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Volkert D, Beck AM, Faxén-Irving G, Frühwald T, Hooper L, Keller H, Porter J, Rothenberg E, Suominen M, Wirth R, Chourdakis M. ESPEN guideline on nutrition and hydration in dementia - Update 2024. Clin Nutr 2024; 43:1599-1626. [PMID: 38772068 DOI: 10.1016/j.clnu.2024.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 04/16/2024] [Accepted: 04/30/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND & AIMS Dementia is accompanied by a variety of changes that result in an increased risk of malnutrition and low-intake dehydration. This guideline update aims to give evidence-based recommendations for nutritional care of persons with dementia in order to prevent and treat these syndromes. METHODS The previous guideline version was reviewed and expanded in accordance with the standard operating procedure for ESPEN guidelines. Based on a systematic search in three databases, strength of evidence of appropriate literature was graded by use of the SIGN system. The original recommendations were reviewed and reformulated, and new recommendations were added, which all then underwent a consensus process. RESULTS 40 recommendations for nutritional care of older persons with dementia were developed and agreed, seven at institutional level and 33 at individual level. As a prerequisite for good nutritional care, organizations caring for persons with dementia are recommended to employ sufficient qualified staff and offer attractive food and drinks with choice in a functional and appealing environment. Nutritional care should be based on a written care concept with standardized operating procedures. At the individual level, routine screening for malnutrition and dehydration, nutritional assessment and close monitoring are unquestionable. Oral nutrition may be supported by eliminating potential causes of malnutrition and dehydration, and adequate social and nursing support (including assistance, utensils, training and oral care). Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Routine use of dementia-specific ONS, ketogenic diet, omega-3 fatty acid supplementation and appetite stimulating agents is not recommended. Enteral and parenteral nutrition and hydration are temporary options in patients with mild or moderate dementia, but not in severe dementia or in the terminal phase of life. In all stages of the disease, supporting food and drink intake and maintaining or improving nutrition and hydration status requires an individualized, comprehensive approach. Due to a lack of appropriate studies, most recommendations are good practice points. CONCLUSION Nutritional care should be an integral part of dementia management. Numerous interventions are available that should be implemented in daily practice. Future high-quality studies are needed to clarify the evidence.
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Affiliation(s)
- Dorothee Volkert
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nuremberg, Germany.
| | - Anne Marie Beck
- Dietetic and Nutritional Research Unit, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Gerd Faxén-Irving
- Division of Clinical Geriatrics, Department of Neurobiology, Care Science and Society, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Frühwald
- Department of Geriatric Acute Care, Hietzing Municipal Hospital, Vienna, Austria
| | - Lee Hooper
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Heather Keller
- Department of Kinesiology & Health Sciences, Faculty of Health, University of Waterloo, Waterloo, Canada; Schlegel-UW Research Institute for Aging, Waterloo, Canada
| | - Judi Porter
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - Elisabet Rothenberg
- Department of Nursing and Integrated Health Sciences, Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden
| | - Merja Suominen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - Rainer Wirth
- Department of Geriatric Medicine, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Michael Chourdakis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
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Turan UF, Katar MK. Evaluation of 644 Percutaneous Endoscopic Gastrostomy Patients in a Single Center. Cureus 2023; 15:e38324. [PMID: 37261172 PMCID: PMC10228164 DOI: 10.7759/cureus.38324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2023] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVE Our study aimed to review and evaluate the indications, complications, complication-related risk factors, and mortality rates of percutaneous endoscopic gastrostomy (PEG) performed in a single university hospital. METHODS We retrospectively examined hospital records of all 819 patients who underwent PEG between January 2010 and January 2019. Patients whose information was not available for various reasons, who had a history of gastrectomy, who were under 18 years old, and/or who had undergone PEG before, were excluded from the study. RESULTS The mean age of the patients was 65.12 ± 15.42 years, and the majority of the patients (60.6%) were female. In the vast majority of patients, the PEG indication was due to neurological causes (71.5%), among which the majority was a stroke. The overall complication rate in our study was 11.2%. The most common was a peristomal infection in 37 (5.7%) patients. Patients who were not under any antibiotic treatment and/or had diabetes mellitus had a higher risk for peristomal infection. Dementia increased the risk of tube dislodgement. The use of clopidogrel, the simultaneous use of aspirin and clopidogrel, and hypertension were independent risk factors for bleeding complications. The one-year mortality risk was significantly higher in patients who underwent PEG due to neurological causes compared to those who underwent PEG due to malignancy or other reasons (p = 0.021, p = 0.038, respectively). CONCLUSION The PEG procedure is a safe and feasible technique due to its low complication and mortality rate in patients with swallowing disorders who need long-term nutritional support.
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ESPEN practical guideline: Clinical nutrition and hydration in geriatrics. Clin Nutr 2022; 41:958-989. [DOI: 10.1016/j.clnu.2022.01.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 11/15/2022]
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Herb J, Rodriguez-Ormaza N, Cunningham C, Bartl N, Jadi J, Charles A, Reid T. Gastrostomy Tube Outcomes Among Surgical and Non-Surgical Services: A Retrospective Review. Am Surg 2021:31348211047173. [PMID: 34569313 DOI: 10.1177/00031348211047173] [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: 11/17/2022]
Abstract
BACKGROUND Our objective was to evaluate differences in baseline characteristics, complications, and mortality among patients receiving a gastrostomy tube (GT) by surgical or non-surgical services. METHODS We performed a retrospective analysis of adult patients who underwent GT placement from 2014 to 2017 at a single institution. Using bivariate and multivariable analyses, we compared baseline characteristics, complications, and overall 30-day mortality of patients undergoing GT placement with surgical or non-surgical services. RESULTS Of the 1339 adults who underwent GT placement, surgical and non-surgical services performed 45% (n = 609) and 55% (n = 730) procedures, respectively. Gastrostomy tube-related complications were similar (29.6% surgical vs 28.8% non-surgical, P = .76). Thirty-day mortality was higher among non-surgical services (23.7% vs 16.5%, P = .004). On multivariable analysis, this was not significant (OR 1.21, 95% CI 0.83; 1.77). CONCLUSION Surgical and non-surgical service placement of GTs had equivalent GT-related mortality and complication rates.
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Affiliation(s)
- Joshua Herb
- Department of Surgery, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nidia Rodriguez-Ormaza
- Department of Surgery, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Clark Cunningham
- Department of Surgery, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Neal Bartl
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jihane Jadi
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anthony Charles
- Department of Surgery, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Trista Reid
- Department of Surgery, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Lima DL, Miranda LEC, da Penha MRC, Lima RNCL, Dos Santos DC, Eufrânio MS, Miranda ACG, Pereira LMMB. Factors Associated with 30-Day Mortality in Patients after Percutaneous Endoscopic Gastrostomy. JSLS 2021; 25:JSLS.2021.00040. [PMID: 34456551 PMCID: PMC8372986 DOI: 10.4293/jsls.2021.00040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Introduction: Percutaneous endoscopic gastrostomy (PEG) is the main accepted method for long-term tube feeding. The aim of this study is to investigate the risk factors associated with early mortality after PEG. Methods: It is a retrospective survival analysis in a tertiary-level hospital. We reviewed the medical records of 277 patients with PEG placement. The data were analyzed by the Kaplan-Meier method. Multivariable Cox proportional regression models were also built to test the effects of PEG on mortality. Results: A total of 277 patients who submitted to PEG were studied. One-hundred and sixty (58%) were female, mean age of 73.3 ± 15.7 years. Ninety-three patients (33.6%) had diabetes mellitus and 165 (59.6%) had blood hypertension. The indications for PEG placement were chronic neurologic dysphagia in 247 (89.5%) patients and tumors and other diseases in 29 (10.5%). The 30 days proportional mortality probability rate was 13%. In a multivariate Cox proportional regression model, preoperative ICU hospitalization (HR 1.79, 95% CI 1.36–2.36, P = 0.000) and hemoglobin (HR 0.91, 95% CI 0.85–0.98, P = 0.015) were predictors of early mortality. Conclusion: In patients who had underwent PEG tube insertion for long-term nutrition, anemia and previous ICU admission were predictors of mortality at four weeks. These factors may guide physicians to discourage the indication for PEG.
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Affiliation(s)
- Diego L Lima
- Department of Surgery, Montefiore Medical Center, The Bronx, New York, USA
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Miranda LE, Penha MRCD, Miranda ACG, Lima DL, Costa MWF, Amorim ADO. RISK FACTORS ASSOCIATED WITH EARLY MORTALITY AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY IN PATIENTS AT A TERTIARY CARE CENTER IN BRAZIL: A RETROSPECTIVE SINGLE-CENTER SURVIVAL STUDY. ARQUIVOS DE GASTROENTEROLOGIA 2020; 56:412-418. [PMID: 31800738 DOI: 10.1590/s0004-2803.201900000-83] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/14/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy (PEG) is the main accepted method for long-term tube feeding. OBJECTIVE To investigate the risk factors associated with early mortality after PEG. METHODS Retrospective survival analysis in a tertiary-level center in Recife, Brazil. We reviewed the medical records of 150 patients with PEG placement. The data were analysed by the Kaplan-Meier method. Multivariable Cox proportional regression models were also built to test the effects of PEG on mortality. RESULTS A total of 150 patients who submitted to PEG were studied (70 male). Of the participants, 87 (58%) had blood hypertension; 51 (34%) patients had diabetes; 6 (4%) patients had chronic renal disease; and 6 (4%) had malignancy. Chronic neurodegenerative diseases were the more common clinical indication for PEG. The 30-day and 60-day proportional mortality probability rates were 11.05% and 15.34% respectively. A multivariate Cox proportional regression model, haemoglobin (HR 4.39, 95%CI 1.30-14.81, P=0.017) and pre-procedure UCI staying (HR 0.66, 95% CI 0.50-0.87, P=0.004) were significant predictors of early mortality.A haemoglobin cut-off value of 10.05 g/dL was shown to have a sensibility of 82.6% (61.2% to 95% CI) and an acceptable sensitivity of 59.0 (50.6% to68.6% CI), and a likelihood ratio of 2.06 for eight weeks mortality. CONCLUSION In patients who had been subjected to the PEG procedure for long-term nutrition, low haemoglobin, pre-procedure intensive care unit internment or both are associated with the risk of early mortality.
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Affiliation(s)
- Luiz Eduardo Miranda
- Universidade de Pernambuco, Hospital Universitário Oswaldo Cruz, Departamento de Cirurgia Geral e Transplante Hepático, Recife, PE, Brasil
| | - Marcel Rolland Ciro da Penha
- Universidade de Pernambuco, Hospital Universitário Oswaldo Cruz, Departamento de Cirurgia Geral e Transplante Hepático, Recife, PE, Brasil
| | | | - Diego Laurentino Lima
- Universidade de Pernambuco, Hospital Universitário Oswaldo Cruz, Departamento de Cirurgia Geral e Transplante Hepático, Recife, PE, Brasil
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ESPEN guideline on clinical nutrition and hydration in geriatrics. Clin Nutr 2018; 38:10-47. [PMID: 30005900 DOI: 10.1016/j.clnu.2018.05.024] [Citation(s) in RCA: 642] [Impact Index Per Article: 107.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 05/29/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats. AIM To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons. METHODS This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process. RESULTS We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counseling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach. CONCLUSION A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used.
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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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9
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Shin CM, Lee DH. Is Percutaneous Endoscopic Gastrostomy Acceptable in Centenarian Patients? Clin Endosc 2018; 51:1-2. [PMID: 29397652 PMCID: PMC5806917 DOI: 10.5946/ce.2018.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 11/22/2022] Open
Affiliation(s)
- Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong Ho Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Sobani ZA, Tin K, Guttmann S, Abbasi AA, Mayer I, Tsirlin Y. Safety of Percutaneous Endoscopic Gastrostomy Tubes in Centenarian Patients. Clin Endosc 2017; 51:56-60. [PMID: 28728345 PMCID: PMC5806912 DOI: 10.5946/ce.2017.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 05/26/2017] [Accepted: 06/11/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND/AIMS Percutaneous endoscopic gastrostomy (PEG) is a relatively safe procedure; however, no study has evaluated the safety of PEG tube placement in patients over the age of 100 years. METHODS We conducted a retrospective review of patient records for patients who underwent PEG tube placement. Thirty patients aged 100 years and older were identified and a random sample of 275 patients was selected for comparison. RESULTS The mean age of the patients was 80.6±16.2 years. No procedure-related deaths or major complications were identified; the overall inpatient mortality rate was 7.6%. Minor complications were noted in 4% (n=12) of the patients. Centenarian patients were predominantly female (80% [n=24] vs. 54% [n=147], p=0.006), with a mean age of 100.5±0.9 years. There was no significant difference in procedural success rates (93.3% vs. 97.4%, p=0.222) or inpatient mortality (6.7% [n=2] vs. 7.7% [n=21], p=1.000) between the two groups. However, a higher minor complication rate was noted in the older patients (13.3% [n=4] vs. 2.9% [n=8], p=0.022). CONCLUSIONS Success rates, major complications and inpatient mortality associated with PEG tubes in patients aged over 100 years are comparable to those observed in relatively younger patients at our center; however minor complication rates are relatively higher. These findings lead us to believe that PEG tubes may be safely attempted in carefully selected patients in this subset of the population.
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Affiliation(s)
- Zain A Sobani
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Kevin Tin
- Division of Gastroenterology, Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Steven Guttmann
- Long Island Jewish Forest Hills, Queens, NY, USA.,Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | - Anna A Abbasi
- Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - Ira Mayer
- Division of Gastroenterology, Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA.,Albert Einstein College of Medicine, Yeshiva University, Bronx, NY, USA
| | - Yuriy Tsirlin
- Division of Gastroenterology, Department of Medicine, Maimonides Medical Center, Brooklyn, NY, USA
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Clarke E, Pitts N, Latchford A, Lewis S. A large prospective audit of morbidity and mortality associated with feeding gastrostomies in the community. Clin Nutr 2017; 36:485-490. [DOI: 10.1016/j.clnu.2016.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 12/23/2015] [Accepted: 01/14/2016] [Indexed: 01/30/2023]
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Baeza-Monedero ME, Montero-Errasquín B, Sánchez-Corral J, Cruz-Jentoft AJ. [Use of gastrostomies in patients over 75 years old]. Rev Esp Geriatr Gerontol 2017; 52:71-74. [PMID: 27157001 DOI: 10.1016/j.regg.2016.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 03/15/2016] [Accepted: 03/17/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To describe the indications of insertion of a percutaneous gastrostomy (PG) in older patients in a university hospital, as well as patient characteristics, short and long term complications, and mortality. METHODS Retrospective descriptive study of all patients over 75 years who had a PG inserted during a three year period by the Interventional Radiology Department. The indication of the procedure was reviewed, and the incidence of complications and mortality during a 36 months follow-up period were assessed through electronic medical records. RESULTS The study included 74 patients, with a mean age of 84±6.1 years, and 57% were female. Furthermore, 40% lived in nursing homes and 80% had cognitive impairment. The main indications for PG insertion were dysphagia in severe dementia (56.8%), tumours of the oropharyngeal cavity (12.2%), Parkinson's disease (10.8%), and stroke (9.6%). PG was permanent in 90.5% of cases. The most common complication was aspiration pneumonia (32.4%). Overall mortality was 59.5% after a median follow-up of 18 months. CONCLUSIONS Dysphagia in severe dementia was the main indication for PG in patients over 75 years. This intervention did not prevent aspiration pneumonia, which was the most common complication. Mortality in patients who have a PG was high.
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Affiliation(s)
| | | | - Juan Sánchez-Corral
- Unidad de Radiología Intervencionista, Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, España
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Wirth R, Diekmann R, Fleiter O, Fricke L, Kreilkamp A, Modreker MK, Marburger C, Nels S, Schaefer R, Willschrei HP, Volkert D. [Refeeding syndrome in geriatric patients : A frequently overlooked complication]. Z Gerontol Geriatr 2017; 51:34-40. [PMID: 28070675 DOI: 10.1007/s00391-016-1160-8] [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] [Received: 05/26/2016] [Revised: 10/19/2016] [Accepted: 11/11/2016] [Indexed: 11/24/2022]
Abstract
The refeeding syndrome is a life-threatening complication that can occur after initiation of a nutrition therapy in malnourished patients. If the risk factors and pathophysiology are known, the refeeding syndrome can effectively be prevented and treated, if recognized early. A slow increase of food intake and the close monitoring of serum electrolyte levels play an important role. Because the refeeding syndrome is not well known and the symptoms may vary extremely, this complication is poorly recognized, especially against the background of geriatric multimorbidity. This overview is intended to increase the awareness of the refeeding syndrome in the risk group of geriatric patients.
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Affiliation(s)
- Rainer Wirth
- Klinik für Altersmedizin und Frührehabilitation, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Deutschland. .,Lehrstuhl für Geriatrie, Ruhr-Universität Bochum, Bochum, Deutschland.
| | - Rebecca Diekmann
- Universitätsklinik für Geriatrie, Klinikum Oldenburg, Oldenburg, Deutschland
| | - Olga Fleiter
- Klinik für Innere Medizin, Franziskus Hospital Bielefeld, Bielefeld, Deutschland
| | - Leonhardt Fricke
- Klinik für Geriatrie, St. Katharinen-Krankenhaus, Frankfurt, Deutschland
| | - Annika Kreilkamp
- Lehrstuhl für Geriatrie, Ruhr-Universität Bochum, Bochum, Deutschland
| | | | - Christian Marburger
- Klinik für Geriatrische Rehabilitation, Klinikum Christophsbad, Göppingen, Deutschland
| | - Stefan Nels
- Klinik für Geriatrie, Hochtaunus Kliniken, Bad Homburg, Deutschland
| | - Rolf Schaefer
- Klinik für Geriatrie, Marien-Krankenhaus Bergisch-Gladbach, Bergisch-Gladbach, Deutschland
| | - Heinz-Peter Willschrei
- Klinik für Innere Medizin/Geriatrie, Malteser Krankenhaus St. Josefshospital, Krefeld, Deutschland
| | - Dorothee Volkert
- Institut für Biomedizin des Alterns, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Deutschland
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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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Practice variation in PEG tube placement: trends and predictors among providers in the United States. Gastrointest Endosc 2015; 82:37-45. [PMID: 25845635 PMCID: PMC4469567 DOI: 10.1016/j.gie.2014.12.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 12/21/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND Enteral access placement is performed among a variety of providers and specialties, yet there is a dearth of literature on trends and factors related to enteral access placement in the United States. OBJECTIVE To examine trends in the incidence of enteral access procedures performed by gastroenterologists in the United States. DESIGN Retrospective review of upper endoscopic procedures that involved PEG tube placement between 2000 and 2010. SETTING Endoscopy sites participating in the Clinical Outcomes Research Initiative (CORI). PATIENTS Patients undergoing upper endoscopy. INTERVENTIONS PEG tube placement. MAIN OUTCOME MEASUREMENTS Number of PEG tubes placed. RESULTS Overall PEG tube placement by a provider from 2000 to 2010 was 1.7% (number of PEG tubes performed/number of upper endoscopies performed), with the majority of them being performed by gastroenterologists. Very young and very old, non-white racial background (Hispanic: odds ratio [OR] 1.21; 95% CI, 1.13-1.28; black: OR 2.24; 95% CI, 2.12-2.36), and men (OR 1.44; 95% CI, 1.39-1.50) were patient characteristics associated with greater PEG tube placement. In terms of practice setting, PEG tube placement occurred more frequently in community and/or health maintenance organization environments and on the East Coast. With respect to provider characteristics, male providers were less likely than female providers to perform a PEG tube insertion (OR 0.67; 95% CI, 0.64-0.71), and there was a trend that as providers were further out of medical school they were less likely to perform a PEG tube procedure. Interestingly, surgeons (OR 6.69; 95% CI, 6.18-7.24) and other providers (non-pediatric/non-general practice) (OR 3.22; 95% CI, 2.63-3.94) were more likely to perform PEG tube procedures than were gastroenterologists. LIMITATIONS Participation in CORI is voluntary and may not capture data on non-gastroenterologist providers. CONCLUSION Significant practice variation was noted in PEG tube placement in the United States with respect to patient and provider characteristics, geographic region, and endoscopy settings.
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Schneider AS, Schettler A, Markowski A, Luettig B, Kaufmann B, Klamt S, Lenzen H, Momma M, Seipt C, Lankisch T, Negm AA. Complication and mortality rate after percutaneous endoscopic gastrostomy are low and indication-dependent. Scand J Gastroenterol 2014; 49:891-8. [PMID: 24896841 DOI: 10.3109/00365521.2014.916343] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Percutaneous endoscopic gastrostomy (PEG) is often used for the feeding of patients with malnutrition due to dysphagia, and despite more than 30 years experience, numerous questions on its benefit remain. This was a prospective observational study to assess the safety of PEG. MATERIAL AND METHODS One hundred and nineteen patients mean age 63 years (21-91 years) who were admitted to the Hannover Medical School between November 2010 and March 2012 and had an indication for PEG according to the German guidelines were included. Primary endpoints were the following: reason for indication, date of in-hospital mortality after PEG insertion, death within 3 months after PEG placement, and complications. RESULTS Most patients (54.6%) received PEG for dysphagia caused by tumors and second (29.4%) for neurologic diseases with a minor proportion of dementia (3%). About 73% of our patients had no complications at all and only 10% suffered severe effects. We saw only 1 case of aspiration, which did not lead to pneumonia. The 30-day mortality was 10%, and no patient died as a result of the PEG procedure. Significantly more patients with neurologic disorders died within 24 weeks of PEG placement than tumor patients (60% versus 27.7%, respectively, p = 0.002, n = 100). CONCLUSION It is important to select patients receiving PEG very carefully. The patients' indications, their primary disease, and their capability for mental cooperation are essential. If these aspects are taken into account, PEG is a safe method with few mainly mild complications.
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Affiliation(s)
- Andrea S Schneider
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School , Hannover , Germany
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Katzenschlager R, Poewe W. Intestinal levodopa infusion in PD—the first randomized trial. Nat Rev Neurol 2014; 10:128-9. [DOI: 10.1038/nrneurol.2014.26] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Affiliation(s)
- Olivier Rascol
- Clinical Investigation Center CIC-9302, NS-Park Network and Departments of Clinical Pharmacology and Neurosciences, INSERM, Toulouse University Hospital and University Paul Sabatier Toulouse III, Toulouse, France.
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Finucane TE. Post hoc ergo propter hoc: Complications and Death after Gastrostomy Placement. J Am Med Dir Assoc 2012; 13:197-8. [DOI: 10.1016/j.jamda.2011.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 10/14/2011] [Indexed: 11/16/2022]
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Prevalence of malnutrition in orally and tube-fed elderly nursing home residents in Germany and its relation to health complaints and dietary intake. Gastroenterol Res Pract 2011; 2011:247315. [PMID: 21687611 PMCID: PMC3112531 DOI: 10.1155/2011/247315] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Accepted: 03/20/2011] [Indexed: 12/13/2022] Open
Abstract
Objective. To investigate the prevalence of malnutrition in orally and tube-fed nursing home (NH) residents in Germany and its relation to common health complaints and dietary intake. Methods. In 350 NH residents, subjects' characteristics, Mini Nutritional Assessment (MNA), and several health problems were inquired with the nursing staff using standardised interviews. In a subset of 122 residents, dietary intake was assessed by 3-day weighing records. Results. 7.7% of the participants were tube fed. 24.1% of orally nourished and 57.7% of tube-fed residents were malnourished (MNA < 17 p.). Malnutrition was significantly related to nausea/vomiting, constipation, pressure ulcers, dehydration, infections, antibiotic use, and hospitalisation. Mean daily energy intake was 1535 ± 413 kcal and mean protein intake was 54.2 ± 0.9 g/d irrespective of the nutritional state. Conclusion. In Germany, malnutrition is widespread among NH residents and is related to common health problems. The MNA rather reflects health condition than currently reduced dietary intake.
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