Nasogastric tube feeding versus assisted hand feeding in-home healthcare older adults with severe dementia in Taiwan: a prognosis comparison.

BACKGROUND: All individuals with severe dementia should be offered careful hand feeding. However, under certain circumstances, people with severe dementia have a feeding tube placed. In Taiwan, tube feeding rate in demented older home care residents is increasing; however, the benefits of tube feeding in this population remain unknown. We compared the clinical prognosis and mortality of older patients with severe dementia receiving nasogastric tube feeding (NGF) or assisted hand feeding (AHF). METHODS: Data from the in-home healthcare system between January 1 and December 31, 2017 were analyzed to identify 169 participants over 60 years of age in this retrospective longitudinal study. All subjects with severe dementia and complete functional dependence suffered from difficulty in oral intake and required either AHF or NGF. Data were collected from both groups to analyze pneumonia, hospitalization, and mortality rates. RESULTS: A total of 169 subjects (56 males and 113 females, aged 85.9 ± 7.5 years) were analyzed. 39 required AHF and 130 NGF. All subjects were bedridden; 129 (76%) showed Barthel index < 10. Pneumonia risk was higher in the NGF group (48%) than in the AHF group (26%, p = 0.015). After adjusting for multiple factors in the regression model, the risk of pneumonia was not significantly higher in the NGF group compared with the AHF group. One-year mortality rates in the AHF and NGF groups were 8 and 15%, respectively, and no significant difference was observed after adjustment with logistic regression (aOR = 2.38; 95% CI, 0.58-9.70). There were no significant differences in hospitalization rate and duration. CONCLUSIONS: For older patients with dementia requiring in-home healthcare, NGF is not associated with a significantly lower risk of pneumonia than AHF. Additionally, neither mortality nor hospitalization rates decreased with NGF. On the contrary, a nonsignificant trend of increased risk of pneumonia was observed in NGF group. Therefore, the benefits of NGF are debatable in older patients with severe dementia requiring in-home healthcare. Continued careful hand feeding could be an alternative to NG feeding in patients with severe dementia. Furthermore, large-scale studies on in-home healthcare would be required to support these results.

Factors Contributing to the Preferred Method of Feeding in End-Stage Dementia: A Scoping Review.

Dementia is reported to be the overall fourth leading non-communicable cause of death, and accounted for almost two million deaths worldwide (3.5% of the total number) in 2016. Dysphagia and aspiration pneumonia secondary to dementia are the two most serious comorbidities. As the dementia progresses and the severity of an individual's dysphagia increases, the question of whether to commence an artificial nutrition or allow a person to continue to eat and drink orally is raised, both having associated risks. The purpose of this study was to establish current perspectives regarding the method(s) of feeding being used or preferred, once an individual with dementia has reached the end stages of the disease and is unable to swallow safely and efficiently, and ascertain the reasons for the choice made. An online search was completed, and articles published in English available up to April 2018 were considered for inclusion. Hand searching inclusive of the grey literature was also completed to obtain the maximum amount of relevant information. The total yield numbered 1888 studies, and following exclusions, full text studies deemed suitable for review amounted to 18. Themes were generated during the review process, relevant information was extracted, and six main themes emerged: feeding method; aspiration pneumonia; mortality; malnutrition; ethical considerations, and religion. The review indicated that the preferred method of feeding in end-stage dementia was artificial nutrition, in most cases via percutaneous endoscopic gastrostomy. However, despite the perceived advantage of providing artificial nutrition, no convincing evidence was found to support the use of tube feeding in end-stage dementia. In fact, initiating tube feeding was considered to have adverse effects such as aspiration pneumonia, malnutrition and expedited death. Longitudinal research regarding current practice is therefore indicated to establish an optimal procedure for individuals with end-stage dementia and dysphagia.