Feeding Tubes in Dementia

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Teno JM, et al. "Does feeding tube insertion and its timing improve survival?". J Am Geriatr Soc. 2012. 60(10):1918-1921.
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Clinical Question

Among nursing home residents in the U.S. with cognitive impairment from dementia who develop eating problems, does the placement of a percutaneous endoscopic gastrostomy (PEG) tube affect survival? Additionally, does the time from onset of eating problems to PEG tube insertion affect survival?

Bottom Line

For nursing home patients with feeding difficulties secondary to dementia, this observational study found no association between PEG tube placement and survival. It also concludes that placing a PEG tube earlier does not affect post-treatment survival.

Major Points

The onset of progressive difficulty eating marks a stage of advanced dementia where maintaining nutritional status becomes a challenge and presents caregivers with the decision to continue oral feeding by hand or to place a long-term feeding tube like a percutaneous endoscopic gastrostomy (PEG) tube. In these patients PEG tube placement has presumed benefits of preventing aspiration, improving malnutrition, alleviating hunger and thirst symptoms, and increasing survival. However, a 2009 systematic review found seven observational studies which showed no evidence of increased survival, but raised concerns of selection bias.and questions of whether earlier placement would show benefit.

This large nationwide cohort study included 34,492 nursing home patients with advanced dementia requiring eating assistance in 2012, following interventions and outcomes during the year following documented onset of feeding difficulty. The primary exposure was whether a feeding tube was placed in the first year after onset of difficulty eating, and the primary outcomes were survival time after onset of feeding difficulty, and survival after placement of feeding tube.The sample was 78.1% female, and 8.2% African American, and 5.4% of patients received a feeding tube during that year. Overall, African Americans (6.9% of cohort without feeding tube vs. 30.7% of cohort with) and Hispanics were more likely to have a feeding tube, and a larger proportion of those without feeding tubes had documented advanced care planning, like a DPOA for Healthcare (41.9% of cohort without feeding tube vs. 22.8% of those with).

The median survival after development of needing assistance in eating for those with a PEG feeding tube was 177 days. Propensity score weighting was used to control for patient and advance care planning characteristics. In adjusted analyses, no association was found between insertion of PEG feeding tube and survival (AHR 1.03, 95%CI: 0.94-1.13). In a second analysis, the authors compared post-PEG tube placement survival with adjusted survival curves among those who had feeding tubes placed at 1, 2, 3, and >3 months, with no significant difference found between the groups (1 month vs. >3 months AHR 1.01 95%CI:0.86-1.20). The study concludes that the neither the placement of a PEG feeding tube nor the timing of insertion improve survival in nursing home patients with advanced dementia.

Design

  • Multicenter cohort study
  • N=36,492
    • Without feeding tube (n=34,536)
    • Feeding tube inserted within 1 year of difficulty feeding (n=1,956)
      • Inserted one month after need for eating assistance (n=569)
      • Inserted two months after need for eating assistance (n=310)
      • Inserted three months after need for eating assistance (n=205)
      • Inserted four or more months after need for eating assistance (n=872)
  • Setting: All U.S Nursing Homes
  • Enrollment: Utilized data from Medicare Claims files and the Minimum Data Set (MDS), 1999-2007
  • Follow-up time: Cohort followed for 1 year
  • Primary outcome: Survival time in days
  • Covariates included in propensity score weights for multivariate analysis: socio-demographic variables, advance care planning (DNR, DNH, feeding restrictions), and clinical characteristics (diagnoses, clinical conditions, functional status, and disease severity measures).

Population

Inclusion Criteria

  • US Nursing Home resident.
  • Diagnosis of dementia.
  • Cognitive Performance Score of 6 for the first time (with a prior score of 4 or 5) from 1999 to 2007.

Exclusion Criteria

  • Comatose.
  • Death within two weeks of MDS assessment
  • Evidence of PEG feeding tube in prior six months.

Baseline Characteristics

Without PEG feeding tube vs. With PEG feeding tube

(P<0.001 for all variables listed)

  • Mean age, years: 85.0 vs 83.1
  • Female, %: 79 vs. 71
  • African-american, %: 7 vs. 31
  • Documentation of advance care planning:
    • DPOA (Health Care), %: 42 vs. 23
    • Living Will, %: 24 vs. 10
    • DNR Order, %: 74 vs. 36
    • DNH Order, %: 7 vs. 1
  • Weight loss, %: 23 vs. 27
  • Swallowing problems, %: 32 vs. 39
  • Mean ADL score: 26.2 vs 26.5


Interventions

  • Followed patients for one year after transition from CPS of 4 or 5 to CPS of 6, indicating difficulty feeding due to dementia.
  • 5.4% of residents received a feeding tube within 1 year of need for assistance in eating.

Statistical Analysis

  • Propensity score weighting multivariable model
  • Covariates in the model included:

- Sociodemographic variables

- Evidence of advance care planning including advance directives

- Pertinent medical diagnoses

- Clinical conditions including dehydration, inability to consume food/fluids, fever, would infection, weight loss, swallowing problems, chewing problems, syringe feeding, mechanically altered diet, and dietary supplementation, body mass index, and presence of pressure ulcer.

- Measures of functional status and disease severity including Activities of Daily Living score and two models that predict mortality (ADEPT score and CHESS score).

Outcome

Median survival time during 1 year following documentation of CPS of 6, comparing those who received a PEG feeding tube vs. those who did not.

Primary Outcomes

No difference in survival from development of need for assistance in eating

Median survival for those with a PEG feeding tube: 177 days.
Adjusted hazard ratio for PEG feeding tube placement vs. those without: 1.03 95% 0.94-1.13

Subgroup Analysis

No difference in adjusted survival after feeding tube placement between cohorts of time-to-tube-placement (1, 2, 3, and >3 months post onset of feeding difficulties).

For PEG tube placement in month 1 vs. after 3 months: AHR 1.01 (95% CI 0.86-1.20)
For PEG tube placement in month 2 vs. after 3 months: AHR 1.12 (95% CI 0.93-1.35)
For PEG tube placement in month 3 vs. after 3 months: AHR 0.82 (95% CI 0.64-1.04)

Criticisms

  • Unadjusted survival time is reported only for those who received a PEG feeding tube; not for those without a feeding tube, nor for those within each subgroup analysis (placement at 1, 2, 3, 4+ months), limiting comparison between groups, and assessment of competing risk from dying before PEG feeding tube could be placed, which would bias the unexposed group to appear more sick than they were for the research question of whether to place tube.
  • Components of the propensity score weighting for the adjusted survival model are listed but their relative contributions are not given, limiting assessment of whether confounders and selection biases for PEG tube placement were appropriately controlled. Similarly, hospital characteristics have been associated with feeding tube placement (Teno et al., "Hospital characteristics associated with feeding tube placement in nursing home residents with advanced cognitive impairment." JAMA 2010) but were not taken into account in this model.
  • Sub-group analysis of time-to-tube-placement cohorts reports a different outcome (survival from tube placement) than the primary analysis (survival from need for feeding assistance), which creates two conclusions that do not completely agree. The primary analysis finds no survival benefit to PEG tube insertion, and the subgroup analysis finds that early insertion of feeding tubes is not associated with a longer survival. Thus these analyses also suggest that a consistent survival time is observed after insertion, and that delayed insertion would is associated with longer overall survival from onset of need for feeding assistance.

Funding

National Institute of Aging Research Grants R01 AG024265 and 1RC1 AG036418-01.

Further Reading

American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American Geriatrics Society feeding tubes in advanced dementia position statement. J Am Geriatr Soc 2014;62:1590–1593

Teno JM, Mitchell SL, Gozalo PL, Dosa D, Hsu A, Intrator O, Mor V. "Hospital characteristics associated with feeding tube placement in nursing home residents with advanced cognitive impairment." JAMA 2010 Feb 10;303(6):544-50.

Sampson EL, Candy B, Jones L. "Enteral tube feeding for older people with advanced dementia." Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007209.