Feeding tube use in advanced dementia patients depends on provider, despite guidelines

Although several guidelines now recommend against the use of feeding tubes in patients with advanced dementia, the type of physician attending those patients may determine whether current recommendations are followed. Feeding tubes are more likely to be used by subspecialists than by hospitalists, according to a new study published in Health Affairs.

Feeding tube use in patients with advanced Alzheimer's disease was previously thought to help prevent malnutrition and delay death, but recent guidelines say feeding tubes do not achieve those goals. In fact, the tubes can lead to agitation, worsening of pressure ulcers, infections, increased aspiration and the need for physical and chemical restraints, according to the American Geriatrics Society. The AGS recommends careful hand-feeding instead. Similarly, the Alzheimer's Association notes feeding tubes do not usually improve nutritional status and that the disadvantages, compared to oral feeding, may outweigh the advantages in long-term use.

Despite such guidelines, researchers found that patients who were attended by subspecialists had gastric feeding tubes inserted in 15.6% of cases, compared to only 1.6% of patients attended by a hospitalist. The analysis included more than 53,000 hospitalizations of nursing-home residents with advanced Alzheimer's disease between 2001 and 2010.

“If you're a hospital with a high rate of feeding tubes [in patients with advanced dementia], it's really important to look at whether these are reflecting informed patient goals and values,” said Dr. Joan Teno, associate director of the Center for Gerontology and Health Care Research at Brown University Medical School, Providence, R.I., and lead author of the Health Affairs study. She said she was surprised by the findings. Researchers had expected to find that the introduction of hospitalists, a relatively new provider position, was driving higher feeding-tube use rates. “I was proven wrong, and that's good,” Teno said.

Subspecialists tend to see patients on a limited basis, and as a result, may not have comprehensive knowledge about the risks and benefits of using feeding tubes with these types of patients, researchers suggested. In addition to Brown Medical School, study researchers were affiliated with Butler Hospital in Providence, the Institute for Aging Research in Boston, and the University of Chicago.

“There is a tendency of subspecialists to focus on fixing a problem, but not necessarily to look at the patient as a whole,” said Teno.

The report also found that in areas where patients were transferred more frequently between facilities, feeding-tube insertion rates were higher. Better coordination of care and communication during handoffs might reduce that trend, the authors suggested.

Patients in the final stages of Alzheimer's disease often lose the ability to swallow or eat on their own, or may forget to do so, leading to complications and hospitalizations. Previous studies have found that as many as 34% of nursing home residents in the U.S. with advanced dementia have feeding tubes, most of which are inserted during an acute-care hospital stay.

Physicians are encouraged to share alternative options, including continued oral feeding, with families and other caregivers of patients with advanced Alzheimer's disease who suffer from persistent eating problems.

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