Survival in older adults with dementia and eating problems: To PEG or not to PEG?

doi:10.1016/j.clnu.2016.04.001

Clinical Nutrition

Volume 35, Issue 6, December 2016, Pages 1512-1516

https://doi.org/10.1016/j.clnu.2016.04.001 Get rights and content

Summary

Background & aims

Despite guidelines, long-term enteral nutrition (EN) through percutaneous endoscopic gastrostomy (PEG) is often prescribed to older individuals with dementia and eating problems (refusal to eat or dysphagia). The aim of this prospective observational non-randomized un-blinded study was to assess the role of this procedure on risk of mortality.

Methods

184 demented malnourished patients (58 M, age 82.2 ± 7.7) with eating problems, discharged from a hospital ward in Italy, were enrolled. Information on dementia type and staging (FAST and CDR scores), Charlson Comorbidity Score and setting of living (community vs nursing home) was collected. After an 18-month follow-up, a telephonic interview with caregivers was planned to assess mortality. Survival of patients discharged on EN by PEG vs oral nutrition (ON) was analyzed by Kaplan–Meier method. Multivariable Cox proportional regression models were also built to test the effects of EN over mortality.

Results

EN was prescribed in 54 patients (15 M). At follow-up, mortality was higher in EN than in ON group (70% vs 40%, p = 0.0002). Survival was significantly shorter in the EN group (log-rank 17.259, p < 0.0001; average length 0.66 ± 0.09 vs 1.28 ± 0.08 years, p < 0.0001). At multivariate Cox proportional regression model, EN was a significant predictor of death (HR 1.82, 95% CI 1.09–3.02, p = 0.02) independent of age, dementia type, FAST, CDR, Charlson score and setting of living in the whole cohort, but not in those with CDR score ranking 4–5.

Conclusions

In elderly individuals with dementia and eating problems, long-term PEG feeding increases the risk of mortality and should be discouraged.

Section snippets

Background

The best way to feed patients with dementia, when refusal to eat or dysphagia arise, is a major controversy in geriatric clinical practice. Current guidelines from geriatrics and nutrition scientific societies do not recommend artificial nutrition, i.e. tube feeding by percutaneous endoscopic gastrostomy (PEG), in this setting, unless for limited periods of time in order to overcome a critic phase [1], [2]. In fact, no significant benefit in terms of survival, improvement of nutritional status,

Methods

All patients with dementia consecutively admitted to Internal Medicine and Critical Subacute Care Unit of Parma University Hospital, Italy, from July to December 2013 were considered for enrollment in this prospective observational non-randomized unblinded study. Inclusion criteria were: age ≥65 years, predicted life expectancy >1 month, well-established diagnosis of dementia (of any etiology) with FAST (Functional Assessment Staging Test) score ≥5 and CDR (Clinical Dementia Rating Scale) score

Results

The number of patients with dementia and eating problems considered eligible for inclusion in the study was 240 (84 M, 156 F). Among them, 8 (3 M, 5 F) refused to participate and 38 (18 M, 20 F) died during hospital stay. Further 10 patients (5 M, 5 F) were withdrawn at follow-up, since the caregiver was uncontactable or unwilling to answer questions. Thus, the final study cohort was composed of 184 subjects (58 M, 126 F, mean age 82.2 ± 7.7 years). Their general characteristics, split

Discussion

In a cohort of elderly patients hospitalized with dementia and eating problems (i.e. dysphagia or refusal to eat), PEG insertion and subsequent prolonged enteral nutrition was associated with an earlier mortality at follow-up, even after correction for possible confounders, such as type and staging of dementia, comorbidities and setting of living. This significant association was confirmed separately for mild (CDR 1 or 2) and severe cases (CDR 3), but was not shown when considering only those

Conclusions

In a cohort of elderly multimorbid patients with dementia and eating problems, long-term enteral nutrition by PEG is associated with a significantly shorter survival than continuation of oral nutrition after an average 18 month follow-up. Thus, PEG insertion in this clinical scenario should be strongly discouraged as underlined in the most recent recommendations.

Statement of authorship

Andrea Ticinesi conducted research, wrote the paper and had the final responsibility for its content.

Antonio Nouvenne designed the study, conducted research and was responsible for data interpretation.

Fulvio Lauretani analyzed data and performed statistical analyses.

Beatrice Prati conducted research.

Nicoletta Cerundolo conducted research.

Marcello Maggio analyzed and interpreted data and wrote the paper.

Tiziana Meschi designed research and has primary responsibility for final content.

Funding sources

The study was carried out without any extra-institutional source of funding.

Conflict of interest

None of the authors has any personal or financial conflict of interest.

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Cited by (31)

Clinical and functional assessment in patients admitted with pluripathological dysphagia according to the mode of feeding: Through a gastrostomy tube or oral
2023, Enfermeria Clinica
Los pacientes pluripatológicos constituyen una población vulnerable con alta comorbilidad, deterioro funcional y riesgo nutricional. Casi un 50% de estos pacientes hospitalizados presentan disfagia. No existe consenso sobre si la colocación de una sonda de gastrostomía percutánea endoscópica (PEG) aporta mayor beneficio clínico. El propósito de este estudio fue conocer y comparar 2 grupos de pacientes pluripatológicos con disfagia según el modo de alimentación: PEG vs. vía oral.
Estudio descriptivo retrospectivo con pacientes hospitalizados (2016-2019), pluripatológicos, con disfagia, riesgo nutricional, mayores de 50 años con diagnósticos de: demencia, accidente cerebrovascular (ACV), enfermedad neurológica o neoplasia orofaríngea. Se excluyó a los pacientes en fase terminal, con sonda de yeyunostomía o nutrición parenteral. Se evaluaron variables sociodemográficas, situación clínica y comorbilidades. Se realizó análisis bivariado para comparar ambos grupos según su alimentación, estableciendo nivel de significación p < 0,05.
Mil novecientos veintiocho pacientes pluripatológicos. El grupo PEG lo formaron 84 pacientes (n = 122). Se seleccionó de forma aleatoria 84 para formar el grupo no PEG (n = 434). Este grupo presentó menos antecedentes de broncoaspiración/neumonía (p = 0,008), su diagnóstico principal fue el ACV frente la demencia en el grupo PEG (p < 0,001). Ambos grupos presentaron más de un 45% de alto riesgo de comorbilidad (p = 0,77).
Los pacientes pluripatológicos con disfagia portadores de PEG suelen tener como diagnóstico principal una demencia; sin embargo, es el ACV la enfermedad más relevante en los alimentados de forma oral. Ambos grupos llevan asociados factores de riesgo, alta comorbilidad y dependencia. Esto hace que su pronóstico vital esté limitado independientemente del modo de alimentación.
Multipathological patients are a vulnerable population with high comorbidity, functional impairment, and nutritional risk. Almost 50% of these hospitalized patients have dysphagia. There is no consensus on whether placement of a percutaneous endoscopic gastrostomy (PEG) tube provides greater clinical benefit. The purpose of this study was to know and compare 2 groups of multipathological patients with dysphagia according to the mode of feeding: PEG vs. oral.
Retrospective descriptive study with hospitalized patients (2016-19), pluripathological, with dysphagia, nutritional risk, over 50 years with diagnoses of: dementia, cerebrovascular accident (CVA), neurological disease, or oropharyngeal neoplasia. Terminally ill patients with jejunostomy tube or parenteral nutrition were excluded. Sociodemographic variables, clinical situation, and comorbidities were evaluated. Bivariate analysis was performed to compare both groups according to their diet, establishing a significance level of P<.05.
1928 multipathological patients. The PEG group consisted of 84 patients (n=122). A total of 84 were randomly selected to form the non-PEG group (n_434). This group had less history of bronchoaspiration/pneumonia (P=.008), its main diagnosis was stroke versus dementia in the PEG group (P<.001). Both groups had more than a 45% risk of comorbidity (P=.77).
Multipathological patients with dysphagia with PEG usually have dementia as their main diagnosis, however, stroke is the most relevant pathology in those fed orally. Both groups have associated risk factors, high comorbidity, and dependence. This causes their vital prognosis to be limited regardless of the mode of feeding.
Executive Summary of the Position Paper on the Use of Enteral Nutrition in Advanced Dementia
2022, Endocrinologia, Diabetes y Nutricion
La demencia es una enfermedad cada vez más prevalente en nuestro entorno, con importantes repercusiones sanitarias y sociales. Pese a la evidencia científica disponible, aún existe controversia sobre el empleo de la nutrición enteral por sonda en las personas con demencia avanzada. En el presente documento se pretende reflexionar sobre los aspectos clave de la demencia avanzada, el tratamiento nutricional por sonda y las consideraciones éticas relacionadas, así como dar respuesta a una serie de cuestiones frecuentes que se nos plantean en nuestra práctica clínica diaria.
Dementia is an increasingly prevalent disease in our environment, with significant health and social repercussions. Despite the available scientific evidence, there is still controversy regarding the use of enteral tube nutrition in people with advanced dementia. This document aims to reflect on the key aspects of advanced dementia, tube nutritional therapy and related ethical considerations, as well as to respond to several frequent questions that arise in our daily clinical practice.
Reduced Pneumonia Risk in Advanced Dementia Patients on Careful Hand Feeding Compared With Nasogastric Tube Feeding
2022, Journal of the American Medical Directors Association
Citation Excerpt :
To examine whether the type and severity of feeding problem affected survival and pneumonia risk in patients on NGF or CHF, we collected data on the speech therapist's bedside evaluation of the feeding problem as the primary indication for tube feeding. Based on previous studies,30–32 the following potential confounding variables were collected: sociodemographic variables including age, sex, marital status, education, and type of residence (home vs residential care home); nutritional parameters including body mass index (BMI), serum albumin, and lymphocyte count; presence of pressure injury; measures of functional status including Functional Assessment Staging Tool and level of dependence for activities of daily living; aspiration pneumonia prior to feeding mode decision; history of stroke and other comorbidities for determining the Charlson Comorbidity Index (CCI); and evidence of advance care planning including advance care planning documentation and Do-Not-Attempt Cardiopulmonary Resuscitation (DNACPR) orders for nonhospitalized patients. The primary outcomes were 1-year survival and pneumonia incidence.
To compare survival and pneumonia risk among hospitalized patients with advanced dementia on nasogastric tube feeding (NGF) vs careful hand feeding (CHF) and to examine outcomes by feeding problem type.
Retrospective cohort study.
Advanced dementia patients aged ≥60 years with indication for tube feeding admitted to 2 geriatric convalescent hospitals between January 1, 2015, and June 30, 2019.
Comparison on the effect of NGF and CHF on survival and pneumonia risk using Kaplan Meier survival analysis and Cox proportional hazards models.
Of the 764 patients (mean age 89 years, 61% female, 74% residential care home residents), 464 (61%) were initiated on NGF and 300 (39%) on CHF. The primary feeding problem types were dysphagia (50%), behavioral feeding problem (33%), or both (17%). There was no difference in 1-year survival rate between NGF and CHF groups (36% vs 37%, P = .71) and survival did not differ by feeding problem type. Nasogastric tube feeding was not a significant predictor for survival (adjusted hazard ratio 1.15, 95% CI 0.94-1.39). Among 577 (76%) patients who survived to discharge, pneumonia rates were lower in the CHF group (48% vs 60%, P = .004). After adjusting for cofounders, NGF was a significant risk factor for pneumonia (adjusted hazard ratio 1.41, 95% CI 1.08-1.85). In subgroup analyses, NGF was associated with increased pneumonia risk for patients with both dysphagia and behavioral feeding problem (P = .01) but not in patients with behavioral feeding problem alone (P = .24) or dysphagia alone (P = .30).
For advanced dementia patients with feeding problems, there is no difference in survival between NGF and CHF. However, NGF is associated with a higher pneumonia risk, particularly for patients with both dysphagia and behavioral feeding problem. Further research on how the feeding problem type impacts pneumonia risk for patients on NGF is needed.
The Efficacy and Safety of Tube Feeding in Advanced Dementia Patients: A Systemic Review and Meta-Analysis Study
2021, Journal of the American Medical Directors Association
Citation Excerpt :
A total of 114 articles were included for full-text assessment for eligibility, and 102 articles were excluded for specific reasons (Supplementary Table 4). Thus, 12 articles met the inclusion criteria (Table 1).15–22,27–30 A total of 5666 patients with advanced dementia were included, with 1805 patients receiving tube feeding (mean age: 82.8 ± 8.0; 71.3% female) and 3861 patients without tube feeding (mean age: 82.7 ± 7.7; 68.7% female).
The current study aimed to conduct a systematic review and meta-analysis to explore the efficacy and safety of tube feeding in patients with advanced dementia.
Systematic review and meta-analysis.
PubMed, Medline, Embase, and Cochrane Library were searched from inception until March 7, 2020, to obtain relevant studies.
Feeding with nasogastric tube or percutaneous endoscopic gastrostomy (PEG).
We evaluated the associations of tube feeding and the risk of mortality, period of survival days, tube-related complications, and nutritional status. Data from original studies were synthesized by using a random-effects model. Each selected article was assessed for bias using the Newcastle-Ottawa Scale. A narrative synthesis and pooled analyses are reported.
Twelve trials were eligible, involving 1805 patients with tube feeding (mean age: 82.8 years; 71.3% female) and 3861 without tube feeding (mean age: 82.7; 68.7% female). For mortality rate, patients with advanced dementia with tube feeding are associated with significantly higher mortality rate [k = 8; odds ratio (OR) 1.79; 95% confidence interval (CI) 1.04–3.07; P = .03]. Initially, no association was found for the risk of pneumonia and pressure sore between groups. However, sensitivity analysis showed patients with advanced dementia with PEG tube feeding have significantly higher risk of pneumonia (OR 3.56; 95% CI 2.32–5.44; P < .001) and pressure sore (OR 2.25; 95% CI 1.92–2.63; P < .001). Finally, no association was found for the survival period and nutritional status between groups.
This meta-analysis indicates that tube feeding is associated with increased mortality rate and possible tube-related complications, but not improves with prolonging survival days and nutritional status. Shared decision-making routinely before insertion of a tube between caregivers and physicians is recommended.
Pseudovolvulus of the sigmoid colon after percutaneous endoscopic gastrostomy tube placement: A case report
2020, International Journal of Surgery Case Reports
Citation Excerpt :
The patient’s swallowing function should be evaluated to estimate whether it may recover with rehabilitation before deciding to place a PEG tube. Further, long-term PEG feeding is discouraged because it increases the risk of mortality in individuals with dementia and eating problems [20]. Recently, the concept of “comfort feeding only” has become an integral part of advanced care planning.
Percutaneous endoscopic gastrostomy (PEG) provides long-term enteral nutritional access for patients with inability to eat. Although considered safe, PEG tube placement is associated with complications. We report a rare case of PEG-related sigmoid colon pseudovolvulus.
A 78-year-old man with a history of Parkinson’s disease developed severe abdominal pain and vomited continuously 50 days after PEG tube placement. Contrast-enhanced computed tomography revealed internal herniation of the sigmoid colon between the abdominal wall and the stomach at the gastrostomy site. Intraoperatively, the gastrostomy tube penetrated the sigmoid mesentery, which rotated around the tube, and the sigmoid colon was herniated towards the upper abdomen. The herniated colon was reduced and Hartmann’s procedure was performed. Subsequently, gastrostomy was reinforced with anterior gastropexy. The postoperative course was uneventful.
This case highlights the need for caution when placing a PEG tube because of a mobile sigmoid mesocolon, raising the awareness of potential major complications. Complications can be avoided by directly visualising the intraabdominal organs using laparoscopic gastrostomy or laparoscopic-assisted PEG. However, these methods require general anaesthesia. Thus, the presence of redundant colons should be determined in advance to assess the risk of sigmoid mesocolon perforation. We should also assess the patients’ swallowing function and estimate whether it may recover with rehabilitation before deciding to place a PEG tube.
PEG tube should be considered after careful patient evaluation. If PEG is required, clinicians should recognise the patient-specific risks and consider other surgical procedures to avoid complications.
A systematic review of the cost and economic outcomes of home enteral nutrition
2018, Clinical Nutrition
Citation Excerpt :
There are also systematic reviews and meta-analyses that indicated the importance and benefits of enteral nutrition in patients who are malnourished or at risk of malnutrition, in the prevention of pressure ulcers, and in cancer patients [10–13]. There are however instances where HEN use is controversial, such as in patients with dementia, with a recent study reporting 70% mortality in these patients [14]. There is insufficient evidence to suggest that enteral nutrition improves survival, nutritional status or prevalence of pressure ulcers [15,16].
Studies are lacking in the health economic implications of home enteral nutrition (HEN) in home-residing and long-term care/institutionalized patients. The aims of this review were to determine the total costs, the cost-effectiveness and other economic outcomes for HEN.
A systematic search of randomized trials and observational studies available from January 2000 to April 2016 was performed using standard literature and electronic databases. Inclusion criteria were adults receiving HEN with economic outcomes in the long-term care or home settings. There was no restriction to the control groups used in the studies.
A total of 10 studies met the inclusion criteria. The majority of the studies were not specifically designed for economic evaluation. Cost per QALY was lower in residents residing in home compared to long-term care facilities, and HEN appeared to be cost-effective for those with pressure ulcers. Higher costs were incurred for patients with dementia on HEN. Lower hospitalization costs and infection rates were reported for patients who switched to commercial feeds from blenderized food. The availability of nutritional support teams may decrease overall costs but these studies were of poor study quality.
The lack of good quality economic evaluation studies affected the ability to conclude the overall cost-effectiveness of HEN. There is a trend for cost-saving and improved clinical outcomes in some populations. HEN is unlikely beneficial for patients with dementia. The availability of a nutrition support team may lead to cost savings and improved clinical outcomes for HEN.

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Original articleSurvival in older adults with dementia and eating problems: To PEG or not to PEG?

Summary

Background & aims

Methods

Results

Conclusions

Section snippets

Background

Methods

Results

Discussion

Conclusions

Statement of authorship

Funding sources

Conflict of interest

Clin Nutr

J Pain Symptom Manage

J Nutr Health Aging

J Nutr Health Aging

Am J Gastroenterol

J Nutr Health Aging

Am J Gastroenterol

J Am Med Dir Assoc

Eur Neuropsychopharmacol

American Geriatrics Society feeding tubes in advanced dementia position statement

J Am Geriatr Soc

Clinical practice. Advanced dementia

N Engl J Med

The role of gastrostomy tube placement in advanced dementia with dysphagia: a critical review

Clin Interv Aging

Gastrostomy tube placement in patients with advanced dementia or near end of life

Nutr Clin Pract

Percutaneous endoscopic gastrostomy in the dementia patient: helpful or hindering?

Am J Gastroenterol

Original article
Survival in older adults with dementia and eating problems: To PEG or not to PEG?