A common approach to problems with nutritional intake in elderly patients, particularly those with altered cognition or fluctuating consciousness, is insertion of a feeding tube.5 According to Medicare data from the 1990s, in individuals older than 85, one in 131 whites, and one in 58 African-Americans had a gastrostomy.
Despite the large numbers of feeding-tube placements in elderly patients, proof of their effectiveness is scant. No randomized trials have been performed to determine whether this practice improves survival, and observational data reveal that the one-year survival for these patients is less than 40%.
Feeding tubes are often placed to reverse the clinical sequelae of malnutrition—to heal pressure ulcers, prevent infection, and improve the patient’s functional status. But prospective observational studies do not support this methodology, and some contradictory evidence in the form of worsening pressure ulcers has been observed.
Aspiration pneumonia is the most serious infection for which tube feeding is considered a preventive measure. The condition results from the misdirection of pharyngeal contents and is believed to develop when nonpathologic oral secretions are deposited in dependent areas of the lung. The bacterial inoculum is high enough to overcome local defenses, which results in an infectious, febrile illness, usually involving mixed gram-negative rods and anaerobes.
Summaries of current data show that tube feeding may increase the risk of aspiration pneumonia. Further support for this hypothesis comes from the observation that jejunostomy feeding also does not appear to reduce the risk of aspiration pneumonia. If a patient is unable to protect his airway during mealtimes, he will also be at risk of aspiration and pneumonia between meals, regardless of how nutrition is delivered. TH
Dr. Landis is a rheumatologist and freelance writer.
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- Finucane T, Williams M. Tube feeding the demented patient: a review of the evidence. American Geriatrics Society Annual Scientific Meeting 2001.