japanese patients with dementia. Psychiatry Clin Neurosci. 2012;66:418-22.

6. Heyland DK, Wischmeyer PE. Does artificial nutrition improve outcome of critical illness? An alternative viewpoint!. Crit Care. 2013;17:324.

7. Kreymann KG, Berger MM, Deutz NE, et al. ESPEN Guidelines on Enteral Nutrition: Intensive care. Clin Nutr. 22006;5:210-23.

8. Krishnan JA, Parce PB, Martinez A, Diette GB, Brower RG. Caloric intake in medical ICU patients: consistency of care with guidelines and relationship to clinical outcomes. Chest. 2003;124:297-305.

9. Faisy C, Candela llerena M, Savalle M, Mainardi JL, Fagon JY. Early ICU energy deficit is a risk factor for Staphylococcus aureus ventilator-associated pneumonia. Chest. 2011;140:1254-60.

10. Abdallah A. Gharraf H. Okasha H. Early ICU energy deficit: Is it a risk factor for ventilator-associated pneumonia? Egypt J Chest Dis Tuberc 2014;63:3-7.

11. Huang HH, Hsu CW, Kang SP, Liu MY, Chang SJ. Association between illness severity and timing of initial enteral feeding in critically ill patients: a retrospective observational study. Nutr J. 2012;11:30.

12. Faisy C, Lerolle N, Dachraoui F, et al. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. Br J Nutr. 2009;101:1079-87.

13. Soguel L, Revelly JP, Schaller MD, Longchamp C, Berger MM. Energy deficit and length of hospital stay can be reduced by a two-step quality improvement of nutrition therapy: the intensive care unit dietitian can make the difference. Crit Care Med. 2012;40:412-9.

14. Villet S, Chiolero RL, Bollmann MD, et al. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr. 2005;24:502-9.

15. Dvir D, Cohen J, Singer P. Computerized energy balance and complications in critically ill patients: an observational study. Clin Nutr. 2006;25(1):37-44.

16. Hegazi RA, Dewitt T. Enteral nutrition and immune modulation of acute pancreatitis. World J Gastroentel. 2014;20:1610-5.