Tube feeding in patients with dementia

Case presentation:
80 –years old patient with advanced dementia was hospitalized because of dehydration and prerenal acute renal failure.He was successfully treated by IV fluids and renal failure resolved. His wife reported that in few last months he refuses to eat and drink. Occasionally, he eats, but he has problems in managing the food bolus, including less solid food. Objectively, the patient is actually in the state of malnutrition (according to the physical examination and the blood tests). The family asks to help them to provide him some nutrition and hydration.


What should we do?
1. Do nothing
2. Insert the NG tube
3. Insert PEG
4. Insert the NG tube now and few weeks latter insert PEG

The issue of tube feeding in patients with advanced dementia is one of most common problems in a gastroenterologist’s practice (1,2). Patients with dementia commonly develop feeding difficulties, because of refuse to eat, indifference to food, fail to manage the food folus properly and aspirations during swallowing because of bedridden state. Some of them have neurological problems too, including swallowing abnormalities. Tube feeding has been suggested in the purpose to prevent death from starvation and dehydration in these patients. But does it wise think to do?
We will discuss ethical aspect of this issue, as well as medical aspect.
Ethical aspect (2,3,4): The quality of life of severely demented patients is very diminished. They have no interest in living and are not aware of their location or medical condition. But both medical and nursing staff, as well as most families are feeling uncomfortable to do nothing with patients with hand-feeding problems. Despite the legal acknowledgement that tube feeding and hydration is a medical treatment, most of population in Israel and other countries consider the food and the water as the basic needs of human being and not as ‘’life-prolonging treatment’’, like ventilator support, dialysis and antibiotics. In such circumstances, the Gastroenterology Departments has no choice but provide tube feeding in most of demented patients. However, a change in the public perception in the future may allow to decide about tube feeding on the basis of pure medical considerations. We are as doctors should contribute to this change.
Medical aspect: The important questions are—does tube feeding improves a survival rate, a nutritional status or a functional status of demented patients.
Survival rate.
The published studies reported high rate of mortality in demented patients with gastrostomy feeding. In a large study of Grant et.al 24% mortality at 30 days, 63% by 1 y, 81.3% by 3 y. were demonstrated ( 5 ). The other studies pointed at similar rate of mortality(6,7,8 ). Sanders et.al. presented a higher than usual rate of mortality (54% mortality at 30 days and 90% at 1y after PEG insertion) ( 9 ). Retrospective studies found no survival advantage with tube feeding in comparison with hand-feeding and even increased mortality among tube-fed patient (10,11).
Nutritional status
There is not enough studies regarding the relationship between tube feeding, improvement in markers of nutritional state and the possible impact on survival rate. A study of Kaw et.al. demonstrated no improvement in nutritional status in 46 nursing home residents with PEG feeding ( 8 ).
Functional status
A retrospective study of Kaw et.al. ( 8 ) found no improvement in functional status as measured by the Functional Independence Measurement scale during 18 months after PEG tube replacement.
Nasogastric tube versus PEG
PEG was first introduced into clinical practice in 1980. It became the most common method of enteral feeding in patients who require long-term tube feeding. PEG are used as alternative to NG tubes, because of well-knowen faults of NG tubes, like:
high rate of self extubation by a patients; misplacement—intubations of tracheobronchial tree, intracranial placement; erosive tissue damage—nasopharyngeal erosions, pharyngitis, sinusitis, otitis media, pneumothorax, GI tract perforation. In the study of Dwolatzky et.al. a prospective comparison between NG tube and PEG showed an improved survival rate, better tolerance and lower incidence of aspiration in PEG group (12 ). Nutritional status was similar in both groups. However, PEG insertion engaged with a mean procedure mortality rate of 0.6% (13) and considerable complication rate of 3-5% ( 14).
The timing of PEG placement
Some studies pointed at high mortality rate in patients hospitalized with acute illness and recommended defer the placement until recovery from acute illness ( 15 ).
Hypoalbuminemia is considered as a poor predictor of survival after PEG placement in demented patients, so there may be some benefit in performing PEG before the onset of severe hypoalbuminemia ( 16 ).
Summary points:
1. The issue of tube feeding in patients with advanced dementia is one of most common problems in a gastroenterologist’s practice.
2. Because of public perception of food and water as the basic need of human being, gastroenterologists are forced to insert PEG in most demented patients with hand-feeding difficulties.
3. There is no evidence of survival, nutritional or functional improvement in the demented patients who were supported by PEG feeding.
4. PEG is a preferable alternative to NG tube in patients who require long-term feeding. It placement should be defer until recovety from acute illness.
References:
1. Finucane TE, et.al. Tube feeding in patients with advanced dementia. JAMA 1999;282(14):1365-70.
2. Angus F, et.al. The percutaneous endoscopic gastrostomy tube: medical and ethical issues in placement. Am J Gastroenterol 2003; 98(2);272-7.
3. Niv Y, et.al. Ethical aspects of percutaneous endoscopic gastrostomy insertion. IMAJ 2003; 5:1-2.
4. Niv Y, et.al. Indications for percutaneous endoscopic gastrostomy insertion: ethical aspects. Dig Dis 2002; 20(3-4):253-6.
5. Grant MD,et.al. Gastrostomy placement and mortality among hospitalized Medicare beneficiaries. JAMA 1998; 279:1973-6.
6. Bergstom et.al. Utilization and outcome of surgical gastrostomies and jejunostomies in an era of percutaneous endoscopic gastrostomy: a population-based study. Mayo Clin Proc 1995; 70:829-36.
7. Fishman et.al. Survival after percutaneous endoscopic gastrostomy among older residents of Quebec. J Am Geriatr Soc 1999; 47:349-53.
8. Kaw M, et.al. Long-term follow-up of consequences of percutaneous endoscopic gastrosomy (PEG) tubes in nursing home patients. Dig Dis Sci 1994; 39(4): 738-43.
9. Sander DS, et.al. Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia. Am J Gastroenterol 2000; 95(6): 1472-5.
10. Mitchell SL, et.al. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Arch Inter Med 1997; 157:327-332.
11. Mitchell SL, et.al. Does artificial enteral nutrition prolong the survival of institutionalized elders with chewing and swallowing problems ? J Gerontol 1998; 53A:M1-M7.
12. Dwolatzky T, et.al. A prospective comparison of the use of nasogastric and percutaneous endoscopic gastrostomy tubes for long-term enteral feeding in older people. Clin Nutr 2001; 20(6): 535-40.
13. Miller RE, et.al. Percutaneous endoscopic gastrostomy. Surg Endosc 1989; 3:186-90.
14. James A, et.al. Long-term outcome of pecutaneous endoscopic gastrostomy feeding in patients with dysphagic stroke. Aging 1998;27:671-6.
15. Abuksis G, et.al. Percutaneous endoscopic gastrostomy: high mortality rates in hospitalized patients. Am J Gastroenterol 2000; 95(1): 128-32.
16. Nair S, et.al. Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia. Am J Gastroenterol 2000; 95(1):133-6.