1. Tube Feeding Alia Tuqan, M.D.

2. Goals and Objectives Review the types of tube feedings Understand indications for tube feedings Discuss risk and benefits of tube feedings in dementia and palliative care patients

3. Types Nasogastric (NG) tubes ▫For shorter-periods of time, no more than 2 weeks, typically ▫Often seen in critically-ill patients Percutaneous endoscopic gastrostomy (PEG) tubes ▫For longer periods of time ▫Often seen in post-stroke and ALS patients

4. Indications Short-stay, critically-ill patients Post-stroke patients with dysphagia Patients with good functional status who have cancers causing proximal obstructions Patients undergoing chemotherapy and radiation for cancers in the upper GI tract or head and neck ALS patients Shiga, 2012

5. Tube Feeding in Dementia Dementia gets to a terminal condition Patients with advanced dementia lose the ability to eat and develop dysphasia, which is associated with malnutrition, electrolyte disturbances, aspiration, pneumonia, and death Mitchell et al, 2009 looked at nursing home patients with dementia ▫85.8% had an “eating problem” ▫6-month mortality for residents with an “eating problem” was 38.6%

6. Tube Feeding in Dementia Artificial nutrition does not improve quality of life, morbidity or mortality in patients with advanced dementia Sampson et al, 2009 completed a meta-analysis ▫“no conclusive evidence that enteral tube nutrition is effective in terms of prolonging survival, improving quality of life, or leading to better nourishment or decreasing the risk of pressure sores” ▫May increase risk of aspiration, pneumonia and death

7. Tube Feeding in Dementia Teno et al, 2012 looked at nursing home patients with severe cognitive impairment who had been hospitalized within the last year ▫Patients who had PEGs were almost 2 times more likely to develop pressure ulcers than patients who did not (35.6% v 19.8%) ▫Patients who had PEGs were less likely to see improvement in pressure ulcers than patients who did not (27.1% v 34.6%) Patients who have feeding tubes may have diarrhea, leading to skin breakdown, and may have to be physically and chemically restrained, leading to immobility and skin breakdown

8. Tube Feeding in Dementia Meier et al, 2001 ▫6-month mortality was the same in patients with advanced cognitive impairment who received a feeding tube during hospitalization and those who did not (195 days v 189 days) Murphy et al, 2003 ▫Median mortality was the same in patients with dementia who received PEGs and those who did not (59 days v 60 days)

9. PEG Tube Side Effects in Dementia Pain Infection Bleeding Malfunctioning Aspiration Diarrhea Physical and chemical restraints Immobility Pressure ulcers Decreased socialization

10. Hand Feeding in Dementia Eliminates side-effects associated with tube feeding Allows for comfort Relieves hunger and thirst Allows for socialization

11. Goals of Care Patients should discuss with their care team early on wishes for artificial tube feeding Patients with dementia may wish to document goals for long term wishes Plan of care should be discussed with power of attorney, family and physician

12. Sources Thomas E. Finucane, Coleen Christmas, and Kathy Travis. Tube Feeding in Patients with Advanced Dementia: a Review of the Evidence. JAMA. 1999; 282(14): 1365-1370. James Hallenbeck. #10 Tube Feed or Not Tube Feed?, 2 nd Edition. Fast Facts and Concepts. End of Life/Palliative Education Resource Center, Medical College of Wisconsin. Ina Li. Feeding Tubes in Patients with Severe Dementia. American Family Physician. 2002; 65(8): 1605-1608. Diane E. Meier, Judith C. Ahronheim, Jane Morris, Shari Baskin-Lyons, and R. Sean Morrison. High Short-term Mortality in Hospitalized Patients with Advanced Dementia. Arch Intern Med. 2001; 161: 594-599. Susan L. Mitchell, Joan M. Teno, Dan K. Kiely, Michele L. Shaffer, Richard N. Jones, Holly G. Prigerson, Ladislav Volicer, Jane L. Givens, and Mary Beth Hamel. The Clinical Course of Advanced Dementia. JAMA. 2009; 361(16): 1529-1538. Lynne M. Murphy and Timothy O. Lipman. Percutaneous Endoscopic Gastrostomy Does Not Prolong Survival in Patients with Dementia. Arch Intern Med. 2003; 163: 1351-1353. Eric J. Palecek, Joan M. Teno, David J. Casarett, Laura C. Hanson, Romona L. Rhodes, and Susan L. Mitchell. Comfort Feeding Only: A Proposal to Bring Clarity to Decision-Making Regarding Difficulty with Eating in Persons with Advanced Dementia. JAGS. 2010; 58(3): 580-584. E. L. Sampson, B Candy, and L Jones. Enteral tube feeding for older people with advanced dementia (Review). The Cochrane Library. 2009; 2: 1-25. Joseph Shiga. Dementia. AAHPM Intensive Board Review Course DVD. 2012. Joan M. Teno, Pedro Gazalo, Susan L. Mitchell, Sylvia Kuo, Ana T. Fulto, and Vincent Mor. Feeding Tubes and the Prevention or Healing of Pressure Ulcers. Arch Intern Med. 2012; 172(9): 697- 701.