Correspondence
Clinical pathway to reduce feeding tube insertions in patients with advanced dementia
Vía clínica para reducir la inserción de sondas de alimentación en pacientes con demencia avanzada
F.J. Mena-Martín
, M.M. Cobos-Siles, P. Cubero-Morais, I. Arroyo Jiménez
Corresponding author
Servicio de Medicina Interna, Hospital Universitario Río Hortega, Valladolid, Spain
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Mena-Martín, M.M. Cobos-Siles, P. Cubero-Morais, I. Arroyo Jiménez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "F.J." "apellidos" => "Mena-Martín" "email" => array:1 [ 0 => "fmenama@saludcastillayleon.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.M." "apellidos" => "Cobos-Siles" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Cubero-Morais" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Arroyo Jiménez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Río Hortega, Valladolid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Vía clínica para reducir la inserción de sondas de alimentación en pacientes con demencia avanzada" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In our daily practice, advanced dementia is still one of the main reasons for inserting a nasogastric or gastrostomy tube (percutaneous endoscopic gastrostomy [PEG]) for enteral nutrition (EN).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However, a 2009 Cochrane review revealed the lack of benefit of EN in these patients in terms of survival, nutritional state and the prevalence of pressure ulcers and aspiration pneumonia.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In the last 10 years, numerous scientific societies have published recommendations opposing this futile therapeutic measure, in the context of initiatives such as <span class="elsevierStyleItalic">Choosing Wisely</span> in the United States and Canada, the National Institute for Health and Care Excellence recommendations in the United Kingdom and the “Inadvisable Practices” in Spain.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In June 2017, our hospital launched a clinical pathway for reducing the insertion of feeding tubes in patients with advanced dementia, an approach agreed upon by primary and specialized care. To this end and on the initiative of the internal medicine department, several clinical sessions were conducted with the most directly involved departments, as well as another general hospital session, all as part of the “Inadvisable Practices” recommendations promoted by the Spanish Ministry of Health.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> We then retrospectively analyzed the discharge reports of all patients hospitalized at our center who were diagnosed with dementia (472 in the second semester of 2015 and 452 for the same period in 2017). We collected their demographic characteristics, comorbidity and type of feeding at discharge (oral, nasogastric or gastrostomy). We defined advanced dementia as stage 7 of the Global Deterioration Scale.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the patients with each type of EN for both periods and the significance levels with Fisher’s exact test, showing the high degree of compliance with the recommendations indicated in the clinical pathway. The high degree of multidisciplinary consensus in preparing these recommendations was the key element in achieving these results. “Therapeutic inertia” in managing dysphagia in patients with advanced dementia has changed, although it is possible that the decreased use of tubes in hospitals will entail an increase in the use of tubes in geriatric centers, which would require the implementation of other strategies.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">According to the United Nations, there were 24 million individuals with dementia worldwide in 2001; by 2040, the number is expected to increase to 81 million, due in large measure to the increased life expectancy.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In the population 85 years or older, almost 50% present chronic cognitive impairment.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> For many patients with advanced dementia, feeding problems are the most common complication, affecting more than 85% of such patients.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> For their family members, the decision to start enteral feeding is affected by complex bioethical issues, although they are typically aware of the natural and irreversible disease progression.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> A study on a cohort of institutionalized patients with advanced dementia estimated that 6-month mortality was 25% and that mean survival was 1.3 years,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> similar figures to that of other diseases with poor prognoses (e.g., numerous cancers and functional class IV heart failure). In this respect, our role as health professionals should be to inform patients and their families as soon as possible as to the manifestations that will appear in the advanced phase of dementia and what the best scientific evidence recommends. These recommendations should always be presented with the utmost respect for the previous instructions expressed by the patient or by their family acting as representatives. In the US, however, 15% of internists who treat this type of patient are unaware that inserting feeding tubes is associated with agitation, 38% are unaware of the scientific societies’ recommendations on this subject, and 63% stated that the family requested inserting a PEG against the physician’s recommendations.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In Spain, the “Assistive Document for Decision Making in Managing Patients with Advanced Dementia”,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> written in 2008 by the Andalusian Society of Internal Medicine, recommended that, given the lack of scientific evidence to justify EN for these patients, healthcare practitioners should not promote the use of EN for these patients. In the “Commitment for Quality by the Scientific Societies”, the Spanish Society of Geriatric Medicine and the Spanish Society of Geriatrics and Gerontology have since 2016 included the recommendation to “<span class="elsevierStyleItalic">not indicate nasogastric or percutaneous gastrostomy tubes for patients with advanced phase dementia</span>”,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> a recommendation that will surely be progressively implemented in clinical practice in the coming years.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Mena-Martín FJ, Cobos-Siles MM, Cubero-Morais P, Arroyo Jiménez I. Vía clínica para reducir la inserción de sondas de alimentación en pacientes con demencia avanzada. Rev Clin Esp. 2020;220:77–78.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The data show the absolute number of patients, with the percentage between parentheses. The right column shows the level of statistical significance when comparing the percentages of the 2 study periods.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: EN, enteral nutrition, NGT, nasogastric tube, PEG, percutaneous endoscopic gastrostomy.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Results before the intervention: Second semester of 2015 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Results after the intervention: Second semester of 2017 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients for whom EN by NGT was started during the hospitalization/total number of discharges with dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6/472 (1.27%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0/452 (0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.0031 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients for whom EN by PEG was started during the hospitalization/total number of discharges with dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10/472 (2.12%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1/452 (0.22%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.008 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patients with dementia for whom EN was started during the hospitalization/total number of discharges with dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16/472 (3.39%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1/452 (0.22%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total number of patients with dementia and EN at discharge/total number of discharges with dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35/472 (7.42%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17/452 (3.76%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.016 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2237775.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hospital discharges of patients with dementia.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous feeding tubes in individuals with advanced dementia: Are physicians “Choosing Wisely”?" 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