Leitlinie Enterale Ernährung der DGEM und DGG:
Enterale Ernährung (Trink- und Sondennahrung) in der Geriatrie und geriatrisch-neurologischen Rehabilitation

Zusammenfassung

Bei geriatrischen Patienten stellt die bedarfsgerechte Versorgung mit Flüssigkeit und Nährstoffen ein häufiges Problem dar. Enterale Ernährung mittels Trink- und Sondennahrung bietet die Möglichkeit, bei unzureichender Lebensmittelaufnahme die Nährstoffversorgung zu verbessern bzw. sicher zu stellen. Die vorliegende Leitlinie gibt evidenzbasierte Empfehlungen für den Einsatz von Trink- und Sondennahrung bei geriatrischen Patienten. Sie wurde, basierend auf den seit 1985 erschienenen themenbezogenen Fachpublikationen, in einer interdisziplinär besetzten Expertengruppe nach den Richtlinien der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) und des Ärztlichen Zentrums für Qualität in der Medizin (ÄZQ) erarbeitet und im Rahmen einer Konsensuskonferenz verabschiedet. Enterale Ernährungstherapie in Form von Trinknahrung wird bei drohender oder manifester Mangelernährung, bei Multimorbidität und Gebrechlichkeit, nach Schenkelhalsfrakturen und orthopädisch-chirugischen Eingriffen empfohlen. Sie führt bei drohender oder manifester Mangelernährung zu Verbesserungen im Ernährungszustand, Verkürzung der Krankenhausaufenthaltsdauer und zu einer Verlängerung der Überlebenszeit sowie nach Schenkelhalsfrakturen und orthopädisch-chirurgischen Eingriffen zu einer Reduktion von Komplikationen. Sondenernährung ist eindeutig bei neurologisch bedingten Schluckstörungen indiziert und wird bei Depression zur Überbrückung der Phase der schweren Antriebs- und Essstörung empfohlen. Nicht indiziert ist Sondenernährung dagegen in finalen Krankheitsstadien einschließlich finalen Stadien der Demenz sowie zur Pflegeerleichterung oder Zeitersparnis. Unabhängig von der Indikation muss die Entscheidung für oder gegen Sondenernährung immer individuell unter Berücksichtigung des (mutmaßlichen) Patientenwillens, vorhandener Komorbiditäten, des Krankheitsgrades und der Prognose getroffen werden. Insgesamt wird dringend empfohlen, Ernährungstherapie nicht erst bei schwerer Mangelernährung zu beginnen, sondern frühzeitig, sobald Hinweise auf Ernährungsrisiken vorliegen.

Abstract

Nutrient and fluid intake is often compromised in elderly, multimorbid patients. Enteral nutrition by means of oral liquid supplements and tube feeding offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of oral liquid supplements and tube feeding in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. Enteral nutrition by means of oral liquid supplements is recommended for geriatric patients with malnutrition or at risk of malnutrition, in case of multimorbidity and frailty, and following femur fractures and orthopaedic-surgical procedures. In elderly people at risk of malnutrition oral liquid supplements may improve nutritional status, reduce length of hospital stay and lower mortality. After femur fractures and orthopaedic-surgery oral liquid supplements may reduce unfavourable outcome. Tube feeding is clearly indicated in patients with neurologic dysphagia and is recommended in case of depression in order to overcome phases of severe loss of motivation and refusal to eat. In contrast, tube feeding is not indicated in final disease states, including final dementia, and in order to facilitate patient care and to save time. Independent of the indication, the decision for or against enteral nutrition has to be made individually, in line with the (assumed) patient will and under consideration of comorbidities, severity of illness and prognosis. Altogether, it is strongly recommended not to wait until severe malnutrition has developed, but to start enteral nutrition therapy early, as soon as a nutritional risk becomes apparent.

Schlüsselwörter

Leitlinie - Empfehlungen - geriatrische Patienten - Mangelernährung - enterale Ernährung - Trinknahrung - Sondennahrung

Key words

Guideline - recommendations - geriatric patients - malnutrition - enteral nutrition - oral liquid supplementation - tube feeding

Literatur

• 1 Bundesministerium für Familie, Senioren, Frauen und Jugend .Erster Altenbericht der Bundesregierung über die Lebenssituation älterer Menschen in Deutschland. Bonn; 1993
• 2 Runge M, Rehfeld G. Geriatrische Rehabilitation im Therapeutischen Team. Stuttgart, New York; Thieme 1995
• 3 Lochs H. Leitlinie Enterale Ernährung.  Aktuel Ernaehr Med. 2003;  28, Suppl 1 S1-S120
• 4 Lorenz W. Das Leitlinien-Manual von AWMF und ÄZQ, Entwicklung und Implementierung von Leitlinien in der Medizin.  ZaeFQ. 2001;  95, Suppl 1 1-84
• 5 Milne A C, Potter J, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev 2002; CD003288
• 6 Volkert D, Hübsch S, Oster P, Schlierf G. Nutritional support and functional status in undernourished geriatric patients during hospitalization and 6-month follow-up.  Aging Clin Exp Res. 1996;  8 386-395
• 7 Payette H, Boutier V, Coulombe C, Gray-Donald K. Benefits of nutritional supplementation in free-living, frail, undernourished elderly people: a prospective randomized community trial.  J Am Diet Assoc. 2002;  102 1088-1095
• 8 Lawson R M, Doshi M K, Ingoe L E, Colligan J M, Barton J R, Cobden I. Compliance of orthopaedic patients with postoperative oral nutritional supplementation.  Clin Nutr. 2000;  19 171-175
• 9 Roebothan B V, Chandra R K. Relationship between nutritional status and immune function of elderly people.  Age Ageing. 1994;  23 49-53
• 10 Williams C M, Driver L T, Older J, Dickerson J WT. A controlled trial of sip-feed supplements in elderly orthopaedic patients.  Eur J Clin Nutr. 1989;  43 267-274
• 11 Gray-Donald K, Payette H, Boutier V. Randomized clinical trial of nutritional supplementation shows little effect on functional status among free-living frail elderly.  J Nutr. 1995;  125 2965-2971
• 12 Larsson J, Unosson M, Ek A-C, Nilsson L, Thorslund S, Bjurulf P. Effects of dietary supplement on nutritional status and clinical outcome in 501 geriatric patients - a randomized study.  Clin Nutr. 1990;  9 179-184
• 13 Norton B, Homer-Ward M, Donnelly M T, Long R G, Holmes G K. A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke.  Br Med J. 1996;  312 13-16
• 14 Park R H, Allison M C, Lang J. et al . Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia.  Br Med J. 1992;  304 1406-1409
• 15 Bastow M D, Rawlings J, Allison S P. Benefits of supplementary tube feeding after fractured neck of femur: a randomised controlled trial.  Br Med J. 1983;  287 1589-1592
• 16 Hartgrink H H, Wille J, Konig P, Hermans J, Breslau P J. Pressure sores and tube feeding in patients with a fracture of the hip: a randomized clinical trial.  Clin Nutr. 1998;  17 287-292
• 17 Sullivan D H, Nelson C L, Bopp M M, Puskarich-May C L, Walls R C. Nightly enteral nutrition support of elderly hip fracture patients: a phase I trial.  J Am Coll Nutr. 1998;  17 155-161
• 18 Norregaard O, Tottrup A, Saaek A, Hessov I. Effects of oral supplements to adults with chronic obstructive pulmonary disease (abstract).  Clin Resp Physiol. 1987;  23 388s
• 19 Jensen M B, Hessov I. Dietary supplementation at home improves the regain of lean body mass after surgery.  Nutrition. 1997;  13 422-430
• 20 Bos C, Benamouzig R, Bruhat A. et al . Nutritional status after short-term dietary supplementation in hospitalized malnourished geriatric patients.  Clin Nutr. 2001;  20 225-233
• 21 Hübsch S, Volkert D, Oster P, Schlierf G. Möglichkeiten und Grenzen der Anwendung flüssiger Nährstoffkonzentrate in der Therapie der Mangelernährung geriatrischer Patienten.  Aktuel Ernaehr Med. 1994;  19 109-114
• 22 Fiatarone Singh M A, Bernstein M A, Ryan A D, O'Neill E F, Clements K M, Evans W J. The effect of oral nutritional supplements on habitual dietary quality and quantity in frail elders.  J Nutr Health Aging. 2000;  4 5-12
• 23 Meredith C N, Frontera W R, O'Reilly K P, Evans W J. Body composition in elderly men. Effect of dietary modification during strength training.  J Am Geriatr Soc. 1992;  40 155-162
• 24 Wouters-Wesseling W, Hooijdonk C Van, Wagenaar L, Bindels J, Groot L de, Staveren W van. The effect of a liquid nutrition supplement on body composition and physical functioning in elderly people.  Clin Nutr. 2003;  22 371-377
• 25 Bourdel-Marchasson I, Joseph P A, Dehail P. et al . Functional and metabolic early changes in calf muscle occurring during nutritional repletion in malnourished elderly patients.  Am J Clin Nutr. 2001;  73 832-838
• 26 Callahan C M, Haag K M, Weinberger M. et al . Outcomes of percutaneous endoscopic gastrostomy among older adults in a community setting.  J Am Geriatr Soc. 2000;  48 1048-1054
• 27 Ciocon J O, Silverstone F A, Graver L M, Foley C J. Tube feedings in elderly patients. Indications, benefits, and complications.  Arch Intern Med. 1988;  148 429-433
• 28 Nair S, Hertan H, Pitchumoni C S. Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia.  Am J Gastroenterol. 2000;  95 133-136
• 29 Okada K, Yamagami H, Sawada S. et al . The nutritional status of elderly bed-ridden patients receiving tube feeding.  J Nutr Sci Vitaminol. 2001;  47 236-241
• 30 Paillaud E, Bories P N, Merlier I, Richardet J P, Jeanfaivre V, Campillo B. Prognosis factors of short and long-term survival in elderly hospitalized patients after percutaneous endoscopic gastrostomy.  Gastroenterol Clin Biol. 2002;  26 443-447
• 31 Abitbol V, Selinger-Leneman H, Gallais Y. et al . Percutaneous endoscopic gastrostomy in elderly patients. A prospective study in a geriatric hospital.  Gastroenterol Clin Biol. 2002;  26 448-453
• 32 Kaw M, Sekas G. Long-term follow-up of consequences of percutaneous endoscopic gastrostomy (PEG) tubes in nursing home patients.  Dig Dis Sci. 1994;  39 738-743
• 33 Panos M Z, Reilly H, Moran A. et al . Percutaneous endoscopic gastrostomy in a general hospital: prospective evaluation of indications, outcome, and randomised comparison of two tube designs.  Gut. 1994;  35 1551-1556
• 34 Sitzmann J V. Nutritional support of the dysphagic patient: methods, risks, and complications of therapy.  J Parent Ent Nutr. 1990;  14 60-63
• 35 Hébuterne X, Schneider S, Peroux J-L, Rampal P. Effects of refeeding by cyclic enteral nutrition on body composition: comparative study of elderly and younger patients.  Clin Nutr. 1997;  16 283-289
• 36 Shizgal H M, Martin M F, Gimmon Z. The effect of age on the caloric requirement of malnourished individuals.  Am J Clin Nutr. 1992;  55 783-789
• 37 Fiatarone M A, O'Neill E F, Doyle N, Clements K M, Roberts S B. et al . The Boston FISCIT Study: The effects of resistance training and nutritional supplementation on physical frailty in the oldest old.  J Am Geriatr Soc. 1993;  41 333-337
• 38 Fay D E, Poplausky M, Gruber M, Lance P. Long-term enteral feeding: a retrospective comparison of delivery via percutaneous endoscopic gastrostomy and nasoenteric tubes.  Am J Gastroenterol. 1991;  86 1604-1609
• 39 Vetta F, Gianni W, Ronzoni S. et al . Role of aging in malnutrition and in restitution of nutritional parameters by tube feeding.  Arch Gerontol Geriatr. 1996;  Suppl 5 599-604
• 40 Peck A, Cohen C E, Mulvihill M N. Long-term enteral feeding of aged demented nursing home patients.  J Am Geriatr Soc. 1990;  38 1195-1198
• 41 Golden A, Beber C, Weber R, Kumar V, Musson N, Silverman M. Long-term survival of elderly nursing home residents after percutaneous endoscopic gastrostomy for nutritional support.  Nurs Home Med. 1997;  5 382-389
• 42 Unosson M, Larsson J, Ek A-C, Bjurulf P. Effects of dietary supplement on functional condition and clinical outcome measured with a modified Norton scale.  Clin Nutr. 1992;  11 134-139
• 43 Potter J M. Oral supplements in the elderly.  Curr Opin Clin Nutr Metab Care. 2001;  4 21-28
• 44 Woo J, Ho S C, Mak Y T, Law L K, Cheung A. Nutritional status of elderly patients during recovery from chest infection and the role of nutritional supplementation assessed by a prospective trial.  Age Ageing. 1994;  23 40-48
• 45 Espaulella J, Guyer H, Diaz-Escriu F, Mellado-Navas J A, Castells M, Pladevall M. Nutritional supplementation of elderly hip fracture patients. A randomized, double-blind, placebo-controlled trial.  Age Ageing. 2000;  29 425-431
• 46 Gariballa S E, Parker S G, Taub N, Castleden C M. A randomized, controlled, single-blind trial of nutritional supplementation after acute stroke.  J Parent Ent Nutr. 1998;  22 315-319
• 47 Wouters-Wesseling W, Wouters A E, Kleijer C N, Bindels J G, Groot C P de, Staveren W A van. Study of the effect of a liquid nutrition supplement on the nutritional status of psycho-geriatric nursing home patients.  Eur J Clin Nutr. 2002;  56 245-251
• 48 Faxen-Irving G, Andren-Olsson B, Geijerstam A af, Basun H, Cederholm T. The effect of nutritional intervention in elderly subjects residing in group-living for the demented.  Eur J Clin Nutr. 2002;  56 221-227
• 49 Saudny-Unterberger H, Martin J G, Gray-Donald K. Impact of nutritional support on functional status during an acute exacerbation of chronic obstructive pulmonary disease.  Am J Respir Crit Care Med. 1997;  156 794-799
• 50 Kwok T, Woo J, Kwan M. Does low lactose milk powder improve the nutritional intake and nutritional status of frail older Chinese people living in nursing homes?.  J Nutr Health Aging. 2001;  5 17-21
• 51 Lauque S, Arnaud-Battandier F, Mansourian R, Guigoz Y. Protein-energy oral supplementation in malnourished nursing-home residents. A controlled trial.  Age Ageing. 2000;  29 51-56
• 52 Efthimiou J, Fleming J, Gomes C, Spiro S G. The effect of supplementary oral nutrition in poorly nourished patients with chronic obstructive pulmonary disease.  Am Rev Respir Dis. 1988;  137 1075-1082
• 53 Cederholm T E, Hellström K H. Reversibiliy of protein-energy malnutrition in a group of chronically-ill elderly outpatients.  Clin Nutr. 1995;  14 81-87
• 54 Katakity M, Webb J F, Dickerson J WT. Some effects of a food supplement in elderly hospital patients. A longitudinal study.  Hum Nutr Appl Nutr. 1983;  37A 85-93
• 55 Abuksis G, Mor M, Segal N. et al . Percutaneous endoscopic gastrostomy: high mortality rates in hospitalized patients.  Am J Gastroenterol. 2000;  95 128-132
• 56 Skelly R H, Kupfer R M, Metcalfe M E. et al . Percutaneous endoscopic gastrostomy (PEG): change in practice since 1988.  Clin Nutr. 2002;  21 389-394
• 57 Sanders D S, Carter M J, D'Silva J, James G, Bolton R P, Bardhan K D. Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia.  Am J Gastroenterol. 2000;  95 1472-1475
• 58 Bourdel-Marchasson I, Dumas F, Pinganaud G, Emeriau J-P, Decamps A. Audit of percutaneous endoscopic gastrostomy in long-term enteral feeding in a nursing home.  Internat J Quality Health Care. 1997;  9 297-302
• 59 Rudberg M A, Egleston B L, Grant M D, Brody J A. Effectiveness of feeding tubes in nursing home residents with swallowing disorders.  J Parent Ent Nutr. 2000;  24 97-102
• 60 Mitchell S L, Kiely D K, Lipsitz L A. 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
• 61 Mitchell S L, Kiely D K, Lipsitz L A. Does artificial enteral nutrition prolong the survival of institutionalized elders with chewing and swallowing problems?.  J Gerontol A Biol Sci Med Sci. 1998;  53 M207-M213
• 62 Sanders H, Newall S, Norton B, Holmes G T. Gastrostomy feeding in the elderly after acute dysphagic stroke.  J Nutr Health Aging. 2000;  4 58-60
• 63 Weaver J P, Odell P, Nelson C. Evaluation of the benefits of gastric tube feeding in an elderly population.  Arch Fam Med. 1993;  2 953-956
• 64 Delmi M, Rapin C-H, Benoga J M, Delmas P D, Vasey H. Dietary supplementation in elderly patients with fractured neck of femur.  Lancet. 1990;  335 1013-1016
• 65 Tkatch L, Rapin C-H, Rizzoli R. et al . Benefits of oral protein supplementation in elderly patients with fracture of the proximal femur.  J Am Coll Nutr. 1992;  11 519-525
• 66 Schurch M A, Rizzoli R, Slosman D, Vadas L, Vergnaud P, Bonjour J P. Protein supplements increase serum insulin-like growth factor-I levels and attenuate proximal femur bone loss in patients with recent hip fracture. A randomized, double-blind, placebo-controlled trial.  Ann Intern Med. 1998;  128 801-809
• 67 Brown K M, Seabrock N A. Nutritional influences on recovery and length of hospital stay in elderly women following femoral fracture.  Proc Nutr Soc. 1992;  51 132A
• 68 Avenell A, Handoll H H. Nutritional supplementation for hip fracture aftercare in the elderly. Cochrane Database Syst Rev 2000; CD001880
• 69 Krondl M, Coleman P H, Bradley C L, Lau D, Ryan N. Subjectively healthy elderly consuming a a liquid nutrition supplement maintained body mass index and improved some nutritional parameters and perceived well-being.  J Am Diet Assoc. 1999;  99 1542-1548
• 70 Bannerman E, Pendlebury J, Phillips F, Ghosh S. A cross-sectional and longitudinal study of health-related quality of life after percutaneous gastrostomy.  Eur J Gastroenterol Hepatol. 2000;  12 1101-1109
• 71 Verhoef M J, Rosendaal G M van. Patient outcomes related to percutaneous endoscopic gastrostomy placement.  J Clin Gastroenterol. 2001;  32 49-53
• 72 Stratton R J, Green C J, Elia M. Disease-related malnutrition. An evidence-based approach to treatment. Oxon, UK; CABI Publishing 2003: p 461
• 73 Meier D E, Ahronheim J C, Morris J, Baskin-Lyons S, Morrison R S. High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding.  Arch Intern Med. 2001;  161 594-599
• 74 Cowen M E, Simpson S L, Vettese T E. Survival estimates for patients with abnormal swallowing studies.  J Gen Intern Med. 1997;  12 88-94
• 75 Murphy L M, Lipman T O. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia.  Arch Intern Med. 2003;  163 1351-1353
• 76 Croghan J E, Burke E M, Caplan S, Denman S. Pilot study of 12-month outcomes of nursing home patients with aspiration on videofluoroscopy.  Dysphagia. 1994;  9 141-146
• 77 Dwolatzky T, Berezovski S, Friedmann R. et al . A prospective comparison of the use of nasogastric and percutaneous endoscopic gastrostomy tubes for long-term enteral feeding in older people.  Clin Nutr. 2001;  20 535-540
• 78 Finucane P, Aslan S M, Duncan D. Percutaneous endoscopic gastrostomy in elderly patients.  Postgrad Med J. 1991;  67 371-373
• 79 Horton W L, Colwell D L, Burlon D T. Experience with percutaneous endoscopic gastrotomy in a community hospital.  Am J Gastroenterol. 1991;  86 168-170
• 80 Schneider S M, Raina C, Pugliese P, Pouget I, Rampal P, Hebuterne X. Outcome of patients treated with home enteral nutrition.  J Parent Ent Nutr. 2001;  25 203-209
• 81 Mitchell S L, Tetroe J M. Survival after percutaneous endoscopic gastrostomy placement in older persons.  J Gerontol A Biol Sci Med Sci. 2000;  55 M735-M739
• 82 Lindemann B, Nikolaus P T. Outcomes of percutaneous endoscopic gastrostomy in dementia patients.  J Am Geriatr Soc. 2001;  49 838-839
• 83 Quill T E. Utilization of nasogastric feeding tubes in a group of chronically ill, elderly patients in a community hospital.  Arch Intern Med. 1989;  149 1937-1941
• 84 Bussone M, Meaune S. Percutaneous endoscopic gastrostomy in old age patients.  Age Nutrition. 1992;  3 110-111
• 85 Bussone M, Lalo M, Piette F, Hirsch J F, Senecal P. Percutaneous endoscopic gastrostomy: its value in assisted alimentation in malnutrition in elderly patients. Apropos of 101 consecutive cases in patients over 70 years of age.  Annales de Chirurgie. 1992;  46 59-66
• 86 Markgraf R, Geitmann K, Pientka L, Scholten T. Ernährung über perkutane endoskopische Gastrostomie. Langzeitergebnisse bei polymorbiden geriatrischen Patienten.  Geriatrie Forschung. 1994;  4 123-129
• 87 Raha S K, Woodhouse K. The use of percutaneous endoscopic gastrostomy (PEG) in 161 consecutive elderly patients.  Age Ageing. 1994;  23 162-163
• 88 James A, Kapur K, Hawthorne A B. Long-term outcome of percutaneous endoscopic gastrostomy feeding in patients with dysphagic stroke.  Age Ageing. 1998;  27 671-676
• 89 Wanklyn P, Cox N, Belfield P. Outcome in patients who require a gastrostomy after stroke.  Age Ageing. 1995;  24 510-514
• 90 Wijdicks E F, McMahon M M. Percutaneous endoscopic gastrostomy after acute stroke: complications and outcome.  Cerebrovascular Diseases. 1999;  9 109-111
• 91 Clarkston W K, Smith O J, Walden J M. Percutaneous endoscopic gastrostomy and early mortality.  South Med J. 1990;  83 1433-1436
• 92 Friedenberg F, Jensen G, Gujral N, Braitman L E, Levine G M. Serum albumin is predictive of 30-day survival after percutaneous endoscopic gastrostomy.  J Parent Ent Nutr. 1997;  21 72-74
• 93 Kohli H, Bloch R. Percutaneous endoscopic gastrostomy: a community hospital experience.  Am Surg. 1995;  61 191-194
• 94 Larson D E, Burton D D, Schroeder K W, DiMagno E P. Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients.  Gastroenterol. 1987;  93 48-52
• 95 Light V L, Slezak F A, Porter J A, Gerson L W, McCord G. Predictive factors for early mortality after percutaneous endoscopic gastrostomy.  Gastrointest Endosc. 1995;  42 330-335
• 96 Llaneza P P, Menendez A M, Roberts R, Dunn G D. Percutaneous endoscopic gastrostomy: clinical experience and follow-up.  South Med J. 1988;  81 321-324
• 97 Markgraf R, Geitmann K, Pientka L, Scholten T. Long-term results of enteral nutrition by percutaneous endoscopic gastrostomy in multi-morbid internal medicine patients.  Z Gastroenterol. 1993;  31, Suppl 5 21-23
• 98 Nicholson F B, Korman M G, Richardson M A. Percutaneous endoscopic gastrostomy: a review of indications, complications and outcome.  J Gastroenterol Hepatol. 2000;  15 21-25
• 99 Rabeneck L, Wray N P, Petersen N J. Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes.  J Gen Intern Med. 1996;  11 287-293
• 100 Rimon E. The safety and feasibility of percutaneous endoscopic gastrostomy placement by a single physician.  Endoscopy. 2001;  33 241-244
• 101 Sali A, Wong P T, Read A, McQuillan T, Conboy D. Percutaneous endoscopic gastrostomy: the Heidelberg Repatriation Hospital experience.  Aust N Z J Surg. 1993;  63 545-550
• 102 Stuart S P, Tiley E H, Boland J P. Feeding gastrostomy: a critical review of its indications and mortality rate.  South Med J. 1993;  86 169-172
• 103 Tan W, Rajnakova A, Kum C K, Alponat A, Goh P M. Evaluation of percutaneous endoscopic gastrostomy in a university hospital.  Hepato-Gastroenterology. 1998;  45 2060-2063
• 104 Taylor C A, Larson D E, Ballard D J. et al . Predictors of outcome after percutaneous endoscopic gastrostomy: a community-based study.  Mayo Clin Proc. 1992;  67 1042-1049
• 105 Wolfsen H C, Kozarek R A, Ball T J, Patterson D J, Botoman V A, Ryan J A. Long-term survival in patients undergoing percutaneous endoscopic gastrostomy and jejunostomy.  Am J Gastroenterol. 1990;  85 1120-1122
• 106 Elia M, Stratton R J, Holden C. et al . Home enteral tube feeding following cerebrovascular accident.  Clin Nutr. 2001;  20 27-30
• 107 Howard L, Malone M. Clinical outcome of geriatric patients in the United States receiving home parenteral and enteral nutrition.  Am J Clin Nutr. 1997;  66 1364-1370
• 108 Sanders D S, Carter M J, D'Silva J, McAlindon M E, Willemse P J, Bardham K D. Percutaneous endoscopic gastrostomy: a prospective analysis of hospital support required and complications following discharge to the community.  Eur J Clin Nutr. 2001;  55 610-614
• 109 Potter J M, Roberts M A, McColl J H, Reilly J J. Protein energy supplements in unwell elderly patients - a randomized controlled trial.  J Parent Ent Nutr. 2001;  25 323-329
• 110 Chandra R K, Puri S. Nutritional support improves antibody response to influenza virus vaccine in the elderly.  Br Med J. 1985;  291 705-706
• 111 Wouters-Wesseling W, Wagenaar L W, Groot L C de, Bindels J G, Staveren W A van. Biochemical antioxidant levels respond to supplementation with an enriched drink in frail elderly people.  J Am Coll Nutr. 2003;  22 232-238
• 112 Banerjee A K, Brocklehurst J C, Wainwright H, Swindell R. Nutritional status of long-stay geriatric in-patients: effects of a food supplement (Complain).  Age Ageing. 1978;  7 237-243
• 113 Banerjee A K, Brocklehurst J C, Swindell R. Protein status in long-stay geriatric in-patients.  Gerontology. 1981;  27 161-166
• 114 Beck A M, Ovesen L, Schroll M. Home-made oral supplement as nutritional support of old nursing home residents, who are undernourished or at risk of undernutrition based on the MNA. A pilot trial. Mini Nutritional Assessment.  Aging Clin Exp Res. 2002;  14 212-215
• 115 Ek A-C, Larsson J, Schenck H von, Thorslund S, Unosson M, Bjurulf P. The correlation between anergy, malnutrition and clinical outcome in an elderly hospital population.  Clin Nutr. 1990;  9 185-189
• 116 Hankey C R, Summerbell J, Wynne H A. The effect of dietary supplementation in continuing-care people: Nutritional, anthropometric and biochemical parameters.  J Hum Nutr Diet. 1993;  6 317-322
• 117 McEvoy A W, James O FW. The effect of a dietary supplement (Build-up) on nutritional status in hospitalized elderly patients.  Hum Nutr Appl Nutr. 1982;  36A 374-376
• 118 Bunker V W, Stansfield M F, Deacon-Smith R, Marzil R A, Hounslow A, Clayton B E. Dietary supplementation and immunocompetence in housebound elderly subjects.  Br J Biomed Sci. 1994;  51 128-135
• 119 Bourdel-Marchasson I, Barateau M, Rondeau V. et al . A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients.  Nutrition. 2000;  16 1-5
• 120 Chandra R K, Joshi P, Au B, Woodford G. Nutrition and immunocompetence of the elderly: effect of short-term nutritional supplementation on cell-mediated immunity and lymphocyte subsets.  Nutr Res. 1982;  2 223-232
• 121 Gray-Donald K, Payette H, Boutier V, Page S. Evaluation of the dietary intake of homebound elderly and the feasibility of dietary supplementation.  J Am Coll Nutr. 1994;  13 277-284
• 122 Lipschitz D A, Mitchell C O, Steele R W, Milton K Y. Nutritional evaluation and supplementation of elderly subjects participating in a „meals-on-wheals” program.  J Parent Ent Nutr. 1985;  9 343-347
• 123 Harrill I, Kunz M, Kylen A. Dietary supplementation and nutritional status in elderly women.  J Nutr Elderly. 1981;  1 3-13
• 124 Welch P K, Dowson M, Endres J M. The effect of nutrient supplements on high risk long-term care residents receiving pureed diets.  J Nutr Elderly. 1991;  10 49-62
• 125 Joosten E, Elst B Vander. Does nutritional supplementation influence the voluntary dietary intake in an acute geriatric hospitalized population?.  Aging (Milano). 2001;  13 391-394
• 126 Brin M F, Younger D. Neurologic disorders and aspiration.  Otolaryngol Clin North Am. 1988;  21 691-699
• 127 Daniels S K, Brailey K, Priestly D H, Herrington L R, Weisberg L A, Foundas A L. Aspiration in patients with acute stroke.  Arch Phys Med Rehabil. 1998;  79 14-19
• 128 Smithard D G, O'Neill P A, Parks C, Morris J. Complications and outcome after acute stroke - does dysphagia matter?.  Stroke. 1996;  27 1200-1204
• 129 Teasell R W, McRae M, Marchuk Y, Finestone H M. Pneumonia associated with aspiration following stroke.  Arch Phys Med Rehabil. 1996;  77 707-709
• 130 Odderson I R, Keaton J C, McKenna B S. Swallow management in patients on an acute stroke pathway: quality is cost effective.  Arch Phys Med Rehabil. 1995;  76 1130-1133
• 131 Smithard D G, Kenwick D, Martin D, O'Neill P. Chest infection following acute stroke: does aspiration matter?.  Age Ageing. 1993;  22, Suppl 3 24-29
• 132 Axelsson K, Asplund K, Norberg A, Eriksson S. Eating problems and nutritional status during hospital stay of patients with severe stroke.  J Am Diet Assoc. 1989;  89 1092-1096
• 133 Gariballa S E, Parker S G, Taub N, Castleden M. Nutritional status of hospitalized acute stroke patients.  Br J Nutr. 1998;  79 481-487
• 134 FOOD Trial Collaboration . Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the FOOD trial.  Stroke. 2003;  34 1450-1456
• 135 Bath P M, Bath F J, Smithard D G. Interventions for dysphagia in acute stroke. Cochrane Database Syst Rev 2000; CD000323
• 136 Broadley S, Croser D, Cottrell J. et al . Predictors of prolonged dysphagia following acute stroke.  J Clin Neurosci. 2003;  10 300-305
• 137 Nyswonger G D, Helmchen R H. Early enteral nutrition and length of stay in stroke patients.  J Neurosci Nurs. 1992;  24 220-223
• 138 Taylor S J. Audit of nasogastric feeding practice at two acute hospitals: is early enteral feeding associated with reduced mortality and hospital stay?.  J Hum Nutr Diet. 1993;  6 477-489
• 139 Smithard D G, O'Neill P A, England R E, Park C L, Wyatt R, Martin D, Morris J. The natural history of dysphagia following a stroke.  Dysphagia. 1997;  12 188-193
• 140 Barer D H. The natural history and functional consequences of dysphagia in hemispheric stroke.  J Neurol Neurosurg Psychiatry. 1989;  52 236-241
• 141 Gordon C, Hewer R L, Wade D T. Dysphagia in acute stroke.  Br Med J. 1987;  295 411-414
• 142 Houwing R H, Rozendaal M, Wouters-Wesseling W, Beulens J W, Buskens E, Haalboom J R. A randomised, double-blind assessment of the effect of nutritional supplementation on the prevention of pressure ulcers in hip-fracture patients.  Clin Nutr. 2003;  22 401-405
• 143 Lawson R M, Doshi M K, Barton J R, Cobden I. The effect of unselected post-operative nutritional supplementation on nutritional status and clinical outcome of orthopaedic patients.  Clin Nutr. 2003;  22 39-46
• 144 Stableforth P G. Supplement feed and nitrogen and calorie balance following femoral neck fracture.  Br J Surg. 1986;  73 651-655
• 145 Carver A D, Dobson A M. Effects of dietary supplementation of elderly demented hospital residents.  J Hum Nutr Diet. 1995;  8 389-394
• 146 Arens J, Zürcher G, Fietkau R, Aulbert E, Frick B, Holm M, Kneba M, Mestrom H J, Zander A. Leitlinie Enterale Ernährung: Onkologie.  Aktuel Ernaehr Med. 2003;  28, Suppl 1 S61-68
• 147 Patel P H, Thomas E. Risk factors for pneumonia after percutaneous endoscopic gastrostomy.  J Clin Gastroenterol. 1990;  12 389-392
• 148 Baeten C, Hoefnagels J. Feeding via nasogastric tube or percutaneous endoscopic gastrostomy. A comparison.  Scand J Gastroenterol. 1992;  194 95-98
• 149 Peschl L, Zeilinger M, Munda W, Prem H, Schragel D. Percutaneous endoscopic gastrostomy - a possibility for enteral feeding of patients with severe cerebral dysfunctions.  Wien Klin Wochenschr. 1988;  100 314-318
• 150 Leibovitz A, Plotnikov G, Habot B, Rosenberg M, Segal R. Pathogenic colonization of oral flora in frail elderly patients fed by nasogastric tube or percutaneous enterogastric tube.  J Gerontol A Biol Sci Med Sci. 2003;  58 52-55
• 151 Gomes G F, Pisani J C, Macedo E D, Campos A C. The nasogastric feeding tube as a risk factor for aspiration and aspiration pneumonia.  Curr Opin Clin Nutr Metab Care. 2003;  6 327-333
• 152 Ek A-C, Unosson M, Larsson H, Schenck H von, Bjurulf P. The development and healing of pressure sores related to the nutritional state.  Clin Nutr. 1991;  10 245-250
• 153 Bourdel-Marchasson I, Barateau M, Rondeau V. et al . A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. GAGE Group. Groupe Aquitain Geriatrique d'Evaluation.  Nutrition. 2000;  16 1-5
• 154 Finucane T E. Malnutrition, tube feeding and pressure sores: data are incomplete.  J Am Geriatr Soc. 1995;  43 447-451
• 155 Breslow R A, Hallfrisch J, Guy D G, Crawley B, Goldbert A P. The importance of dietary protein in healing pressure ulcers.  J Am Geriatr Soc. 1993;  41 357-362
• 156 McCarter T L, Condon S C, Aguilar R C, Gibson D J, Chen Y K. Randomized prospective trial of early versus delayed feeding after percutaneous endoscopic gastrostomy placement.  Am J Gastroenterol. 1998;  93 419-421
• 157 Brown D N, Miedema B W, King P D, Marshall J B. Safety of early feeding after percutaneous endoscopic gastrostomy.  J Clin Gastroenterol. 1995;  21 330-331
• 158 Choudhry U, Barde C J, Markert R, Gopalswamy N. Percutaneous endoscopic gastrostomy: a randomized prospective comparison of early and delayed feeding.  Gastrointest Endosc. 1996;  44 164-167
• 159 Dormann A, Stehle P, Radziwill R, Löser C, Paul C, Keymling M, Lochs H. Leitlinie Enterale Ernährung: Grundlagen.  Aktuel Ernaehr Med. 2003;  28, Suppl 1 S26-35