Gastrostomies in dementia: bad practice or bad evidence?

Healthcare Professionals' Perceptions of Stabilized Edible Foam with Adults with Severe Dysphagia; an exploratory study: Use of stabilized edible foam with adults with dysphagia: Use of stabilized edible foam with adults with dysphagia

BACKGROUND

Improving the quality of life for individuals with severe dysphagia is a priority when considering new areas of dysphagia management, especially if this increases opportunities to participate in social activities associated with eating and drinking. Edible foam is widely researched and available in the food industry; however, the use of edible foam within the field of dysphagia remains unexplored. Despite no research published on effectiveness and safety, a commercial product currently on the market is widely distributed across both Europe and the UK, including 28 NHS Trusts, suggesting that it is increasingly being used in clinical practice.

AIMS

To explore the perceptions and experiences of healthcare professionals on the use of stabilized edible foam (SEF) with adults with severe dysphagia in order to inform areas for future research in this novel dysphagia intervention.

METHODS & PROCEDURES

Healthcare professionals were recruited using purposeful sampling and snowballing technique. A total of 56 healthcare professionals were initially approached, of which 10 completed the semi-structured interviews. Interview questions were developed from a topic guide and a pilot questionnaire.

OUTCOMES & RESULTS

Thematic analysis was used to identify three themes: potential impact, consideration of risk and perceived experiences. Overarching each of these themes was the element of the unknown.

CONCLUSIONS & IMPLICATIONS

Use of SEF with adults with dysphagia is in its infancy. Whilst results indicate that some clinicians are embracing this novel approach, others express concerns. Therefore, further research is needed, particularly in relation of direct experience of individuals and contra-indications.

WHAT THIS PAPER ADDS

What is already known on the subject The use of SEF with individuals with swallowing problems is a relatively novel area of dysphagia intervention in the UK. There are currently no published studies on its effectiveness and safety profile. What this paper adds to existing knowledge This study provides valuable preliminary work into the area of SEF and adults with severe dysphagia, capturing the experience and perceptions of healthcare professions who have an awareness of SEF. What are the potential or actual clinical implications of this work? Increasing clinicians and researcher's awareness of this novel area of dysphagia management.

Enteral tube feeding for people with severe dementia

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The Efficacy and Safety of Tube Feeding in Advanced Dementia Patients: A Systemic Review and Meta-Analysis Study

OBJECTIVES

The current study aimed to conduct a systematic review and meta-analysis to explore the efficacy and safety of tube feeding in patients with advanced dementia.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

PubMed, Medline, Embase, and Cochrane Library were searched from inception until March 7, 2020, to obtain relevant studies.

INTERVENTION

Feeding with nasogastric tube or percutaneous endoscopic gastrostomy (PEG).

MEASURES

We evaluated the associations of tube feeding and the risk of mortality, period of survival days, tube-related complications, and nutritional status. Data from original studies were synthesized by using a random-effects model. Each selected article was assessed for bias using the Newcastle-Ottawa Scale. A narrative synthesis and pooled analyses are reported.

RESULTS

Twelve trials were eligible, involving 1805 patients with tube feeding (mean age: 82.8 years; 71.3% female) and 3861 without tube feeding (mean age: 82.7; 68.7% female). For mortality rate, patients with advanced dementia with tube feeding are associated with significantly higher mortality rate [k = 8; odds ratio (OR) 1.79; 95% confidence interval (CI) 1.04-3.07; P = .03]. Initially, no association was found for the risk of pneumonia and pressure sore between groups. However, sensitivity analysis showed patients with advanced dementia with PEG tube feeding have significantly higher risk of pneumonia (OR 3.56; 95% CI 2.32-5.44; P < .001) and pressure sore (OR 2.25; 95% CI 1.92-2.63; P < .001). Finally, no association was found for the survival period and nutritional status between groups.

CONCLUSIONS AND IMPLICATIONS

This meta-analysis indicates that tube feeding is associated with increased mortality rate and possible tube-related complications, but not improves with prolonging survival days and nutritional status. Shared decision-making routinely before insertion of a tube between caregivers and physicians is recommended.

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.

The perils of 'risk feeding'

'Risk feeding' policies, for when people continue to eat and drink despite a perceived risk of choking or aspiration have become common in recent years. We argue that 'feeding' is demeaning language if referring to a person who is eating and drinking rather than to a healthcare technique and that 'risk-anything' is not how decisions are reached. It is true that patients with dysphagia are often unnecessarily designated nil-by-mouth (NBM), especially after a decision has been made that tube feeding is not indicated or is unwanted. However, risk-feeding policies may perpetuate common misperceptions that there is a straightforward relationship between aspiration and pneumonia and that interventions like NBM or tube feeding will reduce the risk of pneumonia. Such policies may reduce the potential for individualised and flexible decision making: many people's swallowing abilities and preferences fluctuate, sometimes from hour to hour, and staff need to have, and be encouraged to use, common sense, flexibility and judgement in these circumstances. There is also the potential for delays in providing food, fluid and medications if meetings must be held and risk-feeding paperwork completed and signed by someone with the necessary seniority and confidence. Further debate and discussion is required before risk-feeding policies become an established standard of care.

Percutaneous endoscopic gastrostomy for nutritional support in dementia patients

BACKGROUND

A link between aging, dementia and malnutrition is established and leads to poor prognosis. Endoscopic gastrostomy (PEG) is used without clear benefit on survival, nutritional status or quality of life.

AIMS

This work aims to assess the effectiveness of PEG-feeding for nutritional support in patients with dementia.

METHODS

We conducted an observational, longitudinal and retrospective study using records from patients with moderate-severe dementia that underwent PEG. Age, gender, dementia subtype and mortality were considered. Body mass index (BMI), serum albumin, transferrin and total cholesterol were recorded at the time of the PEG procedure (T0) and repeated after 3 months (T3). The evolution of those parameters was analysed and compared to survival.

RESULTS

We obtained data from 46 patients (16 men/30 women) between 50 and 94 years (M = 79 years). Most had Alzheimer's. Mean survival was 21 months. Mortality rate at 3 months was 15 %. At T0, 30 patients were undernourished according to BMI and 29, 31 and 16 patients displayed low albumin, transferrin and total cholesterol, respectively. Albumin (p < 0.01) and transferrin levels (p < 0.05) were significantly increased from T0 to T3. High albumin (r = 0.2), transferrin (r = 0.3) and cholesterol (r = 0.1) at T0 were positively correlated with longer survival.

CONCLUSIONS

Low albumin, transferrin and cholesterol were predictors of a poor survival. PEG improves low albumin and transferrin, serum markers of malnutrition and poor outcome. PEG should be considered on an individual basis in patients with moderate-severe dementia when risk of malnutrition and aspiration is present.

Is tube feeding futile in advanced dementia?

It is controversial whether tube feeding in people with dementia improves nutritional status or prolongs survival. Guidelines published by several professional societies cite observational studies that have shown no benefit and conclude that tube feeding in patients with advanced dementia should be avoided. However, all studies on tube feeding in dementia have major methodological flaws that invalidate their findings. The present evidence is not sufficient to justify general guidelines. Patients with advanced dementia represent a very heterogeneous group, and evidence demonstrates that some patients with dementia benefit from tube feeding. However, presently available guidelines make a single recommendation against tube feeding for all patients. Clinicians, patients, and surrogates should be aware that the guidelines and prior commentary on this topic tend both to overestimate the strength of evidence for futility and to exaggerate the burdens of tube feeding. Shared decision making requires accurate information tailored to the individual patient's particular situation, not blanket guidelines based on flawed data. Lay Summary: Many doctors believe that tube feeding does not help people with advanced dementia. Scientific studies suggest that people with dementia who have feeding tubes do not live longer or gain weight compared with those who are carefully hand fed. However, these studies are not very helpful because of flaws in design, which are discussed in this article. Guidelines from professional societies make a blanket recommendation against feeding tubes for anyone with dementia, but an individual approach that takes each person's situation into account seems more appropriate. Patients and surrogates should be aware that the guidelines on this topic tend both to underestimate the benefit and exaggerate the burdens of tube feeding.

Outcomes of enteral nutrition for patients with advanced dementia: a systematic review

The present article aims to evaluate the outcomes of enteral nutrition for people with advanced dementia. A systematic review was conducted by searching The Cochrane Library, MEDLINE, EMBASE, PROQUEST and LILACS for articles that were published from 2008 to 2013. Prospective and retrospective studies involving a control group were searched. Data were independently extracted and assessed by one reviewer and checked by a second. Searched outcomes included survival, clinical and nutritional parameters and complications. In total, nine controlled studies were identified from several parts of the world: Israel, Italy, Japan, the United States and Brazil. Most of the studies did not report any outcome of harm with enteral nutrition use in dementia patients compared with patients without dementia. A study with a higher follow-up period demonstrated improvements in albumin, weight and chronic inflammation parameters. It is not possible to affirm that tube feeding is harmful for dementia patients. Thus, an adequate follow-up by a multidisciplinary team may lower complications associated with this therapy and thus improve survival.

The decision-making and communication capacities of older adults with dementia: a population-based study

The present study assessed the decision-making and communication capacities of older adults with dementia who required assistance and care and measured the subsequent changes in these capacities. Of 845 older adults who received long-term care between April 2003 and December 2004, about half of them without dementia were excluded and the remaining 448 were finally included in the analyses. These individuals were completed follow-up for assessment for two years. The data were obtained from the Long-Term Care Insurance Certification Committee for Eligibility in Gujo City. A total of 73.7% of people with dementia were somewhat capable of making decisions (32.4% were reported as being "always capable"; 41.3% were reported as being "sometimes capable"). A total of 93.7% were somewhat capable of communicating with others (78.3% were reported as being "always capable"; 15.4% were reported as being "sometimes capable"). The results indicate that older adults with dementia can participate in their own care decisions, even if they require assistance and support in their daily lives. The present study shows, however, that baseline decision-making capacity declined to about half what they were after one year and to about one-third of what they were after two years, suggesting that earlier efforts are needed to ensure that the preferences of individuals with dementia are reflected in their care.

Dysphagia: implications for older people

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

Dysphagia and quality of life

Swallowing difficulties can be a symptom of many different disease processes, and are associated with adverse health outcomes; malnutrition, dehydration, pneumonia and death. The use of feeding tubes directly into the stomach as in percutaneous endoscopic gastrosomy (PEG) is an increasingly common treatment option for these patients with more and more being cared for in the community. Living with a gastrostomy tube brings physical and emotional impacts and direct consequences for quality of life. Guidance from the Royal College of Physicians recommends 'nil by mouth' should be a last resort even when swallow function is deemed unsafe. Impaired swallowing can cause increased anxiety and fear. Many patients avoid oral intake leading to malnutrition, isolation and depression. Understanding and balancing the risks and potential benefits of continuing oral intake or choosing gastrostomy makes this a complex and challenging area of health care.

The challenges of providing palliative care for older people with dementia

Palliative care seems the right approach to dementia, except that it suggests a dichotomy between cure and care. As in cancer care, supportive care provides a broader framework, viewing dementia from the time of diagnosis until death and bereavement. The challenge is to find the right approach to the individual. This challenge arises in the person's own home, in long-term care homes, and in hospitals. The challenging features of palliative care for older people with dementia are found in connection with the use of antibiotics, antipsychotics, and other medications, as well as in decisions about whether the person is in pain or in distress, or whether artificial feeding should be contemplated or not, as well as about the use of advance care plans. In short, the challenges are essentially ethical as well as clinical. The right approach will be the one that recognizes this facet of clinical care.

Palliative care for people with dementia

The number of people with dementia will rise dramatically over the next 20 years. Currently, one in three people over the age of 65 will die with dementia. A PubMed search using MeSH headings for 'dementia' AND 'palliative care' and for specific areas, i.e. enteral feeding. National reports, UK guidelines and policies were also consulted. Advanced dementia is now being perceived as a 'terminal illness' with a similar symptom burden and prognosis to advanced cancer. People with dementia have poor access to good quality end-of-life care. Interventions such as antibiotics, fever management policies and enteral tube feeding remain in use despite little evidence that they improve quality of life or other outcomes. Research is required on the effectiveness of 'holistic' palliative care, outcome measures and the impact on carers and families.