Home Enteral Nutrition in Singapore's Long-Term Care Homes-Incidence, Prevalence, Cost, and Staffing

Knowledge, Attitudes, and Practices Regarding Swallowing Disorders Among General Practitioners

Background

Swallowing disorders constitute a significant clinical concern, necessitating effective management and early detection. General practitioners (GPs) play a pivotal role in identifying and referring patients with swallowing disorders, emphasizing the importance of assessing their Knowledge, Attitudes, and Practices (KAP) in this domain.

Methods

A cross-sectional study was conducted between July and October 2023, involving general practitioners who completed a self-administered questionnaire containing demographic information and KAP assessment.

Results

The final analysis included 365 participates, with 242 (66.3%) completed by female participants and 106 (29.04%) by individuals with 5-10 years of professional working experience. The mean scores for knowledge, attitude, and practice were 12.41 ± 4.202 (possible range: 0-18), 22.25 ± 2.06 (possible range: 6-30), and 32.81 ± 9.48 (possible range: 10-50), respectively. Knowledge was demonstrated a positive correlation with attitude (r = 0.329, P < 0.001) and practice (r = 0.375, P < 0.001), while attitude also showed a positive correlation with practice (r = 0.309, P < 0.001). According to multivariate analysis, knowledge (OR = 1.13, 95% CI: [1.07-1.20], P < 0.001) and attitude (OR = 1.19, 95% CI: [1.05-1.36], P = 0.005) were independently associated with proactive practice.

Conclusion

General practitioners demonstrated moderate knowledge, attitudes, and practices regarding swallowing disorders. Targeted educational interventions are essential to enhance general practitioners' knowledge regarding swallowing disorders.

Healing Through Nutrition: Evaluating Dietary Support in Jordanian Hospitals

Background/Objective: Adequate nutrition is essential for patient recovery and overall health, yet hospital food services often fail to meet dietary guidelines. This study aimed to catch the gap between the dietary recommendation and the real intake. Methods: A total of 300 inpatients (100 per hospital type) were included in this cross-sectional study, which was conducted over two months. Nutritional intake was measured via weighed food records and actual intake was analyzed to calculate actual nutrient intake. Data were evaluated against dietary reference intakes (DRIs) and analyzed statistically via SPSS. One-way ANOVA and paired-sample t tests were used to identify significant differences between hospital categories and meal components. Results: The results revealed that private hospitals provided energy and macronutrient intakes closer to the recommended levels, with the total energy intake (2098.54 ± 97.33 kcal) exceeding the recommended level. Governmental and educational hospitals fell short, providing 1118.59 ± 68.21 kcal and 1285.91 ± 78.42 kcal, respectively. All hospital types served inadequate fiber, but private hospitals (23.18 ± 1.14 g) were closer to the recommendations. Micronutrient deficiencies were prevalent, particularly for vitamin D, vitamin E, and iron, across all hospital types. Conclusions: Nutritional intake varies significantly across Jordanian hospital categories, with private hospitals performing better than governmental and educational facilities do. Addressing these disparities through enhanced meal planning and monitoring is essential to improve patient health outcomes and reduce the risk of malnutrition.

The Impact of Home Enteral Tube-Feeding on the Intent and Experience of Going Out in Public: A Qualitative Study on Patients' and Caregivers' Perspectives

BACKGROUND

Individuals on tube-feeding experience significant lifestyle changes and social isolation, but the barriers and support for travelling out while on tube-feeding to reintegrate into the community have not been studied. This research explores the factors influencing the decisions of individuals on tube-feeding and their carers to travel outside of their homes, their experiences, and perceived barriers and support when performing tube-feeding in public settings.

METHODS

A qualitative design using purposive sampling explored the experiences of three individuals and five carers living at home on long-term tube-feeding. One-to-one semi-structured interviews were conducted and transcribed. Thematic analysis was conducted via open coding and merging of recurring codes to form themes.

RESULTS

Six themes emerged: (1) Motivators and deterrents to going out: Motivators include desire for social normalcy. Deterrents include physical health, logistics and psychosocial considerations, such as fear of negative public perception and the loss of travelling and dining as motivating social activities. (2) Going out requires meticulous preparation and planning. (3) Inadequate tube-feeding facilities in the community contribute to ambivalence and discomfort to tube-feeding outside. Participants must accept potential negative emotions when confronted with public reaction to tube-feeding. (4) Ideal tube-feeding facilities should be private and hygienic, in highly frequented locations. (5) Community support and awareness are needed to support tube-feeding. (6) Adaptability is crucial when satisfactory feeding locations are absent during local and overseas travel.

CONCLUSIONS

Carers and healthcare professionals are pivotal in encouraging patients to disregard public curiosity, planning tube-feeding logistics, and advocating for the right to tube feed in public spaces without shame. Public awareness, carer support, and availability of tube-feeding facilities should be improved for patients to live, work and engage meaningfully in the community.

Clinical Outcomes of Tube Feeding vs. Hand Feeding in Advanced Dementia

Dementia is a growing public health issue, with the number of cases projected to triple by 2050 as society ages. Although the American Geriatrics Society recommends careful hand feeding over tube feeding for patients with advanced dementia, an increasing proportion of patients are receiving tube feeding. Although decisions regarding tube feeding are often based on the physician, recent studies have shown that tube feeding has significant implications for clinical outcomes and quality of life. Tube feeding is associated with an increased risk of mortality, pneumonia and the use of restraints. Although tube feeding may reduce caregiver burden, it does not improve survival or nutritional status and incurs significant financial costs. Caregivers that hand feed patients often experience stress, particularly in regions where support services are limited. However, there are various strategies available to promote hand feeding which include environmental interventions, mealtime assistance and caregiver training. Although hand feeding is the most comfortable option for patients, the frequency of mealtimes and financial and mental health impact on caregivers requires the physician to conduct a holistic assessment of the patient when deciding on the mode of feeding for patients with advanced dementia.

Navigating dementia feeding decisions in Asia: a mixed methods study of caregivers

BACKGROUND

Tube feeding is discouraged among older adults with advanced dementia; nevertheless, caregivers often find feeding decisions challenging to navigate.

AIM

This study aims to gain a comprehensive understanding of tube feeding among community-dwelling older adults with advanced dementia in Singapore and its relationship to older adult quality of life (QoL) and caregiver psychological distress.

METHODS

We use a convergent mixed-methods design, synthesising analysis of qualitative caregiver interviews (n = 25) and two-year prospective, longitudinal cohort survey data (n = 215, 1018 observations).

RESULTS

Findings from the qualitative interviews revealed caregivers' expectations of reduced QoL for older adults with feeding tubes and their own distress related to making feeding decisions and fears prompting plans to tube-feed. Sixteen percent of community-dwelling older adults with advanced dementia relied on feeding tubes during the two-year study period. Adjusting for potential confounding and using instrumental variables estimation, tube feeding was associated with reduced older adult QoL (P < .05) and increased caregiver anxiety and depression (P < .10).

CONCLUSION

Consistent with expert guidelines, we found that tube feeding was associated with significantly reduced QOL among older adults living with dementia and increased distress among caregivers relative to those of older adults without feeding tubes. Despite caregivers' recognition of reduced QOL associated with older adult use of feeding tubes, many expressed angst related to feeding choices. Our findings suggest the need for decision tools to support caregivers in making informed decisions concordant with their values.

The Effect of Oral Diet Training in Indwelling Nasogastric Tube Patients with Prolonged Dysphagia

Background: Patients with severe dysphagia are usually fed using a nasogastric tube (NGT). Many patients who receive long-term NGT feeding are unable to obtain sufficient nutrients orally immediately after NGT removal. Thus, a transitional period involving oral diet training is required to transition from NGT feeding to exclusive oral feeding. We aimed to investigate the therapeutic effect of oral diet training in indwelling NGT patients with prolonged dysphagia. Methods: A total of 175 patients who were fed using an NGT for more than 4 weeks were enrolled. Their swallowing function was evaluated by a videofluoroscopic swallowing study (VFSS). During the VFSS, patients received thick and thin barium while the NGT was inserted. Then, the patients underwent a VFSS without an NGT thirty minutes after NGT removal. If a patient had no aspiration with NGT inserted during the VFSS, oral diet training combined with NGT feeding was recommended. Results: Of the 49 indwelling NGT patients who were recommended to receive oral diet training, 39 (79.6%) transitioned to exclusive oral feeding. A transition period of 2-8 weeks was required for them to achieve full oral feeding. Patients who were eligible for oral feeding trials showed no significant aspiration during the VFSS with an NGT inserted and had sufficient cough function. Patients who required prolonged NGT feeding and who could not complete oral trials showed significant aspiration during the VFSS when an NGT was inserted. Conclusions: This study demonstrated that oral diet training combined with NGT feeding is safe in patients with prolonged dysphagia who have sufficient cough function and no aspiration during VFSS. We suggest that if the patient is a proper candidate for NGT removal, direct oral feeding training with an NGT inserted could be a useful therapeutic strategy during the transitional period from long-term NGT feeding to successful oral feeding.

Effects of fibre-supplemented enteral feeds on bowel function of non-critically ill tube-fed adults: a meta-analysis of randomised controlled trials

Diarrhoea is common in enterally fed patients and can impact their nutritional and overall outcomes. This meta-analysis evaluates the potential benefits of fibre-supplemented (FS) feeds on incidence of diarrhoea and stool frequency in non-critically ill tube-fed adults. Databases including PubMed, Embase and CINAHL with full text were searched for randomised controlled trials (RCT) with adults on exclusive tube feeding, published until August 2022. The Cochrane Collaboration's tool was used for quality assessment. Studies with published results on incidence of diarrhoea and stool frequency were analysed using RevMan 5. Thirteen RCT with 847 non-critically ill patients between 20 and 90 years old without diarrhoea at the onset of enteral feeding were included. Study duration ranged from 3 to 35 d. Nine papers investigated the incidence of diarrhoea where intervention group was given FS and control was given non-fibre-supplemented (NFS) enteral feeds. Those receiving FS feeds were significantly less likely to experience diarrhoea as compared with those using NFS feeds (OR 0·44; 95 % CI 0·20, 0·95; P = 0·04; I2 = 71 %). Combined analysis showed no differences in stool frequency in those receiving NFS feeds (SMD 0·32; 95 % CI -0·53, 1·16; P = 0·47; I2 = 90 %). Results should be interpreted with caution due to considerable heterogeneity between study population, assessment tool for diarrhoea, potential conflict of interest and short duration of studies. This meta-analysis shows that FS feeds can reduce the incidence of diarrhoea in non-critically ill adults; however, the effects of stool frequency remain debatable.

Impact of Mobile Apps in Conjunction With Percutaneous Endoscopic Gastrostomy on Patients' Complications, Quality of Life, and Health-Related Self-Care Behaviors: Randomized Clinical Trial

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is commonly chosen for long-term enteral nutrition support. However, common complications of PEG include wound infection, leakage, obstruction, bleeding, dislodgement, pneumonia, peritonitis, and more. The anticipation of these complications by both patients and their family caregivers underscores the essential requirement of ongoing technical guidance for the daily care of PEG and the adoption of preventative strategies.

OBJECTIVE

This study aimed to establish and compare a health education program utilizing a tracking system for PEG using a mobile app (PEG app) and instant messaging software versus a paper-based health education program with instant messaging software. Their effectiveness in preventing complications, avoiding hospital readmissions, improving self-care practices, and enhancing quality of life outcomes was assessed.

METHODS

A randomized controlled trial design was used, and the study sample consisted of patients from a medical center in central Taiwan who underwent thoracic surgery or gastroenterology procedures. Inclusion criteria were being a new case undergoing his or her first gastric tube insertion and having the ability to operate a smartphone. Exclusion criteria were cases requiring tube replacement or nasogastric tubes. A total of 74 participants were enrolled, with 37 participants in the experimental group and 37 participants in the control group. Data collection took place from hospitalization until 1 month after discharge. The experimental group received care using the gastric tube tracking system (PEG app) and the Line app that included phone, text, and photo capture capabilities, while the control group received routine nursing care and used the Line app.

RESULTS

The experimental group demonstrated a significant reduction in the occurrence of complications compared with the control group (χ21=12.087, P=.001). Specifically, the occurrence of leakage events was significantly lower in the experimental group than in the control group (χ21=12.906, P=.001). However, the experimental group exhibited superior self-care ability compared with the control group (t72=2.203, P=.03). There was no significant difference in overall quality of life scores between the experimental and control groups (t72=1.603, P=.11). However, the experimental group showed better social aspects of quality of life than the control group (t72=2.164, P=.03).

CONCLUSIONS

Integration of the PEG app with instant messaging can enhance self-care ability, improve social aspects of quality of life, and reduce complications. The study results suggest that the PEG app could be used as an adjunct tool to promote patients' self-directed management of their gastric tube at home, particularly for patients who have undergone their first PEG placement and are being discharged from the hospital.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2300071271; https://tinyurl.com/4vvy584e.

Transiting Back Home: Caregivers' Lived Experiences in Caring for Loved Ones on the Nasogastric Tube in the Home-Setting in Singapore

INTRODUCTION

Little is understood about caregivers' lived experiences when first caring for patients on the nasogastric tube at home in an Asian setting. To enhance understanding, our study aimed to chart these caregivers' psycho-emotional evolutions felt during such caregiving experiences in Singapore.

METHOD

Utilizing purposive sampling, a descriptive phenomenological study was performed, with semi-structured interviews of 10 caregivers of persons on nasogastric tube feeding conducted. Thematic analysis was utilized.

RESULTS

Our findings chart four psycho-emotional transitions of a caregiver's journey in nasogastric tube feeding and the cultural dynamics involved-(a) Disruption of Caregivers' Normality: Attempting to Grasp Reality, (b) Encountering Road-Blocks: Despondency Arises and Frustrations Abound, (c) Adjusting to the New Normal: Reclaiming Confidence and Positivity, (d) Thriving and Integrating into the New Normal, and (e) Cultural Dynamics At Play.

DISCUSSION

Our findings illuminate the understanding of caregivers' varying needs, guiding delivery of culturally-congruent caregiver support targeted at each psycho-emotional evolution.

[Caregiver burden and reported quality of life in neurological patients with gastrostomy tubes.]

OBJECTIVE

the aim of the study is to determine if the use of home enteral nutrition (HEN) by percutaneous endoscopic gastrostomy (PEG) reduces the burden on the caregiver and improves the patients' quality of life reported by the caregivers.

MATERIAL AND METHODS

a prospective, cross-sectional, descriptive, and observational study of a single cohort of 30 patients was conducted.

RESULTS

the results showed an improvement in nutritional status and analytical parameters. Fewer admissions (1.50 ± 0.90 vs 0.17 ± 0.38; p < 0.001) and hospital stays were reported at 3 months after gastrostomy (10.2 ± 8.02 days vs 0.27 ± 0.69 days; p < 0.001). The minutes spent by caregivers administering NEDs decreased after PEG placement by 28.5 minutes per feeding, which amounts to almost 150 minutes over a day and 5 feedings per day. In the Zarit questionnaire, there was a reduction of 13.5 points in the perception of overload. A total of 56.6 % of caregivers reported that quality of life had improved "quite a lot", compared to 6.7 % who reported little improvement, and 36.7 % who reported a lot of improvement. In the QoL-AD questionnaire, a higher score of 3.40 points was obtained.

CONCLUSION

the use of HEN by PEG tube reduces the time spent by the caregiver administering EN, which results in a reduced burden. In addition, the quality of life of patients reported by caregivers improved.

Survival and characteristics of older adults receiving home-based medical care: A nationwide analysis in Taiwan

BACKGROUND

In Taiwan, the National Health Insurance Administration initiated the integrated home-based medical care (iHBMC) program in 2016 to improve accessibility to health care for homebound patients. This study aimed to describe the characteristics of older people receiving iHBMC services in Taiwan as well as the relationship between patient characteristics and survival.

METHODS

All older adults registered in the iHBMC application dataset were enrolled between March 1, 2016, and December 31, 2018. Data on social determinants of health (income level, residential area), functional status, consciousness status, nasogastric tube or urinary catheter placement, and major diseases were retrieved from the database. Data on the frequency of multidisciplinary team members' visits were collected. The survival rate was investigated using the Kaplan-Meier method. A Cox proportional hazards univariate regression was conducted to analyze factors influencing survival rates.

RESULTS

A total of 41,079 patients aged ≥65 years were enrolled in iHBMC services. The results showed that the one-year survival rates were 72.1%, 67.4%, and 14.7% in the home-based primary care (HBPC), home-based primary care plus (HBPC-Plus), and home-based palliative care (HBPalC), respectively. Nearly two-thirds of the HBPC-Plus patients underwent nasogastric tube placement. The Cox proportional hazards univariate regression analysis showed that a low urbanization level, a low income level, a low functional status, and an impaired consciousness status were significant predictors of poor survival after adjustment for confounding variables.

CONCLUSIONS

Older adults receiving iHBMC services had a high mortality rate. The high rate of feeding tube use indicated that education and support for both clinical practitioners and family caregivers regarding careful hand feeding are warranted. There was a relationship between low income levels and poor survival in rural areas. Further research on whether social care could impact prognosis should be considered.

Reduced Pneumonia Risk in Advanced Dementia Patients on Careful Hand Feeding Compared With Nasogastric Tube Feeding

OBJECTIVES

To compare survival and pneumonia risk among hospitalized patients with advanced dementia on nasogastric tube feeding (NGF) vs careful hand feeding (CHF) and to examine outcomes by feeding problem type.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Advanced dementia patients aged ≥60 years with indication for tube feeding admitted to 2 geriatric convalescent hospitals between January 1, 2015, and June 30, 2019.

METHODS

Comparison on the effect of NGF and CHF on survival and pneumonia risk using Kaplan Meier survival analysis and Cox proportional hazards models.

RESULTS

Of the 764 patients (mean age 89 years, 61% female, 74% residential care home residents), 464 (61%) were initiated on NGF and 300 (39%) on CHF. The primary feeding problem types were dysphagia (50%), behavioral feeding problem (33%), or both (17%). There was no difference in 1-year survival rate between NGF and CHF groups (36% vs 37%, P = .71) and survival did not differ by feeding problem type. Nasogastric tube feeding was not a significant predictor for survival (adjusted hazard ratio 1.15, 95% CI 0.94-1.39). Among 577 (76%) patients who survived to discharge, pneumonia rates were lower in the CHF group (48% vs 60%, P = .004). After adjusting for cofounders, NGF was a significant risk factor for pneumonia (adjusted hazard ratio 1.41, 95% CI 1.08-1.85). In subgroup analyses, NGF was associated with increased pneumonia risk for patients with both dysphagia and behavioral feeding problem (P = .01) but not in patients with behavioral feeding problem alone (P = .24) or dysphagia alone (P = .30).

CONCLUSIONS AND IMPLICATIONS

For advanced dementia patients with feeding problems, there is no difference in survival between NGF and CHF. However, NGF is associated with a higher pneumonia risk, particularly for patients with both dysphagia and behavioral feeding problem. Further research on how the feeding problem type impacts pneumonia risk for patients on NGF is needed.

The Effects of Enteral Nutrition on the Intestinal Environment in Patients in a Persistent Vegetative State

Enteral nutrition (EN) is a rational approach to providing nutritional intake via the intestines in patients who are unable to tolerate parenteral nutrition. We conducted a preliminary study to investigate the effects of EN on the intestinal environment in 10 patients in a persistent vegetative state (PVS) (n = 5 each in the EN and EN with probiotics; Clostridium butyricum MIYAIRI 588) groups compared with 10 healthy controls. The results of 16S amplicon sequencing of the intestinal microbiota showed that EN led to dysbiosis with a decrease in α-diversity and an obvious change in β-diversity. A particularly significant decrease was seen in useful intestinal bacteria such as Bifidobacterium and butyrate-producing bacteria. Analysis of intestinal metabolites also supported these results, showing significant decreases in butyric and pyruvic acid after EN. Although C. butyricumMIYAIRI 588 improved some intestinal metabolites that were decreased after EN, it did not improve the dysbiosis of the intestinal microbiota. These findings indicate that EN causes dysbiosis of the intestinal microbiota and an imbalance in some intestinal metabolites in patients in a PVS. Moreover, although C. butyricumMIYAIRI 588 improved the imbalance of some intestinal metabolites after EN, it did not prevent dysbiosis of the intestinal microbiota.

Adult malnutrition, nutritional interventions and outcomes in Singapore: a scoping review of local studies for the past 20 years

Background:

There is currently no review published on the prevalence and incidence of malnutrition in Singapore across various populations, or what interventions or policies are in place for preventing/treating malnutrition.

Objectives:

This review aims to determine the: (a) incidence and prevalence of malnutrition in the community, and in acute, intermediate and long-term care facilities; (b) interventions implemented for screening, assessing and treating/preventing malnutrition; (c) specific clinical populations investigated for malnutrition or nutritional therapy; and (d) implications of malnutrition and effectiveness of treating malnutrition or using nutritional therapy in Singapore.

Methods:

A structured search strategy was applied to available electronic databases (MEDLINE/PubMed, EMBASE, CINAHL, the Cochrane Library and Google Scholar) using selected search terms, with additional reports and grey literature identified using iterative searches.

Results:

Forty-two articles were found, with the majority of research performed in the community and acute care settings. Malnutrition screening and assessment is the most common nutritional research performed in Singapore. Approximately 14.7% to 65.0% of acute care and 2.8% to 31.5% of community populations are found to be malnourished. Limited interventional and economic-related studies are available.

Conclusion:

Malnutrition rates in Singapore appear to be similar to other developed countries. Future studies will need to focus on nutritional intervention, cost-effectiveness analyses and specific populations such as the underprivileged, chronically ill and those dependent on nutritional support.

Underrecognition and undertreatment of thirst among hospitalized patients with restricted oral feeding and drinking

Thirst is distressing but overlooked by healthcare professionals. Patients experience thirst due to comorbidities, physical or cognitive limitations, and iatrogenesis. Nasogastric tube (NGT) use and nil-by-mouth(NBM) orders are common practices that can lead to thirst. However, thirst in these populations has never been formally studied. We aim to examine prevalence of recognition and treatment of thirst among NGT + NBM and NBM patients. Our descriptive study was conducted intermittently over 25 weeks, across 1.5 years, in 12 adult general medicine wards of a tertiary hospital. Cognitively intact NGT + NBM or NBM inpatients, defined as Abbreviated Mental Test score ≥ 8, were studied. One-time questionnaire was administered. Variables included: demography, co-morbidities, clinical condition, feeding route, thirst defined by thirst distress and/or intensity ≥ 3, pain, hunger and volume status. 88 NGT + NBM and NBM patients were studied. 69.3% suffered from thirst. Thirsty patients experienced significant thirst-related distress (mean score ± SD: 5.7 ± 2.5). Subjects with previous stroke and who were euvolemic tended towards thirst. 13.6% were asked about thirst by doctors or nurses. Thirst was a major source of patient distress in our study. We suggest that thirst needs to be actively identified and targeted to achieve person-centred care.

Medical Nutrition Reimbursement in Singapore: Who Are the Patients Receiving MediFund Assistance? An Audit of Clinical Outcomes and Issues Pertaining to Reimbursement in a Public Hospital in Singapore

BACKGROUND

Financial reimbursement (MediFund) of medical nutrition products (MNPs) was recently implemented in some of the public hospitals in Singapore for patients with financial difficulties. This study aimed to investigate the sustainability of this policy and the benefits conferred.

METHODS

We performed a 1-year retrospective audit of patients in a tertiary hospital who received MediFund. Demographics, presupport and postsupport clinical outcomes, and cost of support were determined and analyzed.

RESULTS

A total of 129 patients received MediFund for MNPs. The median length of financial support was 115 days (interquartile range, 37-269). Overall, body mass index increased after nutrition support (20.9 ± 5.1 vs 20.4 ± 5.3; P = .012). There was a significant decrease in the number of malnourished patients (final, 55.1% vs initial, 86.8%; P < .001) and a significant increase in 7-point subjective global assessment scores (final, 4.9 ± 1.3 vs initial, 4.1 ± 1.3; P < .001) after MNP support. MNP adherence was high for 88.5% of patients who returned for follow-up appointments. Patients who defaulted follow-up appointments were more likely to have 30-day readmission (50% vs 19.5%; P < .001) and had higher mortality rates (35.7% vs 10.3%; P < .001). Total reimbursement of S $108,960 was provided to subsidize MNPs over 1 year.

CONCLUSION

Supporting patients with financial difficulties led to an improvement in their nutrition status. Regular dietitian reviews of patients and monitoring compliance to consumption of MNPs are essential to ensure patients benefit from the support.