Mortality is high in patients with severely abnormal swallowing studies.11 The reasons commonly used to start tube feeding—preventing aspiration pneumonia, to improve quality of life, and to improve functional status—have not been proven in patients with severe dementia.12 In addition, PEG tube feeding does not provide survival benefits in this group of patients, either.13 Therefore, carefully consider tube feeding in older adults with advanced dementia. Some authorities even discourage the widespread use of PEG tubes for patients who suffer from advance dementia.12
For Mrs. H, additional resources that can be used to facilitate her care include geriatric or palliative consult services, chaplaincy, or ethics committee consultations. If the decision is made to place a PEG tube, a time-limited trial with functional and cognitive goals can follow. On the other hand, if the decision of not placing a PEG tube is reached, allowing Mrs. H to eat and drink freely—even if aspiration risk is present—is an alternative. Comfort measures independent of the decision can always be provided. Families who decide against PEG tube placement can be expected to second-guess their decision and will need continued team support.
PEG Indications and Benefits
A PEG tube should be considered for older adults who have a functional gastrointestinal tract but are unable to consume sufficient oral intake to meet their nutritional needs. Frequent indications for PEG placement include impaired swallowing associated with neurological conditions such as cerebrovascular accident and neoplastic diseases or trauma of the oropharynx, larynx, and esophagus. Other but infrequent use of PEG tube is for gastric decompression in selected patients with gastrointestinal tract obstruction.
For some older adults, PEG tube feeding can provide long-term enteral nutrition and hydration with low risk for complications. It can also provide psychological benefits for patients and family members. These benefits include helping them to avoid guilt about deciding to withhold non-oral feedings and by providing hope for future clinical improvement.
PEG tubes appear to be beneficial as a nutritional treatment of choice for patients with acute dysphagic stroke and for some older adults with neoplastic diseases of the oropharynx, larynx, and esophagus. PEG tubes appear inappropriate for patients with a rapidly progressing incurable illness. PEG tube feeding has not been proven to improve quality of life, symptoms of thirst, or survival across the population of older adults at the end of life.
Burdens and Risks of PEG Tube Nutrition
Adverse effects of PEG tubes include wound infections, abdominal pain, aspiration, obstruction of the feeding tube, and agitation. After PEG tube feeding begins, some older adults become agitated and attempt to remove the tube. They may even require chemical and physical restraints for behavioral control.14 A nursing home study found that after PEG tube placement, older adults did not experience functional improvement. PEG-related complications occurred in close to 30% of the patients and the one-year mortality rate was 50% after tube placement.15
About a quarter of patients will have a complication, such as tube occlusion, wound infection, pain, aspiration pneumonitis, and peritonitis, after the PEG tube is placed.16 Aspiration occurs frequently after PEG tube placement and can occur in up to half of older patients with feeding tubes regardless of whether nasogastric or gastric tubes are used.14,17 Some predictors of early mortality after PEG tube placement are age (75 and older), diabetes mellitus, low body mass index, low albumin, COPD, confusion, and advanced cancer.18,19
In a study of Medicare beneficiaries following gastrostomy placement, the in-hospital mortality rate was 15.3%, and the one-year mortality rate was close to 60%.19 In patients after dysphagic stroke, the in-hospital mortality and one-year mortality rates were close to 25% and 50%, respectively after PEG tube placement.20 The mortality rate and the rate of complications, however, will mainly depend on the primary disease. For example, Mrs. H has a poor prognosis independent of PEG tube placement. For some older adults, PEG tubes have shown to have more benefits—especially for those with good functional status, and proximal GI obstruction due to cancer.