Outcomes of enteral nutrition for patients with advanced dementia: a systematic review

Nutrition and Outcome of 100 Endoscopic Gastrostomy-Fed Citizens with Severe Dementia

Dementia is a rising public health concern. Feeding and nutritional problems increase as the disease progresses, affecting the clinical course and caregiver burden. While some guidelines advise against percutaneous endoscopic gastrostomy (PEG) and tube feeding in advanced dementia, conflicting evidence exists. This study aims to evaluate the nutritional status and influence of PEG feeding on the outcome and evolution of nutritional/prognosis markers of patients with severe dementia (PWSD) who underwent gastrostomy for nutritional support. We conducted a 16-year retrospective study on 100 PEG-fed PWSD with strong familial support. We evaluated the survival PEG-feeding period, safety, and objective nutritional/prognosis data on the gastrostomy day and after 3 months: Body Mass Index (BMI), Mid Upper Arm Circumference, Tricipital Skinfold, Mid-Arm Muscle Circumference, albumin, transferrin, total cholesterol, and hemoglobin. Most patients presented low values in these nutritional/prognosis parameters. No major life-threatening PEG complications were reported. The mean survival time after gastrostomy was 27.9 months (median of 17 months). Female sex, BMI recovery at 3 months, and higher baseline hemoglobin levels were associated with a reduced risk of death and increased survival time. The study concluded that, in carefully selected PWSD with strong familial support, PEG feeding can improve nutritional status and have a positive impact on survival.

Management in severe dementia: recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology

ABSTRACT Alzheimer’s disease (AD) and other neurodegenerative dementias have a progressive course, impairing cognition, functional capacity, and behavior. Most studies have focused on AD. Severe dementia is associated with increased age, higher morbidity-mortality, and rising costs of care. It is fundamental to recognize that severe dementia is the longest period of progression, with patients living for many years in this stage. It is the most heterogeneous phase in the process, with different abilities and life expectancies. This practice guideline focuses on severe dementia to improve management and care in this stage of dementia. As it is a long period in the continuum of dementia, clinical practice should consider non-pharmacological and pharmacological approaches. Multidisciplinary interventions (physical therapy, speech therapy, nutrition, nursing, and others) are essential, besides educational and support to caregivers.

Manejo das demências em fase avançada: recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia

RESUMO A doença de Alzheimer (DA) e outras demências neurodegenerativas têm um curso progressivo com comprometimento da cognição, capacidade funcional e comportamento. A maioria dos estudos enfocou a DA. A demência grave está associada ao aumento da idade, maior morbimortalidade e aumento dos custos de cuidados. É fundamental reconhecer que a demência grave é o período mais longo de progressão, com o paciente vivendo muitos anos nesta fase. É a fase mais heterogênea do processo, com diferentes habilidades e expectativa de vida. Esta diretriz de prática concentra-se na demência grave para melhorar o manejo e o cuidado nessa fase da demência. Como um longo período no continuum da demência, as abordagens não farmacológicas e farmacológicas devem ser consideradas. Intervenções multidisciplinares (fisioterapia, fonoaudiologia, nutrição, enfermagem, entre outras) são essenciais, além de educacionais e de apoio aos cuidadores.

Managing feeding needs in advanced dementia: perspectives from ethics of care and ubuntu philosophy

The response to feeding needs in advanced dementia patients is a subject of ethical inquiry. Advanced dementia is the debilitating result of a range of neurodegenerative diseases. As this terminal illness progresses, patients develop mild to severe dysphagia that can make swallowing difficult. Of the two available options, artificial tube feeding or oral hand feeding, an estimated one-third of these patients will receive artificial tube feeding. However, observational studies have failed to validate the clinical benefits of tube feeding. Ethics of care, the feminist philosophical perspective, and Ubuntu philosophy offer arguments for the choice of oral hand-feeding as a preferrable first option by caregivers as far as possible. These moral theories acknowledge that human beings can be dependent for long periods, mostly early and later years of life. Both views reflect an approach that draws people into a system of interdependent caring relationships. They encourage hand feeding as a way of exhibiting solidarity and respecting human dignity even at the end of life.

Palliative and end-of-life care for people living with dementia in rural areas: A scoping review

Background and objectives

People living with dementia deserve to experience the benefits of receiving palliative care and end-of-life services and supports, yet they often do not receive this care compared to those with other terminal diseases. People living with dementia in rural areas often face additional challenges to accessing such care. The purpose of this scoping review was to systematically review and synthesize the literature on palliative and end-of-life care for people with dementia living in rural areas, and to identify and describe key findings and gaps in the literature.

Methods

A collaborative research team approach was used in an iterative process across all stages of this review. Systematic, comprehensive searches were conducted across ten databases and eight targeted websites for relevant peer-reviewed, original research and other less formal literature, published in English, which yielded a total of 4476 results. After duplicate removal, screening, and review, 24 items were included for synthesis.

Results

All items were described and illustrated by frequency distribution, findings were grouped thematically, and five key themes emerged, including: 1) Knowledge about dementia, 2) Availability, accessibility, and utilization of palliative and end-of-life care services and supports, 3) Decision-making about care, the value of a person-centered approach and collaborative support, 4) Perspectives on artificial nutrition, hydration, and comfort care, and 5) Quality of life and death. The main gap identified was literature pertaining to rural populations, especially from locations other than the United States. The influence of rurality on relevant findings was mixed across rural-urban comparison studies, as was the effect of sex and gender across the literature.

Conclusions

Several areas were highlighted including the importance of increasing knowledge about dementia, having early conversations about advanced care and treatment options, providing a person-centered approach, and the potential for using technology to address rural access issues. These findings can be used to inform future research and policy and the development of services, supports, and strategies for rural people living with dementia. Further research is recommended.

The Efficacy and Safety of Tube Feeding in Advanced Dementia Patients: A Systemic Review and Meta-Analysis Study

OBJECTIVES

The current study aimed to conduct a systematic review and meta-analysis to explore the efficacy and safety of tube feeding in patients with advanced dementia.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

PubMed, Medline, Embase, and Cochrane Library were searched from inception until March 7, 2020, to obtain relevant studies.

INTERVENTION

Feeding with nasogastric tube or percutaneous endoscopic gastrostomy (PEG).

MEASURES

We evaluated the associations of tube feeding and the risk of mortality, period of survival days, tube-related complications, and nutritional status. Data from original studies were synthesized by using a random-effects model. Each selected article was assessed for bias using the Newcastle-Ottawa Scale. A narrative synthesis and pooled analyses are reported.

RESULTS

Twelve trials were eligible, involving 1805 patients with tube feeding (mean age: 82.8 years; 71.3% female) and 3861 without tube feeding (mean age: 82.7; 68.7% female). For mortality rate, patients with advanced dementia with tube feeding are associated with significantly higher mortality rate [k = 8; odds ratio (OR) 1.79; 95% confidence interval (CI) 1.04-3.07; P = .03]. Initially, no association was found for the risk of pneumonia and pressure sore between groups. However, sensitivity analysis showed patients with advanced dementia with PEG tube feeding have significantly higher risk of pneumonia (OR 3.56; 95% CI 2.32-5.44; P < .001) and pressure sore (OR 2.25; 95% CI 1.92-2.63; P < .001). Finally, no association was found for the survival period and nutritional status between groups.

CONCLUSIONS AND IMPLICATIONS

This meta-analysis indicates that tube feeding is associated with increased mortality rate and possible tube-related complications, but not improves with prolonging survival days and nutritional status. Shared decision-making routinely before insertion of a tube between caregivers and physicians is recommended.

Tube Feeding in Individuals with Advanced Dementia: A Review of Its Burdens and Perceived Benefits

Background

Dementia remains a growing concern for societies globally, particularly as people now live longer. About 90% of individuals with advanced dementia suffer from eating problems that lead to general health decline and ultimately impacts upon the physical, psychological, and economic wellbeing of the individuals, caregivers, and the wider society.

Objective

To evaluate the burdens and perceived benefits of tube feeding in individuals with advanced dementia.

Design

Narrative review.

Methods

Computerized databases, including PubMed, Embase, Medline, CINAHL, PsycInfo, and Google Scholar were searched from 2000 to 2019 to identify research papers, originally written in or translated into English language, which investigated oral versus tube feeding outcome in individuals with advanced dementia.

Results

Over 400 articles were retrieved. After quality assessment and careful review of the identified articles, only those that met the inclusion criteria were included for review.

Conclusion

Tube feeding neither stops dementia disease progression nor prevents imminent death. Each decision for feeding tube placement in individuals with advanced dementia should be made on a case-by-case basis and involve a multidisciplinary team comprising experienced physicians, nurses, family surrogates, and the relevant allied health professionals. Careful considerations of the benefit-harm ratio should be discussed and checked with surrogate families if they would be consistent with the wishes of the demented person. Further research is required to establish whether tube feeding of individuals with advanced dementia provides more burdens than benefits or vice-versa and evaluate the impacts on quality of life and survival.

Enteral versus oral feeding in advanced dementia

The global population is aging, and with this demographic shift, the incidence and prevalence of dementia are expected to increase. According to the World Health Organization, an estimated 50 million people are living with dementia worldwide, and this number is expected to triple to 150 million by 2050. Dementia initially affects the brain, eventually affecting the entire body culminating in death, commonly from the complications and comorbidities. People with dementia often experience eating difficulties in addition to a severe decline in cognitive, verbal, and functional abilities secondary to gradual neurodegenerative process, leading to weight loss, malnutrition, and dehydration. When eating difficulties and weight loss occur, health care providers and families often feel obligated to decide to either continue the oral feeding or opt for feeding tube placement. Primary care clinicians, both nurse practitioners and physicians, are presented with challenges when facilitating the decision regarding the feeding options in patients with advanced dementia. This narrative review aims at evaluating the impact of enteral nutrition versus oral feeding by comparing the rates of survival and adverse events in older adults with advanced dementia. It also highlights the best approaches to optimizing nutrition for this frail population.

Tube feeding decreases pneumonia rate in patients with severe dementia: comparison between pre- and post-intervention

Background

It is widely supposed that there is no benefit, including extended survival and decreased rate of pneumonia, in patients with severe dementia receiving enteral tube feeding (TF). However, there have been few studies comparing the frequency of pneumonia before and after TF in severe dementia.

Methods

Nine psychiatric hospitals in Okayama Prefecture participated in this retrospective survey. All inpatients fulfilling the entry criteria were evaluated. All subjects suffered from difficulty in oral intake. Attending physicians thought that the patients could not live without long-term artificial nutrition, and they decided whether or not to make use of long-term artificial nutrition from January 1, 2014 to December 31, 2014.

Results

We evaluated 58 patients including 46 with TF and 12 without. The mean age of all patients was 79.6 ± 9.0 years old. Patients with probable Alzheimer’s disease (n = 38) formed the biggest group, and those with vascular dementia the second (n = 14). Median survival times were 23 months among patients with TF and two months among patients without TF. The start of TF decreased the frequency of pneumonia and the use of intravenous antibiotics.

Conclusions

TF decreased pneumonia and antibiotic use, even in patients with severe dementia. The results of this study do not necessarily indicate that we should administer TF to patients with severe dementia. We should consider the quality of life of patients carefully before deciding the use or disuse of TF for patients with severe dementia.

Survival times with and without tube feeding in patients with dementia or psychiatric diseases in Japan

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.

Is tube feeding futile in advanced dementia?

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.

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

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.

Person-centered Feeding Care: A Protocol to Re-introduce Oral Feeding for Nursing Home Patients with Tube Feeding

BACKGROUND

Although the literature on nursing home (NH) patients with tube feeding (TF) has focused primarily on the continuation vs. discontinuation of TF, the reassessment of these patients for oral feeding has been understudied. Re-assessing patients for oral feeding may be better received by families and NH staff than approaches focused on stopping TF, and may provide an opportunity to address TF in less cognitively impaired patients as well as those with end-stage conditions. However, the literature contains little guidance on a systematic interdisciplinary team approach to the oral feeding reassessment of patients with TF, who are admitted to NHs.

METHODS

This project had two parts that were conducted in one 170-bed intermediate/skilled, Medicare-certified NH in Honolulu, Hawai'i. Part 1 consisted of a retrospective observational study of characteristics of TF patients versus non-tube fed patients at NH admission (2003-2006) and longitudinal follow-up (through death or 6/30/2011) with usual care of the TF patients for outcomes of: feeding and swallowing reassessment, goals of care reassessment, feeding status (TF and/or per oral (PO) feedings), and hospice status. Part 2 involved the development of an interdisciplinary TF reassessment protocol through working group discussions and a pilot test of the protocol on a new set of patients admitted with TF from 2011-2014.

RESULTS

Part 1: Of 238 admitted patients, 13.4% (32/238) had TF. Prior stroke and lack of DNR status was associated with increased likelihood of TF. Of the 32 patients with TF at NH admission, 15 could communicate and interact (mild, moderate or no cognitive impairment with prior stroke or pneumonia); while 17 were nonverbal and/or bedbound patients (advanced cognitive impairment or terminal disease). In the more cognitively intact group, 9/15 (60%) were never reassessed for tolerance of oral diets and 10/15 (66.7%) remained with TF without any oral feeding until death. Of the end-stage group, 13/17 (76.5%) did not have goals of care reassessed and remained with TF without oral feeding until death. Part 2: The protocol pilot project included all TF patients admitted to the facility in 2011-2014 (N=33). Of those who were more cognitively intact (n=22), 21/22 (95.5%) had swallowing reassessed, 11/22 (50%) resumed oral feedings but 11 (50%) failed reassessment and continued exclusive TF. Of those with end-stage disease (n=11), 100% had goals of care reassessed and 9 (81.8%) families elected individualized oral feeding (with or without TF).

CONCLUSION

Using findings from our retrospective study of usual care, our NH's interdisciplinary team developed and pilot-tested a protocol that successfully reintroduced oral feedings to tube-fed NH patients who previously would not have resumed oral feeding.