Does feeding tube insertion and its timing improve survival?

Characteristics of older adults receiving enteral feeding at a geriatric medical center

BACKGROUND

Malnutrition is a prevalent and hard-to-treat condition in older adults. enteral feeding is common in acute and long-term care. Data regarding the prognosis of patients receiving enteral feeding in geriatric medical settings is lacking. Such data is important for decision-making and preliminary instructions for patients, caregivers, and physicians. This study aimed to evaluate the prognosis and risk factors for mortality among older adults admitted to a geriatric medical center receiving or starting enteral nutrition (EN).

METHODS

A cohort retrospective study, conducted from 2019 to 2021. Patients admitted to our geriatric medical center who received EN were included. Data was collected from electronic medical records including demographic, clinical, and blood tests, duration of enteral feeding, Norton scale, and Short Nutritional Assessment Questionnaire score. Mortality was assessed during and after hospitalization. Data were compared between survivors and non-survivors. Multivariate logistic regressions were performed to identify the variables most significantly associated with in-hospital mortality.

RESULTS

Of 9169 patients admitted, 124 (1.35%) received enteral feeding tubes. More than half of the patients (50.8%) had polypharmacy (over 8 medications), 62% suffered from more than 10 chronic illnesses and the majority of patients (122/124) had a Norton scale under 14. Most of the patients had a nasogastric tube (NGT) (95/124) and 29 had percutaneous endoscopic gastrostomies (PEGs). Ninety patients (72%) died during the trial period with a median follow-up of 12.7 months (0.1-62.9 months) and one-year mortality was 16% (20/124). Associations to mortality were found for marital status, oxygen use, and Red Cell Distribution Width (RDW). Age and poly-morbidity were not associated with mortality.

CONCLUSION

In patients receiving EN at a geriatric medical center mortality was lower than in a general hospital. The prognosis remained grim with high mortality rates and low quality of life. This data should aid decision-making and promote preliminary instructions.

When to feed after percutaneous endoscopic gastrostomy: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Initiation of feeding after percutaneous endoscopic gastrostomy (PEG) placement has been debated. Randomized controlled trials (RCTs) have been performed on early feeding compared with delayed feeding after PEG placement with varying results. Therefore, a meta-analysis was conducted examining early vs delayed feeding after placement of a PEG.

METHODS

A comprehensive search of databases was conducted in January 2024. Peer-reviewed published RCTs comparing early feeding (≤4 h) with delayed feeding (>4 h) were identified and included in the meta-analysis. Meta-analysis was completed using pooled estimates of overall complications, individual complications, mortality ≤72 h, and number of day 1 significant gastric residual volumes.

RESULTS

Six RCTs (n = 467) were included in the analysis. Comparison of early feeding with delayed feeding after PEG showed no statistically significant differences for overall complications (P = 0.18), mortality ≤72 h (P = 0.3), and number of day 1 significant gastric residual volumes (P = 0.05). No differences were also noted for individual complications, including vomiting, wound infection, bleeding, or diarrhea.

CONCLUSION

Feeding ≤4 h after PEG have no differences in minor and major complications compared with that of delayed feeding. Early feeding ≤4 h is safe and should be recommended in future guidelines.

ESPEN guideline on nutrition and hydration in dementia - Update 2024

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.

Outpatient neuropalliative care

Palliative care is an approach to patient care that focuses on enhancing quality of life through relief of physical, emotional, and spiritual sources of distress and patient-tailored discussions about goals of care. The palliative care approach can be delivered by any provider, and can occur alongside disease-modifying therapies. For patients with a serious neurologic illness or a neurodegenerative disease, neuropalliative care is a growing field focused on providing high-quality palliative care to neurology patients. There are three models of neuropalliative care delivery in the outpatient setting: a consultative model with a palliative care specialist, an integrated model with an embedded palliative care provider, and a primary palliative care model with the patient's neurology provider. The main components of an outpatient palliative care visit include symptom assessment and treatment, communication about serious illness, advance care planning, and assessment of caregiver needs. For patients with advanced illness, palliative care can help facilitate timely referral to hospice. Through a palliative care approach, outpatient care for patients with serious neurologic disease or neurodegenerative disease can focus on the issues most important to the patient, promote improved illness understanding and planning, and can improve the overall quality of care.

Factors Associated with In-Hospital Mortality in Elderly Internal Medicine Patients with Nasogastric Tube Feeding

Purpose

To evaluate demographic, clinical, and laboratory variables, and their associations with in-hospital mortality, among elderly internal medicine patients with nasogastric tube (NGT) feeding.

Patients and Methods

Demographic, clinical, and laboratory data were collected retrospectively for 129 patients aged ≥80 years who initiated NGT feeding during their hospitalization in internal medicine wards. The data were compared between survivors and non-survivors. Multivariate logistic regressions were performed to identify the variables most significantly associated with in-hospital mortality.

Results

The in-hospital mortality rate was 60.5%. Compared to survivors, non-survivors more often presented with pressure sores (P=0.005) and lymphopenia (P<0.001), were more often treated with invasive mechanical ventilation (P<0.001), and less often underwent geriatric assessment (P<0.001). Non-survivors demonstrated higher mean levels of C-reactive protein, and lower mean values of serum cholesterol, triglycerides, total protein, and albumin (P<0.001 for all comparisons). On multivariate analysis, the following variables were most significantly associated with in-hospital mortality in the entire cohort: the presence of pressure sores (odds ratio [OR], 4.34; 95% confidence interval [CI], 1.68-11.48; P=0.003) and lymphopenia (OR, 4.09; 95% CI, 1.51-11.08; P=0.006), and serum cholesterol (OR, 0.98; 95% CI, 0.96-0.99; P=0.003).

Conclusion

Among elderly acutely ill patients who initiated NGT feeding during hospitalization, in-hospital mortality was extremely high. The factors most strongly associated with in-hospital mortality were the presence of pressure sores and lymphopenia, and lower serum cholesterol levels. These findings may provide useful prognostic information for decision-making regarding initiation of NGT feeding in elderly hospitalized patients.

When Should the Appropriateness of PEG be Questioned?

PURPOSE OF REVIEW

This review aims to analyze the evidence regarding the appropriateness of PEG placement in the following clinical situations: short bowel syndrome, head and neck cancer, dementia and palliative use in malignant bowel obstruction.

RECENT FINDINGS

Percutaneous endoscopic gastrostomy (PEG) tubes are placed for a variety of clinical indications by numerous different specialties. First described in 1980, PEG tubes are now the dominant method of enteral access. Typically, PEG tubes are technically feasible procedures that can come with significant risk for both minor and major complications. Therefore, it is important to perform an in-depth, patient specific risk-benefit analysis when considering insertion. By analyzing the current evidence regarding benefits in these situations, superimposed by the lens of biomedical ethics, we make recommendations that are accessible to any provider who may be a consultant or proceduralist, helping to provide informed care that is in the patient's best interest.

Executive summary of the position paper on the use of enteral nutrition in advanced dementia

Dementia is an increasingly prevalent disease in our environment, with significant health and social repercussions. Despite the available scientific evidence, there is still controversy regarding the use of enteral tube nutrition in people with advanced dementia. This document aims to reflect on the key aspects of advanced dementia, tube nutritional therapy and related ethical considerations, as well as to respond to several frequent questions that arise in our daily clinical practice.

Decision Aid Interventions for Family Caregivers of Persons With Advanced Dementia in Decision-Making About Feeding Options: A Scoping Review

OBJECTIVES

We provided an overview of the literature on decision aid interventions for family caregivers of older adults with advanced dementia regarding decision making about tube feeding. We synthesized (1) the use of theory during the development, implementation, and evaluation of decision aids; (2) the development, content, and delivery of decision aid interventions; (3) caregivers' experience with decision aid interventions; and (4) the effect of decision aid interventions on caregivers' quality of decision-making about feeding options.

DESIGN

Scoping review.

METHODS

We conducted a scoping review of peer-reviewed studies published January 1, 2000-June 30, 2022, in MEDLINE, EMBASE, The Cochrane Library, CINAHL, and Web of Science databases. The process was guided by Arksey and O'Malley's methodological framework, which includes identifying the research question, choosing related studies, charting the data, and summarizing results. Empirical articles concerning the decision aid interventions about feeding options were selected.

RESULTS

Six publications reporting 4 unique decision aid interventions were included. All the interventions targeted caregivers of older adults with advanced dementia. Three decision aids were culturally adapted from existing decision aids. The Ottawa Decision Support Framework and the International Patient Decision Aid Standards Framework were used in these 6 publications. Interventions aimed to improve decision making regarding tube feeding for caregivers through static delivery methods. Caregivers rated these decision aids as helpful and acceptable. Decisional conflict and knowledge of feeding options were the most common outcomes evaluated. Reduction in decisional conflict and increase in knowledge were consistently found among dementia caregivers, but no intervention effects were found on preferences for the use of tube feeding.

CONCLUSIONS AND IMPLICATIONS

Decision aid interventions effectively improve decision-making regarding tube feeding among the target population. Cultural adaptation of an existing decision aid intervention is the main strategy. However, the lack of guidance of a cultural adaptation framework in this process may lead to difficulties explaining caregivers' behavioral changes. Moreover, merely providing information is not enough to change caregivers' preferences or behavior of use of tube feeding. A systematic approach to cultural adaptation and interactive intervention is needed in future studies.

The Treatment and Prognosis of Older Tuberculosis Patients with a Poor Performance Status Caused by Underlying Diseases

Objective The incidence of tuberculosis in Japan has been decreasing in the overall population but is increasing in older patients ≥90 years old. A poor performance status due to underlying diseases makes it difficult for patients with tuberculosis to receive standard oral treatment. However, there is no consensus concerning alternative treatments. This study examined the treatments and outcomes of older patients with tuberculosis and a poor performance status and determined the limitations of tuberculosis treatment for them. Patients and Methods We retrospectively enrolled 121 older patients with tuberculosis and a performance status of 3 or 4 due to underlying diseases during their hospitalization between April 2015 and March 2017 at National Hospital Organization Tokyo National Hospital. We classified them according to the drug administration route (oral, enteral, and injection routes) on admission and compared the characteristics and prognoses among the three groups. Results There were 79 patients in the oral route group, 28 (35.4%) of whom died during hospitalization. Among the 15 patients in the enteral route group, 6 (40.0%) died. Among the 27 patients in the injection route group who received non-oral agents, 22 (81.5%) died. The prognosis of the injection route group was poor, with a median survival time of 21 days. Conclusion Treatment success cannot be expected with injection treatment in patients with a poor general condition because of complications. Although injection treatment may be a viable alternative treatment, its establishment as the standard treatment cannot be currently endorsed.

Improving communication about goals of care for hospitalized patients with serious illness: Study protocol for two complementary randomized trials

BACKGROUND

Although goals-of-care discussions are important for high-quality palliative care, this communication is often lacking for hospitalized older patients with serious illness. Electronic health records (EHR) provide an opportunity to identify patients who might benefit from these discussions and promote their occurrence, yet prior interventions using the EHR for this purpose are limited. We designed two complementary yet independent randomized trials to examine effectiveness of a communication-priming intervention (Jumpstart) for hospitalized older adults with serious illness.

METHODS

We report the protocol for these 2 randomized trials. Trial 1 has two arms, usual care and a clinician-facing Jumpstart, and is a pragmatic trial assessing outcomes with the EHR only (n = 2000). Trial 2 has three arms: usual care, clinician-facing Jumpstart, and clinician- and patient-facing (bi-directional) Jumpstart (n = 600). We hypothesize the clinician-facing Jumpstart will improve outcomes over usual care and the bi-directional Jumpstart will improve outcomes over the clinician-facing Jumpstart and usual care. We use a hybrid effectiveness-implementation design to examine implementation barriers and facilitators.

OUTCOMES

For both trials, the primary outcome is EHR documentation of a goals-of-care discussion within 30 days of randomization; additional outcomes include intensity of end-of-life care. Trial 2 also examines patient- or family-reported outcomes assessed by surveys targeting 3-5 days and 4-8 weeks after randomization including quality of goals-of-care communication, receipt of goal-concordant care, and psychological symptoms.

CONCLUSIONS

This novel study incorporates two complementary randomized trials and a hybrid effectiveness-implementation approach to improve the quality and value of care for hospitalized older adults with serious illness.

CLINICAL TRIALS REGISTRATION

STUDY00007031-A and STUDY00007031-B.

Facility Characteristics Associated With Intensity of Care of Nursing Homes and Hospital Referral Regions

OBJECTIVES

Intensity of care, such as hospital transfers and tube feeding of residents with advanced dementia varies by nursing home (NH) within and across regions. Little work has been done to understand how these 2 levels of influence relate. This study's objectives are to identify facility factors associated with NHs providing high-intensity care to residents with advanced dementia and determine whether these factors differ within and across hospital referral regions (HRRs).

DESIGN

Cross-sectional analysis.

SETTING AND PARTICIPANTS

1449 NHs.

METHODS

Nationwide 2016-2017 Minimum Data Set was used to categorize NHs and HRRs into 4 levels of care intensity based on rates of hospital transfers and tube feeding among residents with advanced dementia: low-intensity NH in a low-intensity HRR, high-intensity NH in a low-intensity HRR, low-intensity NH in a high-intensity HRR, and a high-intensity NH in a high-intensity HRR.

RESULTS

In high-intensity HRRs, high-vs low-intensity NHs were more likely to be urban, lack a dementia unit, have a nurse practitioner or physician (NP or PA) on staff, and have a higher proportion of residents who were male, aged <65 years, Black, had pressure ulcers, and shorter hospice stays. In low-intensity HRRs, higher proportion of Black residents was the only characteristic associated with being a high-intensity NH.

CONCLUSIONS AND IMPLICATIONS

These findings suggest that within high-intensity HRRs, there are potentially modifiable factors that could be targeted to reduce burdensome care in advanced dementia, including having a dementia unit, palliative care training for NPs and PAs, and increased use of hospice care.

[Mortality in patients with dementia admitted in critical care units]

OBJECTIVE

To determine the mortality and comorbidities associated of patients with dementia admitted to the Intensive Care Unit (ICU) on the hospitalization and at one year of follow-up.

MATERIALS AND METHODS

A retrospective observational cohort study was carried out between 2012 and 2017 at the Hospital Italiano de San Justo, of patients who were admitted to the ICU, these were observed up to hospitalary death, out hospital death one year of hospitalization, the disenrollment from the institution's health plan or the end of the follow-up.

RESULTS

A total of 163 patients were included for analysis. We recorded those 79 patients (48.47%) died one year after the hospitalization, of them 25 (15.34%) in ICU and 8 (4.91%) in general room. The most frequent causes of death were respiratory. The factors most associated with mortality were: orotracheal intubation (HR=2.01; 95% CI: 1.11-3.65; P=.02), history of leukemia (HR=8.55; 95% CI: 1.82-40.05; P≤.05), elevated Charlson (HR=1.16, 95% CI: 1.04-1.41; P=.05), and elevated APACHE II at admission (HR=1.07; 95% CI: 1.03-1.11; P≤.05).

CONCLUSIONS

The present study expresses the prognosis of patients with a diagnosis of dementia admitted to the ICU and that depends not only on their baseline neurological status but also on the severity at admission and comorbidities.

Reduced Pneumonia Risk in Advanced Dementia Patients on Careful Hand Feeding Compared With Nasogastric Tube Feeding

OBJECTIVES

To compare survival and pneumonia risk among hospitalized patients with advanced dementia on nasogastric tube feeding (NGF) vs careful hand feeding (CHF) and to examine outcomes by feeding problem type.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Advanced dementia patients aged ≥60 years with indication for tube feeding admitted to 2 geriatric convalescent hospitals between January 1, 2015, and June 30, 2019.

METHODS

Comparison on the effect of NGF and CHF on survival and pneumonia risk using Kaplan Meier survival analysis and Cox proportional hazards models.

RESULTS

Of the 764 patients (mean age 89 years, 61% female, 74% residential care home residents), 464 (61%) were initiated on NGF and 300 (39%) on CHF. The primary feeding problem types were dysphagia (50%), behavioral feeding problem (33%), or both (17%). There was no difference in 1-year survival rate between NGF and CHF groups (36% vs 37%, P = .71) and survival did not differ by feeding problem type. Nasogastric tube feeding was not a significant predictor for survival (adjusted hazard ratio 1.15, 95% CI 0.94-1.39). Among 577 (76%) patients who survived to discharge, pneumonia rates were lower in the CHF group (48% vs 60%, P = .004). After adjusting for cofounders, NGF was a significant risk factor for pneumonia (adjusted hazard ratio 1.41, 95% CI 1.08-1.85). In subgroup analyses, NGF was associated with increased pneumonia risk for patients with both dysphagia and behavioral feeding problem (P = .01) but not in patients with behavioral feeding problem alone (P = .24) or dysphagia alone (P = .30).

CONCLUSIONS AND IMPLICATIONS

For advanced dementia patients with feeding problems, there is no difference in survival between NGF and CHF. However, NGF is associated with a higher pneumonia risk, particularly for patients with both dysphagia and behavioral feeding problem. Further research on how the feeding problem type impacts pneumonia risk for patients on NGF is needed.

Association of Nursing Home Organizational Culture and Staff Perspectives With Variability in Advanced Dementia Care: The ADVANCE Study

IMPORTANCE

Regional, facility, and racial and ethnic variability in intensity of care provided to nursing home residents with advanced dementia is well documented but poorly understood.

OBJECTIVE

To assess the factors associated with facility and regional variation in the intensity of care for nursing home residents with advanced dementia.

DESIGN, SETTING, AND PARTICIPANTS

In the ADVANCE (Assessment of Disparities and Variation for Alzheimer Disease Nursing Home Care at End of Life) qualitative study, conducted from June 1, 2018, to July 31, 2021, nationwide 2016-2017 Medicare Minimum Data Set information identified 4 hospital referral regions (HRRs) with high (n = 2) and low (n = 2) intensity of care for patients with advanced dementia based on hospital transfer and tube-feeding rates. Within those HRRs, 14 facilities providing relatively high-intensity and low-intensity care were recruited. A total of 169 nursing home staff members were interviewed, including administrators, directors of nursing, nurses, certified nursing assistants, social workers, occupational therapists, speech-language pathologists, dieticians, medical clinicians, and chaplains.

MAIN OUTCOMES AND MEASURES

Data included 275 hours of observation, 169 staff interviews, and abstraction of public nursing home material (eg, websites). Framework analyses explored organizational factors and staff perceptions across HRRs and nursing homes in the following 4 domains: physical environment, care processes, decision-making processes, and implicit and explicit values.

RESULTS

Among 169 staff members interviewed, 153 (90.5%) were women, the mean (SD) age was 47.6 (4.7) years, and 54 (32.0%) were Black. Tube-feeding rates ranged from 0% in 5 low-intensity facilities to 44.3% in 1 high-intensity facility, and hospital transfer rates ranged from 0 transfers per resident-year in 2 low-intensity facilities to 1.6 transfers per resident-year in 1 high-intensity facility. The proportion of Black residents in facilities ranged from 2.9% in 1 low-intensity facility to 71.6% in 1 high-intensity facility, and the proportion of Medicaid recipients ranged from 45.3% in 1 low-intensity facility to 81.3% in 1 high-intensity facility. Factors distinguishing facilities providing the lowest-intensity care from those providing the highest-intensity care facilities included more pleasant physical environment (eg, good repair and nonmalodorous), standardized advance care planning, greater staff engagement in shared decision-making, and staff implicit values unfavorable to tube feeding. Many staff perceptions were ubiquitous (eg, adequate staffing needs), with no distinct pattern across nursing homes or HRRs. Staff in all nursing homes expressed assumptions that proxies for Black residents were reluctant to engage in advance care planning and favored more aggressive care. Except in nursing homes providing the lowest-intensity care, many staff believed that feeding tubes prolonged life and had other clinical benefits.

CONCLUSIONS AND RELEVANCE

This study found that variability in the care of patients with advanced dementia may be reduced by addressing modifiable nursing home factors, including enhancing support for low-resource facilities, standardizing advance care planning, and educating staff about evidence-based care and shared decision-making. Given pervasive staff biases toward proxies of Black residents, achieving health equity for nursing home residents with advanced dementia must be the goal behind all efforts aimed at reducing disparities in their care.

Using routine databases to evaluate Electronic Palliative Care Co-ordination Systems (EPaCCS)

In response to the government's drive to expand Electronic Palliative Care Co-ordination Systems (EPaCCS) across England by 2020, further evidence for this intervention needs to be established quickly. With palliative and end-of-life care research being an underfunded area, the availability and lower costs of routine databases make it an attractive resource to integrate into studies evaluating EPaCCS without jeopardising research quality. This article describes how routine databases can be used to address the current paucity of high-quality evidence; they can be used in a range of study designs, including randomised controlled trials and quasi-experimental designs, and may also be able to contribute quality of life or patient-reported outcome measures.

Race and prevalence of percutaneous endoscopic gastrostomy tubes in patients with advanced dementia

OBJECTIVE

Millions of Americans may face hard decisions when it comes to providing nutrition for their loved ones with advanced dementia. This study aimed to ascertain whether there is a difference in feeding tube placement between White and Black patients with advanced dementia and whether this potential difference varied by patient's other demographic and clinical characteristics.

METHOD

This is a retrospective, observational study conducted at Novant Health, a 15-hospital system in the southeastern United States. Data were obtained from Epic systems and included all hospital admissions with a diagnosis of advanced dementia, a total of 21,939, between July 1, 2015, and December 31, 2018. Descriptive statistics and logistics analyses were conducted to assess the relationship between receiving percutaneous endoscopic gastrostomy (PEG) and race, controlling for demographic and clinical characteristics.

RESULTS

Among patients admitted with advanced dementia, the multivariable logistic regression, controlled for age, gender, LOS, palliative care, and vascular etiology showed that Blacks had higher odds of having PEG tubes inserted than White patients (OR 1.97; CI 1.51-2.55; P < 0.001). Patients with longer stays had higher odds of PEG tube insertion. Females had lower odds of PEG tube insertion than males. There was no statistical significance in PEG insertion based on age, etiology, and palliative care consult.

SIGNIFICANCE OF RESULTS

The reasons for the observed higher odds of receiving PEG tubes among Black patients than White patients are likely multifactorial and embedded in a different approach to end-of-life care conversations by providers and caregivers of Black and White patients. Providers may need to be more aware of potential unconscious biases when talking to caregivers, especially in race-discordant relationships, have courageous conversations with caregivers, and be more aware of the importance of keeping in mind families' and caregivers' culture, including spirituality, when making end-of-life decisions.

Risk of an Adverse Event in Individuals Who Aspirate: A Review of Current Literature on Host Defenses and Individual Differences

PURPOSE

The presence of oropharyngeal dysphagia increases the likelihood of prandial aspiration, and aspiration increases the likelihood of a dysphagia-related pulmonary sequelae such as aspiration pneumonia, acute respiratory distress syndrome, pulmonary fibrosis, and even death. Although these outcomes are unfortunate, it is important to point out that these consequences are not solely determined by the presence of aspiration. The purpose of this tutorial is to provide current information on pulmonary defenses and the variables that increase risk of an adverse outcome in individuals who aspirate.

METHOD

This tutorial reviews the basics of lung defenses and summarizes the literature to make the case that the host is a central theme in dysphagia management. Case studies are employed to highlight the key variables.

RESULTS

Based on a literature review, a series of questions are proposed for consideration in dysphagia management. These questions, which take the focus away from the presence of aspiration and toward the associated risks within an individual, are then applied to two case studies.

CONCLUSIONS

A guiding framework is proposed to encourage clinicians to assess more than the presence of aspiration and consider the individual's ability to cope with the aspirated material. In the presence of aspiration, clinicians are urged to focus on the risk factors that can lead to a negative consequence, identify which factors are modifiable, and determine when a level of risk is acceptable.

Does it Matter Who Decides? Outcomes of Surrogate Decision-Making for Community-Dwelling, Cognitively Impaired Older Adults Near the End of Life

CONTEXT

Cognitively impaired older adults frequently need surrogate decision-making near the end-of-life. It is unknown whether differences in the surrogate's relationship to the decedent are associated with different end-of-life treatment choices.

OBJECTIVES

To describe differences in end-of-life care for community dwelling, cognitively impaired older adults when children and spouses are involved in decision-making.

METHODS

Retrospective observational study.

RESULTS

Among 742 community-dwelling adults with cognitive impairment (mild cognitive impairment or dementia) prior to death, children participated in end-of-life decisions for 615 patients (83%) and spouses participated in decisions for 258 patients (35%), with both children and spouses participating for 131 patients (18%). When controlling for demographic characteristics, decedents with only a spouse decision-maker were less likely to undergo a life-sustaining treatment than decedents with only children decision-makers (P < 0.05). There was no difference in the probability of in-hospital death or burdensome transfers across facilities across decedent-decision-maker relationships. Differences in rates of life-sustaining treatment were greater when we restricted to decedents with dementia.

CONCLUSION

Decedents with cognitive impairment or dementia were less likely to receive life-sustaining treatments when spouses versus children were involved with end-of-life treatment decisions but were no less likely to experience other measures of potentially burdensome end-of-life care.

Enteral tube feeding for people with severe dementia

BACKGROUND

The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the lack of evidenced benefit and potential risks of enteral tube feeding. In some areas of the world, the use of enteral tube feeding is decreasing, and in other areas it is increasing.

OBJECTIVES

To assess the effectiveness and safety of enteral tube feeding for people with severe dementia who develop problems with eating and swallowing or who have reduced food and fluid intake.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases and two trials registers on 14 April 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), or controlled non-randomised studies. Our population of interest was adults of any age with a diagnosis of primary degenerative dementia of any cause, with severe cognitive and functional impairment, and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of enteral tube feeding via a nasogastric or gastrostomy tube, or via jejunal post-pyloric feeding, in comparison with standard care or enhanced standard care, such as an intervention to promote oral intake. Our primary outcomes were survival time, quality of life, and pressure ulcers.

DATA COLLECTION AND ANALYSIS

Three review authors screened citations and two review authors assessed full texts of potentially eligible studies against inclusion criteria. One review author extracted data, which were then checked independently by a second review author. We used the 'Risk Of Bias In Non-randomised Studies of Interventions' (ROBINS-I) tool to assess the risk of bias in the included studies. Risk of confounding was assessed against a pre-agreed list of key potential confounding variables. Our primary outcomes were survival time, quality of life, and pressure ulcers. Results were not suitable for meta-analysis, so we presented them narratively. We presented results separately for studies of percutaneous endoscopic gastrostomy (PEG) feeding, nasogastric tube feeding and studies using mixed or unspecified enteral tube feeding methods. We used GRADE methods to assess the overall certainty of the evidence related to each outcome for each study.

MAIN RESULTS

We found no eligible RCTs. We included fourteen controlled, non-randomised studies. All the included studies compared outcomes between groups of people who had been assigned to enteral tube feeding or oral feeding by prior decision of a healthcare professional. Some studies controlled for a range of confounding factors, but there were high or very high risks of bias due to confounding in all studies, and high or critical risks of selection bias in some studies. Four studies with 36,816 participants assessed the effect of PEG feeding on survival time. None found any evidence of effects on survival time (low-certainty evidence). Three of four studies using mixed or unspecified enteral tube feeding methods in 310 participants (227 enteral tube feeding, 83 no enteral tube feeding) found them to be associated with longer survival time. The fourth study (1386 participants: 135 enteral tube feeding, 1251 no enteral tube feeding) found no evidence of an effect. The certainty of this body of evidence is very low. One study of PEG feeding (4421 participants: 1585 PEG, 2836 no enteral tube feeding) found PEG feeding increased the risk of pressure ulcers (moderate-certainty evidence). Two of three studies reported an increase in the number of pressure ulcers in those receiving mixed or unspecified enteral tube feeding (234 participants: 88 enteral tube feeding, 146 no enteral tube feeding). The third study found no effect (very-low certainty evidence).  Two studies of nasogastric tube feeding did not report data on survival time or pressure ulcers. None of the included studies assessed quality of life. Only one study, using mixed methods of enteral tube feeding, reported on pain and comfort, finding no difference between groups. In the same study, a higher proportion of carers reported very heavy burden in the enteral tube feeding group compared to no enteral tube feeding. Two studies assessed the effect of nasogastric tube feeding on mortality (236 participants: 144 nasogastric group, 92 no enteral tube feeding). One study of 67 participants (14 nasogastric, 53 no enteral tube feeding) found nasogastric feeding was associated with increased mortality risk. The second study found no difference in mortality between groups. The certainty of this evidence is very low. Results on mortality for those using PEG or mixed methods of enteral tube feeding were mixed and the certainty of evidence was very low. There was some evidence from two studies for enteral tube feeding improving nutritional parameters, but this was very low-certainty evidence. Five studies reported a variety of harm-related outcomes with inconsistent results. The balance of evidence suggested increased risk of pneumonia with enteral tube feeding. None of the included studies assessed behavioural and psychological symptoms of dementia.

AUTHORS' CONCLUSIONS

We found no evidence that tube feeding improves survival; improves quality of life; reduces pain; reduces mortality; decreases behavioural and psychological symptoms of dementia; leads to better nourishment; improves family or carer outcomes such as depression, anxiety, carer burden, or satisfaction with care; and no indication of harm. We found some evidence that there is a clinically significant risk of pressure ulcers from enteral tube feeding. Future research should focus on better reporting and matching of control and intervention groups, and clearly defined interventions, measuring all the outcomes referred to here.

ADVANCE: Methodology of a qualitative study

BACKGROUND/OBJECTIVES

Quantitative studies have documented persistent regional, facility, and racial differences in the intensity of care provided to nursing home (NH) residents with advanced dementia including, greater intensity in the Southeastern United States, among black residents, and wide variation among NHs in the same hospital referral region (HRR). The reasons for these differences are poorly understood, and the appropriate way to study them is poorly described.

DESIGN

Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life (ADVANCE) is a large qualitative study to elucidate factors related to NH organizational culture and proxy perspectives contributing to differences in the intensity of advanced dementia care. Using nationwide 2016-2017 Minimum DataSet information, four HRRs were identified in which the relative intensity of advanced dementia care was high (N = 2 HRRs) and low (N = 2 HRRs) based on hospital transfer and tube-feeding rates among residents with this condition. Within those HRRs, we identified facilities providing high (N = 2 NHs) and low (N = 2 NHs) intensity care relative to all NHs in that HRR (N = 16 total facilities; 4 facilities/HRR).

RESULTS/CONCLUSIONS

To date, the research team conducted 275 h of observation in 13 NHs and interviewed 158 NH providers from varied disciplines to assess physical environment, care processes, decision-making processes, and values. We interviewed 44 proxies (black, N = 19; white, N = 25) about their perceptions of advance care planning, decision-making, values, communication, support, trust, literacy, beliefs about death, and spirituality. This report describes ADVANCE study design and the facilitators and challenges of its implementation, providing a template for the successful application of large qualitative studies focused on quality care in NHs.

Artificial Nutrition in Patients with Advanced Malignancy

Cancer is a progressive disease that can lead to malnutrition and cachexia. Artificial nutrition is a medical therapy used to combat malnutrition in these patients. In this article, the authors discuss factors affecting the decision to use artificial nutrition, including the patient's mental and physical health, technical factors of the procedures used to deliver artificial nutrition, and the oncologic factors affecting treatment. Through this review, the authors provide guidelines on who is and is not likely to benefit from therapy, available routes of administration, and necessary factors to consider for appropriate decision-making for palliative patients and those with advanced cancers."

Procedure-Related Complications and Survival after Gastrostomy: Results from a Japanese Cohort

INTRODUCTION

In 2010, a large-scale multi-institutional study in Japan showed a good prognosis for percutaneous endoscopic gastrostomy (PEG). However, the function and efficacy of PEG are not fully understood by patients, families, and health-care professionals; thus, the number of PEG treatments in Japan has declined. Therefore, we aimed to investigate the safety of the PEG procedure and subsequent survival after PEG.

METHODS

In total, 249 PEGs were performed at Juzenkai Hospital from 2005 to 2017. PEG was originally performed using the pull method and then by a modified introducer method from mid-2011. We examined procedure-related complications and survival rates after PEG.

RESULTS

Fifty-one (20.5%) procedure-related complications occurred; emergency surgery was required in 4 cases. Infections accounted for 76.5% (39/51) of complications. More infections occurred with the pull method than with the modified introducer method. The 1-year survival rate was 66.8%; the median survival time was 678 days. Nine patients (3.6%) died within 30 days; no deaths were directly related to PEG. Sex, age, and albumin level before surgery significantly influenced the prognosis.

CONCLUSION

Due to changes in the PEG insertion method and other factors, PEG has become a safer treatment method. Additionally, PEG-based nutritional supplementation is associated with adequate survival.

Dementia and Early Do-Not-Resuscitate Orders Associated With Less Intensive of End-of-Life Care: A Retrospective Cohort Study

BACKGROUND

Dementia is a leading cause of death among US older adults. Little is known about end-of-life care intensity and do-not-resuscitate orders (DNRs) among patients with dementia who die in hospital.

AIM

Examine the relationship between dementia, DNR timing, and end-of-life care intensity.

DESIGN

Observational cohort study.

SETTING/PARTICIPANTS

Inpatient electronic health record extraction for 2,566 persons age 65 and older who died in 2 New York City hospitals in the United States from 2015 to 2017.

RESULTS

Multivariable logistic regression analyses modeled associations between dementia diagnosis, DNR timing, and 6 end-of-life care outcomes. 31% of subjects had a dementia diagnosis; 23% had a DNR on day of hospital admission. Patients with dementia were 18%-40% less likely to have received 4 of 6 types of intensive care (mechanical ventilation AOR: 0.82, 95%CI: 0.67 -1.00; intensive care unit admission AOR: 0.60, 95%CI: 0.49-0.83). Having a DNR on file was inversely associated with staying in the intensive care unit (AOR: 0.57, 95%CI: 0.47-0.70) and avoiding other intensive care measures. DNR placement later during the hospitalization and not having a DNR were associated with more intensive care compared to having a DNR upon admission.

CONCLUSIONS

Having dementia and a do-not resuscitate order upon hospital admission are associated with less intensive end-of-life care. Additional research is needed to understand why persons with dementia receive less intensive care. In clinical practice, encouraging advance care planning prior to and at hospital admission may be particularly important for patients wishing to avoid intensive end-of-life care, including patients with dementia.

Speech therapy aspects in patients’ palliative care

ABSTRACT Purpose: to describe the speech therapy aspects of patients treated by the palliative care team in a hospital. Methods: an observational and cross-sectional study, performed from medical records of patients treated under Palliative Care Program, in a hospital, from July to September 2018. Information from the anamnesis and speech-language assessments, which were analyzed by frequency measures, were collected. Results: the sample was composed by 41 medical records, including 25 males and 16 females, with an average age of 61.2 years and hospitalization average time of 20.7 days. Oral feeding was present in 73% of the sample. It was observed that 24% of the patients had impaired expressive language, 56% had reduced maximum phonation times and 34% showed altered mobility phonoarticulatory organs. For swallowing, 22% showed difficulty in some consistency. A nutritional feeding was verified in 74% of the sample and the remaining was making use of comfort feeding. In relation to assistance, 46% of the sample was under management, 7% in therapy, and the remaining did not have follow-up indication. Conclusion: relevant alterations to orofacial motricity, voice, language and swallowing were found in patients under palliative care.

Top Ten Tips Palliative Care Clinicians Should Know About Cognitive Impairment and Institutional Care

Most long-term care (LTC) residents are of age >65 years and have multiple chronic health conditions affecting their cognitive and physical functioning. Although some individuals in nursing homes return home after receiving therapy services, most will remain in a LTC facility until their deaths. This article seeks to provide guidance on how to assess and effectively select treatment for delirium, behavioral and psychological symptoms for patients with dementia, and address other common challenges such as advanced care planning, decision-making capacity, and artificial hydration at the end of life. To do so, we draw upon a team of physicians with training in various backgrounds such as geriatrics, palliative medicine, neurology, and psychiatry to shed light on those important topics in the following "Top 10" tips.

End-of-Life Nutrition Considerations: Attitudes, Beliefs, and Outcomes

OBJECTIVE

To assess the physiological outcomes and interpersonal influences that should be considered when making the decision to provide artificial nutrition and hydration (AN&H) for patients in hospice/palliative programs.

METHODS

A systematic review was conducted using items from the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 checklist. Distinct search strategies were employed to find primary research articles that addressed: General health outcomes of artificial nutrition and hydration interventions and nutrition therapy interventions (n = 16), nutrition-related symptoms in end-of-life care (n = 8), and the attitudes of patients and providers toward artificial nutrition and hydration (n = 21).

RESULTS

The effect of AN&H on health outcomes, quality-of-life measures and nutrition-related symptoms is limited and may vary by patient setting and diagnosis. In the absence of consistent evidence for specific health outcomes, decisions regarding AN&H should be made in context of the desires and beliefs of a patient, their family, and their medical providers. These beliefs may not be consistent with likely outcomes or may be inconsistent between individuals involved in the decision-making process, and individuals of different cultures or geographic regions may approach AN&H decisions from different perspectives. To help navigate the intersection of nutrition-related health outcomes and patient/provider beliefs, palliative care teams may employ a variety of strategies for approaching the decision-making process, and may benefit from specific involvement of a Registered Dietitian to help contribute to or lead these discussions.

Nursing staff participation in end-of-life nutrition and hydration decision-making in a nursing home: A qualitative study

AIM

To better understand the participation of nursing staff in end-of-life nutrition and hydration decision-making in an American nursing home.

DESIGN

A qualitative exploration with ethnographic focus.

METHODS

In April 2017, in-person, semi-structured interviews were performed with 19 nursing staff members in a nursing home located in the south-eastern United States. Additional information was gathered through participant observation during interviews and review of organizational and regulatory policies. Transcripts were coded and analysed using qualitative methods described by Roper and Shapira (2000).

RESULTS

Three primary themes relating to nursing staff participation in end-of-life nutrition and hydration decision-making were identified: (a) Formal decision-making: decisions made and implemented by persons with the authority to make legal and binding care decisions in the nursing home setting; (b) Informal decision-making: decisions not requiring medical orders; and (c) Influential factors: factors that influence actions of nursing staff.

CONCLUSION

A variety of factors have an impact on nursing staff participation in end-of-life nutrition and hydration decision-making. Participation is closely aligned with the type of decision, whether formal or informal, and role, whether Certified Nursing Assistant/Aide, Licensed Practical/Vocational Nurse, or Registered Nurse.

IMPACT

End-of-life nutrition and hydration decision-making in nursing homes differs from decision-making in other care settings and presents a challenge globally. Interventions that support the participation of nursing staff in end-of-life nutrition and hydration decision-making have the potential to positively impact the experiences of residents and family members faced with these issues in the nursing home setting.

Continuity of Hospital Care and Feeding Tube Use in Cognitively Impaired Hospitalized Persons

OBJECTIVES

Hospitalists are increasingly the attending physician for hospitalized patients, and the scheduling of their shifts can affect patient continuity. For dementia patients, the impact is unknown.

DESIGN

Longitudinal study using physician billing claims between 2000 and 2014 to examine the association of continuity of care with the insertion of a feeding tube (FT).

SETTING

US hospitals.

PARTICIPANTS

Between 2000 and 2014, 166,056 hospitalizations of patients with a prior nursing home stay, advanced cognitive impairment, and impairments in four or more activities of daily living (mean age = 84.2 years; 30.4% male; 81.0% white).

MEASUREMENTS

Continuity of care measured at the hospital level with the Sequential Continuity Index (SECON; range = 0 to 100; higher score indicates higher continuity).

RESULTS

Rates of a hospitalist acting as the attending physician increased from 9.6% in 2000 to 22.6% in 2010, whereas a primary care physician with a predominant outpatient focus acting as the attending physician decreased from 50.3% in 2000 to 12.6% in 2014. Post-2010, a mixture of physician specialties increased from 55.5% to 66.4% with a reduction in hospitalists from 22.6% (2010) to 14.1% (2013). Continuity of care decreased over time with SECON dropping from 63.0 to 43.5. Adjusting for patient baseline risk factors, a nonlinear association was observed between SECON and FT insertion. Using cubic splines in the multivariate logistics regression model, the risk of FT insertion in hospitals where the SECON score dropped from 82 to 23 had an adjusted risk ratio (ARR) of FT insertion of 1.48 (95% confidence interval [CI] = 1.34-1.63); hospitals in which SECON dropped from 51 to 23 had an ARR of FT insertion of 1.38 (95% CI = 1.27-1.50).

CONCLUSION

Hospitalized dementia patients in hospitals in which continuity of care was lower had higher rates of FT insertions. Newer models of care are needed to enhance care continuity and thus ensure treatment consistent with likely outcomes of care and goals of care. J Am Geriatr Soc 68:1852-1856, 2020.

Lifestyle Medicine Interventions in Patients With Advanced Disease Receiving Palliative or Hospice Care

Background: Lifestyle medicine interventions have the potential to improve symptom management, daily function, and quality of life (QOL) in patients with advanced or terminal disease receiving palliative or hospice care. The goal of this review is to summarize the current state of the literature on this subject. Methods: The authors used a broad search strategy to identify relevant studies, reviews, and expert opinions, followed by narrative summary of available information. Results: Four main categories of lifestyle interventions feature prominently in the palliative care literature: exercise, nutrition, stress management, and substance use. High-quality studies in this vulnerable population are relatively sparse. Some interventions show promise. However, most show mixed results or inadequate evidence. For some interventions, risks in this generally frail population outweigh the benefits. Clinical decision making involves balancing research findings, including the risks and benefits of interventions, with a clear understanding of patients' prognosis, goals of care, and current physical, emotional, and spiritual state. Achieving optimum QOL, safety, and ethical care are emphasized. Conclusions: The use of lifestyle interventions in patients receiving palliative or hospice care is a complex undertaking, requiring tailoring recommendations to individual patients. There is potential for considerable benefits; however, more research is needed.

Comfort and Satisfaction With Care of Home-Dwelling Dementia Patients at the End of Life

CONTEXT

Despite the preference to pass away at home, many dementia patients die in institutions, resulting in a paucity of studies examining end-of-life care outcomes in the home setting.

OBJECTIVE

The objective of this study was to identify modifiable factors associated with the comfort of dementia patients dying at home and families' satisfaction with care.

METHODS

This is a prospective cohort study conducted from October 2014 to April 2019 in Singapore. Dementia patients at Stage 7 on the Functional Assessment Staging Scale, with albumin <35 g/L, enteral feeding, or pneumonia, were recruited from a palliative homecare program. Independent variables included demographics, medical information, and care preferences. The Comfort Assessment in Dying with Dementia scale assessed dying patients' comfort, whereas the Satisfaction with Care at the End-of-Life in Dementia scale evaluated family caregivers' satisfaction two months after bereavement. Gamma regression identified factors independently associated with comfort and satisfaction.

RESULTS

The median age of 202 deceased patients whose comfort was assessed was 88 years. Anti-cholinergic prescription (60.4% of patients) [β (95% CI) = 1.823 (0.660-2.986), P = 0.002] was positively associated with comfort, whereas opioid prescription (89.6%) [β (95% CI) = -2.179 (-4.107 to -0.251), P = 0.027] and >1 antibiotic courses used in the last two weeks of life (77.2%) [β (95% CI) = -1.968 (-3.196 to -0.740), P = 0.002] were negatively associated. Independent factors associated with families' satisfaction with care were comfort [β (95% CI) = 0.149 (0.012-0.286), P = 0.033] and honoring of medical intervention preferences (96.0%) [β (95% CI) = 3.969 (1.485-6.453), P = 0.002].

CONCLUSION

Achieving comfort and satisfaction with care for dementia patients dying at home involves an interplay of modifiable factors. Honoring medical intervention preferences, such as those with palliative intent associated with patients' comfort, determined families' satisfaction with care.

Nasogastric tube feeding versus assisted hand feeding in-home healthcare older adults with severe dementia in Taiwan: a prognosis comparison

BACKGROUND

All individuals with severe dementia should be offered careful hand feeding. However, under certain circumstances, people with severe dementia have a feeding tube placed. In Taiwan, tube feeding rate in demented older home care residents is increasing; however, the benefits of tube feeding in this population remain unknown. We compared the clinical prognosis and mortality of older patients with severe dementia receiving nasogastric tube feeding (NGF) or assisted hand feeding (AHF).

METHODS

Data from the in-home healthcare system between January 1 and December 31, 2017 were analyzed to identify 169 participants over 60 years of age in this retrospective longitudinal study. All subjects with severe dementia and complete functional dependence suffered from difficulty in oral intake and required either AHF or NGF. Data were collected from both groups to analyze pneumonia, hospitalization, and mortality rates.

RESULTS

A total of 169 subjects (56 males and 113 females, aged 85.9 ± 7.5 years) were analyzed. 39 required AHF and 130 NGF. All subjects were bedridden; 129 (76%) showed Barthel index < 10. Pneumonia risk was higher in the NGF group (48%) than in the AHF group (26%, p = 0.015). After adjusting for multiple factors in the regression model, the risk of pneumonia was not significantly higher in the NGF group compared with the AHF group. One-year mortality rates in the AHF and NGF groups were 8 and 15%, respectively, and no significant difference was observed after adjustment with logistic regression (aOR = 2.38; 95% CI, 0.58-9.70). There were no significant differences in hospitalization rate and duration.

CONCLUSIONS

For older patients with dementia requiring in-home healthcare, NGF is not associated with a significantly lower risk of pneumonia than AHF. Additionally, neither mortality nor hospitalization rates decreased with NGF. On the contrary, a nonsignificant trend of increased risk of pneumonia was observed in NGF group. Therefore, the benefits of NGF are debatable in older patients with severe dementia requiring in-home healthcare. Continued careful hand feeding could be an alternative to NG feeding in patients with severe dementia. Furthermore, large-scale studies on in-home healthcare would be required to support these results.

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

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.

Palliative Care in Advanced Dementia

Dementia syndrome is common and expected to increase significantly among older people and characterized by the loss of cognitive, psychological and physical functions. Palliative care is applicable for people with dementia, however they are less likely to have access to palliative care. This narrative review summarizes specifics of palliative care in advanced dementia. Most people with advanced dementia live and die in institutional care and they suffer a range of burdensome symptoms and complications. Shortly before dying people with advanced dementia suffer symptoms as pain, eating problems, breathlessness, neuropsychiatric symptoms, and complications as respiratory or urinary infections and frequently experience burdensome transitions. Pharmacological and nonpharmacological interventions may reduce symptom burden. Sensitive observation and appropriate assessment tools enable health professionals to assess symptoms and needs and to evaluate interventions. Due to lack of decisional capacity, proxy decision making is often necessary. Advanced care planning is an opportunity establishing values and preferences and is associated with comfort and decrease of burdensome interventions. Family carers are important for people with advanced dementia they also experience distress and are in need for support. Recommendations refer to early integration of palliative care, recognizing signs of approaching death, symptom assessment and management, advanced care planning, person-centered care, continuity of care, and collaboration of health care providers.

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.

Gastropexy can be as safe as conventional percutaneous endoscopic gastrostomy (PEG), and biomarkers do not predict short-term or long-term outcomes: a 7-year follow-up audit

OBJECTIVE

Gastrostomy facilitates artificial enteral feeding but controversy exists around associated morbidity and mortality. This study aimed to report short and long-term outcomes, and identify parameters associated with overall survival.

METHODS

A 7-year follow-up audit was undertaken at Aberdeen Royal Infirmary, UK. All patients undergoing endoscopic gastrostomy insertion October 2011-September 2018 were included. Last follow-up was February 2019. Clinical data were prospectively collected. Blood results were retrospectively obtained from electronic records. Statistical analysis was with IBM SPSS V.25.

RESULTS

691 procedures were performed over the 7-year period (520 traditional pull-through percutaneous endoscopic gastrostomy (PEG) and 171 gastropexy procedures to facilitate gastrostomy). Frequency of complications (gastrointestinal bleeding, perforation and peritonitis) was low (each n=1). Overall 7-day and 30-day mortality was 2.2% and 8.4%, respectively. One-year mortality reached 47.6%. There was no difference in survival between PEG and gastropexy procedures (p=0.410). Multivariate analysis reported increased age (p<0.001), increased alkaline phosphatase (p<0.001) and clinical indication (p=0.002) as independently associated with an increased hazard of death. Only age was moderately predictive of mortality (area under the curve 0.74, 95% CI 0.70 to 0.78, p<0.001) in the PEG group. Clinical indication was the only parameter independently associated with mortality in the gastropexy cohort (p=0.003).

CONCLUSION

Endoscopic gastrostomy placement can be safe with a low mortality and low risk of serious complications. Blood markers were not associated with short-term or long-term outcomes. Gastropexy to facilitate gastrostomy is a safe alternative to traditional pull-through PEG procedures. Future work should consider quality of life outcomes to assess the benefit of gastrostomy from a patient perspective.

Japanese elderly individuals wish for enteral tube feeding more strongly for their parents than for themselves

[Introduction] The purpose of this study was to investigate the differences in the preference of enteral tube feeding between elderly inhabitants of Mugi town, Tokushima Prefecture, Japan, and their parents in various physical conditions. [Methods] This population-based questionnaire survey studied 300 randomly selected participants aged 65-80 years. Respondents were to consider a situation where eating was difficult, and were questioned on their desire for tube feeding, using a visual analogue scale (VAS) ranging from "do not want tube feeding (0)" to "want tube feeding (100)." [Results] Valid responses of 103 (34.4%) participants were analyzed. Under conditions of being "healthy," "bedridden," "with dementia," and "bedridden and with dementia," the median (IQR) of the VAS values for the desire for tube feeding were 31.8 (3.3 to 83.8), 19.3 (2.4 to 52.3), 5.2 (0.7 to 18.9), 4.0 (0.3 to 15.2) for respondents and 55.2 (11.6 to 92.2), 48.7 (5.5 to 85.5), 9.0 (1.2 to 46.8), 5.1 (0.1 to 36.5) for parents, respectively. The VAS values for the parents were significantly higher (p=0.001, 0.002, 0.001, and 0.01, respectively for the four conditions described) for the same items. [Conclusion] Surrogate decisions made by family members often differ from what the patients would have desired. J. Med. Invest. 66 : 258-263, August, 2019.

Advanced dementia: an integrated homecare programme

Objectives

We established an integrated palliative homecare programme for advanced dementia. This study explores patients’ symptoms and quality-of-life and their association with enteral feeding, evaluates the impact of the programme on these parameters and examines familial caregiver burden.

Methods

This is a prospective cohort study. Patients at Functional Assessment Stage 7, with an albumin level <35 g/L, pneumonia or enteral feeding were recruited. At baseline and regular intervals, the multidisciplinary homecare team used the Pain Assessment in Advanced Dementia, Mini Nutritional Assessment and Neuropsychiatric Inventory Questionnaire (NPI-Q) to identify patients’ symptoms, and the Quality of Life in Late-Stage Dementia (QUALID) tool to assess quality-of-life as primary outcomes, stratified by feeding status. The Zarit Burden Interview (ZBI) investigated caregiver burden, stratified by living arrangement and availability of stay-in help. Mann-Whitney U and χ2 tests compared continuous and categorical variables respectively between groups while Wilcoxon signed-rank test compared assessment scores at baseline and on review.

Results

At baseline, 49.2% of the 254 patients had pain, 92.5% were malnourished and 85.0% experienced neuropsychiatric challenges. Patients on enteral feeding had lower NPI-Q score (median=3; IQR 1–6) than orally fed patients ((median=4; IQR 2–7), p=0.004) and higher QUALID score (median=25; IQR 21–30 vs median=21; IQR 17–25 for orally fed patients), p<0.0001, indicating a better quality-of-life for orally fed patients. Both symptoms and quality-of-life improved significantly for the 53 patients reviewed at the fifth month. Median ZBI score for caregivers was 26 (IQR 15–36). Having stay-in help reduced it from 39.5 (IQR 25–49) to 25 (IQR 15–35), p=0.001.

Conclusion

An integrated multidisciplinary palliative homecare team with geriatric training that is accessible all-hours addressed the needs of home-dwelling patients with advanced dementia, improved their quality-of-life and supported families to care for them at home.

Gastrostomy Tube Use in the Critically Ill, 1994-2014

Rationale: Although gastrostomy tubes have shown to be of limited benefit in patients with advanced dementia, they continue to be used to deliver nutritional support in critically ill patients. The epidemiology and short-term outcomes are unclear. Objectives: To quantify national practice patterns and short-term outcomes of gastrostomy tube placement among the critically ill over the last two decades in the United States. Methods: Using the U.S. Agency for Healthcare and Research Quality's Healthcare Cost and Utilization Project's National Inpatient Sample, we evaluated trends in annual population-standardized rates of gastrostomy tube placement among critically ill adults from 1994 to 2014; we also quantified trends in length of stay, in-hospital mortality, and discharge location. We conducted sensitivity analyses among mechanically ventilated patients, survivors, and decedents of critical illness, and in a critically ill population excluding patients with dementia. Results: From 1994 to 2014, population-based rates of gastrostomy tube use in critically ill patients increased from 11.9 to 28.8 gastrostomies per 100,000 U.S. adults (peak in incidence in 2010), an increase of 142% (31,392-91,990 gastrostomy tubes in critically ill patients; P < 0.001). Patients receiving gastrostomy tubes during critical illness occupied a growing proportion of all gastrostomy tube placements, accounting for 19.6% of all gastrostomy tubes placed in 1994 and 50.8% in 2014. The rate of gastrostomies in critically ill patients remained roughly stable, from 2.5% of critically ill patients in 1994 to a peak of 3.7% in 2002 before declining again to 2.4% in 2014. Hospital length of stay and in-hospital mortality decreased among gastrostomy tube recipients (28.7 d to 20.5 d, P < 0.001; 25.9-11.3%, P < 0.001; respectively), whereas discharges to long-term facilities increased significantly (49.6-70.6%; P < 0.001). Sensitivity analyses among mechanically ventilated patients revealed similar increases in population-based estimates of gastrostomy tube placement. Conclusions: The incidence of gastrostomy tube placement among critically ill patients more than doubled between 1994 and 2014, with most patients being discharged to long-term care facilities. Critically ill patients are now the primary utilizer of gastrostomy tubes placed in the United States. Additional research is needed to better characterize the long-term risk and benefits of gastrostomy tube use in critically ill patients.

Ten-Year Trends of Utilization of Palliative Care Services and Life-Sustaining Treatments and Hospital Costs Associated With Patients With Terminally Ill Lung Cancer in the United States From 2005 to 2014

Background:

Palliative care services and life-sustaining treatments are provided to dying patients with lung cancer in the United States. However, data on the utilization trends of palliative care services and life-sustaining treatments of dying patients with lung cancer are not available.

Methods:

This study was a retrospective analysis of the National Inpatient Sample data (2005-2014) and included patients with lung cancer, aged ≥ 18 years, who died in the hospitals. Claims data of palliative care services and life-sustaining treatments that contained systemic procedures, local procedures, or surgeries were extracted. Compound annual growth rates (CAGRs) using Rao-Scott correction for χ2 tests were used to determine the statistical significance of temporal utilization trends of palliative care services and life-sustaining treatments and their hospital costs. Multilevel multivariate regressions were performed to identify factors associated with hospital costs.

Results:

A total of 120 144 weighted patients with lung cancer died in the hospitals and 41.9% of them received palliative care services. The CAGRs of systemic procedures, local procedures, surgeries, palliative care services, and hospital cost were 3.42%, 3.48%, 6.08%, 18.5%, and 5.0% (all P < .001), respectively. Increased hospital cost was attributed to systemic procedures (50.6%), local procedures (74.4%), and surgeries (68.5%; all P < .001), respectively. Palliative care services were related to decreasing hospital costs by 28.6% ( P < .001).

Conclusion:

The temporal trends of palliative care services indicate that their utilization has increased gradually. Palliative care services were associated with reduced hospital costs. However, life-sustaining treatments were associated with increased hospital costs.

Enhancing the decision-making process when considering artificial nutrition in advanced dementia care

Background:

Nutritional problems often manifest during late-stage dementia, and some families may request to instigate artificial nutrition and hydration (ANH) therapies. In the US, an estimated one-third of nursing home patients with a severe cognitive impairment have artificial feeding tubes inserted. Fear that a relative could experience extreme hunger or thirst if they are not mechanically fed tends to be the main driver behind family's requests to implement artificial or enteral feeding methods. In contrast, artificial hydration is rarely given to older people with dementia in the UK and this practice of non-intervention tends to apply across all healthcare and hospice type environments.

Aim:

This literature review aims to evaluate the evidence to support the use and non-use of ANH.

Method:

A literature review was undertaken to examine the evidence around ANH for patients with dementia to offer support to families or carers contemplating feeding choices.

Conclusion:

This paper challenges the implementation of invasive ANH worldwide. It highlights how resorting to ANH does not necessarily lead to improvements in comfort, survival or wound healing. The risk of aspiration does not appear to significantly alter either.

Cachexia and advanced dementia

Cachexia is a complex metabolic process that is associated with several end-stage organ diseases. It is known to be also associated with advanced dementia, although the pathophysiologic mechanisms are still largely unknown. The present narrative review is aimed at presenting recent insights concerning the pathophysiology of weight loss and wasting syndrome in dementia, the putative mechanisms involved in the dysregulation of energy balance, and the interplay among the chronic clinical conditions of sarcopenia, malnutrition, and frailty in the elderly. We discuss the clinical implications of these new insights, with particular attention to the challenging question of nutritional needs in advanced dementia and the utility of tube feeding in order to optimize the management of end-stage dementia.

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.

Trends in the Utilization of Life-Sustaining Procedures and Palliative Care Consultation Among Dying Patients With Advanced Chronic Pancreas Illnesses in US Hospitals: 2005 to 2014

AIM

Pancreas cancer continues to carry a poor prognosis. Hospitalized patients with advanced chronic pancreatic illnesses increasingly receive palliative care due to its perceived clinical benefits. Meanwhile, a growing proportion of elderly patients are reportedly receiving life-sustaining procedures. Temporal trends in the utilization of life-sustaining procedures and palliative care consultation among dying patients with advanced chronic pancreatic illnesses in US hospitals were examined.

METHODS AND MATERIALS

A serial, cross-sectional analysis was carried out using the National Inpatient Sample Database. Decedents 18 years and older with a principal diagnosis of pancreas cancer or other advanced chronic pancreatic illnesses from 2005 through 2014. The compound annual growth rates (CAGRs) and Cochrane-Armitage correction of χ² statistic were used. The receipt of life-sustaining systemic procedures, intra-abdominal local procedures and surgeries, and palliative care consultation were examined. Multilevel multivariate logistic regressions were performed to examine the association of various procedures with the utilization of palliative care consultation.

RESULTS

Among 77 394 183 hospitalizations, 29 515 patients were examined. The CAGRs of systemic procedures, intra-abdominal procedures, surgeries, and palliative care were -4.19% (P = .008), 2.17%, -1.40%, and 14.03% (P < .001), respectively. The receipt of systemic procedures (odds ratio [OR] = 2.40, 95% confidence interval [CI], 2.08-2.74), local intra-abdominal procedures (OR = 1.46, 95% CI, 1.27-1.70), and surgeries (OR = 2.51, 95% CI, 2.07-3.05) was associated with palliative care consultation (Ps < .001).

CONCLUSIONS

Among adults with pancreatic cancer or other advanced chronic pancreatic illnesses in the US hospitals from 2005 to 2014, the utilization of life-sustaining systemic procedures decreased while the prevalence of palliative care consultation increased.

Perceptions of Reducing Tube Feeding for Persons with Advanced Dementia among Various Professions in a Teaching Hospital

BACKGROUND

Even though no evidence suggests tube feeding is beneficial for individuals with advanced dementia, many are still tube fed.

OBJECTIVE

To assess perceptions of hospital staff regarding reducing tube feeding (RTF) of patients with advanced dementia.

DESIGN

Cross-sectional survey.

SETTING

A regional teaching hospital in Taipei, Taiwan.

SUBJECTS

Hospital staff (n = 624), including physicians, nurses, dieticians, paramedical personnel, social workers, volunteers, attendants, and administrators.

MEASUREMENTS

Anonymous questionnaires.

RESULTS

The overall awareness of RTF for advanced dementia patients averaged 10.2 ± 3.74 points (maximum, 19 points) among all respondents. Among the different hospital professions, dieticians scored the highest, whereas nurses and attendants/volunteers had relatively low scores. Over half of respondents (57%) agreed tube feeding is the best choice for advanced dementia with dysphagia. Physicians of different specialties had significantly different responses toward RTF with regard to the belief that tube feeding reduces the risk of aspiration pneumonia, referring patients who refuse tube feeding to other health care team members, and the belief that family members would be able to accept the patient's death along with insufficient food/fluid intake. Only 35.1% of respondents believed they were able to implement comfort feeding.

CONCLUSIONS

The present survey shows a persistent knowledge gap among various health care professions regarding tube feeding of patients with advanced dementia. Also, there is insufficient awareness about this subject, indicating that promotion of comfort feeding by enhanced training and communication within medical teams is essential to achieving better person-centered care and preventing unnecessary suffering.

Effects of gastrostomy fee schedule revision on artificial nutrition routes among older people with dementia in Japan: A time series observational study

AIM

The present study aimed to investigate the effects of the 2014 Japanese fee schedule revision on trends in artificial nutrition routes, including gastrostomy, nasogastric tube and parenteral nutrition, among older people with dementia, using time series analysis.

METHODS

The study used claim data in Japan submitted to Fukuoka Late Elders' Health Insurance from fiscal year 2010 to fiscal year 2016. We identified older people with dementia provided for the first time with artificial nutrition via gastrostomy, nasogastric tube or central venous line and aggregated their data by month. Interrupted time series analyses were used to examine trends in artificial nutrition routes over time.

RESULTS

The numbers of older people with dementia receiving nutrition via gastrostomy, nasogastric tube and parenterally declined consistently. The slopes for pre-revision trends in gastrostomy, nasogastric tube and parenteral nutrition procedures were all significantly negative in the interrupted time series analyses. The post-revision trends in gastrostomy and parenteral nutrition continuously had significant negative slopes. In contrast, the significant negative trend in nasogastric tube procedures in the pre-revision period had disappeared during the post-revision period.

CONCLUSIONS

The study showed that the fee schedule revision had limited impact on gastrostomy and parenteral nutrition. However the trend for nasogastric tube was ambiguous; hence, sustainable surveillance is required for evidence-based health policy. Geriatr Gerontol Int 2018; 18: 1405-1409.