12/30/2015. Objectives. Feeding Tubes in Older Adults with Dementia and Delirium. Outline. Background: Swallowing and Aging.

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1 Objectives Feeding Tubes in Older Adults with and Delirium Elizabeth Chapman, MD Colleen Foley MS, RN, ACNS-BC, APNP Recognize relationship between dementia, dysphagia and delirium Describe the data related to feeding tubes in older adults with advanced dementia Discuss alternatives to feeding tubes in advanced dementia with poor oral intake or dysphagia Review legal implications of feeding tubes when guardianship is in place Outline Background: Swallowing and Aging Background Swallowing and Aging Delirium Choosing Wisely Guidelines from the American Geriatrics Society Evidence Behind G-Tubes in Older Adults with Dobhoff Tubes and Older Adults Alternatives to Feeding Tubes Guardianship/ Capacity and Percutaneous Feeding Tubes Pathway to change from respiratory to digestive and back to respiratory Swallow response Reaction time in submental muscles Lingual strength Impairment in efficacy and safety of swallow * with sarcopenia of head and neck muscles frailty Become impaired * Rofes, L., Arreola, V., Almirall, J., Cabré, M., Campins, L., García-Peris, P., Clavé, P. (2011). Diagnosis and Management of Oropharyngeal Dysphagia and Its Nutritional and Respiratory Complications in the Elderly. Gastroenterology Research and Practice, Background: Definitions (AKA Major Neurocognitive Disorder): A decline in cognitive abilities from baseline with deficits in memory or executive function or with development of aphasia, apraxia, or agnosia that interferes with independence and is not better explained by delirium or another mental disorder. Often a chronic and slowly progressing disease Adapted from: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC. 1

2 Alzheimer s Vascular No Prevention Disease 60-80% or 10% Creutzfeldlt-Jakob Disease Parkinson s Disease Cure Huntington s Disease with Lewy Bodies Frontotemporal Background: Stages Functional Assessment Staging 1: Normal adult 2: Normal older adult 3: Early dementia 4: Mild dementia 5: Moderate dementia 6: Moderately severe dementia 7: Severe dementia Advanced Reisberg, B. Functional Assessment Staging (FAST). Psychopharmacology Bulletin. 1988:24: Background: Advanced Moderately Severe : Background: Advanced Severe : Background: Advanced Eating problems and weight loss in advanced stages are an expected part of the natural progression of the disease Background: The Drive to Maintain Weight at SNFs CMS requires monthly weights on nursing home residents Facilities that do not address unintended weight loss can receive citations 2

3 Background: Delirium Acute change from a patients baseline mental status Waxes and wanes Inattention Disorganized thinking Altered consciousness Three forms: Hypoactive Hyperactive/Agitated Mixed Background: Delirium Fluctuating Mental Status: Ability to swallow or participate in evaluation may vary from day to day or minute to minute Background: Delirium Features Inattention: Trouble focusing on eating, swallowing Difficulty following instructions Background: Delirium Features Disorganized Thinking: Disoriented to situation or place Miss cues to eat, swallow Marcantonio ER, Ngo LH, O Connor M, Jones RN, Crane PK, Metzger ED, Inouye SK. 3D-CAM: Derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium. Ann Intern Med. 2014; 161: Background: Delirium Features Background: Delirium Risk Factors you can t fix them all! Altered Consciousness: Too lethargic to participate Too paranoid to eat Marcantonio ER, Ngo LH, O Connor M, Jones RN, Crane PK, Metzger ED, Inouye SK. 3D-CAM: Derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium. Ann Intern Med. 2014; 161: Non-Modifiable or Cognitive Impairment Advanced Age (>65) History of delirium, stroke, neurological disease, falls/ gait disorder Multiple comorbidities Male Chronic Renal or Hepatic Disease Primary neurologic disease Modifiable Sensory Impairment Immobilization Tethers Electrolyte Imbalance Environment Pain Poor Sleep Dehydration Poor Nutrition Surgery Certain Medications (i.e. benzodiazipines) 3

4 Background: Delirium over time Background: Delirium Cognitive Function Insult Increases Dysphagia Risk Increases Delirium Risk Perfect Storm of Risk Factors Delirium Increases Dysphagia Risk Time 6 months Many Hospitalized Advanced Patients with Dysphagia Background: Delirium/Swallowing Conundrum #1 Background: Delirium/Swallowing Conundrum #2 Delirium Clear Delirium Not Clear When to perform swallow study??? Risk of Aspiration Choosing Wisely Choosing Wisely: AGS List Aims to promote conversations between providers and patients by helping patients choose care that is: Supported by evidence Not duplicative of tests or procedures already received Free from harm Truly necessary Adapted from: 4

5 The data are limited: Most studies examine those with advanced dementia Most studies are retrospective or observational : Incidence 323 nursing home residents with advanced dementia in Boston area 85.8% developed eating problems 54.8% died 41.1% developed pneumonia 18 months 8.0% were tube fed 7.2% of these were tube-fed Mitchell S, Teno JM, Kiely DK, Shaffer ML, Jones RN, Prigerson HG, Volicer L, Givens JL, Hamel MB. The clinical course of advanced dementia. N Engl J Med 2009; 361: : State by State Prevalence >7-fold difference : Change Over Time Purpose: Investigate trends in PEG tube placement in older adults Design: Retrospective review of Nationwide Inpatient Sample data set Results: Although the benefits of these tubes are not clear at best and not present at worst, more and more were being placed. 38% increase in all comers from % increase in those with Alzheimer s Disease from Mitchell SL, Teno JM, Roy J, Kabumoto G, Mor V. Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment. JAMA 2003: 290(1): Mendiratta P et al. Trends in percutaneous endoscopic gastrostomy placement in the elderly from 1993 to 2003 Am J Alzheimers Dis Other Demen December ; 27(8): Why is a feeding tube even considered in advanced dementia? Guilt Do everything approach Quantity of life valued over quality Perception that it will improve problems (poor appetite, weight loss, dehydration) End points in studies for G-Tubes in this population focus on: Mortality Medicare costs Hospital and ER usage Aspiration risk Pressure ulcer risk 5

6 Purpose: Evaluate enteral tube feeding for older people with advanced dementia Design: Systematic Review Results: No benefit in most studies, in some mortality was higher Quality of life: (not specifically measured) Nonsignificant increase in restraint use Nutritional parameters: no increase in albumin Pressure ulcers: variable results; no clear benefit Aspiration: higher risk with enteral feeding tubes Purpose: Review literature for gastrostomy tubes in advanced dementia Design: Systematic review Results: Mortality: No clear benefit across 10 studies Those with dementia or >80 years old may have increased mortality Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia (Review). Cochrane Database of Systematic Reviews 2009, Issue 2. Goldberg LS, Altman KW. The role of gastrostomy tube placement in advanced dementia with dysphagia: a critical review. Clinical interventions in aging 2014; 9: Purpose: Estimate Medicare inpatient care costs in year after G-tube placement Design: Retrospective cohort; Medicare claims data of nearly 4000 patients with/without tubes analyzed Results: Increase in inpatient costs Increase in hospital days and ICU days G-tubes in Older Adults with Purpose: Evaluate outcomes of those with advanced dementia who are/aren t tube fed Design: Prospective observational cohort study 67 patients, >60 years old; 57 classified as a FAST 7c; 36 oral feeding and 31 for alternative feeding (n = 28 nasogastric tube, 3 gastrostomies). Results: 3- month mortality rate: 11.1% for oral feeding group vs 41.9% for alternative feeding group (p = 0.004) 6-month mortality rate: 27.8% with oral feeding and 58.1% with alternative feeding, (p = 0.012) Aspiration pneumonia rate: higher in alternative feeding group (p = 0.006) No difference in the number of hospital admissions Hwang D et al. Feeding tubes and health costs post insertion in nursing home residents with advanced dementia. Journal of Pain and Symptom Management 2014; 47: Cintra MT, de Rezende NA, de Moraes EN, Cunha LC, da Gama Torres HO. A comparison of survival, pneumonia, and hospitalization in patients with advanced dementia and dysphagia receiving either oral or enteral nutrition. J Nutr Health Aging Dec;18(10): In general, the data does not show benefit to G-Tubes in this population Essentially no data on those with less severe dementia Heterogeneity among studies No randomized trials Dobhoff tubes and older adults Data similar G-Tubes Mortality: No benefit, may be higher Other considerations Discharge disposition SNFs often do not accept Dobhoff tubes LTACHs may be only option Possibility for erosions of nasopharynx Smaller diameter can clog more easily Patient discomfort More restraint use in hospital? 6

7 Alternatives to Feeding Tubes Very little data regarding efficacy of alternatives! Alternatives to Feeding Tubes Proposed alternatives: Environmental modifications High-calorie supplements Careful hand-feeding Appetite stimulants Alternatives: Environmental Changes Alternatives: Environmental Changes Make meals a social event Quiet or pleasant music Less clutter More visually attractive food loss of sense of semll reduced ability to taste Images from: Alternatives: Environmental Changes Alternatives: Environmental Changes Good meal hygiene Up in a chair Lights on Food uncovered, accessible, correct temperature Food preferences considered Image from: 7

8 Alternatives: Appetite Stimulants Alternatives: Appetite Stimulants Most studies are not done with older adults FDA-approved for HIV, cancer cachexia Off-label use for dementia patients Little consensus on use in older adults Purpose: Analyze effect of megestrol acetate on intake in nursing home residents Design: Prospective observational study 17 NH residents; megestrol acetate x 63 days Each received usual NH care weeks 1, 3, 5 and optimal feeding assistance weeks 2, 4, 6 Results: No increased intake with Megestrol acetate during usual NH care Intake did improve with optimal feeding assistance and megestrol No study of optimal feeding assistance alone Simmons, S. F., Walker, K. A., & Osterweil, D. (2004). The Effect of Megestrol Acetate on Oral Food and Fluid Intake in Nursing Home Residents: A Pilot Study. Journal of the American Medical Directors Association, 5(1), Alternatives to Feeding Tubes Final point: Difficult to measure pleasure and comfort that oral feeding brings Guardian versus power of attorney: Person unable to make decisions Has HC POA document No HC POA Activate POA Needs guardian Patient refuses certain interventions How does a person get an activated POA for health care? Two physicians/psychologists assess patient s capacity to make medical decisions If incapacitated, providers sign document and surrogate becomes decision-maker Decisions made based on what person would have wanted if he/she could speak for himself/herself : Wisconsin HC- POA Document Person may decide whether or not to give the authority to remove feeding tubes to designated POA agent. 8

9 How does a person get a guardian? Paperwork (lots of it!) Lawyers Money (usually thousands of dollars) Judge decides whether a person has competency to make decisions If not, then a guardian is appointed Guardian may be family, friend, or stranger Decisions made in best interest of patient (Preservation of life is in best interest.) Permanent feeding tubes placed in those with a guardian can only be removed in certain circumstances No longer indicated medically Persistent vegetative state End-of-life Prior to incapacitation, patient had documented preference not to have a feeding tube Here comes trouble Many patients who need guardians have never completed a living will or health care power of attorney Those who have completed the documents often have not discussed wishes with their surrogates A sizeable number of guardians do not know the patient prior to becoming the guardian Decision needs to be made carefully! Even though there is no clear benefit to tube feeds in those with advanced dementia, the tubes often cannot be removed once placed. Case #1 Bob D 92 y/o man with a h/o dementia (moderate) Admitted with a fall but no fractures Delirious on admission and thereafter with little improvement Severely impaired swallowing abilities found Dobhoff tube placed Frequently restrained due to pulling tubes/lines Never improved swallowing abilities Discharged with Dobhoff tube in place to LTACH Case #2 Betty P 68 y/o woman Admitted after a car rolled over her Did not have dementia at baseline and intact functionally at baseline Very delirious during hospital stay (>30 days) G-Tube placed Guardianship proceedings were initiated; sister did not want to be her decision-maker Unclear if her cognition will recover 9

10 Case #3 John L 88 y/o man with a h/o advanced dementia Admitted after wandering outside and getting hit by a car Sustained some fractures and a hip hematoma Discharged to a SNF and returned with pneumonia Dysphagia found, Dobhoff tube placed Became more delirious After multiple family discussions, discharged to home with hospice without a Dobhoff tube or G- Tube Case #4 Jane P 74 y/o woman with intact cognition at baseline, caregiver for husband with dementia Sustains brain hemorrhage and develops unilateral weakness, lethargy Initial swallowing evaluation notes only mild dysphagia Confusion worsens as day goes by Aspirates and gets intubated Dobhoff tube placed for temporary nutrition Is G-Tube the right next step? Take Home Points #1- Does the patient hold a diagnosis of dementia? #2- Is dementia is a suspected* diagnosis? (*This is something that may not be documented anywhere!) #3- Is or will delirium will be a player? #4- Trust your gut!, dysphagia, and delirium commonly occur together in the hospital Nutrition options in this context are complicated from a legal, ethical, and practical perspective Feeding tubes have not been shown to improve outcomes in those with advanced dementia Make a POA for health care and share your preferences with your agents! References Cintra MT, de Rezende NA, de Moraes EN, Cunha LC, da Gama Torres HO. A comparison of survival, pneumonia, and hospitalization in patients with advanced dementia and dysphagia receiving either oral or enteral nutrition. J Nutr Health Aging Dec;18(10): Tamara G. Fong, Samir R. Tulebaev, and Sharon K. Inouye. (2009). Delirium in elderly adults: diagnosis, prevention and treatment. NIH. Nat Rev Neurol April ; 5(4): Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia (Review). Cochrane Database of Systematic Reviews 2009, Issue 2. Goldberg LS, Altman KW. The role of gastrostomy tube placement in advanced dementia with dysphagia: a critical review. Clinical interventions in aging 2014; 9: Hwang D et al. Feeding tubes and health costs postinsertion in nursing home residents with advanced dementia. Journal of Pain and Symptom Management 2014; 47: Mendiratta P et al. Trends in percutaneous endoscopic gastrostomy placement in the elderly from 1993 to 2003 Am J Alzheimers Dis Other Demen December ; 27(8): Rofes, L., Arreola, V., Almirall, J., Cabré, M., Campins, L., García-Peris, P., Clavé, P. (2011). Diagnosis and Management of Oropharyngeal Dysphagia and Its Nutritional and Respiratory Complications in the Elderly. Gastroenterology Research and Practice, Simmons, S. F., Walker, K. A., & Osterweil, D. (2004). The Effect of Megestrol Acetate on Oral Food and Fluid Intake in Nursing Home Residents: A Pilot Study. Journal of the American Medical Directors Association, 5(1),