Reducing Feeding Tube Insertions in Advanced Dementia Patients

Abstract

Dysphagia is common in advanced dementia patients (ADP) and usually worsens as the disease progresses. It is often complicated by dehydration and malnutrition, and is a common cause of aspiration pneumonia, one of the leading causes of death in these patients. Over the past two decades, numerous studies have discouraged the use of enteral nutrition (EN) in ADP, as there is no evidence that tube feeding improves nutritional status, prolongs survival, or reduces the risk of pressure ulcers. Additionally, weight loss often continues despite EN, and laboratory nutritional markers frequently show no improvement. Moreover, in ADP, the use of a feeding tube clearly leads to a decline in quality of life. Accordingly, the 2024 European guidelines on nutrition and hydration recommend that EN should not be initiated in ADP.

In June 2017, we implemented a clinical pathway to avoid EN in patients with ADP. Initially, we conducted informational sessions with various specialties to introduce the protocol. Subsequently, we reviewed hospital discharges of patients with ADP, analyzing whether EN was initiated during admission, either via nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG). In the second half of 2015, before the protocol was implemented, EN was initiated during admission in 16 patients with ADP. After implementation, EN was initiated in 1 patient in the second half of 2017 and in 2 patients in the second half of 2021. All differences (NGT, PEG, and total) were statistically significant when comparing 2017 and 2021 with 2015.

Numerous studies have shown that enteral feeding in these patients does not increase life expectancy, improve nutritional status, reduce the risk of aspiration, or reduce the prevalence of pressure ulcers, but rather clearly impairs their quality of life. Therefore, feeding tubes in patients with ADP may serve as an indicator of poor-quality healthcare.