Is there a role for indirect calorimetry in maximizing patient outcome from nutritional alimentation in the long-term nursing care setting?

Background: Patients in a long-term nursing care center (NCC) are at risk for the complications of malnutrition because of altered mental status and reduced mobility. Objective: This prospective study sought to determine the need for accurately measuring energy expenditure by indirect calorimetry (IC) and providing sufficient nutrition support, by evaluating the effect of energy balance on nutrition-related complications in the NCC. Design: Patients residing in one NCC were included in this study if there was evidence of hypoalbuminemia, pressure sores, weight loss, actual/ideal body weight less than 85% or more than 150%, or the need for enteral tube feeding or total parenteral nutrition (TPN). After 4 weeks of initial monitoring, patients were evaluated weekly by IC for 8 weeks. Caloric requirements were denned by the measured resting energy expenditure with 10% to 15% added for an activity factor. Monitors included: daily temperature and stool frequency; weekly calorie count, Norton scale (NS), weight, pressure sore number/stage, and serum prealbumin level; and monthly quality of life measure by Minimum Data Set. Results: Of 110 patients screened, 41 met study criteria but 17 were excluded for reasons of agitation, refusal to participate, discharge from the NCC, or death. Of the 24 patients completing the study, 20.8% were male with a mean age of 77.1 years (range 29 to 104 years) and could be grouped on the basis of energy balance. Group 1 (n = 13) had positive cumulative energy balance for the 8 weeks of the study, 30.8% lost weight, 53.8% showed a slight increase in their risk for pressure sores (as evidenced by decreases in NS score) but only 15.4% developed pressure sores. Group 2 (n = 11) had negative cumulative energy balance for the 8 weeks of the study, 63.6% lost weight (odds ratio [OR] = 0.25; 95% confidence interval [CI]: 0.03 to 1.82), 27.3% showed a slight increase in their risk for pressure sores with decreases in NS score (OR = 3.11; 95% CI: 0.43 to 25.76) but in contrast, 36.4% developed pressure sores (OR = 0.32; 95% CI: 0.02 to 3.08). The mean cost of treatment for the pressure sores in group 1 was much less than that for group 2, $296 ± $863 vs $1, 960 ± $3, 501, respectively (p = .399). There was 64% noncompliance to the recommendations based on IC in group 2 due to advanced directives prohibiting tube feeds, disbelief in the accuracy of the calorie count, or desire for weight loss in obese patients by primary care physicians. Cumulative energy balance was weakly correlated with development of a pressure sore (r = -.84, p = .390) when all patients were considered; however, when stratified by risk of pressure sores as measured by the NS score at baseline, those at moderate risk for pressure sores had a much stronger association between cumulative energy balance and development of pressure sores (r = -0.604; p = .085) than did those at high risk for pressure sores (r = -0.070, p = .847). Conclusions: Use of IC to determine energy balance identified patients at risk for nutrition-related complications. Maintenance of positive energy balance markedly reduced the cost of treating pressure sores, possibly by accelerating the healing process or preventing new formation of lesions. Maintenance of a positive energy balance appears to have a much greater impact in preventing pressure sores in patients at moderate risk than in patients at high risk for pressure sores based on multiple nonnutritional factors. Although indirect calorimetry may have a role in the long-term NCC, its efficacy is limited by bias and ethical concerns. Education of patients, families, dietitians, and physicians regarding nutritional issues is needed to ensure positive energy balance through inexpensive enteral feeding and to reduce the morbidity and expense of associated complications.