Feeding Tube Dells Presentation Handouts.pptx …...– No study of optimal feeding assistance alone Simmons, S. F., Walker, K. A., & Osterweil, D. (2004). The Effect of Megestrol

12/30/2015

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Feeding Tubes in Older Adults with Dementia and Delirium

Elizabeth Chapman, MD

Colleen Foley MS, RN, ACNS-BC, APNP

• Recognize relationship between dementia, dysphagia and delirium

• Describe the data related to feeding tubes in older adults with advanced dementia

• Discuss alternatives to feeding tubes in advanced dementia with poor oral intake or dysphagia

• Review legal implications of feeding tubes when guardianship is in place

Objectives

Outline

• Background– Swallowing and Aging– Dementia – Delirium

• Choosing Wisely Guidelines from the American Geriatrics Society

• Evidence Behind G-Tubes in Older Adults with Dementia

• Dobhoff Tubes and Older Adults• Alternatives to Feeding Tubes• Guardianship/ Capacity and Percutaneous Feeding

Tubes

Background: Swallowing and Aging

• Pathway to change from respiratory to digestive and back to respiratory

• Swallow response

• Reaction time in submental muscles

• Lingual strength

* with sarcopenia of head and neck muscles frailty

Become impaired

Rofes, L., Arreola, V., Almirall, J., Cabré, M., Campins, L., García-Peris, P., … Clavé, P. (2011). Diagnosis and Management of Oropharyngeal Dysphagia and Its Nutritional and Respiratory Complications in the Elderly. Gastroenterology Research and Practice, 2011. http://doi.org/10.1155/2011/818979

↑

↓*

Impairment in efficacy and safety of swallow

Dementia (AKA Major Neurocognitive Disorder):

A decline in cognitive abilities from baseline with deficits in memory or executive function or with development of aphasia, apraxia, or agnosia that interferes with independence and is not better explained by delirium or another mental disorder.

Background: Definitions

Adapted from: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

Dementia (AKA Major Neurocognitive Disorder):

A decline in cognitive abilities from baseline with deficits in memory or executive functionor with development of aphasia, apraxia, or agnosia that interferes with independenceand is not better explained by delirium or another mental disorder.

Dementia

Often a chronic and slowly progressing disease

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Dementia with Lewy Bodies

Vascular Dementia

10%

Parkinson’s Disease Dementia

Creutzfeldlt-JakobDisease

FrontotemporalDementia

Huntington’s Disease

Dementia

Alzheimer’s Disease60-80%No Prevention or

Cure

Functional Assessment Staging1: Normal adult

2: Normal older adult

3: Early dementia

4: Mild dementia

5: Moderate dementia

6: Moderately severe dementia

7: Severe dementia

Background: Dementia Stages

Reisberg, B. Functional Assessment Staging (FAST). Psychopharmacology Bulletin. 1988:24: 653-659.

AdvancedDementia

Moderately Severe Dementia:

Background: Advanced Dementia

Severe Dementia:

Background: Advanced Dementia

Eating problems and weight loss in advanced stages are an expected part of the

natural progression of the disease

Background: Advanced DementiaBackground: The Drive to Maintain

Weight at SNFs

• CMS requires monthly weights on nursing home residents

• Facilities that do not address “unintended weight loss” can receive citations

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/nursinghomedatacompendium_508.pdf

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Background: Delirium

• Acute change from a patients baseline mental status– Waxes and wanes– Inattention– Disorganized thinking– Altered consciousness

• Three forms:– Hypoactive– Hyperactive/Agitated– Mixed


• Fluctuating Mental Status:– Ability to swallow or

participate in evaluation may vary from day to day or minute to minute

• Inattention:– Trouble focusing on

eating, swallowing

– Difficulty following instructions

Background: Delirium Features

• Disorganized Thinking:– Disoriented to

situation or place

– Miss cues to eat, swallow


Marcantonio ER, Ngo LH, O’Connor M, Jones RN, Crane PK, Metzger ED, Inouye SK. 3D-CAM: Derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium. Ann Intern Med. 2014; 161: 554-61.

• Altered Consciousness:– Too lethargic to

participate

– Too paranoid to eat


Marcantonio ER, Ngo LH, O’Connor M, Jones RN, Crane PK, Metzger ED, Inouye SK. 3D-CAM: Derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium. Ann Intern Med. 2014; 161: 554-61.

Background: Delirium Risk Factors… you can’t fix them all!

Non-Modifiable Modifiable• Dementia or Cognitive Impairment

• Advanced Age (>65)

• History of delirium, stroke, neurological disease,

falls/ gait disorder

• Multiple comorbidities

• Male

• Chronic Renal or Hepatic Disease

• Primary neurologic disease

• Sensory Impairment

• Immobilization

• Tethers

• Electrolyte Imbalance

• Environment

• Pain

• Poor Sleep

• Dehydration

• Poor Nutrition

• Surgery

• Certain Medications (i.e. benzodiazipines)

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Background: Delirium over time

Cognitive Function

Time

Insult

6 months


Many Hospitalized Advanced Dementia

Patients with Dysphagia

Dementia Increases Dysphagia Risk

Dementia Increases Delirium Risk

Delirium Increases Dysphagia Risk

Perfect Storm of Risk Factors

Background: Delirium/Swallowing Conundrum #1

Risk of Aspiration

Background: Delirium/Swallowing Conundrum #2

Delirium Clear Delirium Not Clear

When to perform swallow study???

Choosing Wisely

“Aims to promote conversations between providers and patients by helping patients choose care that is:

– Supported by evidence

– Not duplicative of tests or procedures already received

– Free from harm

– Truly necessary”

Adapted from: http://www.choosingwisely.org/about-us/

Choosing Wisely: AGS List

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G-Tubes in Older Adults with Dementia

The data are limited:

• Most studies examine those with “advanced dementia”

• Most studies are retrospective or observational

G-Tubes in Older Adults with Dementia: Incidence

Mitchell S, Teno JM, Kiely DK, Shaffer ML, Jones RN, Prigerson HG, Volicer L, Givens JL, Hamel MB. The clinical course of advanced dementia. N Engl J Med 2009; 361: 1529-38.

85.8% developed eating problems

54.8% died

41.1% developed pneumonia

18 months

8.0% were tube fed

7.2% of these were tube-fed

323 nursing home residents with advanced dementia in Boston area

G-Tubes in Older Adults with Dementia: State by State Prevalence

Mitchell SL, Teno JM, Roy J, Kabumoto G, Mor V. Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment. JAMA 2003: 290(1): 73-80.

>7-fold difference

G-Tubes in Older Adults with Dementia: Change Over Time

• Purpose: Investigate trends in PEG tube placement in older adults

• Design: Retrospective review of Nationwide Inpatient Sample data set

• Results: – Although the benefits of these tubes are not clear

at best and not present at worst, more and more were being placed.

– 38% increase in all comers from 1993-2003– 100% increase in those with Alzheimer’s Disease

from 1993-2003

Mendiratta P et al. “Trends in percutaneous endoscopic gastrostomy placement in the elderly from 1993 to 2003” Am J Alzheimers Dis Other Demen. 2012 December ; 27(8): 609–613.

Why is a feeding tube even considered in advanced dementia?

• Guilt

• “Do everything” approach

• Quantity of life valued over quality

• Perception that it will improve problems (poor appetite, weight loss, dehydration)


• End points in studies for G-Tubes in this population focus on:– Mortality

– Medicare costs

– Hospital and ER usage

– Aspiration risk

– Pressure ulcer risk

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• Purpose: Evaluate enteral tube feeding for older people with advanced dementia

• Design: Systematic Review• Results: No benefit in most studies, in some

mortality was higher– Quality of life: (not specifically measured) Non-

significant increase in restraint use– Nutritional parameters: no increase in albumin– Pressure ulcers: variable results; no clear benefit– Aspiration: higher risk with enteral feeding tubes

Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia (Review). Cochrane Database of Systematic Reviews 2009, Issue 2.


• Purpose: Review literature for gastrostomy tubes in advanced dementia

• Design: Systematic review

• Results:– Mortality: No clear benefit across 10 studies

– Those with dementia or >80 years old may have increased mortality

Goldberg LS, Altman KW. The role of gastrostomy tube placement in advanced dementia with dysphagia: a critical review. Clinical interventions in aging 2014; 9: 1733-9.


• Purpose: Estimate Medicare inpatient care costs in year after G-tube placement

• Design: Retrospective cohort; Medicare claims data of nearly 4000 patients with/without tubes analyzed

• Results: – Increase in inpatient costs

– Increase in hospital days and ICU days

Hwang D et al. Feeding tubes and health costs post insertion in nursing home residents with advanced dementia. Journal of Pain and Symptom Management 2014; 47: 1116-20.

G-tubes in Older Adults with Dementia

• Purpose: Evaluate outcomes of those with advanced dementia who are/aren’t tube fed

• Design: Prospective observational cohort study– 67 patients, >60 years old; 57 classified as a FAST 7c; – 36 oral feeding and 31 for alternative feeding (n = 28 nasogastric

tube, 3 gastrostomies).

• Results:– 3- month mortality rate: 11.1% for oral feeding group vs 41.9%

for alternative feeding group (p = 0.004)– 6-month mortality rate: 27.8% with oral feeding and 58.1% with

alternative feeding, (p = 0.012)– Aspiration pneumonia rate: higher in alternative feeding group (p

= 0.006)– No difference in the number of hospital admissions

Cintra MT, de Rezende NA, de Moraes EN, Cunha LC, da Gama Torres HO. A comparison of survival, pneumonia, and hospitalization in patients with advanced dementia and dysphagia receiving either oral or enteral nutrition. J Nutr Health Aging. 2014 Dec;18(10):894‐9.


• In general, the data does not show benefit to G-Tubes in this population– Essentially no data on those with less severe

dementia

– Heterogeneity among studies

– No randomized trials

Dobhoff tubes and older adults

• Data similar G-Tubes– Mortality: No benefit, may be higher

• Other considerations– Discharge disposition

• SNFs often do not accept Dobhoff tubes• LTACHs may be only option

– Possibility for erosions of nasopharynx – Smaller diameter can clog more easily– Patient discomfort– More restraint use in hospital?

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Alternatives to Feeding Tubes

Very little data regarding efficacy of alternatives!


• Proposed alternatives: – Environmental modifications

– High-calorie supplements

– Careful hand-feeding

– Appetite stimulants

Alternatives: Environmental Changes

• Make meals a social event

• Quiet or pleasant music

• Less clutter

• More visually attractive food– Dementia loss of sense of semll

reduced ability to taste

Images from: http://www.vitalitymedical.com/media/extendware/ewimageopt/media/inline/31/2/wheelchair-table-and-over-bed-table-adjustable-by-carex-8bb.jpghttp://www.stockfreeimages.com/1134254/Bedside-urinal-as-used-in-hospitals.html



Image from: http://food-management.com/healthcare/room-service-way-order-great-hcahps-scores


• Good “meal hygiene”– Up in a chair

– Lights on

– Food uncovered, accessible, correct temperature

– Food preferences considered

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Alternatives: Appetite Stimulants

• Most studies are not done with older adults– FDA-approved for HIV, cancer cachexia

– Off-label use for dementia patients

• Little consensus on use in older adults

Alternatives: Appetite Stimulants

• Purpose: Analyze effect of megestrol acetate on intake in nursing home residents

• Design: Prospective observational study– 17 NH residents; megestrol acetate x 63 days

– Each received “usual NH care” weeks 1, 3, 5 and “optimal feeding assistance” weeks 2, 4, 6

• Results:– No increased intake with Megestrol acetate during usual NH

care

– Intake did improve with optimal feeding assistance and megestrol

– No study of optimal feeding assistance alone

Simmons, S. F., Walker, K. A., & Osterweil, D. (2004). The Effect of Megestrol Acetate on Oral Food and Fluid Intake in Nursing Home Residents: A Pilot Study. Journal of the American Medical Directors Association, 5(1), 24–30. http://doi.org/10.1016/S1525-8610(04)70040-7


Final point: Difficult to measure pleasure and comfort that oral feeding brings

Guardianship and G-Tubes

• Guardian versus power of attorney:Person unable

to make decisions

Has HC‐POA document

No HC‐POA

Activate POA Needs guardian

Patient refuses certain

interventions


• How does a person get an activated POA for health care?– Two physicians/psychologists assess patient’s

capacity to make medical decisions

– If incapacitated, providers sign document and surrogate becomes decision-maker

– Decisions made based on what person would have wanted if he/she could speak for himself/herself

Guardianship and G-Tubes: Wisconsin HC- POA Document

Person may decide whether or not to give the authority to remove feeding tubes to designated POA agent.

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• How does a person get a guardian?– Paperwork (lots of it!)

– Lawyers

– Money (usually thousands of dollars)

– Judge decides whether a person has competency to make decisions

– If not, then a guardian is appointed

– Guardian may be family, friend, or stranger

– Decisions made in best interest of patient (Preservation of life is “in best interest”.)


• Permanent feeding tubes placed in those with a guardian can only be removed in certain circumstances– No longer indicated medically

– Persistent vegetative state

– End-of-life

– Prior to incapacitation, patient had documented preference not to have a feeding tube


Here comes trouble…

• Many patients who need guardians have never completed a living will or health care power of attorney

• Those who have completed the documents often have not discussed wishes with their surrogates

• A sizeable number of guardians do not know the patient prior to becoming the guardian


• Decision needs to be made carefully!

• Even though there is no clear benefit to tube feeds in those with advanced dementia, the tubes often cannot be removed once placed.

Case #1

• Bob D – 92 y/o man with a h/o dementia (moderate) – Admitted with a fall but no fractures– Delirious on admission and thereafter with little

improvement– Severely impaired swallowing abilities found– Dobhoff tube placed– Frequently restrained due to pulling tubes/lines– Never improved swallowing abilities– Discharged with Dobhoff tube in place to LTACH

Case #2

• Betty P – 68 y/o woman – Admitted after a car rolled over her

– Did not have dementia at baseline and intact functionally at baseline

– Very delirious during hospital stay (>30 days)

– G-Tube placed

– Guardianship proceedings were initiated; sister did not want to be her decision-maker

– Unclear if her cognition will recover

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Case #3

• John L – 88 y/o man with a h/o advanced dementia– Admitted after wandering outside and getting hit

by a car– Sustained some fractures and a hip hematoma– Discharged to a SNF and returned with

pneumonia– Dysphagia found, Dobhoff tube placed– Became more delirious– After multiple family discussions, discharged to

home with hospice without a Dobhoff tube or G-Tube

Case #4

• Jane P – 74 y/o woman with intact cognition at baseline, caregiver for husband with dementia– Sustains brain hemorrhage and develops

unilateral weakness, lethargy

– Initial swallowing evaluation notes only mild dysphagia

– Confusion worsens as day goes by

– Aspirates and gets intubated

– Dobhoff tube placed for temporary nutrition

Is G-Tube the right next step?

#1- Does the patient hold a diagnosis of dementia?

#2- Is dementia is a suspected* diagnosis? (*This is something that may not be documented anywhere!)

#3- Is or will delirium will be a player?

#4- Trust your gut!

Take Home Points

• Dementia, dysphagia, and delirium commonly occur together in the hospital

• Nutrition options in this context are complicated from a legal, ethical, and practical perspective

• Feeding tubes have not been shown to improve outcomes in those with advanced dementia

• Make a POA for health care and share your preferences with your agents!

References

Cintra MT, de Rezende NA, de Moraes EN, Cunha LC, da Gama Torres HO. A comparison of survival, pneumonia, and hospitalization in patients with advanced dementia and dysphagia receiving either oral or enteral nutrition. J Nutr Health Aging. 2014 Dec;18(10):894‐9.

Tamara G. Fong, Samir R. Tulebaev, and Sharon K. Inouye. (2009). Delirium in elderly adults: diagnosis, prevention and treatment. NIH. Nat Rev Neurol. 2009 April ; 5(4): 210–220 http://www.choosingwisely.org/doctor-patient-lists/american-geriatrics-society/

Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia (Review). Cochrane Database of Systematic Reviews 2009, Issue 2.

Goldberg LS, Altman KW. The role of gastrostomy tube placement in advanced dementia with dysphagia: a critical review. Clinical interventions in aging 2014; 9: 1733-9.

Hwang D et al. Feeding tubes and health costs postinsertion in nursing home residents with advanced dementia. Journal of Pain and Symptom Management 2014; 47: 1116-20.

Mendiratta P et al. “Trends in percutaneous endoscopic gastrostomy placement in the elderly from 1993 to 2003” Am J AlzheimersDis Other Demen. 2012 December ; 27(8): 609–613.

Rofes, L., Arreola, V., Almirall, J., Cabré, M., Campins, L., García-Peris, P., … Clavé, P. (2011). Diagnosis and Management of Oropharyngeal Dysphagia and Its Nutritional and Respiratory Complications in the Elderly. Gastroenterology Research and Practice, 2011. http://doi.org/10.1155/2011/818979

Simmons, S. F., Walker, K. A., & Osterweil, D. (2004). The Effect of Megestrol Acetate on Oral Food and Fluid Intake in Nursing Home Residents: A Pilot Study. Journal of the American Medical Directors Association, 5(1), 24–30. http://doi.org/10.1016/S1525-8610(04)70040-7

Documents

Feeding Tube Dells Presentation Handouts.pptx …...– No study of optimal feeding assistance alone Simmons, S. F., Walker, K. A., & Osterweil, D. (2004). The Effect of Megestrol