Enteral tube feeding for older people with advanced dementia

 

Abstract

Background

The use of enteral tube feeding for patients with advanced dementia who have poor nutritional intake is common. In one US survey 34% of 186,835 nursing home residents with advanced cognitive impairment were tube fed. Potential benefits or harms of this practice are unclear.

Objectives

To evaluate the outcome of enteral tube nutrition for older people with advanced dementia who develop problems with eating and swallowing and/or have poor nutritional intake.

Search methods

The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched in April 2008. Citation checking was undertaken. Where it was not possible to accept or reject, the full text of the citation was obtained for further evaluation.

Selection criteria

Randomized controlled trials (RCTs), controlled clinical trials, controlled before and after studies and interrupted time series studies that evaluated the effectiveness of enteral feeding via a nasogastric tube or via a tube passed by percutaneous endoscopic gastrostomy (PEG) were planned to be included. In addition, controlled observational studies were included. The study population comprised adults aged 50 and over (either sex), with a diagnosis of primary degenerative dementia made according to validated diagnostic criteria such as DSM-IV or ICD-10 (APA 1994; WHO 1993) and with advanced cognitive impairment defined by a recognised and validated tool or by clinical assessment and had poor nutrition intake and/or develop problems with eating and swallowing. Where data were limited we also considered studies in which the majority of participants had dementia.

Data collection and analysis

Data were independently extracted and assessed by one reviewer, checked by a second and if necessary, in the case of any disagreement or discrepancy it was planned that it would be reviewed by the third reviewer. Where information was lacking, we attempted contact with authors. It was planned that meta-analysis would be considered for RCTs with comparable key characteristics. The primary outcomes were survival and quality of life (QoL).

Main results

No RCTs were identified. Seven observational controlled studies were identified. Six assessed mortality. The other study assessed nutritional outcomes. There was no evidence of increased survival in patients receiving enteral tube feeding. None of the studies examined QoL and there was no evidence of benefit in terms of nutritional status or the prevalence of pressure ulcers.

Authors' conclusions

Despite the very large number of patients receiving this intervention, there is insufficient evidence to suggest that enteral tube feeding is beneficial in patients with advanced dementia. Data are lacking on the adverse effects of this intervention.

 

Plain language summary

There is insufficient evidence to suggest that enteral tube feeding is beneficial in patients with advanced dementia. Data are lacking on the adverse effects of this intervention

Patients with advanced dementia often develop dysphagia (difficulties swallowing). They also experience changes in appetite and apraxia (difficulty co-coordinating movements) and may have difficulties feeding themselves. Two methods of enteral tube feeding are commonly used: the administration of food and fluids via a nasogastric tube (a tube that is passed through the nose and into the stomach) or via a percutaneous endoscopic gastrostomy (PEG) where a feeding tube is inserted into the stomach and is accessed through a permanent incision in the abdominal wall. The decision to use artificial hydration and nutrition in someone with dementia is often emotive and complex. Relatives and carers may request the intervention because they are concerned that the patient may starve; clinicians may be aware of the risks but feel pressurised by institutional, societal or even legal directives to intervene. We found no conclusive evidence that enteral tube nutrition is effective in terms of prolonging survival, improving quality of life, or leading to better nourishment or decreasing the risk of pressure sores. It may actually increase the risk of developing pneumonia due to inhaling small quantities of the feed and even death.  This area is difficult to research but better designed studies are required to provide more robust evidence.

 

摘要

背景

腸道灌食法(Enteral tube feeding)對於較年長嚴重失智症患者(advanced dementia)的影響

使用腸道營養治療是嚴重失智症患者攝取營養不良常見的治療方式。在美國針對186,835位患有嚴重認知損傷、居住於護理之家住民的調查中，有34進行管灌餵食(tube fed)。這項療法的潛在的效益或損害尚不清楚。

目標

評估腸道營養治療對於較年長嚴重失智症且發展出進食及咀嚼及/或貧乏的營養攝取之人們的結果，於是進行了以下的研究。

搜尋策略

2008年4月搜尋Cochrane Dementia and Cognitive Improvement Group (CDCIG)的Specialized Register資料庫及The Cochrane Library、 MEDLINE、 EMBASE、 PsycINFO、 CINAHL 及 LILACS。進行了索引的檢查。若無法接受或是拒絕，則會取得參考文獻的全文進行評估。

選擇標準

預計納入採用RCTs、臨床對照試驗、研究前後的對照及間斷時間序列研究(interrupted time series studies)，評估藉由鼻胃管(nasogastric tube)或經由經皮內視鏡胃造廔術(percutaneous endoscopic gastrostomy (PEG))腸灌食的效益。 此外，對照觀察研究也被納入。研究對象包括:年齡為50及超過50的成年人(任一性別)，具有根據診斷確效如DSMIV or ICD10 (APA 1994; WHO 1993)而判定有基本退化性失智症的人，以及具有藉由認知及確效工具而定義為嚴重認知損傷、或藉由臨床評估、以及具有貧乏營養攝取、及/或隨著進食及咀嚼發展成問題者。即使資料有限，我們也(還是)認為該研究內的大多數參加者具有失智症。

資料收集與分析

獨立地摘錄資料，且由一位回顧者評估，由第二位檢查。且若有必要，例如意見不一，或有所差異，將另由第三個回顧者回顧。資訊缺乏之處，我們會與作者們聯繫。因為RCTs，所以計畫將考慮伴隨著可進行比較的關鍵特性，進行統合分析。該基本結果是:存活及生活品質(QoL)。

主要結論

未鑑別出任何RCTs。7項根據觀察的對照研究為:6個評估死亡率。另1項研究則評估了病患的營養狀況。 接受腸道營養治療的病患中，並無證據顯示存活率有所增加。沒有研究詳細檢查生活品質，且在營養狀態方面或褥瘡盛行率方面無證據顯示有所效益。

作者結論

儘管有相當大數目的病患接受這介入(治療)，但證據不足以指出腸道營養治療對嚴重失智症病患有所助益。本介入(治療)欠缺不良效果的資料。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

嚴重失智症病患常發展出吞嚥困難(dysphagia)。他們也體驗到食慾上的變化以，及失用症(操作能力不佳apraxia)且可能在自己食用食品時遭遇困難。 屬於腸道營養治療的兩個方法常被使用:食物及流體經由鼻胃管(nasogastric tube)給予，或經由一經皮內視鏡胃造廔術(percutaneous endoscopic gastrostomy (PEG))該處一餵食管被置入胃內且經由腹腔壁永久性插入給予病患食物。 對某位失智症患者是否使用人為給水及供給營養的決定，通常具有感情因素且決定的過程複雜。親戚及照護者可能要求給予該介入(治療)，因為他們考慮到病患可能挨餓；臨床醫師可要注意到治療的風險，但會受到醫療院所的、社會的或甚至法律上對於介入指導之壓力。 我們發現在延長存活、改善生活品質、或引入更好的營養品、或減少褥瘡的風險等方面，沒有具有結論性的證據可證明腸道營養治療對前述因素有效。 因為吸入小量餵食物，會增加肺炎甚至死亡的風險。這部分的研究困難，需要設計更為優良的研究來提供更多強而有力的證據。