Transcript USE OF SUPPLEMENTAL NUTRITITION IN THE AGING …

USE OF SUPPLEMENTAL
NUTRITITION IN THE AGING
POPULATION
Objectives
1. Describe the presence of malnutrition in the elderly today
2. Identify the factors that contribute to malnutrition in the elderly
3. Identify when oral nutrition supplements are indicated and should
be prescribed
4. Identify common oral nutrition supplements available
5. Identify methods for improving patient acceptance of oral
supplements
6. Identify disadvantages associated with the use of oral supplements
6. Identify when enteral nutrition support is indicated and should be
prescribed
7. Identify common enteral nutrition supplements available
8. Identify disadvantages/risks associated with the use of enteral
nutrition supplements
Prevalence of Malnutrition in the Elderly (1)
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Aging is accompanied by physiologic changes that
can negatively impact nutritional status.
Chronic disease can negatively impact nutritional
status.
In the United States, the prevalence of malnutrition in the elderly is less
than 1% in individuals who are independent and healthy.
 The prevalence of malnutrition in the elderly is 23% to 85% in nursing
home residents.
 The prevalence of malnutrition in the elderly is 33% to 55% in those
hospitalized.
 An estimated 85% of Americans age 65 and older have one or more
chronic disease that may benefit from nutritional intervention for
reduction of morbidity and mortality.
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Types of Malnutrition
Malnutrition: Any disorder of nutritional status,
including disorders resulting from a deficiency
of nutrient intake, impaired nutrient metabolism,
or over-nutrition.
 Protein-energy under-nutrition: The presence of
clinical (i.e., physical signs such as wasting, low
body mass index [BMI]) and biochemical (i.e.,
albumin or other serum protein) evidence of
insufficient intake.
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Causes of Malnutrition (2)
Dietary intake
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Energy needs decrease with age; yet the need
for most nutrients remains relatively unchanged
resulting in an increased risk of malnutrition.
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Little or no appetite
Problems with eating or swallowing
Eating inadequate servings of nutrients
Eating fewer than two meals a day
Limited income
◦ Restriction in the number of meals eaten per day
◦ Reduced dietary quality of meals
Isolation
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Older adults who live alone may lose desire
to cook because of loneliness
Appetite of widows decreases
Difficulty cooking due to disabilities
Lack of access to transportation to buy
food
Chronic illness and acute conditions
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Acute and Chronic conditions can affect
intake and/or increase nutritional demands.
◦ Drug–nutrient interactions
◦ Disability
◦ Depression
◦ Poor oral health
◦ Dysphagia
Physiological changes
Decrease in lean body mass and redistribution of fat
around internal organs lead to decreased caloric
requirements.
 Change in taste from medications, nutrient
deficiencies, or tastebud atrophy can also alter
nutritional status.
 Bioavailability of micronutrients
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Progressive Undernutrition (2)
The cumulative effect of the interaction between
nutrition and changes seen in aging is progressive
undernutrition which often goes undiagnosed.
 Early detection of malnutrition is important since it
has been associated with diminished cognitive
function and a diminished ability to care for one's
self.
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Identifying Malnutrition in the Elderly
BMI alone does not identify
undernutrition in obese people and may
falsely identify thin people as
malnourished.
 Plasma albumin, as a nutritional parameter,
is difficult to use in people with
inflammation or dehydration; two very
frequent conditions in the frail elderly.
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Nutrition Screening (3)
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U.S. hospitals required by Joint Commission to
provide nutrition screening to all patients within
24 hours of admission.
◦ This does not cover patients in other settings.
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There is not a standardized assessment tool for
finding malnutrition in older adults.
◦ There are assessment tools available specifically for
the geriatric patient.
Elderly specific screening tools should address the following:
◦ Does patient
 Suffer from chronic disease?
 Take multiple medications?
 Had decline in food intake over the past 3 months due
to loss of appetite, digestive problems, chewing or
swallowing difficulties?
 Experienced weight loss during the last 3 months?
 Decline/change in mobility ?
 Experienced psychological stress or acute disease in the
past 3 months?
 Have Neuropsychological problems?
 Financial concerns?
 Body Mass Index (BMI) less than 19 ? Over 25?
Nursing strategies (2)
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Collaboration
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Alleviate dry mouth
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Improve oral intake
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Provide conducive environment for meals
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Specialized Nutrition Support when indicated
Start Specialized Nutritional Support
When a patient cannot, should not, or will
not eat adequately.
 If the benefits of nutrition outweigh the
associated risks.
 If the patient's advanced directives
regarding the use of artificial nutrition and
hydration allows.
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(6)
Nutrition Support
Beyond that provided by normal food intake
Includes
◦ Modified food and menus
◦ Food fortification
◦ Oral nutrition supplements (ONS)
◦ Vitamin/Mineral supplementation
◦ Enteral nutrition/tube feeding (EN)
◦ Parenteral nutrition
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Liberalized Diets
There is a growing recognition that
nutrient intake of hospitalized patients
and long-term care residents is negatively
impacted by overly restrictive diets.
 In order to improve patient satisfaction
and allow for optimal nutrient intake, the
most liberalized diet order possible is
encouraged.
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Food Fortification
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Dietary Manipulation
◦ Food fortification using protein and energy
rich food ingredients or commercially
available protein or energy powders and
liquids added to the diet.
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Additional Foods
◦ Snacks, cakes, puddings, icecream
Dietary Fortification
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Adding Calories
◦ Oil
◦ Cream
◦ Sour cream
◦ Butter
◦ Milk
◦ Cheese
◦ Sugar
◦ Skimmed milk powder
◦ Commercial Carbohydrate/protein
powder or liquids
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Flavor enhancers
◦ Monosodium glutamate
◦ Salt
Strengths
 Availability
 Familiarity
 Palatability
 Extra calories
 Cheap
Weaknesses
 Increase in food volume or
quantity may be unsuitable for
anorexia.
 May be difficult for those with
chewing or swallowing
difficulties.
 Other nutrients.
 Ease of use/preparation
 high blood pressure or some
allergies.
Common Oral Supplements
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Suitable for patients with poor po
intake or increased calorie needs
Standard 1-1.2 kcal/ml with or without fiber
8-16 grams protein
Flavored
With or without specific micronutrients
Can be added to regular foods
Many can also be used as tube feeding
formula
Many available at local pharmacies and
grocery stores
General Use
Lactose Free
Gluten Free
Most sodium friendly
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Ensure, Ensure Plus
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Healthshake
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Resource Plus
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Isosource, Fibresource
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Boost
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Jevity
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Respiratory Product
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Pulmocare
Diabetic Products
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Glucerna
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Glucerna 1.2 cal
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Resource Diabetic
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Boost Glucose Control
Renal Products
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Nepro; dialysis
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NovaSource Renal
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Suplena; pre-dialysis
Protein Only
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Unjury-protein only
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Beneprotein
COMMON CLEAR LIQUID SUPPLEMENTS
•Use
for clear liquid diets, pre- and post-surgical,
bowel prep, fat-malabsorptive, and fat-restricted
diets.
•Use
for providing extra calories and/or protein
as an alternative to creamy shake-like
supplements.
Available in 1-6 oz servings
100-200 calories
8-24 grams protein
Flavored or Unflavored
With or without specific
micronutrients
•Can be added to regular foods
• Some can be added to tube feedings to boost
protein needs
•Fat Free
• Lactose Free
• Gluten Free
•Most sodium friendly
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Increasing Protein
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Healthy Shot, Double Shot
Enlive
Juven
Promod
Increasing Calories
◦ Polycose Powder -100 cal/oz
◦ BeneCalorie
SUPPLEMENTAL FOODS
•May
be disease specific
•Can be used to help
increase calories/protein
•Can be used to provide
variety to restricted diets
•Can be used to enhance
nutrient intake with
limited added calories
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Ensure
Boost
◦ Pudding
Diabetic Products
◦ Glucerna
 Snack Bar
 Shake
 Pudding
 Cereal
Specialized nutritional support –
Oral Nutrition Supplements (ONS) (5)
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At nutritional risk or who are undernourished
Following orthopedic-surgical procedures
In demented patients
At risk for or with Pressure Ulcers
Frail Elderly
Problems associated with the use of ONS (7)
Reduction in the intake of normal food
 Low palatability
 Adverse effects
 Wastage
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Palatability of Oral Nutritional Supplements
Poor patient acceptance is a common barrier
to intake of oral nutrition supplements.
 Taste is a key limiting factor for older people.
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Methods of ONS Delivery Shown to
Improve Intake
Timing around meals and bedtime
 MedPass
 Targeted Feeding Assistance
 Dietitian Involvement
 Group Meals and Snack Service; Nursing
Homes, Rehab
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Problems associated with the use of ONS
cont
Oral nutritional therapy via assisted feeding and
dietary supplements is often difficult, time-consuming
and demanding in elderly patients due to
multimorbidity and slow responses.
◦ However assisted oral feeding and supplements are able to
support the physical and psychological rehabilitation of
most elderly patients.
Considerations for ongoing use of a supplement
may include:
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Is the patient using the supplement?
Is there any wastage?
Is the original clinical indication still valid?
Is the patient gaining weight?
Has a dietician been consulted to assist with the nutritional planning for
this patient?
Could the patient be encouraged to adopt a diet that meets their energy
needs, through the use of supermarket products or prepared meals?
Is there a plan in place to gradually replace use of the supplement with a
regular diet?
Dysphagia
(8)
Managing Dysphagia
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Factors to consider before initiating modified oral nutrition
support and hydration and/or enteral nutrition
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Recurrent chest infections
Mobility
Dependency on others for assistance to eat
Perceived palatability and appearance of food or drink
Level of alertness
Compromised physiology
Poor oral hygiene
Compromised medical status
Metabolic and nutritional requirements
Vulnerability or immunocompromised
Comorbidities
National Dysphagia Diet (NDD)
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In 2002, the American Dietetic Association
established the National Dysphagia Diet guidelines
for thickened dietary supplements.
◦ This Task Force proposed viscosity ranges for thin,
nectar, and honey-thick liquids.
The National Dysphaia Diet, cont (9)
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Prescribes four levels of food modification
◦ Level 1
 Patients with significant impairment in control
◦ Levels 2 and 3
 Patients with some ability to chew
◦ Level 4
 Patients able to eat an unrestricted regular diet
National Dysphagia Level 1: Pureed (9)
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For people who have moderate to severe dysphagia, with poor oral phase abilities
and reduced ability to protect their airway.
◦ Close or complete supervision and alternate feeding methods may be required.
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Pureed, homogenous, and cohesive foods
◦ Food should be “pudding-like”.
◦ No coarse textures, raw fruits or vegetables, nuts, and so forth are allowed.
◦ Any food that require bolus formation, controlled manipulation, or mastication
are excluded.
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Includes all unthickened beverages and supplements
◦ Liquid Consistency
 Thin
 Nectar-like
 Honey-like
 Spoon-thick/ pudding
Ready-to-serve vs point of care thickeners
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Modified fluids and foods are available for purchase in a
ready-to-serve form.
Commercially available thickening agents that specify
viscosity ranges include
◦ RESOURCE® ThickenUp®
◦ Hormel Thick & Easy® Instant Thickeners
◦ Thik & Clear®
Consistency of Food and Beverage
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Usage Chart for bottle for RESOURCE® ThickenUp® :
One stroke will deliver approximately 15g of
thickening gel.
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Desired Consistency
 Per 4oz
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Nectar
 1 stroke
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2 strokes
Honey
 2 strokes
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Per 8 oz.
4 strokes
Pudding
 4 strokes
8 strokes
Dysphagia Diet Foods (10)
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Are thickened as recommended by the National
Dysphagia Diet (NDD) guidelines.
◦ Can be cost effective for the institution.
◦ The viscosities of commercial dysphagia diet foods
have been shown to be inconsistent with NDD
guidelines.
Pureed Meals
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Provides about 550-600 calories per meal and
19-23 gm protein per meal.
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Typical Pureed Meal Service Hospital Setting:
◦ Breakfast:
 Pureed eggs, strained oatmeal, thickened milk and
thickened juice.
◦ Noon/Eve:
 Pureed Beef, Pureed Carrots, Mashed Potatoes
Brown Gravy 2 oz. thickened milk and thickened
juice.
Problems with Dysphagia Diet (11)
◦ Statistically significant results indicate that older
people on texture-modified diets have a lower intake
of energy and protein than those consuming a normal
hospital diet and it is likely that other nutrients will be
inadequate.
◦ The viscosity of barium test feeds is much greater
than the correspondingly named diet foods and the
NDD guidelines.
◦ Variety in pureed menus may be lacking.
◦ Poor patient acceptance.
◦ Lack of or delayed advancement in level.
Recommendations
◦ All patients on texture-modified diets should be
assessed by the dietitian for nutritional support.
◦ Evidence based strategies for improving overall
nutrient intake should be identified.
Strategies
Educate and inform patients and family
members.
 Be well informed/trained about
modification practices in your facility.
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◦ “thicker is not always better”
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Monitor status and advocate for
reevaluation for diet advancement.
Severe Neurological Dysphagia (5)
Enteral Nutrition (EN) is clearly indicated.
 For long-term nutritional support PEG should
be preferred to NGT.
 EN should be initiated as soon as possible and
accompany intensive swallowing therapy until
safe and sufficient oral intake from a normal
diet is possible.
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Enteral Nutrition
Indications for enteral nutrition (6)
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Unconscious patient
Neuromuscular swallowing disorder
Physiological anorexia
*Upper GI obstruction ,GI dysfunction or
malabsorption
Increased nutritional requirements
Psychological problems
Specific treatment
Mental health
Considerations when prescribing
enteral formula type (13)
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Formulary of Institution
◦ A potential safety issue may arise if limited to
products based on an institutional contract in
that they might not be appropriate for the
patient population or setting.
◦ Should be specific to the institution.
 Should be established based on patient population
and estimated nutrient needs rather than specific
diagnosis.
Considerations when prescribing enteral
formula type, cont
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Considerations should include
◦ Nutrition and physical assessment, metabolic
abnormalities, GI function, overall medical
condition, and expected outcomes.
◦ Comparison of the patient’s condition and
nutrient needs with the specific properties of
the available nutritional formulas.
Standard Formulas (14)
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Most contain enough electrolytes and minerals to meet
the minimum daily requirement of Sodium, Potassium,
Calcium, Magnesium and Phosphorus if the patient is
receiving enough to meet energy needs.
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Some are designed specifically for patients with low
energy needs but still requiring adequate electrolytes
vitamins and minerals.
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ICU patients not meeting criteria for immune-modulating
formulas should receive standard formulas.
Considerations with Renal Impairment
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ICU patients: acute renal failure/acute kidney injury (ARF) (AKI)
◦ Use standard formulas
 If significant electrolyte abnormalities exist or develop:
 a specialty formulation designed for renal failure (with
appropriate electrolyte profile) may be considered.
Patients receiving dialysis
◦ Should receive increased protein, up to a maximum of 2.5 g/kg/d.
Patients with renal insufficiency
◦ Protein should not be restricted in means to avoid or delay
initiation of dialysis therapy.
Considerations with Hepatic Impairment
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Cirrhosis and hepatic failure
◦ EN is the preferred route of nutrition therapy in
ICU patients with acute and/or chronic liver
disease versus PN. Avoid restricting protein.
ICU patients with acute and chronic liver disease
◦ Use standard enteral formulations.
◦ In encephalopathic patients who are refractory to
standard treatment with luminal acting antibiotics
and lactulose:
 Use branched chain amino acid formulations
Pancreatitis
Mild to moderate acute pancreatitis
◦ Does not require nutrition support therapy
unless:
 An unexpected complication develops.
 There is failure to advance to oral diet
within 7 days.
 Severe acute pancreatitis
◦ Feed enteral by gastric or jejunal route.
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Immune-modulating Formulas
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Supplemented with immune enhancing agents
◦ Arginine, glutamine, nucleic acid, ω-3 fatty acids,and antioxidants.
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Should be used for the appropriate patient population.
◦ Major elective surgery, trauma, burns, head and neck
cancer, and critically ill patients on mechanical
ventilation
◦ Caution in severe sepsis.
◦ Surgical ICU patients
◦ Medical ICU patients
Immune-Modulating Formulas, cont
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Evidence of Benefits
◦ More uniformly seen in patients undergoing major
surgery than in critically ill patients on mechanical
ventilation.
◦ More pronounced when given in the preoperative period.
◦ Are dose-dependent.
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No Benefit
◦ Hypothesized that there may be some increased risk with
the use of arginine-containing formulations in medical ICU
patients who are severely septic.
◦ Patients not meeting the criteria
 Decreased likelihood that immune-modulating formulas change
outcome.
 The added cost of these specialty formulas cannot be justified
and standard enteral formulas should be used..
Anti-inflammatory
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Supplemented with anti-inflammatory lipid
profile
◦ ω-3 fish oils, borage oil and antioxidants.
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Benefits
◦ Patients with Acute Respiratory Distress Syndrome
(ARDS) and severe acute lung injury (ALI) should be
placed on an enteral formulation with the antiinflammatory lipid profile.
Fiber and Elemental Formulas
Evidence of diarrhea
◦ Soluble fiber-containing or small peptide
formulas
 Critically ill patients
◦ Insoluble fiber should be avoided
 Patients at high risk for bowel ischemia or
severe dysmotility
◦ Both soluble and insoluble fiber should be
avoided
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Motility Agents and Probiotics
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Impaired gastrointestinal motility may cause
abdominal distension, vomiting, GERD, pulmonary
aspiration , pneumonia, sepsis.
◦ Administration of prokinetic agents can improve gastric
emptying and intestinal motility.
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Probiotic agents have been shown to improve
outcome in specific critically ill patient populations .
◦ Most consistently by decreasing infection.
◦ Transplantation, major abdominal surgery, and severe
trauma.
The Goals of Enteral Nutrition Therapy in
the Elderly (5)
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The Provision of sufficient amounts of energy, protein
and micronutrients.
Maintenance or improvement of nutritional status.
Maintenance or improvement of function, activity and
capacity for rehabilitation.
Maintenance or improvement of quality of life.
Reduction in morbidity and mortality.
Considering the reduced adaptive and regenerative
capacity of the elderly, EN may be indicated earlier
and for longer periods than in younger patients.
Frail elderly may benefit from EN as long as their
general condition is stable.
Indications for EN in the Elderly
Undernutrition and risk of undernutrition.
 Depression
 Early and moderate dementia consider ONS
and occasionally EN
 Pressure ulcers.
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Label Content and Health Claims Attributed
to Oral and Enteral Formulas (14)
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Patients and healthcare professionals must give
special attention to the veracity of enteral
formula manufacturers on the labeled content
and health claims attributed to formulas.
◦ Enteral Formulas are classified by the U.S. Food and
Drug Administration (FDA) under the heading of
medical foods.
◦ Medical foods have been defined, but they are not
regulated as either conventional food or as drugs.
Enteral Formula Type and Use (6)
Common Enteral Supplements
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Jevity Can and Jevity Ready to Hang with Fiber
Jevity 1.2 Can Jevity 1.2 Ready to Hang
Nepro,
Nutrihep Ready to Hang
Optisource Hi Pro
Osmolite can and Osmolite Ready to Hang
Perative can and Perative Ready to Hang
Promote can and Promote Ready to Hang
Pulmocare can and Pulmocare Ready to Hang
Suplena Two Cal HN
Vital HN
Vivonex
Oxepa
Jevity 1 Cal with Fiber and Jevity 1.5 with Fiber
Complications and Adverse Effects of Enteral
Feeding (6)
Insertion
 Post insertion trauma
 Displacement
 Reflux
 GI intolerance
 Metabolic
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Refeeding Syndrome
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Criteria for determining elderly people at high risk of developing refeeding
problems: Patient has one or more of the following
◦ BMI less than 16 kg/m2
◦ Unintentional weight loss greater than 15% within the last 3-6 months
◦ Little or now nutritional intake for more than 10 days
◦ Low levels of K P04, mg prior to feeding
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Or patient has two or more of the following
◦ BMI less than 18.5 kg/m2
◦ Unintentional weight loss greater than 10% within the last 3-6 months
◦ Little or no nutritional intake for more than 5 days
◦ A history of alcohol abuse or drugs including insulin chemotherapy antacids or
diuretics.
To promote tolerance
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Tube placement
◦ NG or PEG/ PEJ
Formula Selection
◦ RD consult
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Initiate at rates of 50 cc/hr in adults and advance by 20-30 cc/hr.
Use Isotonic (300 mOsm/L) formulas.
Use continuous infusion to establish tolerance initially and later
transition to an intermittent infusion schedule.
Monitoring
◦ Checking gastric residuals every 4-6 hr until desired rate is
established. I
◦ Hold for 1 hour if gastric residual is >(1.0 to 1.5) x hourly rate
or >150 mL before bolus or intermittent feeding.
◦ Daily weights, I/O records, serum electrolytes, phosphorus,
magnesium, and ionized calcium should be monitored until
tolerance is established and patient is stable.
Decision Making Concerning EN in the
Elderly (5)
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Does the patient suffer from a condition that is likely to
benefit from EN?
Will nutritional support improve outcome and/or accelerate
recovery?
Does the patient suffer from an incurable disease, but one in
which quality of life and wellbeing can be maintained or
improved by EN?
Does the anticipated benefit outweigh the potential risks?
Does EN accord with the expressed or presumed will of
the patient, or in the case of incompetent patients, of his/her
legal representative?
Are there sufficient resources available to manage EN
properly?
If long-term EN implies a different living situation (institution
vs. home), will the change benefit the patient overall?
Long-term Nutrition Support (6)
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Living with the reality of what it meant not to eat
was reported by the National Collaborating Centre
for Acute Care .
◦ Patients expressed the importance of sharing their
experiences with someone who is also receiving long term
nutrition support.
◦ A predominant feature in the literature was the need for
counseling.
Patients Reported:
 Difficulty in coping with the temptation not to eat.
 Feelings of guilt and low self esteem.
 Guilt and personal responsibility in relation to their
illness.
 Reluctance to join social events.
 Concerns that others found it uncomfortable to eat in
the presence of them.
 Disturbed sleeping patterns .
 The most difficult aspect emotionally was related to
reactions of friends, family and the community.
Recommendations for Patients Receiving
Long Term Nutrition Support:
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Patients should be kept fully informed and have
access to appropriate sources of information in
formats, languages and ways that are suited to the
individual.
Patients should have the opportunity to discuss
diagnosis, treatment options and relevant physical
psychological and social issues.
Cognition, gender, physical needs, culture and
stage of life to the individual should be
considered.
Contact details for relevant support groups,
charities and voluntary organizations should be
provided.
Nutrition Therapy in End-of-Life Situations
(12)
Specialized nutrition therapy is not obligatory in
cases of futile care or end-of-life situations.
 The decision to provide nutrition therapy
should be based on effective
patient/family communication, realistic goals, and
respect for patient autonomy.
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Foregoing aggressive nutrition therapy(15)
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The following decreases in symptoms, although
not all-encompassing, may benefit the patient.
◦ Gastrointestinal and venous distention
◦ Nausea
◦ Vomiting
◦ Potential for aspiration
◦ Diarrhea
◦ Urinary problems
◦ Pulmonary secretions
Conclusions
As the population ages, the problem of poor
nutrition among the elderly grows.
 Improved care for the vulnerable older
population calls for increased awareness of the
importance of nutrition, updated and enhanced
treatment standards, and implementation of
care strategies that prevent or delay
consequences of poor nutrition.
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Conclusions
The use of Nutritional Supplements oral or enteral in the Aging Population
Nutrition Supplementation oral or
enteral Benefits
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When administered
appropriately
◦ Can increase calorie, protein
intake for those at risk for
malnutrition or with
malnutrition or with increased
needs.
◦ Can be cost-effective.
◦ Can have significant impact on
recovery from illness or
quality of life.
Nutrition Supplementation oral or
enteral Disadvantages
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When administered
inappropriately
◦ Can be ineffective.
◦ Can be costly.
◦ Can be detrimental to
patients safety and/or
recovery.
◦ May not be suitable for all
elderly patients.
References
1. Nurse Practitioner, Mar 2001 by Ennis, Beth Waters, Saffel-Shrier, Susan, Verson, Hilary
2.NUTRITION IN THE ELDERLY Nursing Standard of Practice Protocol: Nutrition in Aging
Rose Ann DiMaria-Ghalili, PhD, RN, CNSN Evidence-Based Content - Updated January 2008
3. AJN, American Journal of Nursing February 2008 Volume 108 Number 2 Pages 50 - 59
4. Aging Clin Exp Res. 2008 Aug;20(4):322-8.
5. ESPEN Guidelines on Enteral Nutrition: Geriatrics 19 January 2006
6 National Collaborating Centre for Acute Care, February 2006. Nutrition support in adults Oral nutrition support, enteral tube feeding
and parenteral nutrition.National Collaborating Centre for Acute Care, London. Available from www.rcseng.ac.uk Commissioned by
the National Institute for Health and Clinical Excellence
7. Guigoz Y, Vellas B, Garry PJ. Assessing the nutritional status of the elderly: The Mini Nutritional Assessment as part of the geriatric
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8. Published online before print March 13, 2008, doi: 10.1378/chest.08-0255 CHEST June 2008 vol. 133 no. 6 1397-1401
Lindsay Strowd, BS, Julie Kyzima, MA, CCC/SLP, David Pillsbury, MA, CCC/A, Tom Valley, BS, and
Bruce R. Rubin, MEngr, MD, MBA, FCCP
9. AJN, American Journal of Nursing: November 2010 - Volume 110 - Issue 11 - pp 26-33 doi: 10.1097/01.NAJ.0000390519.83887.02
Feature Articles Managing Dysphagia Through Diet Modifications Garcia, Jane Mertz PhD, CCC-SLP; Chambers, Edgar
IV PhD
10. CHEST June 2008 vol. 133 no. 6 1397-1401 Lindsay Strowd, BS, Julie Kyzima, MA, CCC/SLP, David Pillsbury, MA, CCC/A, Tom Valley,
BS, and Bruce R.
Rubin, MEngr, MD, MBA, FCCP Published online before print March 13, 2008, doi: 10.1378/chest.08-0255
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Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient:
13. ASPEN Clinical Guidelines 2009 Adult Critical Care - In collaboration with the Society of Critical Care Medicine (SCCM)
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