Ask the Geriatrician: Tube Feeding, and Alternatives, for Older Adults With Advanced Dementia
Ask the Expert
Thomas Finucane, MD
Johns Hopkins Bayview Medical Center
Q: Why do older adults with advanced dementia develop difficulty swallowing and eating?
A: Though swallowing may seem a simple process, it’s actually complex. There are three multipart steps to swallowing. These involve deciding to swallow, then coordinating many muscles in the head and neck, and key nerves that travel to the brain and its “swallowing center.” It takes a lot to move the food safely past the airway and into the esophagus (swallowing tubes heading for the stomach).
One type of problem arises with getting things started; recognizing there is food in your mouth and deciding to swallow it. This is called “oral-phase dysphagia,” the first of the three steps. Dementia is the most common cause of this form of dysphagia.
Q: Is dysphagia dangerous?
A: It can be. When older adults develop swallowing and eating problems, they often eat and drink less, lose weight and develop the risk of becoming dehydrated and malnourished.
In addition, people with advanced dementia may develop a kind of dysphagia in which food passes into the airway and lungs, instead of the stomach, after it is swallowed. Sometimes this also happens when swallowed food is “regurgitated” or “thrown up.” When food goes into the airway and lungs, this is called “aspiration.” Aspiration can lead to a dangerous, even fatal, lung infection called “aspiration pneumonia.” In many cases, however, patients simply cough up the food, or saliva, and no harm is done.
Q: What are “percutaneous feeding tubes” and are they a solution for older adults with dementia who have dysphagia?
A: A percutaneous feeding tube, or “gastric feeding tube,” is a special flexible, plastic tube that is used to carry nutritious fluids directly to the stomach. A feeding tube may also be used to give patients medications if necessary.
The tube is designed to prevent dehydration and malnutrition in patients with dysphagia. The bottom end of the tube is inserted through the abdominal wall, directly into the stomach, so the patient no longer needs to swallow his or her food.
Q: Are there any alternatives to feeding tubes?
A: Yes. Before feeding tubes were invented, patients with dysphagia were carefully fed by loved ones and nursing home staff. Hand feeding involves carefully feeding food – often pureed—to the patient by hand. The caregiver offers the patient only as much food as the patient wants to accept; and stops feeding as soon as he refuses the food, or begins to cough or choke. The person feeding the patient should be carefully watching the patient’s cues.
Q: How do these two approaches compare? Is one better than the other?
A: Though much more time-consuming, hand feeding appears to be a better alternative than tube feeding for older adults with advanced dementia who are at risk of aspiration pneumonia.
While tube feeding is designed to prevent aspiration pneumonia, studies have not shown that it does so. In contrast, some research suggests that carefully hand-fed patients may actually have fewer episodes of major aspiration than those fed by tube.
Tube feeding is also intended to improve the nutritional status of these patients so they can better function, and better fight off infections if they occur. Yet research has not found that tube feeding improves the nutritional status of these patients, or their functioning, to a meaningful extent. A recent review of research to date, for example, failed to find that tube-fed patients live longer, have fewer infections or pressure ulcers, or have higher functioning or greater comfort than those receiving hand feeding.
Tube feeding also appears to carry additional risks. These include infections at the site where the tube is inserted, and complications that may occur when the tubes leak. In addition, some patients with feeding tubes must be restrained physically or with drugs to keep them from trying to remove the tubes.
Q. What should be done when death is near and an older person with dementia no longer wants hand feeding? At that point, isn’t tube feeding –even if it simply provides water – necessary, so he or she doesn’t suffer at the end?
A. Patients who are fed by hand usually live just as long as those who are given tube feeding. As for suffering, most dying patients no longer feel hunger or thirst. When a dying patient indicates she wants water it is often because her mouth is dry. Wetting the mouth with a small chip of ice or frozen juice in the mouth, or using glycerin swabs, can keep the mouth and lips moist and comfortable.
Updated: February 2013
Posted: February 2013