Feeding Tubes in Patients with Advanced Dementia
If you work in healthcare, you've probably had some experience with the placement of alternative sources of nutrition and hydration in patients with advanced dementia. Many patients with dementia develop dysphagia. Swallowing deficits can then lead to the recommendation of feeding tubes, but is it truly in the best interest of a patient with advanced dementia for a feeding tube to be placed? Read on to learn more.
What the Experts Say...
According to the American Geriatrics Society (2014), placement of feeding tubes for patients with advanced dementia is not recommended. In fact, they go on to tell us that the use of feeding tubes for these individuals often results in:
Increased agitation
More use of physical and chemical restraints
Feeding tube complications
The occurrence of pressure ulcers
The Alzheimer's Association (2015) states, "The Association asserts that research evidence supports no medical benefit from feeding tubes in advance dementia and that feeding tubes may actually cause harm in the advanced stages of Alzheimer's. Additionally, it is ethically permissible to withhold nutrition and hydration artificially administered by vein or gastric tube when the individual with Alzheimer's or dementia is in the end stages of the disease and is no longer able to receive food or water by mouth. The Association emphasizes that careful hand feeding offers the highest quality of care and should be offered to all individuals with advanced Alzheimers' disease who can competently and comfortably handle oral feeding. Concerted efforts are called for to educate and support professional and family caregivers in techniques of careful hand feeding."
The Alzheimer's Association (2015) further states that they recommend prospective planning be conducted with the patient and the family using advanced directives, and that the risks vs benefits of tube feeding and hand feeding be discussed in order for the individual and family to make an informed decision.
Why are Feeding Tubes Placed and Does this Apply for those with Advanced Dementia?
The intent of this blog post is not to say that feeding tubes aren't beneficial - in some cases, they are crucial tools! However, they are not appropriate for all patients. So what are some of the common reasons that feeding tubes are recommended?
According to Mitchell et al. (2000) feeding tubes are often recommended to prevent aspiration pneumonia and to prolong life. As clinicians it is our role and responsibility to work with the interdisciplinary team to determine the risk vs. the benefit for all recommendations. For those with dementia, current literature indicates that feedings tubes may not increase lenght of life or reduce the risk of aspiration pneumonia.
Again, the Alzheimer's Association (2015) provides us with insight to these topics as they tell us that research demonstrates that tube feeding does NOT usually increase length of life, improve nutritional status, OR lower occurrence of aspiration pneumonia.
So…what ARE Predictors of Aspiration Pneumonia?
So if we're being told that feeding tubes don't lower the occurrence of aspiration pneumonia, what can we as clinicians be looking for as far as risk factors go? I have good news! Langmore et al. (1998) tell us that the best predictors include:
Dependency for feeding
Dependency for oral care
The number of decayed teeth
Tube feeding
More than one medical diagnosis
The amount of medications
Smoking
Dr. John Ashford and colleagues, have conducted extensive work examining risk factors for aspiration pneumonia. A framework provided by Dr. Ashford and colleagues on the SASS website, are the Three Pillars of Aspiration Pneumonia, which include health status, oral health, and swallowing safety. The team even provides a wonderful a Pneumonia Risk Predictor chart for clinical use. To check out this wonderful resource and additional information on the Three Pillars of Aspiration Pneumonia, click here: https://www.sasspllc.com/three-pillars-pneumonia/
Clinical decision making requires critical thinking, risk vs. benefit mitigation, collaboration with colleagues, as well as education and counseling with patients so that they can make decisions that are best for them!
In Conclusion....
In my clinical experience, this is a topic that requires your time and expertise. Many family members and even healthcare professionals are unaware of the negative impacts that feeding tubes can have for patients with advanced dementia. They are making these decisions from a place of compassion and concern, however, they may be unaware of the current literature on placement of feeding tubes in those with advanced dementia. It is our job as healthcare professionals to advocate for our patients, and to provide the most current research to all members of the interdisciplinary team.
As always, I appreciate you being here with me. Please reach out to me with any questions or concerns.
References
American Geriatrics Society (2014). American Geriatrics Society feeding tubes in advanced dementia position statement. Journal of American Geriatrics Society, 62(8), 1590-1593.
Alzheimer's Association (2015). Alzheimer's Association feeding issues in advanced dementia [Position statement]. https://www.alz.org/media/Documents/feeding-issues-statement.pdf
Langmore, S., Terpenning, M., Schork, A. et al. Predictors of Aspiration Pneumonia: How Important Is Dysphagia?. Dysphagia13, 69–81 (1998). https://doi.org/10.1007/PL00009559