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To Tube or Not to Tube

From: The Hospitalist, August 2006

The implications of PEG tube use in the hospitalized older adult

by Luis F. Amador, MD

The ability to maintain nutrition and hydration is essential when caring for hospitalized older adults. When physicians recognize that long-term nutrition and hydration cannot be maintained through an oral route, percutaneous endoscopic gastrostomy (PEG) tube placement may need to be considered for long-term nutritional support. This decision is often distressing for the patient, family, and physician for several reasons.

First, the significant number of competing benefits, risks, and burdens of long-term enteral feeding that have to be considered can be overwhelming. The second reason is the lack of clinical data regarding outcomes of PEG tubes for many patients. The last and usually most distressing reason in the decision of PEG tube feeding involves the cultural, ethical, and religious beliefs involved in this decision.

For many families and physicians providing nutrition, including enteral nutrition, using a PEG tube symbolizes compassion, love, and care. This is because eating represents one of the most basic of human needs. For some, not providing nutrition with a PEG tube is morally and ethically wrong. Withholding PEG tube placement can be perceived as assisted suicide or murder. Some physicians also fear legal, ethical, or religious misconduct should they decide against tube feeding.

Physicians need not fear the legal consequences of discontinuing life-sustaining treatment if an appropriate decision-making process has been followed.1 An adult patient who has decision-making capacity and is appropriately informed has the right to forego any forms of medical therapy including life-sustaining therapy such as PEG tube feeding.2

Deciding whether or not to recommend PEG tube feeding can be accomplished in a series of steps. The first step is to evaluate the clinical benefits, risks, and burdens of long-term nutrition for the individual patient. The second step involves discussing the patient’s life goals with them and their family. On many occasions, the decision to place a PEG tube will be made by a surrogate decision-maker such as the patient’s spouse or child. Usually discussions about nutrition and hydration by PEG tube will occur between patients, families, and physicians when the overall end-of-life goals are reviewed. A physician’s role includes assisting patients and their families by providing information and a clear recommendation for or against the use of a feeding tube, giving alternative options, and ensuring there is true informed consent prior to feeding tube insertion.

The most frequent indication for long-term PEG tube feeding is a neurological disorder such as a stroke.3 PEG tube feeding has been developed as a practical alternative to parental feeding for patients with a functioning gastrointestinal (GI) tract who lack the ability to take food by mouth. PEG tube feeding is considered a medical intervention and, like any other intervention, has to be considered according to specific patient situations.

Why Are Older Adults at Risk?

With advancing age comes a linear decline in food intake. Involuntary weight loss is common among older adults, especially in those who are chronically ill. Poor caloric intake and weight loss can lead to multiple problems such as muscle wasting, anemia, and depression. There is a strong correlation between weight loss and morbidity and mortality.4 Even with mild weight loss of 5% of their body weight in one month, institutionalized older adults are four times more likely to die within one year.5 Similarly, community-dwelling older adults who have mild weight loss are at a higher risk of death after adjusting for multiple variables.6

Age-related changes can negatively affect the body’s ability to regulate energy intake and puts older adults at risk for negative energy balance.7 Older adults are more likely to have additional medical problems, use more medications, and experience psychosocial issues that can lead to weight loss and poor nutrition.8 Common causes of weight loss in older hospitalized adults include cancer, gastrointestinal disorder, and depression.9

Mechanical problems, such as dysphagia secondary to cerebrovascular accidents or degenerative brain diseases that affect swallowing are frequently encountered in the hospitalized older patient. Also, diseases that affect appetite and feeding increase the risk for negative energy balance such as GI diseases, endocrine diseases, infections, COPD, and others.

Many drugs have been associated with weight loss, especially in frail older adults. Drugs can cause a decrease in appetite, changes in food tastes and adsorption, and increase the body’s metabolism, making the patients unable to meet their caloric needs. Drugs implicated in malnutrition and weight loss in older persons include digoxin, amiodarone, methotrexate, lithium, and amitriptyline (to name a few).

Often the patient has poor oral intake for weeks—even months—prior to hospitalization. The duration of poor intake or weight loss may affect the patient’s prognosis and treatment. The inability to meet the calories needed by mouth can be a potential marker for a serious disease. Social factors such as isolation, poverty, and lack of transportation may also play a role in poor oral intake and even weight loss. Therefore, the mechanisms of poor nutrition or weight loss have to be identified before PEG tube placement is recommended.

The Clinical Case of Mrs. H

Mrs. H is an 88-year-old, 90-pound white woman admitted to the hospital for the third time this year secondary to aspiration pneumonia. She has a significant past medical history of 20-pound weight loss in the past year and advanced Alzheimer’s disease with severe aphasia. Her functional status is poor. She has been unable to walk or feed herself for at least a year.

Situations like this often arise in the acute care setting. The practitioner may ask how much and what kind of care makes sense for someone like Mrs. H with a limited life expectancy. She has advanced dementia with possible dysphasia and aspiration pneumonia that can explain her poor oral intake. In Mrs. H’s case, other factors can cause her poor oral intake, such as medications, malignancy, delirium, and psychosocial issues.

In this case, the first goal is to identify the cause(s) of poor oral intake and weight loss for future treatment and prognosis. Target your diagnostic investigation at the most probable explanation. “Shotgun” investigations have low yields and should be avoided. In Mrs. H’s case, discontinue medications that can affect her oral intake such as anticholinergic drugs if possible.

If Mrs. H can swallow, the next step is to provide frequent, small meals with liquid oral supplements between meals (60 to 90 minutes before meals). Oral protein and energy supplements have been shown to reduce all-cause mortality in older patients.10 You might consider the use of orexigenic medications, but they usually take significant time to work and their benefit in Mrs. H’s case is questionable. If she is diagnosed as depressed, a trial with mirtazapine may help both her depression and weight loss.

Other effective strategies to promote oral intake in older adults involve eliminating dietary restrictions and allowing unlimited intake of favorite foods. However, in Mrs. H’s case, poor intake may not improve due to the acute medical problems of aspiration pneumonia and the severity of her dementia with dysphagia. Often, a short course of tube feeding through a nasogastric tube can be tried until the patient’s acute illness improves. In Mrs. H’s case though, she has received nasogastric nutrition during her two recent hospitalizations, and her clinical situation has continued to worsen.

Mrs. H’s two daughters want to discuss PEG placement to improve her nutritional status. She had a recent modified barium swallowing study that showed dysphagia with high risk for aspiration of solids and liquids.

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.

Conclusion

Many patients come to the hospital with poor oral intake and weight loss. Clinicians, patients, and families should think carefully about the benefits, risks, and burdens of PEG tube use before initiating placement. The goals should be in concert with patients’ previously expressed wishes and values.

Deciding against PEG tube placement and focusing on comfort and palliative care can always play a role in the care of acutely and chronically ill older adults. PEG tube placement remains an ethically complex, emotionally charged, and difficult area for the managing physician, the patient, and the family. Further research is required in this area to assist these individuals in making the most appropriate decision. TH

Dr. Amador works in the Division of Geriatrics University of Texas Medical Center. His work is supported by the Geriatric Academic Career Award 1 K01 HP 00056-01 by the Bureau of Health Professions.

References

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  16. Erdil A, Saka M, Ates Y, et al. Enteral nutrition via percutaneous endoscopic gastrostomy and nutritional status of patients: Five-year prospective study. J Gastroenterol Hepatol. 2005 Jul;20(7):1002-1007.
  17. Ciocon JO, Silverstone FA, Graver LM, et al. Tube feedings in elderly patients. Arch Intern Med. 1988 Feb;148(2):429-433.
  18. Mitchell SL, Tetroe JM. Survival after percutaneous endoscopic gastrostomy placement in older persons. J Gerontol A Biol Sci Med Sci. 2000 Dec;55:M735-M739.
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  20. James A, Kapur K, Hawthorne AB. Long-term outcome of percutaneous endoscopic gastrostomy feeding in patients with dysphagic stroke. Age and Ageing. 1998 Nov; 27(6):671-676.

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