Controversy: Tube Feeding in Advanced Dementia
Reduced food intake and weight loss are normal features of advancing age. Evidence is increasing that non-demented elderly malnourished people benefit from nutritional supplements. Randomized trials are not evident in the literature on demented patients and benefits they may receive from nutritional supplements via tube. This article highlights two problems from the tube feeding of demented patients: 1) they lack the potential for physical or neurological rehabilitation and 2) they are not starving. They are, the article argues, in a state of physical homeostasis.
Doctors can readily determine which of their patients are starving by weighing them. In advanced dementia, a constant weight, even if subnormal, rules out progressive starvation and thus, the need for tube feeding. Vitamin deficiencies can be dealt with by giving a multivitamin daily to avoid such caveats as Wernickes encephalopathy, folic acid deficiency and the like. From a moral standpoint, the ethic of patient autonomy should be considered from the metabolic point of view. Once correctable issues have been identified and dealt with (i.e. ill-fitting dentures, depression, and dysphagia) the moral argument for tube feeding does not apply to the severely demented person who merely indicates a disinclination to eat much food and whose weight remains fairly constant.
The researchers furthermore state that evidence based medicine requires attention to the design of trials that provide practice guidelines to explicitly define what is being treated. They conclude with the following practice pearls:
- Patients with advanced dementia should be weighed and their dry body weight recorded at four week intervals
- Constant body weight rules out starvation even if the patient is disinclined to eat what seems to be an adequate amount of food
- Medically stable patients who lose weight require attention to the characteristics, quality and presentation of their food
- A patient who continues to lose weight despite optimization of their nutritional needs but whose body weight remains greater than a BMI of 18.5 is more likely harmed than helped by tube feeding
Clearly more research is needed and this is a controversial area morally, ethically and metabolically speaking. It is, however, an area that needs to be addressed further with evidence-based research so that we, as medical practitioners, do no harm.
About the Author
Kathy Shattler received her Master of Science degree from Michigan State University in E. Lansing Michigan in Human Nutrition. Her twenty-two years of practice includes holding positions as a Lecturer, Chief Clinical Dietitian and Program Manager. Kathy is the Founder of Nutri-Care Consulting and is currently the Nutrition Director of www.CEU4U.COM, an online continuing education management company for Registered Dietitians and Dietetic Technicians.
Michelle responds:
Posted: April 4th, 2008 at 7:36 am →
Thank you Kathy for a nice article to give direction to those working with the elderly. Additional information for healthcare professionals working with individuals who require nutrition support, whether tube feeding or parenteral nutrition is always available on the website of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) at www.nutritioncare.org. A.S.P.E.N. is a multidisciplinary medical specialty society with the mission to improve patient care by advancing the science and practice of nutrition support therapy.
Kathy J. Shattler, M.S.,RD responds:
Posted: April 4th, 2008 at 10:09 am →
Michelle,
Thank you for your nice comment. I apologize for not mentioning ASPEN before you brought up this wonderful organization. I have found the ASPENET listserv to be particularly useful for many years and ASPEN as an organization is a very good resource to have when dealing with the complexities of nutrition support, particularly TPN and enteral nutrition.
healthyfoodstoday responds:
Posted: April 11th, 2008 at 12:23 am →
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NutrtionalSupplements responds:
Posted: April 21st, 2008 at 12:44 am →
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