Tube feeding in advanced dementia: an exploratory survey of physician knowledge.

The administration of artificial nutrition by means of a percutaneous endotcopic gastrostomy (PEG) tube in older persons in the advanced stages of dementia it commonplace, yet the treatment it associated with significant treatment burdent and unclear benefits in this population. In addition, there it wide and unexplained geographic variability in the use of PEG in advanced dementia, which may them partly from physiciant' lack of understanding about its indications, risks, benefits, and effect on quality of life in advanced dementia. This study was a mail survey undertaken to assess phytician knowledge regarding tube feeding in advanced dementia and explore whether certification in geriatrics or other phytician characteristics are associated with phytician knowledge. To assess knowledge about tube feeding, we asked participants to rate the importance of commonly cited, but non-evidence based, indications far tube feeding in advanced dementia, including recurrent aspiration pneumonia, abnormal swallowing evaluations, abnormal nutritionalparameters, preventing an uncomfortable death, and others. Discrepancies between phytician knowledge and current evidence regarding tube feeding in advanced dementia were found, indicating a need for improved education of primary care physicians in order to ultimately provide better end-oflife care far patients with advanced dementia. Keywords: tube feeding; dysphagia; feeding difficulties; advanced dementia; end-of-life care Patients with late-stage dementia commonly develop decreased oral intake as their illness progresses (Blandfbrd, 2003; Volicer et al., 1989). Although potentially reversible causes exist, such as medication side effects and infection, patients with advanced dementia eventually experience irreversible reeding difficulties as part of the progression of their dementia. Persistent failure to eat is characterized by aversive feeding behaviors and progressive oral dyspraxia, which result from the irreversible neurodegenerative process affecting anatomical areas of the brain controlling the oral phase and other aspects of eating (Blandfbrd, 2003). Persistent failure to eat can be considered a marker of the terminal phase of the illness (Blandford, Watkins, & Mulvihill, 1998; Gillick, 2000). Long-term tube feeding is often used under these circumstances, although clear benefit has not been shown, and its use is being questioned (Casarett, Kapo, & Caplan, 2005; Gillick, 2000; McCann, 1999; Meier, Ahronheim, Morris, BaskinLyons, & Morrison, 2001 ). We present this study as an exploration of physician knowledge and attitudes about tube feeding in advanced dementia and believe that it serves as useful pilot work for a larger analysis. The number of percutaneous endoscopic gastrostomy (PEG) feeding rubes placed in older patients has risen substantially over the last 10 to 15 years (Grant, Rudberg, & Brody, 1998). More than one-third of severely cognitively impaired nursing home residents in the United States receive tube feeding, with substantial geographic variation in its use (Ahronheim, Mulvihill, Sieger, Park, & Fries, 2001; Mitchell, Teno, Roy, Kabumoto, & Mor, 2003). The high prevalence and variability most likely stem partly from physicians' lack of understanding about its indications, risks, benefits, and effect on quality of life (Ahronheim, 1996; Callahan, Haag, Buchanan, & Nisi, 1999). The nutrition and geriatric literature suggest that decisions to insert a PEG in patients with advanced dementia are based on beliefs rather than on empirical evidence (Ahronheim, 1996; Finucane, Christmas, & Travis, 1999; Morley, 2004). For example, abnormal swallowing evaluations are seen by many as an indication for PEG placement (Callahan et al., 1999), but evidence suggests that these evaluations lack sufficient sensitivity and specificity to predict risk of clinical aspiration, pneumonia, or other clinical outcomes in dementia (Crogan, Burke, Caplan, & Denman, 1994; Feinberg, 1993; Groher, 1994). …