February 2004
Nutritional Deficiencies in Long-Term Care, Part II: Management of Protein Energy Malnutrition and Dehydration
David R. Thomas, MD, Hosam K. Kamel, MD, John E. Morley, MB, BCh
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From the Geriatric Research, Education and Clinical Center, St. Louis VAMC, St. Louis, Missouri, and Division of Geriatric Medicine, St. Louis University Medical School, Address for correspondence: John Morley, MB, BCh, Dammert Professor of Gerontology, St. Louis University Health Sciences Center, 1402 S. Grand, Room M238, St. Louis, MO 63104.

For other nutrition-related material, please visit the Council for Nutritional Clinical Strategies in Long-Term Care’s website at www.LTCnutrition.org or call Programs in Medicine at 610-325-4580.

Part II – Management of Protein Energy Malnutrition and Dehydration

By David R. Thomas, MD, Hosam K. Kamel, MD, and John E. Morley, MB, BCh

Abstract The careful assessment of potential nutrition problems is key to improving outcomes for persons residing in nursing homes. The second installment of this 3-part article series highlights the different causes of, and available means to, manage protein energy malnutrition in nursing home residents. The management of dehydration is also reviewed in this article. (Annals of Long-Term Care 1998;6[8}:250-258)

Introduction Protein energy malnutrition (PEM) in nursing home residents may be caused by a variety of interacting factors, although a single cause can be found in most cases.1 The most common, treatable causes of PEM appear in Table I, using the mnemonic MEALS-ON-WHEELS that was developed by Morley et al.2 An algorithm for the assessment of undernutrition in long-term care settings has been developed by the Council for Nutritional Strategies in Long-Term Care.3 This algorithm addresses the diagnosis of undernutrition in this population and suggests treatment options.

Depression is an important cause of weight loss in nursing home residents. Two epidemiologic studies in nursing homes have found depression to be strongly associated with weight loss.4,5 Morley and colleagues1 found depression to be the most common cause of weight loss in nursing home residents. Depression is present in 8% to 38% of these residents.6 Treatment of this disease has been shown to result in the regaining of lost weight.7 Tricyclic antidepressants and monoamine oxidase inhibitors are more likely to produce weight gain than the selective serotonin reuptake inhibitors or the newer antidepressants. Mirtazapine appears to be particularly useful in stimulating appetite.8 Clinical trials report weight gain as the most common side effect of mirtazapine.9 Whether this effect can be translated into long-term care settings for the treatment of depression in older adults with weight loss has not been studied.

Dementia is another condition commonly associated with weight loss. Nursing home residents with dementia often forget to eat, and feeding can become a time-consuming process. Excessive wandering, psychotropic medications, paranoid ideation, and associated depression are other factors that contribute to weight loss in these patients. Some residents with dementia develop apraxia of swallowing and must be reminded to swallow after each mouthful of food.10 Late-life paranoia, late-life mania, and anorexia nervosa are other psychological conditions that may contribute to malnutrition in nursing home residents.

Several medical conditions can result in PEM in nursing home residents (Table II). These can lead to weight loss by 1 or more of the following mechanisms: hypermetabolism, anorexia, swallowing difficulty, and/or malabsorption. Infections are an important cause of PEM, occurring in 15% to 20% of nursing home residents.11 It is estimated that the average nursing home resident acquires a new acute infection every 3 months.12 Infection may result in confusion, anorexia, and negative nitrogen balance, all of which contribute to PEM.13 Other medical conditions that may cause PEM in nursing home residents include cancer, chronic obstructive pulmonary disease, congestive heart failure, malabsorption, hyperthyroidism, and hyperparathyroidism. Acquired immunodeficiency syndrome (AIDS) and rheumatoid arthritis have been shown to cause PEM by increasing the levels of circulating cytokines leading to increased resting energy expenditure and decreased serum albumin levels.14

Polypharmacy is also a common cause of malnutrition in nursing home residents. Numerous medications have been linked to PEM in these residents. Those most frequently implicated include digoxin, theophylline, nonsteroidal anti-inflammatory drugs, iron supplements, and psychoactive drugs, particularly fluoxetine, lithium, and phenothiazines. A number of studies have suggested that therapeutic diets should be avoided in nursing homes. 2,15,16 Unnecessary dietary restrictions in nursing homes may also contribute to the development of PEM.

Management of PEM in the Nursing Home Management of PEM entails both early detection and management of treatable disorders. Body weight should be measured monthly, and serum albumin as well as cholesterol should be checked at least once a year.17 Special attention should be paid to treating depression and eliminating anorexigenic drugs or unnecessary dietary restrictions. Assistance with feeding is often the key to maintaining food intake in residents with dementia or other functional disabilities. (This will be discussed further in the next section of this article.) In addition, it is important to note ethnic food preferences of nursing home residents and to involve them in menu revision and food selection.

Dysphagia is an important cause of PEM in nursing home residents. The presence of dysphagia and the degree of aspiration risk can usually be determined by a bedside swallowing evaluation performed by a speech pathologist. People with dysphagia can be taught the correct swallowing techniques and the appropriate positioning for swallowing safety. Dietary manipulation (eg, use of thickened liquids) is an important component of dysphagia management.

Feeding Techniques Careful attention to the needs of nursing home residents at each mealtime remains a key to the maintenance of high nutritional states in the nursing home. Feeding of residents with dementia and/or dysphagia is a time-consuming, labor-intensive process. Utilizing semicircular tables in which 1 aide can feed 3 to 5 residents can be an extremely effective method. As mentioned, some individuals with dementia develop apraxia of swallowing and need to be reminded to swallow with each mouthful of food. Segregating persons who need special help with feeding or modification of food texture often ensures that these residents receive the special attention they require at mealtimes. In the Veterans Administration (VA) nursing homes, the use of volunteers to feed residents has proven to have a positive effect on the residents’ quality of life.18 In the Silver Spoons program, volunteers provide supervised feeding. The Centers for Medicare & Medicaid Services has recently published revised rules for paid feeding assistants in long-term care settings. In persons with dysphagia, appropriate positioning and tilting of the head are essential. Some patients must be taught to double swallow and/or cough after swallowing to clear their throats. Unfortunately, interventions to improve dysphagia are limited in effectiveness.19 In many cases, the consistency of the resident’s food simply needs to be modified. Thickened liquids are used for persons with poor oral control and weak tongue movements. When a resident has an impaired chewing mechanism but adequate tongue strength, smooth blended foods (eg, pudding and gelatin) can be used. Residents with intact chewing mechanisms may need finely chopped or minced meats as well as puréed products. In some cases, all consistencies may be acceptable, but they cannot be given to the patient together. Foods that poorly form boluses (eg, ice) should be avoided.20

Nutrition Therapy The administration of nutrition therapy to nursing home residents can be in 1 of 3 forms: oral supplementation, tube feeding, and parenteral feeding.

Oral Supplements When a patient’s intake of protein and calories is insufficient, the provision of concentrated feeding formulas is often prescribed. The logic seems to be that patients who cannot or will not consume an adequate usual diet can consume enough low-volume, concentrated supplements to meet protein and calorie needs.

This logic of oral supplements has been tested in several studies. In a long-term care geriatric hospital, 115 out of 435 newly admitted patients (29%) were malnourished by index score.21 Patients randomly received either a standard diet or a standard diet plus twice-daily nutritional supplementation. Thirty-nine intervention patients refused to take the supplement, and 8 control patients received a supplement. At 8 weeks, 41% of malnourished patients who received dietary supplements improved; only 18% of malnourished patients who did not receive nutritional supplements improved. Although improvement was demonstrated, 59% of patients receiving supplements did not improve during follow-up. This failure rate may be higher, because patients who were offered supplementation but refused ingestion were not included. Both experimental and control groups showed a decrease in weight index, triceps skin fold thickness, and mid-arm circumference after 26 weeks, although the initially nonmalnourished group who received supplemental feedings showed less decline. There were no differences in prealbumin, albumin, or anti-trypsin levels between groups. The mortality rate was higher (19% versus 9%) in the initially malnourished group.

In another geriatric hospital, 87 consecutive medical patients were randomized into a placebo-controlled trial of a supplemental glucose drink plus vitamin A, B1, B2, B3, and B6 supplements.22 Compliance with the supplement was poor, with only one third of subjects consuming more than 50% of the offered drink. Even when the analysis was limited to compliant subjects, there was no beneficial effect observed. Severely malnourished patients (body mass index less than 15 kg/m2) were excluded from this study.

There is evidence, however, that oral supplementation may improve outcomes in persons with hip fractures,23 pressure ulcers,24 and chest infections.25 Some nursing homes now give liquid caloric supplements as the necessary fluid to accompany medicines administered to persons with weight loss. The validity of this approach has not been determined. Other data suggest that liquid supplements given 60 minutes before a meal produce an increased total caloric intake.26 There are currently many commercially available formulas. These differ in caloric density, osmolality, lactose content, protein source, and cost. Most formulas provide 1 kcal/mL. The total number of calories equals the volume of feeding. When water restriction is necessary, as in the syndrome of inappropriate antidiuretic hormone (ADH) secretion, increased calories can be given with formulas that provide 1.5 to 2.0 kcal/mL. Nutrient-dense formulas are hyperosmolar and may increase the incidence of diarrhea. Specialized formulas or formula modifications are necessary for specific disease states, such as pulmonary disease (decreased carbohydrates), liver disease (increased branched chain amino acids), renal disease (decreased protein), or gastrointestinal malabsorption (use "elemental" formula based on free amino acids and monosaccharides).17,27 Residents with lactase deficiency may benefit from lactose-free formulas. Similarly, residents with constipation may benefit from formulas with added fiber. Supplements should be given between meals and at least 1 hour before the next meal.12 The product choice depends on the condition of the gut and the expected degree of digestion required.

Overall, routine nutritional supplementation was associated with weight gain, (weighted mean difference 2.06%, 95% confidence intervals 1.63, 2.49), and reduced case fatality rate by 34% (odds ratio 0.66, 95% confidence interval 0.48, 0.91).28

Tube Feeding The indication for enteral nutrition by feeding tube generally falls into 1 of 3 categories. First, neuromuscular disease may impair swallowing or gag reflexes. Second, patients exhibiting an increased metabolic rate may be unable to meet their nutritional needs through eating alone, as evidenced in patients with cancer or cachexia. Finally, an underlying condition may prevent eating, such as in postoperative patients or those using ventilators. The only contraindication to enteral feeding is mechanical obstruction. Diarrhea, vomiting, fistulae, and aspiration represent problems that complicate feeding; however, these are not contraindications.

Access to the gut can be achieved by nasogastric (NG), nasointestinal, percutaneous gastric, or percutaneous jejunal routes. Each route is associated with benefits and risks, but percutaneous endoscopic gastrostomy (PEG) is the most common and, arguably, the most preferred route. Most oral medication cannot be used with jejunal intubation, and long-term nasogastric intubation may be uncomfortable for the patient.

Aspiration is the most serious among the complications of tube feedings. As high as 40% of deaths associated with tube feedings result directly from aspiration pneumonia. Risk factors for aspiration include such conditions as diabetes, pancreatitis, vagotomy, and malnutrition. Certain drugs may also inhibit gastric emptying. Feeding-associated risks include high-nutrient density formulas,29 hypo- and hyperosmolar solutions,30 and cold formulas. There have been suggestions that the type of tube affects the rate of aspiration. It has been concluded that PEG tubes convey some protection over NG tubes and that jejunostomies eliminate the risk.31 However, aspiration occurs with 44% of NG tubes and 56% of PEGs used in a long-term setting. Duodenally placed tubes are not better than PEG tubes. Jejunal tubes placed distally to the ligament of Tritz are theoretically superior to other tubes in prevention of aspiration. In one study, the only risk factor associated with subsequent aspiration in gastrostomy tubes was previous pneumonia.32 Age, mental status, or method of feeding (intermittent versus continuous) were not associated with subsequent risk.

Selecting an enteral product should not be difficult. All formulas contain protein, fat, and carbohydrates. The numerous formulas currently on the market have caused each manufacturer to offer a complete line of products across the spectrum of nutritional indications. In similar categories, there is very little difference between products. Products differ in sources of protein and in the degree of digestion; as the required degree of digestion lessens, the cost rises considerably. The choice of a product depends on the condition of the gut and the expected degree of digestion required (Table III).

Simple nutritional calculations are necessary to determine the total volume required to deliver adequate protein, calories, and water. Proteins are a critical component. For most institutionalized patients, an enteral protein intake should be 1.2 to 1.5 gm/kg/day. However, half of all chronically ill elderly persons are unable to maintain nitrogen balance at this level.28 Controversy exists over the percentage of total caloric requirement derived from protein. Generally, formulas contain about 7% to 16% of total calories from protein. Adjusting the percentage upwards may have some benefit in special patients, such as those with chronic wounds.21 However, increasing the total protein percentage may simply supply calories from protein rather than from carbohydrate sources, and this may dehydrate the patient.

Caloric requirements can be met at 30 to 35 kcal/kg per day. Various formulas, including the Harris–Benedict equation, can be used to predict caloric requirements, but controversy exists over accuracy in obese or severely malnourished individuals.34 Other formulas have been adjusted for severely stressed hospitalized subjects.35 Considerable debate exists over whether to use ideal body weight or adjusted body weight. Most feeding formulas contain 1 kcal/mL. Carbohydrates in feeding formulas derive from many sources including starch, polysaccharides, disaccharides, and monosaccharides. The chief difference among formulas is whether the source includes milk, and thus lactose. The majority of formulas are lactose-free. All products require an intact intestinal brush border for absorption. Alternative calories per unit volume are available, ranging from 0.5 to 2.0 kcal/mL. As caloric density increases, gastric motility and emptying decrease; this may increase the risk of aspiration.

Free water requirements are 30 to 35 mL/kg per day. Each product varies in the amount of free water per unit volume, but in most products it is about 80% to 85% of volume. The product’s free water should be subtracted from the total calculated daily water requirement. Water flushes of the tube can be adjusted to meet free water requirements. Using a low-calorie formula results in a higher volume requirement to meet caloric needs, which results in increased fluid intake. When 2.0 kcal/cc density formulas are used, the volume necessary to meet caloric needs decreases and the amount of free water decreases. This can be useful when fluid restriction is necessary in certain clinical conditions, such as in inappropriate ADH secretion or congestive heart failure. A number of enteral formulas contain inadequate salt concentrations; thus, when hyponatremia develops, salt must be added.

Fats are added to formulas for additional calories, for flavor, and for absorption of fat-soluble vitamins. The amount of fat and source of fat differ from product to product. The percentage of fat should be about 30% of calories, but an exact requirement is not known.

Numerous studies have attempted to characterize the benefits of tube feeding. In an analysis of 434 tube-fed residents on the Wisconsin Minimum Data Set sample, Grant et al36 found that 51% of the residents had a diagnosis of stroke; 36% of the residents were diagnosed with dementia; only 10% of the residents ambulated independently; and 74% of the residents were incontinent of either urine or feces. Only one third of those residents assessed could communicate adequately. Mitchell et al,37 in a study of 1386 nursing home residents with cognitive impairment, found no evidence that tube feeding prolonged survival. The most common reasons for choosing tube feeding were aspiration risk, dysphagia, presence of pressure ulcers, stroke, lack of dementia, younger age, and a lower level of activity of daily living impairment. Weaver et al,38 in a small study of the quality of life in patients being tube fed, found no improvement in their quality of life. Forty-nine percent of family members responded that they would not have chosen a feeding tube under other circumstances. O’Brien et al39 found that 25% of patients surveyed would have refused feeding tubes if they had known that they might be restrained. This study also revealed that males and African-Americans were more likely to choose tube feeding than other groups. In another study, tube feeding was associated with better wound healing and a lower rate of late mortality.40 In this study, 80% of those assessed had cutaneous complications, 39% had pulmonary aspiration, 15% had vomiting, and 20% attempted to withdraw the tube.

Overall, these studies suggest that tube feeding is not a panacea. 41 Only a small subset of nursing home residents benefit from tube feeding. The decision to tube-feed patients depends as much on the desires of the residents and their families as it does on therapeutic efficacy. Further studies are required to determine which residents can significantly benefit from this active intervention.

Peripheral Parenteral Nutrition A high percentage of patients are extremely malnourished when they are discharged from the hospital. Often, they are incapable of ingesting adequate calories to restore their nutritional state. These residents require short-term tube feeding or peripheral parenteral nutrition (PPN). The latter is particularly useful in persons recovering from a stroke, because these individuals often have some degree of dysphagia. Sitzman.42 found that patients with dysphagia with nasoenteric tubes had a 10% complication incidence resulting in a 30% mortality rate. Those patients with nasoenteric tube feeding had a significantly higher death and complication rate than patients requiring PPN.

Peripheral parenteral nutrition can be given overnight, allowing residents to eat to their limit during the day and to take part in physical therapy and other activities. Table IV compares the advantages of PPN with tube feeding for select residents.

Pharmacologic Interventions Megestrol acetate has been shown to stimulate appetite and promote weight gain in patients with AIDS43 and cancer-related cachexia.44,45 Castle and colleagues46 administered 400 mg per day of megestrol acetate to 4 nursing home residents between 72 and 103 years of age with severe weight loss. Of the 4 residents, 2 experienced weight gain, but only 1 completed the course of therapy. The treatment was complicated by the development of some degree of delirium in 3 of the 4 patients. Megestrol acetate at the 160-mg dosage was shown to prevent nutritional deterioration in older males with head and neck cancer receiving either radio- or chemotherapy.45 Megestrol acetate also improved performance in patients receiving cancer therapy.47 Additionally, megestrol acetate increased albumin in malnourished patients on dialysis.48

Megestrol acetate has been evaluated in two long-term care settings. In a prospective trial, 69 patients in a Veterans Nursing home were randomized to receive 800 mg of megestrol acetate or placebo for 12 weeks. Forty-four patients completed a 25-week evaluation. Weight gain occurred in 68% of treated subjects. The treatment group gained 1.1 kg compared to 0.9 kg in the control group at 12 weeks. By 25 weeks, the treatment group continued to gain weight (3.0 kg) compared to a weight loss (0.5 kg) in the control group.49 In another study of 13 elderly nursing home residents who were losing weight and refused enteral feeding, megestrol acetate was prescribed. All residents showed improvement in food intake, body mass index, and serum albumin. One patient had an exacerbation of congestive heart failure.50 The data are suggestive that megestrol may have some effect in producing weight gain in nursing home residents.

The short-term use of a human growth hormone (GH), although extremely expensive, may be promising in severely cachectic nursing home residents. Kaiser and colleagues51 demonstrated that a 3-week course of GH therapy in older malnourished patients enhanced weight gain without notable adverse effects. Prolonged administration of GH is complicated by the development of carpal tunnel syndrome, gynecomastia, and hyperglycemia.52

Oxandrolone, an oral anabolic steroid with potent anabolic activity and minimal androgenic effects, was shown to have a positive impact on weight gain in patients with AIDS-wasting myopathy53 and alcoholic hepatitis.54 The authors report that the use of oxandrolone in several severely malnourished patients was generally well tolerated and had a positive impact on weight gain. Additionally, they have used testosterone in males with low weakly bound testosterone levels to increase strength and food intakes in nursing home residents (HKK, DRT, and JEM, unpublished data, 1998).

Ornithine oxoglutarate, a drug available only in Europe, appears to be a promising drug for older persons with PEM. Brocker and colleagues,55 in a double-blind randomized study involving 194 patients older than 65 years, have shown that ornithine oxoglutarate improved appetite, weight gain, and quality of life.

Dronabinol is an antiemetic that promotes food intake. It has been shown to promote mild weight gain in patients with cancer or AIDS.56 Dronabinol has been shown to cause nausea, dizziness, somnolence, and cognitive impairment.10 Volicer et al57 utilized a placebo crossover design of 6 weeks for each treatment in patients with Alzheimer’s disease. Dronabinol increased weight more than placebo and decreased the severity of the disturbed behavior. Adverse effects seen with dronabinol included euphoria, somnolence, and tiredness. Potential drugs available to treat PEM in nursing home residents are listed in Table V.

Management of Dehydration Elderly residents of nursing homes have a high plasma osmolality and associated mortality.58 Management of dehydration requires both fluid and sodium replacement. Prevention plays a key role in the management of dehydration. Residents should be carefully monitored, and when the nurse believes that residents are not ingesting fluids, they should be checked for orthostasis. The diagnosis of dehydration in elderly subjects is difficult.59 Blood urea nitrogen (BUN) and creatinine should also be measured. Ratios of BUN/creatinine greater than 20:1 are highly suggestive of dehydration. Armstrong-Esther et al60 have found that, in general, nurses’ knowledge of the signs and complications of dehydration and the fluid requirements of the elderly are inadequate. In patients who can drink, mild dehydration may be corrected using oral fluids. In the hot summer months, fluids should be regularly offered. It is important to recognize that elderly individuals have a relative hypodypsia and often fail to recognize their need for fluids. Hypodermoclysis—subcutaneous infusion of parenteral fluids—is a minimally invasive procedure and ideal for use in nursing home settings. Infused fluids should be isotonic to avoid undue soft tissue irritation. Sites such as thigh and abdomen, with a large surface area, are preferred for use. The addition of hyaluronidase to the infusion fluid may further facilitate absorption.61

Conclusion Much of the protein energy malnutrition present in nursing home residents is treatable. Unless ethical considerations call for an alternate approach, physicians must be more aggressive in recognizing and treating PEM in nursing home residents.

References 1. Morley JE, Kraenzle D. Causes of weight loss in a community nursing home. J Am Geriatr Soc 1994;42:583-585. 2. Morley JE, Silver AJ. Nutritional issues in nursing home care. Ann Intern Med 1995;123:850-859. 3. Thomas DR, Ashmen W, Morley JE, Evans WJ. Nutritional management in long-term care: Development of a clinical guideline. Council for Nutritional Strategies in Long-Term Care. J Gerontol A Biol Sci Med Sci 2000;55(12):M725-34. 4. Blaum CS, Fries BE, Fiatarone MA. Factors associated with low body mass index and weight loss in nursing home residents. J Gerontol A Biol Sci Med Sci 1995;50:M162-M168. 5. Katz IR, Beaston-Wimmer P, Parmelell P, et al. Failure to thrive in the elderly: Exploration of the concept and delineation of psychiatric components. J Geriatr Psychiatry Neurol 1993;6:161-169. 6. Fitten LJ, Morley JE, Gross PI, et al. Depression. J Am Geriatr Soc 1989;37: 459-472. 7. Kahn R. Weight loss and depression in a community nursing home. J Am Geriatr Soc 1995;43:83. 8. Fava M. Weight gain and antidepressants. Journal of Clinical Psychiatry 2000;11S:37-41. 9. Gelenberg AJ, Laukes C, McGahuey C, et al. Mirtazapine substitution in SSRI-induced sexual dysfunction. Journal of Clinical Psychiatry 2000;61:356-360; Carpenter LL, Leon Z, Yasmin S, Price LH. Clinical experience with mirtazapine in the treatment of panic disorder. Ann Clin Psychiatry 1999;11:81-86.; Carpenter LL, Jocic Z, Hall JM, Rasmussen SA, Price LH. Mirtazapine augmentation in the treatment of refractory depression. J Clin Psychiatry 1999;60:45-49. 10. Morley JE. Anorexia in older persons. Drugs Aging 1996;8:134-152. 11. Rudman D, Feller AG. Protein-calorie undernutrition in the nursing home. J Am Geriatr Soc 1989;37:173-183. 12. Farber BF, Brennen C, Puntereri AJ, et al. A prospective study of nosocomial infections in chronic care facility. J Am Geriatr Soc 1984;32: 499-502. 13. Beisel WR. Magnitude of the host nutritional responses to infection. Am J Clin Nutr 1977;30:1236-1247. 14. Roubenoff R, Grimm LW, Roubenoff RA. Albumin, body composition and dietary intake in chronic inflammation. In: Rosenberg IM, ed. Nutritional Assessment of Elderly Population. New York, NY: Raven Press; 1995: 30-39. 15. Buckler DA, Kelber ST, Goodwin JS. The use of dietary restrictions in malnourished nursing home patients. J Am Geriatr Soc 1994;42: 1100-1102. 16. Coulston AM, Mandelbaum D, Reaven GM. Dietary management of nursing home residents with non-insulin dependent diabetes mellitus. Am J Clin Nutr 1990;51(1):67-71. 17. Rudman DK, Cohn ME. Nutrition in the elderly. In: Calkins E, Ford AB, Katz P, eds. Practice of Geriatrics. 2nd ed. Philadelphia, Pa: WB Saunders; 1992:19-32. 18. Musson ND, Kincaid J, Ryan P, et al. Nature, nutrition: Interdisciplinary programs to address the prevention of malnutrition and dehydration. Dysphagia 1990;5:96-101. 19. Chouinard J. Dysphagia in Alzheimer disease: A review. Journal of Nutrition, Health & Aging 2000;4(4):214-7. 20. Matthews LE. Dysphagia. In: Morley JE, Glik Z, Rubenstein LZ, eds. Geriatric Nutrition. 2nd ed. New York, NY: Raven Press; 1995:329-333. 21. Larsson J, Unosson M, Ek AC, et al. Effect of dietary supplement on nutritional status and clinical outcome in 501 geriatric patients: A randomized study. Clinical Nutrition 1990;9:179-184. 22. Hogarth MB, Marshall P, Lovat LB, et al. Nutritional supplementation in elderly medical in-patients: A double-blind placebo-controlled trial. Age Ageing 1996;25:453-457. 23. Delmi M, Rapin CH, Bengoa JM, et al. Dietary supplementation in elderly patients with fractured neck of the femur. Lancet 1990;335:1013-1016. 24. Breslow RA, Hallfrisch J, Guy DG, et al. The importance of dietary protein in healing pressure ulcers. J Am Geriatr Soc 1993;41: 357-362. 25. Woo J, Ho SC, Mak YT, et al. Nutritional status of elderly patients during recovery from chest infection and the role of nutritional supplementation assessed by a prospective randomized single blind trial. Age Ageing 1994;23:40-48. 26. Wilson MM, Purushothaman R, Morley JE. Effect of liquid dietary supplements on energy intake in the elderly. Am J Clin Nutr 2002;75(5): 944-7. 27. Bernard MA, Rombeau JL. Nutritional support for the elderly patient. In: Young EA, ed. Nutrition, Aging and Health. New York, NY: Alan R. Liss, Inc; 1986:229-258. 28. Potter J, Langhorne P, Roberts M. Routine protein energy supplementation in adults: Systematic review. BMJ 1998;317(7157):495-501. 29. Hunt JN, Stubbs DF. The volume and energy content of meals as determination of gastric emptying. J Physiol 1974;245:209. 30. Davenport HW. Physiology of the Digestive Tract. 4th ed. Chicago, Ill: Year Book Medical Publishers; 1977. 31. Gustke R, Varme R, Soergel K. Gastric reflux during perfusion of the proximal small bowel. Gastroenterology 1970;59:890-895. 32. Cogen R, Weinryb J. Aspiration pneumonia in nursing home patients fed via gastrostomy tubes. Am J Gastroenterol 1989;84:1509-1512. 33. Gersovitz MK, Munro HN, Motil K, et al. Human protein requirements: Assessment of the adequacy of the current Recommended Dietary Allowance for dietary protein in elderly men and women. Am J Clin Nutr 1982;35: 6-14. 34. Choban PS, Burge JC, Flancbaum L. Nutrition support of obese hospitalized patients. Nutrition in Clinical Practice 1997;12:149-154. 35. Ireton-Jones CS. Evaluation of energy expenditures in obese patient. Nutrition in Clinical Practice 1989;4(4):127-129. 36. Grant MD, Rudberg M, Brody JA. Life on the slippery slope: Tube-fed in the nursing home. Gerontologist 1996;36:47. 37. Mitchell SI, Keely DL, Lipitz LA. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Arch Intern Med 1997;157:327-332. 38. Weaver JP, Odell P, Nelson C. Evaluation of the benefits of gastric tube feeding in an elderly population. Arch Fam Med 1993;2: 953-956. 39. O’Brien LA, Siegert EA, Grisso JA, et al. Tube feeding preferences among nursing home residents. J Gen Intern Med 1997;12:364-371. 40. Bourdel-Marchasson I, Dumas F, Finganaud G, et al. Audit of percutaneous endoscopic gastrostomy in long-term enteral feeding in a nursing home. Int J Qual Health Care 1997;8:297. 41. Haddad RY, Thomas DR. Enteral nutrition and enteral tube feeding. Review of the evidence. Clinics in Geriatric Medicine 2002;18(4):867-81. 42. Sitzman JV. Nutritional support of the dysphagic patient: Methods, risks and complications of therapy. JPEN Parenter Enteral Nutr 1990;14: 60-63. 43. Roenn JHV. Randomized trials of megestrol acetate for AIDS-associated anorexia and cachexia. Oncology 1994:51:19-24. 44. Simons JP, Aaronson NK, Vansteenkiste JF, et al. Effects of medroxyprogesterone acetate on appetite, weight and quality of life in advanced-state non-hormone-sensitive cancer: A placebo-controlled multicenter study. J Clin Oncol 1996;14:1077-1084. 45. Fietau R, Riepl M, Kettner H, et al. Supportive use of megestrol acetate in patients with head and neck cancer during radio(chemo)therapy. Eur J Cancer 1997;33:75-79. 46. Castle S, Nguyen C, Joaquin A, et al. Megestrol acetate suspension therapy in the treatment of geriatric anorexia/cachexia in nursing home patients. J Am Geriatr Soc 1995;43:835-836. 47. Neri B, Garosi VL, Intini C. Effect of medroxyprogesterone acetate on the quality of life of the oncologic patient: A multicenter cooperative study. Anti-Cancer Drugs 1997;8(5):459-465. 48. Lien YH, Ruffenach SJ. Low dose megestrol increases serum albumin in malnourished dialysis patients. Int J Artif Organs 1996;19: 147-150. 49. Yeh SS, Wu SY, Lee TP, et al. Improvement in quality-of-life measures and stimulation of weight gain after treatment with megestrol acetate oral suspension in geriatric cachexia: Results of a double-blind, placebo-controlled study. J Am Geriatr Soc 2000;48:485-492. 50. Karcic E, Philpot C, Morley JE. Treating malnutrition with megestrol acetate: Literature review and review of our experience. The Journal of Nutrition, Health, and Aging 2002;6:1191-2000. 51. Kaiser FE, Silver AJ, Morley J. The effect of recombinant human growth hormone on malnourished older individuals. J Am Geriatr Soc 1991;39: 235-240. 52. Cohn L, Feller AG, Draper MW, et al. Carpal tunnel syndrome and gynecomastia during human growth hormone treatment of elderly men with low circulating IGF-1 concentrations. Clin Endocrinol 1993;39:417-425. 53. Berger JR, Pall L, Hall CD, et al. Oxandrolone in AIDS-wasting myopathy. AIDS 1996;10:1657-1662. 54. Mendenhall CL, Mortiz TE, Roselle GA, et al. A study of oral nutritional support with oxandrolone in malnourished patients with alcoholic hepatitis: Results of a Department of Veterans Affairs cooperative study. Hematology 1993;17:564-576. 55. Bocker P, Vellas B, Albarede JL, et al. A two-center, randomized, double-blind trial of ornithine oxoglutarate in 194 elderly, ambulatory, convalescent subjects. Age Ageing 1994;23:303-306. 56. Beal JE, Olson R, Laubenstein L, et al. Dronabinol as a treatment for anorexia associated with weight loss in patients with AIDS. J Pain Symptom Manage 1995:10:89-97. 57. Volicer L, Stelly M, Morris J, et al. Effects of dronabinol on anorexia and disturbed behavior in patients with Alzheimer’s disease. Int J Geriatr Psychiatry 1997;12:913-919. 58. O’Neill PA, Duggan J, Davies I. Response to dehydration in elderly patients in long-term care. Aging 1997;9:372-377. 59. Thomas DR, Tariq SH, Makhdomm S, Haddad R, Moinuddin A. Physician misdiagnosis of dehydration in older adults. Journal of the American Medical Directors Association 2003;4(5):251-4. 60. Armstrong-Esther CA, Brone KD, Armstrong-Esther DC, et al. The institutionalized elderly: Dry to the bone. Int J Nurs Stud 1996;33: 619-628. 61. Berger EY. Nutrition by hypodermoclysis. J Am Geriatr Soc 1984;32:199.