An estimated 2 million people in the United States suffer

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2007;5:1372 1378 REVIEW Feeding Alternatives in Patients With Dementia: Examining the Evidence DONALD GARROW,*, PAM PRIDE,* WILLIAM MORAN,* JANE ZAPKA, ELAINE AMELLA, and MARK DELEGGE *Department of Medicine, Division of General Internal Medicine, Division of Gastroenterology and Hepatology, Digestive Disease Center, Department of Biostatistics, Bioinformatics and Epidemiology, and College of Nursing Medical University of South Carolina, Charleston, South Carolina Percutaneous endoscopic gastrostomy tubes are being placed with increasing frequency in the United States among elderly patients with dementia. Health care providers believe there may be long-term benefits for enteral feeding in this population, yet previous study of this topic has failed to yield any convincing evidence to support this hypothesis. In this study, we review the evidence regarding outcomes for artificial enteral feeding in older individuals with dementia. We found that there is a lack of evidence supporting artificial feeding in the specific outcomes of survival, pressure ulcers, nutrition, and aspiration pneumonia. A brief discussion regarding hand feeding is included. The data suggest that hand feeding may be a viable alternative to tube feeding in elderly patients with dementia, although a direct comparison trial of the 2 interventions is lacking. An estimated 2 million people in the United States suffer from severe dementia (or cognitive impairment), and another 1 to 5 million people experience mild to moderate dementia. 1 Five percent to 8% of people older than the age of 65 have some form of dementia, with a doubling in the incidence of dementia every 5 years over age 65. 1 The prevalence of dementia has increased over the past few decades, either because of greater awareness and more accurate diagnosis, or because increased longevity is creating a larger population of elderly, which is the age group most commonly affected. As dementia progresses, it often leads to difficulty eating, subsequent malnutrition, and other physical complications (pressure ulcers, aspiration). 2 Percutaneous endoscopic gastrostomy (PEG) tubes are being placed with increasing frequency in patients with dementia in the United States. 3 First introduced in 1980 as a means to provide nutrition to children, 4,5 PEG tubes currently often are placed in elderly patients with perceived low oral intake. In 1989, approximately 15,000 PEG tubes were placed; in 1995, 121,000 PEG tubes were implanted, and in the year 2000, more than 216,000 tubes were inserted for feeding. 6,7 Feeding tube placement is a relatively easy procedure. It can be performed typically in less than 30 minutes by a gastroenterologist, surgeon, or radiologist. It allows for reception of liquid food into the stomach via intermittent bolus or continuous infusion to supplant perceived caloric deficiencies. PEG is indicated by the AGA Institute when the patient cannot or will not eat, when the gut is functional, and if the patient may tolerate the procedure. 6 Complications from PEG placement and enteral feeding include diarrhea, inadvertent removal of tubes by demented patients, cellulitis, bleeding or pain at the PEG tube abdominal wall insertion, ileus, gastroesophageal reflux, and frequent clogging of the tube. 8,9 Although these situations may be perceived as minor, they can be cumbersome and worrisome for the patient, family, and caregivers. In addition, many of these complications result in the need for further medical attention, including hospitalization. 10 Hand feeding is an alternative to tube feeding. In studies of other debilitating or terminal conditions such as stroke and cancer, hand feeding small amounts of food to patients with anorexia or dysphagia results in alleviation of perceived hunger and thirst, despite failure to replete complete calorie deficiencies. 11,12 Also, elderly patients often do not feel dehydrated because their thirst mechanism is impaired, likely a natural adaptive compensation. 13 Oral feeding, even in limited amounts, allows for the possibility of the enjoyment received from eating. With placement of an enteral feeding tube, patients often are deprived of this basic life pleasure. Enteral tube feeding is provided to many demented individuals with the intention of preventing or limiting the frequency of oral-tracheal aspiration, pressure ulcer formation, and increasing survival. 2 Although little data suggest that any of these are ameliorated by tube feeding, physician surveys revealed that almost 4 of 5 physicians believe enteral tube feeding decreases the frequency of these outcomes. 14 This article reviews the current evidence concerning feeding tube insertion and outcomes in the dementia patient population via a systematic analysis. Our analysis includes consideration of study design, population, and settings and investigates the evidence concerning 4 major outcomes often associated with an impaired functional status in the elderly and dementia patient: (1) survival, (2) oral-tracheal aspiration, (3) pressure ulcer formation, and (4) nutrition. Methods Search Strategy We searched MEDLINE via PubMed and the Nursing and Allied Health Literature from January 1966 through March 2007 using variations in several search terms. We combined the Medical Subject Heading term dementia individually with the Abbreviations used in this paper: PEG, Percutaneous endoscopic gastronomy. 2007 by the AGA Institute 1542-3565/07/$32.00 doi:10.1016/j.cgh.2007.09.014

December 2007 FEEDING ALTERNATIVES IN DEMENTIA PATIENTS 1373 terms feeding, PEG, gastrostomy, enteral nutrition, malnutrition, aspiration, decubitus, and complications. We reviewed all citations in each article. We manually reviewed published abstracts and those from national gastroenterologic meetings. Inclusion and Exclusion Criteria We included studies that analyzed a cohort of elderly subjects with dementia and their associated outcomes after enteral feeding tube placement. Each study was required to include either one or more of the following outcomes in their analysis: oral-tracheal aspiration, pressure ulcers, nutrition/ weight, or survival. We excluded descriptive reviews, economic evaluations, editorials, letters, and case reports or case series. If an investigator had more than one study that appeared relevant to the review, we assessed whether the data overlapped by either reviewing the recruitment period or contacting the author. Definition of Dementia Dementia was defined in different manners in each included study. Some studies relied on chart diagnosis only and others used standardized dementia scales. Table 1 shows the definition of dementia for each study. Quality Assessment Two authors (D.G., P.P.) performed independent searches of PubMed and the Nursing and Allied Health Literature as described earlier. Each of these authors then reviewed the eligibility for review given the inclusion criteria. A third author (M.D.) arbitrated discrepancies. All authors reviewed the contents of Table 1 for accuracy. Data Stratification We created a data table for each study within a Microsoft Excel (Microsoft Corp, Redmond, VA) spreadsheet. Within the spreadsheet we identified the study investigator, publication year, study period, setting, study design, statistical analyses used, subject description, sample size, and study findings. Results Our MEDLINE search via PubMed yielded 397 abstracts and more than 30 complete articles that appeared to fulfill the inclusion criteria outlined previously. After careful manual review, we determined that 10 articles and no abstracts qualified for our analysis (Table 1). 7,15 23 All included studies reported PEG tubes as the choice of enteral feeding, except for the study by Peck et al, 18 and Alvarez- Fernandez 19 in which a flexible nasogastric tube was used. Design and Participant Description After careful review of the 10 included studies, 3 different types of patient cohorts emerged. There were 4 studies that evaluated survival in a dementia subgroup among a cohort of PEG patients. 7,15 17 Five studies determined survival based on comparison of PEG vs non-peg patients among a cohort of dementia patients. 19 23 One study looked at outcomes not including survival in PEG compared with non-peg patients among a cohort of nursing home patients, many of whom had dementia. 18 Of the 10 studies, only 1 was randomized. 21 However, the randomization was not PEG vs non-peg, but standard medical care vs palliative care in a dementia population. Survival Among the 5 dementia cohort studies in which subjects were compared with or without PEG tubes, there was no significant difference noted in survival for 3 studies, 20,21,23 and in the other 2 studies feeding tubes were associated with greater mortality than the non tube-fed patients. 19,22 In the 4 PEG-patient cohort studies, dementia subjects were either associated with increased mortality 15,17 or approximately 50% mortality at 1 year. 7,16 Aspiration One study looked at oral-tracheal aspiration in a group of nursing home patients. Peck et al 18 found rates of aspiration pneumonia to be 3 times higher in the tube-fed dementia patients when compared with a convenience sample of non tube-fed dementia nursing home patients over a 6-month time period. Pressure Ulcers The data for pressure ulcers in the tube-fed dementia population are limited to one comparative study set in a nursing home. Peck et al 18 looked at the rates of pressure ulcers among tube-fed dementia patients and found no significant difference in rates of pressure ulcer formation when compared with the non tube-fed patients. Nutrition/Weight Gain Serum albumin level is used commonly as a marker of overall nutrition and as justification for feeding-tube placement. Nair et al 22 noted in their analysis that a very low serum albumin level ( 2.8 g/dl) before placement of a feeding tube significantly predicted poor survival at 6 months after hospital discharge. Kaw et al 16 found that there was no significant improvement in serum albumin or overall functional status after feeding tube insertion in a demented nursing-home population. In the same study, Kaw et al 16 also noted that individuals with serum albumin levels of 3.5 g/dl or greater had significantly improved survival when compared with individuals with serum albumin levels less than 3.5 g/dl. Alvarez- Fernandez et al 19 also found that serum albumin levels less than 3.5 g/dl predicted increased mortality in hospitalized patients in Spain. Peck et al 18 found significant weight gain in their tube-fed nursing home patients compared with their convenience sample of hand-fed patients. Discussion Our review illustrates major design issues in studies purporting to investigate clinical outcomes of PEG feeding in dementia patients. However, even in view of these study design limitations, our review suggests that tube feeding does not prolong life in demented individuals, 20,21,23 and may in fact shorten the life of these subjects. 15,19,22 The review also suggests tube feeding does not reduce rates of aspiration pneumonia or pressure ulcers among individuals with dementia. 18 Tube feeding also does not improve serum albumin measures, 16 and low serum albumin level predicts worse survival prognosis. 22

1374 GARROW ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 5, No. 12 Table 1. Summary of Literature Review for Feeding Tubes in the Elderly Dementia Population Study Sanders et al, 2000 Study period August 1992 July 1997 2 general hospitals in England Design and analyses Retrospective; PEG-tube cohort Dementia compared with 3 other diagnoses Subjects and sample size 361 consecutive subjects with PEG insertions 103 in diagnostic subgroup of dementia Dementia defined as exclusion of metabolic, nutritional, and Parkinson s as cause Dementia subjects had worse survival than other groups 54% mortality at 1 month, 90% mortality at 1 year Study Kaw et al, 1994 Study period August 1998 November 1990 Academic hospital in Pittsburgh, PA Design and analyses Retrospective; PEG-tube cohort Subjects and sample size 46 total subjects received PEG tube 24 subjects with dementia (52%) Dementia defined as diagnosis in chart of dementia ; not attributable to Parkinson s Mortality of subjects 50% at 12 months and 60% at 18 months No significant improvement in nutritional status Initial serum albumin level 3.5 g/dl associated with improved survival PEG-related complications occurred in 34.7% of subjects Study Grant et al, 1998 Study period January 1991 December 1991 Hospitalized Medicare beneficiaries with PEG placed in 1991 Design and analyses Retrospective; PEG-tube cohort Subjects and sample size 81,105 total hospitalized Medicare beneficiaries discharged with PEG 8688 (10.7%) with dementia Dementia defined as ICD-9 diagnosis of dementia in chart Female dementia subgroup with mortality 13% at 1 month, 50% at 1 year, and 78% at 3 years Male dementia subgroup with mortality 18% at 1 month, 61% at 1 year, and 84% at 3 years Study Rimon et al, 2005 Study period January 1992 December 2002 Gastroenterology unit of a community hospital Design and analyses Prospective; PEG-tube cohort Subjects and sample size 674 consecutive subjects age 50 referred for PEG insertion 280 (41.5%) with feeding difficulty typically owing to dementia Dementia defined as stage 6 or 7 of Global Deterioration Scale Survival significantly worse in diabetics, inpatient referrals, and subjects with dementia over age 80 Best survival was seen in individuals with dementia younger than age 80 and women younger than age 80 referred from nursing homes Study Peck et al, 1990 Study period May 1989 June 1989 Nursing home in New York city Design and analyses Prospective; nursing home cohort Tube-fed vs non tube-fed patients for 6 months Feeding tube is a permanent nasogastric tube (NGT) Subjects and sample size 104 total subjects (52 tube-fed and 52 random controls) Dementia present in 100% of tube-fed, 71% of controls Dementia defined as Mini-Mental Status Examination score 20 Tube-fed subjects had significant increase in aspiration pneumonia (58% vs 17%; P.01) and weight gain (48% vs 17%; P.01) No significant difference noted in decubitus ulcers or use of restraints Study Alvarez-Fernandez et al, 2005 Study period February 1999 June 1999 Tertiary hospital in Magala, Spain Design and analyses Prospective; dementia cohort Feeding tube is permanent nasogastric tube (NGT) Subjects and sample size 67 subjects with advanced dementia 62 female subjects (92.5%); 14 subjects with NGT (20.9%) Dementia defined as score 7 on Functional Assessment Staging (FAST) Significant predictors of mortality were serum albumin 3.5 g/dl (P.028), permanent NGT (P.003), and pneumonia within previous year (P.001)

December 2007 FEEDING ALTERNATIVES IN DEMENTIA PATIENTS 1375 Table 1. Continued Study Murphy et al, 2003 Study period 2-year analysis, dates not reported Veterans Association Medical Center in Washington, DC Design and analyses Retrospective; dementia cohort Tube-fed vs non tube-fed patients who refused PEG Subjects and sample size 41 consecutive subjects with dementia enrolled, 23 accepted PEG, 18 declined (controls) Dementia defined as diagnosis in chart of dementia Median survival 59 days in PEG group, 60 days in non-peg group 1 major complication (fatal sepsis from abdominal abscess) in PEG group (4.3%) Study Meier et al, 2001 Study period August 1994 June 1997 Academic hospital in New York city Design and analyses Randomized and prospective; dementia cohort Randomization was for continued medical care vs palliative care consult Subjects and sample size 99 eligible subjects with advanced dementia and surrogate caregiver available 17 (17.2%) had PEG on admission, 51 (51.5%) had PEG placed during hospitalization Dementia defined as score 6d on FAST Median mortality in both PEG and non-peg group 50% at 6 months Predictors of new feeding-tube placement African American race (HR, 4.9; Cl, 1.02 2.50) and nursing home residence (HR, 9.43; CI, 2.10 43.20) Study Nair et al, 2000 Study period July 1997 April 1998 Academic hospital in New York city Design and analyses Prospective; dementia cohort Tube-fed vs non tube-fed patients Subjects and sample size 55 consecutive subjects with dementia and inadequate oral intake 36 comparison subjects in age, sex, and comorbid Illnesses Dementia defined as secondary to Alzheimer s, multi-infarct, or degenerative disease Mortality 44% among PEG subjects vs 26% among controls at 6 months (P.03) Serum albumin 2.8 g/dl predicted poorer survival in PEG subjects Study Mitchell et al, 1997 Study period January 1991 December 1992 Nursing homes in Washington state (via Minimum Data Set) Design and analyses Retrospective; dementia cohort Tube-fed vs non tube-fed patients Subjects and sample size 1386 subjects age 65 and recent progression to severe dementia 135 subjects (9.7%) underwent placement of a feeding tube Dementia defined as progression to a score of 6 on the Cognitive Performance Scale No difference in survival between tube-fed and control groups (P.66) Nutrition in the dementia population was not found to be improved by tube feeding. These patients often have low serum albumin levels before feeding tube insertion owing to chronic illness and poor oral intake. 24 This poor result after feeding tube insertion appears to extend beyond the subset of dementia to most elderly residents of nursing homes. Henderson et al 25 noted that tube-fed patients in long-term care still have persistent loss of weight and lean muscle mass despite generous amounts of enteral formula. Another study by Ciocon et al 26 noted no improvement in albumin level or other serum markers after feeding tubes were placed in elderly nursing-home patients. It may be that the physiologic consequences of long-term illnesses in the elderly nursing-home population pre-empt any positive effects feeding may have. 25 Weight did increase significantly in one PEG-fed group. 18 Because the feeding tubes were placed for nutrition, we are led to the question of how useful a marker of prognosis weight gain is in the demented population. Our results for pressure ulcers are limited by the lack of data in the dementia population. The study by Peck et al 18 is the only source for our review and it was limited by a small sample size and single institution. Other studies looking at feeding and pressure ulcers in nursing homes revealed mixed results. Decreased oral intake has been associated with increased frequency of pressure ulcers. 27,28 However, these studies did not assess whether tube feeding helped prevent or limit the occurrence of pressure ulcers. Two reviews by Finucane et al 2,24 suggest there are no clear data to support the routine use of tube feeding to decrease frequency or hasten healing of pressure ulcers. The risk or occurrence of aspiration pneumonia is one of the most frequently used reasons by physicians to place a feeding tube in dementia patients. 29 The study by Peck et al 18 suggested that aspiration pneumonia frequency was increased after tube placement in the dementia population. Other published data did not suggest that tube feeds decrease the event rate of aspiration pneumonia in any population. 30,31 The site of feeding tube placement does not appear to impact aspiration frequency. A meta-analysis comparing gastrostomy with jejunostomy tubes found no significant difference in aspiration pneumonia frequency. 32 The aspiration pneumonia risk after feeding tubes are placed is likely caused by persistent or wors-

1376 GARROW ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 5, No. 12 ened gastroesophageal reflux followed by aspiration of secretions. 33 Survival is the most commonly cited reason for feeding tube placement in the nursing home setting. 23 More than 4 of 5 caregivers cite prolongation of life as the main reason for the feeding tube placement. 34 In our analysis of feeding tube outcomes in dementia, survival is the most commonly sought outcome. None of the included studies reflected improved survival in the feeding tube cohort, and in 3 studies the feeding tubes were associated with shorter survival. Mitchell and Tetroe 35 noted previously that only 38% of all nursing home patients were alive at 1 year after feeding tube placement. The median survival for the cohort of dementia patients in the nursing home was reported to be 50% at 1 year. 29 Loss of appetite and inability to eat has been described as a normal part of end-stage illness such as dementia and may be refractory to medical interventions such as gastrostomy and enteral feeding. 36 Despite the results of our review and the aforementioned previous studies, PEG tube feeding is used widely in the elderly dementia population. 2 The AGA Institute recommends PEG feeding for patients who are unable to receive an adequate amount of oral nutrition. 6 Almost 30% of PEG tubes in the United States are placed in dementia individuals; nearly 10% of all patients in skilled nursing facilities receive enteral tube feedings. 6,29 The reason for many of these tube feedings likely stems from a feeling among family members that they cannot let the demented patient starve to death. They may believe there is no other option other than placing an enteral tube for feeding. 37 Family also may hold too optimistic a view regarding the clinical course of their demented family member. 38,39 Physicians often suggest that the feeding tube may be removed if patients regain the ability to eat normally, 40 but removal for all feeding-tube indications hovers around 20%, 40,41 and probably is significantly less in dementia patients. Not only do almost 80% of physicians believe that clinical outcomes are improved by tube feeding, 14 but approximately 40% of physicians believe that tube feedings and hydration should continue even if other life-sustaining measures such as mechanical ventilation and dialysis are stopped. 42 Also, physicians report considerable distress when recommending feeding tubes, including perceived pressures from families or other health care professionals. 37 In one physician survey, almost half of respondents reported that a nursing home had requested a feeding tube placement and the provider acquiesced. 14 Reimbursement may be a major factor influencing feeding decisions, particularly when nursing-home care is needed. Payments to skilled nursing facilities are potentially higher under state Medicaid programs owing to the presumed higher level of care for artificially fed dementia patients. 43 Nursing facilities have a potential financial incentive to tube-feed residents because of the higher daily reimbursement rate from Medicaid, yet the patients require less expensive total nursing care. 44 Conversely, from a Medicare perspective, tube-fed patients are more costly because of fees associated with feeding-tube placement and management of complications as they arise. 44 These potential financial incentives may influence tube-feeding decisions in practice. One common long-term issue with feeding tube placement is the necessity of restraining the dementia patient. A demented elderly patient may not remember or understand that they have a feeding tube inserted into their stomach, and hence pull it out. To prevent the untimely removal of a feeding tube, physicians often order mechanical restraints for these patients. 45 This may lead to frustration and agitation in the patient, possibly leading to pharmacologic sedation. 45 This leads to the difficult question of trade-off between quality of life and the possibility of quantity of life-years gained from the feeding tube intervention. Gastroenterologists or other endoscopists are frequently the technicians in the process of PEG placement. Discussions concerning enteral feeding often already have occurred between the primary physician and the family before the gastroenterologist is consulted. The family already may have come to the decision to implement a feeding tube before the gastroenterology consult. Typically, the gastroenterologist does not have a previous relationship with the patient or family, making the introduction of alternative means of feeding or therapy difficult to initiate. Often, the primary physician may not be aware of the current literature denoting poor outcomes associated with tube feeding in the dementia patient. 2,3,29 This can be frustrating for the gastroenterologist if he/she perceives futility in this intervention. Complicating the issue of treatment futility with artificial feeding are familial, cultural, religious, and legal considerations. Some families will insist on aggressive measure of all types in the dementia, hoping for a miraculous turnaround in the patient s condition. Preserving life at any cost is the perceived belief for many religions, overriding physician comments regarding futility of care. 46 A pastoral care provider or palliative care consultant may be useful in balancing religious beliefs with medical futility. The provider should endeavor to empathize with the family s beliefs, using appropriate doctrines from the family s culture or religion to explain their position as a practitioner. 47 Providers also may consider legal consequences to not placing a feeding tube. If a patient with end-stage dementia appears malnourished, cannot consume adequate oral calories, and does not have a feeding tube, the practitioner may fear legal action and recommend or acquiesce to caregiver requests for enteral feeding, despite a lack of clear data on outcomes. 29 Assisted hand-feeding may provide a viable alternative to tube feeding in patients with dementia who cannot feed themselves or who have impaired swallowing. A number of individuals with dementia experience difficulty eating not because of an inability to swallow, but because of the inability to recognize food or feed themselves. 48 Hand feeding can be a viable option in nursing homes for patients with difficulty eating on their own. A number of influences and techniques for improving eating patterns of nursing-home patients with dementia have been reported. Lange-Alberts and Shott 49 determined that touch and/or verbal cuing independently or together significantly impacted the amount of food consumed at each meal. VanOrt and Phillips 50,51 have found a number of actions that influence the amount of food consumed by nursing-home residents including: reorienting the resident to the meal, hugging or kissing the resident, maintaining touch between the feeder and resident, and responding to verbal cues from the resident. Amella 52 noted that patients with dementia form relationships with caregivers and feeders, even in late-stage disease, thus influencing their ability and amount to be fed. Miceli 53 integrated feeding techniques at a nursing facility such as head posturing, special eating utensils, and modifying food consis-

December 2007 FEEDING ALTERNATIVES IN DEMENTIA PATIENTS 1377 tency into a system of feeding that ensures safer swallowing among nursing-home residents. Caregivers involved in feeding patients with dementia can provide patients with frequent reminders to swallow, multiple swallows per each bolus feed, encourage gentle and small coughs between feeds, use thickeners frequently, and limit food bolus size to less than 1 tablespoon. 29,54 The environment in a nursing home is purported to be an important component of feeding. Nursing home residents with dementia who eat meals in a dining hall become highly distracted by television or surrounding conversations and are less likely to complete their meal. 55 To create a more pleasant and comfortable dining hall environment, soft music has been incorporated during meal time, leading to increased food consumption and less tension among residents with dementia. 56 58 A useful guide to maximizing interaction and meal consumption has been developed by Amella. 59 The lunchtime meal should be the largest and most calorie-dense meal of the day, taking advantage of the patient s daily maximal cognitive function. 29 Snacks that the patient is known to prefer should be left at bedside within reach whenever it is safe to increase daily calorie consumption. 60 Calculating the daily caloric needs for dementia patients should be computed by the Harris Benedict equation. 61 This formula uses the basal metabolic rate of each patient (based on age, height, and weight) and then applies an activity factor to determine the estimated total daily energy expenditure (calories). If certain parameters to calculate the equation are unavailable, the daily caloric intake may be approximated at 25 kcal/kg. Before placing a feeding tube, health care providers should evaluate patients for minor and reversible causes of diminished oral intake, determine if there is another chronic disease present that may be contributing to decreased appetite (eg, depression), and consider medication interactions that may diminish appetite. 48 Prolonging hand feeding reduces chances of PEG-related complications or accidental removal of the feeding tube. Inadvertent removal or malfunctioning feeding tubes cost almost $11 million annually in the United States. 62 In summary, the placement of PEG tubes for artificial feeding in the dementia population has become commonplace in the United States, without the necessary supporting evidence. Our review substantiates previous review literature in the elderly, suggesting no improvement in major clinical outcomes with the use of enteral access and artificial feeding. Physicians have clear patterns of triage for feeding tube recommendations, but the assumptions underlying these patterns are not well supported by the medical literature. 37,63 Dementia patients represent a disadvantaged group of individuals in our society because of their inability to make medical decisions for themselves. Medical providers would do well to explain the lack of improvement in outcomes to decision makers for these patients before embarking on a path of artificial feeding. Hand feeding attempts should be maximized to avoid PEG-related complications and costs while maintaining comfort and intimacy. The lack of rigor in the included studies of our review is clearly a limiting factor in attempting to change current medical practice. Future comparative studies examining mortality, nutrition, adverse events, and quality of life in this population are crucial to provide us with the best treatment option. We believe a well-designed, prospective, randomized study of hand feeding vs tube feeding in dementia patients will provide a more concrete answer of the value of enteral tube-feeding vs assisted hand feeding in this population. References 1. Hendrie H. Epidemiology of dementia and Alzheimer s disease. Am J Geriatr Psychiatry 1998;6:S3 S18. 2. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999;282: 1365 1370. 3. Cervo FA, Bryan L, Farber S. To PEG or not to PEG: a review of evidence for placing feeding tubes in advanced dementia and the decision-making process. Geriatrics 2006;61:30 35. 4. Reimer SL, Michener WM, Steiger E. Nutritional support of the critically ill child. Pediatr Clin North Am 1980;27:647 660. 5. 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