Tube Feeding in Advanced Dementia: An Exploratory Survey of Physician Knowledge

Factors Associated with Differences in Physicians' Attitudes toward Percutaneous Endoscopic Gastrostomy Feeding in Older Adults Receiving End-of-Life Care in Japan: A Cross-Sectional Study

Background

Although percutaneous endoscopic gastrostomy (PEG) placement is still widely practiced in Japan, studies from Western countries report that it is less beneficial for patients in end-of-life care with cognitive decline. Decisions regarding PEG placement are largely influenced by physician judgment.

Objectives

The aim of this study was to investigate the background and perceptions of Japanese physicians regarding PEG for older adults in end-of-life care and to identify the factors associated with differences in physician judgment regarding PEG.

Design

The study employed a cross-sectional design.

Setting/Subjects

A questionnaire on PEG for older adults in end-of-life care was sent to Japanese physicians. Logistic regression analysis was used to calculate the odds ratios (ORs) and confidence intervals (CIs) of the association between PEG recommendations and each factor.

Results

PEG placement was advised for bedridden patients and older adults with cognitive decline by 26% of the physicians who responded to the survey. Differences in physician perceptions of PEG feeding were associated with the recommendation for PEG, benefits of preventing aspiration pneumonia (OR: 4.9; 95% CI: 3.1-8.2), impact on post-discharge accommodation decisions (OR: 6.1; 95% CI: 1.9-30.9), and hesitancy to recommend a PEG placement (OR: 1.9; 95% CI: 1.3-4.5). Working in a facility with PEG placement (OR: 2.0; 95% CI: 1.2-3.5) was an associated background factor.

Conclusions

Differences in Japanese physicians' attitudes toward using PEG feeding for older adults in end-of-life care were significantly associated with differences in their perceptions of the impact of PEG feeding and working in a facility with PEG placement.

Strategies for home nutritional support in dementia care and its relevance in low-middle-income countries

Older people suffering from dementia are prone to develop malnutrition. Ensuring adequate nutrition among such patients has always been a challenge for the carers due to the pathological and chronic nature of the disease. In this article, the author tries to analyze the use of five different strategies in providing adequate nutrition for such patients in their own homes by the carers using a narrative literature review method. The strategies include nutrition screening and assessment, training and education program for the caregiver, mealtime environment and routine modification, provision of nutritional supplements, and role of artificial nutrition and hydration (ANH). An attempt was made to critically engage the readers while exploring the feasibility and challenges involved in implementing such strategies in resource-poor settings like low-middle-income countries. The article concludes that the first four strategies should be used in tandem to prevent the risk of malnutrition. It does not recommend ANH and concludes that it does not bring in any added benefit and may worsen the quality of life.

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.

Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified?

BACKGROUND

Although modifying diets, by thickening liquids and modifying the texture of foods, to reduce the risk of aspiration has become central to the current management of dysphagia, the effectiveness of this intervention has been questioned. This narrative review examines, and discusses possible reasons for, the apparent discrepancy between the widespread use of modified diets in current clinical practice and the limited evidence base regarding the benefits and risks of this approach.

DISCUSSION

There is no good evidence to date that thickening liquids reduces pneumonia in dysphagia and this intervention may be associated with reduced fluid intake. Texture-modified foods may contribute to undernutrition in those with dysphagia. Modified diets worsen the quality of life of those with dysphagia, and non-compliance is common. There is substantial variability in terminology and standards for modified diets, in the recommendations of individual therapists, and in the consistency of diets prepared by healthcare staff for consumption. Although use of modified diets might appear to have a rational pathophysiological basis in dysphagia, the relationship between aspiration and pneumonia is not clear-cut. Clinical experience may be a more important determinant of everyday practice than research evidence and patient preferences. There are situations in the management of dysphagia where common sense and the necessity of intervention will clearly outweigh any lack of evidence or when application of evidence-based principles can enable good decision making despite the absence of robust evidence. Nevertheless, there is a significant discrepancy between the paucity of the evidence base supporting use of modified diets and the beliefs and practices of practitioners.

CONCLUSION

The disconnect between the limited evidence base and the widespread use of modified diets suggests the need for more careful consideration as to when modified diets might be recommended to patients. Patients (or their representatives) have a choice whether or not to accept a modified diet and must receive adequate information, about the potential risks and impact on quality of life as well as the possible benefits, to make that choice. There is an urgent need for better quality evidence regarding this intervention.

Artificial Nutrition and Hydration in People With Late-Stage Dementia

The progressive nature of dementia marks this disease as a terminal illness in the advanced stage, and palliative care rather than curative treatment is indicated. The use of feeding tubes to deliver artificial nutrition and hydration at end of life is often part of the plan of care for people with dementia. Current evidence, however, suggests that tube feeding in advanced dementia is not beneficial and the burdens of the procedure and the feedings themselves outweigh any benefits. Evidence also reveals that healthcare providers may lack evidence-based knowledge about artificial nutrition and hydration to adequately inform families and surrogate decision makers. This article examines the evidence regarding use of artificial nutrition and hydration for patients with end-stage dementia and offers implications for home care clinicians.

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.

Percutaneous endoscopic gastrostomy (PEG) tubes are placed in elderly adults in Japan with advanced dementia regardless of expectation of improvement in quality of life

BACKGROUND

The Japan Geriatrics Society published a guideline on the decision-making process for health care for the elderly in June 2012, noting that withholding or withdrawing feeding tubes are treatment options that should be discussed during the decision-making process. Arguments against the guideline posit that the insertion of a percutaneous endoscopic gastrostomy (PEG) tube feeding may improve quality of life (QOL) for elderly adults and their relatives.

OBJECTIVES

The aim of the present study was to explore (a) expected outcomes with PEG tube placement and (b) outcomes from PEG tube feeding in long-term care settings among elderly adults with advanced dementia in Japan.

DESIGN

This study was conducted using a cross-sectional study design.

SETTING

A total of 381 hospitals and 985 long-term care facilities provided sets of completed questionnaires.

PARTICIPANTS

There were 1 199 hospital patients and 2 160 long-term care patients aged 65 years or older with PEG tube placement included in the analysis.

MEASUREMENTS

The nurses or physicians at each hospital provided information on the level of dementia at the time of PEG tube placement and on the expected outcomes of PEG tube feeding for elderly hospital patients. The nurses or other direct care workers at each facility provided information on the level of dementia and outcomes from PEG tube feeding for the long-term care patients.

RESULTS

In the hospital patient group, 62.9% of patients had advanced dementia. PEG tube feeding was expected to prolong survival for 51.1% of hospital patients with advanced dementia. Improved QOL was expected for 39.1% of them. In the long-term care patient group, 61.7% of patients had advanced dementia. The rate of patients enjoying their own lives was lower in long-term care patients who had advanced dementia (4.2%) than in the other patients (16.4%). Approximately 60% of relatives reported satisfaction with the QOL of the patients, both in the long-term care patients with advanced dementia and the other patients.

CONCLUSION

Our results question the assumption that PEG tube feeding may improve QOL among elderly adults with advanced dementia. The national health policy should explore an approach to help patients, relatives, and practitioners make decisions about feeding options.

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

CONTEXT

Speech-language pathologists (SLP) are often called on to evaluate eating difficulties in patients with dementia.

OBJECTIVES

To assess factors associated with SLPs' knowledge and recommendations about feeding tubes in patients with advanced dementia.

METHODS

A mail survey was administered to a probability sample of 1500 SLPs from the American Speech-Language-Hearing Association mailing list; 731 usable surveys were received (response rate=53.7%). Self-perceived preparedness, knowledge, and care recommendations were measured. Knowledge items were scored as "evidence based" or not according to the best evidence in the literature.

RESULTS

Only 42.1% of SLP respondents felt moderately/well prepared to manage dysphagia. Only 22.0% of respondents recognized that tube feeding is unlikely to reduce risk of aspiration pneumonia whereas a slight majority understood that tube feeding would not likely prevent an uncomfortable death (50.2%), improve functional status (54.5%), or enhance quality of life (QOL) (63.2%). A majority (70.0%) was willing to consider recommending oral feeding despite high risk of aspiration. Logistic regression analyses indicated that those willing to consider this recommendation gave the most evidence-based responses to knowledge questions about tube feeding outcomes: aspiration pneumonia (odds ratio [OR]=1.75, 95% confidence interval [CI]=1.07-2.87), functional status (OR=1.43, 95% CI=1.0-2.06), QOL (OR=2.19, 95% CI=1.52-3.17), and prevent uncomfortable death (OR=1.97, 95% CI=1.37-2.88). Logistic regression analyses also indicated that those with more experience evaluating patients with dementia gave the most evidence-based response to two knowledge questions: aspiration pneumonia (OR=2.64, 95% CI=1.48-4.72) and prevent uncomfortable death (OR=2.03, 95% CI=1.35-3.05) whereas those with higher self-perceived preparedness in managing dysphagia in dementia had less knowledge in two areas: aspiration pneumonia (OR=0.57, 95% CI=0.38-0.84) and QOL (OR=0.72, 95% CI=0.51-1.01).

CONCLUSION

Misperceptions among SLPs about tube feeding in advanced dementia are common, especially in relation to risk of aspiration. Knowledge about tube feeding outcomes was positively associated with experience and inversely associated with self-perceived higher preparedness in evaluating patients with dementia.

Artificial nutrition and hydration: the evolution of ethics, evidence, and policy

INTRODUCTION

The debate over use of artificial nutrition and hydration (ANH) in terminal illness, including advanced dementia, remains contentious despite extensive ethical and empirical investigation.

METHODS

For this narrative review we undertook a focused, selective review of literature reflecting ethical analysis, empirical assessment of outcomes, legal responses, and thinking within the Roman Catholic religious tradition.

RESULTS

The history of the debate over the past 60 years results from a complex interplay of ethical concerns, a growing empirical database, legal changes, public opinion, and financial as well as institutional concerns. Discussions of ANH today are often conducted without any understanding of this historical context.

DISCUSSION

Patients' interests could be better protected through remedial action at both the individual and the policy levels.

Senescent swallowing: impact, strategies, and interventions

The risk for disordered oropharyngeal swallowing (dysphagia) increases with age. Loss of swallowing function can have devastating health implications, including dehydration, malnutrition, pneumonia, and reduced quality of life. Age-related changes increase risk for dysphagia. First, natural, healthy aging takes its toll on head and neck anatomy and physiologic and neural mechanisms underpinning swallowing function. This progression of change contributes to alterations in the swallowing in healthy older adults and is termed presbyphagia, naturally diminishing functional reserve. Second, disease prevalence increases with age, and dysphagia is a comorbidity of many age-related diseases and/or their treatments. Sensory changes, medication, sarcopenia, and age-related diseases are discussed herein. Recent findings that health complications are associated with dysphagia are presented. Nutrient requirements, fluid intake, and nutrition assessment for older adults are reviewed relative to dysphagia. Dysphagia screening and the pros and cons of tube feeding as a solution are discussed. Optimal intervention strategies for elders with dysphagia ranging from compensatory interventions to more rigorous exercise approaches are presented. Compelling evidence of improved functional swallowing and eating outcomes resulting from active rehabilitation focusing on increasing strength of head and neck musculature is provided. In summary, although oropharyngeal dysphagia may be life threatening, so are some of the traditional alternatives, particularly for frail, elderly patients. Although the state of the evidence calls for more research, this review indicates that the behavioral, dietary, and environmental modifications emerging in this past decade are compassionate, promising, and, in many cases, preferred alternatives to the always present option of tube feeding.

Physicians' expectations of benefit from tube feeding

OBJECTIVE

Tube feeding is increasingly common, despite evidence for limited medical benefits. We interviewed treating physicians to describe their expectation of benefit for patients receiving a new feeding tube, and to determine whether expected benefits vary by patient characteristics.

METHODS

We recruited treating physicians and surrogate decision-makers for 288 hospitalized patients in a prospective study of new feeding tube decisions. In structured interviews, physicians provided information on patients' diagnosis and whether they expected any of eight potential medical benefits for a specific patient; surrogates provided information about the patients' function, race, age, prior residence, and ability to eat by mouth.

RESULTS

We completed interviews with 173 physicians about tube feeding for 280 patients (response rate, 97%). Patients commonly had acute stroke (30%), neurodegenerative disease (16%), or head and neck cancer (22%); 70% were somewhat or severely malnourished. In half or more cases, physicians expected benefits of improved nutrition (93%), hydration (60%), prolonged life (58%), ease providing medication (55%), and less aspiration risk (49%). Physicians endorsed more expected benefits for patients with stroke or those completely unable to eat by mouth (p < 0.05).

CONCLUSION

Treating physicians expected multiple medical benefits for a diverse population of patients receiving feeding tubes. Physicians may be unaware of evidence, or expect more optimistic outcomes for their specific patient population. Further education and decision support may improve evidence-based decision-making about feeding tubes.