Comparison of long-term outcomes between enteral nutrition via gastrostomy and total parenteral nutrition in older persons with dysphagia: A propensity-matched cohort study

Incidence of dysphagia-related safety incidents in older adults across feeding methods: A systematic review and meta-analysis

OBJECTIVE

Dysphagia-related safety incidents encompass near-miss events, no-harm occurrences, or harmful incidents associated with oral or enteral feeding methods. This systematic review and meta-analysis aimed to assess the incidence rates of dysphagia-related safety incidents in older adults across various feeding methods.

METHODS

A comprehensive literature search was conducted using PubMed, Embase, Web of Science, Cochrane Library, and CINAHL databases to identify studies reporting dysphagia-related safety incidents in older adults. The feeding methods analyzed included oral feeding, nasogastric (NG) tube feeding, and percutaneous endoscopic gastrostomy (PEG) tube feeding. Randomized controlled trials (RCTs), non-randomized studies, and cohort studies were included. The analysis adhered to the PRISMA guidelines, and meta-analytic outcomes were presented with 95% confidence intervals (CIs).

RESULTS

A total of 30 studies satisfied the inclusion criteria. The overall incidence rates of safety incidents were 13.8% for oral feeding, 23.9% for NG tube feeding, and 26.5% for PEG tube feeding. Aspiration pneumonia emerged as the most prevalent safety incident across all feeding methods, with incidence rates of 12.0% for oral feeding, 20.6% for NG tube feeding, and 12.4% for PEG tube feeding. Tube feeding methods were associated with diarrhea and wound infection. Additionally, specialized safety incidents were observed for each feeding method: suffocation in oral feeding; gastroesophageal reflux in NG tube feeding; and tube blockage, tube dislodgment, tube leakage, vomiting, nausea, site pain, gastrointestinal hemorrhage, and peritonitis in PEG tube feeding.

CONCLUSIONS

Dysphagia-related safety incidents in older adults demonstrated considerable variability in type and frequency across different feeding methods. Understanding these differences could provide healthcare professionals with valuable insights for targeted risk prediction and proactive management strategies to mitigate such incidents.

Importance of Enteral Feeding: Enhancing Patient Care through Interventional Radiology

Enteral feeding plays a vital role for patients who are unable to meet their nutritional needs through oral intake, providing benefit to those with conditions such as inflammatory bowel disease, postsurgical recovery, chronic dysphagia, dysfunctional gastrointestinal tract, and critical illness. The role of interventional radiologists in enteral access is expanding, reflecting our pivotal role in nutritional support in clinical practice. This review explores the development, comparative benefits, and clinical outcomes associated with enteral nutrition (EN), highlighting its strengths and weaknesses as compared to parenteral nutrition (PN). EN supports gut mucosal health and immune function by stimulating gastrointestinal systems' native cellular programs, while reducing infection risks compared to PN. Modern advancements in EN formulations and delivery methods have enhanced patient care, demonstrating improved survival rates, reduced hospital stays, and improved quality of life.

A systematic review on dysphagia treatments for persons living with dementia

PURPOSE

Dysphagia in persons living with dementia (PLWD) is raising concern due to the absence of swallowing treatments specific to this population. Dysphagia can result in detrimental effects, such as malnutrition, dehydration, and aspiration pneumonia. This systematic review aimed to evaluate the existing literature on dysphagia management of PLWD and reveal their limitations to facilitate clinical practitioners in decision-making.

METHODS

Five electronic databases were searched systematically from the date of inception to January 2024 by two independent reviewers. Eligible studies investigated any treatments with outcome measurements evaluating swallowing function. Qualitative analyses were performed.

RESULTS

A total of 10 studies, involving 1360 participants, were included in the systematic review. They were analyzed qualitatively and evaluated for quality. Studies included were observational (n = 5) with prospective or retrospective designs, and randomized controlled trials (n = 5). Compensatory, rehabilitative, stimulation, and pharmacological treatments were addressed.

CONCLUSION

There is currently limited evidence available revealing the efficacy of dysphagia treatments for PLWD. Based on the current evidence, no definitive conclusions can be drawn on which treatments are more effective for this population. In the future, more randomized controlled trials with large sample sizes investigating the long-term effects of treatments are warranted.

Extremely Poor Post-discharge Prognosis in Aspiration Pneumonia and Its Prognostic Factors: A Retrospective Cohort Study

There is little evidence regarding the long-term prognosis of patients with aspiration pneumonia. This study aimed to investigate post-discharge survival time and prognostic factors in older patients hospitalized for aspiration pneumonia. This retrospective cohort study included patients aged ≥ 65 years hospitalized for aspiration pneumonia and discharged alive from a tertiary care hospital in Japan between April 2009 and September 2014. Candidate prognostic factors were patient's age, sex, body mass index (BMI), performance status, chronic conditions, CURB-65 score, serum albumin level, hematocrit concentration, nutritional pathway at discharge, and discharge location. Kaplan-Meier curves were determined and multivariable survival analysis using Cox regression model was performed to analyze the effect of each factor on mortality. In total, 209 patients were included in this study. The median age was 85 years, 58% of the patients were males, 33% had a performance status of 4 and 34% were discharged home. Among the patients, 65% received oral intake, 23% received tube feeding, and 21% received parenteral nutrition at discharge. During the follow-up period, 77% of the patients died, and the median post-discharge survival time was 369 days. Besides male sex and low BMI, tube feeding (adjusted hazard ratio (aHR) = 1.70, 95% confidence interval (CI) 1.11-2.59) and parenteral nutrition (aHR = 4.42, 95% CI 2.57-7.60) were strongly associated with mortality. Long-term prognosis of patients hospitalized for aspiration pneumonia was extremely poor. The nutritional pathway at discharge was a major prognostic factor. These results may be useful for future care and research.

Incidence of Enteral Nutrition-Related Diarrhea Among Critically Ill Patients in Intensive Care Units

Enteral nutrition is a common nutritional modality in intensive care units. Despite its valuable benefits, it has many complications among which diarrhea is the most important. However, the incidence of enteral nutrition-related diarrhea is variable in the literature, with no established baseline in Jordan. The aim of this study was to investigate the incidence of enteral nutrition-related diarrhea in intensive care units of a major public hospital in Jordan. A prospective cohort design was adopted over 4 months. Using a consecutive sampling technique, 84 critically ill patients receiving enteral nutrition were recruited. King's Stool Chart was used. The incidence of enteral nutrition-related diarrhea calculated per patient and per feeding day was 63.1% and 13.2%, respectively. Significant positive associations were found between the incidence of diarrhea with feeding days (r = .356, p = .001) and intensive care unit length of stay (r = .254, p = .020). The same was found for the frequency of diarrhea (r = .633, p = .000; r = .439, p = .000, respectively). Conversely, a significant negative association was found between baseline serum albumin and frequency of diarrhea (r = -.250, p = .037). Enteral nutrition-related diarrhea is prevalent in Jordanian intensive care units, but it should not be a barrier to enteral nutrition delivery. It would be beneficial for intensive care unit nurses to improve their nutritional practices by following a nurse-led enteral nutrition protocol to guide the enteral nutrition practices utilizing multidisciplinary approaches.

Association between the C-reactive protein/albumin ratio and mortality in older Japanese patients with dysphagia

Background

C-reactive protein-to-albumin ratio (CRP/ALB) has been proven to represent a biomarker for predicting prognosis in many groups of patients with severe diseases. However, few studies have investigated the association between CRP/ALB and mortality in Japan older people with dysphagia patients.

Objective

This retrospective cohort study aimed to assess the prognostic value of C-reactive protein/albumin ratio (CAR) in older Japanese patients with dysphagia.

Methods

We analyzed data from 253 patients diagnosed with dysphagia at a single center between January 2014 and January 2017. Cox regression analysis was used to compare the mortality rates across the CAR tertiles. Subgroup analyses were conducted, and Kaplan-Meier curves were used to determine the median survival times.

Results

The study included 154 female and 99 male patients, with a median age of 83 years. After adjusting for all covariates, the multivariable Cox regression analysis revealed a significant association between increasing CAR (HR = 1.19, 95% CI: 1.03-1.37, P = 0.022) and the risk of mortality. Compared to the reference group T1 (< 0.149), the adjusted hazard ratios for T2 (0.149-0.815) and T3 (> 0.815) were 1.75 (95% CI: 1.07-2.87, P = 0.027) and 2.15 (95% CI: 1.34-3.46, P = 0.002), respectively. Kaplan-Meier curves indicated median survival times of 864, 371, and 223 days for T1, T2, and T3, respectively.

Conclusion

The C-reactive protein/albumin ratio was positively related to mortality in Japan older people with dysphagia patients. There was no interaction for the subgroup analysis. The result was stable.

Does enteral nutrition through a percutaneous endoscopic gastrostomy, attenuate Helicobacter pylori colonization?: is it worth mentioning?

OBJECTIVE

In patients who experience difficulties in oral feeding, alimentary intake can be supported by creating direct access into the stomach through a percutaneous endoscopic gastrostomy. The present study purposed to compare naïve and exchanged percutaneous endoscopic gastrostomy tubes in terms of Helicobacter pylori infection and other clinical characteristics.

METHODS

A total of 96 cases who underwent naïve or exchanged percutaneous endoscopic gastrostomy procedures with various indications were incorporated into the study. The patients' demographic data, such as age and gender, etiology of percutaneous endoscopic gastrostomy, anti-HBs status, Helicobacter pylori status, the presence of atrophy and intestinal metaplasia, biochemical parameters, and lipid profiles, had been analyzed. In addition, the anti-HCV and anti-HIV statuses had also been evaluated.

RESULTS

The most common indication for percutaneous endoscopic gastrostomy placement was dementia in 26 (27.08%) cases (p=0.033). The presence of Helicobacter pylori positivity was significantly lower in the exchange group compared to the naïve group (p=0.022). Total protein, albumin, and lymphocyte levels were significantly higher in the exchange group compared to the naïve group (both p=0.001), and the mean calcium, hemoglobin, and hematocrit levels were statistically significantly higher in the exchange group (p<0.001).

CONCLUSION

Preliminary outcomes of the present study revealed that enteral nutrition attenuates the incidence of Helicobacter pylori infection. Considering the acute-phase reactant, the significantly lower ferritin values in the exchange group suggest that there is no active inflammatory process in the patients and that immunity is sufficient.

Association between serum albumin and mortality in Japan older people with dysphagia

To determine whether there is a link between serum albumin and mortality among participants in the elderly in Japan. This is a single-center,retrospective cohort study analysis of 253 old patients with dysphagia from Japan, conducted from January 2014 to January 2017. The primary outcome was mortality. We performed Cox regression analysis to compare the mortality between the two groups (divided by serum albumin = 3 g/dl). 253 patients were included in the analysis, of whom the number of serum albumin under 3 g/dl was 93. The log-rank test showed a significant longer mortality in the high group (serum albumin >  = 3 g/dl) compared with the low group (median, 382 vs. 176 days, P < 0.0001). Cox regression analysis showed that unadjusted HR for the high group relative to the low group was 0.40 (95% CI: 0.29-0.57; P < 0.001). After adjusting 3 models in multivariable analysis, serum albumin was significantly associated with mortality. The adjusted HRs (95% CI) for total mortality rates were 0.46 (0.33-0.65), 0.66 (0.44-0.99) and 0.64 (0.42-0.97), from model 2 to model 4. There is negative association between serum albumin and mortality in Japanese old people with dysphagia.

Nutritional Impact of Percutaneous Endoscopic Gastrostomy: A Retrospective Single-center Study

Background/Aims

Several conditions may cause difficulties with oral feeding. Percutaneous endoscopic gastrostomy (PEG) is commonly performed on patients who require enteral feeding for >2-3 weeks. This study examined the nutritional state of patients who required enteral feeding and underwent PEG to quantify the benefits of the procedure.

Methods

This retrospective study included patients who underwent PEG at the Chungnam National University Hospital between January 2013 and December 2018. A gastroenterologist performed all PEG procedures using the pull technique, and all patients were followed up for >3 weeks postoperatively. The BMI and lymphocyte count, along with the levels of hemoglobin, total protein, albumin, total cholesterol, BUN, and creatinine pre-PEG and between 3 weeks and 6 months post-PEG were evaluated.

Results

Overall, 151 patients (116 males; mean age 64.92 years) were evaluated. Of these patients, 112 (74.2%), 34 (22.5%), and five (3.3%) underwent PEG tube insertion because of neurological diseases, malignancy, and other conditions, respectively. The BMI and the hemoglobin, total protein, albumin, and total cholesterol levels were significantly higher post-PEG than pre-PEG.

Conclusions

These findings highlight the usefulness of PEG in the management of nutritionally poor patients with difficulties in feeding orally.

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.

Nasogastric Tube Feeding in Older Patients: A Review of Current Practice and Challenges Faced

Nasogastric tube feeding is an essential way of delivering enteral nutrition when the oral route is insufficient or unsafe. Malnutrition is recognised as a reversible factor for sarcopenia and frailty. It is therefore crucial that malnutrition is treated in older inpatients who have dysphagia and require enteral nutrition. Despite five National Patient Safety Alerts since 2005, “Never Events” related to nasogastric feeding persist. In addition to placement errors, current practice often leads to delays in feeding, which subsequently result in worse patient outcomes. It is crucial that tube placement is confirmed accurately and in a timely way. Medical advancements in this area have been slow to find a solution which meets this need. In this paper, we provide an updated review on the current use of feeding nasogastric tubes in the older population, the issues associated with confirming correct placement, and innovative solutions for improving safety and outcomes in older patients.

Nutritional Assessment in Adult Patients with Dysphagia: A Scoping Review

Malnutrition negatively affects the quality of life of patients with dysphagia. Despite the need for nutritional status assessment in patients with dysphagia, standard, effective nutritional assessments are not yet available, and the identification of optimal nutritional assessment items for patients with dysphagia is inadequate. We conducted a scoping review of the use of nutritional assessment items in adult patients with oropharyngeal and esophageal dysphagia. The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched to identify articles published in English within the last 30 years. Twenty-two studies met the inclusion criteria. Seven nutritional assessment categories were identified: body mass index (BMI), nutritional screening tool, anthropometric measurements, body composition, dietary assessment, blood biomarkers, and other. BMI and albumin were more commonly assessed in adults. The Global Leadership Initiative on Malnutrition (GLIM), defining new diagnostic criteria for malnutrition, includes the categories of BMI, nutritional screening tool, anthropometric measurements, body composition, and dietary assessment as its required components, but not the blood biomarkers and the "other" categories. We recommend assessing nutritional status, including GLIM criteria, in adult patients with dysphagia. This would standardize nutritional assessments in patients with dysphagia and allow future global comparisons of the prevalence and outcomes of malnutrition, as well as of appropriate interventions.

Long-term prognosis of enteral feeding and parenteral nutrition in a population aged 75 years and older: a population-based cohort study

Background

Enteral feeding and parenteral nutrition (PN) using gastrostomy (GS) and a nasogastric tube feeding (NGT) and PN should be initiated for older patients based on their prognoses. This study aimed to investigate the long-term prognosis of patients aged ≥75 years who underwent enteral feeding via GS and NGT as well as PN.

Methods

A population-based cohort study was conducted using Japan’s universal health insurance claims in the Nara Prefecture. This study enrolled 3,548 patients aged ≥75 years who received GS (N=770), NGT (N=2,370), and PN (N=408) during hospital admissions between April 2014 and March 2016. The GS group was further categorized into secondary GS (N=400) with preceding NGT or PN within 365 days and primary GS (N=370) without preceding NGT or PN groups. In the secondary GS group, 356 (96%) patients received NGT (versus PN). The outcome was mortality within 730 days after receiving GS, NGT, and PN. Cox regression analyses in cases with or without malignant diseases, adjusted for sex, age, comorbidity, and hospital type, were performed to compare mortality in the groups.

Results

Of the 3,548 participants, 2,384 (67%) died within 730 days after the initiation of GS and NGT and PN. The 2-year mortality rates in the secondary GS, primary GS, NGT, and PN groups were 58%, 66%, 68%, and 83% in patients without malignancies and 67%, 71%, 74%, and 87% in those with malignancies, respectively. In the non-malignant group, Cox regression analysis revealed that secondary GS (hazard ratio (HR) = 0.43, 95% CI: 0.34–0.54), primary GS (HR = 0.51, 95% CI: 0.40–0.64), and NGT (HR = 0.71, 95% CI: 0.58-0.87) were statistically significantly associated with lower mortality compared with PN.

Conclusions

Approximately 58% to 87% patients aged ≥75 years died within 730 days after initiation of nutrition through GS, NGT, or PN. Patients with non-malignant diseases who received secondary GS exhibited better 2-year prognosis than those who received NGT or PN. Healthcare professionals should be aware of the effectiveness and limitations of enteral feeding and PN when considering their initiation.

Percutaneous endoscopic gastrostomy – Too often? Too late? Who are the right patients for gastrostomy?

Percutaneous endoscopic gastrostomy is an established method to provide nutrition to patients with restricted oral uptake of fluids and calories. Here, we review the methods, indications and complications of this procedure. While gastrostomy can be safely and easily performed during gastroscopy, the right patients and timing for this intervention are not always chosen. Especially in patients with dementia, the indication for and timing of gastrostomies are often improper. In this patient group, clear data for enteral nutrition are lacking; however, some evidence suggests that patients with advanced dementia do not benefit, whereas patients with mild to moderate dementia might benefit from early enteral nutrition. Additionally, other patient groups with temporary or permanent restriction of oral uptake might be a useful target population for early enteral nutrition to maintain mobilization and muscle strength. We plead for a coordinated study program for these patient groups to identify suitable patients and the best timing for tube implantation.

Nasogastric Tube Feeding Versus Total Parenteral Nutrition in Older Dysphagic Patients with Pneumonia: Retrospective Cohort Study

OBJECTIVES

Many older patients with pneumonia cannot intake orally after admission and may need nutritional care such as nasogastric tube feeding or total parenteral nutrition. This study sought to compare in-hospital outcomes between patients receiving nasogastric tube feeding and total parenteral nutrition.

DESIGN

This is a retrospective cohort study.

SETTING

A hospital-based database constructed by the Diagnosis Procedure Combination survey data comprising more than 100 acute-care hospitals.

PARTICIPANTS

The study included consecutive older inpatients aged >65 years admitted to participating hospitals with a diagnosis of pneumonia from 2014 through 2017.

MEASUREMENTS

We compared patients who received total parenteral nutrition and those who received nasogastric tube feeding in terms of characteristics and outcomes.

RESULTS

Among the included inpatients, a total of 336 (73.2%) patients received total parenteral nutrition and 123 (26.8%) patients received nasogastric tube feeding. Patients with nasogastric tube feeding had less in-hospital mortality (13.8% vs 27.1%, p = 0.003) and a smaller number of complications (mean; 0.71 vs 1.44, p <0.001), shorter length of hospital stay (mean; 27.6 vs 48.9, p <0.001), more discharges home (72.4% vs 35.1%, p <0.001), and more discharges without oral intake (65.9% vs 45.8%, p <0.001) than patients with total parenteral nutrition. The same results were obtained in propensity score analysis.

CONCLUSIONS

Older patients with pneumonia treated with total parenteral nutrition were significantly more likely to have higher in-hospital mortality than those receiving nasogastric tube feeding.