The current study aimed to conduct a systematic review and meta-analysis to explore the efficacy and safety of tube feeding in patients with advanced dementia.
Systematic review and meta-analysis.
Setting and Participants
PubMed, Medline, Embase, and Cochrane Library were searched from inception until March 7, 2020, to obtain relevant studies.
Feeding with nasogastric tube or percutaneous endoscopic gastrostomy (PEG).
We evaluated the associations of tube feeding and the risk of mortality, period of survival days, tube-related complications, and nutritional status. Data from original studies were synthesized by using a random-effects model. Each selected article was assessed for bias using the Newcastle-Ottawa Scale. A narrative synthesis and pooled analyses are reported.
Twelve trials were eligible, involving 1805 patients with tube feeding (mean age: 82.8 years; 71.3% female) and 3861 without tube feeding (mean age: 82.7; 68.7% female). For mortality rate, patients with advanced dementia with tube feeding are associated with significantly higher mortality rate [k = 8; odds ratio (OR) 1.79; 95% confidence interval (CI) 1.04–3.07; P = .03]. Initially, no association was found for the risk of pneumonia and pressure sore between groups. However, sensitivity analysis showed patients with advanced dementia with PEG tube feeding have significantly higher risk of pneumonia (OR 3.56; 95% CI 2.32–5.44; P < .001) and pressure sore (OR 2.25; 95% CI 1.92–2.63; P < .001). Finally, no association was found for the survival period and nutritional status between groups.
Conclusions and Implications
This meta-analysis indicates that tube feeding is associated with increased mortality rate and possible tube-related complications, but not improves with prolonging survival days and nutritional status. Shared decision-making routinely before insertion of a tube between caregivers and physicians is recommended.
To read this article in full you will need to make a payment
Purchase one-time access:Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:Subscribe to Journal of the American Medical Directors Association
Already a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
- Alzheimer's disease.Lancet. 2016; 388: 505-517
- Decision-making for long-term tube-feeding in cognitively impaired elderly people.CMAJ. 1999; 160: 1705-1709
- The clinical course of advanced dementia.N Engl J Med. 2009; 361: 1529-1538
- ESPEN guidelines on nutrition in dementia.Clin Nutr. 2015; 34: 1052-1073
- The impact of dysphagia on mortality of nursing home residents: Results from the Nutrition Day Project.J Am Med Dir Assoc. 2018; 19: 775-778
- Dementia: Support People with Dementia and Their Carers in Health and Social Care.National Institute for Health and Care Excellence (UK), London2006
- Dementia: Assessment, Management and Support for People Living with Dementia and Their Carers.National Institute for Health and Care Excellence (UK), London2018
- American Geriatrics Society feeding tubes in advanced dementia position statement.J Am Geriatr Soc. 2014; 62: 1590-1593
- Factors predictive of survival after percutaneous endoscopic gastrostomy in the elderly: Is dementia really a risk factor?.Am J Gastroenterol. 2008; 103 (quiz 17): 1011-1016
- Efficacy and ethics of artificial nutrition in patients with neurologic impairments in home care.J Clin Neurosci. 2013; 20: 220-223
- Enteral nutrition in dementia: A systematic review.Nutrients. 2015; 7: 2456-2468
- Outcomes of enteral nutrition for patients with advanced dementia: A systematic review.J Nutr Health Aging. 2015; 19: 169-177
- Enteral tube feeding for older people with advanced dementia.Cochrane Database Syst Rev. 2009; : CD007209
- Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: Elaboration and explanation.BMJ. 2015; 350: g7647
- Survival of a cohort of elderly patients with advanced dementia: Nasogastric tube feeding as a risk factor for mortality.Int J Geriatr Psychiatry. 2005; 20: 363-370
- Nasogastric tube feeding versus assisted hand feeding in-home healthcare older adults with severe dementia in Taiwan: A prognosis comparison.BMC Geriatr. 2020; 20: 60
- A comparison of survival, pneumonia, and hospitalization in patients with advanced dementia and dysphagia receiving either oral or enteral nutrition.J Nutr Health Aging. 2014; 18: 894-899
- High short-term mortality in hospitalized patients with advanced dementia: Lack of benefit of tube feeding.Arch Intern Med. 2001; 161: 594-599
- Survival in older adults with dementia and eating problems: To PEG or not to PEG?.Clin Nutr. 2016; 35: 1512-1516
- The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment.Arch Intern Med. 1997; 157: 327-332
- Feeding tubes and the prevention or healing of pressure ulcers.Arch Intern Med. 2012; 172: 697-701
- Tube feeding in the demented elderly with severe disabilities.Isr Med Assoc J. 2006; 8: 870-874
- Matter over mind: A randomised-controlled trial of single-session biofeedback training on performance anxiety and heart rate variability in musicians.PLoS One. 2012; 7: e46597
- How should meta-regression analyses be undertaken and interpreted?.Stat Med. 2002; 21: 1559-1573
- Assessing the influence of a single study in the meta-analysis estimate.Stata Technical Bulletin. 1999; 8
- A basic introduction to fixed-effect and random-effects models for meta-analysis.Res Synth Methods. 2010; 1: 97-111
- Evaluation of the benefits of enteral nutrition in long-term care elderly patients.J Am Med Dir Assoc. 2008; 9: 657-662
- Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia.Arch Intern Med. 2003; 163: 1351-1353
- Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia.Am J Gastroenterol. 2000; 95: 133-136
- Long-term enteral feeding of aged demented nursing home patients.J Am Geriatr Soc. 1990; 38: 1195-1198
- Tube feeding in individuals with advanced dementia: A review of its burdens and perceived benefits.J Aging Res. 2019; 2019: 7272067
- Use of tube feeding to prevent aspiration pneumonia.Lancet. 1996; 348: 1421-1424
- Gastroenteric tube feeding: Techniques, problems and solutions.World J Gastroenterol. 2014; 20: 8505-8524
- Factors associated with the trend of physical and chemical restraint use among long-term care facility residents in Hong Kong: Data from an 11-year observational study.J Am Med Dir Assoc. 2017; 18: 1043-1048
- Gastrostomies in dementia: Bad practice or bad evidence?.Age Ageing. 2010; 39: 282-284
- Tube feeding in advanced dementia: The metabolic perspective.BMJ. 2006; 333: 1214-1215
- Decision-making and outcomes of feeding tube insertion: A five-state study.J Am Geriatr Soc. 2011; 59: 881-886
- International survey of physicians' perspectives on percutaneous endoscopic gastrostomy tube feeding in patients with dementia and review of literature.Cureus. 2019; 11: e4578
- Tube feeding preferences among nursing home residents.J Gen Intern Med. 1997; 12: 364-371
- Percutaneous feeding tubes in individuals with advanced dementia: Are physicians “choosing wisely”?.J Am Geriatr Soc. 2018; 66: 64-69
- Pause before a PEG: A feeding tube may not be necessary in every candidate!.J Am Med Dir Assoc. 2010; 11: 453-456
Published online: July 28, 2020
Y.F.L. and T.W.H. contributed equally as first authors.
The authors declare no conflicts of interest.
This work was supported by Kaohsiung Veterans General Hospital (Grant VGHKS109–070).
© 2020 AMDA - The Society for Post-Acute and Long-Term Care Medicine.