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Feeding Tubes May Be Over-Used In Dementia Patients

Picture-58The effectiveness of feeding tubes in dementia patients is questionable– according to a study to be published in the Journal of the American Medical Association.  The study carried out by Dr. Joan Teno evaluated a sampling of nursing home patients who had been admitted to acute-care hospitals between 2000 and 2007.  In addition to a questionable improvement in the quality of life of dementia patients, the study determined that this group was more likely to receive a feeding tube if they received medical treatment at large, for-profit hospitals.

Feeding tube use amongst dementia patients is extremely common.  According to a Business Week article, more than one-third of dementia patients in nursing homes currently have feeding tubes, with the majority of those being inserted during an acute care-hospitalization.

One reason possible reason for the frequency in the insertion of feeding tubes during acute hospitalizations may be due to the fact that when dementia patients enter a new environment– such as an acute-care hospital, they have a difficult time adjusting to the new environment and may not immediately eat.

“They often get very stressed out, have disruptive behavior, get medications to treat that behavior, which leads them to developing bed sores and problems with eating, which leads to having a feeding tube inserted,” according to Teno. “Part of what we need to do is align the incentives to keep frail older dementia patients in the least restrictive setting that will provide the best medical care.”

As an alternative to feeding tubes, some experts suggest ‘spoon feeding’ patients.  Using a spoon feeding method, a person literally feeds the person with a spoon at his or her own pace.  Some experts suggest that spoon feeding may not necessarily prolong the life of the individual, but it can improve the quality of it.

Patients who have feeding tubes in a nursing home or hospital setting are at risk for a variety of medical complications including:

Gastroesophageal reflux caused from gastric juices being forced back into the esophagus can occur with feeding tubes because the tubes sometimes cause a delay in the emptying of the stomach. This means that a person has to have more frequent, smaller feedings.

Clogging: Most feeding tubes are very narrow, and commercial tube feeding formulas such as Ensure, are designed so that they will not clog the tube; they are not too thick and do not leave a residue. Most formulas are designed to have water added to them to ensure that the patient is receiving enough dietary water, and to further thin the formula for ease of use. Staff should flush the tube with water before and after feedings, or after medications have been administered through the tube.  The use of noncommercial formulas is discouraged, because there is a greater likelihood that they will contribute to clogging. After the tube is placed, a registered dietitian or a nurse who specializes in nutrition should assess the patient to determine their nutritional needs, the amount of calories, protein, and fluids that will be necessary, as well as the most appropriate nutritional formula and how much of that formula will be needed each day.

Nausea and vomiting is a common problem with feeding tubes. It occurs when liquid food is administered to an individual through a tube too quickly, or when the formula provided through the tube is too high in protein and/or calories. Migration (shifting) of the tube, bacterial infections and air in the stomach can cause nausea and vomiting as well.

Leakage is a complication of feeding tubes that occurs typically because the size of the stoma around the tube has increased, or because the position of the tube is improper due to bad placement or general shifting. This problem sometimes requires replacement of the tube, and it forces an individual or attending physician to keep the stoma clean with protective gauze and ointment.

Constipation occurs frequently with feeding tubes because the liquids that are administered through the tubes don’t always have as much bulk or fiber as normal foods. Without fiber, an individual’s digestive system has trouble retaining enough fluid and staying regular enough to produce frequent bowel movements. This problem means that the individual either has to find a way to introduce liquids that are higher in fiber through the tube (which can increase the risk of the tube clogging), or she has to take medications to relieve constipation.

Choking / Aspiration can occur if an individual is administered food through a feeding tube while in an improper position. This can result in choking, coughing and pneumonia. These, in turn, can aggravate the stoma, because the abdominal wall is forced to engage forcefully during a cough or sneeze. The aggravation of the stoma can lead to further infection. Most medical professionals suggest feeding patients when they are as up-right as possible to avoid aspiration on the food.

Many of these problems can be avoided when facilities employ adequate numbers of properly trained staff.  Consequently, if you have a loved one who require tube feeding, it is important to check with the facility to make sure they are accustomed to handling patients with these medical needs.

Resources:

Too Many With End-Stage Dementia Get Feeding Tubes, BusinessWeek, February 9, 2010

Common Complications of Tube Feeding

Nursing Home Staff Must Pay Special Attention To Avoid Complications When Caring For Patients Dependent On Feeding Tubes

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