(8/6/01)- In January of the year 2000, we wrote an article in which we cited studies that questioned the use of tube feeding in the demented elderly. Recently, the American Geriatrics Society Annual Meeting (2001) reviewed the evidence for tube feeding. They reported, that a common approach to problems with nutritional intake in elderly patients has been insertion of a feeding tube. According to Medicare claims that indicated gastrostomy tube placement during 1991 (the latest available data) 81,105 older American received a feeding tube during a period of hospitalization. In individuals aged 85 or older, 1 in 131 white and 1 in 58 black patients had a gastrostomy The conclusion of their review states, " [D]espite the number of feeding tube placements in elderly patients suffering from dementia, evidence to support the effectiveness of this practice remains scant".

Medical researchers presented evidence on a study that comprised over 81,000 patients who received e ither percutaneous endoscopic gastroscopy (PEG) or surgical gastronostomy. It showed only 38% of the patients survived 1-year post tube insertion. If PEG feeding is to prevent gradual wasting and death from cachexia, the survival rate for this group would be greater than those who received careful feeding by hand. This is not what the data showed. (See: Rudberg MA, Egleston BI, Grant MD, Brody JA. Effectiveness of feeding tubes in nursing home residents with swallowing disorders. J Parenter Enteral Nutr 20 00; 24:97-102.) A study by Finucane and Bynum showed that tube fed patients suffering from aspiration pneumonia are just as susceptible to the risk of pneumonia as non-tube fed patients.

It should be also pointed out that a variety of infections have been shown to result from tube feeding including sinus, middle ear, esophagus, lung, pleura, peritoneum, abdominal wall and gut infections. To date, no published data have suggested that the risk of any infectious disease is reduced by placement of feeding tu be. The big question remains about the quality of life faced by elderly demented patients who are tube fed. Food is usually associated with joyous and fulfilling moments reflected in the facial expressions and body language of the individual. In patients w ith dementia, no such cues are present. Dr. Robert McCann, University of Rochester Medical College, studied mentally aware patients dying of cancer who were in the last days and weeks of life. Many of these individuals were taking very little food or water . All patients reported that hunger resolved in the days preceding death and that local mouth care and sips of water provided palliation for thirst. It was not necessary to correct any metabolic abnormalities to provide comfort. (This was presented at the American Geriatrics Society Annual Scientific Meeting 2001;May 12, 2001;Chicago, Illinois.)

These studies suggest that it is important to educate families about existing data concerning tube feeding of demented individuals as well as clearly understanding the motivations and goals of the family members. All parties need to accept the enormous uncertainty about whether tube feeding produces any benefit.

Not to be overlooked in the demented patient is treatment for depression, a not uncommon symptom in the early stages of dementia of the Alzheimer type. It is also found in late stages and can be treated with a therapeutic trail of antidepressant medication.

In conclusion, uncertainty about the role of tube feeding continues. Issues that appear important in selection of tube feeding include the humanitarian idea that providing nutrition to an ill person is the thing to do. Also there are the issues of liability, reimbursement, and administrative convenience. Malpractice lawyers and nursing home regulators ma y influence this very important decision. Standards in ensuring the rational use of tube feeding for vulnerable patients need to be established. It is most likely that the utilization of tube feeding in the care of patients with advanced dementia will grad ually decrease over the next few years. No study to date shows that the function of the demented individual is improved, or that suffering is limited by the placement of a feeding tube in elderly demented individuals.

See: Use of Feeding Tubes in Advanced Alzheimer's Disease and Dementia Patients-Part I

FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "Selecting a Nursing Home"

Harold Rubin, MS, ABD, CRC, Guest Lecturer
August 6, 2001
http://www.therubins.com

To e-mail: hrubin12@rr.nyc.com or rubin@brainlink.com

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