Nutritional status and clinical evolution of the elderly in home enteral nutritional therapy: a retrospective cohort study

Objective to evaluate the clinical and nutritional evolution of elderly patients receiving home enteral nutritional therapy. Method retrospective cohort observational study. Data collection was performed through the analysis of clinical and nutritional records. The demographic, nutritional and clinical variables were analyzed. The sample consisted of elderly patients using home enteral nutritional therapy via the probe or the stomach. For the statistical analysis, the Statistical Package for the Social Sciences program was used, adopting the level of significance of 5%. Results the sample was 218 participants, with a mean age of 76 ± 10.12 years, of which 54.1% were female. The main morbidity was the stroke sequelae. Malnutrition was the nutritional diagnosis and the overall subjective assessment, the main instrument of nutritional evaluation. The route of administration of the most prevalent diet was the nasoenteric/nasogastric tube, however, after one year of follow-up, gastrostomy became the main route. It was observed the predominance of general condition maintenance and the most prevalent clinical outcome was death. Conclusion the majority of patients in home enteral nutrition therapy presented maintenance and / or improvement of clinical and nutritional status. Therefore, this therapy may contribute to a better clinical and nutritional evolution.


Introduction
The growth of the elderly population is a worldwide phenomenon and, in Brazil, the population is gradually aging (1) . With this demographic transition, there is a growing increase in the incidence of chronic noncommunicable diseases, which has a major impact on health systems (1)(2) . Thus, the number of elderly with home enteral nutritional therapy (HENT) has grown worldwide (3) .
HENT refers to nutritional assistance related to nutrient administration through home enteral nutrition (4) ; promotes discharge and reintegration into the family nucleus. In addition, de-hospitalization stimulates the humanization of care, provides bed rotation, reduces iatrogenic risks and treatment costs (5) .
The Department of Health of the Federal District The elderly in HENT can enter home care with risk of malnutrition or installed malnutrition, but may also become malnourished during home care (4) . And, considering also the need to emphasize the importance of incentives to HENT programs within the scope of At the SES-DF, patient care is performed at the regional health service according to the household, classification of the regional health services of the

Results
According to GENUT data, from January 2018, 3020 patients were attended by HENTP from September 2016 to February 2017. Of these, 856 (28%) were elderly using HENT both by probe / stoma and oral routes. The sample of this study comprised 218 patients, which represents 25.5% of the total of the elderly assisted by the HENTP and 100% of the elderly with probe or ostomies that entered this program in the mentioned period.
The patients analyzed had a mean age of 76 ± 10.12 years and the female sex represented 54.1% (n = 118). The main regional service was the Center-South, comprising 26.1% (n = 57) of the services, however, the Southwest region, with 24.3% (n = 53), was the one that comprised the highest percentage of residence of patients (Table 1). Table 1 -Distribution of the elderly attended by the HENTP* by regional of service and regional of residence.

Regional of Residence n (%) n (%)
The most prevalent initial nutritional diagnosis was malnutrition, representing 65.1% (n = 142) of the cases, and in the group that completed the four reevaluations, this prevalence reduced, in absolute numbers, to 47.5% (n = 29), according to Table 3.
The route of administration of the most prevalent     *HENTP = Home Enteral Nutritional Therapy Program; † Intake evaluation refers to the first nutritional evaluation performed at the time of patient's entry into the Home Enteral Nutritional Therapy Program; ‡ First reevaluation is the nutritional reevaluation carried out three months after entering the program; § Second reassessment is the nutritional reassessment performed six months after entry into the program and three months after the first nutritional reevaluation; || The third reassessment is the nutritional reassessment performed nine months after entry into the program and three months after the second nutritional reassessment; ¶ Fourth reassessment is the nutritional reassessment performed 12 months after entry into the program and three months after the third nutritional reassessment    Regarding the modules, 15.5% (n = 34) of the patients at the entrance were used, with casein being the most frequently used module (67.6%, n = 23), followed by the glutamine module (11.8%, n = 4).

Discussion
The prevalence of elderly individuals aged 70 or over, as found in the sample studied, is compatible with the literature in relation to patients assisted in home care (5,(7)(8)(9)(10)(11) . This fact can be explained by the process of demographic transition associated with the increase of disability levels, according to the rise of chronic diseases in aging (1) .
Similar to other studies on home care (7)(8)(9)(11)(12) , there was a predominance of females. This fact is justified by the higher mortality in the male population due to biological factors and / or unequal exposure to health risk factors. When analyzing the Federal District, there is also a greater expectation of life among women (1) .
Regarding the distribution by regional of attendance, it was observed a greater concentration of the attendance in the Central-South region, which is justified by the location of one of the largest hospitals in the Federal District. In relation to the regional of residence, the Southwest was the most prevalent; it has expanded and the satellite city of Taguatinga is among the highest percentage of elderly, according to the District Survey by Household Sample of the Federal District (PDAD/DF) (13) .
A decrease of 72% of the sample was observed between the entry in the program and the last reevaluation. The main reason for leaving the HENTP was death, which can be justified by the profile of chronic diseases of patients associated with various sequelae and comorbidities, corroborating the data found in other studies (7,(9)(10) . Regarding the percentage of re-hospitalization, results lower than those found in this study were obtained from a survey of a home care service in the Northeast (7) and in a study on Home Hospitalization Service in Southern Brazil (14) in which 24% and 26.3% of the patients, respectively, presented hospital readmissions during home care. However, there is no standardized reference value to consider a high readmission rate and there is a lack of HENTP studies in Brazil (15) , which makes it difficult to judge the percentage found in the study. It should be pointed out that re-hospitalization is an indicator of quality of care that can be used to measure the resolution of home care (7) .
The literature demonstrates a high prevalence of neurological disorders as the main clinical cause that leads to the use of HENT, with stroke being the most common diagnosis (7)(8)10,14,(16)(17)(18)(19) . The study conducted in the Federal District with patients from the HENTP, in 2005, found a prevalence of 42.6% in the elderly with stroke (8) . In a survey carried out in a home care service in Maceió -Alagoas, the percentage of patients with stroke was 35.2% (7) , corroborating this study. These results corroborate the Spanish study that found a higher prevalence of neurological disorders (10,12) .
The measurement of weight and height of patients in HENT is not always possible due to the physical limitations of the patients. The estimation was the method most used in the study to obtain these parameters, the same technique used by two studies evaluated in a literature review (19) . Weight estimation may be by visual www.eerp.usp.br/rlae 7 Menezes CS, Fortes RC.
BMI or validated formula of weight suggestion, such as using the arm circumference measure (20) . Height can be estimated by the formula validated in 1985, using the measure of knee height (21) . From the data collected, it was not possible to know the type of method used in these anthropometric estimates.
The mean BMI in this study was 21.0 ± 4.24 kg / m 2 , which shows a tendency to malnutrition. Due to the physiological limitations imposed by the aging process, a BMI <22 kg / m 2 is considered as a cutoff point for the classification of malnutrition in the elderly (22) . Even considering the limitations inherent to the use of BMI, it is emphasized that it is an indicator widely used in clinical and epidemiological studies (23) .  (23)(24)(25) .
A high prevalence of malnutrition (65.1%) was observed in the admission of HENTP patients, which is consistent with the literature, which reports that the elderly in HENT can already enter home care in the presence of risk of malnutrition or installed malnutrition (4) . These results are also plausible with other studies from Brazil and the world that found a high prevalence of malnutrition in patients admitted to home care (5,8,12) .
Malnutrition in the elderly is a public health problem due to physiological, nutritional, psychological and social factors. Weight loss in the elderly is often associated with sarcopenia (loss of muscle mass, strength and performance), which influences functional status and thus quality of life (1)(2)(26)(27) . There is a relationship between the nutritional diagnosis and the severity of the disease (2,19) , and malnutrition has direct correlations with clinical complications such as mortality rate, pressure lesions and the number of readmissions (5,27) .
Regarding the route of administration, this study found a greater predominance of NEC / NGC, in agreement with the literature review conducted in 2014 (19) . The study on home care in Maceió also found, in patients assisted by the public service, a higher prevalence of NEC / NGC (7) . In 2009, a study conducted in the Federal District also found a higher prevalence of NEC / NGC in HENTP patients. The authors justified that the high cost associated with the TWG in relation to the NEC / NGC access may have implications for the lower prevalence of this technique in the UHS (8) .
The "gold" standard for probe access is percutaneous endoscopic gastrostomy and its use is recommended when the tube feeding time is longer than two or three weeks, considering the lower risk of complications and higher quality of life (17)(18)28) . In this study, there was an increase in GTT percentages (75%) in patients who reached one year of follow-up, a trend that was also observed in the literature (10) .
Regarding the clinical evolution, the maintenance of the general condition of the patients was predominant.
This data is formed from a subjective evaluation of the nutritionist who is attending the patient and the patient caregiver's report. The caregiver follows the evolution of the patient and becomes an important component of the care team (29)(30) . Nutritional intervention is essential and must be considered in the treatment of PU. The prescription of formulas with higher protein and immunomodulatory nutrients has been recommended because it interferes positively in the healing process (32) . As was observed in HENTP of DF, the most commonly used probe supplement was PU indicated, being normo-caloric, hyper-proteic and rich in arginine, besides the protein module being the most used, which characterizes the prescription of hyper-proteic diets.
The most common complication of GIT was intestinal constipation, a result similar to that found in other HENT studies in the literature (5,11) . On the other hand, an investigation that analyzed the challenges of HENT worldwide found diarrhea as the most prevalent complication (3) , the same one reported by the study carried out in Belo Horizonte -Minas Gerais (9) .
The most prescribed formula was polymeric, in agreement with other researches (18,33) . Prescription should always consider the clinical condition, nutritional status, access route, and expected results of HENT.
No difference was found between the evaluations, which may demonstrate the benefits of HENT in not allowing the elderly to worsen their nutritional status. It is well elucidated that HENT is capable of guaranteeing nutritional needs, assisting in the recovery of nutritional status and providing tissue regeneration.
In spite of the results found in this study, the lack of data in the medical records is an important limitation, which justifies the need for greater awareness among the professionals that attend the elderly in the home, on the need for complete information, mainly aiming at patient safety, besides allowing future researches capable of subsidizing UHS actions.
However, it should be noted that the SES-DF HENTP highlights the importance of HENT and the advances in public policies aimed at the elderly population, as well as being a strategy for the de-hospitalization and humanization of UHS care.

Conclusion
It was identified that the majority of patients in home enteral nutrition therapy presented maintenance and / or improvement of clinical and nutritional status.