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Care of the older person
There is no evidence to suggest that ET feeding improves survival in people with severe dementia
  1. Karen Harrison-Dening
  1. Research and Publications, Dementia UK, London EC3N 1RE, UK
  1. Correspondence to Dr Karen Harrison-Dening, Research and Publications, Dementia UK, London EC3N 1RE, UK; Karen.Harrison-Dening{at}dementiauk.org

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Commentary on: Davies N, Barrado-Martín Y, Vickerstaff V, et al. Enteral tube feeding for people with severe dementia. Cochrane Database Syst Rev 2021;8:CD013503.

Implications for practice and research

  • Percutaneous endoscopic gastrostomy (PEG) feeding does not prolong the life of a person with severe dementia and leads to an increased risk of developing pressure sores.

  • There is no evidence that enteral feeding improves the quality of life of a person with severe dementia, although research into quality of life in this population is challenging.

Context

There are an estimated 890 000 people with dementia (PWD) in the UK.1 Dementia is now the leading cause of death in England and Wales.2 Identifying when PWD are reaching the end of life is challenging.

People with severe dementia suffer from a range of symptoms, with pressure sores, agitation and eating problems common as the end of life approaches.3 There is increasing clinical and research interest in how a palliative approach may benefit PWD, such as interventions of artificial hydration and nutrition. There are two types of enteral tube (ET) feeding: nasogastric tube and PEG; both are invasive and present risks. PEG is more invasive, requiring surgery under general anaesthetic, and so presents higher risks, for example, aspiration pneumonia and wound infection.

Methods

A Cochrane review assessed the effectiveness and safety of ET feeding for people with severe dementia who develop problems with eating and swallowing.3 Davies et al 3 searched for randomised control trials (RCTs) or controlled non-randomised studies involving adults with a diagnosis of primary degenerative dementia who had severe cognitive and functional impairment and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of ET feeding in comparison with usual care or enhanced standard care. Their primary outcomes were survival time, quality of life and pressure sores.

Findings

There were no eligible RCTs, although 14 controlled, non-randomised studies were included, all of which compared outcomes between groups of people assigned to ET feeding or oral feeding. While some studies controlled for a range of confounding factors, there were high or very high risks of bias due to confounding in all studies, as well as a high or critical risk of selection bias in some. With regard to survival time, four studies (n=36 816) assessed the effect of PEG feeding on survival time and overall found no evidence to suggest an increase and study quality was very low. With regard to pressure sores, one study (PEG n=1585; no enteral feeding n=2836) found PEG presented an increased risk of pressure sores. No studies reported on quality of life.

Commentary

Davies et al 3 found no evidence to suggest that ET feeding improves survival, improves quality of life or reduces mortality. Similarly, there is no evidence to suggest ET feeding of PWD improves outcomes for family carers, such as depression and anxiety, reduces carer burden, or improves their satisfaction with care. Whether or not to embark on ET feeding in severe dementia remains controversial. Of concern is that there will continue to be divided opinions in clinical practice as whether to proceed or not in a situation where a person in the severe stages of dementia has problems swallowing.

Many clinicians believe that ET feeding does not help people with severe dementia but feel pressurised by family members, societal or local laws to intervene. Having sound evidence to back up their beliefs would aid them in the often difficult conversations with families at such times. On the one hand, we have learnt from the updated Cochrane review3 that there is little evidence on outcomes for this population, but because the study designs may be flawed any evidence remains weak and unfit to guide clinical decision-making. Conversely, families want to do everything possible for someone who is ill, but may lack information about what the best approach might be and turn to clinicians for expert guidance. Accordingly, conversations and shared decision-making with families on the issues of ET feeding can be fraught. However, the authors of this Cochrane review3 have included an excellent lay summary which outlines the main points that could be used in everyday practice, from describing what tube feeding is and how this relates to people with severe dementia, and clearly states the findings of their enquiry. Given to families affected by dementia, this in of itself would make an excellent starting point to holding these difficult conversations.

References

Footnotes

  • Twitter @kdening

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.