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Feeding tubes don’t prevent or heal pressure sores in dementia patients

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Percutaneous endoscopic gastrostomy (PEG) feeding tubes do more harm than good in nursing home residents with advanced cognitive impairment, a propensity-matched cohort study confirms.

The study found that feeding tubes did little to help prevent or heal pressure ulcers, but instead doubled the risk of a pressure ulcer forming.

“Health care providers should avoid the rush to insert feeding tubes in hospitalized nursing home residents with advanced dementia, Dr. Joan M. Teno of the Warren Alpert School of Medicine of Brown University in Providence, Rhode Island, advised in email to Reuters Health. “PEG feeding tubes are like any medical procedure that has risks and benefits. Careful consideration must be given to these risks and benefits,” she added.

Dr. Colleen Christmas and Dr. Thomas Finucane, geriatric medicine specialists at Johns Hopkins Bayview Medical Center in Baltimore, Maryland agree. These new findings “extend and confirm most earlier studies in this area and are now the most rigorous data we have on the subject, they write in an invited commentary published with the study May 14 in Archives of Internal Medicine.

“The clinical bottom line is that use of tube feeding in patients with advanced dementia is ever more difficult to justify,” they say.

Dr. Teno’s team used a large administrative database to compare a group of nursing home residents with advanced dementia and newly inserted feeding tubes and a similar group without feeding tubes who were propensity matched to be about as likely to develop pressure ulcers or to have them heal if already present.

Matched residents with and without a PEG tube had comparable sociodemographic characteristics, rates of feeding tube risk factors, and mortality, they note.

After adjusting for risk factors, tube-fed residents without a pressure ulcer at entry (n=1124) were 2.27 times more likely to develop a new pressure ulcer and those with a pressure ulcer (n=461) at tube placement were significantly less likely to have the ulcer heal (OR 0.70), compared with the propensity-matched group without feeding tubes.

“While earlier studies suggested that feeding tubes did not offer a benefit for pressure sore outcomes, Teno and colleagues demonstrate harm with this approach,” say Drs. Christmas and Finucane.

How could feeding tubes worsen pressure sore outcomes? The study didn’t address this, but there are several possibilities. Physical and pharmacological restraints may result in immobility, a known risk factor for pressure sores, and the osmolarity of the tube-feeding may induce diarrhea, another well-known risk factor for pressure sores, the authors note.

Dr. Teno said, “I suspect that based on my clinical experience and the research finding of no difference in survival that many, if not the majority, of persons would do well with careful hand feeding. Such hand feeding is a more humane way of treating these patients.”

Echoing her sentiment, the editorial writers say, in their opinion, “physiology and morality each support an approach in all settings where all patients with severe dementia should be offered a conscientious, careful program of hand feeding.”

“I strongly believe,” Dr. Teno added, “that decisions should reflect the patient preference and values.” Yet, in a recent five-state survey of bereaved family members, more than one third of said that they were not informed about the risks of feeding tube insertion, Dr. Teno told Reuters Health.

The study was funded by the National Institute on Aging.

SOURCE:

Feeding Tubes and the Prevention or Healing of Pressure Ulcers

Arch Intern Med 2012;172;697-702.