Tube Feeding in Patients With Advanced Dementia.

Thomas E. Finucane et al., Tube Feeding in Patients With Advanced Dementia, 282 JAMA 1365 (1999).

Patients with advanced dementia commonly develop difficulty eating, often when they become bedridden and dependent in all activities of daily living. They may resist or be indifferent to food, fail to manage the food bolus properly once it is in the mouth (oral phase dysphagia), or aspirate when swallowing (pharyngeal phase dysphagia). Enteral tube feeding is intended to prevent aspiration pneumonia, forestall malnutrition and its sequelae, including death by starvation, and provide comfort. The authors reviewed data about whether any type of tube feeding can accomplish these goals in this group of patients. Studies limited to patients with cancer, burns, trauma, dysphagic stroke, mechanical obstruction, critical illness, pediatric patients, or patients receiving ventilatory assistance were not considered. The article does not include discussion of ethical issues, since the focus was on clinical evidence.

The authors searched MEDLINE from 1966 through March 1999 and found no relevant randomized clinical trials comparing tube feeding with oral feeding in the severely demented. Thus, a meta-analysis was not possible; rather, they present a summary of the data available. In each section, the authors describe how articles were identified and summarize the findings. The goal was to present the relevant data in a way that is useful to clinicians, patients, families, and perhaps policy makers.

The authors identified no direct data to support tube feeding of demented patients with eating difficulties for any of the commonly cited indications. Tube feeding is a risk factor for aspiration pneumonia, but according to the authors, it has never been shown to be an effective treatment, and neither regurgitated gastric contents nor contaminated oral secretions can be kept out of the airways with a feeding tube. Survival has not been shown to be prolonged by tube feeding. Periprocedure mortality is substantial and...