April 21, 2010
Problems with eating are a big concern in people with Alzheimer's disease, particularly in the late stages when patients cannot feed themselves or swallow and suffer from a variety of medical issues. In about a third of patients in nursing homes, medical staff place feeding tubes into the stomach to provide additional nutrition.
Feeding tubes are often inserted after a patient enters the hospital for another medical issue, with wide variations from state to state and in different regions of the country. A new study published in the Journal of the American Medical Association shows that certain kinds of hospitals are much more likely to resort to using feeding tubes, despite their questionable benefits.
Researchers at Brown University in Providence, R.I., examined Medicare records for seniors with advanced Alzheimer's and other forms of dementia who entered the hospital for intensive care. During the study period, from 2000 to 2007, 280,869 admissions occurred among 163,022 nursing home residents, whose average age was 84. The rate of feeding tube insertion varied widely, from zero to 38.9 per 100 patients admitted to the hospital.
They found that patients who entered for-profit hospitals were more likely to get feeding tubes than those who entered hospitals owned by state or locals governments. Larger hospitals with more than 300 beds had higher rates of feeding tube use than those with fewer than 100 beds, as did those with more intensive care unit use for chronically ill patients in the last six months of life.
Poor patients were also more likely to get feeding tubes. Consistent with earlier studies, so were black and Hispanic patients.
"Feeding tube insertion in persons with advanced cognitive impairment demonstrates a disconnect with the existing evidence of their effectiveness," the authors noted.
Citing these differences in care in different kinds of hospitals and patient socioeconomic and ethnic groups, the authors question whether feeding tubes are necessary in many cases. They note that patients and their families should discuss the risks and benefits of feeding tubes with their physicians.
"The decision to place a feeding tube in a patient with advanced dementia is one of the sentinel decisions that family members and health care professionals grapple with in the nursing home environment," the authors wrote. They cited two large studies that showed that the use of feeding tubes in patients with advanced dementia does not improve survival, prevent aspiration pneumonia, heal bed sores or improve other clinical outcomes.
Given that feeding tubes are of dubious use in advanced Alzheimer's, it may also be important for patients and their families to fill out written advance directives that spell out specific wishes about desire care near the end of life. Do not resuscitate orders and order to forgo artificial hydration and nutrition were all associated with less use of feeding tubes.
"These results are the first to our knowledge to document the national variation in rates of feeding tube insertions among acute care hospitals. Future research is needed to better understand why this variation occurs and to intervene to ensure that feeding tube insertion reflects informed patient preferences based on discussion of the evidence of risks versus benefits."
Joan M. Teno; Susan L. Mitchell; Pedro L. Gozalo; David Dosa; Amy Hsu; Orna Intrator; Vincent Mor: "Hospital Characteristics Associated With Feeding Tube Placement in Nursing Home Residents With Advanced Cognitive Impairment." Journal of the American Medical Association, Feb. 10, 2010, Vol. 303 (No. 6), pages 544-550.