Rethinking the role of tube feeding in patients with advanced dementia

Can an effective end-of-life intervention for advanced dementia be viewed as moral?

Many people dread prolonged dying with suffering in the terminal illness, advanced dementia. To successfully facilitate a timely dying, advance directives must be effective and acceptable. This article considers whether authorities, including treating physicians, can accept as moral, the effective intervention that ceases caregivers' assistance with oral feeding and hydrating. The article presents eight criticisms and "alternate views" regarding ceasing assisted feeding/hydrating. It draws on perspectives from clinical medicine, law, ethics, and religion. The conflict is between (A) people's core beliefs that reflect cultural norms and religious teachings regarding what is moral versus (B) patients' autonomous right of self-determination and claim right to avoid suffering. The article presents each side as strongly as possible. Accepting the intervention as moral could allow patients a peaceful and timely dying from patients' underlying disease. Confidence in future success can deter patients and their surrogates from considering a hastened dying in earlier stages of dementia.

Medical choices regarding feeding tubes in patients with end-stage dementia in Israel: nasogastric vs. percutaneous endoscopic gastrostomy

A previous study conducted more than 15 years ago in Israel found a high overall use of tube-feeding for institutionalized end-stage dementia patients (52%) and a proportionally higher use (2:1) of naso-gastric tube (NG) over Percutaneous Endoscopic Gastrostomy (PEG) tubes for enteral feeding. This rate was markedly higher than that observed in other western countries (4.9-34%), and did not conform with clinical guidelines preferring spoon-feeding over tube-feeding for these patients, and PEG over NG for those in whom tube-feeding was initiated in long-term care. Over the past decade, the Israeli Ministry of Health conducted a policy reform to neutralize the administrative incentives presumed to be responsible for this situation. Further administrative and legislative developments followed suit. Despite these, we found no significant reduction in the prevalence of tube-feeding over spoon-feeding. However, we did observe a reduction in the proportional use of NG over PEG.

Life-Sustaining Treatments Among Medicare Beneficiaries with and without Dementia at the End of Life

BACKGROUND

Older adults with dementia including Alzheimer's disease may have difficulty communicating their treatment preferences and thus may receive intensive end-of-life (EOL) care that confers limited benefits.

OBJECTIVE

This study compared the use of life-sustaining interventions during the last 90 days of life among Medicare beneficiaries with and without dementia.

METHODS

This cohort study utilized population-based national survey data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims. Our sample included Medicare fee-for-service beneficiaries aged 65 years or older deceased between 2000 and 2016. The main outcome was receipt of any life-sustaining interventions during the last 90 days of life, including mechanical ventilation, tracheostomy, tube feeding, and cardiopulmonary resuscitation. We used logistic regression, stratified by nursing home use, to examine dementia status (no dementia, non-advanced dementia, advanced dementia) and patient characteristics associated with receiving those interventions.

RESULTS

Community dwellers with dementia were more likely than those without dementia to receive life-sustaining treatments in their last 90 days of life (advanced dementia: OR = 1.83 [1.42-2.35]; non-advanced dementia: OR = 1.16 [1.01-1.32]). Advance care planning was associated with lower odds of receiving life-sustaining treatments in the community (OR = 0.84 [0.74-0.96]) and in nursing homes (OR = 0.68 [0.53-0.86]). More beneficiaries with advanced dementia received interventions discordant with their EOL treatment preferences.

CONCLUSIONS

Community dwellers with advanced dementia were more likely to receive life-sustaining treatments at the end of life and such treatments may be discordant with their EOL wishes. Enhancing advance care planning and patient-physician communication may improve EOL care quality for persons with dementia.

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.

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.

Older adults' preferences for and actual situations of artificial hydration and nutrition in end-of-life care: An 11-year follow-up study in a care home

Aim

To clarify older adults' preferences for and actual situations of artificial hydration and nutrition (AHN) in end‐of‐life care in a care home.

Methods

Participants were residents of a care home who had completed advance directives regarding preferred methods of AHN from 2009 to 2018. Advance directives alone were available from April 2009 to June 2016 (Wave 1), and advance care planning for AHN including advance directives was introduced in July 2016 (Wave 2). AHN preferences included (i) intensive methods (percutaneous endoscopic gastrostomy, nasogastric tube feeding and total parenteral nutrition), (ii) drip infusion, and (iii) oral intake only. Participants were followed until the end of 2020, and we checked whether decisions about AHN were based on older adults' preferences.

Results

In total, 272 participants had completed advance directives. Most participants preferred “oral intake only” (59.5%), followed by drip infusion (32.0%) and intensive methods (8.5%) in advance directives. Ninety of the 272 participants completed advance directives twice; 83.3% did not change their AHN preferences from Wave 1 to Wave 2. By the end of 2020, 93 of the 272 participants died in the care home. AHN was provided according to older adults' preferences in 48.9% (oral intake only), in 51.4% (drip infusion) and in 55.6% (intensive methods) of cases respectively.

Conclusions

Most participants preferred oral intake only, and their preferences were reflected in decisions about actual situations of AHN in end‐of‐life care. To prepare for advanced dementia and senility, early advance care planning for AHN should be promoted. Geriatr Gerontol Int 2022; 22: 581–587.

Managing feeding needs in advanced dementia: perspectives from ethics of care and ubuntu philosophy

The response to feeding needs in advanced dementia patients is a subject of ethical inquiry. Advanced dementia is the debilitating result of a range of neurodegenerative diseases. As this terminal illness progresses, patients develop mild to severe dysphagia that can make swallowing difficult. Of the two available options, artificial tube feeding or oral hand feeding, an estimated one-third of these patients will receive artificial tube feeding. However, observational studies have failed to validate the clinical benefits of tube feeding. Ethics of care, the feminist philosophical perspective, and Ubuntu philosophy offer arguments for the choice of oral hand-feeding as a preferrable first option by caregivers as far as possible. These moral theories acknowledge that human beings can be dependent for long periods, mostly early and later years of life. Both views reflect an approach that draws people into a system of interdependent caring relationships. They encourage hand feeding as a way of exhibiting solidarity and respecting human dignity even at the end of life.

A Retrospective Analysis of Swallowing Function and Physiology in Patients Living with Dementia

Dysphagia is commonly diagnosed in patients living with dementia, but we lack understanding of changes in swallowing physiology and the resulting relationship to impairments of safety and efficiency. The purpose of this study was to describe the pathophysiology of dysphagia in a retrospective sample of patients living with dementia. Videofluoroscopy data from 106 adults (mean age: 84) diagnosed with dementia were scored by blinded raters. Raters analyzed 412 thin liquid swallows for safety [Penetration-Aspiration Scale (PAS)], efficiency [% of (C2-C4)²], timing [Pharyngeal Transit Time (PTT), Swallow Reaction Time (SRT), Laryngeal Vestibule Closure Reaction Time (LVCrt), Upper Esophageal Sphincter Opening Duration (UESO)], and kinematics (pharyngeal constriction). Impairment thresholds from existing literature were used to characterize swallowing. Chi-square tests and Pearson's correlations were used to determine associations between swallowing physiology and function. Compared to published norms, we identified significant differences in PTT, SRT, LVCrt, UESO, and degree of maximum pharyngeal constriction. Unsafe swallowing (PAS > 2) was seen in 17% of swallows. Clinically significant residue (i.e., % of (C2-C4)² > 0.54 vallecular; > 0.34 pyriforms) was seen in most patients. Chi-square tests revealed significant associations between LVCrt and unsafe swallowing. There was a weak positive association between post-swallow residue in the pyriforms and poor pharyngeal constriction. Detailed analysis of swallowing physiology in this sample provides insight into the pathophysiological mechanisms associated with dysphagia in patients living with dementia. Further work is needed to explore additional bolus consistencies and to identify how physiology changes based on type and severity of dementia diagnosis.

An expanding role for interventional radiology: Medicare trends in fluoroscopic, endoscopic, and surgical enteric tube placement and maintenance from 2010 to 2018

BACKGROUND

The purpose of this study is to provide an update on trends in physician volume and payments for enteric tube placement and maintenance procedures by method, provider specialty, and practice setting amongst Medicare beneficiaries from 2010 to 2018.

MATERIALS AND METHODS

Claims from the Medicare Part B Physician/Supplier Procedure Summary Master File (PSPSMF) for the years 2010 to 2018 were extracted using current procedural terminology (CPT) codes for gastrostomy and jejunostomy placement, as well as conversion of gastrostomy to gastrojejunostomy, fluoroscopy guided and non-image guided replacement. Total volumes and provider reimbursement were analyzed by provider specialty and practice setting.

RESULTS

Volume of de novo placement of all enteric tubes decreased from 157,123 to 106,549 (-32.2%). While endoscopic placement decreased from 133,658 to 81,171 (-39.3%), the volume of fluoroscopic placement increased from 17,999 to 21,277 (18.2%). Fluoroscopic placement was largely performed by interventional radiology (IR) (91.7% in 2018). Surgical placement decreased from 5466 to 4101 (-25.0%). Volume of fluoroscopic replacement increased from 24,799 to 38,470 (55.1%), while non-image guided replacements decreased from 61,377 to 55,116 (-10.2%). Share of both fluoroscopic and non-image guided replacements by advanced practice providers (APPs) more than doubled over this time period.

CONCLUSION

De novo placement of enteric tubes decreased from 2010 to 2018, likely related to increased awareness of the complications and limited benefits in scenarios such as end of life care. In contrast to the diminishing volume for gastroenterologists, there was increased participation by IR in both placement and maintenance procedures under fluoroscopic guidance.

SUMMARY STATEMENT

Decreasing placement of enteric tubes suggests shifting attitudes and recommendations around end-of-life care. Increase in role by IR/APPs highlights the need for comprehensive care in these patients.

Views of Registered Dietitians Compared to Speech-Language Pathologists on Artificial Nutrition and Hydration at the End of Life

OBJECTIVE

To analyze and compare the knowledge and opinions of registered dietitian nutritionists (RDNs) about artificial nutrition and hydration (ANH) in a terminal illness. Beliefs of speech-language pathologists (SLPs) were also considered and compared against RDN data.

METHODS

This is a descriptive analysis utilizing survey responses from RDNs and SLPs regarding ANH in a case study patient with advanced dementia.

RESULTS

There was a strong belief among RDNs that ANH at end of life (EOL) would improve nutritional status, although a correlation was found between those in favor of ANH and believing it was ethical to withhold ANH at EOL (R² = 0.109, p = 0.002). Responses indicated that SLPs need more education regarding ANH techniques, while RDNs felt ANH would improve aspiration risk. Place of employment, religion and age of respondents were also found to impact beliefs.

CONCLUSION

Clinicians, specifically RDNs, working with patients at EOL need more evidenced-based education on the risks and benefits of ANH. Decisions regarding care of patients at EOL should be void of clinicians' personal bias which may affect ethical treatment in the clinical setting. Further controlled trials must be performed before claims can be made regarding ANH at EOL.

Analysis of clinical outcomes in elderly patients with impaired swallowing function

Japan is the world’s leading aging society, and increasing medical expenses for elderly people is an urgent issue. Since aspiration pneumonia in elderly people with impaired swallowing function is a huge problem in Japan, their expected long-term clinical course should be clarified. Accordingly, we collected data from 991 elderly (≥75 years old) patients whose swallowing function was evaluated by Kitasato Institute Hospital’s speech therapists (January 1, 2010 to December 31, 2017). We analyzed the relationship between swallowing function and the subjects’ long-term prognosis. To clarify the prognostic factors of patients with dysphagia, we obtained their clinical information (age, gender, activities of daily living, nutritional status, availability of alternative feeding pathways such as percutaneous endoscopic gastrostomy, and cognitive function). We confirmed 372 death cases and stratified the cases into three groups using Fujishima’s swallowing ability grade, which is used to predict elderly people’s real-world life expectancy. Results showed the median survival days were 331 and 952 days in Groups I (Grades 1–3, n = 308) and II (Grades 4–6, n = 153), respectively, whereas the median survival days for Group III (Grades 7–10, n = 530) could not be calculated. We conducted a multivariate analysis using the Cox proportional hazards model with Group I, which revealed that initial grade and percutaneous endoscopic gastrostomy were significant prognostic factors for the subjects’ long-term survival. Nevertheless, further discussion is necessary, particularly to determine advanced care planning regarding indications for alternative feeding pathways in elderly patients with severe dysphagia, since percutaneous endoscopic gastrostomy could significantly prolong their survival.

Challenges faced by patients, relatives and clinicians in end-stage dementia decision-making: a qualitative study of swallowing problems

BACKGROUND

Decision-making in end-stage dementia (ESD) is a complex process involving medical, social, legal and ethical issues. In ESD, the person suffers from severe cognitive problems leading to a loss of capacity to decide matters regarding health and end-of-life issues. The decisional responsibility is usually passed to clinicians and relatives who can face significant difficulty in making moral decisions, particularly in the presence of life-threatening swallowing problems.

AIM

This study aimed to understand the decision-making processes of clinical teams and relatives in addressing life-threatening swallowing difficulties in ESD in long-term care in Malta.

METHOD

The study followed a qualitative approach where six case studies, involving six different teams and relatives of six different patients, were interviewed retrospectively to understand their decision-making in connection with the management of swallowing difficulties in ESD. Data were collected through semistructured interviews with each stakeholder. All data were transcribed and subjected to thematic analysis.

RESULTS

Four themes were identified: the vulnerability of patients in dementia decision-making; the difficult role of relatives in decision-making; the decisional conflict between aggressive care through tube feeding versus oral comfort feeding; a consensus-building decision-making process as ideal to facilitate agreement and respect for patient's dignity.

CONCLUSION

Decision-making to manage swallowing difficulties in ESD is a challenging process, which involves an interpretation of personal values, beliefs, patient preferences, care needs and clinical practice. Better communication between clinicians and relatives in dementia helps promote agreement between stakeholders leading to a care plan that respects the dignity of patients at their end of life.

Prescribing medications of questionable benefit prior to death: a retrospective study on older nursing home residents with and without dementia in Germany

Purpose

We studied the prevalence of medications of questionable benefit in the last 6 months of life among older nursing home residents with and without dementia in Germany.

Methods

A retrospective cohort study was conducted on claims data from 67,328 deceased nursing home residents aged 65+ years who were admitted between 2010 and 2014. We analyzed prescription regimens of medications of questionable benefit in the 180–91-day period and the 90-day period prior to death for residents with dementia (n = 29,052) and without dementia (n = 38,276). Factors associated with new prescriptions of medications of questionable benefit prior to death were analyzed using logistic regression models among all nursing home residents and stratified by dementia.

Results

A higher proportion of nursing home residents with dementia were prescribed at least one medication of questionable benefit in the 180–91-day (29.6%) and 90-day (26.8%) periods prior to death, compared with residents without dementia (180–91 days, 22.8%; 90 days, 20.1%). Lipid-lowering agents were the most commonly prescribed medications. New prescriptions of medications of questionable benefit were more common among residents with dementia (9.8% vs. 8.7%). When excluding anti-dementia medication, new prescriptions of these medications were more common among residents without dementia (6.4% vs. 8.0%). The presence of dementia (odds ratio [OR] 1.40, 95% confidence interval [95%CI] 1.32–1.48) and excessive polypharmacy were associated with new prescriptions of medications of questionable benefit prior to death (OR 4.74, 95%CI 4.15–5.42).

Conclusion

Even when accounting for anti-dementia prescriptions, the prevalence of nursing home residents with dementia receiving medications of questionable benefit is considerable and may require further attention.

Electronic supplementary material

The online version of this article (10.1007/s00228-020-02859-3) contains supplementary material, which is available to authorized users.

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.

Impact of the Consistency of Food Substances on Health and Related Factors of Residents in Welfare Facilities for Seniors in Japan

The aim of this study is to determine the effect of food consistency on health and related factors among residents in welfare facilities for seniors (n = 227; mean age, 86.2 ± 8.0 years; 78.9% female). Residents who ate regular food had a lower incidence of fever during the 3-month period (p < 0.001) and consumed more calories (1325.97 ± 220.2 kcal) than those who ate chopped (1125.0 ± 256.8 kcal), paste (1122.0 ± 288.5 kcal), and gastric tube food (812.5 ± 150.7 kcal) (p < 0.001). Modifying a resident’s food by making it softer and finer did not reduce the incidence of choking. Logistic regression analysis (backward elimination method) revealed four factors related to eating regular food: vitality index, appetite, number of remaining teeth, and choking frequency. Causal relationships were not obtained because this was a cross-sectional study. The findings of this study suggest that a regular consistency of food positively influences the health of older individuals.

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.

Effects of an advance care planning educational programme intervention on the end-of-life care attitudes of multidisciplinary practitioners at an acute hospital: A pre- and post-study

BACKGROUND

Advance care planning is a crucial end-of-life care practice. However, an advance care planning educational programme for practitioners in an acute care setting has not yet been established. Consequently, we examined the effects of an advance care planning educational programme in an acute hospital in the hope of achieving increased awareness of end-of-life care.

DESIGN

A mixed-methods, pre- and post-design was employed to evaluate the change in attitudes of practitioners post-programme. The intervention programme was conducted thrice over 3 months in 90-min sessions.

SETTING/PARTICIPANTS

This study included 85 participants in the baseline assessment working at B acute hospital in Osaka.

RESULTS

Participants' scores on the 'Positive attitude for end-of-life care' subscale on the short version of the Frommelt Attitude Toward Care of Dying scale significantly increased after the 6-month intervention. A 'Positive attitude for end-of-life-care' implies that participants would not be afraid to practice end-of-life care. Further, participants' scores on the 'Death relief' subscale of the Death Attitude Inventory also significantly increased. The term 'Death relief' means that death helps in ending suffering. It means participants are not afraid of death. Qualitative results implied that participants believed advance care planning implementation and communicating with patients and patients' families were critical.

CONCLUSIONS

Six months post-intervention, participants displayed sustained positive attitudes towards end-of-life care. These results suggest that the present programme was effective at improving practitioners' attitudes towards patients' end-of-life care.

International review of national-level guidelines on end-of-life care with focus on the withholding and withdrawing of artificial nutrition and hydration

AIM

The purpose of the present study was to collate examples of end-of-life care guidelines from various counties, examine their contents, and gain an overall picture of how end-of-life care guidance is offered to physicians and care providers internationally.

METHODS

In this study, eight researchers worked independently to source and examine national-level end-of-life care guidelines from different countries and regions. Data collected by each researcher were gathered into a unified table. The items in the table included basic information (publisher, year, URL etc.) and more specific items, such as the presence/absence of legal information and family's role in decision-making. These data were then used to identify trends, and examine the mechanics and delivery of guidance on this topic.

RESULTS

A total of 54 guidelines were included in the study. All the guidelines were published between 2000 and 2016, and 60% (n = 33) were published after 2012. The length of the guidelines varied from two to 487 pages (median 38 pages), and had different target audiences - both lay and professional. A total of 38 (70%) of the guidelines included information about the relevant laws and legal issues, 47 (87%) offered advice on withholding and withdrawing treatment, 46 (85%) discussed the family's role in decision-making and 46 (85%) emphasized the teamwork aspect of care.

CONCLUSIONS

The present findings show that end-of-life care guidelines are generally made reactively in response to the trend toward patient-centered care, and that to create effective guidelines and implement them requires multilevel cooperation between governmental bodies, healthcare teams, and patients and their families. Geriatr Gerontol Int 2019; 19: 847-853.

Association between High Proportions of Seriously Mentally Ill Nursing Home Residents and the Quality of Resident Care

OBJECTIVES

To examine the association between the quality of care delivered to nursing home residents with and without a serious mental illness (SMI) and the proportion of nursing home residents with SMI.

DESIGN

Instrumental variable study. Relative distance to the nearest nursing home with a high proportion of SMI residents was used to account for potential selection of patients between high- and low-SMI facilities. Data were obtained from the 2006-2010 Minimum Data Set assessments linked with Medicare claims and nursing home information from the Online Survey, Certification, and Reporting database.

SETTING

Nursing homes with high (defined as at least 10% of a facility's population having an SMI diagnosis) and low proportions of SMI residents.

PARTICIPANTS

A total of 58 571 Medicare nursing residents with an SMI diagnosis (ie, schizophrenia or bipolar disorder) and 558 699 individuals without an SMI diagnosis who were admitted to the same nursing homes.

MEASUREMENTS

Outcomes were nursing home quality measures: (1) use of physical restraints, (2) any hospitalization in the last 3 months, (3) use of an indwelling catheter, (4) use of a feeding tube, and (5) presence of pressure ulcer(s).

RESULTS

For individuals with SMI, admission to a high-SMI facility was associated with a 3.7 percentage point (95% confidence interval [CI] = 1.4-6.0) increase in the probability of feeding tube use relative to individuals admitted to a low-SMI facility. Among individuals without SMI, admission to a high-SMI facility was associated with a 1.7 percentage point increase in the probability of catheter use (95 CI = .03-3.47), a 3.8 percentage point increase in the probability of being hospitalized (95% CI = 2.16-5.44), and a 2.1 percentage point increase in the probability of having a feeding tube (95% CI = .43-3.74).

CONCLUSION

Admission to nursing homes with high concentrations of residents with SMI is associated with worse outcomes for both residents with and without SMI. J Am Geriatr Soc 67:2346-2352, 2019.

Experiences of caregivers desiring to refuse life-prolonging treatment for their elderly parents at the end of life

Purpose: This study aimed to clarify the experiences of caregivers desiring to refuse life-prolonging treatment for their elderly parents at the end of life.

Methods: A semi-structured interview was performed for four family caregivers who wanted to refuse life-prolonging treatment suggested by the physicians.

Results: In this study, four caregivers who refused life-prolonging treatment suggested by the physicians for their elderly parents completed semi-structured interviews. The obtained data were analyzed in relation to the theme “Experiences of caregivers who desire to refuse life-prolonging treatment for their elderly parents at the end of life.” As a result, 38 subcategories and 12 categories were extracted.

Conclusions: Participants in this study initially had a negative view of life-prolonging treatment. However, they agonized over the decision when they received conflicting advice from the physicians. The participants indicated that physicians’ advice and attitudes complicated their decisions to reject life-prolonging treatment for their elderly parents.

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.

Concordance Between Proxy Level of Care Preference and Advance Directives Among Nursing Home Residents With Advanced Dementia: A Cluster Randomized Clinical Trial

CONTEXT

Care consistent with goals is the desired outcome of advance care planning (ACP).

OBJECTIVES

The objectives of this study were to examine concordance between advance directives and proxy care preferences among nursing home residents with advanced dementia and to determine the impact of an ACP video on concordance.

METHODS

Data were from Educational Video to Improve Nursing home Care in End-stage dementia, a cluster randomized clinical trial conducted in 64 Boston-area facilities (32/arm) from 2013 to 2017. Participants included advanced dementia residents and their proxies (N = 328 dyads). At the baseline and quarterly (up to 12 months), proxies stated their preferred level of care for the resident (comfort, basic, or intensive) and advance directives for specific treatments (resuscitation, hospitalization, tube-feeding, intravenous hydration, antibiotics) were abstracted from the charts. At the baseline, proxies in intervention facilities viewed an ACP video. Their care preferences after viewing it were shared via a written communication with the primary care team. At each assessment, concordance between directives and proxy preferences was determined.

RESULTS

Among the residents (mean age, 86.6 years; 19.5% male), the most prevalent directive was DNR (89.3%) and foregoing antibiotics was least common (parenteral, 8.2%; any type, 4.0%). Concordance between directives and each level of care preference was as follows: comfort, 7%; basic, 49%; and intensive, 58%. When comfort care was preferred, concordance was higher in intervention versus control facilities (10.8% vs. 2.5%; adjusted odds ratio, 2.48; 95% CI, 1.01-6.09).

CONCLUSION

Better alignment between preferences for comfort-focused care and advance directives is needed in advanced dementia. An ACP video may help achieve that goal.

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.

Use of the STTGMA Tool to Risk Stratify 1-Year Functional Outcomes and Mortality in Geriatric Trauma Patients

OBJECTIVES

To determine whether a novel inpatient mortality risk assessment tool designed to be calculated in the emergency department setting can risk stratify patient-reported functional outcomes and mortality at 1 year.

DESIGN

Prospective cohort.

SETTING

Academic level 1 trauma center.

PATIENTS

Six hundred eight-five patients >55 years of age who were orthopaedic surgery consults or trauma surgery consults in the emergency department between January 10, 2014, and September 30, 2015.

INTERVENTION

Calculation of the validated score for trauma triage in the geriatric and middle-aged (STTGMA) using each patient's demographics, injury severity, and functional status.

MAIN OUTCOME MEASUREMENTS

Mortality, EQ-5D questionnaire, and percent return to baseline function since their hospitalization at 1-year after hospitalization.

RESULTS

Forty-five (6.6%) patients died within the year after hospitalization. Of remaining 639 patients available for follow-up, 247 (38.7%) were successfully contacted. There was no observed difference between patients who were successfully contacted and those who were not. The mean STTGMA score was 2.1% ± 3.6%. Patients reported on average a 76.4% ± 27.5% return to baseline function. When comparing patients between risk groups, there was a significant difference in EQ-5D scores and percent return to baseline. The Kaplan-Meier survival curve shows that high-risk patients had pronounced decreased survival within the initial days after discharge compared with other cohorts.

CONCLUSIONS

This study demonstrates that patients identified with the STTGMA tool as having an increased risk of inpatient mortality after trauma correlate with poorer functional outcomes at 1 year. The STTGMA risk score is also a valuable tool to stratify risk of mortality up to 1 year after discharge.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Impact of Dementia Special Care Units on Quality of Care: An Instrumental Variables Analysis

OBJECTIVE

To compare the quality of care following admission to a nursing home (NH) with and without a dementia special care unit (SCU) for residents with dementia.

DATA SOURCES/STUDY SETTING

National resident-level minimum dataset assessments (MDS) 2005-2010 merged with Medicare claims and provider-level data from the Online Survey, Certification, and Reporting database.

STUDY DESIGN

We employ an instrumental variable approach to address the endogeneity of selection into an SCU facility controlling for a range of individual-level covariates. We use "differential distance" to a nursing home with and without an SCU as our instrument.

DATA COLLECTION/EXTRACTION METHODS

Minimum dataset assessments performed at NH admission and every quarter thereafter.

PRINCIPAL FINDINGS

Admission to a facility with an SCU led to a reduction in inappropriate antipsychotics (-9.7 percent), physical restraints (-9.6 percent), pressure ulcers (-3.3 percent), feeding tubes (-8.3 percent), and hospitalizations (-14.7 percent). We found no impact on the use of indwelling urinary catheters. Results held in sensitivity analyses that accounted for the share of SCU beds and the facilities' overall quality.

CONCLUSIONS

Facilities with an SCU provide better quality of care as measured by several validated quality indicators. Given the aging population, policies to promote the expansion and use of dementia SCUs may be warranted.

Doctors' Knowledge and Attitudes Regarding Enteral Feeding and Eating Problems in Advanced Dementia

BACKGROUND

The use of feeding tubes (FTs) in patients with advanced dementia does not yield positive health outcomes and can have a negative effect.

METHODS

A cross-sectional study assessed the knowledge and attitudes of physicians on the use of FTs for patients with advanced dementia.

RESULTS

201 of 240 doctors (83.8%) participated in the study; 61.7% of the doctors claimed that FTs prevent aspiration, 51.7% that they prevent pneumonia, and 38.8% that they prevent weight gain. Almost one-third (32.3%) said that the decision to use FTs could be taken by a hospitalist or a primary physician (28.9%).

CONCLUSION

We found large gaps in knowledge among doctors about the use of FTs and consequences in patients with advanced dementia.

"Music & Memory" and improved swallowing in advanced dementia

Background

Dysphagia and difficulty with eating affects a significant portion of individuals with advanced dementia. Such problems with oral intake can have serious health consequences including mealtime distress, dehydration and malnutrition, aspiration, reduced quality of life, and increased mortality risk.

Design

We present the first data indicating that “Music & Memory” interventions improve swallowing in individuals with advanced dementia, thereby making oral feeding easier and potentially diminishing reliance on PEG.

Setting

Columbia Health Care Center, Wyocena, WI (with Music&Memory.org, Mineola, NY and Stony Brook University).

Participants

Residents with advanced dementia (N = 5). Measurements: Observation by eight professional caregivers.

Results

(1) Enhanced swallowing mechanism with Music & Memory prior to dining; (2) decreased incidents of choking during mealtime; (3) improved nutritional status; (4) reduced weight loss; (5) reduced need for speech interventions; (6) enhanced quality of life.

Conclusions

The preliminary results call for additional research.

Shared decision-making when choosing the feeding method of patients with severe dementia: a systematic review

Abstract Objectives: To evaluate whether the use of a support tool for shared decision-making in the choice of feeding method for patients with severe dementia can benefit the patient/caregiver dyad, and to evaluate the quality of the decision-making process. Method: A search was performed in the Medline, LILACS, IBECS, SciELO, WHOLIS databases for randomized controlled trials, whether double-blind or otherwise, and quasi-experimental, cohort, case-control, or cross-sectional observational studies in Portuguese, Spanish, English and French. Results: Eight articles were found that showed that the use of a decision support tool, as an aid for the shared decision-making method, is beneficial as it reduces decisional conflict and increases the knowledge of caregivers about the subject. The quality of the decision-making process is unsatisfactory due to the low frequency of discussions between caregivers and the health team and the poor evaluation of caregivers about the participation of the team in the decision-making process. Conclusion: Decision support tools provide benefits for caregivers/patients undergoing the difficult task of deciding about feeding methods. Findings suggest that the current quality of decision-making is inadequate.

Jonsen's Four Topics Approach as a Framework for Clinical Ethics Consultation

This was an in-depth qualitative study that looked at the reasons patients were referred to the Clinical Ethics Committee (CEC) of an acute hospital in Singapore and explore how the CEC approached cases referred. Jonsen's four topics approach was applied in the deliberative process for all cases. A comprehensive review of the case records of 28 patients referred consecutively to the CEC from 1 January 2012 to 31 December 2014 was conducted. Data and information was collated from the referral forms, patient medical records, and emails communicated among CEC members. A deductive approach to thematic analysis based on Jonsen's four topics approach was used to analyze the documents. Majority of the patients were male (94%), Chinese (76%), and above 65 years of age (41%). Ethical dilemmas surfaced due to differences in opinion regarding withholding of aggressive management (53%), withdrawing treatment (35%), and ascertaining patient's autonomy (12%). In most cases, the patients' preference on end-of-life care was unknown (82%). The main reasons for referral to the CEC were conflicts in clinical management and uncertainty about the decision-making capacity of patients. The CEC members tended to emphasize on "patient preference" more than the other quadrants in the four topics approach as they worked through each case. The Jonsen's four topics approach lays the groundwork to frame ethical dilemmas that can be easily applied in the clinical setting and is a useful tool for the CEC's teaching and discussion. Nonetheless, the approach only organizes ethical dilemmas and requires clinicians to apply own judgment in weighing ethical principles. Further studies can look into adapting the four topics approach to suit the local practices and context.

[Percutaneous endoscopic gastrostomy in geriatrics : Indications, technique and complications]

The technique of percutaneous endoscopic gastrostomy (PEG) was introduced in 1979 as a semi-invasive approach for children with the need for a gastric fistula in order to avoid an operative intervention. The suture pull-through method was rapidly established and is now omnipresent. Because scientific evidence is broadly missing, there is some uncertainty about the indications in geriatric medicine. Guidelines do not recommend the insertion of a PEG in patients with severe dementia and malnutrition. Tube feeding is mainly recommended as a temporary method for patients who cannot take oral nutrition for more than 3 days or for whom the energy intake for more than 10 days presumably covers less than 50% of their needs, assuming that the overall prognosis is reasonable. Insertion of a PEG is only recommended if artificial nutrition is expected to be necessary for more than 3-4 weeks or if a nasogastric tube is not tolerated.

Palliative care in dementia: issues and evidence

Palliative care is an approach that stands well with the aims of person-centred dementia care. There is no doubt that the standards of care for many people with advanced dementia are poor. There is a lack of good-quality evidence, however, to support any particular approach for palliative care in dementia. Still, there are a number of areas in relation to caring for people with severe dementia where a palliative approach might be beneficial. In general, the relevant decisions have to be made on an individual basis but within a palliative framework. Advance care planning is likely to be crucial in encouraging this process. There is certainly a moral imperative behind the idea that care at the end of life for people with dementia should be improved.

The Effectiveness of Advance Care Planning in Improving End-of-Life Outcomes for People With Dementia and Their Carers: A Systematic Review and Critical Discussion

CONTEXT

End-of-life care for people with dementia can be poor, involving emergency hospital admissions, burdensome treatments of uncertain value, and undertreatment of pain and other symptoms. Advance care planning (ACP) is identified, in England and elsewhere, as a means of improving end-of-life outcomes for people with dementia and their carers.

OBJECTIVE

To systematically and critically review empirical evidence concerning the effectiveness of ACP in improving end-of-life outcomes for people with dementia and their carers.

METHODS

Systematic searches of academic databases (CINAHL Plus with full text, PsycINFO, SocINDEX with full text, and PubMed) were conducted to identify research studies, published between January 2000-January 2017 and involving statistical methods, in which ACP is an intervention or independent variable, and in which end-of-life outcomes for people with dementia and/or their carers are reported.

RESULTS

A total of 18 relevant studies were identified. Most found ACP to be associated with some improved end-of-life outcomes. Studies were predominantly, but not exclusively, from the U.S. and care home-based. Type of ACP and outcome measures varied. Quality was assessed using National Institute of Health and Care Excellence quality appraisal checklists. Over half of the studies were of moderate to high quality. Three were randomized controlled trials, two of which were low quality.

CONCLUSION

There is a need for more high-quality outcome studies, particularly using randomized designs to control for confounding. These need to be underpinned by sufficient development work and process evaluation to clarify the appropriateness of outcome measures, explore implementation issues and identify "active elements."

Swallowing impairment is a significant factor for predicting life prognosis of elderly at the end of life

BACKGROUND

In end-of-life care of elderly, the decision of care plan including gastrostomy is difficult frequently because of insufficient knowledge relating the life prognosis of elderly. It is important the families to decide correctly the life prognosis of elderly with geriatric diseases. Our purpose is to examine the significant factors for predicting life prognosis of elderly in end-of-life care.

METHODS

A total of 320 elderly patients was enrolled (male/female 151/169; averaged age: male 84.7 ± 5.9 year, female 86.8 ± 6.3 year) and retrospective analyses were performed. The elderly patients were classified as either: (1) with or without past illness of aspiration pneumonia; (2) with or without incidence of cerebrovascular disorder; (3) impaired or normal cognitive function; (4) impaired or normal swallowing function, and performed Kaplan-Meier survival analysis. Swallowing function was examined using video endoscopic (VE) evaluation method. The Kaplan-Meier analysis of the number of days from implementation of VE test (day 0) to death was evaluated with the log-rank Mantel-Cox test. The maximum follow-up time recorded was 180 days.

RESULTS

There were no significant differences in number of days when divided with or without past illness of aspiration pneumonia, cerebrovascular disorder and impaired cognitive function. The survival probabilities of elderly with impaired swallowing function were significant lower than in elderly with the normal function.

CONCLUSIONS

For judgement of life prognosis, the condition of being frail such as impaired swallowing function might be a useful factor, and the viewpoint would contribute to decide the treatment plan for the good end-of-life care of elderly.

Factors influencing decision regret regarding placement of a PEG among substitute decision-makers of older persons in Japan: a prospective study

Background

A tube feeding decision aid designed at the Ottawa Health Research Institute was specifically created for substitute decision-makers who must decide whether to allow placement of a percutaneous endoscopic gastrostomy (PEG) tube in a cognitively impaired older person. We developed a Japanese version and found that the decision aid promoted the decision-making process of substitute decision-makers to decrease decisional conflict and increase knowledge. However, the factors that influence decision regret among substitute decision-makers were not measured after the decision was made. The objective of this study was to explore the factors that influence decision regret among substitute decision-makers 6 months after using a decision aid for PEG placement.

Methods

In this prospective study, participants comprised substitute decision-makers for 45 inpatients aged 65 years and older who were being considered for placement of a PEG tube in hospitals, nursing homes and patients’ homes in Japan. The Decisional Conflict Scale (DCS) was used to evaluate decisional conflict among substitute decision-makers immediately after deciding whether to introduce tube feeding and the Decision Regret Scale (DRS) was used to evaluate decisional regret among substitute decision-makers 6 months after they made their decision. Normalized scores were evaluated and analysis of variance was used to compare groups.

Results

The results of the multiple regression analysis suggest that PEG placement (P < .01) and decision conflict (P < .001) are explanatory factors of decision regret regarding placement of a PEG among substitute decision-makers.

Conclusions

PEG placement and decision conflict immediately after deciding whether to allow PEG placement have an influence on decision regret among substitute decision-makers after 6 months.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0524-2) contains supplementary material, which is available to authorized users.

The Effect of Pressure Ulcers on the Survival in Patients With Advanced Dementia and Comorbidities

BACKGROUND/STUDY CONTEXT

The mortality rates for many leading causes of death have declined over the past decade. Advanced dementia with comorbidities has steadily increased to become one of the leading causes of death in the elderly population. Therefore, this study examined the effect of pressure ulcers on the survival time of patients with advanced dementia and comorbidities.

METHODS

Data were reviewed from all the files of 147 patients hospitalized over a period of 3½ years. Ninety-nine tube-fed patients suffering from advanced dementia were assessed; 72 (66.5%) had pressure ulcers and 27 (33.5%) were without pressure ulcers at admission. Logistic regression analysis was used to estimate the odds ratio and 95% confidence intervals for pressure ulcers group versus non-pressure ulcers group. Unadjusted Cox model and Cox proportional hazards model were used to assess the hazard ratio for pressure ulcers and the association between pressure ulcers and survival time, respectively. Kaplan-Meier model was used to visually confirm the existence of proportional hazards of pressure ulcers on survival.

RESULTS

The median survival of advanced dementia patients with pressure ulcers was significantly shorter, compared with those without pressure ulcers (96 vs. 863 days). Significant lower hemoglobin and serum albumin levels were found in the patients with pressure ulcers.

CONCLUSION

Advance dementia and pressure ulcers in the same patient results in earlier mortality. Advanced dementia patients with pressure ulcers had significantly lower survival expectancy in comparison with similar patients without pressure ulcers. Clinical and ethical implications are discussed.

The Use of Advance Care Planning to Guide Decisions About Artificial Nutrition and Hydration

Advance care planning is important to ensure that patients, when competent, can influence the kind of medical care they receive if they lose decision-making capacity. Because decisions by surrogates to for-go nutrition support remain controversial, specific inclusion of artificial nutrition and hydration as a part of advance care planning has taken on growing importance. This article reviews the choices about artificial nutrition and hydration that are possible using conventional advance directives such as the living will, the instructional directive, values histories, and combination directives. It summarizes the legal basis for such documents. It also describes the ways that physicians' orders to limit treatment can help implement decisions about the use of artificial nutrition and hydration. Finally, it stresses the importance of clarifying with patients and families the risks and benefits of nutrition support in a variety of common situations such as advanced dementia and metastatic cancer as an essential prerequisite to meaningful advance care planning.

Tube Feeding Patients With Dementia

As the population ages, the incidence of dementia increases. All types of dementia, whether they are reversible or irreversible, lead to loss of intellectual function and judgment, memory impairment, and personality changes. The skills to feed oneself, use eating utensils, and consume items recognized as food, thereby maintaining nutrition status, may be lost as dementia progresses. Reports indicate that nutrition status may be maintained when patients are hand fed, but this is labor intensive and therefore expensive. Feeding via a percutaneous endoscopic gastrostomy tube is often chosen as an acceptable alternative. Research indicates that there is little benefit in this population when aggressive nutrition support is instituted. Providing tube feeding to patients with dementia does not necessarily extend life, increase weight, or reduce the incidence of pressure ulcers or aspiration. There are many legal and ethical issues involved in the decision to place a feeding tube in demented patients. The primary issue in patients with dementia may be autonomy and the right of an individual to decide whether or not a tube should be placed at all. Legally, there is clear precedent that the courts see the insertion of a feeding tube as extraordinary care that the patient has the right to refuse. However, much of case law is derived from cases of patients who were in a persistent vegetative state. Advance directives help to determine what the patient would want for himself. Considering all the options before the patient can no longer make decisions is the most desirable course.

Tube Feeding among Elder in Long-Term Care Facilities: A Systematic Review and Meta-Analysis

OBJECTIVE

The use of tube feeding for elderly patients with poor nutritional intake is a ubiquitous method of feeding. This systematic review and meta-analysis were carried out to compare nutritional benefits of enteral feeding versus oral feeding in long-term care facilities.

SETTING

Databases including the Cochrane Library, ProQuest, PubMed, EMBASE, EBSCO, Web of Science and Google Scholar through April 2014 using keywords including enteral feeding, tube feeding or oral feeding combined with long term care facilities or nursing home.

PARTICIPANTS

Eight articles, with 841 participants were included in meta-analysis and 13 articles were included in systematic review. The elderly had to live in long-term care institutions and could not be on any mechanically assisted ventilation systems or be in any type of post-operative status.

MEASUREMENTS

The three investigators extracted and appraised data using the same study design, baseline characteristics, and outcomes, independently.

RESULTS

Following a systematic review, 13 articles out of 8218 original research articles were selected for this analysis. Meta-analysis of tube-fed patients found lower levels of hemoglobin (Weighted Mean Difference (WMD -0.21g/dl; 95% CI -0.42 to -0.01; p=0.04) and creatinine (WMD -0.08g/dl; 95% CI -0.17 to 0.00, p=0.05). Moreover, the results showed that there were no benefits regarding body mass index (BMI), albumin, dietary intake of proteins, total calories and fat.

CONCLUSIONS

The results show that tube feeding does not increase patients' nutrients absorption to improve nutritional status. Instead, these results indicate that oral feeding is better regarding some nutritional biochemical parameters.

Enteral Access Procedures: An 18-Year Analysis of Changing Patterns of Utilization in the Medicare Population

PURPOSE

To evaluate national trends in enteral access and maintenance procedures for Medicare beneficiaries with regard to utilization rates, specialty group roles, and sites of service.

MATERIALS AND METHODS

Using Medicare Physician Supplier Procedure Summary Master Files for the period 1994-2012, claims for gastrostomy and gastrojejunostomy access and maintenance procedures were identified. Longitudinal utilization rates were calculated using annual enrollment data. Procedure volumes by site of service and medical specialty were analyzed.

RESULTS

Between 1994 and 2012, de novo enteral access procedure utilization decreased from 61.6 to 42.3 per 10,000 Medicare Part B beneficiaries (-31%). Gastroenterologists and surgeons performed > 80% of procedures (unchanged over study period) with 97% in the hospital setting. Over time, relative use of an endoscopic approach (62% in 1994; 82% in 2012) increased as percutaneous (21% to 12%) and open surgical (17% to 5%) procedures declined. Existing enteral access maintenance services increased 29% (from 20.1 to 25.9 per 10,000 beneficiaries). Radiologists (from 13% to 31%) surpassed gastroenterologists (from 36% to 21%) as dominant providers of maintenance procedures. Emergency physicians (from 8% to 23%) and nonphysician providers (from 0% to 6%) have seen rapid growth as maintenance services providers as these services have transitioned increasingly to the emergency department setting (from 18% to 32%).

CONCLUSIONS

Among Medicare beneficiaries, de novo enteral access procedures have declined in the last 2 decades as existing access maintenance services have increased. The latter are increasingly performed by radiologists, emergency physicians, and nonphysician providers.

European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome

This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization's classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.