Feeding Alternatives in Patients With Dementia: Examining the Evidence
2007; Elsevier BV; Volume: 5; Issue: 12 Linguagem: Inglês
10.1016/j.cgh.2007.09.014
ISSN1542-7714
AutoresDonald Garrow, Pam J. Pride, William P. Moran, Jane G. Zapka, Elaine J. Amella, Mark H. DeLegge,
Tópico(s)Intensive Care Unit Cognitive Disorders
ResumoPercutaneous endoscopic gastrostomy tubes are being placed with increasing frequency in the United States among elderly patients with dementia. Health care providers believe there may be long-term benefits for enteral feeding in this population, yet previous study of this topic has failed to yield any convincing evidence to support this hypothesis. In this study, we review the evidence regarding outcomes for artificial enteral feeding in older individuals with dementia. We found that there is a lack of evidence supporting artificial feeding in the specific outcomes of survival, pressure ulcers, nutrition, and aspiration pneumonia. A brief discussion regarding hand feeding is included. The data suggest that hand feeding may be a viable alternative to tube feeding in elderly patients with dementia, although a direct comparison trial of the 2 interventions is lacking. Percutaneous endoscopic gastrostomy tubes are being placed with increasing frequency in the United States among elderly patients with dementia. Health care providers believe there may be long-term benefits for enteral feeding in this population, yet previous study of this topic has failed to yield any convincing evidence to support this hypothesis. In this study, we review the evidence regarding outcomes for artificial enteral feeding in older individuals with dementia. We found that there is a lack of evidence supporting artificial feeding in the specific outcomes of survival, pressure ulcers, nutrition, and aspiration pneumonia. A brief discussion regarding hand feeding is included. The data suggest that hand feeding may be a viable alternative to tube feeding in elderly patients with dementia, although a direct comparison trial of the 2 interventions is lacking. An estimated 2 million people in the United States suffer from severe dementia (or cognitive impairment), and another 1 to 5 million people experience mild to moderate dementia.1Hendrie H. Epidemiology of dementia and Alzheimer’s disease.Am J Geriatr Psychiatry. 1998; 6: S3-S18Abstract Full Text Full Text PDF PubMed Scopus (279) Google Scholar Five percent to 8% of people older than the age of 65 have some form of dementia, with a doubling in the incidence of dementia every 5 years over age 65.1Hendrie H. Epidemiology of dementia and Alzheimer’s disease.Am J Geriatr Psychiatry. 1998; 6: S3-S18Abstract Full Text Full Text PDF PubMed Scopus (279) Google Scholar The prevalence of dementia has increased over the past few decades, either because of greater awareness and more accurate diagnosis, or because increased longevity is creating a larger population of elderly, which is the age group most commonly affected. As dementia progresses, it often leads to difficulty eating, subsequent malnutrition, and other physical complications (pressure ulcers, aspiration).2Finucane T.E. Christmas C. Travis K. Tube feeding in patients with advanced dementia: a review of the evidence.JAMA. 1999; 282: 1365-1370Crossref PubMed Scopus (816) Google Scholar Percutaneous endoscopic gastrostomy (PEG) tubes are being placed with increasing frequency in patients with dementia in the United States.3Cervo F.A. Bryan L. Farber S. To PEG or not to PEG: a review of evidence for placing feeding tubes in advanced dementia and the decision-making process.Geriatrics. 2006; 61: 30-35PubMed Google Scholar First introduced in 1980 as a means to provide nutrition to children,4Reimer S.L. Michener W.M. Steiger E. Nutritional support of the critically ill child.Pediatr Clin North Am. 1980; 27: 647-660PubMed Google Scholar, 5Gauderer M.W.P.J. Izant Jr, R.J. Gastrostomy without laparotomy: a percutaneous endoscopic technique.J Pediatr Surg. 1980; 15: 872-875Abstract Full Text PDF PubMed Scopus (1748) Google Scholar PEG tubes currently often are placed in elderly patients with perceived low oral intake. In 1989, approximately 15,000 PEG tubes were placed; in 1995, 121,000 PEG tubes were implanted, and in the year 2000, more than 216,000 tubes were inserted for feeding.6Roche V. Percutaneous endoscopic gastrostomy: clinical care of PEG tubes in older adults.Geriatrics. 2003; 58: 22-29PubMed Google Scholar, 7Grant M.D. Rudberg M. Brody J. Gastrostomy placement and mortality among hospitalized Medicare beneficiaries.JAMA. 1998; 279: 1973-1976Crossref PubMed Scopus (245) Google Scholar Feeding tube placement is a relatively easy procedure. It can be performed typically in less than 30 minutes by a gastroenterologist, surgeon, or radiologist. It allows for reception of liquid food into the stomach via intermittent bolus or continuous infusion to supplant perceived caloric deficiencies. PEG is indicated by the AGA Institute when the patient cannot or will not eat, when the gut is functional, and if the patient may tolerate the procedure.6Roche V. Percutaneous endoscopic gastrostomy: clinical care of PEG tubes in older adults.Geriatrics. 2003; 58: 22-29PubMed Google Scholar Complications from PEG placement and enteral feeding include diarrhea, inadvertent removal of tubes by demented patients, cellulitis, bleeding or pain at the PEG tube abdominal wall insertion, ileus, gastroesophageal reflux, and frequent clogging of the tube.8Madan A.K. Batra A. Percutaneous endoscopic gastrostomy in the elderly: complications.J Nutr Elder. 1996; 15: 39-49Crossref PubMed Scopus (16) Google Scholar, 9Loser C. Wolters S. Folson U. Enteral long-term nutrition via percutaneous endoscopic gastrostomy (PEG) in 210 patients: a four-year prospective study.Dig Dis Sci. 1998; 43: 2549-2557Crossref PubMed Scopus (150) Google Scholar Although these situations may be perceived as minor, they can be cumbersome and worrisome for the patient, family, and caregivers. In addition, many of these complications result in the need for further medical attention, including hospitalization.10Metheny N.A. Meert K.L. Clouse R.E. Complications related to feeding tube placement.Curr Opin Gastroenterol. 2007; 23: 178-182Crossref PubMed Scopus (113) Google Scholar Hand feeding is an alternative to tube feeding. In studies of other debilitating or terminal conditions such as stroke and cancer, hand feeding small amounts of food to patients with anorexia or dysphagia results in alleviation of perceived hunger and thirst, despite failure to replete complete calorie deficiencies.11Vullo-Navich K. Smith S. Andrews M. et al.Comfort and incidence of abnormal serum sodium, BUN, creatinine and osmolality in dehydration of terminal illness.Am J Hosp Palliat Care. 1998; 15: 77-84Crossref PubMed Scopus (46) Google Scholar, 12McCann R.M. Hall W.J. Groth-Juncker A. Comfort care for terminally ill patients: the appropriate use of nutrition and hydration.JAMA. 1994; 272: 1263-1266Crossref PubMed Scopus (462) Google Scholar Also, elderly patients often do not feel dehydrated because their thirst mechanism is impaired, likely a natural adaptive compensation.13Phillips P.A. Rolls B.J. Ledingham J. Reduced thirst after water deprivation in healthy elderly men.N Engl J Med. 1984; 311: 753-759Crossref PubMed Scopus (588) Google Scholar Oral feeding, even in limited amounts, allows for the possibility of the enjoyment received from eating. With placement of an enteral feeding tube, patients often are deprived of this basic life pleasure. Enteral tube feeding is provided to many demented individuals with the intention of preventing or limiting the frequency of oral-tracheal aspiration, pressure ulcer formation, and increasing survival.2Finucane T.E. Christmas C. Travis K. Tube feeding in patients with advanced dementia: a review of the evidence.JAMA. 1999; 282: 1365-1370Crossref PubMed Scopus (816) Google Scholar Although little data suggest that any of these are ameliorated by tube feeding, physician surveys revealed that almost 4 of 5 physicians believe enteral tube feeding decreases the frequency of these outcomes.14Shega J.W. Hougham G.W. Stocking C.B. et al.Barriers to limiting the practice of feeding tube placement in advanced dementia.J Palliat Med. 2003; 6: 885-893Crossref PubMed Scopus (78) Google Scholar This article reviews the current evidence concerning feeding tube insertion and outcomes in the dementia patient population via a systematic analysis. Our analysis includes consideration of study design, population, and settings and investigates the evidence concerning 4 major outcomes often associated with an impaired functional status in the elderly and dementia patient: (1) survival, (2) oral-tracheal aspiration, (3) pressure ulcer formation, and (4) nutrition. We searched MEDLINE via PubMed and the Nursing and Allied Health Literature from January 1966 through March 2007 using variations in several search terms. We combined the Medical Subject Heading term dementia individually with the terms feeding, PEG, gastrostomy, enteral nutrition, malnutrition, aspiration, decubitus, and complications. We reviewed all citations in each article. We manually reviewed published abstracts and those from national gastroenterologic meetings. We included studies that analyzed a cohort of elderly subjects with dementia and their associated outcomes after enteral feeding tube placement. Each study was required to include either one or more of the following outcomes in their analysis: oral-tracheal aspiration, pressure ulcers, nutrition/weight, or survival. We excluded descriptive reviews, economic evaluations, editorials, letters, and case reports or case series. If an investigator had more than one study that appeared relevant to the review, we assessed whether the data overlapped by either reviewing the recruitment period or contacting the author. Dementia was defined in different manners in each included study. Some studies relied on chart diagnosis only and others used standardized dementia scales. Table 1 shows the definition of dementia for each study.Table 1Summary of Literature Review for Feeding Tubes in the Elderly Dementia PopulationStudySanders et al, 2000Study periodAugust 1992–July 1997Setting2 general hospitals in EnglandDesign and analysesRetrospective; PEG-tube cohortDementia compared with 3 other diagnosesSubjects and sample size361 consecutive subjects with PEG insertions103 in diagnostic subgroup of dementiaDementia defined as exclusion of metabolic, nutritional, and Parkinson’s as causeFindingsDementia subjects had worse survival than other groups54% mortality at 1 month, 90% mortality at 1 yearStudyKaw et al, 1994Study periodAugust 1998–November 1990SettingAcademic hospital in Pittsburgh, PADesign and analysesRetrospective; PEG-tube cohortSubjects and sample size46 total subjects received PEG tube24 subjects with dementia (52%)Dementia defined as diagnosis in chart of “dementia”; not attributable to Parkinson’sFindingsMortality of subjects ∼50% at 12 months and 60% at 18 monthsNo significant improvement in nutritional statusInitial serum albumin level > 3.5 g/dL associated with improved survivalPEG-related complications occurred in 34.7% of subjectsStudyGrant et al, 1998Study periodJanuary 1991–December 1991SettingHospitalized Medicare beneficiaries with PEG placed in 1991Design and analysesRetrospective; PEG-tube cohortSubjects and sample size81,105 total hospitalized Medicare beneficiaries discharged with PEG8688 (10.7%) with dementiaDementia defined as ICD-9 diagnosis of “dementia” in chartFindingsFemale dementia subgroup with mortality ∼13% at 1 month, 50% at 1 year, and 78% at 3 yearsMale dementia subgroup with mortality ∼18% at 1 month, 61% at 1 year, and 84% at 3 yearsStudyRimon et al, 2005Study periodJanuary 1992–December 2002SettingGastroenterology unit of a community hospitalDesign and analysesProspective; PEG-tube cohortSubjects and sample size674 consecutive subjects age >50 referred for PEG insertion280 (41.5%) with “feeding difficulty” typically owing to dementiaDementia defined as stage 6 or 7 of Global Deterioration ScaleFindingsSurvival significantly worse in diabetics, inpatient referrals, and subjects with dementia over age 80Best survival was seen in individuals with dementia younger than age 80 and women younger than age 80 referred from nursing homesStudyPeck et al, 1990Study periodMay 1989–June 1989SettingNursing home in New York cityDesign and analysesProspective; nursing home cohortTube-fed vs non–tube-fed patients for 6 monthsFeeding tube is a permanent nasogastric tube (NGT)Subjects and sample size104 total subjects (52 tube-fed and 52 random controls)Dementia present in 100% of tube-fed, 71% of controlsDementia defined as Mini-Mental Status Examination score <20FindingsTube-fed subjects had significant increase in aspiration pneumonia (58% vs 17%; P < .01) and weight gain (48% vs 17%; P < .01)No significant difference noted in decubitus ulcers or use of restraintsStudyAlvarez-Fernandez et al, 2005Study periodFebruary 1999–June 1999SettingTertiary hospital in Magala, SpainDesign and analysesProspective; dementia cohortFeeding tube is permanent nasogastric tube (NGT)Subjects and sample size67 subjects with advanced dementia62 female subjects (92.5%); 14 subjects with NGT (20.9%)Dementia defined as score >7 on Functional Assessment Staging (FAST)FindingsSignificant predictors of mortality were serum albumin 6d on FASTFindingsMedian mortality in both PEG and non-PEG group = 50% at 6 monthsPredictors of new feeding-tube placement = African American race (HR, 4.9; Cl, 1.02–2.50) and nursing home residence (HR, 9.43; CI, 2.10–43.20)StudyNair et al, 2000Study periodJuly 1997–April 1998SettingAcademic hospital in New York cityDesign and analysesProspective; dementia cohortTube-fed vs non–tube-fed patientsSubjects and sample size55 consecutive subjects with dementia and inadequate oral intake36 comparison subjects in age, sex, and comorbid IllnessesDementia defined as secondary to Alzheimer’s, multi-infarct, or degenerative diseaseFindingsMortality = 44% among PEG subjects vs 26% among controls at 6 months (P = .03)Serum albumin 65 and recent progression to severe dementia135 subjects (9.7%) underwent placement of a feeding tubeDementia defined as progression to a score of 6 on the Cognitive Performance ScaleFindingsNo difference in survival between tube-fed and control groups (P = .66) Open table in a new tab Two authors (D.G., P.P.) performed independent searches of PubMed and the Nursing and Allied Health Literature as described earlier. Each of these authors then reviewed the eligibility for review given the inclusion criteria. A third author (M.D.) arbitrated discrepancies. All authors reviewed the contents of Table 1 for accuracy. We created a data table for each study within a Microsoft Excel (Microsoft Corp, Redmond, VA) spreadsheet. Within the spreadsheet we identified the study investigator, publication year, study period, setting, study design, statistical analyses used, subject description, sample size, and study findings. Our MEDLINE search via PubMed yielded 397 abstracts and more than 30 complete articles that appeared to fulfill the inclusion criteria outlined previously. After careful manual review, we determined that 10 articles and no abstracts qualified for our analysis (Table 1).7Grant M.D. Rudberg M. Brody J. Gastrostomy placement and mortality among hospitalized Medicare beneficiaries.JAMA. 1998; 279: 1973-1976Crossref PubMed Scopus (245) Google Scholar, 15Sanders D.S. Carter M.J. D’Silva J. et al.Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia.Am J Gastroenterol. 2000; 95: 1472-1475Crossref PubMed Google Scholar, 16Kaw M. Sekas G. Long-term follow-up of consequences of percutaneous endoscopic gastrostomy (PEG) tubes in nursing home patients.Dig Dis Sci. 1994; 39: 738-743Crossref PubMed Scopus (166) Google Scholar, 17Rimon E. Kagansky N. Levy S. Percutaneous endoscopic gastrostomy; evidence of different prognosis in various patient subgroups.Age Ageing. 2005; 34: 353-357Crossref PubMed Scopus (63) Google Scholar, 18Peck A. Cohen C.E. Mulvihill M. Long-term enteral feeding of aged demented nursing home patients.J Am Geriatr Soc. 1990; 38: 1195-1198Crossref PubMed Scopus (158) Google Scholar, 19Alvarez-Fernandez B. Garcia-Ordonez M.A. Martinez-Manzanares C. et al.Survival of a cohort of elderly patients with advanced dementia: nasogastric tube feeding as a risk factor for mortality.Int J Geriatr Psychiatry. 2005; 20: 363-370Crossref PubMed Scopus (56) Google Scholar, 20Murphy L.M. Lipman T. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia.Arch Intern Med. 2003; 163: 1351-1353Crossref PubMed Scopus (165) Google Scholar, 21Meier D.E. Ahronheim J.C. Morris J. et al.High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding.Arch Intern Med. 2001; 161: 594-599Crossref PubMed Scopus (216) Google Scholar, 22Nair S. Hertan H. Pitchumoni C. Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia.Am J Gastroenterol. 2000; 95: 133-136Crossref PubMed Google Scholar, 23Mitchell S.L. Kiely D.K. Lipsitz L. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment.Arch Intern Med. 1997; 157: 327-332Crossref PubMed Google Scholar All included studies reported PEG tubes as the choice of enteral feeding, except for the study by Peck et al,18Peck A. Cohen C.E. Mulvihill M. Long-term enteral feeding of aged demented nursing home patients.J Am Geriatr Soc. 1990; 38: 1195-1198Crossref PubMed Scopus (158) Google Scholar and Alvarez-Fernandez19Alvarez-Fernandez B. Garcia-Ordonez M.A. Martinez-Manzanares C. et al.Survival of a cohort of elderly patients with advanced dementia: nasogastric tube feeding as a risk factor for mortality.Int J Geriatr Psychiatry. 2005; 20: 363-370Crossref PubMed Scopus (56) Google Scholar in which a flexible nasogastric tube was used. After careful review of the 10 included studies, 3 different types of patient cohorts emerged. There were 4 studies that evaluated survival in a dementia subgroup among a cohort of PEG patients.7Grant M.D. Rudberg M. Brody J. Gastrostomy placement and mortality among hospitalized Medicare beneficiaries.JAMA. 1998; 279: 1973-1976Crossref PubMed Scopus (245) Google Scholar, 15Sanders D.S. Carter M.J. D’Silva J. et al.Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia.Am J Gastroenterol. 2000; 95: 1472-1475Crossref PubMed Google Scholar, 16Kaw M. Sekas G. Long-term follow-up of consequences of percutaneous endoscopic gastrostomy (PEG) tubes in nursing home patients.Dig Dis Sci. 1994; 39: 738-743Crossref PubMed Scopus (166) Google Scholar, 17Rimon E. Kagansky N. Levy S. Percutaneous endoscopic gastrostomy; evidence of different prognosis in various patient subgroups.Age Ageing. 2005; 34: 353-357Crossref PubMed Scopus (63) Google Scholar Five studies determined survival based on comparison of PEG vs non-PEG patients among a cohort of dementia patients.19Alvarez-Fernandez B. Garcia-Ordonez M.A. Martinez-Manzanares C. et al.Survival of a cohort of elderly patients with advanced dementia: nasogastric tube feeding as a risk factor for mortality.Int J Geriatr Psychiatry. 2005; 20: 363-370Crossref PubMed Scopus (56) Google Scholar, 20Murphy L.M. Lipman T. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia.Arch Intern Med. 2003; 163: 1351-1353Crossref PubMed Scopus (165) Google Scholar, 21Meier D.E. Ahronheim J.C. Morris J. et al.High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding.Arch Intern Med. 2001; 161: 594-599Crossref PubMed Scopus (216) Google Scholar, 22Nair S. Hertan H. Pitchumoni C. Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia.Am J Gastroenterol. 2000; 95: 133-136Crossref PubMed Google Scholar, 23Mitchell S.L. Kiely D.K. Lipsitz L. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment.Arch Intern Med. 1997; 157: 327-332Crossref PubMed Google Scholar One study looked at outcomes not including survival in PEG compared with non-PEG patients among a cohort of nursing home patients, many of whom had dementia.18Peck A. Cohen C.E. Mulvihill M. Long-term enteral feeding of aged demented nursing home patients.J Am Geriatr Soc. 1990; 38: 1195-1198Crossref PubMed Scopus (158) Google Scholar Of the 10 studies, only 1 was randomized.21Meier D.E. Ahronheim J.C. Morris J. et al.High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding.Arch Intern Med. 2001; 161: 594-599Crossref PubMed Scopus (216) Google Scholar However, the randomization was not PEG vs non-PEG, but standard medical care vs palliative care in a dementia population. Among the 5 dementia cohort studies in which subjects were compared with or without PEG tubes, there was no significant difference noted in survival for 3 studies,20Murphy L.M. Lipman T. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia.Arch Intern Med. 2003; 163: 1351-1353Crossref PubMed Scopus (165) Google Scholar, 21Meier D.E. Ahronheim J.C. Morris J. et al.High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding.Arch Intern Med. 2001; 161: 594-599Crossref PubMed Scopus (216) Google Scholar, 23Mitchell S.L. Kiely D.K. Lipsitz L. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment.Arch Intern Med. 1997; 157: 327-332Crossref PubMed Google Scholar and in the other 2 studies feeding tubes were associated with greater mortality than the non–tube-fed patients.19Alvarez-Fernandez B. Garcia-Ordonez M.A. Martinez-Manzanares C. et al.Survival of a cohort of elderly patients with advanced dementia: nasogastric tube feeding as a risk factor for mortality.Int J Geriatr Psychiatry. 2005; 20: 363-370Crossref PubMed Scopus (56) Google Scholar, 22Nair S. Hertan H. Pitchumoni C. Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia.Am J Gastroenterol. 2000; 95: 133-136Crossref PubMed Google Scholar In the 4 PEG-patient cohort studies, dementia subjects were either associated with increased mortality15Sanders D.S. Carter M.J. D’Silva J. et al.Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia.Am J Gastroenterol. 2000; 95: 1472-1475Crossref PubMed Google Scholar, 17Rimon E. Kagansky N. Levy S. Percutaneous endoscopic gastrostomy; evidence of different prognosis in various patient subgroups.Age Ageing. 2005; 34: 353-357Crossref PubMed Scopus (63) Google Scholar or approximately 50% mortality at 1 year.7Grant M.D. Rudberg M. Brody J. Gastrostomy placement and mortality among hospitalized Medicare beneficiaries.JAMA. 1998; 279: 1973-1976Crossref PubMed Scopus (245) Google Scholar, 16Kaw M. Sekas G. Long-term follow-up of consequences of percutaneous endoscopic gastrostomy (PEG) tubes in nursing home patients.Dig Dis Sci. 1994; 39: 738-743Crossref PubMed Scopus (166) Google Scholar One study looked at oral-tracheal aspiration in a group of nursing home patients. Peck et al18Peck A. Cohen C.E. Mulvihill M. Long-term enteral feeding of aged demented nursing home patients.J Am Geriatr Soc. 1990; 38: 1195-1198Crossref PubMed Scopus (158) Google Scholar found rates of aspiration pneumonia to be 3 times higher in the tube-fed dementia patients when compared with a convenience sample of non–tube-fed dementia nursing home patients over a 6-month time period. The data for pressure ulcers in the tube-fed dementia population are limited to one comparative study set in a nursing home. Peck et al18Peck A. Cohen C.E. Mulvihill M. Long-term enteral feeding of aged demented nursing home patients.J Am Geriatr Soc. 1990; 38: 1195-1198Crossref PubMed Scopus (158) Google Scholar looked at the rates of pressure ulcers among tube-fed dementia patients and found no significant difference in rates of pressure ulcer formation when compared with the non–tube-fed patients. Serum albumin level is used commonly as a marker of overall nutrition and as justification for feeding-tube placement. Nair et al22Nair S. Hertan H. Pitchumoni C. Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia.Am J Gastroenterol. 2000; 95: 133-136Crossref PubMed Google Scholar noted in their analysis that a very low serum albumin level (<2.8 g/dL) before placement of a feeding tube significantly predicted poor survival at 6 months after hospital discharge. Kaw et al16Kaw M. Sekas G. Long-term follow-up of consequences of percutaneous endoscopic gastrostomy (PEG) tubes in nursing home patients.Dig Dis Sci. 1994; 39: 738-743Crossref PubMed Scopus (166) Google Scholar found that there was no significant improvement in serum albumin or overall functional status after feeding tube insertion in a demented nursing-home population. In the same study, Kaw et al16Kaw M. Sekas G. Long-term follow-up of consequences of percutaneous endoscopic gastrostomy (PEG) tubes in nursing home patients.Dig Dis Sci. 1994; 39: 738-743Crossref PubMed Scopus (166) Google Scholar also noted that individuals with serum albumin levels of 3.5 g/dL or greater had significantly improved survival when compared with individuals with serum albumin levels less than 3.5 g/dL. Alvarez-Fernandez et al19Alvarez-Fernandez B. Garcia-Ordonez M.A. Martinez-Manzanares C. et al.Survival of a cohort of elderly patients with advanced dementia: nasogastric tube feeding as a risk factor for mortality.Int J Geriatr Psychiatry. 2005; 20: 363-370Crossref PubMed Scopus (56) Google Scholar also found that serum albumin levels less than 3.5 g/dL predicted increased mortality in hospitalized patients in Spain. Peck et al18Peck A. Cohen C.E. Mulvihill M. Long-term enteral feeding of aged demented nursing home patients.J Am Geriatr Soc. 1990; 38: 1195-1198Crossref PubMed Scopus (158) Google Scholar found significant weight gain in their tube-fed nursing home patients compared with their convenience sample of hand-fed patients. Our review illustrates major design issues in studies purporting to investigate clinical outcomes of PEG feeding in dementia patients. However, even in view of these study design limitations, our review suggests that tube feeding does not prolong life in demented individuals,20Murphy L.M. Lipman T. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia.Arch Intern Med. 2003; 163: 1351-1353Crossref PubMed Scopus (165) Google Scholar, 21Meier D.E. Ahronheim J.C. Morris J. et al.High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding.Arch Intern Med. 2001; 161: 594-599Crossref PubMed Scopus (216) Google Scholar, 23Mitchell S.L. Kiely D.K. Lipsitz L. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment.Arch Intern Med. 1997; 157: 327-332Crossref PubMed Google Scholar and may in fact shorten the life of these subjects.15Sanders D.S. Carter M.J. D’Silva J. et al.Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia.Am J Gastroenterol. 2000; 95: 1472-1475Crossref PubMed Google Scholar, 19Alvarez-Fernandez B. Garcia-Ordonez M.A. Martinez-Manzanares C. et al.Survival of a cohort of elderly patients with advanced dementia: nasogastric tube feeding as a risk factor for mortality.Int J Geriatr Psychiatry. 2005; 20: 363-370Crossref PubMed Scopus (56) Google Scholar, 22Nair S. Hertan H. Pitchumoni C. Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia.Am J Gastroenterol. 2000; 95: 133-136Crossref PubMed Google Scholar The review also suggests tube feeding does not reduce rates of aspiration pneumonia or pressure ulcers among individuals with dementia.18Peck A. Cohen C.E. Mulvihill M. Long-term enteral feeding of aged demented nursing home patients.J Am Geriatr Soc. 1990; 38: 1195-1198Crossref PubMed Scopus (158) Google Scholar Tube feeding also does not improve serum albumin measures,16Kaw M. Sekas G. Long-term follow-up of consequences of percutaneous endoscopic ga
Referência(s)