Journal Club 12_09_2014

Enteral Feeding in Advanced
Dementia Adults
Journal Club 12/09/2014
Ann, Matt, Philip, Winnie

Background/Intro
•American Geriatrics Society Position:
–“(When eating difficulties arise) feeding tubes are not recommended for
older adults with advanced dementia. Careful hand feeding should be
offered because hand feeding has been shown to be as good as tube feeding for the
outcomes of death, aspiration pneumonia, functional status, and comfort. Tube
feeding is associated with agitation, greater use of physical and chemical
restraints, greater healthcare use due to tube-related complications, and
development of new pressure ulcers.”
–“Efforts to enhance oral feeding by altering the environment and creating
individual-centered approaches to feeding should be part of usual care for
older adults with advanced dementia.”
American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American
Geriatrics Society Feeding Tubes in Advanced Dementia Position Statement. JAGS. 2014; 62 (8): 1590-1593.

American Geriatrics Society Position cont…
•“Tube feeding is a medical therapy that an individual’s surrogate
decision-maker can decline or accept in accordance with advance
directives, previously stated wishes, or what is though the individual
would want.”
•“It is the responsibility of all members of the healthcare team…to
understand any previously expressed wishes of the
individuals…regarding tube feeding and to incorporate these wishes into the
care plan.”
•…“Institutions should not impose obligations or exert pressure on
individuals or providers to institute tube feeding.”

cont...
•A randomized, controlled trial comparing benefits/disadvantages of
TF vs. PO in advance dementia has not been done due to ethical
considerations (i.e. age/vulnerability)
•Caregivers report little conversation surrounding TF decisions (more
than ½ report no conversation or one that last 15 min.)
–Many times families feel pressured to use1

Background continued
Management of Feeding Tube Complications in the Long-Term
Care Resident
Shai Gavi, DO, MPH, Jennifer Hensley, MD, Frank Cervo, MD,
Catherine Nicastri, MD, and Suzanne Fields, MD

Introduction
• 2006 MDS data indicated that 8.1% of all
nursing home residents were receiving tube
feedings.
• States vary-Nebraska lowest (3.8%) and
District of Columbia highest (44.8%).
• 3 types of tube feedings (nasoenteral,
gastrostomy, jejunal).
Gavi S, Hensley J, Cervo F, Nicastri C, Fields S. Management of Feeding Tube Complications in the Long-
Term Care Resident. Clinical Care and Aging. 2008: 16 (4). 1-3.

Tube Feeding Complications
• Aspiration
• Diarrhea
• Nausea, vomiting or abdominal bloating
• Metabolic
• Mechanical
Gavi S, Hensley J, Cervo F, Nicastri C, Fields S. Management of Feeding Tube Complications in the Long-
Term Care Resident. Clinical Care and Aging. 2008: 16 (4). 1-3.

Other Issues
• Medications and tube feedings
• Many of these medication interactions can be
avoided by withholding tube feedings for two
hours before and after giving medications.2
Gavi S, Hensley J, Cervo F, Nicastri C, Fields S. Management of Feeding Tube Complications in the Long-Term Care Resident.
Clinical Care and Aging. 2008: 16 (4). 1-3.

Enteral Tube Feeding in Older
Adults with Dementia
Authors: Candy B., Sampson EL, Jones L.
Presented by: Winnie

Purpose
● Poor PO is commonly observed in dementia patients
due to various reasons
● ETF is an obvious solution to tackle the poor nutrition
in advanced dementia patients, via NG tube or PEG
● Benefits or harms are not evaluated, and there is no
outcomes are measured in the studies, hence this
systematic review
Candy B., Sampson EL, Jones L. Enteral tube feeding in older people with advanced dementia: Findings from a
Cochrane systematic review. International Journal of Palliative Nursing. 2009; 15(8):396-404.

● Systematic review
● Studies were included if NG tube or PEG are evaluated;
patients age of 50 years and over of both genders; poor PO or
had developed problems with eating and swallowing; most
patients were diagnosed of degenerative dementia
● Studies regarding administration of IV fluid are excluded
because usually are short-termed
● Primary outcomes were mortality and quality of life (QOL)
Methods

Results
● No RCTs were identified
● Case note review or analysis of an existing data set
● 7 observational controlled cohort studies
● 3 studies used prospective methods
● 1 study randomly selected controls

● Studies included were undertaken in the US, Spain, and
Israel
● Study population was recruited from inpatient/ tertiary
hospital populations or nursing homes.
● 409 patients received enteral feeding and 1467
comparison subjects

● Primary outcomes: No study stated that QOL was
measured; 6 studies evaluated mortality
● Secondary outcomes: (a range of nutritional
parameters) weight, BMI, hematocrit and cholesterol
levels.
● 2 studies reported adverse effects, i.e. aspirational
pneumonia (58% vs 17%) and death (1 reported)

Discussion
● Evidence of benefits in enteral feeding in dementia
patients is inconclusive.
● No evaluation was found on QOL, physical function, or
behavioral/ psychiatric symptoms of dementia.
● Little info was given on adverse events for the invasive
procedures.

Implications
● Formulating care plans to facilitate swallowing and
supplementing intake
● Hand-feeding carefully
● Playing quiet and smooth music at mealtimes3

Do Patients With Advanced Cognitive
Impairment Admitted to Hospitals With Higher
Rates of Feeding Tube Insertion Have
Improved Survival
Shubing Cai, PhD, Pedro L. Gozalo, PhD, Susan L. Mitchell, MD, MPH, Sylvia Kuo, PhD,
Julie P.W. Bynum, MD, MPH, Vincent Mor, PhD, and Joan M. Teno, MD, MS
Presented By Phil

Methods
• There were 56,824 nursing home residents
from 1773 hospitals.
• MDS was used to match Medicare claims from
2000-2007.
Cai S, Gozalo PL, Mitchell SL, Kuo S, Bynum JPW, Mor V, Teno JM. Do Patients with Advanced Cognitive
Impairment Admitted to Hospitals With Higher Rates of Feeding Tube Insertion Have Improved Survival? J
Pain Symptom Manage. 2013: 45 (3). 1-7.

Results
• Of the 1773 hospitals, 18.5% or 228 had low rates of
tube insertion.
• 20.6% or 366 hospitals had high rates.
• Individuals admitted to hospitals with high insertion
rates did not experience improved 6 month survival
compared to those with hospitals with low insertion
rates.
Cai S, Gozalo PL, Mitchell SL, Kuo S, Bynum JPW, Mor V, Teno JM. Do Patients with Advanced Cognitive Impairment
Admitted to Hospitals With Higher Rates of Feeding Tube Insertion Have Improved Survival? J Pain Symptom Manage.
2013: 45 (3). 1-7.

Limitations and Strengths
Limitations
• Only MDS measures were
used.
• Ages made it difficult for long
term study.
• They were not able to
distinguish effect of care
provided in the hospital from
care received after discharge.
Strengths
• Large population
• Many facilities funded the
study
Cai S, Gozalo PL, Mitchell SL, Kuo S, Bynum JPW, Mor V, Teno JM. Do Patients with Advanced Cognitive Impairment
Admitted to Hospitals With Higher Rates of Feeding Tube Insertion Have Improved Survival? J Pain Symptom Manage.
2013: 45 (3). 1-7

Discussion
• The findings were consistent with results of
prior research that showed tube feeding does
not improve survival among patients with
dementia.4
Cai S, Gozalo PL, Mitchell SL, Kuo S, Bynum JPW, Mor V, Teno JM. Do Patients with Advanced Cognitive

Survival Effect of TF in Pts with
Advanced Dementia and
Comorbidities
Authors: Efraim Jaul, Raz Levin, Jacob
Menczel
Presented by: Ann

Purpose
The aim of the study is:
To report the effects of tube feeding on the survival rates of
patients with advanced dementia who also suffer from
severe disease
To Compare these results with those who were orally fed
Efraim Jaul, Raz Levin, Jacob Menczel. Survival Effect of Tube Feeding in Patients with Advanced Dementia
and Comorbidities. International Journal of Clinical Medicine. 2014; 5: 611-616.

Methods
Data was collected from the skilled geriatric nursing department at Herzog Hospital in
Jerusalem
Patients recruited for the study had advanced dementia and had other complications
such as extensive and deep pressure ulcers.
Patients were evaluated for feeding method: Oral Feeding (OF) or Tube Feeding (TF)
The data was collected from the medical, nursing, social and nutrition files
Logistic regression models were used to estimate the Odds Ratio (OR) and 95%
confidence intervals (CI) for TF vs OF by study covariates.

Results
One hundred forty nine patients were included in the study: 99 (66.5%) were
with TF and 50 (33.5%) with OF at admission
The underlying medical conditions were significantly higher in the TF group,
such as: cerebrovascular accidents (CVA), chronic renal failure (CRF) and lung
diseases
Parkinson’s disease, diabetes mellitus, ischemic heart disease (IHD) and
peripheral vascular disease (PVD) were not significantly different between the
two groups

Statistically significant higher prevalence of pressure ulcers (75% vs 25%),
tracheostomies (91% vs. 9%) and urinary catheters (72% vs. 28%) were found
in the TF patients
The mean Functional Assessment Staging of Alzheimer Disease (FAST) was
significantly higher in the TF group (6.54 ± 0.6 vs. 6.02 ± 0.5, p < 0.001).
The mean Glasgow Coma Scale (GCS) (10.9 ± 2.99 vs. 13.8 ± 1.64,
p < 0.001) and the total Norton score (8.75 ± 2.2 vs 11.04 ± 2.5; p < 0.001)
were significantly lower in the TF patients compare to the OF patients.
The median survival time of patients with TF was 164 days and that of the OF
group was 78 days (χ2 = 0.94; p = 0.33)

Efraim Jaul, Raz Levin, Jacob Menczel. Survival Effect of Tube Feeding in Patients with Advanced Dementia and
Comorbidities. International Journal of Clinical Medicine. 2014; 5: 611-616.

Discussion
The tube fed group suffered from more complications including pressure
ulcers, low Hgb level, use of urinary catheters and tracheostomies as compared
to the oral fed patients
The main result of the study is that the survival time of the TF patients was
longer, yet not statistically significant
TF was beneficial in patients with specific risk factors, such as low Hgb, low
BMI and pressure ulcers

Conclusion
The advanced dementia patients described in the study
were unable to eat and to drink, suffered from additional
diseases, and had a clear indication for tube feeding
The study concluded that the median survival period in the
TF group was longer as compared to the OF patients

Limitations
The study limitations include the study’s setting; conducted in a skilled nursing
department rather than in the community or in nursing homes
The study is associated with a selection bias towards sicker patients with higher
comorbidities
The control group is composed of patients who met department admission
criteria and therefore the results may not be generalizable to community or
nursing home patients

The role of gastrostomy tube placement
in advanced dementia with dysphagia a
critical review
Authors: Goldberg LS, Altman KW
Presented by: Matt Caldanaro

Introduction/Research Questions
•Much controversy regarding use and timing of EN in those with dysphagia & aspiration
risk
•Add to it advanced dementia & ethical issues with comfort care (PO), PEG placement,
and mortality rates→ becomes even more complex
•Purpose of study: Evaluate PEG placement in those with advanced dementia with
associated mortality rates
•Hypothesis: PEG does not prolong life
•Also, explored impact of PEG placement in specific dementia groups to identify
prognoses that may be used to develop comprehensive guidelines
Goldberg LS, Altman, KW. The role of gastrostomy tube placement in advance dementia with dysphagia: a critical
review. Clinical Interventions in Aging. 2014; 9: 1733-1739.

Methods
•Systematic review of literature using PubMed (1995-2012)
•100 articles (yielded greatest results) used terms “dementia” OR “Alzheimer” AND
“dysphagia” OR “aspiration” OR “swallowing difficulty” AND “percutaneous endoscopic
gastrostomy” OR “enteral” OR “feeding tube”
•Inclusion criteria required: 1) scientific research paper 2) addressed dementia,
dysphagia or aspiration risk, or PEG tube placement 3) originally written in or translated
into English
•Next, references studied for relevance, level of evidence, year of study, if based on
systematic review of literature, size of study, number of patients with dementia within
study, specific outcomes (i.e. survival- compared dementia patients with PEGs vs. those
without)

Data Analysis
•After applying inclusion and exclusion criteria, 10 articles remained
•Retrospective studies:
1. 10 year study; 8,688 dementia patients with PEGs: 1 year mortality rate for males
61%, 1 year mortality rate for females 50%; 3 year mortality rate for 78% for females,
84% for males
2. 311 patients with PEGs, 143 with dementia: 51% 12-month survival rate with
dementia, 49% without dementia (3 predictors of poor survival after PEG: male,
>80 years, & hypoalbuminemia)
3. Last study audited 719 patients who died within 30 days after PEG: 18% had
dementia, 82%- 70 years or older, 50%- >80 years (29% written consent for
procedure among dementia patients)

Data Analysis cont…
•Prospective studies:
1. 99 hospital patients with advanced dementia: median mortality rate 6
months “post-feeding tube” 195 days, without feeding tube 189 days
(mortality 50% in both groups)
2. 674 patients (280 dementia/PEG, over half > 80 years, with age
distribution similar to PEG placements in US): median survival rate
171 days for those over 80 with dementia (worse), compared to
dementia/stroke 181 days, dementia/nursing homes 423 days, &
dementia/younger than 80 years 467 days

Results and Conclusions
•5 studies revealed mortality at 30 days with dementia/PEG placement
–13-18%, 14.4%, 18%, 25%, and 54%
•4/5 studies revealed mortality at ~50% at 1 year with dementia/PEG
placement
–45.6%, 51%, 50-61%, and 58%
•Conclusion: Presently no evidence in literature to suggest long-term survival
rates improved in patients with advanced dementia who underwent PEG
placement

Strengths and Limitations
•Strengths: multiple studies, many with larger sample sizes
•Limitations/benefits of PEG not addressed: route for medications, hydration
and nutrition supplementation, allows for “compassionate PO” or “comfort
care”, and bridging nutritional needs during readmissions due to declining
mental status
•Ethical considerations?
•Statistical evaluation of studies?

Discussion
•Should a PEG be placed in a dementia patient who is aspirating or has dysphagia? Should
interventions be done sooner? When is it too late?
–Must consider quality of life (PO an option? “Starving” patient if no PEG?), stage/progression
of dementia (6=moderate-severe, 7=severe), age onset of dysphagia, comorbidities
–Discussions regarding PEG placement do not appear to be happening during early stages of
dementia diagnosis, and many of those who receive PEG do not have health care proxies (need
more involvement between medical staff and families!)
–Research shows increased survival rate in dementia patients under 80 years (double than
patients over 80)
–Males have higher risk of 30-day mortality after PEG insertion6

Any questions? Or
further
discussion/comments?
Thank-you!

References
1. American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American
2. Gavi S, Hensley J, Cervo F, Nicastri C, Fields S. Management of Feeding Tube Complications in the Long-Term
Care Resident. Clinical Care and Aging. 2008: 16 (4). 1-3.
3. Candy B., Sampson EL, Jones L. Enteral tube feeding in older people with advanced dementia: Findings from a
4. Cai S, Gozalo PL, Mitchell SL, Kuo S, Bynum JPW, Mor V, Teno JM. Do Patients with Advanced Cognitive
5. Efraim Jaul, Raz Levin, Jacob Menczel. Survival Effect of Tube Feeding in Patients with Advanced Dementia and
Comorbidities. International Journal of Clinical Medicine. 2014; 5: 611-616.
6. Goldberg LS, Altman, KW. The role of gastrostomy tube placement in advance dementia with dysphagia: a
critical review. Clinical Interventions in Aging. 2014; 9: 1733-1739.

Journal Club 12_09_2014

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