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Tube Feeding in Elderly Demented Patients-_Part II

(9/24/14)- Below you will find the abstract from an article accessed on 9/22/14 entitled "American Gerontological Society Feeding Tubes in Advanced Dementia Position Statement" as developed by the American Gerontological Society Ethics Committee and Clinical Practice and Models of Care. It was accessed at
http://www.medscape.com/viewarticle/830114?src=wnl_edit_tpal&uac=120704ER.

It is important that readers of this page understand the information before making a decision about use of a feeding tube with individuals who have advanced dementia. This information may not apply to individuals with other medical issues. For greater clarification, we suggest you read the entire article.


ABSTRACT

"When eating difficulties arise, feeding tubes are not recommended for older adults with advanced dementia. Careful hand feeding should be offered because hand feeding has been shown to be as good as tube feeding for the outcomes of death, aspiration pneumonia, functional status, and comfort. Moreover, tube feeding is associated with agitation, greater use of physical and chemical restraints, healthcare use due to tube-related complications, and development of new pressure ulcers. Efforts to enhance oral feeding by altering the environment and creating patient-centered approaches to feeding should be part of usual care for older adults with advanced dementia. Tube feeding is a medical therapy that an individual's surrogate decision-maker can decline or accept in accordance with advance directives, previously stated wishes, or what it is thought the individual would want. It is the responsibility of all members of the healthcare team caring for residents in long-term care settings to understand any previously expressed wishes of the individuals (through review of advance directives and with surrogate caregivers) regarding tube feeding and to incorporate these wishes into the care plan. Institutions such as hospitals, nursing homes, and other care settings should promote choice, endorse shared and informed decision-making, and honor preferences regarding tube feeding. They should not impose obligations or exert pressure on individuals or providers to institute tube feeding."

Harold Rubin

(2/10/13)- The following is Harold's response to a recent e-mail that we received concerning feed-tubes. We at therubins wish to thank Mr. Butler for taking the time to send in his query.

Dear Mr. Butler:
Thank you for the kind words about our web site. It is a labor of love dedicated to our mother who died in a nursing home. At the home, she had a PEG tube inserted to maintain her nutritional intake. Below, we provide you a copy of a comprehensive report on long term use of feeding tube that we found in our research on this topic. We always leave it up to our readers to interpret this kind of report. At a later time, we will send you information about the use of CPR in nursing homes. We hope this information will prove helpful to you. As time goes on, and we come across further information on long term use of feeding tubes, we will share it with you.
Harold Rubin, Coeditor
http://www.therubins.com

Management of Feeding Tube Complications in the Long-Term Care Resident
Author(s):
Shai Gavi, DO, MPH, Jennifer Hensley, MD, Frank Cervo, MD, Catherine Nicastri, MD, and Suzanne Fields, MD

Introduction
In long-term care (LTC) residents with impaired caloric or fluid intake and a functional gastrointestinal tract, enteral nutrition through the use of a feeding tube is an important option.1-4 Year 2006 Minimum Data Set (MDS) data from New York State revealed that 8.1% of all nursing home residents were receiving tube feedings. State-to-state rates varied widely, with Nebraska having the lowest rate of 3.8% and the District of Columbia having the highest rate of 44.8%. Enteral nutrition may be provided to patients utilizing nasoenteral, gastrostomy, and jejunal feeding tubes.3 These tubes are easy to insert and suitable for short- and long-term use. However, feeding tubes are associated with various complications that require close monitoring.5,6

Feeding Tube Types
Nasoenteral feeding includes nasogastric, nasoduodenal, and nasojejunal tubes.1 Most common are the nasogastric tubes.3 They may be used in patients with competent lower esophageal sphincter, lack of involvement of the stomach by the primary disease process, and normal gastric emptying. The large reservoir capacity of the stomach is an advantage for their use. Nasoduodenal and nasojejunal tubes may be used in patients who cannot tolerate gastric feedings or who need to lie flat, (ie, ileus, critically ill patients).3

Gastrostomy tubes are used when a patient cannot or will not eat for a prolonged time course (longer than 4 wk) and has a functional gut.7 Gastrostomy tubes are generally placed in the procedure commonly known as percutaneous endoscopic gastrostomy (PEG).7 Gastrostomy tubes may also be placed surgically, and more recently via a computed tomography–guided procedure.4 In the year 2000, more than 216,000 gastrostomy tubes were placed in the United States alone.7

Jejunostomy is indicated for patients who need long-term enteral nutrition and have chronic aspiration, gastric outlet obstruction, or stomach or duodenal disease, or for patients with prior gastrectomy.2-4 Jejunal feedings may be achieved using direct endoscopic techniques or with jejunal extension of a feeding tube through an existing PEG.

Feeding Tube Complications
Aspiration
Aspiration is one of the most important and controversial complications in patients receiving enteral nutrition, and is among the leading causes of death in tube-fed patients due to aspiration pneumonia.7-10 However, differentiation of aspiration from oropharyngeal or gastric contents is difficult to assess.11 The rate of aspiration pneumonia in tube-fed patients ranges from approximately 5% to 58%.7-9 Aspiration often occurs without obvious evidence of vomiting or regurgitation and is recognized by the development of clinical signs of respiratory compromise or pneumonia.9,10 Nasoenteral and gastrostomy tubes are used by some to prevent aspiration, although evidence is lacking to support this belief.9 Additional risk factors for the development of aspiration pneumonia include advanced age, the presence of esophagitis on endoscopy, gastroesophageal reflux, prior history of aspiration or pneumonia, impaired level of consciousness, neurologic deficits, poor oral hygiene, and sedative medications.10 Treatment includes stopping the feed, attempts at aspirating the feed from the lungs, and antibiotics if signs of infection are evident. Feeding beyond the duodenum likely lowers the incidence of aspiration, although no conclusive evidence supports this premise.9,10

The goal in the LTC setting is to use preventive measures to decrease the incidence of aspiration and its development into pneumonia by targeting modifiable risk factors. To minimize the risk of aspiration, patients should be fed sitting up or at a 30- to 45-degree semirecumbent body position.8,11 They should remain in the position at least one hour after feeding is completed. Iso-osmotic feeds may be preferred since high-osmolality feeds can delay gastric emptying.

References:
1. American Gastroenterological Association Medical Position Statement: Guidelines for the use of enteral nutrition. Gastroenterology 1995;108(4):1280-1281.

2. Pearce CB, Duncan HD. Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: Its indications and limitations. Postgrad Med J 2002;78(918):198-204.

3. Stroud M, Duncan H, Nightingale J; British Society of Gastroenterology. Guidelines for enteral feeding in adult hospital patients. Gut 2003;52 (Suppl 7):vii1-vii12.

4. Drickamer MA, Cooney LM Jr. A geriatrician’s guide to enteral feeding. J Am Geriatr Soc 1993;41(6):672-679.

5. Parrish CR. Enteral feeding: The art and the science. Nutr Clin Pract 2003;18(1):76-85.

6. Dharmarajan TS, Unnikrishnan D. Tube feeding in the elderly. The technique, complications, and outcome. Postgrad Med 2004;115(2):51-54, 58-61.

7. Roche V. Percutaneous endoscopic gastrostomy. Clinical care of PEG tubes in older adults. Geriatrics 2003;58(11):22-26, 28-29.

8. Opilla M. Aspiration risk and enteral feeding: A clinical approach. Practical Gastroenterology 2003;89-96.

9. Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest 2003;124(1):328-336.

10. Loeb M, McGeer A, McArthur M, et al. Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities. Arch Intern Med 1999;159(17):2058-2064.

11. Loeb MB, Becker M, Eady A, Walker-Dilks C. Interventions to prevent aspiration pneumonia in older adults: A systematic review. J Am Geriatr Soc 2003;51(7):1018-1022.

12. Vandewoude MF, Paridaens KM, Suy RA, et al. Fibre-supplemented tube feeding in the hospitalised elderly. Age Ageing 2005;34(2):120-124. Epub 2004 Nov 29.

13. Lee JS, Auyeung TW. A comparison of two feeding methods in the alleviation of diarrhoea in older tube-fed patients: A randomised controlled trial. Age Ageing 2003;32(4):388-393.

14. Vanlandingham S, Simpson S, Daniel P, Newmark SR. Metabolic abnormalities in patients supported with enteral tube feeding. JPEN J Parenter Enteral Nutr 1981;5(4):322-324.

15. Seshadri V, Meyer-Tettambel OM. Electrolyte and drug management in nutritional support. Crit Care Nurs Clin North Am 1993;5(1):31-36.

16. Solomon SM, Kirby DF. The refeeding syndrome: A review. JPEN J Parenter Enteral Nutr 1990;14(1):90-97.

17. Baskin WN. Acute complications associated with bedside placement of feeding tubes. Nutr Clin Pract 2006;21(1):40-55.

18. Bumpers HL, Collure DW, Best IM, et al. Unusual complications of long-term percutaneous gastrostomy tubes. J Gastrointest Surg 2003;7(7):917-920.

19. Burke DT, El Shami A, Heinle E, Pina BD. Comparison of gastrostomy tube replacement verification using air insufflation versus gastrograffin. Arch Phys Med Rehabil 2006;87(11):1530-1533.

20. Santos PM, McDonald J. Percutaneous endoscopic gastrostomy: Avoiding complications. Otolaryngol Head Neck Surg 1999;120(2):195-199.

21. Rino Y, Tokunaga M, Morinaga S, et al. The buried bumper syndrome: An early complication of percutaneous endoscopic gastrostomy. Hepatogastroenterology 2002;49(46):1183-1184.

22. Anagnostopoulos GK, Kostopoulos P, Arvanitidis DM. Buried bumper syndrome with a fatal outcome, presenting early as gastrointestinal bleeding after percutaneous endoscopic gastrostomy placement. J Postgrad Med 2003;49(4):325-327.

23. Siegel TR, Douglass M. Perforation of an ileostomy by a retained percutaneous endoscopic gastrostomy (PEG) tube bumper. Surg Endosc 2004;18(2):348. Epub 2003 Dec 29.

24. Thomson FC, Naysmith MR, Lindsay A. Managing drug therapy in patients receiving enteral and parenteral nutrition. Hospital Pharmacist 2000;7(6):155-164.

25. Sacks GS. Drug-nutrient considerations in patients receiving parenteral and enteral nutrition. Practical Gastroenterology 2004;39-48.

26. Lourenco R. Enteral feeding: Drug/nutrient interaction. Clin Nutr 2001;20(2):187-193.

27. Lingtak-Neander C. Drug-nutrient interaction in clinical nutrition. Curr Opin Clin Nutr Metab Care 2002;5:327-332.


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---- Ray Butler <oraypiano@gmail.com> wrote:

I enjoy your many articles . I am looking for articles on efficacy and ethics of CPR for elderly in nursing homes , and feeding tubes long term use thank you

Sent from my iPad

(2/23/10)- The results of a recent study involving nursing home residents with advanced dementia who were sent to various hospital, found that large hospitals, hospitals deemed aggressive about providing end-of-life care and for-profit hospitals were more likely than others to insert feeding tubes

The variation between hospitals was huge, with some providing the feeding tubes only in one of every 100 patients with advanced dementia, while other hospitals did it as much as in one of every three patients under their care.

The results of the study were published in the February 10 issue of The Journal of the American Medical Association. It analyzed more than a quarter of a million admissions of nursing home residents to thousands of hospitals from 2000 to 2007.

The results of the study indicated that the practice of the hospital rather than the desire of the patient or his/her medical advisor was the key reason why the insertion of the feeding tube was made.

Dr. Joan M. Teno, a professor of community health at the Warren Alpert School of Medicine of Brown University was the lead author of the study.

(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
updated September 24, 2014

http://www.therubins.com

To e-mail: hrubin12@rr.nyc.com or allanrubin4@gmail.com

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