Journal Club 12_09_2014

Enteral Feeding in Advanced Dementia Adults

Journal Club 12/09/2014

Ann, Matt, Philip, Winnie

Background/Intro •American Geriatrics Society Position:

–“(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. Tube

feeding is associated with agitation, greater use of physical and chemical

restraints, greater healthcare use due to tube-related complications, and

development of new pressure ulcers.”

–“Efforts to enhance oral feeding by altering the environment and creating

individual-centered approaches to feeding should be part of usual care for

older adults with advanced dementia.”

American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American

Geriatrics Society Feeding Tubes in Advanced Dementia Position Statement. JAGS. 2014; 62 (8): 1590-1593.

American Geriatrics Society Position cont…

•“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 is though the individual

would want.”

•“It is the responsibility of all members of the healthcare team…to

understand any previously expressed wishes of the

individuals…regarding tube feeding and to incorporate these wishes into the

care plan.”

•…“Institutions should not impose obligations or exert pressure on

individuals or providers to institute tube feeding.”



cont...

•A randomized, controlled trial comparing benefits/disadvantages of

TF vs. PO in advance dementia has not been done due to ethical

considerations (i.e. age/vulnerability)

•Caregivers report little conversation surrounding TF decisions (more

than ½ report no conversation or one that last 15 min.)

–Many times families feel pressured to use1



Background continued

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

Introduction • 2006 MDS data indicated that 8.1% of all

nursing home residents were receiving tube feedings.

• States vary-Nebraska lowest (3.8%) and District of Columbia highest (44.8%).

• 3 types of tube feedings (nasoenteral, gastrostomy, jejunal).

Gavi S, Hensley J, Cervo F, Nicastri C, Fields S. Management of Feeding Tube Complications in the Long-Term Care Resident. Clinical Care and Aging. 2008: 16 (4). 1-3.

Tube Feeding Complications

• Aspiration

• Diarrhea

• Nausea, vomiting or abdominal bloating

• Metabolic

• Mechanical


Other Issues

• Medications and tube feedings

• Many of these medication interactions can be avoided by withholding tube feedings for two hours before and after giving medications.2


Enteral Tube Feeding in Older Adults with Dementia

Authors: Candy B., Sampson EL, Jones L. Presented by: Winnie

Purpose ● Poor PO is commonly observed in dementia patients

due to various reasons ● ETF is an obvious solution to tackle the poor nutrition

in advanced dementia patients, via NG tube or PEG ● Benefits or harms are not evaluated, and there is no

outcomes are measured in the studies, hence this systematic review

Candy B., Sampson EL, Jones L. Enteral tube feeding in older people with advanced dementia: Findings from a Cochrane systematic review. International Journal of Palliative Nursing. 2009; 15(8):396-404.

● Systematic review ● Studies were included if NG tube or PEG are evaluated;

patients age of 50 years and over of both genders; poor PO or had developed problems with eating and swallowing; most patients were diagnosed of degenerative dementia

● Studies regarding administration of IV fluid are excluded because usually are short-termed

● Primary outcomes were mortality and quality of life (QOL)

Methods


Results

● No RCTs were identified ● Case note review or analysis of an existing data set ● 7 observational controlled cohort studies ● 3 studies used prospective methods ● 1 study randomly selected controls


● Studies included were undertaken in the US, Spain, and Israel

● Study population was recruited from inpatient/ tertiary hospital populations or nursing homes.

● 409 patients received enteral feeding and 1467 comparison subjects


● Primary outcomes: No study stated that QOL was measured; 6 studies evaluated mortality

● Secondary outcomes: (a range of nutritional parameters) weight, BMI, hematocrit and cholesterol levels.

● 2 studies reported adverse effects, i.e. aspirational pneumonia (58% vs 17%) and death (1 reported)


Discussion

● Evidence of benefits in enteral feeding in dementia patients is inconclusive.

● No evaluation was found on QOL, physical function, or behavioral/ psychiatric symptoms of dementia.

● Little info was given on adverse events for the invasive procedures.


Implications

● Formulating care plans to facilitate swallowing and supplementing intake

● Hand-feeding carefully ● Playing quiet and smooth music at mealtimes3


Do Patients With Advanced Cognitive Impairment Admitted to Hospitals With Higher Rates of Feeding Tube Insertion Have Improved Survival Shubing Cai, PhD, Pedro L. Gozalo, PhD, Susan L. Mitchell, MD, MPH, Sylvia Kuo, PhD, Julie P.W. Bynum, MD, MPH, Vincent Mor, PhD, and Joan M. Teno, MD, MS

Presented By Phil

Methods

• There were 56,824 nursing home residents from 1773 hospitals.

• MDS was used to match Medicare claims from 2000-2007.

Cai S, Gozalo PL, Mitchell SL, Kuo S, Bynum JPW, Mor V, Teno JM. Do Patients with Advanced Cognitive Impairment Admitted to Hospitals With Higher Rates of Feeding Tube Insertion Have Improved Survival? J

Pain Symptom Manage. 2013: 45 (3). 1-7.

Results

• Of the 1773 hospitals, 18.5% or 228 had low rates of tube insertion.

• 20.6% or 366 hospitals had high rates.

• Individuals admitted to hospitals with high insertion rates did not experience improved 6 month survival compared to those with hospitals with low insertion rates.

Cai S, Gozalo PL, Mitchell SL, Kuo S, Bynum JPW, Mor V, Teno JM. Do Patients with Advanced Cognitive Impairment Admitted to Hospitals With Higher Rates of Feeding Tube Insertion Have Improved Survival? J Pain Symptom Manage.

2013: 45 (3). 1-7.

Limitations and Strengths Limitations

• Only MDS measures were used.

• Ages made it difficult for long term study.

• They were not able to distinguish effect of care provided in the hospital from care received after discharge.

Strengths

• Large population

• Many facilities funded the study

Cai S, Gozalo PL, Mitchell SL, Kuo S, Bynum JPW, Mor V, Teno JM. Do Patients with Advanced Cognitive Impairment Admitted to Hospitals With Higher Rates of Feeding Tube Insertion Have Improved Survival? J Pain Symptom Manage. 2013: 45 (3). 1-7

Discussion

• The findings were consistent with results of prior research that showed tube feeding does not improve survival among patients with dementia.4

Cai S, Gozalo PL, Mitchell SL, Kuo S, Bynum JPW, Mor V, Teno JM. Do Patients with Advanced Cognitive Impairment Admitted to Hospitals With Higher Rates of Feeding Tube Insertion Have Improved Survival? J Pain Symptom Manage. 2013: 45 (3). 1-7.

Survival Effect of TF in Pts with Advanced Dementia and Comorbidities

Authors: Efraim Jaul, Raz Levin, Jacob Menczel Presented by: Ann

Purpose

The aim of the study is: To report the effects of tube feeding on the survival rates of patients with advanced dementia who also suffer from severe disease To Compare these results with those who were orally fed

Efraim Jaul, Raz Levin, Jacob Menczel. Survival Effect of Tube Feeding in Patients with Advanced Dementia and Comorbidities. International Journal of Clinical Medicine. 2014; 5: 611-616.

Methods Data was collected from the skilled geriatric nursing department at Herzog Hospital in Jerusalem Patients recruited for the study had advanced dementia and had other complications such as extensive and deep pressure ulcers. Patients were evaluated for feeding method: Oral Feeding (OF) or Tube Feeding (TF) The data was collected from the medical, nursing, social and nutrition files Logistic regression models were used to estimate the Odds Ratio (OR) and 95% confidence intervals (CI) for TF vs OF by study covariates.


Results One hundred forty nine patients were included in the study: 99 (66.5%) were with TF and 50 (33.5%) with OF at admission The underlying medical conditions were significantly higher in the TF group, such as: cerebrovascular accidents (CVA), chronic renal failure (CRF) and lung diseases Parkinson’s disease, diabetes mellitus, ischemic heart disease (IHD) and peripheral vascular disease (PVD) were not significantly different between the two groups


Statistically significant higher prevalence of pressure ulcers (75% vs 25%), tracheostomies (91% vs. 9%) and urinary catheters (72% vs. 28%) were found in the TF patients The mean Functional Assessment Staging of Alzheimer Disease (FAST) was significantly higher in the TF group (6.54 ± 0.6 vs. 6.02 ± 0.5, p < 0.001). The mean Glasgow Coma Scale (GCS) (10.9 ± 2.99 vs. 13.8 ± 1.64, p < 0.001) and the total Norton score (8.75 ± 2.2 vs 11.04 ± 2.5; p < 0.001) were significantly lower in the TF patients compare to the OF patients. The median survival time of patients with TF was 164 days and that of the OF group was 78 days (χ2 = 0.94; p = 0.33)



Discussion The tube fed group suffered from more complications including pressure ulcers, low Hgb level, use of urinary catheters and tracheostomies as compared to the oral fed patients The main result of the study is that the survival time of the TF patients was longer, yet not statistically significant TF was beneficial in patients with specific risk factors, such as low Hgb, low BMI and pressure ulcers Efraim Jaul, Raz Levin, Jacob Menczel. Survival Effect of Tube Feeding in Patients with Advanced Dementia

and Comorbidities. International Journal of Clinical Medicine. 2014; 5: 611-616.

Conclusion

The advanced dementia patients described in the study were unable to eat and to drink, suffered from additional diseases, and had a clear indication for tube feeding

The study concluded that the median survival period in the TF group was longer as compared to the OF patients


Limitations The study limitations include the study’s setting; conducted in a skilled nursing department rather than in the community or in nursing homes The study is associated with a selection bias towards sicker patients with higher comorbidities The control group is composed of patients who met department admission criteria and therefore the results may not be generalizable to community or nursing home patients


The role of gastrostomy tube placement

in advanced dementia with dysphagia a

critical review

Authors: Goldberg LS, Altman KW

Presented by: Matt Caldanaro

Introduction/Research Questions •Much controversy regarding use and timing of EN in those with dysphagia & aspiration

risk

•Add to it advanced dementia & ethical issues with comfort care (PO), PEG placement,

and mortality rates→ becomes even more complex

•Purpose of study: Evaluate PEG placement in those with advanced dementia with

associated mortality rates

•Hypothesis: PEG does not prolong life

•Also, explored impact of PEG placement in specific dementia groups to identify

prognoses that may be used to develop comprehensive guidelines

Goldberg LS, Altman, KW. The role of gastrostomy tube placement in advance dementia with dysphagia: a critical

review. Clinical Interventions in Aging. 2014; 9: 1733-1739.

Methods •Systematic review of literature using PubMed (1995-2012)

•100 articles (yielded greatest results) used terms “dementia” OR “Alzheimer” AND

“dysphagia” OR “aspiration” OR “swallowing difficulty” AND “percutaneous endoscopic

gastrostomy” OR “enteral” OR “feeding tube”

•Inclusion criteria required: 1) scientific research paper 2) addressed dementia,

dysphagia or aspiration risk, or PEG tube placement 3) originally written in or translated

into English

•Next, references studied for relevance, level of evidence, year of study, if based on

systematic review of literature, size of study, number of patients with dementia within

study, specific outcomes (i.e. survival- compared dementia patients with PEGs vs. those

without)



Data Analysis •After applying inclusion and exclusion criteria, 10 articles remained

•Retrospective studies:

1. 10 year study; 8,688 dementia patients with PEGs: 1 year mortality rate for males

61%, 1 year mortality rate for females 50%; 3 year mortality rate for 78% for females,

84% for males

2. 311 patients with PEGs, 143 with dementia: 51% 12-month survival rate with

dementia, 49% without dementia (3 predictors of poor survival after PEG: male,

>80 years, & hypoalbuminemia)

3. Last study audited 719 patients who died within 30 days after PEG: 18% had

dementia, 82%- 70 years or older, 50%- >80 years (29% written consent for

procedure among dementia patients)



Data Analysis cont… •Prospective studies:

1. 99 hospital patients with advanced dementia: median mortality rate 6

months “post-feeding tube” 195 days, without feeding tube 189 days

(mortality 50% in both groups)

2. 674 patients (280 dementia/PEG, over half > 80 years, with age

distribution similar to PEG placements in US): median survival rate

171 days for those over 80 with dementia (worse), compared to

dementia/stroke 181 days, dementia/nursing homes 423 days, &

dementia/younger than 80 years 467 days



Results and Conclusions •5 studies revealed mortality at 30 days with dementia/PEG placement

–13-18%, 14.4%, 18%, 25%, and 54%

•4/5 studies revealed mortality at ~50% at 1 year with dementia/PEG

placement

–45.6%, 51%, 50-61%, and 58%

•Conclusion: Presently no evidence in literature to suggest long-term survival

rates improved in patients with advanced dementia who underwent PEG

placement



Strengths and Limitations •Strengths: multiple studies, many with larger sample sizes

•Limitations/benefits of PEG not addressed: route for medications, hydration

and nutrition supplementation, allows for “compassionate PO” or “comfort

care”, and bridging nutritional needs during readmissions due to declining

mental status

•Ethical considerations?

•Statistical evaluation of studies?



Discussion •Should a PEG be placed in a dementia patient who is aspirating or has dysphagia? Should

interventions be done sooner? When is it too late?

–Must consider quality of life (PO an option? “Starving” patient if no PEG?), stage/progression

of dementia (6=moderate-severe, 7=severe), age onset of dysphagia, comorbidities

–Discussions regarding PEG placement do not appear to be happening during early stages of

dementia diagnosis, and many of those who receive PEG do not have health care proxies (need

more involvement between medical staff and families!)

–Research shows increased survival rate in dementia patients under 80 years (double than

patients over 80)

–Males have higher risk of 30-day mortality after PEG insertion6



Polling Questions

Any questions? Or further

discussion/comments?

Thank-you!

References

1. American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American


2. Gavi S, Hensley J, Cervo F, Nicastri C, Fields S. Management of Feeding Tube Complications in the Long-Term

Care Resident. Clinical Care and Aging. 2008: 16 (4). 1-3.

3. Candy B., Sampson EL, Jones L. Enteral tube feeding in older people with advanced dementia: Findings from a Cochrane systematic review. International Journal of Palliative Nursing. 2009; 15(8):396-404.

4. Cai S, Gozalo PL, Mitchell SL, Kuo S, Bynum JPW, Mor V, Teno JM. Do Patients with Advanced Cognitive

Impairment Admitted to Hospitals With Higher Rates of Feeding Tube Insertion Have Improved Survival? J Pain Symptom Manage. 2013: 45 (3). 1-7.

5. Efraim Jaul, Raz Levin, Jacob Menczel. Survival Effect of Tube Feeding in Patients with Advanced Dementia and

Comorbidities. International Journal of Clinical Medicine. 2014; 5: 611-616.

6. Goldberg LS, Altman, KW. The role of gastrostomy tube placement in advance dementia with dysphagia: a

critical review. Clinical Interventions in Aging. 2014; 9: 1733-1739.

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Journal Club 12_09_2014

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