Tube feeding in patients with advanced dementia: knowledge and practice of speech-language pathologists

Perspectives of Speech-Language Pathologists and Students on Providing Care to People Living With Dementia: A Scoping Review

PURPOSE

This scoping review aimed to explore the extant literature on the experiences and views of speech-language pathologists (SLPs) and SLP students regarding the provision of care to people living with dementia (PLWD).

METHOD

A systematic search was conducted using 10 databases for sources published in English from January 2000 through January 2022. Sources were included if participants were practicing SLPs and/or students enrolled in undergraduate communicative disorders or graduate SLP programs and if the concepts of experiences or views on the provision of SLP services to PLWD were explored in the context of any clinical or educational setting. Included sources were systematically extracted for pertinent study characteristics, including SLP roles and settings, concept domains, measures utilized, and facilitators/barriers to effective dementia care.

RESULTS

The majority of the 29 included sources were published in either academic journals (n = 20) or professional organization publications (n = 5) and used a cross-sectional study design (n = 19). Participants included SLPs (n = 22 studies) and graduate (n = 6 studies), undergraduate (n = 3 studies), and doctoral students (n = 1 study). The included studies addressed five primary conceptual domains: experiences, attitudes, roles, knowledge, and confidence. The most commonly addressed barriers and facilitators of effective dementia care were education and training.

CONCLUSIONS

Mapping and analysis of the current body of knowledge within this scoping review illuminated several knowledge gaps that we propose need to be addressed to meet the education and training needs of SLPs to provide optimal care to PLWD. These include systematically measuring access to and outcomes of evidence-based education and training programs both within and outside of an interprofessional collaborative context.

Approaches to Eating and Drinking with Acknowledged Risk: A Systematic Review

BACKGROUND

Patients with dysphagia may consider eating and drinking with acknowledged risk (EDAR) instead of artificial hydration/nutrition. Timely consideration of complex issues is required including dysphagia reversibility, risk/benefit discussions, patient wishes, their capacity and best interests.

OBJECTIVE

This study aimed to establish if EDAR protocols improve care through a systematic literature review with a secondary aim to explore important factors for the development and success of a protocol.

METHODS

PUBMED, MEDLINE, CINAHL and EMBASE were searched for English language articles to May 2019 with terms related to EDAR, dysphagia and end of life. Articles were agreed for inclusion by three independent reviewers. Levels of evidence were assessed using the modified Sackett scale. Study themes were identified and discussed.

RESULTS

8 articles met the inclusion criteria with varied methodology. The highest level of evidence was III (cohort study). Most were limited to patients with dementia, stroke, in older person's wards or residential homes. Three articles described a systematic approach to EDAR for in-patients, reporting reductions in days nil-by-mouth until feeding plans are made and improvements in documentation of decision making, nutrition plans and capacity assessment. Five papers explored the views and knowledge of staff, patients and families/carers relating to EDAR and complex feeding decisions. Formal meta-analysis was not possible due to the level and mix of methodology.

CONCLUSION

There is a paucity of evidence to determine if EDAR protocols improve care. However, support is emerging for a coordinated approach to managing EDAR. Findings suggest having a protocol is not enough; training and communication within teams is essential, together with incorporating feedback from patients and carers, and this justifies further work.

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.

Clinical decision-making for complex feeding decisions: A national survey of current approaches and perspectives

OBJECTIVES

Decision-making around dysphagia management is becoming increasingly challenging due to the complexity of contexts associated with an ageing population. The current study explores current decision-making practices used by speech language therapists (SLTs) surrounding contexts related to palliative care, dementia, neuro-degenerative diseases, guardianship/family decisions, and other issues relevant to ongoing care of individuals with dysphagia.

METHODS

An exploratory prospective electronic survey of SLTs was conducted. A total of 202 respondents were eligible for inclusion.

RESULTS

Only 55% of respondents reported their workplace had a standard approach to documentation. Only 19% reported their service had a defined policy to support decision-making, with only 28% reporting the existence of patient information brochures.

CONCLUSION

Limited formal guidance or practice standards exist in the setting of complex dysphagia management, which limits the consistency of practice and clinical efficiency. This insight into current practices and perspectives supports the development of clinical guidelines.

Speech-Language Pathologists’ Views About Aspiration Risk and Comfort Feeding in Advanced Dementia

Background:

Speech-language pathologists (SLPs) are often called upon to assess swallowing function for older adults with advanced dementia at high risk of aspiration and make recommendations about whether the patient can safely continue oral nutrition.

Objective:

To describe the circumstances under which SLPs recommend oral nutritional intake for these patients.

Methods:

A mail survey of a national probability sample of SLPs (n = 731). Speech-language pathologists were asked if there were circumstances in which they would recommend oral feeding for patients with advanced dementia at high risk of aspiration, and if yes, to describe the circumstances under which they do so.

Results:

Six themes emerged: (1) when patient preferences are known; (2) for quality of life near end of life; (3) if aspiration risk mitigation strategies are employed; (4) if physician’s preference; (5) if aspiration risk is clearly documented and acknowledged; and (6) if SLP is knowledgeable about current evidence of lack of benefit of feeding tubes in advanced dementia or that nothing by mouth status will not necessarily prevent aspiration pneumonia.

Conclusions:

Speech-language pathologists have an important role within the interprofessional team in assessing swallowing in patients with advanced dementia, advising family and hospital staff about risks and benefits of oral feeding, and the safest techniques for doing so, to maximize quality of life for these patients near the end of life. Speech-language pathologists are often faced with balancing concerns about aspiration risk and recommending the more palliative approach of oral feeding for pleasure and comfort, potentially creating moral distress for the SLP.

Practitioner Knowledge, Personal Values, and Work Setting Influence Registered Dietitians' Feeding Tube Recommendations for Patients With Advanced Dementia

BACKGROUND

Current guidelines discourage tube-feeding older adults with advanced dementia (AD), as this practice does not improve nutrition status or survival and decreases quality of life in these patients. Because registered dietitians (RDs) often provide feeding recommendations for patients with AD, this study aimed to identify factors that influenced RDs' feeding tube recommendations for older adults with AD.

METHODS

A random sample of RDs who work with older adults in the United States completed a validated, electronic survey. Logistic regression analysis was used to identify factors related to the likelihood of RDs recommending a feeding tube for patients with AD. Independent variables included participant demographics and the 6 subscales of the Attitudes Toward Tube-Feeding in Advanced Dementia Questionnaire, which measured individual and environmental influences on RDs' recommendations.

RESULTS

Among the 662 RDs who responded, 72.2% were unlikely to recommend a feeding tube in patients with AD, and 15.4% were likely to do so (with the remaining being "neutral"). Factors associated with avoiding recommending a feeding tube include significantly higher total knowledge [odds ratio (OR) = 1.47, 95% CI (1.30, 1.66)] and personal values scores [OR = 7.51, 95% CI (3.96, 14.24)] and employment in long-term care settings [OR 3.29, 95% CI (1.38, 7.80)].

CONCLUSION

In this survey, most RDs were likely to make recommendations that are consistent with current guidelines for tube feeding patients with AD. RDs who work outside the long-term care setting may benefit from additional training. Future research is needed to understand how personal values may influence recommendations.

The Attitudes Toward Tube-Feeding in Advanced Dementia (ATT-FAD) Questionnaire: A Valid and Reliable Tool

Registered Dietitians (RDs) should participate in interdisciplinary feeding discussions for patients with advanced dementia, but research on how RDs make such feeding recommendations is scarce. This study developed and validated a theory-based questionnaire to assess the knowledge, beliefs, and attitudes of RDs regarding feeding tube use among older adults with advanced dementia. The instrument was drafted based on the Social Ecological Model, and face and content validity were established through an expert panel review. Pilot testing with 70 RDs provided an initial measure of internal consistency reliability and reduced the number of items in the survey. Efficacy testing with 662 RDs allowed for a second analysis of internal consistency reliability and eliminated additional items. Construct validity was then established using validation by extreme groups and exploratory factor analysis, yielding six subscales, each with adequate internal consistency and test-retest correlation coefficients: (I) Total Knowledge, (II) Knowledge Self-Efficacy, (III) Religion/Spirituality/Culture, (IV) Personal Values, (V) Perceived Organization and Training, and (VI) Perceived Policy. The survey, based on the Social Ecological Model, was deemed a valid and reliable tool to assess RDs' knowledge and attitudes regarding feeding tube use among older adults with advanced dementia.

Social Ecological Perspectives of Tube-Feeding Older Adults with Advanced Dementia: A Systematic Literature Review

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.

Ethically Navigating the Maze of Billing, Documentation, and Reimbursement for Dysphagia Services in Long-Term Care

Speech-language pathologists (SLPs) have an obligation to accurately record the services that they provide according to the guidelines from the patient's payer, meeting the expectations in the state's practice act and in keeping with the employer's policies relative to billing practices. Accurate, complete, and timely documentation of dysphagia services is a requirement of the ASHA Code of Ethics, as well as an expectation of employers and third-party payers, and is subject to review when determining coverage for claims submitted. Acquiring a familiarity with the myriad of policies, rules, regulations, and expectations can be likened to finding a way through a maze. Clinicians need to balance effective dysphagia service delivery with the demands of the various payers and the regulatory requirements in the SNF to practice in an ethical manner.

Dysphagia: implications for older people

Dysphagia represents a salient concern in many conditions prevalent in older people. There are direct implications for morbidity and mortality. The importance of recognizing and managing dysphagia in hospital and the community also extends to psychosocial impact and quality of life, as well as health, economic and ethical-legal issues. This review outlines reasons for the importance of recognizing and treating dysphagia. It then proceeds to look at recent developments in our understanding of the nature, assessment and management of dysphagia in older people. Whilst there are well-established practices in assessment and management, ongoing work continues to challenge the validity and reliability of many methods. These concerns are covered and directions for future developments highlighted.