Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK.
Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK; School of Medical Science, University of Manchester, Manchester, UK.
Clin Nutr. 2020 May;39(5):1418-1422. doi: 10.1016/j.clnu.2019.06.019. Epub 2019 Jun 29.
The population in developed countries is getting older and with advancing age comes increasing co-morbidity and demand on health care services. The use of home parenteral nutrition (HPN) is also increasing in the UK and elsewhere. Age and co-morbidity need to be taken into consideration when HPN is contemplated because of the significant associated economic burden and clinical risk. However, there are minimal data on HPN outcomes specific to the elderly.
We performed an observational study of a prospectively maintained database of patients dependent on HPN managed at a national U.K. referral centre. Data were collected on the 31st March 2018. Charlson index was used to assess co-morbidity. Data included demographics, HPN requirements, underlying disease aetiology, mechanism of intestinal failure, and whether the patient, carer or home care nurses administered the PN. The main outcome was the occurrence of at least one catheter-related blood stream infection (CRBSI) during HPN, with putative predictors of CRBSI assessed by uni- and multi-variable logistic regression.
Two hundred and seventy-seven patients were included in this study, 62% were female and the overall mean age of the entire cohort was 58 years (range 20-93). The mean duration of HPN was 1778 days (range 45-12,832). One hundred patients were aged 65 years or older. Patients aged 65 years or older had a higher Charlson index (1.8 vs 1.1, p = <0.0001), were more likely to require a home care nurse to administer PN (p = 0.01), and had the lowest risk of CRBSI (25% vs 39%; p = 0.01). Home care nurse administration was associated with the lowest risk of CRBSI, followed by carer and self-administration (P = 0.001). In multivariable analysis, duration of HPN and CVC care provider were the only independent predictors of CRBSI occurrence. There was no significant difference in unplanned intestinal failure-related hospital admissions between those under or above 65 years of age (p = 0.08).
HPN can be safely used in patients over the age of 65, even with increased co-morbidity. In this large cohort study, increasing age was found to be protective against CRBSI. CVC care provider was an independent predictor of CRBSI, while age and co-morbidity were not, suggesting that the use of home care nurses for PN administration is the principal reason for the low CRBSI rate in the elderly. Hence, older age should not be seen as a contra-indication for HPN, but increased healthcare resource may be required as those aged over 65 are more likely to require nursing assistance for CVC care.
发达国家的人口正在老龄化，随着年龄的增长，合并症越来越多，对医疗保健服务的需求也越来越大。在英国和其他地方，家庭肠外营养（HPN）的使用也在增加。在考虑 HPN 时，需要考虑年龄和合并症，因为这会带来显著的相关经济负担和临床风险。然而，针对老年人的 HPN 结果的相关数据很少。
我们对一个全国性英国转诊中心管理的依赖 HPN 的患者前瞻性维护数据库进行了观察性研究。数据于 2018 年 3 月 31 日收集。Charlson 指数用于评估合并症。数据包括人口统计学、HPN 需求、潜在疾病病因、肠衰竭的发病机制，以及患者、护理人员或家庭护理护士是否管理 PN。主要结局是在 HPN 期间至少发生一次与导管相关的血流感染（CRBSI），并通过单变量和多变量逻辑回归评估 CRBSI 的潜在预测因素。
本研究共纳入 277 名患者，其中 62%为女性，整个队列的平均年龄为 58 岁（范围 20-93 岁）。HPN 的平均持续时间为 1778 天（范围 45-12832 天）。100 名患者年龄在 65 岁或以上。年龄在 65 岁或以上的患者 Charlson 指数更高（1.8 比 1.1，p<0.0001），更有可能需要家庭护理护士来管理 PN（p=0.01），并且发生 CRBSI 的风险最低（25%比 39%；p=0.01）。家庭护理护士管理与 CRBSI 风险最低相关，其次是护理人员和自我管理（P=0.001）。多变量分析显示，HPN 持续时间和 CVC 护理提供者是 CRBSI 发生的唯一独立预测因素。年龄在 65 岁以下和以上的患者因计划外肠衰竭相关住院的发生率无显著差异（p=0.08）。
即使合并症增加，HPN 也可以安全用于 65 岁以上的患者。在这项大型队列研究中，年龄越大发现对 CRBSI 具有保护作用。CVC 护理提供者是 CRBSI 的独立预测因素，而年龄和合并症不是，这表明家庭护理护士进行 PN 管理是老年人 CRBSI 发生率低的主要原因。因此，年龄不应被视为 HPN 的禁忌症，但需要更多的医疗保健资源，因为年龄在 65 岁以上的患者更有可能需要护理人员协助 CVC 护理。
