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LETTERS TO THE EDITOR
COMMENTS/RESPONSES SOME QUESTIONS ABOUT DEMENTIA AND TUBE FEEDINGS To the Editor: We agree with the American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee1 in that careful hand feeding should be offered to all individuals with advanced dementia. However, people with dementia must have a feeding tube placed under certain circumstances (e.g., beliefs, family burdens, family-related responsibilities, nursing home characteristics, acute hospital settings). Sometimes, surprisingly, the main and only indication for placing a feeding tube is prevention of aspiration pneumonia.2 Taking this into consideration those circumstances, we disagree that difficulty eating and feeding is associated with poor prognosis over the short term. Although the short-term prognosis, accurate prognosis of survival in advanced dementia is elusive.3 In addition, the assertion that tube feeding is associated with agitation and greater use of physical and chemical restraints is not completely correct. The setting might be completely different for individuals with dementia with a nasoenteric tube and those with percutaneous gastrostomy (PEG). In the case of nasoenteric tube, behavioral disturbances appear in many individuals and it is therefore necessary to prescribe physical or chemical (e.g., neuroleptics, benzodiazepines) restraints. In a previous letter to this journal, we reported that individuals with advanced dementia and PEG tubes did not exhibit PEG-associated behavioral disturbances and did not need any physical or chemical restrain.4 Although advanced dementia is a serious burden for health systems, professionals, relatives, and the individuals themselves we must be aware of some opinions on this topic. The individual’s comfort must be the main goal, but is an untreated individual with pneumonia, fever, or eating problems comfortable? Finally, advanced dementia is usually a complicated condition with a long trajectory. To affirm that all individuals with dementia have a terminal illness5 and therefore that use of a PEG tube must be completely excluded in elderly adults with dementia is similar to the idea described in a famous children’s story: “Sentence first—verdict afterwards.”6 Carlos Fernandez-Viadero, MD, PhD Valdecilla University Hospital, Santander, Cantabria, Spain Department of Biogerontology, School of Medicine, University of Cantabria, Cantabria, Spain Magdalena Jimenez-Sanz, RN Valdecilla University Hospital, Santander, Cantabria, Spain Rosario Verduga, MD, PhD Department of Psychobiology & Health Education, Universidad Nacional de Educaci on a Distancia, Cantabria, Spain
JULY 2015–VOL. 63, NO. 7
JAGS
Damaso Crespo, MD, PhD Department of Biogerontology, School of Medicine, University of Cantabria, Cantabria, Spain
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Fernandez-Viadero: study concept and design, preparation of manuscript. Jimenez-Sanz, Verduga: preparation of manuscript. Crespo: design, preparation of manuscript. Sponsor’s Role: The research group is supported in part by a grant from the Spanish Geriatrics & Gerontology Society, which had no responsibility for the concept or the idea of this letter. No funds have been diverted for this contribution.
REFERENCES 1. American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American Geriatrics Society feeding tubes in advanced dementia position statement. J Am Geriatr Soc 2014;62:1590–1593. 2. Tawk MM, Elya MK. Recurrent aspiration pneumonia. N Engl J Med 2008;359:e27. 3. Mitchell SL, Black BS, Ersek M et al. Advanced dementia: State of the art and priorities for the next decade. Ann Intern Med 2012;156:45–51. 4. Fernandez-Viadero C, Pe~ na Sarabia N, Jimenez-Sanz M et al. Percutaneous endoscopic gastrotomy: Better than nasoenteric tube? J Am Geriatr Soc 2002;50:199–200. 5. Congedo M, Causarano RI, Alberti F et al. Ethical issues in end of life treatments for patients with dementia. Eur J Neurol 2010;17:774–779. 6. Carroll L. Alice’s Adventures in Wonderland. First published in 1865 by Macmillan & Co., London. Released 1866 by D. Appleton & Co., New York. A BookVirtual Digital Edition, v.1.2. Chicago, Illinois 2000. Available at https://www.adobe.com/be_en/active-use/pdf/Alice_in_Wonder land.pdf
AMERICAN GERIATRICS SOCIETY POSITION STATEMENT ON FEEDING TUBES IN ADVANCED DEMENTIA To the Editor: In its position statement on tube feeding for individuals with advanced dementia, the American Geriatrics Society maintains that in individuals with advanced dementia, observational evidence indicates that the benefits of tube feeding do not outweigh substantial associated treatment burdens.1 We would argue that, notwithstanding the evidence, it is difficult to convince nursing homes and geriatric staff that oral hand feeding is better for an individual with dementia who has stopped eating. After all, percutaneous endoscopic gastrostomy (PEG) feeding can deliver 2,000 calories per day with minimal staff effort. Hand feeding delivers at best several hundred calories and requires a great deal of patience, time, and effort, qualities that are in short supply these days, and because weight loss is a major negative quality indicator that is advertised
LETTERS TO THE EDITOR
COMMENTS/RESPONSES SOME QUESTIONS ABOUT DEMENTIA AND TUBE FEEDINGS To the Editor: We agree with the American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee1 in that careful hand feeding should be offered to all individuals with advanced dementia. However, people with dementia must have a feeding tube placed under certain circumstances (e.g., beliefs, family burdens, family-related responsibilities, nursing home characteristics, acute hospital settings). Sometimes, surprisingly, the main and only indication for placing a feeding tube is prevention of aspiration pneumonia.2 Taking this into consideration those circumstances, we disagree that difficulty eating and feeding is associated with poor prognosis over the short term. Although the short-term prognosis, accurate prognosis of survival in advanced dementia is elusive.3 In addition, the assertion that tube feeding is associated with agitation and greater use of physical and chemical restraints is not completely correct. The setting might be completely different for individuals with dementia with a nasoenteric tube and those with percutaneous gastrostomy (PEG). In the case of nasoenteric tube, behavioral disturbances appear in many individuals and it is therefore necessary to prescribe physical or chemical (e.g., neuroleptics, benzodiazepines) restraints. In a previous letter to this journal, we reported that individuals with advanced dementia and PEG tubes did not exhibit PEG-associated behavioral disturbances and did not need any physical or chemical restrain.4 Although advanced dementia is a serious burden for health systems, professionals, relatives, and the individuals themselves we must be aware of some opinions on this topic. The individual’s comfort must be the main goal, but is an untreated individual with pneumonia, fever, or eating problems comfortable? Finally, advanced dementia is usually a complicated condition with a long trajectory. To affirm that all individuals with dementia have a terminal illness5 and therefore that use of a PEG tube must be completely excluded in elderly adults with dementia is similar to the idea described in a famous children’s story: “Sentence first—verdict afterwards.”6 Carlos Fernandez-Viadero, MD, PhD Valdecilla University Hospital, Santander, Cantabria, Spain Department of Biogerontology, School of Medicine, University of Cantabria, Cantabria, Spain Magdalena Jimenez-Sanz, RN Valdecilla University Hospital, Santander, Cantabria, Spain Rosario Verduga, MD, PhD Department of Psychobiology & Health Education, Universidad Nacional de Educaci on a Distancia, Cantabria, Spain
JULY 2015–VOL. 63, NO. 7
JAGS
Damaso Crespo, MD, PhD Department of Biogerontology, School of Medicine, University of Cantabria, Cantabria, Spain
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Fernandez-Viadero: study concept and design, preparation of manuscript. Jimenez-Sanz, Verduga: preparation of manuscript. Crespo: design, preparation of manuscript. Sponsor’s Role: The research group is supported in part by a grant from the Spanish Geriatrics & Gerontology Society, which had no responsibility for the concept or the idea of this letter. No funds have been diverted for this contribution.
REFERENCES 1. American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American Geriatrics Society feeding tubes in advanced dementia position statement. J Am Geriatr Soc 2014;62:1590–1593. 2. Tawk MM, Elya MK. Recurrent aspiration pneumonia. N Engl J Med 2008;359:e27. 3. Mitchell SL, Black BS, Ersek M et al. Advanced dementia: State of the art and priorities for the next decade. Ann Intern Med 2012;156:45–51. 4. Fernandez-Viadero C, Pe~ na Sarabia N, Jimenez-Sanz M et al. Percutaneous endoscopic gastrotomy: Better than nasoenteric tube? J Am Geriatr Soc 2002;50:199–200. 5. Congedo M, Causarano RI, Alberti F et al. Ethical issues in end of life treatments for patients with dementia. Eur J Neurol 2010;17:774–779. 6. Carroll L. Alice’s Adventures in Wonderland. First published in 1865 by Macmillan & Co., London. Released 1866 by D. Appleton & Co., New York. A BookVirtual Digital Edition, v.1.2. Chicago, Illinois 2000. Available at https://www.adobe.com/be_en/active-use/pdf/Alice_in_Wonder land.pdf
AMERICAN GERIATRICS SOCIETY POSITION STATEMENT ON FEEDING TUBES IN ADVANCED DEMENTIA To the Editor: In its position statement on tube feeding for individuals with advanced dementia, the American Geriatrics Society maintains that in individuals with advanced dementia, observational evidence indicates that the benefits of tube feeding do not outweigh substantial associated treatment burdens.1 We would argue that, notwithstanding the evidence, it is difficult to convince nursing homes and geriatric staff that oral hand feeding is better for an individual with dementia who has stopped eating. After all, percutaneous endoscopic gastrostomy (PEG) feeding can deliver 2,000 calories per day with minimal staff effort. Hand feeding delivers at best several hundred calories and requires a great deal of patience, time, and effort, qualities that are in short supply these days, and because weight loss is a major negative quality indicator that is advertised
