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. 2021 Aug 13;8(8):CD013503.
doi: 10.1002/14651858.CD013503.pub2.

Enteral tube feeding for people with severe dementia

Nathan Davies  1 , Yolanda Barrado-Martín  1 , Victoria Vickerstaff  2 , Greta Rait  3 , Akiko Fukui  4 , Bridget Candy  2 , Christina H Smith  5 , Jill Manthorpe  6 , Kirsten J Moore  2   7 , Elizabeth L Sampson  2
Affiliations

Enteral tube feeding for people with severe dementia

Nathan Davies et al. Cochrane Database Syst Rev. .

Abstract

Background: The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the lack of evidenced benefit and potential risks of enteral tube feeding. In some areas of the world, the use of enteral tube feeding is decreasing, and in other areas it is increasing.

Objectives: To assess the effectiveness and safety of enteral tube feeding for people with severe dementia who develop problems with eating and swallowing or who have reduced food and fluid intake.

Search methods: We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases and two trials registers on 14 April 2021.

Selection criteria: We included randomised controlled trials (RCTs), or controlled non-randomised studies. Our population of interest was adults of any age with a diagnosis of primary degenerative dementia of any cause, with severe cognitive and functional impairment, and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of enteral tube feeding via a nasogastric or gastrostomy tube, or via jejunal post-pyloric feeding, in comparison with standard care or enhanced standard care, such as an intervention to promote oral intake. Our primary outcomes were survival time, quality of life, and pressure ulcers.

Data collection and analysis: Three review authors screened citations and two review authors assessed full texts of potentially eligible studies against inclusion criteria. One review author extracted data, which were then checked independently by a second review author. We used the 'Risk Of Bias In Non-randomised Studies of Interventions' (ROBINS-I) tool to assess the risk of bias in the included studies. Risk of confounding was assessed against a pre-agreed list of key potential confounding variables. Our primary outcomes were survival time, quality of life, and pressure ulcers. Results were not suitable for meta-analysis, so we presented them narratively. We presented results separately for studies of percutaneous endoscopic gastrostomy (PEG) feeding, nasogastric tube feeding and studies using mixed or unspecified enteral tube feeding methods. We used GRADE methods to assess the overall certainty of the evidence related to each outcome for each study.

Main results: We found no eligible RCTs. We included fourteen controlled, non-randomised studies. All the included studies compared outcomes between groups of people who had been assigned to enteral tube feeding or oral feeding by prior decision of a healthcare professional. Some studies controlled for a range of confounding factors, but there were high or very high risks of bias due to confounding in all studies, and high or critical risks of selection bias in some studies. Four studies with 36,816 participants assessed the effect of PEG feeding on survival time. None found any evidence of effects on survival time (low-certainty evidence). Three of four studies using mixed or unspecified enteral tube feeding methods in 310 participants (227 enteral tube feeding, 83 no enteral tube feeding) found them to be associated with longer survival time. The fourth study (1386 participants: 135 enteral tube feeding, 1251 no enteral tube feeding) found no evidence of an effect. The certainty of this body of evidence is very low. One study of PEG feeding (4421 participants: 1585 PEG, 2836 no enteral tube feeding) found PEG feeding increased the risk of pressure ulcers (moderate-certainty evidence). Two of three studies reported an increase in the number of pressure ulcers in those receiving mixed or unspecified enteral tube feeding (234 participants: 88 enteral tube feeding, 146 no enteral tube feeding). The third study found no effect (very-low certainty evidence). Two studies of nasogastric tube feeding did not report data on survival time or pressure ulcers. None of the included studies assessed quality of life. Only one study, using mixed methods of enteral tube feeding, reported on pain and comfort, finding no difference between groups. In the same study, a higher proportion of carers reported very heavy burden in the enteral tube feeding group compared to no enteral tube feeding. Two studies assessed the effect of nasogastric tube feeding on mortality (236 participants: 144 nasogastric group, 92 no enteral tube feeding). One study of 67 participants (14 nasogastric, 53 no enteral tube feeding) found nasogastric feeding was associated with increased mortality risk. The second study found no difference in mortality between groups. The certainty of this evidence is very low. Results on mortality for those using PEG or mixed methods of enteral tube feeding were mixed and the certainty of evidence was very low. There was some evidence from two studies for enteral tube feeding improving nutritional parameters, but this was very low-certainty evidence. Five studies reported a variety of harm-related outcomes with inconsistent results. The balance of evidence suggested increased risk of pneumonia with enteral tube feeding. None of the included studies assessed behavioural and psychological symptoms of dementia.

Authors' conclusions: We found no evidence that tube feeding improves survival; improves quality of life; reduces pain; reduces mortality; decreases behavioural and psychological symptoms of dementia; leads to better nourishment; improves family or carer outcomes such as depression, anxiety, carer burden, or satisfaction with care; and no indication of harm. We found some evidence that there is a clinically significant risk of pressure ulcers from enteral tube feeding. Future research should focus on better reporting and matching of control and intervention groups, and clearly defined interventions, measuring all the outcomes referred to here.

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Conflict of interest statement

Nathan Davies: none known. Yolanda Barrado‐Martin: none known. Greta Rait: none known. Akiko Fukui: none known. Bridget Candy: none known. Christina H Smith: none known. Jill Manthorpe: none known. Kirsten J Moore: none known. Elizabeth L Sampson: none known. Victoria Vickerstaff: none known.

Figures

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Study flow diagram
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ROBINS‐I assessments for: PEG Tube versus no enteral tube for people with severe dementia. Outcome: survival time
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3
ROBINS‐I assessments for: PEG tube versus no enteral tube for people with severe dementia. Outcome: pressure ulcers
4
4
ROBINS‐I assessments for: PEG tube versus no enteral tube for people with severe dementia. Outcome: mortality
5
5
ROBINS‐I assessments for: nasogastric tube versus no enteral tube for people with severe dementia. Outcome: mortality
6
6
ROBINS‐I assessments for: nasogastric tube versus no enteral tube for people with severe dementia. Outcome: nutritional parameters
7
7
ROBINS‐I assessments for: mixed (nasogastric or PEG) or unspecified enteral tube feeding for people with severe dementia. Outcome: survival time
8
8
ROBINS‐I assessments for: mixed (nasogastric or PEG) or unspecified enteral tube feeding for people with severe dementia. Outcome: pressure ulcer
9
9
ROBINS‐I assessments for: mixed (nasogastric or PEG) or unspecified enteral tube feeding for people with severe dementia. Outcome: pain and comfort
10
10
ROBINS‐I assessments for: mixed (nasogastric or PEG) or unspecified enteral tube feeding for people with severe dementia. Outcome: mortality
11
11
ROBINS‐I assessments for: mixed (nasogastric or PEG) or unspecified enteral tube feeding for people with severe dementia. Outcome: nutritional parameters
See this image and copyright information in PMC

Comment in

References

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Orlandoni 2019 {published data only}
    1. Orlandoni P, Peladic NJ, Di Rosa M, Venturini C, Fagnani D, Sparvoli D, Giorgini N, Basile R, Cola C. The outcomes of long term home enteral nutrition (HEN) in older patients with severe dementia.. Clinical Nutrition 2019;38:1871-1876. - PubMed
Paccagnella 2016 {published data only}
    1. Paccagnella A, Marcon M L, Baruffi C, Giometto M, Mauri A, Vigo C, et al. Enteral nutrition at home and in nursing homes: an 11-year (2002-2012) epidemiological analysis. Minerva Gastroenterologica Dietologica 2016;62(1):1-10. - PubMed
Paillaud 2002 {published data only}
    1. Paillaud E, Bories P N, Merlier I, Richardet J P, Jeanfaivre V, Campillo B. Prognosis factors of short and long-term survival in elderly hospitalized patients after percutaneous endoscopic gastrostomy. Gastroenterologie clinique et biologique 2002;26(5 MISC3 - GCBID):443-7. - PubMed
Park 2019 {published data only}
    1. Park SK, Kim JY, Koh SJ, Lee YJ, Jang HJ, Park SJ. Complications of percutaneous endoscopic and radiologic gastrostomy tube insertion: a KASID (Korean Association for the Study of Intestinal Diseases) study. Surgical Endoscopy 2019;33(3):750-756. - PubMed
Peck 1990 {published data only}
    1. Peck A, Cohen CE, Mulvihill MN. Long-term enteral feeding of aged demented nursing home patients. Journal of the American Geriatrics Society 1990;38(11):1195-1198. - PubMed
Pfitzenmeyer 2002a {published data only}
    1. Pfitzenmeyer P, Manckoundia P, Mischis-Troussard C, D'Athis P, Michel M, Lussier MD, et al. Enteral nutrition in French institutionalized patients: a multicentric study. Journal of Nutrition, Health & Aging 2002;6(5):301-305. - PubMed
Pfitzenmeyer 2002b {published data only}
    1. Pfitzenmeyer P, Manckoundia P, Mischis-Troussard C, D'Athis P, Michel M, Lussier M D, et al. Enteral nutrition in the French gerontological health care facilities: a multi-centric observational study. La Revue De Geriatrie 2002;27(3):153-158.
Pih 2018 {published data only}
    1. Young PG, Kyong NH, Yong AJ, Wook JK, Hoon KD, Hoon LJ, et al. Risk factors for complications and mortality of percutaneous endoscopic gastrostomy insertion. BMC Gastroenterology 2018;18(1). - PMC - PubMed
Rudman 1989 {published data only}
    1. Rudman D, Mattson DE, Feller AG. Serum fatty acid profile of elderly tube-fed men in a nursing home. Journal of the American Geriatrics Society 1989;37(3):229-234. - PubMed
Sako 2014 {published data only}
    1. Sako A, Yasunaga H, Horiguchi H, Fushimi K, Yanai H, Uemura N. Prevalence and in-hospital mortality of gastrostomy and jejunostomy in Japan: a retrospective study with a national administrative database. Gastrointestinal Endoscopy 2014;80(1):88-96. - PubMed
Sanders 2000 {published data only}
    1. Sanders DS, Carter MJ, D'Silva J, James G, Bolton RP, Bardhan KD. Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia. American Journal of Gastroenterology 2000;95(6):1472-1475. - PubMed
Schneider 2001 {published data only}
    1. Schneider SM, Raina C, Pugliese P, Pouget I, Rampal P, Hebuterne X. Outcome of patients treated with home enteral nutrition. Journal of Parenteral & Enteral Nutrition 2001;25(4):203-209. - PubMed
Sedlackova 2008 {published data only}
    1. Sedlackova M, Shil AB, Sansone G, Frengley D. Does percutaneous endoscopic gastrostomy feeding in advanced dementia patients effect pressure ulcers? Journal of the American Geriatrics Society 2008;56(4):S94.
Sherman 2003 {published data only}
    1. Sherman FT. Nutrition in advanced dementia - Tube-feeding or hand-feeding until death? Geriatrics 2003;58(11):10. - PubMed
Shintani 2013 {published data only}
    1. Shintani S. Efficacy and ethics of artificial nutrition in patients with neurologic impairments in home care. Journal of Clinical Neuroscience 2013;20(2):220-223. - PubMed
Smoliner 2012 {published data only}
    1. Smoliner C, Volkert D, Wittrich A, Sieber CC, Wirth R. Basic geriatric assessment does not predict in-hospital mortality after PEG placement. BMC Geriatrics 2012;12:52. - PMC - PubMed
Stoppe 2005 {published data only}
    1. Stoppe G, Drach L. Percutaneous endoscopic gastrostomy (PEG) in patients with dementia: harm or benefit? A multicenter psychiatric hospital study in Germany. International Psychogeriatrics 2005;17(Supplement 2):280.
Stoppe 2008 {published data only}
    1. Stoppe G, Drac LM. Percutaneous endoscopic gastrostomy (PEG) in patients with dementia – decision-making in German psychogeriatric hospital services. European Journal of Geriatrics 2008;10:1-8.
Sudo 2012 {published data only}
    1. Sudo E, Hanabusa H. 86-aged case of Alzheimer disease followed by nursing home after percutaneous endoscopic gastrostomy. Nippon Ronen Igakkai Zasshi [Japanese Journal of Geriatrics] 2012;49(1):119-122. - PubMed
Suzuki 2006 {published data only}
    1. Suzuki Y, Urashima M, Ninomiya H, Sowa M, Hiki Y, Suzuki H, et al. A survey of percutaneous endoscopic gastrostomy in 202 Japanese medical institutions. Japan Medical Association Journal 2006;49(3):94-105.
Suzuki 2012 {published data only}
    1. Suzuki Y, Urashima M, Izumi M, Ito Y, Uchida N, Okada S, et al. The effects of percutaneous endoscopic gastrostomy on quality of life in patients with dementia. Gastroenterology Research 2012;5(1):10-20. - PMC - PubMed
Teno 2010 {published data only}
    1. Teno JM. Eating problems and tube feeding in advanced dementia. Gerontologist 2010;50:208.
Terai 2012 {published data only}
    1. Terai S, Iwasa Y. A retrospective study of outcome of percutaneous endoscopic gastrostomy in older adults with advanced cognitive impairment and severely reduced activities of daily living. Nippon Ronen Igakkai Zasshi [Japanese Journal of Geriatrics] 2012;49(5 ):602-607. - PubMed
Tokunaga 2008 {published data only}
    1. Tokunaga T, Kubo T, Ryan S, Tomizawa M, Yoshida SI, Takagi K, et al. Long-term outcome after placement of a percutaneous endoscopic gastrostomy tube. Geriatrics & Gerontology International 2008;8(1):19-23. - PubMed
Tominaga 2010 {published data only}
    1. Tominaga N, Shimoda R, Nakano R, Shirahama N, Tsuruoka N, Mannen K, et al. Prognostic factors for one-year survival in patients with percutaneous endoscopic gastrostomy. Gastroenterology 2010;138(5 SUPPL. 1):S236 .
Urena 2004 {published data only}
    1. Urena SY, Zapata VM, Cabrera FS, Calle EB, Monteagudo EV. Percutaneous endoscopic gastrostomy: prospective experience of a national private center [Gastrostomía endoscópica percutánea: experiencia prospectiva de un centro privado nacional]. Revista de Gastroenterología del Perú 2004;24(4):314-22. - PubMed
Urphanishvili 2009 {published data only}
    1. Urphanishvili T, Mozumder M, Patel P, Nair A, Ajmal S, Sedlackova M. The prognostic value of comorbidity on pressure ulcers in demented patients with percutaneous endoscopic gastrostomy feeding. Journal of the American Geriatrics Society 2009;57:S143.
Van Dijk 2006 {published data only}
    1. Dijk Y, Sonnenblick M. Tube feeding of the terminally demented patient. Israel Medical Association journal 2006;8(12 ):894-895. - PubMed
Weaver 1993 {published data only}
    1. Weaver JP, Odell P, Nelson C. Evaluation of the benefits of gastric tube feeding in an elderly population. Archives of Family medicine 1993;2(9):953-956. - PubMed
Wirth 2007 {published data only}
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Ying 2015 {published data only}
    1. Ying I. Artificial nutrition and hydration in advanced dementia. Canadian Family Physician 2015;61(3):245-248. - PMC - PubMed
Yoon 2019 {published data only}
    1. Yoon EW, Yoneda K, Nishihara K. Percutaneous endoscopic gastrostomy for enteral nutrition: a 5-year clinical experience with 324 patients. Minerva Gastroenterologica e Dietologica 2019;65(1):20-29. - PubMed
Zalar 2004 {published data only}
    1. Zalar AE, Guédon C, Piskorz EL, Sánchez Basso A, Ducrotté P. Percutaneous endoscopic gastrostomy in patients with neurological diseases. Results of a prospective multicenter and international study. Acta Gastroenterologica Latinoamericana 2004;34(3):127-132. - PubMed

References to studies awaiting assessment

Alvisi 2016 {published data only}
    1. Alvisi C, Bardone M, Broglia F, Centenara L, Pozzi L, Rovedatti L, et al. PEG in very elderly patients with dementia: a safe procedure. Digestive and Liver Disease 2016;48:E212.
Bell 2012 {published data only}
    1. Bell CL, Davis J, Harrigan R, Braun K, Curb J, Grandinetti A, et al. Factors associated with mortality among nursing home patients: transitions of care and tube feeding. Journal of the American Geriatrics Society 2012;60(Suppl 4):s127.
Burke 2001 {published data only}
    1. Burke GF. Tube feeding and advanced dementia. Ethics and Medics 2001;26(3):1-2. - PubMed
Colby 2015 {published data only}
    1. Colby J, Burch NE. Disease specific outcomes in patients following PEG insertion-a single centre 10 year experience. Gut 2015;64(Suppl 1):A128.
Eghbalieh 2010 {published data only}
    1. Eghbalieh N, Brenes R, Ajemian MS. Outcome complications of percutaneous endoscopic gastrostomy tube placement in severly malnourished patients. Surgical Endoscopy and Other Interventional Techniques 2010;24(1):s557-s558.
Juin 2018 {published data only}
    1. Juin E, Gieniusz M, Ragbir-Toolsie K, Latif R, Patel V, Fishbein J, et al. Long-term care patients with percutaneous endoscopic gastrostomy (PEG) tube: reasons for rehospitalizations. Journal of the American Geriatrics Society 2018;66(Suppl 2):S231.
Kimyagarov 2008 {published data only}
    1. Kimyagarov S, Levenkron S, Shabi A. Artificial tube feeding of elderly suffering from advanced dementia. Harefuah 2008;147(6):500-503. - PubMed
Kurien 2014 {published data only}
    1. Kurien M, Andrews R, McAlindon ME, Sanders DS. Factors influencing mortality following gastrostomy insertion. United European Gastroenterology Journal 2014;2(Suppl 1):A438.
Maeda 2013 {published data only}
    1. Maeda N, Yoshioka T, Tanaka A, Inoue K, Haruma K. Endoscopic and clinical features of 304 consecutive patients with percutaneous endoscopic gastrostomy: advanced atrophy of gastric mucosa is a risk factor of aspiration pneumonia. Gastrointestinal Endoscopy 2013;5 SUPPL. 1:AB268.
Nohara 2017 {published data only}
    1. Nohara C, Ohtake T, Hirabayashi K, Arii K, Kobayashi M, Okamura M, et al. Retrospective study of percutaneous endoscopic gastrostomy in neurodegenerative disease. Journal of the Neurological Sciences 2017;381(Suppl 1):849.
Pannick 2019 {published data only}
    1. Pannick S, Hicks L, Kim J, Velji Z, Colucci K, Wright A, Howson W. Radiologically vs endoscopically-placed gastrostomy feeding tubes: an audit of current practice and clinical outcomes in a large, multi-site UK NHS trust. Endoscopy 2019;51(4):s85.
Sakakibara 2019 {published data only}
    1. Sakakibara Y, Kawamoto Y, Higashi S, Bessho H, Fujii Y, Kato S, et al. Factors influencing premature mortality after percutaneous endoscopic gastrostomy in our hospital. Gastrointestinal Endoscopy 2019;89(6):AB505.
Slawson 2000 {published data only}
    1. Slawson D. Will tube feeding patients with advanced dementia result in improved outcomes? Evidence-Based Practice 2000;3(1):2.
Vanis 2016 {published data only}
    1. Vanis N, Saray A, Zahiragic N. Safety and outcomes of percutaneous endoscopic gastrostomy (PEG) tube placement: results of a 10-year single center survey. Gastrointestinal Endoscopy 2016;83(5):Suppl 1.
Vazquez‐Lopez 2013 {published data only}
    1. Vazquez-Lopez C, Martin-Vila A, Alvarez-Payero M, Suarez-Santamaria M, Martinez-Lopez de Castro N, Pineiro-Corrales G. Pharmaceutical interventions in patients with domiciliary enteral nutrition. International Journal of Clinical Pharmacy 2013;35(6):1314.
Wakita 2014 {published data only}
    1. Wakita S, Tsurudome I, Higashibori R, Miura S, Okada A, Mabuchi T, et al. Clinical investigation of percutaneous endoscopic gastrostomy (PEG) in our clinic. Journal of Gastroenterology and Hepatology 2014;29(Suppl 3):303.
Widjaja 2010 {published data only}
    1. Widjaja D, Wattanapanom P, Thanasawat C, Waghchoure S, Balar B. Findings of upper gastrointestinal tract abnormalities during percutaneus endoscopic gastrostomy tube placement in older adults with dementia. Journal of the American Geriatrics Society 2010;58:s184.
Zelante 2015 {published data only}
    1. Zelante A, Petteno D, Blume Julia F, Trevisani L. Long-term outcome after percutaneous endoscopic gastrostomy (PEG). Digestive and Liver Disease 2015;360:e150.

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