Avoiding Percutaneous Feeding Tubes in Elderly Patients With Advanced Dementia

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1 Avoiding Percutaneous Feeding Tubes in Elderly Patients With Advanced Dementia an evidence based presentation Anthony M Rainho, MS4

2 Outline Current Guidelines Nutrition Aspiration Comfort Death Adverse effects Summary

3 Current Guidelines Most people with dementia eventually develop problems with feeding. 1 Over 1/3 of nursing home patients with advanced dementia have feeding tubes placed despite the growing evidence that they do not improve outcomes. 2 AGS (American Geriatrics Society) recommends against percutaneous feeding tubes (PEG) in patients with advanced dementia as they offer limited benefit and can cause more harm than good. Instead, oral assisted feeding is recommended. Survival of patients with and without advanced dementia who were fed orally was not statistically significant. 1,3

4 Nutrition Increased nutrients via percutaneous feeding in patients with neurologic impairment showed no meaningful difference in clinical outcomes compared to orally-fed patients. However, it is uncertain if tube feeds improve clinical outcomes in patients with dementia. 3 Several randomized studies showed moderate-strength evidence for the use of high-calorie supplementation and oral feeding options but showed that evidence was weak for tube-assisted feeding to promote weight gain in patients with dementia. There was no difference in function or mortality. 1

5 Aspiration Tube feeds have not been found to prevent aspiration of oral secretions or regurgitated gastric contents. Some studies of children and animal models show that PEG tubes reduce lower esophageal sphincter (LES) tone and can lead to an increase of gastric reflux. 3 Several case-control studies showed tube feeds were associated with higher rates of aspiration pneumonia and death. 3,4

6 Comfort Family members of patients with dementia who had died with feeding tubes were less likely to report excellent care at the end of life (OR = 0.42, 95% CI ). 4 Comfort feeding via assisted oral feeds is an alternative to tube feeding that has similar mortality outcomes without the adverse effects of feeding tubes. However, more research should be done since most data is observational. 3 Research has not shown PEG tubes to prevent weight loss, malnutrition, or pressure ulcers. 2,5 Patients with dementia who have PEG tubes placed were occasionally found to be deprived of eating. 5

7 Death Between nursing home residents with advanced dementia who had a PEG placed and those who did not, there was no difference in survival. 1,2,6 Another nonrandomized, retrospective study looking at patients with severe cognitive decline showed similar results, with no survival advantage associated with tube feeds compared to oral feeds. 3

8 Feeding Tube Adverse Effects One large study found that 1/3 of deceased patient with dementia who had a PEG tube had not had a discussion of the risks prior to insertion. 4 Tube-fed patients with dementia are more likely to be restrained and become uncomfortable due to tube placement compared to those without a tube. 3,4,5 Patients with dementia and a PEG tube can have complication rates up to 70%. 5

9 In Summary Based on the current data, feeding tubes do not seem to benefit patients with dementia more than assisted oral feeds. 5 There is no difference in mortality between PEG feeds and oral feeds. 6 PEG tubes are associated with more adverse events such as aspiration pneumonia, restraint use, and tube malfunction compared to orally fed patients. 3,4 PEG tubes are associated with more discomfort than oral feeds and have been associated with decreased satisfaction of end of life care. 4 When faced with a patient suffering from dementia, opt for assisted oral feeding to decrease adverse events and improve patient comfort and treatment satisfaction.

10 References 1. Hanson LC, Ersek M, Gilliam R, Carey TS. Oral feeding options for people with dementia: a systematic review. J Am Geriatr Soc. 2011;59(3): Sorrell JM. Use of feeding tubes in patients with advanced dementia: are we doing harm? J Psychosoc Nurs Ment Health Serv May;48(5): Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: A review of the evidence. JAMA. 1999;282(14): Teno JM, Mitchell SL, Kuo SK, Gozalo PL, Rhodes RL, Lima JC, Mor V. Decisionmaking and outcomes of feeding tube insertion: A ve-state study. J Am Geriatr Soc.[Internet] May;59(5): Palecek EJ, Teno JM, Casarett DJ, Hanson LC, Rhodes RL, Mitchell SL. Comfort feeding only: A proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia. Journal of the American Geriatrics Society. 2010;58(3): Teno JM, Gozalo PL, Mitchell SL, Kuo S, Rhodes RL, Bynum JP, Mor V. Does feeding tube insertion and its timing improve survival? J Am Geriatr Soc Oct;60(10):