P​u​b​l​i​c​a​t​i​o​n​ ​b​y​ ​t​h​e​ ​A​m​e​r​i​c​a​n​ ​G​e​r​i​a​t​r​i​c​ ​S​o​c​i​e​t​y​ ​r​e​ ​D​e​m​e​n​t​i​a​ ​a​n​d​ ​D​y​s​p​h​a​g​i​a

Recommendation: Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.

Careful hand feeding of individuals with severe dementia is associated with comfort and functional status that are as good as, or better than, those associated with tube feeding. Older adults with advanced dementia who are handfed run lower risks of aspiration pneumonia and mortality than those with percutaneous feeding tubes. Tube feeding is associated with agitation, greater use of physical and chemical restraints, and worsening pressure ulcers.

Individuals with advanced dementia frequently develop eating and swallowing difficulties that lead to poor oral intake, weight loss, and aspiration. Approximately one-third of nursing home residents with advanced dementia have feeding tubes.[7] Feeding tube use is intended to prevent serious adverse outcomes such as aspiration pneumonia, malnutrition and its consequences, functional decline, and death. It is also intended to improve comfort. Nevertheless, tube feeding cannot be expected to prevent aspiration of oral secretions or to reduce risk of regurgitation, and no published studies have suggested that feeding tube insertion can reduce the risk of aspiration pneumonia.[8] A nonrandomized study found that orally fed individuals with oropharyngeal dysphagia had significantly fewer major aspiration events than those fed by tube.[9] Regarding undernutrition, no data suggest that providing additional nutrients through a feeding tube improves meaningful clinical outcomes.[8,10] A Cochrane systematic review noted that the use of feeding tubes in individuals with advanced dementia is not associated with better nutritional status, lower risk of pressure ulcers, or longer survival[11] than hand feeding. Another comprehensive review found no evidence to suggest that tube feeding can improve pressure ulcer outcomes, reduce infections, enhance functional status, or increase comfort,[8] and a propensity analysis found that tube feeding was significantly associated with worse pressure ulcer outcomes.[12]

The adverse, burdensome effects of tube feeding are significant. Aspiration pneumonia is the most common adverse event.[13] Others include tube occlusion, leaking, and local infection.[8] Furthermore, individuals may need to be physically or chemically restrained[14] to keep them from pulling the feeding tube out of place.

Conservative hand feeding approaches begin with appropriately positioning the individuals, with the upright position preferred[15] when possible. Other factors that appear to improve outcomes with hand feeding include nursing home staff education; ad lib diets; medication adjustments;[16] and use of finger foods, preferred foods,[17] and foods with strong flavors.[18] Specific feeding[15] techniques—such as offering frequent reminders to swallow multiple times per bolus,[17] reducing bolus size to smaller than one teaspoon,[18] encouraging gentle coughs after each swallow,[18] using facilitating techniques such as stroking the cheeks and neck,[19] placing food and fluid well into the mouth,[19] and optimizing the eating environment—all seem reasonable as well, although an evidence base for these strategies has not been well established.

There are significant opportunities to improve decision-making on behalf of individuals with advanced dementia and feeding difficulties. In a study of relatives of residents with dementia who died in nursing homes and had a feeding tube, 13.7% reported that there was no prior discussion about feeding tube insertion. In cases in which such discussions occurred, 41.6% of relatives reported that the discussion lasted fewer than 15 minutes, and 12.6% reported feeling pressured by the physician to insert the tube. Tellingly, family members with loved ones who died with a feeding tube were less likely to report that their relatives received excellent end-of-life care than family members of those who did not die with the tubes.[20]

Approaches to address this issue have been developed and tested. A randomized controlled trial found that a decision aid for surrogates deciding among feeding options for nursing home residents with advanced dementia improved the quality of decision-making. This intervention showed evidence of sustained benefit over time.[21]

Thank you, Deb for passing along this announcement 🙂

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