Tube feeding in the demented elderly with severe disabilities
Department of Skilled Geriatric Nursing, Herzog Hospital, Jerusalem, Israel, Affiliated to Hebrew University-Hadassah Medical School, Jerusalem, Israel. The Israel Medical Association journal: IMAJ
(Impact Factor: 0.9).
Despite the ongoing debate on tube feeding of severely demented patients, the current approach in western countries is to avoid feeding by tube.
To assess the clinical course and outcome of demented elderly patients with severe disabilities, by feeding mode.
The study was conducted in a skilled nursing department of a major psychogeriatric hospital in Israel. Eighty-eight patients aged 79 +/- 9 years were followed for 17 months: 62 were fed by nasogastric tube and 26 were orally fed. The groups were compared for background characteristics, underlying medical condition, functional impairment, clinical and nutritional outcomes, and survival.
Tube feeding had no beneficial effect on clinical and nutritional outcomes or on healing preexisting pressure ulcers, compared with oral feeding. Very few patients on tube feeding showed signs of discomfort, partly because of low cognitive function. Survival was significantly higher in the tube-fed patients (P < 0.001), which could be partly explain by the different case mix (i.e., the underlying diseases)
Tube feeding seems to have no nutritional advantage in severely demented elderly patients. Median survival was longer in tube-fed individuals who had no acute co-morbidity. However, since tube feeding does not add to patient pain and discomfort, it should not be contraindicated when it complies with the values and wishes of patients and their families.
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ABSTRACT: Palliative wound care should be centered on symptom management and is a viable option for patients whose chronic wounds do not respond to standard interventions, or when the demands of treatment are beyond the patient's tolerance or stamina. Palliative wound care is the incorporation of strategies that prioritize symptomatic relief and wound improvement ahead of wound healing (total closure). Palliative wound care strategies must also work in conjunction with curative treatment objectives as wounds often heal completely in spite of serious illness and advanced disease. Palliative wound care is much more than pain, exudate and odor management. Common curative treatment goals such as physical correction of the underlying pathology, addressing nutrition and other supportive aspects of care, and sensible (nonharmful) local wound treatments should never be ignored.
(1) To provide a fresh and effective approach to palliative wound care by integrating individual clinical expertise with clinical and laboratory evidence from the (curative) wound healing literature and (2) to share our (Calvary Hospital) experience and approach to palliative wound care in an inpatient, home, and outpatient setting. This approach can be summarized with the mnemonic S-P-E-C-I-A-L (S = stabilizing the wound, P = preventing new wounds, E = eliminate odor, C = control pain, I = infection prophylaxis, A = advanced, absorbent wound dressings, L = lessen dressing changes). Throughout this paper we will offer rationale, principles and recipes, for each of the steps of the "SPECIAL" approach in an effort to facilitate the caring for chronic wounds in palliative medicine.
A practical marriage of wound palliation (symptom management) with current wound healing concepts to provide options for the palliative care provider and improve the practice of palliative medicine.
Journal of Palliative Medicine 11/2007; 10(5):1161-89. DOI:10.1089/jpm.2007.9909 · 1.91 Impact Factor
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ABSTRACT: There is a notable discord between physicians' opinions and reported practice regarding percutaneous endoscopic gastrostomy (PEG) nutrition in nursing homes for demented residents.
The aim of this study was to describe the decision and the outcomes of PEG placement in elderly nursing home residents, suffering from advance dementia and dysphagia.
The retrospective study evaluated frequency, complications of dysphagia and survival in 90 patients of Geriatric Center (61 women, 29 men) who underwent PEG. Average age was 85.7 +/- 0.8 years. Dysphagia diagnosed at 58, refusal of food of 36 patients. Following data was examined: age, time of dysphagia, anthropometric and laboratory tests.
Post PEG complications were found in 62.2% of patients and lung aspiration was 38.7% among them. Mortality within 30 days was 14.4% and 1 year survival was 54.4%. Early mortality rate increased with advanced age (over 85 years old), lower serum albumin (< 3.0 gr/dl), hemoglobin (<1 1.0 gr/dl) and cholesterol (< 160 mg/dl), underweight (BMI < 20.0 kg/m2) and time of dysphagia less than 2 months.
Artificial tube feeding (PEG) of elderly nursing home residents, suffering from advanced dementia, may be clinically beneficial for most patients with dysphagia or meal rejection aside to gradual constriction of the indications for PEG, seeing aforesaid predictor factors.
Harefuah 06/2008; 147(6):500-3, 575.
Available from: Elizabeth L Sampson
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ABSTRACT: Patients with advanced dementia often develop dysphagia (difficulties swallowing). They also experience changes in appetite and apraxia (difficulty co-coordinating movements) and may have difficulties feeding themselves. Two methods of enteral tube feeding are commonly used: the administration of food and fluids via a nasogastric tube (a tube that is passed through the nose and into the stomach) or via a percutaneous endoscopic gastrostomy (PEG) where a feeding tube is inserted into the stomach and is accessed through a permanent incision in the abdominal wall. The decision to use artificial hydration and nutrition in someone with dementia is often emotive and complex. Relatives and carers may request the intervention because they are concerned that the patient may starve; clinicians may be aware of the risks but feel pressurised by institutional, societal or even legal directives to intervene. We found 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. It may actually increase the risk of developing pneumonia due to inhaling small quantities of the feed and even death. This area is difficult to research but better designed studies are required to provide more robust evidence.
Cochrane database of systematic reviews (Online) 02/2009; 2(2):CD007209. DOI:10.1002/14651858.CD007209.pub2 · 6.03 Impact Factor
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