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

Gieniusz, Marzena; Sinvani, Liron; Kozikowski, Andrzej; Patel, Vidhi; Nouryan, Christian; Williams, Margaret A.; Kohn, Nina; Pekmezaris, Renée; Wolf‐Klein, Gisele

doi:10.1111/jgs.15125

Cited by 39 publications

(32 citation statements)

References 54 publications

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“…Other studies also report significant higher risk of in-hospital mortality after PEG placement [71][72][73]. A 30-day mortality risk in tube-fed individuals with advanced dementia may vary from as high as 20% to 40% [43,74].…”

Section: Other Burdens and Complicationsmentioning

confidence: 97%

“…e nonsuperiority of tube feeding over oral feeding is supported further in a recent study that evaluated the knowledge and perceptions of 168 physicians about PEG feeding in advanced dementia individuals. e authors report that 71% of the physicians believed careful hand feeding is almost as good as tube feeding for the outcome of comfort, and nearly half (49%) of them believed nutritional status rarely improves with tube feeding [43]. Comparatively, the general consensus among gastroenterologists in the USA is that PEG placement is not beneficial for patients with advanced dementia [44].…”

Section: Burdens Of Tube Feeding In People With Advanced Dementiamentioning

confidence: 99%

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Tube Feeding in Individuals with Advanced Dementia: A Review of Its Burdens and Perceived Benefits

Ijaopo

2019

Journal of Aging Research

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Background. Dementia remains a growing concern for societies globally, particularly as people now live longer. About 90% of individuals with advanced dementia suffer from eating problems that lead to general health decline and ultimately impacts upon the physical, psychological, and economic wellbeing of the individuals, caregivers, and the wider society. Objective. To evaluate the burdens and perceived benefits of tube feeding in individuals with advanced dementia. Design. Narrative review. Methods. Computerized databases, including PubMed, Embase, Medline, CINAHL, PsycInfo, and Google Scholar were searched from 2000 to 2019 to identify research papers, originally written in or translated into English language, which investigated oral versus tube feeding outcome in individuals with advanced dementia. Results. Over 400 articles were retrieved. After quality assessment and careful review of the identified articles, only those that met the inclusion criteria were included for review. Conclusion. Tube feeding neither stops dementia disease progression nor prevents imminent death. Each decision for feeding tube placement in individuals with advanced dementia should be made on a case-by-case basis and involve a multidisciplinary team comprising experienced physicians, nurses, family surrogates, and the relevant allied health professionals. Careful considerations of the benefit-harm ratio should be discussed and checked with surrogate families if they would be consistent with the wishes of the demented person. Further research is required to establish whether tube feeding of individuals with advanced dementia provides more burdens than benefits or vice-versa and evaluate the impacts on quality of life and survival.

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Section: Other Burdens and Complicationsmentioning

confidence: 97%

Section: Burdens Of Tube Feeding In People With Advanced Dementiamentioning

confidence: 99%

Tube Feeding in Individuals with Advanced Dementia: A Review of Its Burdens and Perceived Benefits

Ijaopo

2019

Journal of Aging Research

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“…Fifteen years later, a US group found in their study (2018) among 168 medical doctors that over a third of the interviewees was (partially) unaware of the recommendations stated by the American Board of Internal Medicine/American Geriatrics Society Choosing Wisely recommendations. Two‐third of physicians stated that family of the patient often requested a PEG insertion, against medical recommendations …”

Section: Resultsmentioning

confidence: 99%

“…Two-third of physicians stated that family of the patient often requested a PEG insertion, against medical recommendations. 26 Lack of knowledge regarding course of dementia. In a study in the USA, 323 nursing home residents, identified with advanced dementia, were followed for a period of 18 months; 54.8% died within the study period.…”

Section: Ethical Considerationsmentioning

confidence: 99%

Percutaneous endoscopic gastrostomy in older patients with and without dementia: Survival and ethical considerations

Bruchem-Visser

Mattace-Raso

Beaufort

et al. 2019

J of Gastro and Hepatol

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Background and Aim Notwithstanding multiple recommendations in guidelines, percutaneous endoscopic gastrostomy (PEG)‐tube placement is still performed in patients with dementia. In this study, we aim to investigate survival in patients with and without dementia after PEG‐tube placement. Methods We conducted a retrospective multicenter study in four different hospitals in the Netherlands. Furthermore, we explored the ethical considerations that may play a role in the decision whether or not to insert a PEG tube in a patient with dementia. Results Three‐hundred‐and‐three patients were included, mean age of 77.4 years. Forty‐two (13.9%) patients had dementia. Short‐term complications did not differ between patients with and without cognitive disorders (P 0.224). However, patients with dementia survived significantly shorter after PEG placement than did patients without dementia. Adjusted for age and sex, patients with dementia had a 49% increased risk of mortality (hazard ratio 1.49, 95% confidence interval 1.01–2.19). In our exploratory literature search, we found that several ethical concerns and considerations play a role in the decision process of PEG placement. These considerations are both medical and nonmedical and include beliefs regarding the benefits of a PEG tube, a lack of knowledge about the natural course of dementia in both professionals and family of patients, and a fear of letting a patient die hungry. Conclusions Patients with dementia had higher mortality rates after PEG placement than patients without dementia. Although multiple ethical concerns and considerations play a role, insertion of a PEG tube in patients with dementia is not appropriate.

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“…According to studies, placement of PEG tube in patients with advanced dementia not only leads to immediate post procedural complications but also does not signi cantly improve nutritional status, rates of re-hospitalization and short-or long-term mortality [5,6,7,8,9,10] . In compliance to choose wisely campaign launched by the American Board of Internal Medicine Physicians (ABIM), the American Geriatric Society (AGS) made an evidence-based recommendation in 2013 which stated, "Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding" [11,12] . In our retrospective study, we analyzed the racial and socio-economic disparities among different ethnic groups regarding the PEG tube placement.…”

Section: Introductionmentioning

confidence: 99%

Racial and Socioeconomic Disparities in Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement among elderly patients with dementia in the United States from the National inpatient sample

Kochar

Abugroun

Nayyar

et al. 2020

Preprint

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Background Placement of percutaneous endoscopic gastrostomy (PEG) tube in patients of advanced dementia has not been shown to improve nutritional status or mortality. The objective is to assess racial and socioeconomic disparities for PEG tube placement from National Inpatient Sample. Methods In a cross-sectional study, the National inpatient sample (NIS) registry was queried for all patients aged ≥ 70 who were diagnosed with dementia during the year 2016. Patients with dementia were identified using the Tenth revision (ICD-10) codes (F0150, F0151, F0280, F0281, F0390, F0391, G300, G301, G308, G309, G3109, G3183). Patients who received PEG tube were identified using ICD-10 diagnosis codes (Z431). Multivariable logistic regression models were utilized to determine the likelihood of PEG tube placement with adjustment for Patients demographics, socioeconomic factors, degree of frailty and comorbidities. Results Out of 1,745,028 patients with dementia, 35,075 patients had PEG tube placed. Majority of patients who received PEG tube were females (54.8%), of white race (45.5%) with a mean age of 82.3 years (SEM 0.02). Compared to controls, those who had PEG tube placement were more frail, had higher prevalence of chronic lung disease, diabetes, stroke, psychosis and nutritional deficiency anemias. On multivariable analysis, higher risk for PEG tube placement was seen in African Americans and Hispanics compared to Caucasians with a-OR 3.76 [95%CI: 3.47–4.07], p < 0.001 and 2.59 [95%CI:2.33–2.88], p < 0.001 respectively. A higher risk was also seen in patients with low income with a-OR 1.1(95%CI: 1.04–1.19), p = 0.002 and among those having Medicaid compared to Medicare insurance with a-OR 1.53 [95%CI: 1.30–1.80], p < 0.001. Compared to males, females were found to have low chances for PEG tube placement with a-OR: 0.78 [95%CO:0.74–0.82], p < 0.001. Hospital ownership, bed size and teaching status were found to have no impact on PEG tube utilization. Conclusion Despite the evidence against placement of PEG tubes in dementia patients, our findings confirm that PEG tubes are still being placed in frail and demented elderly. Apart from these, elderly patients with low income, African American origin and Medicaid enrollees have higher incidence of PEG tube placements. Efforts are needed to educate clinicians and community about worse outcomes of PEG tube placement in advanced dementia.

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

Cited by 39 publications

References 54 publications

Tube Feeding in Individuals with Advanced Dementia: A Review of Its Burdens and Perceived Benefits

Tube Feeding in Individuals with Advanced Dementia: A Review of Its Burdens and Perceived Benefits

Percutaneous endoscopic gastrostomy in older patients with and without dementia: Survival and ethical considerations

Racial and Socioeconomic Disparities in Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement among elderly patients with dementia in the United States from the National inpatient sample

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