PEG Tube use in the Elderly

Transcription

1 PEG Tube use in the Elderly Jeffrey Wallace MD, MPH Professor and Director of Clinical Geriatrics University of Colorado Denver October 5, 2009 A Common Dilemma 88 yo F w/alzheimers, CAD, HTN, OP, DVT 6/09 - In ALF had mechanical fell C1 fx neck brace Exam/hx: wt 53kg, Ox1, NAD, intake, NPO + ST eval S.T.: diff swallow/asp risk post-pyloric TF w/bridle Geri consult: family uncertain re:tfs,? PEG,? other? A) Recommend dobhoff/ng TFs B) Recommend PEG TFs C) Assisted feeding w/thickened liquids D) Assisted feeding w/asp precautions (eg chin tuck) PEG Tubes in the Elderly Focus on Patients with Dementia Not s/p acute CVA or head & neck CA Progressive dementia often assoc w/ intake NG TFs generally not an option poorly tolerated, often pulled not accepted in NHs Marker of end-of-life vs time to act? PEG prevalence in NH dementia pts 34% (!) JAMA 2003;290:73

2 PEG Tubes in the Elderly Incidence Data in Dementia Pts Incidence new PEGs in NH pts w/advanced dementia % 2-5% 0.2-1% PEG Tubes in the Elderly Who, Where & Why Are They Placed? Who, Where: National Medicare data NH pts w/advanced dementia: 5% incidence Average age 84yo Most were highly dependent in ADLs 68% PEGs inserted in acute care hospital PEG Tubes in Elderly with Dementia Who, Where & Why Are They Placed? Why: D/C Dx s assoc w/peg in hospital Aspiration PNA 17% Dehydration 10% Dysphagia 7% UTI 6% Malnutrition 6% PNA 5% CVA 5%

3 PEG Tubes in Elderly with Dementia Who, Where & Why Are They Placed? Why: Goals of PEG tubes in older pts To decrease aspiration, PNA To improve nutrition and hydration To improve wound healing To infection/improve function To improve quality of life To decrease mortality, prolong life Do they fulfill their promise? J Palliative Medicine 2008;11:1130 Utility of PEG Tubes in the Elderly Aspiration PNA issue - did you know? 30% of population has no gag reflex most harmful thing aspirated is saliva 50% of healthy adults aspirate oral secretions during sleep aspiration on bedside eval or MBSS is not a good predictor of asp PNA (13-38% specific) dysphagia alone is not good predictor asp PNA J Am Med Dir Assoc 2008;9:455 J Am Geriatr Soc 2003;51:1018 Utility of PEG Tubes in Elderly w/dementia To decrease aspiration & PNA No data that TFs aspiration Saliva and/or reflux gastric contents often source of asp PNA Oral hygiene, avoid PPI/H2-block may risk 3 case-control studies TFs risk asp PNA J Am Med Dir Assoc 2008;9:455 J Am Geriatr Soc 2003;51:1018

4 Utility of PEG Tubes in Elderly w/dementia To improve nutritional status little to no wt or albumin nutrient deficiencies/marasmic like state often persists nutrition or reversal of wt loss not associated with better clinical outcomes JAMA 1999;282:1365 Utility of PEG Tubes in Elderly w/dementia Improve wound issues, infxn, funx Association between nutrition & pressure ulcers is weak 6 mo f/u TF pts: no impact on pressure sores No impact on infxn rates, may (eg cellulitis) Funx not examined as an outcome JAMA 1999;282:1365 Utility of PEG Tubes in Elderly w/dementia To improve quality of life Palliative care data few pts w/anorexia experience hunger or thirst Elderly have impaired thirst mechanism TFs may QL Diarrhea, nausea, local discomfort, restraints Deprive pt of hedonic qualities of eating isolation, human interaction JAMA 1999;282:1365

5 Utility of PEG Tubes in the Elderly To improve mortality 30d mortality 18-24% 1 yr mortality 64%, median survival 56 days Survival rates younger pts, ALS, trauma λ Conclude: intake in advanced dementia is a symptom of terminal CNS process, not a primary dx to treat Arch Intern Med 1997:157:327, J Palliative Medicine 2008;11:1130 JAMA 1999;282:1365 PEG Tube Complications Potential for Harm Major Aspiration rates may Wound infection, bleeding Peritonitis, colonic fistula Inadvertent removal of PEG (20% 1 study) Minor Tube leakage, tube blockage Diarrhea Drug interactions Other: quality of life NEJM 2000;342:206 J GI Liver Dis 2007;16:407 Tube Feeding: Incentives, Ethics, Emotions Incentives Inpt time constraints to explain PEG issues NH time constraints on assisted feeding Financial reimbursement for PEG, PEG care MD view TF as standard of care SP views: TF rates in NH w/st on staff J Palliative Medicine 2008;11:1130

6 Tube Feeding: Incentives, Ethics, Emotions Ethics/Emotions Need to do all that can be done Avoid starving a loved one NHs concerns: wt, quality indic, surveyors Religious and legal considerations J Palliative Medicine 2008;11:1130 Medscape J Med 2008;10:142 Back to our pt 88 yo F w/alzheimers, CAD, HTN, OP, DVT 6/09 - s/p fall C1 fx neck brace NPO and rec TFs Risks-benefits discussed with family Family decided TF not c/w pt preferences Pt to SNF ST eval: variable swallow, cough, intake Barium swallow study to fully inform decisions Did well on MBSS, better intake with clear liqs Diet advanced, slowly improved, returned to ALF PEG tubes in Elderly with Dementia: Conclusions & Recommendations Look for reversible etiologies of feeding problems depression, meds, food preferences assistance, other efforts to optimize intake/nutrition Educate providers & families feeding problems characteristic of late dementia unlikely utility of PEG to alter course Consider geriatric or palliative care consult J Am Med Dir Assoc 2001;2:259