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Trends and Outcomes of Early Versus Late Percutaneous Endoscopic Gastrostomy Placement in Patients With Traumatic Brain Injury: Nationwide Population-based Study. J Neurosurg Anesthesiol 2018; 30:251-257. [DOI: 10.1097/ana.0000000000000434] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Life-Sustaining Procedures, Palliative Care Consultation, and Do-Not Resuscitate Status in Dying Patients With COPD in US Hospitals. J Palliat Care 2018; 33:159-166. [DOI: 10.1177/0825859718777375] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aim: Little is known regarding the extent to which dying patients with chronic obstructive pulmonary disease (COPD) receive life-sustaining procedures and palliative care in US hospitals. We examined temporal trends and the impact of palliative care on the use of life-sustaining procedures in this population. Materials and Methods: A retrospective nationwide cohort analysis was performed using weighted National Inpatient Sample (NIS) data obtained from 2010 to 2014. Decedents ≥18 years of age at the time of death and with a principal diagnosis of COPD were included. We examined the receipt of life-sustaining procedures, defined as1 ventilation (intubation, mechanical ventilation, and noninvasive ventilation),2 vasopressor use (infusion and intravascular monitoring),3 nutrition (enteral and parenteral infusion of concentrated nutrition),4 dialysis, and5 cardiopulmonary resuscitation as well as palliative care consultation and do not resuscitate (DNR). We used compound annual growth rates (CAGRs) and the Rao-Scott correction of the χ2 statistic to determine the statistical significance of temporal trends of life-sustaining procedures, palliative care utilization, and DNR status. Results: Among 37 312 324 hospitalizations, 38 425 patients were examined. The CAGRs of life-sustaining procedures were 6.61% and −9.73% among patients who underwent multiple procedures and patients who did not undergo any procedure, respectively (both P < .001). The CAGRs of palliative consultation and DNR were 5.25% and 36.62%, respectively (both P < .001). Conclusions: Among adults with COPD dying in US hospitals between 2010 and 2014, the utilization of life-sustaining procedures, palliative care, and DNR status increased.
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Punchik B, Komissarov E, Zeldez V, Freud T, Samson T, Press Y. Doctors' Knowledge and Attitudes Regarding Enteral Feeding and Eating Problems in Advanced Dementia. Dement Geriatr Cogn Dis Extra 2018; 8:268-276. [PMID: 30140276 PMCID: PMC6103352 DOI: 10.1159/000489489] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/20/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The use of feeding tubes (FTs) in patients with advanced dementia does not yield positive health outcomes and can have a negative effect. METHODS A cross-sectional study assessed the knowledge and attitudes of physicians on the use of FTs for patients with advanced dementia. RESULTS 201 of 240 doctors (83.8%) participated in the study; 61.7% of the doctors claimed that FTs prevent aspiration, 51.7% that they prevent pneumonia, and 38.8% that they prevent weight gain. Almost one-third (32.3%) said that the decision to use FTs could be taken by a hospitalist or a primary physician (28.9%). CONCLUSION We found large gaps in knowledge among doctors about the use of FTs and consequences in patients with advanced dementia.
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Affiliation(s)
- Boris Punchik
- Home Care Unit, Clalit Health Services, Yasski Clinic, Beer-Sheva, Israel
- Clalit Health Services, Beer-Sheva, Israel
- Unit for Community Geriatrics, Division of Community Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | | | - Vladimir Zeldez
- Emergency Medicine Department, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Tamar Freud
- Department of Family Medicine, Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Tali Samson
- Clalit Health Services, Beer-Sheva, Israel
- Unit for Community Geriatrics, Division of Community Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Family Medicine, Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yan Press
- Home Care Unit, Clalit Health Services, Yasski Clinic, Beer-Sheva, Israel
- Clalit Health Services, Beer-Sheva, Israel
- Unit for Community Geriatrics, Division of Community Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Cohen D, Post SG, Lo A, Lombardo R, Pfeffer B. "Music & Memory" and improved swallowing in advanced dementia. DEMENTIA 2018; 19:195-204. [PMID: 29649909 DOI: 10.1177/1471301218769778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Dysphagia and difficulty with eating affects a significant portion of individuals with advanced dementia. Such problems with oral intake can have serious health consequences including mealtime distress, dehydration and malnutrition, aspiration, reduced quality of life, and increased mortality risk. Design We present the first data indicating that “Music & Memory” interventions improve swallowing in individuals with advanced dementia, thereby making oral feeding easier and potentially diminishing reliance on PEG. Setting Columbia Health Care Center, Wyocena, WI (with Music&Memory.org, Mineola, NY and Stony Brook University). Participants Residents with advanced dementia (N = 5). Measurements: Observation by eight professional caregivers. Results (1) Enhanced swallowing mechanism with Music & Memory prior to dining; (2) decreased incidents of choking during mealtime; (3) improved nutritional status; (4) reduced weight loss; (5) reduced need for speech interventions; (6) enhanced quality of life. Conclusions The preliminary results call for additional research.
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Affiliation(s)
| | | | - Angela Lo
- Stony Brook University School of Medicine, USA
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Lex KM, Kundt FS, Lorenzl S. Using tube feeding and levodopa-carbidopa intestinal gel application in advanced Parkinson's disease. ACTA ACUST UNITED AC 2018. [PMID: 29517331 DOI: 10.12968/bjon.2018.27.5.259] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The inability to achieve adequate nutrition and weight loss are serious problems for patients with advanced Parkinson's disease (PD). To ensure the optimal intake of nutrition and fluids and to administer levodopa-carbidopa intestinal gel (LCIG) (which patients need to increase or maintain their mobility as long as possible), different artificial feeding tubes can be used. Although percutaneous endoscopic gastrostomy (PEG) tubes are frequently used in medical practice, there is little research that addresses key questions, including if and when to administer artificial fluids, nutrition and/or LCIG via tubes. Weight gain through tube feeding is only possible for some patients; nurses should keep in mind that tube insertion and feeding may lead to frequent adverse events. Administering LCIG via tubes is usually advisable as it seems to enhance patients' mobility and therefore has positive outcomes in terms of the quality of life of patients and their families ( Lim et al, 2015 ). The authors aimed to examine the use and consequences of providing nutrition and LCIG via gastrostomy tubes in PD patients with advanced disease.
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Affiliation(s)
- Katharina Maria Lex
- Research Associate, Institute for Nursing Science and Research, Medical University, Salzburg, Austria
| | - Firuzan Sari Kundt
- Research Associate, Institute for Nursing Science and Research, Medical University, Salzburg, Austria
| | - Stefan Lorenzl
- Professor for Interdisciplinary Research in Palliative Care, Institute for Nursing Science and Research, Medical University, Salzburg, Austria
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Wirth R. [Percutaneous endoscopic gastrostomy in geriatrics : Indications, technique and complications]. Z Gerontol Geriatr 2018; 51:237-245. [PMID: 29349584 DOI: 10.1007/s00391-017-1363-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/06/2017] [Accepted: 12/12/2017] [Indexed: 11/26/2022]
Abstract
The technique of percutaneous endoscopic gastrostomy (PEG) was introduced in 1979 as a semi-invasive approach for children with the need for a gastric fistula in order to avoid an operative intervention. The suture pull-through method was rapidly established and is now omnipresent. Because scientific evidence is broadly missing, there is some uncertainty about the indications in geriatric medicine. Guidelines do not recommend the insertion of a PEG in patients with severe dementia and malnutrition. Tube feeding is mainly recommended as a temporary method for patients who cannot take oral nutrition for more than 3 days or for whom the energy intake for more than 10 days presumably covers less than 50% of their needs, assuming that the overall prognosis is reasonable. Insertion of a PEG is only recommended if artificial nutrition is expected to be necessary for more than 3-4 weeks or if a nasogastric tube is not tolerated.
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Affiliation(s)
- Rainer Wirth
- Klinik für Altersmedizin und Frührehabilitation, Marien Hospital Herne - Universitätsklinikum der Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Deutschland.
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Lühnen J, Mühlhauser I, Richter T. Informed decision-making with and for people with dementia: Developing and pilot testing an education program for legal representatives (PRODECIDE). DEMENTIA 2017; 18:2303-2321. [PMID: 29271251 DOI: 10.1177/1471301217746751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background People living with dementia are often appointed a legal representative, to support and protect their ethical and legal rights to informed healthcare decisions. However, legal representatives usually have no qualifications in healthcare. Objective The aim of this study was to explore decision-making processes with participation of legal representatives and, resulting from this, to develop and pilot test an education program for legal representatives in Germany. Methods We conducted interviews with legal representatives and senior citizens about decision-making processes in healthcare, with special focus on percutaneous endoscopic gastrostomy, physical restraints, and prescription of antipsychotics for people with dementia. We generated a curriculum based on systematic literature searches and the results of these interviews. We tested the education program for comprehensibility, feasibility, usability, and acceptance. Results Personal interviews with voluntary ( n = 12) and professional ( n = 12) representatives, and senior citizens ( n = 14) were conducted. Preferences, attitudes, and wishes regarding percutaneous endoscopic gastrostomy, physical restraints, and antipsychotics, and the process of decision-making, were heterogeneous. A structural approach is lacking. The education program proxy-decison-making (PRODECIDE) comprises four modules: (A) decision-making processes and methods; (B–D) evidence-based knowledge about percutaneous endoscopic gastrostomy, physical restraints, and antipsychotics. We conducted eight trainings with 47 legal representatives. PRODECIDE was well accepted. Comprehensibility of contents and materials was rated high. The program seems feasible for implementation. Conclusion PRODECIDE seems suitable to improve the decision-making processes of legal representatives in Germany. Implementation will be appropriate if efficacy is proven; a randomized controlled trial is currently underway.
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Hendriks SA, Smalbrugge M, Deliens L, Koopmans RTCM, Onwuteaka-Philipsen BD, Hertogh CMPM, van der Steen JT. End-of-life treatment decisions in nursing home residents dying with dementia in the Netherlands. Int J Geriatr Psychiatry 2017; 32:e43-e49. [PMID: 28032354 DOI: 10.1002/gps.4650] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 11/27/2016] [Accepted: 12/01/2016] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The objective was to describe end-of-life treatment decisions for patients dying with dementia in various stages of dementia in long-term care facilities in the Netherlands with elderly care physicians responsible for treatment and care. METHODS We present data collected in the nationally representative Dutch End of Life in Dementia study (2007-2011). Within 2 weeks after death, 103 physicians completed questionnaires about the last phase of life in 330 residents with dementia who resided in 1 of 34 participating long-term care facilities. We used descriptive statistics. RESULTS Advance directives were rare (4.9%). A minority was hospitalized (8.0%) in the last month (mainly for fractures) or received antibiotics (24.2%) in the last week (mainly for pneumonia). Four residents received tube feeding or rehydration therapy in the last week. In almost half of the residents (42.3%), decisions were made not to start potentially life-prolonging treatment such as hospital transfer and artificial nutrition and hydration. In more than half of the residents (53.7%), decisions were made to withdraw potentially life-prolonging treatment such as artificial nutrition and hydration and medication. Antibiotics were more frequently prescribed for residents with less advanced dementia, but otherwise there were no differences in treatment decisions between residents with advanced and less advanced dementia. CONCLUSIONS Physicians often withhold potentially burdensome life-prolonging treatment in nursing home residents in all stages of dementia in the Netherlands. This suggests that the physicians feel that a palliative care approach is appropriate at the end of life in dementia in long-term care. Copyright © 2016 John Wiley & Sons, Ltd. StartCopTextCopyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Simone A Hendriks
- Department of General Practice and Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VUmc Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Martin Smalbrugge
- Department of General Practice and Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VUmc Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel, Brussels, Belgium
| | - Raymond T C M Koopmans
- Department of Primary care and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands.,Joachim and Anna, Center for Specialized Geriatric Care, Nijmegen, The Netherlands.,Radboud Alzheimer Centre, Nijmegen, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VUmc Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Cees M P M Hertogh
- Department of General Practice and Elderly Care Medicine and EMGO+ Institute for Health and Care Research, VUmc Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Jenny T van der Steen
- Department of Primary care and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
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Takayama K, Hirayama K, Hirao A, Kondo K, Hayashi H, Kadota K, Asaba H, Ishizu H, Nakata K, Kurisu K, Oshima E, Yokota O, Yamada N, Terada S. Survival times with and without tube feeding in patients with dementia or psychiatric diseases in Japan. Psychogeriatrics 2017; 17:453-459. [PMID: 29178502 DOI: 10.1111/psyg.12274] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 03/01/2017] [Accepted: 03/14/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND It is widely supposed that there has been no evidence of increased survival in patients with advanced dementia receiving enteral tube feeding. However, more than a few studies have reported no harmful outcome from tube feeding in dementia patients compared to in patients without dementia. METHODS This was a retrospective study. Nine psychiatric hospitals in Okayama Prefecture participated in this survey. All inpatients fulfilling the entry criteria were evaluated. All subjects suffered from difficulty with oral intake. Attending physicians thought that the patients could not live without long-term artificial nutrition. The physicians decided whether to make use of long-term artificial nutrition between January 2012 and December 2014. RESULTS We evaluated 185 patients. Their mean age was 76.6 ± 11.4 years. Of all subjects, patients with probable Alzheimer's disease (n = 78) formed the biggest group, schizophrenia patients (n = 44) the second, and those with vascular dementia (n = 30) the third. The median survival times were 711 days for patients with tube feeding and 61 days for patients without tube feeding. In a comparison different types of tube feeding, median survival times were 611 days for patients with a nasogastric tube and more than 1000 days for those with a percutaneous endoscopic gastrostomy tube. CONCLUSION Patients with tube feeding survived longer than those without tube feeding, even among dementia patients. This study suggests that enteral nutrition for patients with dementia prolongs survival. Additionally, percutaneous endoscopic gastrostomy tube feeding may be safer than nasogastric tube feeding among patients in psychiatric hospitals.
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Affiliation(s)
- Keiko Takayama
- Department of Psychiatry, Kibogaoka Hospital, Tsuyama, Japan
| | | | - Akihiko Hirao
- Department of Psychiatry, Kawada Hospital, Okayama, Japan
| | - Keiko Kondo
- Department of Psychiatry, Sekizen Hospital, Tsuyama, Japan
| | - Hideki Hayashi
- Department of Psychiatry, Hayashi Hospital, Okayama, Japan
| | - Koichi Kadota
- Department of Psychiatry, Kurashiki Jinpu Hospital, Kurashiki, Japan
| | - Hiroyuki Asaba
- Department of Psychiatry, Kohnan Hospital, Tamano, Japan
| | - Hideki Ishizu
- Department of Psychiatry, Zikei Hospital, Okayama, Japan
| | - Kenji Nakata
- Department of Psychiatry, Taiyo Hills Hospital, Takahashi, Japan
| | - Kairi Kurisu
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Etsuko Oshima
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Osamu Yokota
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Norihito Yamada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Seishi Terada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Gieniusz M, Sinvani L, Kozikowski A, Patel V, Nouryan C, Williams MS, Kohn N, Pekmezaris R, Wolf‐Klein G. Percutaneous Feeding Tubes in Individuals with Advanced Dementia: Are Physicians “Choosing Wisely”? J Am Geriatr Soc 2017; 66:64-69. [DOI: 10.1111/jgs.15125] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Marzena Gieniusz
- Division of Geriatric and Palliative MedicineNorthwell Health Manhasset New York
| | - Liron Sinvani
- Department of Medicine Northwell HealthManhasset New York
| | | | - Vidhi Patel
- Department of Medicine Northwell HealthManhasset New York
| | | | | | - Nina Kohn
- Feinstein Institute for Medical Research Manhasset New York
| | | | - Gisele Wolf‐Klein
- Division of Geriatric and Palliative MedicineNorthwell Health Manhasset New York
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Lühnen J, Haastert B, Mühlhauser I, Richter T. Informed decision-making with and for people with dementia - efficacy of the PRODECIDE education program for legal representatives: protocol of a randomized controlled trial (PRODECIDE-RCT). BMC Geriatr 2017; 17:217. [PMID: 28915861 PMCID: PMC5603024 DOI: 10.1186/s12877-017-0616-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/07/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In Germany, the guardianship system provides adults who are no longer able to handle their own affairs a court-appointed legal representative, for support without restriction of legal capacity. Although these representatives only rarely are qualified in healthcare, they nevertheless play decisive roles in the decision-making processes for people with dementia. Previously, we developed an education program (PRODECIDE) to address this shortcoming and tested it for feasibility. Typical, autonomy-restricting decisions in the care of people with dementia-namely, using percutaneous endoscopic gastrostomy (PEG) or physical restrains (PR), or the prescription of antipsychotic drugs (AP)-were the subject areas trained. The training course aims to enhance the competency of legal representatives in informed decision-making. In this study, we will evaluate the efficacy of the PRODECIDE education program. METHODS A randomized controlled trial with a six-month follow-up will be conducted to compare the PRODECIDE education program with standard care, enrolling legal representatives (N = 216). The education program lasts 10 h and comprises four modules: A, decision-making processes and methods; and B, C and D, evidence-based knowledge about PEG, PR and AP, respectively. The primary outcome measure is knowledge, which is operationalized as the understanding of decision-making processes in healthcare affairs and in setting realistic expectations about benefits and harms of PEG, PR and AP in people with dementia. Secondary outcomes are sufficient and sustainable knowledge and percentage of persons concerned affected by PEG, FEM or AP. A qualitative process evaluation will be performed. Additionally, to support implementation, a concept for translating the educational contents into e-learning modules will be developed. DISCUSSION The study results will show whether the efficacy of the education program could justify its implementation into the regular training curricula for legal representatives. Additionally, it will determine whether an e-learning course provides a valuable backup or even alternative learning strategy. TRIAL REGISTRATION TRN: ISRCTN17960111 , Date: 01/06/2017.
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Affiliation(s)
- Julia Lühnen
- Unit of Health Sciences and Education, Faculty of Mathematics, Informatics and Natural Sciences (MIN), University of Hamburg, Martin-Luther-King-Platz 6, 20146 Hamburg, Germany.
| | | | - Ingrid Mühlhauser
- Unit of Health Sciences and Education, Faculty of Mathematics, Informatics and Natural Sciences (MIN), University of Hamburg, Martin-Luther-King-Platz 6, 20146 Hamburg, Germany
| | - Tanja Richter
- Unit of Health Sciences and Education, Faculty of Mathematics, Informatics and Natural Sciences (MIN), University of Hamburg, Martin-Luther-King-Platz 6, 20146 Hamburg, Germany
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Hollaar VR, van der Putten GJ, van der Maarel-Wierink CD, Bronkhorst EM, de Swart BJ, de Baat C, Creugers NH. Nursing home-acquired pneumonia, dysphagia and associated diseases in nursing home residents: A retrospective, cross-sectional study. Geriatr Nurs 2017; 38:437-441. [DOI: 10.1016/j.gerinurse.2017.02.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 02/13/2017] [Accepted: 02/14/2017] [Indexed: 12/27/2022]
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Abstract
The progressive nature of dementia marks this disease as a terminal illness in the advanced stage, and palliative care rather than curative treatment is indicated. The use of feeding tubes to deliver artificial nutrition and hydration at end of life is often part of the plan of care for people with dementia. Current evidence, however, suggests that tube feeding in advanced dementia is not beneficial and the burdens of the procedure and the feedings themselves outweigh any benefits. Evidence also reveals that healthcare providers may lack evidence-based knowledge about artificial nutrition and hydration to adequately inform families and surrogate decision makers. This article examines the evidence regarding use of artificial nutrition and hydration for patients with end-stage dementia and offers implications for home care clinicians.
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Affiliation(s)
- Lenora Smith
- Lenora Smith, PhD, RN, is an Assistant Professor, College of Nursing, University of Alabama in Huntsville, Huntsville, Alabama. Rita Ferguson, PhD, RN, CHPN, CNE, is a Clinical Assistant Professor, College of Nursing, University of Alabama in Huntsville, Huntsville, Alabama
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Applications of the propensity score weighting method in psychogeriatric research: correcting selection bias and adjusting for confounders. Int Psychogeriatr 2017; 29:703-706. [PMID: 28095944 DOI: 10.1017/s1041610216002490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The propensity score (PS) weighting method is an analytic technique that has been applied in multiple fields for a number of purposes. Here, we discuss two common applications, which are (1) to correct for selection bias and (2) to adjust for confounding variables when estimating the effect of an exposure variable on the outcome of interest.
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Increasing Serum Albumin Level Shortly After Gastrostomy Tube Insertion Predicts Longer Survival in Elderly Patients With Dementia. J Clin Gastroenterol 2017; 51:339-344. [PMID: 27479141 DOI: 10.1097/mcg.0000000000000616] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOAL To identify factors influencing survival after percutaneous endoscopic gastrostomy (PEG) tube insertion in elderly patients with severe dementia. BACKGROUND Use of PEG in patients with dementia raises medical and ethical questions. STUDY The cohort included 189 patients aged ≥64 years with severe dementia who underwent PEG tube insertion in 2002 to 2011 at a tertiary hospital and were followed through 2014. Data were collected on background diseases, laboratory tests conducted 14 (±10) days before and 90 (±10) days after PEG, and date of death. Multivariate Cox regression analysis was performed and cumulative survival curves plotted. RESULTS Mean baseline serum albumin level was significantly lower in patients who died ≤30 days after PEG (n=32, 16.9%) than patients who survived longer (2.9±0.5 vs. 3.3±0.5 g/dL, P<0.001), and significantly higher in patients who survived 1 year after PEG (n=96, 50.8%) than patients who died earlier (3.4±0.5 vs. 3.1±0.5 g/dL, P=0.002). No significant differences were found for the other laboratory parameters. After adjustment for background diseases, serum albumin level above the median (3.3 g/dL) was the only predictor of survival (hazard ratio 0.51; 95% confidence interval, 0.37-0.72; P<0.001). Patients with stable/increased serum albumin levels at 90 days after PEG (n=80, 42.3%) survived longer than patients with decreased levels. The only predictor of survival after adjustment for age and background diseases was a stable/increased albumin level at 90 days (hazard ratio 0.59; 95% confidence interval, 0.42-0.85; P=0.004). CONCLUSIONS Survival after PEG tube insertion is associated with a higher serum albumin level at baseline and a stable/increased serum albumin level during follow-up.
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Affiliation(s)
- Susan W Tolle
- From the Division of General Internal Medicine and Geriatrics and the Center for Ethics in Health Care, Oregon Health and Science University, Portland (S.W.T.); and the Division of Gerontology and Geriatric Medicine and Cambia Palliative Care Center of Excellence, University of Washington, Seattle (J.M.T.)
| | - Joan M Teno
- From the Division of General Internal Medicine and Geriatrics and the Center for Ethics in Health Care, Oregon Health and Science University, Portland (S.W.T.); and the Division of Gerontology and Geriatric Medicine and Cambia Palliative Care Center of Excellence, University of Washington, Seattle (J.M.T.)
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Douglas JW, Lawrence JC, Turner LW. Social Ecological Perspectives of Tube-Feeding Older Adults with Advanced Dementia: A Systematic Literature Review. J Nutr Gerontol Geriatr 2017; 36:1-17. [PMID: 28140779 DOI: 10.1080/21551197.2016.1277174] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Dementia is a progressive, debilitating disease that often results in weight loss, malnutrition, and dehydration. Feeding tubes are often prescribed; however, this practice can lead to complications. The purpose of this systematic review was to examine the use of feeding tubes in elderly demented patients from a social ecological perspective. Results indicated that family members often receive inadequate decision-making education. Many health care professionals lack knowledge of evidence-based guidelines pertaining to feeding tube use. Organizational and financial reimbursement structures influence feeding tube use. Feeding practices for patients with advanced dementia is a complex issue, warranting approaches that target each level of the Social Ecological Model.
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Affiliation(s)
- Joy W Douglas
- a Department of Human Nutrition and Hospitality Management , The University of Alabama , Tuscaloosa , Alabama , USA
| | - Jeannine C Lawrence
- a Department of Human Nutrition and Hospitality Management , The University of Alabama , Tuscaloosa , Alabama , USA
| | - Lori W Turner
- b College of Human Environmental Sciences , The University of Alabama , Tuscaloosa , Alabama , USA
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Lan SH, Lu LC, Yen YY, Hsieh YP, Chen JC, Wu WJ, Lan SJ, Lin LY. Tube Feeding among Elder in Long-Term Care Facilities: A Systematic Review and Meta-Analysis. J Nutr Health Aging 2017; 21:31-37. [PMID: 27999847 DOI: 10.1007/s12603-016-0717-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The use of tube feeding for elderly patients with poor nutritional intake is a ubiquitous method of feeding. This systematic review and meta-analysis were carried out to compare nutritional benefits of enteral feeding versus oral feeding in long-term care facilities. SETTING Databases including the Cochrane Library, ProQuest, PubMed, EMBASE, EBSCO, Web of Science and Google Scholar through April 2014 using keywords including enteral feeding, tube feeding or oral feeding combined with long term care facilities or nursing home. PARTICIPANTS Eight articles, with 841 participants were included in meta-analysis and 13 articles were included in systematic review. The elderly had to live in long-term care institutions and could not be on any mechanically assisted ventilation systems or be in any type of post-operative status. MEASUREMENTS The three investigators extracted and appraised data using the same study design, baseline characteristics, and outcomes, independently. RESULTS Following a systematic review, 13 articles out of 8218 original research articles were selected for this analysis. Meta-analysis of tube-fed patients found lower levels of hemoglobin (Weighted Mean Difference (WMD -0.21g/dl; 95% CI -0.42 to -0.01; p=0.04) and creatinine (WMD -0.08g/dl; 95% CI -0.17 to 0.00, p=0.05). Moreover, the results showed that there were no benefits regarding body mass index (BMI), albumin, dietary intake of proteins, total calories and fat. CONCLUSIONS The results show that tube feeding does not increase patients' nutrients absorption to improve nutritional status. Instead, these results indicate that oral feeding is better regarding some nutritional biochemical parameters.
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Affiliation(s)
- S-H Lan
- Shou-Jen Lan, Department of Healthcare Administration, Asia University, No. 500, Lioufeng Rd., Wufeng District, Taichung City 41354, Taiwan. , Tel: +886-4-2332-3456 ext. 1945.6414, Fax number: +886-4-2332-1206
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A wandering tube. CAN J EMERG MED 2016; 19:398-399. [PMID: 27916022 DOI: 10.1017/cem.2016.393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The predominant causes of acute mechanical small bowel obstruction in geriatric patients are adhesions and hernias, which is not much different than in other adult age groups. Unusual etiologies may be encountered, such as volvulus or gallstone ileus, but a displaced feeding gastrostomy tube is a distinctly rare cause of intestinal obstruction which needs to be considered by emergency physicians as it may be increasingly encountered.
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Bechtold ML, Mir FA, Boumitri C, Palmer LB, Evans DC, Kiraly LN, Nguyen DL. Long-Term Nutrition. Nutr Clin Pract 2016; 31:737-747. [DOI: 10.1177/0884533616670103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
| | - Fazia A. Mir
- Department of Medicine, University of Missouri, Columbia, Missouri, USA
| | | | - Lena B. Palmer
- Department of Medicine, Loyola University, Chicago, Illinois, USA
| | - David C. Evans
- Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Laszlo N. Kiraly
- Department of Surgery, Oregon Health Sciences University, Portland, Oregon, USA
| | - Douglas L. Nguyen
- Department of Medicine, University of California, Irvine, California, USA
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Hirao A, Abe K, Takayama K, Kondo K, Yokota O, Sato Y, Norikiyo T, Sato S, Nakashima T, Hayashi H, Nakata K, Asaba H, Tanaka K, Tanaka R, Morisada Y, Itakura H, Honda H, Okabe N, Oshima E, Terada S. Heterogeneity of patients receiving artificial nutrition in Japanese psychiatric hospitals: a cross-sectional study. Psychogeriatrics 2016; 16:341-348. [PMID: 26756206 DOI: 10.1111/psyg.12173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 10/11/2015] [Accepted: 10/15/2015] [Indexed: 11/27/2022]
Abstract
AIM Artificial nutrition, including tube feeding, continues to be given to dementia patients in numerous geriatric facilities in Japan. However, the clinical characteristics of patients receiving artificial nutrition have not been fully investigated. Therefore, we tried to evaluate the clinical features of those patients in this study. METHODS Various clinical characteristics of all inpatients at 18 of 20 psychiatric hospitals in Okayama Prefecture, Japan, with a percutaneous endoscopic gastrostomy tube, nasogastric tube, or total parenteral nutrition were evaluated. RESULTS Two hundred twenty-one patients (5.4% of all inpatients) had been receiving artificial nutrition for more than 1 month, and 187 (130 women, 57 men; 84.6% of 221 patients) were fully investigated. The mean age was 78.3 years old, and the mean duration of artificial nutrition was 29.8 months. Eighty-four patients (44.7% of 187 patients) were receiving artificial nutrition for more than 2 years. Patients with Alzheimer's disease (n = 78) formed the biggest group, schizophrenia (n = 37) the second, and vascular dementia (n = 26) the third. CONCLUSION About one-fifth of the subjects receiving artificial nutrition were in a vegetative state. More than a few patients with mental disorders, including schizophrenia, also received long-term artificial nutrition. We should pay more attention to chronic dysphasia syndrome in mental disorders.
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Affiliation(s)
- Akihiko Hirao
- Department of Psychiatry, Kawada Hospital, Okayama, Japan
| | - Keiichi Abe
- Department of Psychiatry, Mannari Hospital, Okayama, Japan
| | - Keiko Takayama
- Department of Psychiatry, Kibogaoka Hospital, Tsuyama, Japan
| | - Keiko Kondo
- Department of Psychiatry, Sekizen Hospital, Tsuyama, Japan
| | - Osamu Yokota
- Department of Psychiatry, Kinoko Espoir Hospital, Kasaoka, Japan
| | - Yoshiki Sato
- Department of Psychiatry, Yura Hospital, Tamano, Japan
| | - Taizo Norikiyo
- Department of Psychiatry, Setouchi Kinen Hospital, Setouchi, Japan
| | - Soichiro Sato
- Department of Psychiatry, Zikei Hospital, Okayama, Japan
| | | | - Hideki Hayashi
- Department of Psychiatry, Hayashi Hospital, Okayama, Japan
| | - Kenji Nakata
- Department of Psychiatry, Taiyo Hills Hospital, Takahashi, Japan
| | - Hiroyuki Asaba
- Department of Psychiatry, Kohnan Hospital, Tamano, Japan
| | | | - Ritsuho Tanaka
- Department of Psychiatry, Kurashiki Jinpu Hospital, Kurashiki, Japan
| | - Yumi Morisada
- Department of Psychiatry, Kurashiki Shinkeika Hospital, Kurashiki, Japan
| | - Hisakazu Itakura
- Department of Psychiatry, Okayama Psychiatric Medical Center, Okayama, Japan
| | - Hajime Honda
- Department of Psychiatry, Okayama Hidamarino-Sato Hospital, Okayama, Japan
| | - Nobuyuki Okabe
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.,Department of Psychiatry, Makibi Hospital, Kurashiki, Japan
| | - Etsuko Oshima
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Seishi Terada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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72
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Abe K, Yamashita R, Kondo K, Takayama K, Yokota O, Sato Y, Kawai M, Ishizu H, Nakashima T, Hayashi H, Nakata K, Asaba H, Kadota K, Tanaka K, Morisada Y, Oshima E, Terada S. Long-Term Survival of Patients Receiving Artificial Nutrition in Japanese Psychiatric Hospitals. Dement Geriatr Cogn Dis Extra 2016; 6:477-485. [PMID: 27843445 PMCID: PMC5091231 DOI: 10.1159/000448242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background/Aims Most patients with dementia suffer from dysphagia in the terminal stage of the disease. In Japan, most elderly patients with dysphagia receive either tube feeding or total parenteral nutrition. Methods In this study, we investigated the factors determining longer survival with artificial nutrition. Various clinical characteristics of 168 inpatients receiving artificial nutrition without oral intake in psychiatric hospitals in Okayama Prefecture, Japan, were evaluated. Results Multiple logistic regression analysis showed that the duration of artificial nutrition was associated with a percutaneous endoscopic gastrostomy (PEG) tube, diagnosis of mental disorder, low MMSE score, and absence of decubitus. Conclusion Patients with mental disorders survived longer than those with dementia diseases on artificial nutrition. A PEG tube and good nutrition seem to be important for long-term survival.
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Affiliation(s)
- Keiichi Abe
- Department of Psychiatry, Mannari Hospital, Okayama, Japan
| | | | - Keiko Kondo
- Department of Psychiatry, Sekizen Hospital, Tsuyama, Japan
| | - Keiko Takayama
- Department of Psychiatry, Kibogaoka Hospital, Tsuyama, Japan
| | - Osamu Yokota
- Department of Psychiatry, Kinoko Espoir Hospital, Kasaoka, Japan
| | - Yoshiki Sato
- Department of Psychiatry, Yura Hospital, Tamano, Japan
| | - Mitsumasa Kawai
- Department of Psychiatry, Setouchi Kinen Hospital, Setouchi, Japan
| | - Hideki Ishizu
- Department of Psychiatry, Zikei Hospital, Okayama, Japan
| | | | - Hideki Hayashi
- Department of Psychiatry, Hayashi Hospital, Okayama, Japan
| | - Kenji Nakata
- Department of Psychiatry, Taiyo Hills Hospital, Takahashi, Japan
| | - Hiroyuki Asaba
- Department of Psychiatry, Kohnan Hospital, Tamano, Japan
| | - Koichi Kadota
- Department of Psychiatry, Kurashiki Jinpu Hospital, Kurashiki, Japan
| | | | - Yumi Morisada
- Department of Psychiatry, Kurashiki Shinkeika Hospital, Kurashiki, Japan
| | - Etsuko Oshima
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Seishi Terada
- Department of Neuropsychiatry, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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73
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Smith L, Amella EJ, Nemeth L. Perceptions of Home Health Nurses Regarding Suffering, Artificial Nutrition, and Hydration in Late-Stage Dementia. Home Healthc Now 2016; 34:478-484. [PMID: 27677061 DOI: 10.1097/nhh.0000000000000459] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The purpose of this study was to explore perceptions of home healthcare nurses related to suffering, artificial nutrition and hydration in people with late-stage dementia, and if these perceptions influence care to people with dementia and their families. Part of a mixed-methods study, the qualitative portion examined perceptions of home healthcare nurses in a rural area in the southern United States. Seventeen home healthcare nurses participated in this study. Semistructured focus group interview questions were used. Constant comparative analysis was the method used for coding transcripts. Three themes emerged from the analysis: patient/family comfort, futility, and symbols of suffering. Although many of the nurses reported that artificial nutrition and hydration was of comfort to the patient and family because of the potential for "starving," they also felt it prolonged the patient's suffering due to the invasive procedure, need for restraints, and possibility of fluid overload. Several nurses felt that artificial nutrition and hydration gave a sense of false hope to the family that the patient would live longer. The perceptions of these home healthcare nurses influence their care to people with dementia and their families related to artificial nutrition and hydration, possibly based on experience. Their perceptions could influence family decisions regarding treatment options. Further research and education with home healthcare nurses is vital to ensure nurses are appropriately caring for patients with dementia and their families.
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Affiliation(s)
- Lenora Smith
- Lenora Smith, PhD, RN, is an Assistant Professor, College of Nursing, University of Alabama in Huntsville, Huntsville, Alabama. Elaine J. Amella, PhD, RN, FAAN, is a Professor, College of Nursing, Medical University of South Carolina, Charleston, South Carolina. Lynne Nemeth, PhD, RN, FAAN, is a Professor, College of Nursing, Medical University of South Carolina, Charleston, South Carolina
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74
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Lembeck ME, Pameijer CR, Westcott AM. The Role of Intravenous Fluids and Enteral or Parenteral Nutrition in Patients with Life-limiting Illness. Med Clin North Am 2016; 100:1131-41. [PMID: 27542432 DOI: 10.1016/j.mcna.2016.04.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The decision of whether or not to use artificial nutrition or hydration is one with which many health care providers, patients, and families struggle. These decisions are particularly challenging in the setting of life-limiting illness, which is often associated with a prolonged decline because of medical advances in these patient populations. A patient-centered and family-centered approach helps to attain high-quality care in this special population.
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Affiliation(s)
- Meghan E Lembeck
- Internal Medicine, PinnacleHealth Primary Care, Annville Family Medicine, 475 North Weaber Street, Annville, PA 17003, USA
| | - Colette R Pameijer
- Penn State College of Medicine, 500 University Drive, Mail Code H149, PO Box 850, Hershey, PA 17033, USA
| | - Amy M Westcott
- Geriatric and Palliative Medicine, Penn State College of Medicine, 500 University Drive, Mail Code H106, PO Box 850, Hershey, PA 17033, USA.
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75
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Mitchell SL, Mor V, Gozalo PL, Servadio JL, Teno JM. Tube Feeding in US Nursing Home Residents With Advanced Dementia, 2000-2014. JAMA 2016; 316:769-70. [PMID: 27533163 PMCID: PMC4991625 DOI: 10.1001/jama.2016.9374] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Susan L. Mitchell
- Hebrew SeniorLife Institute for Aging Research and Harvard Medical School, Boston, MA
| | - Vincent Mor
- Center for Gerontology and Health Care Research, Brown University, Providence, RI
| | - Pedro L. Gozalo
- Center for Gerontology and Health Care Research, Brown University, Providence, RI
| | - Joseph L. Servadio
- Center for Gerontology and Health Care Research, Brown University, Providence, RI
| | - Joan M. Teno
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
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Abstract
It is controversial whether tube feeding in people with dementia improves nutritional status or prolongs survival. Guidelines published by several professional societies cite observational studies that have shown no benefit and conclude that tube feeding in patients with advanced dementia should be avoided. However, all studies on tube feeding in dementia have major methodological flaws that invalidate their findings. The present evidence is not sufficient to justify general guidelines. Patients with advanced dementia represent a very heterogeneous group, and evidence demonstrates that some patients with dementia benefit from tube feeding. However, presently available guidelines make a single recommendation against tube feeding for all patients. Clinicians, patients, and surrogates should be aware that the guidelines and prior commentary on this topic tend both to overestimate the strength of evidence for futility and to exaggerate the burdens of tube feeding. Shared decision making requires accurate information tailored to the individual patient's particular situation, not blanket guidelines based on flawed data. Lay Summary: Many doctors believe that tube feeding does not help people with advanced dementia. Scientific studies suggest that people with dementia who have feeding tubes do not live longer or gain weight compared with those who are carefully hand fed. However, these studies are not very helpful because of flaws in design, which are discussed in this article. Guidelines from professional societies make a blanket recommendation against feeding tubes for anyone with dementia, but an individual approach that takes each person's situation into account seems more appropriate. Patients and surrogates should be aware that the guidelines on this topic tend both to underestimate the benefit and exaggerate the burdens of tube feeding.
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Kara O, Kizilarslanoglu MC, Canbaz B, Arik G, Varan HD, Kuyumcu ME, Kilic MK, Sumer F, Yesil Y, Yavuz BB, Cankurtaran M, Ozturk O, Kav T, Halil M. Survival After Percutaneous Endoscopic Gastrostomy in Older Adults With Neurologic Disorders. Nutr Clin Pract 2016; 31:799-804. [DOI: 10.1177/0884533616648132] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Ozgur Kara
- Hacettepe University Medical School, Department of Internal Medicine, Division of Geriatric Medicine, Ankara, Turkey
| | | | - Busra Canbaz
- Hacettepe University Medical School, Department of Internal Medicine, Division of Geriatric Medicine, Ankara, Turkey
| | - Gunes Arik
- Hacettepe University Medical School, Department of Internal Medicine, Division of Geriatric Medicine, Ankara, Turkey
| | - Hacer Dogan Varan
- Hacettepe University Medical School, Department of Internal Medicine, Division of Geriatric Medicine, Ankara, Turkey
| | - Mehmet Emin Kuyumcu
- Hacettepe University Medical School, Department of Internal Medicine, Division of Geriatric Medicine, Ankara, Turkey
| | - Mustafa Kemal Kilic
- Hacettepe University Medical School, Department of Internal Medicine, Division of Geriatric Medicine, Ankara, Turkey
| | - Fatih Sumer
- Hacettepe University Medical School, Department of Internal Medicine, Division of Geriatric Medicine, Ankara, Turkey
| | - Yusuf Yesil
- Hacettepe University Medical School, Department of Internal Medicine, Division of Geriatric Medicine, Ankara, Turkey
| | - Burcu Balam Yavuz
- Hacettepe University Medical School, Department of Internal Medicine, Division of Geriatric Medicine, Ankara, Turkey
| | - Mustafa Cankurtaran
- Hacettepe University Medical School, Department of Internal Medicine, Division of Geriatric Medicine, Ankara, Turkey
| | - Omer Ozturk
- Hacettepe University Medical School, Department of Internal Medicine, Division of Gastroenterology, Ankara, Turkey
| | - Taylan Kav
- Hacettepe University Medical School, Department of Internal Medicine, Division of Gastroenterology, Ankara, Turkey
| | - Meltem Halil
- Hacettepe University Medical School, Department of Internal Medicine, Division of Geriatric Medicine, Ankara, Turkey
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Abstract
Within the framework of the Choosing wisely initiative of the German Society for Internal Medicine, all scientific societies associated with internal medicine were requested to highlight the unnecessary or underused medical tests or procedures out of the 60 defined examples, which are of immediate relevance within the doctor-patient interaction. Each of the 12 scientific internal medicine societies compiled and substantiated 2 recommendations. This resulted in a spectrum of important recommendations covering the entire field of internal medicine. In difficult situations these recommendations should contribute to developing and supporting the dialogue with patients on an evidence-based level.
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Affiliation(s)
- U R Fölsch
- Klinik für Innere Medizin 1, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Schittenhelmstr. 12, 24105, Kiel, Deutschland.
| | - G Hasenfuß
- Klinik für Kardiologie und Pneumologie, Zentrum für Innere Medizin, Georg-August-Universität Göttingen, Göttingen, Deutschland
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79
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Stavroulakis T, McDermott CJ. Enteral feeding in neurological disorders. Pract Neurol 2016; 16:352-61. [DOI: 10.1136/practneurol-2016-001408] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2016] [Indexed: 02/06/2023]
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Ticinesi A, Nouvenne A, Lauretani F, Prati B, Cerundolo N, Maggio M, Meschi T. Survival in older adults with dementia and eating problems: To PEG or not to PEG? Clin Nutr 2016; 35:1512-1516. [PMID: 27091773 DOI: 10.1016/j.clnu.2016.04.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 02/10/2016] [Accepted: 04/01/2016] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Andrea Ticinesi
- Department of Clinical and Experimental Medicine, University of Parma, Italy; Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital (Azienda Ospedaliero-Universitaria di Parma), Parma, Italy.
| | - Antonio Nouvenne
- Department of Clinical and Experimental Medicine, University of Parma, Italy; Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital (Azienda Ospedaliero-Universitaria di Parma), Parma, Italy
| | - Fulvio Lauretani
- Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital (Azienda Ospedaliero-Universitaria di Parma), Parma, Italy
| | - Beatrice Prati
- Department of Clinical and Experimental Medicine, University of Parma, Italy; Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital (Azienda Ospedaliero-Universitaria di Parma), Parma, Italy
| | - Nicoletta Cerundolo
- Department of Clinical and Experimental Medicine, University of Parma, Italy; Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital (Azienda Ospedaliero-Universitaria di Parma), Parma, Italy
| | - Marcello Maggio
- Department of Clinical and Experimental Medicine, University of Parma, Italy; Geriatrics Clinic, Geriatric-Rehabilitation Department, Parma University Hospital (Azienda Ospedaliero-Universitaria di Parma), Parma, Italy
| | - Tiziana Meschi
- Department of Clinical and Experimental Medicine, University of Parma, Italy; Internal Medicine and Critical Subacute Care Unit, Geriatric-Rehabilitation Department, Parma University Hospital (Azienda Ospedaliero-Universitaria di Parma), Parma, Italy
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Davies JM, Gao W, Sleeman KE, Lindsey K, Murtagh FE, Teno JM, Deliens L, Wee B, Higginson IJ, Verne J. Using routine data to improve palliative and end of life care. BMJ Support Palliat Care 2016; 6:257-62. [PMID: 26928173 PMCID: PMC5013160 DOI: 10.1136/bmjspcare-2015-000994] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 12/16/2015] [Indexed: 11/04/2022]
Abstract
Palliative and end of life care is essential to healthcare systems worldwide, yet a minute proportion of research funding is spent on palliative and end of life care research. Routinely collected health and social care data provide an efficient and useful opportunity for evaluating and improving care for patients and families. There are excellent examples of routine data research in palliative and end of life care, but routine data resources are widely underutilised. We held four workshops on using routinely collected health and social care data in palliative and end of life care. Researchers presented studies from the UK, USA and Europe. The aim was to highlight valuable examples of work with routine data including work with death registries, hospital activity records, primary care data and specialist palliative care registers. This article disseminates that work, describes the benefits of routine data research and identifies major challenges for the future use of routine data, including; access to data, improving data linkage, and the need for more palliative and end of life care specific data.
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Affiliation(s)
- Joanna M Davies
- Kings College London, Cicely Saunders Institute, Department Palliative Care, Policy and Rehabilitation, London, UK
| | - Wei Gao
- Kings College London, Cicely Saunders Institute, Department Palliative Care, Policy and Rehabilitation, London, UK
| | - Katherine E Sleeman
- Kings College London, Cicely Saunders Institute, Department Palliative Care, Policy and Rehabilitation, London, UK
| | - Katie Lindsey
- National End of Life Care Intelligence Network, Public Health England, London, UK
| | - Fliss E Murtagh
- Kings College London, Cicely Saunders Institute, Department Palliative Care, Policy and Rehabilitation, London, UK
| | - Joan M Teno
- Division of Gerontology and Geriatric Medicine, Department of Medicine, Cambia Palliative Care Centre of Excellence, University of Washington, Seattle, Washington, USA
| | - Luc Deliens
- End of Life Care Research Group, University of Brussels and Ghent University, Brussels, Belgium
| | - Bee Wee
- Department of Palliative Care, Experimental Medicine Division, University of Oxford, Oxford, UK
| | - Irene J Higginson
- Kings College London, Cicely Saunders Institute, Department Palliative Care, Policy and Rehabilitation, London, UK
| | - Julia Verne
- Knowledge & Intelligence Team (South West), Public Health England, Bristol, UK
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Maeda T, Babazono A, Nishi T, Yasui M, Harano Y. Investigation of the Existence of Supplier-Induced Demand in use of Gastrostomy Among Older Adults: A Retrospective Cohort Study. Medicine (Baltimore) 2016; 95:e2519. [PMID: 26844459 PMCID: PMC4748876 DOI: 10.1097/md.0000000000002519] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The aim of this study is to clarify whether there is small area variation in the use of gastrostomy that is explained by hospital physician density, so as to detect the existence of supplier-induced demand (SID).The study design is a retrospective cohort using claim data of Fukuoka Late Elders' Health Insurance, submitted from 2010 to 2013. Study participants included 51,785 older adults who had been diagnosed with eating difficulties. We designated use of gastrostomy as an event. Multilevel logistic analyses were then used to investigate the existence of SID.After controlling for patient factors, we found significant regional level variance in gastrectomy use (median odds ratio [MOR]: 1.72, 1.37-2.51). Hospital physician density was significantly positively related with gastrostomy (adjusted OR of hospital physician density: 1.75, 1.25-2.45; P < 0.001). MORs were largely reduced for the input variable of hospital physician density.We found that the small area variation in use of gastrostomy among older adults could be explained by hospital physician density, which might indicate the existence of SID.
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Affiliation(s)
- Toshiki Maeda
- From the Department of Healthcare Administration and Management, Graduate School of Healthcare Sciences, Kyushu University, Japan
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Volkert D, Chourdakis M, Faxen-Irving G, Frühwald T, Landi F, Suominen MH, Vandewoude M, Wirth R, Schneider SM. ESPEN guidelines on nutrition in dementia. Clin Nutr 2015; 34:1052-73. [PMID: 26522922 DOI: 10.1016/j.clnu.2015.09.004] [Citation(s) in RCA: 225] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 09/10/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Older people suffering from dementia are at increased risk of malnutrition due to various nutritional problems, and the question arises which interventions are effective in maintaining adequate nutritional intake and nutritional status in the course of the disease. It is of further interest whether supplementation of energy and/or specific nutrients is able to prevent further cognitive decline or even correct cognitive impairment, and in which situations artificial nutritional support is justified. OBJECTIVE It is the purpose of these guidelines to cover these issues with evidence-based recommendations. METHODS The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds and accepted in an online survey among ESPEN members. RESULTS 26 recommendations for nutritional care of older persons with dementia are given. In every person with dementia, screening for malnutrition and close monitoring of body weight are recommended. In all stages of the disease, oral nutrition may be supported by provision of adequate, attractive food in a pleasant environment, by adequate nursing support and elimination of potential causes of malnutrition. Supplementation of single nutrients is not recommended unless there is a sign of deficiency. Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Artificial nutrition is suggested in patients with mild or moderate dementia for a limited period of time to overcome a crisis situation with markedly insufficient oral intake, if low nutritional intake is predominantly caused by a potentially reversible condition, but not in patients with severe dementia or in the terminal phase of life. CONCLUSION Nutritional care and support should be an integral part of dementia management. In all stages of the disease, the decision for or against nutritional interventions should be made on an individual basis after carefully balancing expected benefit and potential burden, taking the (assumed) patient will and general prognosis into account.
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Affiliation(s)
- Dorothee Volkert
- Institute for Biomedicine of Aging (IBA), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Nuremberg, Germany.
| | - Michael Chourdakis
- Department of Medicine, Aristotle University of Thessaloniki (AUTH), Greece
| | - Gerd Faxen-Irving
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frühwald
- Department of Geriatric Acute Care, Krankenhaus Hietzing, Vienna, Austria
| | - Francesco Landi
- Department of Geriatrics, Neurosciences and Orthopedics, Catholic University of the Sacred Heart, Rome, Italy
| | - Merja H Suominen
- Unit of Primary Health Care, Helsinki University Central Hospital, Helsinki, Finland
| | - Maurits Vandewoude
- Department of Geriatrics, Medical School, University of Antwerp, Belgium
| | - Rainer Wirth
- Institute for Biomedicine of Aging (IBA), Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Nuremberg, Germany; St. Marien-Hospital Borken, Department for Internal Medicine and Geriatrics, Borken, Germany
| | - Stéphane M Schneider
- Nutritional Support Unit, Centre Hospitalier Universitaire de Nice, Nice, France
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Abstract
An 89-year-old male nursing home resident with a 10-year history of Alzheimer’s disease presents with a temperature of 38.3°C, a productive cough, and a respiratory rate of 28 breaths per minute. Nurses report that for the past 6 months he has been coughing at breakfast and having trouble swallowing. He has profound memory deficits, no longer recognizes his daughter (who is his health care proxy), is bedbound, is able to mumble a couple of words, and is unable to perform any activities of daily living. The nurse asks whether he should be hospitalized. How should this patient be evaluated and treated?
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85
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Expectation Conversations About the Very Predictable Events in Advanced Dementia. J Am Med Dir Assoc 2015; 16:724-7. [DOI: 10.1016/j.jamda.2015.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 05/12/2015] [Indexed: 11/21/2022]
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Teno J, Meltzer DO, Mitchell SL, Fulton AT, Gozalo P, Mor V. Type of attending physician influenced feeding tube insertions for hospitalized elderly people with severe dementia. Health Aff (Millwood) 2015; 33:675-82. [PMID: 24711330 DOI: 10.1377/hlthaff.2013.1248] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Striking variation has been documented in the rates of feeding tube insertion for hospitalized patients with advanced dementia. This occurs despite the harms of the procedure, which may outweigh its benefits, and the procedure's inconsistency with care focused on the patient's comfort. Among nursing home residents with advanced dementia who were hospitalized in 2001-10 with an infection or dehydration, we found that rates of insertion of a percutaneous endoscopic gastrostomy feeding tube varied by type of attending physician. Insertion rates were markedly lower when all of a patient's attending physicians were hospitalists (1.6 percent) or nonhospitalist generalists (2.2 percent), compared to all subspecialists (11.0 percent) or a mixture of physicians by type, which typically included a subspecialist (15.6 percent). The portion of patients seen by a mixture of attending physicians increased from 28.9 percent in 2001 to 38.3 percent in 2010. Efforts to improve decision making in the care of patients with advanced dementia should include interventions to improve communication among physicians and the education of subspecialists about the merits of using feeding tubes with this population.
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87
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Nicholas LH, Bynum JPW, Iwashyna TJ, Weir DR, Langa KM. Advance directives and nursing home stays associated with less aggressive end-of-life care for patients with severe dementia. Health Aff (Millwood) 2015; 33:667-74. [PMID: 24711329 DOI: 10.1377/hlthaff.2013.1258] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The number of older adults with cognitive impairment is increasing, and such adults often require a surrogate to make decisions about health care. However, little is known about the aggressiveness of end-of-life care for these people, especially those who reside in the community. We found that cognitive impairment is common among older adults approaching the end of life, whether they live in the community or in a nursing home, and that nearly 30 percent of patients with severe dementia remained in the community until death. Among those patients, having an advance directive in the form of a living will was associated with significantly less aggressive care at the end of life, compared to similar patients without an advance directive-as measured by Medicare spending ($11,461 less per patient), likelihood of in-hospital death (17.9 percentage points lower), and use of the intensive care unit (9.4 percentage points lower). In contrast, advance directives were not associated with differences in care for people with normal cognition or mild dementia, whether they resided in the community or in a nursing home. Timely advance care planning after a diagnosis of cognitive impairment may be particularly important for older adults who reside in the community.
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88
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Flaschner E, Katz D. American Geriatrics Society Position Statement on Feeding Tubes in Advanced Dementia. J Am Geriatr Soc 2015; 63:1490-1. [DOI: 10.1111/jgs.13554] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Edward Flaschner
- Internal Medicine Department D; Shaare Zedek Medical Center; Jerusalem Israel
| | - David Katz
- Internal Medicine Department D; Shaare Zedek Medical Center; Jerusalem Israel
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89
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Abstract
An 89-year-old male nursing home resident with a 10-year history of Alzheimer’s disease presents with a temperature of 38.3°C, a productive cough, and a respiratory rate of 28 breaths per minute. Nurses report that for the past 6 months he has been coughing at breakfast and having trouble swallowing. He has profound memory deficits, no longer recognizes his daughter (who is his health care proxy), is bedbound, is able to mumble a couple of words, and is unable to perform any activities of daily living. The nurse asks whether he should be hospitalized. How should this patient be evaluated and treated?
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90
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Sur MD, Angelos P. Ethical Issues in Surgical Critical Care: The Complexity of Interpersonal Relationships in the Surgical Intensive Care Unit. J Intensive Care Med 2015; 31:442-50. [PMID: 25990272 DOI: 10.1177/0885066615585953] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 04/13/2015] [Indexed: 11/16/2022]
Abstract
A major challenge in the era of shared medical decision making is the navigation of complex relationships between the physicians, patients, and surrogates who guide treatment plans for critically ill patients. This review of ethical issues in adult surgical critical care explores factors influencing interactions among the characters most prominently involved in health care decisions in the surgical intensive care unit: the patient, the surrogate, the surgeon, and the intensivist. Ethical tensions in the surgeon-patient relationship in the elective setting may arise from the preoperative surgical covenant and the development of surgical complications. Unlike that of the surgeon, the intensivist's relationship with the individual patient must be balanced with the need to serve other acutely ill patients. Due to their unique perspectives, surgeons and intensivists may disagree about decisions to pursue life-sustaining therapies for critically ill postoperative patients. Finally, although surrogates are asked to make decisions for patients on the basis of the substituted judgment or best interest standards, these models may underestimate the nuances of postoperative surrogate decision making. Strategies to minimize conflicts regarding treatment decisions are centered on early, honest, and consistent communication between all parties.
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Affiliation(s)
- Malini D Sur
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL, USA
| | - Peter Angelos
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL, USA Bucksbaum Institute for Clinical Excellence, The University of Chicago Medicine, Chicago, IL, USA
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91
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Bentur N, Sternberg S, Shuldiner J, Dwolatzky T. Feeding tubes for older people with advanced dementia living in the community in Israel. Am J Alzheimers Dis Other Demen 2015; 30:165-72. [PMID: 24963078 PMCID: PMC10852585 DOI: 10.1177/1533317514539726] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2024]
Abstract
BACKGROUND Feeding tubes to address eating problems of older people with advanced dementia (OPAD) has been studied primarily in nursing homes. OBJECTIVES To examine the prevalence of feeding tube use among OPAD living in the community; to evaluate the characteristics, quality of care, and the burden on caregivers. METHODS A cross-sectional survey of 117 caregivers of OPAD living in the community. RESULTS Of 117 patients, 26% had feeding tubes. Compared to nonusers, feeding tube users had more use of restraints, greater problems with swallowing, more emergency room visits, and were more likely to have a legal guardian. In addition, caregivers of feeding tube users were older and reported very heavy burden of care. Half of the caregivers reported that the medical team consulted them before insertion of the feeding tube. CONCLUSION Feeding tube use in OPAD in the community is associated with negative outcomes and increased caregiver burden.
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Affiliation(s)
- Netta Bentur
- Aging Department, Myers-JDC-Brookdale Institute, Jerusalem, Israel
| | - Shelley Sternberg
- Division of Public Health, Maccabi Healthcare Services, Jerusalem, Israel Aging Department, Shaarei Zedek Medical Center Memory Clinic, Jerusalem, Israel
| | | | - Tzvi Dwolatzky
- Faculty of Health Sciences, Mental Health Center, and Center for Multidisciplinary Research in Aging, Ben-Gurion University of the Negev, Beersheva, Israel Aging Department, Rambam Health Care Campus, Haifa, Israel
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92
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Reinhardt JP, Boerner K, Downes D. The Positive Association of End-of-Life Treatment Discussions and Care Satisfaction in the Nursing Home. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2015; 11:307-322. [PMID: 26654063 DOI: 10.1080/15524256.2015.1107805] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
With the progression of dementia, the need for families and health care providers to have discussions about end-of-life (EOL) treatments arises. EOL treatment decisions often involve whether or not medical interventions intended to prolong life-such as resuscitation, artificial nutrition and hydration, and use of antibiotics-are desired. It is unclear if family satisfaction with care in the nursing home may be associated with involvement in EOL treatment discussions. The frequency of discussions that family members reported having with health care team members regarding multiple life-sustaining treatments and symptom management for their relatives with advanced dementia were examined over a 6-month period along with the association of these particular discussions with care satisfaction over time. Results showed that greater frequency of discussion of EOL treatment wishes was positively associated with higher care satisfaction scores among family members of nursing home residents with dementia. When considered together, greater frequency of discussion of artificial hydration was uniquely associated with greater care satisfaction and increased care satisfaction over time. Social workers must ensure that EOL treatment discussions with older adults in the nursing home and their family members take place and that preferences are communicated among the various interdisciplinary health team members.
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Affiliation(s)
| | - Kathrin Boerner
- b Department of Gerontology , John W. McCormack Graduate School of Policy and Global Studies, University of Massachusetts Boston , Boston , Massachusetts , USA
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93
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Schwartz DB, Barrocas A, Wesley JR, Kliger G, Pontes-Arruda A, Márquez HA, James RL, Monturo C, Lysen LK, DiTucci A. Gastrostomy Tube Placement in Patients With Advanced Dementia or Near End of Life. Nutr Clin Pract 2014; 29:829-40. [PMID: 25293595 DOI: 10.1177/0884533614546890] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
| | | | - John R. Wesley
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | - Gustavo Kliger
- Clinical Nutrition Service and Nutrition Support Unit, Austral University Hospital, Buenos Aires, Argentina
| | - Alessandro Pontes-Arruda
- Christus University School of Medicine, Fortaleza, Ceara, Brazil
- Baxter Healthcare, Singapore, Singapore
| | | | | | - Cheryl Monturo
- West Chester University of Pennsylvania, West Chester, Pennsylvania
| | | | - Angela DiTucci
- Veterans Affairs Boston Healthcare System–West Roxbury Campus, Boston, Massachusetts
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94
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Zapka J, Amella E, Magwood G, Madisetti M, Garrow D, Batchelor-Aselage M. Challenges in efficacy research: the case of feeding alternatives in patients with dementia. J Adv Nurs 2014; 70:2072-2085. [PMID: 24612316 PMCID: PMC4130777 DOI: 10.1111/jan.12365] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2014] [Indexed: 11/28/2022]
Abstract
AIMS To explore factors at the family caregiver and nursing home administrative levels that may affect participation in a clinical trial to determine the efficacy of hand feeding vs. percutaneous gastrostomy tube feeding in persons with late-stage dementia. BACKGROUND Decision-making regarding use of tube feeding vs. hand feeding for persons with late-stage dementia is fraught with practical, emotional and ethical issues and is not informed by high levels of evidence. DESIGN Qualitative case study. METHODS Transcripts of focus groups with family caregivers were reviewed for themes guided by behavioural theory. Analyses of notes from contacts with nursing home administrators and staff were reviewed for themes guided by an organizational readiness model. Data were collected between the years 2009-2012. RESULTS Factors related to caregiver willingness to participate included understanding of the prognosis of dementia, perceptions of feeding needs and clarity about research protocols. Nursing home willingness to participate was influenced by corporate approval, concerns about legal and regulatory issues, and prior relationships with investigators. CONCLUSION Participation in rigorous trials requires lengthy navigation of complex corporate requirements and training competent study staff. Objective deliberation by caregivers will depend on appropriate recruitment timing, design of recruitment materials and understanding of study requirements. The clinical standards and policy environment and the secular trends there-in have relevance to the responses of people at all levels.
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Affiliation(s)
- Jane Zapka
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Elaine Amella
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gayenell Magwood
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mohan Madisetti
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Donald Garrow
- Gulf Comprehensive Gastroenterology, Englewood, Florida, USA
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95
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Abraham RR, Girotra M, Wei JY, Azhar G. Is short-term percutaneous endoscopic gastrostomy tube placement beneficial in acutely ill cognitively intact elderly patients? A proposed decision-making algorithm. Geriatr Gerontol Int 2014; 15:572-8. [PMID: 25109444 DOI: 10.1111/ggi.12316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2014] [Indexed: 11/27/2022]
Abstract
AIM Percutaneous endoscopic gastrostomy (PEG) tube is an important method of enteral feeding for patients who require temporary or long-term artificial nutritional support to prevent or correct disease-related malnutrition. However, there is paucity of data on the utility of short-term PEG tube placements in acute illnesses in cognitively intact older adults. METHODS We present a series of seven, cognitively intact patients (age range 72-93 years), who had PEG tubes placed for short periods. These patients were diagnosed with "failure to thrive" and were managed by placing a PEG tube temporarily for nutritional management. None of these patients had terminal illness or hospice eligibility, and all of the patients were community dwellers. RESULTS All of the elderly patients experienced good outcomes in terms of their functional status and nutritional support. CONCLUSIONS Our series clearly supports the notion that short-term PEG tube placement in cognitively intact elderly patients could be a successful strategy to support them during an episode of acute illness, and to improve their nutritional deficits and survival.
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Affiliation(s)
- Rtika R Abraham
- Department of Geriatrics and Reynolds Institute of Aging, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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96
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[Dementia and otorhinolaryngologic practice]. HNO 2014; 62:621-6. [PMID: 25103990 DOI: 10.1007/s00106-014-2900-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The interaction between sensorial registration of peripheral stimuli and their central cognitive processing is not yet understood. The role of sensory deficits such as olfactory deterioration or hearing loss in the development of dementia is currently a focus of concern, with hopes of finding new diagnostic aspects and therapeutic options for multimodal treatment concepts in patients with dementia. The expertise of ENT specialists in the diagnostic and therapeutic fields of dysphagia, vestibular dysfunction and olfactory or hearing loss could make an important contribution to the development of future strategies for dealing with dementia. In this report we present up-to-date basic knowledge and ENT-specific aspects relating to the diagnostics and treatment of dementia.
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97
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98
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American Geriatrics Society feeding tubes in advanced dementia position statement. J Am Geriatr Soc 2014; 62:1590-3. [PMID: 25039796 DOI: 10.1111/jgs.12924] [Citation(s) in RCA: 162] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
When eating difficulties arise, feeding tubes are not recommended for older adults with advanced dementia. Careful hand feeding should be offered because hand feeding has been shown to be as good as tube feeding for the outcomes of death, aspiration pneumonia, functional status, and comfort. Moreover, tube feeding is associated with agitation, greater use of physical and chemical restraints, healthcare use due to tube-related complications, and development of new pressure ulcers. Efforts to enhance oral feeding by altering the environment and creating patient-centered approaches to feeding should be part of usual care for older adults with advanced dementia. Tube feeding is a medical therapy that an individual's surrogate decision-maker can decline or accept in accordance with advance directives, previously stated wishes, or what it is thought the individual would want. It is the responsibility of all members of the healthcare team caring for residents in long-term care settings to understand any previously expressed wishes of the individuals (through review of advance directives and with surrogate caregivers) regarding tube feeding and to incorporate these wishes into the care plan. Institutions such as hospitals, nursing homes, and other care settings should promote choice, endorse shared and informed decision-making, and honor preferences regarding tube feeding. They should not impose obligations or exert pressure on individuals or providers to institute tube feeding.
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99
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Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: Indications, technique, complications and management. World J Gastroenterol 2014; 20:7739-7751. [PMID: 24976711 PMCID: PMC4069302 DOI: 10.3748/wjg.v20.i24.7739] [Citation(s) in RCA: 300] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 02/26/2014] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding and nutritional support in patients with a functional gastrointestinal system who require long-term enteral nutrition. Besides its well-known advantages over parenteral nutrition, PEG offers superior access to the gastrointestinal system over surgical methods. Considering that nowadays PEG tube placement is one of the most common endoscopic procedures performed worldwide, knowing its indications and contraindications is of paramount importance in current medicine. PEG tubes are sometimes placed inappropriately in patients unable to tolerate adequate oral intake because of incorrect and unrealistic understanding of their indications and what they can accomplish. Broadly, the two main indications of PEG tube placement are enteral feeding and stomach decompression. On the other hand, distal enteral obstruction, severe uncorrectable coagulopathy and hemodynamic instability constitute the main absolute contraindications for PEG tube placement in hospitalized patients. Although generally considered to be a safe procedure, there is the potential for both minor and major complications. Awareness of these potential complications, as well as understanding routine aftercare of the catheter, can improve the quality of care for patients with a PEG tube. These complications can generally be classified into three major categories: endoscopic technical difficulties, PEG procedure-related complications and late complications associated with PEG tube use and wound care. In this review we describe a variety of minor and major tube-related complications as well as strategies for their management and avoidance. Different methods of percutaneous PEG tube placement into the stomach have been described in the literature with the “pull” technique being the most common method. In the last section of this review, the reader is presented with a brief discussion of these procedures, techniques and related issues. Despite the mentioned PEG tube placement complications, this procedure has gained worldwide popularity as a safe enteral access for nutrition in patients with a functional gastrointestinal system.
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100
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Stephens CE, Sackett N, Govindarajan P, Lee SJ. Emergency department visits and hospitalizations by tube-fed nursing home residents with varying degrees of cognitive impairment: a national study. BMC Geriatr 2014; 14:35. [PMID: 24650076 PMCID: PMC3994482 DOI: 10.1186/1471-2318-14-35] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 03/07/2014] [Indexed: 11/24/2022] Open
Abstract
Background Numerous studies indicate that the use of feeding tubes (FT) in persons with advanced cognitive impairment (CI) does not improve clinical outcomes or survival, and results in higher rates of hospitalization and emergency department (ED) visits. It is not clear, however, whether such risk varies by resident level of CI and whether these ED visits and hospitalizations are potentially preventable. The objective of this study was to determine the rates of ED visits, hospitalizations and potentially preventable ambulatory care sensitive (ACS) ED visits and ACS hospitalizations for long-stay NH residents with FTs at differing levels of CI. Methods We linked Centers for Medicare and Medicaid Services inpatient & outpatient administrative claims and beneficiary eligibility data with Minimum Data Set (MDS) resident assessment data for nursing home residents with feeding tubes in a 5% random sample of Medicare beneficiaries residing in US nursing facilities in 2006 (n = 3479). Severity of CI was measured using the Cognitive Performance Scale (CPS) and categorized into 4 groups: None/Mild (CPS = 0-1, MMSE = 22-25), Moderate (CPS = 2-3, MMSE = 15-19), Severe (CPS = 4-5, MMSE = 5-7) and Very Severe (CPS = 6, MMSE = 0-4). ED visits, hospitalizations, ACS ED visits and ACS hospitalizations were ascertained from inpatient and outpatient administrative claims. We estimated the risk ratio of each outcome by CI level using over-dispersed Poisson models accounting for potential confounding factors. Results Twenty-nine percent of our cohort was considered “comatose” and “without any discernible consciousness”, suggesting that over 20,000 NH residents in the US with feeding tubes are non-interactive. Approximately 25% of NH residents with FTs required an ED visit or hospitalization, with 44% of hospitalizations and 24% of ED visits being potentially preventable or for an ACS condition. Severity of CI had a significant effect on rates of ACS ED visits, but little effect on ACS hospitalizations. Conclusions ED visits and hospitalizations are common in cognitively impaired tube-fed nursing home residents and a substantial proportion of ED visits and hospitalizations are potentially preventable due to ACS conditions.
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Affiliation(s)
- Caroline E Stephens
- Department of Community Health Systems, University of California San Francisco, 2 Koret Way, #N531E, San Francisco, CA 94143-0608, USA.
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