DEMENTIA – THE MOST DOUBTFUL INDICATION FOR GASTROSTOMY
Patients with degenerative cerebral diseases, above all dementia, have increasingly received gastrostomies and represented in some studies and regions the largest group of tube feeded patients[22-24]. Given the lack of evidence for a benefit in this patient group, this issue generates debates already for decades. In a time with an increasing economic health burden, a necessity to improve the efficiency of health care in an aging society and health care workers often pressed for time, this development is understandable but must be viewed with great skepticism.
Frequently, the indication of gastrostomy is the result of an acute deterioration in the health state and/or expression of a state of emergency in caring for these patients. Occasionally, cultural or religious reasons also play a role when relatives do not approve limiting therapy, although the quality of life is already dramatically reduced, and the prognosis is limited. Sometimes, gastrostomy is advocated because people caring for the patient, including their physicians, are unable to cope with difficult nursing and medical situations.
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Comfort feeding[25] is propagated as an alternative to artificial nutrition, but this approach requires more human resources, is very cost-intensive and probably cannot be executed in high numbers in today’s care structures. From a practical point of view, it is understandable that gastrostomy is performed to keep processes and personnel structures within affordable limits in a nursing home, but this approach often does not meet the needs of the patient. Eventually, gastrostomy, as well as long-term tube feeding, carry similar risks as other interventional measures[26,27]; additionally, it may detain patients from the pleasures of tasting and of social contacts. Furthermore, advanced dementia patients tend to manipulate access points and tubes and thereby are prone to injure themselves. A risk-benefit analysis is therefore particularly important in any patient group and should be provided to the patient and/or his relatives.
The wish of supporting the nutrition of demented patients using tube feeding leads to a high rate of gastrostomies in patients with already advanced disease. Often these patients already suffer from progressive malnutrition and immobility. In many studies with demented patients, the complication rate of gastrostomy is unacceptably high[28,29]. We and others think that this is more related to patient factors than an innate risk of the intervention[30]. This view is supported by data from studies showing that control patients (with no PEG) had a very similar or even worse mortality[29,31], and patients with only mild dementia had a significant higher benefit than those with advanced dementia[28].
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We call this the PEG paradox – choosing the patients too late for the intervention leads to missing benefit and greater harm including higher morbidity and mortality.
A Cochrane systematic review conducted in 2009 did not find a single randomized controlled trial that investigated the benefits of tube feeding in patients with dementia[32]. Consequently, recent guidelines do not encourage gastrostomy in patients with advanced dementia[33], although clear and high-quality data in this clinical field are lacking. Table Table33 shows the recent studies that examined the effects of tube feeding in patients with dementia[34-39]. Reviews and meta-analyses[40-42] mostly identified two severe problems of PEG studies in dementia patients. First, no randomized, prospective, properly controlled studies have been conducted. Most available studies have retrospective designs and suffer from a huge selection bias, and control groups are poor or unmatched. Second, in most studies, patients with dementia are not properly staged and are treated as a homogenous patient group. This prevents the identification of subgroups (e.g., patients with only mild to moderate dementia) that might benefit from enteral nutrition via tube feeding. Other problems include poor exclusion and inclusion criteria, inappropriate outcome measures and small sample sizes[42].
Source: https://t-tees.com
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