For patients with advanced dementia, eating, and in particular swallowing, is difficult. Certain types of doctors are more likely than others to insert gastric feeding tubes into patients with advanced dementia rather than feeding them by hand, according to a study published in the journal Health Affairs this month.
Professor of Medicine Joan Teno, who led the study, has researched the effects of feeding tubes in geriatric patients for years, she said. The efficacy of feeding tube use has come into question in recent years.
“Basically the evolving literature says that it doesn’t improve survival, it doesn’t prevent aspiration pneumonia, (it) doesn’t prevent pressure ulcers. So people are questioning, ‘Why are we doing this procedure?’” Teno said.
The frequency of feeding tube insertion is also highly variable, Teno said, with doctors in some fields of medicine calling for the procedure in less than 4 percent of patients with advanced dementia, and others calling for it in up to 44 percent of cases.
A large part of the present study was dedicated to figuring out whether feeding tube insertions were being made in hospitals or in hospices, Teno said. She and her colleagues found that the vast majority of feeding tube are inserted in hospitals.
This led Teno to wonder whether the type of physician treating a patient affects the likelihood of feeding tube insertion. There are more hospitalists — doctors who focus on the care of acutely ill hospitalized patients — than primary care physicians in hospitals where advanced-stage dementia patients are treated. This means patients with dementia often transition between multiple caregivers.
“One of the concerns was, when you start introducing a new physician in this process, it means you have to have a handoff,” Teno said, which led her to wonder whether this handoff was responsible for the increased rates of feeding tube use.
Her study found that primary care physicians and hospitalists had the same low rate of feeding tube use, Teno said. But when subspecialists were added into the equation, the rate of feeding tube use increased.
Physicians should take caution in using feeding tubes at all, Teno said, adding that the disadvantages often outweigh the advantages in patients with dementia.
A central question is whether using feeding tubes improves a patient’s quality of life, Teno said. But this study and previous ones show feeding tubes rarely improve quality of life, and instead cause many people agitation and increase rates of pressure ulcers.
“This is a case where probably doing less is better for the patient,” Teno said. “By doing less, I mean really trying to assiduously offer the patient food, and to rely on hand feeding to help the patient regain their appetite.” She added that subspecialists need to be educated about “the risks and benefits of a feeding tube insertion for this older population.”
This study brought a new nuance of feeding tube use to light, wrote Deon Hayley, associate professor in the division of general and geriatric medicine at the University of Kansas School of Medicine, in an email to The Herald.
“This is new information identifying retrospectively physician care and characteristics with tube feeding placement,” she wrote.
By determining the physicians “associated with a higher rate of tube feeding placement in patients with end-stage dementia, we can focus on change of behavior, perhaps through education or system changes,” Hayley wrote.
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