A 68-year-old cachectic female with a history of Alzheimer’s dementia presents with a slowly progressive decline in functional status. She is bed bound, minimally verbal, and has lost interest in eating.
Her problems with decreased oral intake started when her diet was changed to nectar-thickened liquids. This change was made after the patient was hospitalized multiple times for aspiration pneumonia and she underwent a fluoroscopic swallowing evaluation that revealed aspiration of thin liquids. The patient’s husband requests that a feeding tube be placed so his wife doesn’t “die of pneumonia or starve to death.”
As the U.S. population ages, hospitalists are seeing a steady increase in the average patient age and the prevalence of dementia. Alzheimer’s dementia affects an estimated 4 million to 5 million Americans; this number expected to triple by the year 2050.1
As patients with dementia near the end of life, they often fail to thrive, with less oral intake and more swallowing disorders leading to aspiration. This is when physicians and patient family members must decide whether a feeding tube should be placed.
Placement of a nasogastric or percutaneous endogastric gastrostomy (PEG) feeding tube has become a relatively common medical intervention instituted to maintain or improve a patient’s nutritional status. Prior to 1980, permanent gastric or postpyloric feeding tubes were placed surgically by laparotomy, but the advent of endoscopy and computed tomography (CT) guided procedures offers a simplified procedure requiring only mild sedation and local anesthesia.2
Many patients who suffer multiple bouts of aspiration pneumonia and fail a swallowing evaluation because of an irreversible process are offered a percutaneous feeding tube to maintain nutrition. A feeding tube is also seen as a way to supply nutrition at the end of life in patients no longer able or willing to take food orally.
Although it seems logical that a feeding tube might improve the outcomes of these clinical scenarios, limited literature exists on the topic because of the legal, ethical, emotional, and religious implications a large, randomized, placebo-controlled trial would entail.
Review of the Data
Placement of a PEG has become accepted as a relatively benign procedure, although it is associated with significant morbidity and mortality. Minor complications including pain, abdominal wall ulcers, wound infections, peristomal leakage, and tube displacement occur in approximately 10% of cases.3 Major complications including hemorrhage, bowel or liver perforation, or aspiration occur in 3% of cases.4