Survival in older adults with dementia and eating problems: To PEG or not to PEG?

Ticinesi, Andrea; Nouvenne, Antonio; Lauretani, Fulvio; Prati, Beatrice; Cerundolo, Nicoletta; Maggio, Marcello; Meschi, Tiziana

doi:10.1016/j.clnu.2016.04.001

Cited by 38 publications

(29 citation statements)

References 28 publications

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“…The utility of PEG tubes in older adults came into question less than a decade after first being used in this population . Indeed, even Gauderer, when reflecting on 20 years of PEG use, warned against the potential risks of overuse of this simple and otherwise relatively safe procedure and urged that “we as physicians must continuously strive to demonstrate that our interventions truly benefit the patient.” Gauderer also stated that the goal of the intervention should be to “provide comfort and hope; to facilitate care and improve the quality of life…to return the patient to oral intake whenever possible… [and] avoid additional problems.” As conveyed in the ABIM/AGS Choosing Wisely recommendations, the routine ordering of PEG tube placement in individuals with advanced dementia has not only been shown to lack proven benefits, but also may cause pain and suffering at the end of life …”

Section: Discussionmentioning

confidence: 99%

“…3 As conveyed in the ABIM/AGS Choosing Wisely recommendations, the routine ordering of PEG tube placement in individuals with advanced dementia has not only been shown to lack proven benefits, but also may cause pain and suffering at the end of life. 13,23,[25][26][27]32,33 Poor physician survey response rates generated an anticipated limitation to our study's methodology. Physicians are less likely to respond to surveys than other individuals because of lack of time.…”

Section: Discussionmentioning

confidence: 99%

“…7,13,[23][24][25][26][27][28][29][30][31] Overall, research has failed to show that PEG placement in individuals with advanced dementia fulfills physicians' and families' perceived goals and expectations. 9,13,14,20,21,[23][24][25][26][27][29][30][31][32][33][34][35][36] Thirty-day mortality for individuals with advanced dementia who receive a PEG tube ranges from 20% to 54%, with 1-year mortality reaching 90%. 18,20,[37][38][39][40] Reported 1-year postinsertion mortality was 64% in one study, with half of individuals dying within 2 months.…”

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confidence: 99%

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Percutaneous Feeding Tubes in Individuals with Advanced Dementia: Are Physicians “Choosing Wisely”?

Gieniusz

Sinvani

Kozikowski

et al. 2017

J American Geriatrics Society

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OBJECTIVES:To evaluate physician knowledge and perceptions about the American Board of Internal Medicine/ American Geriatrics Society (ABIM/AGS) Choosing Wisely recommendations regarding percutaneous endoscopic gastrostomy (PEG) in individuals with advanced dementia. DESIGN: Multicenter, mixed-mode, anonymous questionnaire. SETTING: Three tertiary and four community hospitals in New York. PARTICIPANTS: Internal medicine physicians (N = 168). MEASUREMENTS: Physician knowledge and perceptions regarding PEG tubes in individuals with advanced dementia. RESULTS: Ninety-nine percent of physicians reported having cared for someone with advanced dementia; 95% had been involved in the PEG decision-making process; 38% were unsure whether the ABIM/AGS Choosing Wisely recommendations advise for or against PEG tubes in advanced dementia. Physicians who agreed that there is enough evidence to recommend against PEG placement for individuals with advanced dementia were more likely to know the ABIM/AGS Choosing Wisely recommendations (71% vs 28%, P < .001). Fifty-two percent felt in control of the PEG placement decision, and 27% expressed concerns about potential litigation. The most common factor influencing physicians was patient or decision-maker request (70%); 63% stated that families request PEG placement even when physician would not recommend it. Only 4% of the physicians would choose to have a PEG tube if they had advanced dementia. CONCLUSION: Despite the scientific evidence supporting the ABIM/AGS Choosing Wisely recommendations against the use of PEG tubes in individuals with advanced dementia, numerous incentives for placement complicate the decision for PEG placement. In today's healthcare environment, it is incumbent upon healthcare practitioners to be aware of the available evidence and to provide leadership to guide this complex decision-making process to promote true person-centered care. J Am Geriatr Soc 66:64-69, 2018.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Percutaneous Feeding Tubes in Individuals with Advanced Dementia: Are Physicians “Choosing Wisely”?

Gieniusz

Sinvani

Kozikowski

et al. 2017

J American Geriatrics Society

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“…Currently there are no studies which show an association that artificial feeding offers benefits to the individual. On the contrary some studies have demonstrated they increase the chance of infection, aspiration, further complications (Palecek et al, 2010) and potentially mortality (Ticinesi et al, 2016). As with the limited understanding of pain in dementia we similarly have a limited understanding around feelings of hunger and thirst in people with dementia.…”

Section: Artificial Nutrition and Hydrationmentioning

confidence: 99%

Palliative Care in Dementia

Davies¹,

Klapwijk²,

Steen³

2018

Textbook of Palliative Care

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An optimal approach to palliative care for people with dementia has been defined by the European Association for Palliative Care with eleven domains including, for example: Applicability of palliative care; Person-centred care, Communication and shared decision making; Setting care goals and advance care planning. Not all people with dementia will require specialist palliative care and all involved in dementia care, should be able to provide palliative care focussing on care and treatment which aims to increase the comfort and quality of life of the individual and supporting their family. There are many complications and symptoms which may arise for someone with dementia including: increased infections, shortness of breath, swallowing difficulties and pain which the individual may not be able to clearly express. These complications can lead to difficult decisions which need to be made by not only practitioners but also family caregivers as proxy. There should be a shared decision making approach to these complications and symptoms, with advance care planning performed where possible. Caring for someone with dementia is one of the most difficult caring roles support for family caregivers as part of a palliative approach is essential. Each person with dementia is different and needs should be assessed on an individual basis, adopting a person centred approach to care.

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“…Compared to feeding via a nasogastric tube, enteral feeding via PEG can relieve laryngopharyngeal discomfort and prevent intervention failure; therefore, its use has become widespread for long-term enteral feeding in multiple patient groups including pediatric and geriatric populations [3]. However, studies have reported worse outcomes following PEG feeding in patients with dementia [4,5]; therefore, the use of PEG in elderly populations is controversial [6,7].…”

Section: Introductionmentioning

confidence: 99%

Comparison of long-term outcomes between enteral nutrition via gastrostomy and total parenteral nutrition in the elderly with dysphagia: A propensity-matched cohort study

Masaki

Kimura

2019

Preprint

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21Background 22 The long-term outcomes of artificial nutrition and hydration (ANH) in the elderly with 23 dysphagia remain uncertain. Enteral nutrition via percutaneous endoscopic gastrostomy 24 (PEG) and total parenteral nutrition (TPN) are major methods of ANH. Although both 25 can be a life-prolonging treatments, Japan has recently come to view PEG as 26 representative of unnecessary life-prolonging treatment. Consequently, TPN is often 27 chosen for ANH instead. This study aimed to compare the long-term outcomes between 28 PEG and TPN in the elderly. 29 Methods 30This single-center retrospective cohort study identified 253 elderly patients with 31 dysphagia who received enteral nutrition via PEG (n=180) or TPN (n=73) between 32 January 2014 and January 2017. The primary outcome was survival time. Secondary 33 outcomes were oral intake recovery, discharge to home, and the incidence of severe 34 pneumonia and sepsis. We performed one-to-one propensity score matching using a 0.05 35 caliper. The Kaplan-Meier method, log-rank test, and Cox proportional hazards model 36 were used to analyze the survival time between groups. 37 Results 38Older patients with lower nutritional states, and severe dementia were more likely to 39 receive TPN. Propensity score matching created 55 pairs. Survival time was significantly 40 longer in the PEG group (median, 317 vs 195 days; P=0.017). The hazard ratio for PEG 41 relative to TPN was 0.60 (95% confidence interval: 0.39-0.92; P=0.019). There were no 42 significant differences between the groups in oral intake recovery and discharge to home. 43The incidence of severe pneumonia was significantly higher in the PEG group (50.9% vs 44 25.5%, P=0.010), whereas sepsis was significantly higher in the TPN group (10.9% vs 45 30.9%, P=0.018). 46 Conclusions 47PEG was associated with a significantly longer survival time, a higher incidence of 48 severe pneumonia, and a lower incidence of sepsis compared with TPN. These results can 49 be used in the decision-making process before initiating ANH. 50 51 4 56 developed as an enteral feeding technique for pediatric patients with dysphagia [1,2]. 57Compared to feeding via a nasogastric tube, enteral feeding via PEG can relieve 58 laryngopharyngeal discomfort and prevent intervention failure; therefore, its use has 59 become widespread for long-term enteral feeding in multiple patient groups including 60 pediatric and geriatric populations [3]. However, studies have reported worse outcomes 61 following PEG feeding in patients with dementia [4,5]; therefore, the use of PEG in 62 elderly populations is controversial [6,7]. 63TPN is another common method of nutritional management [8,9]. Similar to tube 64 feeding, TPN is also occasionally used for ANH in elderly patients with dysphagia [10]. 65 Comparing the outcomes of enteral nutrition and parenteral nutrition are major concerns 66 among clinicians. Previous studies have demonstrated conflicting results among patients 67 who received enteral nutrition versus those who received parenteral nutr...

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Survival in older adults with dementia and eating problems: To PEG or not to PEG?

Cited by 38 publications

References 28 publications

Percutaneous Feeding Tubes in Individuals with Advanced Dementia: Are Physicians “Choosing Wisely”?

Percutaneous Feeding Tubes in Individuals with Advanced Dementia: Are Physicians “Choosing Wisely”?

Palliative Care in Dementia

Comparison of long-term outcomes between enteral nutrition via gastrostomy and total parenteral nutrition in the elderly with dysphagia: A propensity-matched cohort study

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