High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding. Tube feeding in the demented elderly with severe disabilities. Survival of a cohort of elderly patients with advanced dementia: nasogastric tube feeding as a risk factor for mortality. Long-term enteral feeding of aged demented nursing home patients. Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment.
The influence of tube feeding on survival in hospitalized patients with advanced dementia is controversial.
                To assess long-term survival in an inception cohort, incident tube feeding placement during the index hospitalization, and the influence of tube feeding on survival in this group of patients.
                Ninety-nine hospitalized patients with advanced dementia and an available surrogate decision maker were followed up through and after the index hospitalization for mortality and placement of a feeding tube. Other variables measured included advance directive status, presence of a long-term primary care physician, level of involvement of the surrogate decision maker, admitting diagnosis, prior hospitalizations, comorbidities, and diagnosis related group diagnostic category.
                A new feeding tube was placed in 50% (51/99) of the study patients during the index hospitalization, 31% (31/99) left the hospital without a feeding tube, and 17% (17/99) were admitted with a feeding tube already in place. By stepwise logistic regression analysis, predictors of new feeding tube placement included African American ethnicity (odds ratio, 9.43; 95% confidence interval, 2.1-43.2) and residence in a nursing home (odds ratio, 4.9; 95% confidence interval, 1.02-2.5). Median survival of the 99 patients was 175 days. Eighty-five (85%) survived the index hospitalization, and 28 (28%) were still alive at last follow-up, a range of 1.3 to 4.2 years after enrollment in the study. Tube feeding was not associated with survival (P =.90). An admitting diagnosis of infection was associated with higher mortality (odds ratio, 1.9; 95% confidence interval, 1.01-3.6).
                In this cohort of hospitalized patients with advanced dementia, risk of receiving a new feeding tube is high, associated with African American ethnicity, and prior residence in a nursing home, and has no measurable influence on survival. With or without a feeding tube, these patients have a 50% six-month median mortality. Despite the ongoing debate on tube feeding of severely demented patients, the current approach in western countries is to avoid feeding by tube.
                To assess the clinical course and outcome of demented elderly patients with severe disabilities, by feeding mode.
                The study was conducted in a skilled nursing department of a major psychogeriatric hospital in Israel. Eighty-eight patients aged 79 +/- 9 years were followed for 17 months: 62 were fed by nasogastric tube and 26 were orally fed. The groups were compared for background characteristics, underlying medical condition, functional impairment, clinical and nutritional outcomes, and survival.
                Tube feeding had no beneficial effect on clinical and nutritional outcomes or on healing preexisting pressure ulcers, compared with oral feeding. Very few patients on tube feeding showed signs of discomfort, partly because of low cognitive function. Survival was significantly higher in the tube-fed patients (P < 0.001), which could be partly explain by the different case mix (i.e., the underlying diseases)
                Tube feeding seems to have no nutritional advantage in severely demented elderly patients. Median survival was longer in tube-fed individuals who had no acute co-morbidity. However, since tube feeding does not add to patient pain and discomfort, it should not be contraindicated when it complies with the values and wishes of patients and their families. To evaluate and identify factors determining survival in elderly patients with advanced dementia.
                A prospective, follow-up, observational analysis in a cohort of 67 community-based patients aged 65 years or older with dementia defined by DSM-IV and stage 7A or above on the FAST scale. Data were recorded on socio-demographic variables, FAST, Katz index, language, swallowing ability, diet, nutritional status (from anthropometric and laboratory data), associated diseases and medical complications during the previous 12 months. Survival was analyzed by the Kaplan-Meier method. Prognostic factors for survival were identified by the Cox proportional hazards regression model.
                The median follow-up was 832 days. The mean age was 82.2+/-6.7 years and 92.5% were women. A comorbid condition was present in 71.6%, most frequently hypertension (22.4%). A clinical event had occurred in 52 (77.6%) patients during the previous year (pneumonia, urinary infection, stroke, pressure sore, dehydration, sepsis or others). A total of 25 (37.3%) patients died. The mean survival was 676 days (95% confidence interval, 600-752 days). Cox proportional hazards model showed that independent prognostic factors for mortality were having pneumonia within the previous year (RR:3.7; p=0.001), a permanent nasogastric tube (RR:3.5; p=0.003) and serum albumin values below 3.5 g/dL (RR:2.9; p=0.028).
                In patients with advanced dementia, hypoalbuminemia and pneumonia are strongly and positively associated with mortality. Artificial nutrition via a nasogastric tube reduces survival in these patients.
                Copyright 2005 John Wiley & Sons, Ltd. The terminal phase of dementia is initiated by the inability to swallow. New techniques of enteral alimentation permit more effective, longer intubation. To assess the application of these new techniques to late-stage demented aged patients, all current intubations in a teaching nursing home were reviewed. Of 52 feeding intubations, 26 had been in situ for more than 1 year. A randomly selected comparison group of nonintubated patients was also studied. Weight increased for 48% of the intubated group versus 17% of the nonintubated group (P less than .01). Aspiration pneumonia occurred more often in the intubated group (58%) than in the nonintubated group (17%) (P less than .01). Decubitus ulcers were also more common in the intubated group (21%) than in the nonintubated group (14%). Restraints were used more in the intubated group (71%) than in the nonintubated group (56%). These differences did not reach statistical significance. All of the intubated patients were severely demented, with MMSE scores of zero. Seventy-one percent of the nonintubated group were demented, with MMSE scores of less than 23. Prolongation of the terminal phase of dementia in the aged by tube feeding is now feasible. The implications of this change in the life-span of demented nursing home patients need attention by families, nursing homes, and those who make public health policy. Percutaneous endoscopic gastrostomy (PEG) is widely used for long-term enteral nutrition in patients with dementia and inadequate oral intake, although its benefit in prolonging the survival of the patient is not clear. Patients are often referred for PEG placement after a significant weight loss or fall in serum albumin. It is not known whether this delay in referral adversely affects the survival. Our aim was to determine the survival after PEG placement in patients with inadequate oral intake secondary to cognitive impairment and to determine whether-the nutritional parameters at the time of placement of PEG predict survival.
                After excluding patients with cancer, cerebrovascular accident (CVA), and anoxic encephalopathy, 56 consecutive patients with dementia and inadequate oral intake were included in the study. The following parameters were analyzed to predict survival benefit: demographics, reason for admission to the hospital, nutritional indices, Karnofsky performance status before and after PEG, comorbid medical illnesses, and complications after PEG. A control group was selected from patients admitted to the geriatric division who did not receive PEG. Patients with CVA, cancer, and anoxic encephalopathy were also excluded in the control group. Both groups were followed-up for 6 months.
                One patient was lost to follow-up and complete data were available for 55 patients. The control group of 33 patients was comparable to the patients in age, gender, and comorbid illnesses. During a 6-month follow-up period, the mortality was 44% among patients and 26% among controls (p = 0.03). The only factor that predicted poor survival in patients at 6 months was a serum albumin of <2.8 g/dl. The predictive value of low serum albumin was higher in patients with sepsis on hospital admission and in patients younger than 85 yr. The mean serum albumin of the patients was significantly lower than the control group (p = 0.0001).
                Only 50% of demented patients with inadequate oral intake are likely to survive beyond 6 months after PEG placement. No improvement in performance status is likely to occur in any patient. These limited benefits should be realized before initiating PEG feeding. Since the survival in the age-matched control group with a higher mean serum albumin was better than in the patients who had PEG, there may be some benefit in performing PEG before the onset of severe hypoalbuminemia. Artificial feeding by a percutaneous endoscopic gastrostomy (PEG) tube in patients with dementia has increased since the introduction of the endoscopic method of tube placement. Few studies have documented survival benefit from this intervention. This report reviews our experience with PEG tube placement for feeding patients with dementia.
                All consultations for PEG tube placement were evaluated by a certified nutrition support nurse (L.M.M.) in consultation with a member of the gastroenterology physician staff (T.O.L.) for 24 months. Evaluation included the attainment of a brief medical history, a physical examination, and a review of comorbid conditions, laboratory variables for nutrition status, and bleeding risk. Interviews with patients or surrogates were conducted, including an explanation of the risks and benefits of PEG tube placement. A Kaplan-Meier survival curve was used to compare the median survival between patients with dementia who received a PEG tube and patients with dementia in whom PEG tube placement was refused.
                We received 41 consultations for PEG tube placement in patients with dementia. Percutaneous endoscopic gastrostomy was performed in 23 patients; 18 patients met the medical criteria for PEG tube placement, but surrogates refused placement. The median survival for the 23 patients who underwent PEG was 59 days; the median survival for the 18 patients who did not undergo PEG was 60 days.
                There seems to be no survival benefit in patients with dementia who receive artificial feeding by a PEG tube. The provision of artificial enteral nutrition to an aged person with severe cognitive impairment is a complex dilemma in the long-term care setting.
                To determine the risk factors and impact on survival of feeding tubes in nursing home residents with advanced cognitive impairment.
                We conducted a cohort study with 24-month follow-up using Minimum Data Set resident assessments on 1386 nursing home residents older than 65 years with recent progression to severe cognitive impairment in the state of Washington. Residents within this population who underwent feeding tube placement were identified. Clinical characteristics and survival for a period of 24 months were compared for residents who were and were not tube fed.
                Among the residents with recent progression to severe cognitive impairment, 9.7% underwent placement of a feeding tube. Factors independently associated with feeding tube placement included age younger than 87 years (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.25-2.78), aspiration (OR, 5.46; 95% CI, 2.66-11.20), swallowing problems (OR, 3.00; 95% CI, 1.81-4.97), pressure ulcer (OR, 1.64; 95% CI, 1.23-2.95), stroke (OR, 2.12; 95% CI, 1.17-2.62), less baseline functional impairment (OR, 2.07; 95% CI, 1.27-3.36), no do-not-resuscitate order (OR, 3.03; 95% CI, 1.92-4.85), and no dementia (OR, 2.17; 95% CI, 1.43-3.22). Survival did not differ between groups of residents with and without feeding tubes even after adjusting for independent risk factors for feeding tube placement.
                There are specific risk factors associated with feeding tube placement in nursing home residents with severe cognitive impairment. However, there is no survival benefit compared with similar residents who are not tube fed. These prognostic data are important for health care providers, families, and patients making decisions regarding enteral nutritional support in long-term care.
Despite the very large number of patients receiving this intervention, there is insufficient evidence to suggest that enteral tube feeding is beneficial in patients with advanced dementia. Data are lacking on the adverse effects of this intervention.