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Medicare only reimburses professional home nutrition services for patients with diabetes or predialysis kidney disease, and these services are typically limited to three visits after hospital discharge. As a result, more than 75 percent of older adults who are malnourished due to other conditions rely on informal caregivers (unpaid family/relatives, friends, or neighbors) to manage their home enteral nutrition (HEN) or tube feeding. These caregivers often are unprepared for caregiving, lack competence and confidence, and feel sad, overwhelmed, and frustrated, says Heidi J. Silver, Ph.D., R.N., C.N.S.D., of Vanderbilt University.
In a recent study that was supported in part by the Agency for Healthcare Research and Quality (HS11276), Dr. Silver and her colleagues found that
patients didn't fare well when untrained informal caregivers managed their HEN. HEN did not reverse their malnutrition or improve their health, functioning, or quality of life. Dr. Silver and colleagues conducted in-home interviews with a multiethnic sample of 30 older adults (mean age of 68 years) during their first 3 months of HEN to assess relationships among patient characteristics, HEN regimen prescription and adherence, formal provider involvement, and health care outcomes.
Despite compliance with enteral prescriptions, these patients had multiple negative outcomes. Gastrointestinal complications, occurring in up to 63 percent of patients, interrupted daily infusions. One-third reported tube clogging or leaking, and one-third had tube displacement. Water intake was half of calculated need. In addition, average weight change was a loss of 4.35 pounds, and 17 patients were underweight, suggesting that their protein-energy undernutrition was continuing. Tube displacement, tube clogging, infection, and dehydration often led to hospital readmission.
The provision of HEN in older adults requires more frequent monitoring, reassessment, and intervention from a highly skilled multidisciplinary team that includes dietitians, conclude the researchers. They also note the need for more intensive training of informal caregivers.
See "Older adults receiving home enteral nutrition: Enteral regimen, provider involvement, and health care outcomes," by Dr. Silver, Nancy S. Wellman, Ph.D., R.D., David J. Arnold, M.D., F.A.C.S., and others, in the March 2004 Journal of Parenteral and Enteral Nutrition 28, pp. 92-98.
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