Paolo Orlandoni1, Nikolina Jukic Peladic2, Mirko Di Rosa3, Claudia Venturini4, Donata Fagnani5, Debora Sparvoli6, Natascia Giorgini7, Redenta Basile8, Claudia Cola9. 1. Clinical Nutrition Unit, Regional Reference Centre for Home Artificial Nutrition, IRCCS INRCA Ancona, Via Montagnola 81, 60100 Italy. Electronic address: p.orlandoni@inrca.it. 2. Vivisol Srl, Via Gerolamo Borgazzi 27, Monza, 20900 Italy. Electronic address: rackog@yahoo.it. 3. Laboratory of Geriatric Pharmacoepidemiology, IRCCS INRCA, Via S. Margherita 5, Ancona, 60124 Italy. Electronic address: m.dirosa@inrca.it. 4. Clinical Nutrition Unit, Regional Reference Centre for Home Artificial Nutrition, IRCCS INRCA Ancona, Via Montagnola 81, 60100 Italy. Electronic address: c.venturini@inrca.it. 5. Vivisol Srl, Via Gerolamo Borgazzi 27, Monza, 20900 Italy. Electronic address: d.fagnani@hotmail.it. 6. Vivisol Srl, Via Gerolamo Borgazzi 27, Monza, 20900 Italy. Electronic address: deborasparvoli@tiscali.it. 7. Vivisol Srl, Via Gerolamo Borgazzi 27, Monza, 20900 Italy. Electronic address: n.giorgini@inrca.it. 8. Clinical Nutrition Unit, Regional Reference Centre for Home Artificial Nutrition, IRCCS INRCA Ancona, Via Montagnola 81, 60100 Italy. Electronic address: r.basile@inrca.it. 9. Vivisol Srl, Via Gerolamo Borgazzi 27, Monza, 20900 Italy. Electronic address: cola.claudia@alice.it.
Abstract
BACKGROUND AND AIMS: European and international guidelines advice against initiating tube-feeding in patients with severe dementia. These recommendations are based on studies with important methodological limitations that evaluated the benefits of artificial nutrition in patients with percutaneous endoscopic gastrostomy almost exclusively in terms of the prolongation of survival. The aims of this study were to assess the harmful effects of home enteral nutrition administered via the nasogastric tube and percutaneous endoscopic gastrostomy in patients with advanced dementia in terms of mechanical, gastrointestinal and metabolic complications, to estimate the survival, to explore the risk factors for mortality and to compare the outcomes of patients with advanced dementia with those of patients without dementia. METHODS: The retrospective observational study was carried out on 585 consecutive patients of the mean age of 85.6 ± 6.9 years. They were treated using home enteral nutrition from 2010 to 2015 according to follow-up protocols adopted by the Clinical Nutrition Unit of an Italian geriatric research hospital (IRCCS-INRCA, Ancona). Incidence rates of mechanical, gastrointestinal and metabolic complications and survival rates in patients with severe dementia were compared to those in patients without dementia. The Cox proportional hazards model was used to evaluate the mortality risk factors. RESULTS: There was no difference between the incidence rates of complications in patients with severe dementia and those in patients without dementia. The incidence of mechanical complications was 1.35/1000 days for patients without dementia vs. 1.53/1000 days for patients with dementia (p = 0.270), the incidence of gastrointestinal complications was 1.30/1000 days for patients without dementia vs. 1.35/1000 days for patients with dementia (p = 0.984) and the incidence of metabolic complications was 0.36/1000 days for patients without dementia vs. 0.35/1000 days for patients with dementia (p = 0.252). The Kaplan Mailer analyses showed that there was no evidence to support the theses on poorer prognosis of survival of patients with dementia (median survival was 193 days for patients without dementia vs. 192 days for patients with dementia, (p > 0.05)). The female gender, advanced age, nasogastric tube, diabetes mellitus and chronic renal failure were identified as risk factors. Subjects whose Geriatric Nutritional Risk Index values were higher had a lower risk of mortality. CONCLUSIONS: The discussion on the appropriateness of enteral nutrition in patients with severe dementia is still open. Our results show that, if there is a medical prescription for tube-feeding and a patient's surrogate decision-makers express free and informed consent to the tube-feeding of the patient, enteral nutrition should not be contraindicated a priori if the patient has severe dementia. Regular follow-up is mandatory to guarantee adherence to the therapy and achieve its initial aims and to ensure that the principles of beneficence and nonmaleficence are respected.
BACKGROUND AND AIMS: European and international guidelines advice against initiating tube-feeding in patients with severe dementia. These recommendations are based on studies with important methodological limitations that evaluated the benefits of artificial nutrition in patients with percutaneous endoscopic gastrostomy almost exclusively in terms of the prolongation of survival. The aims of this study were to assess the harmful effects of home enteral nutrition administered via the nasogastric tube and percutaneous endoscopic gastrostomy in patients with advanced dementia in terms of mechanical, gastrointestinal and metabolic complications, to estimate the survival, to explore the risk factors for mortality and to compare the outcomes of patients with advanced dementia with those of patients without dementia. METHODS: The retrospective observational study was carried out on 585 consecutive patients of the mean age of 85.6 ± 6.9 years. They were treated using home enteral nutrition from 2010 to 2015 according to follow-up protocols adopted by the Clinical Nutrition Unit of an Italian geriatric research hospital (IRCCS-INRCA, Ancona). Incidence rates of mechanical, gastrointestinal and metabolic complications and survival rates in patients with severe dementia were compared to those in patients without dementia. The Cox proportional hazards model was used to evaluate the mortality risk factors. RESULTS: There was no difference between the incidence rates of complications in patients with severe dementia and those in patients without dementia. The incidence of mechanical complications was 1.35/1000 days for patients without dementia vs. 1.53/1000 days for patients with dementia (p = 0.270), the incidence of gastrointestinal complications was 1.30/1000 days for patients without dementia vs. 1.35/1000 days for patients with dementia (p = 0.984) and the incidence of metabolic complications was 0.36/1000 days for patients without dementia vs. 0.35/1000 days for patients with dementia (p = 0.252). The Kaplan Mailer analyses showed that there was no evidence to support the theses on poorer prognosis of survival of patients with dementia (median survival was 193 days for patients without dementia vs. 192 days for patients with dementia, (p > 0.05)). The female gender, advanced age, nasogastric tube, diabetes mellitus and chronic renal failure were identified as risk factors. Subjects whose Geriatric Nutritional Risk Index values were higher had a lower risk of mortality. CONCLUSIONS: The discussion on the appropriateness of enteral nutrition in patients with severe dementia is still open. Our results show that, if there is a medical prescription for tube-feeding and a patient's surrogate decision-makers express free and informed consent to the tube-feeding of the patient, enteral nutrition should not be contraindicated a priori if the patient has severe dementia. Regular follow-up is mandatory to guarantee adherence to the therapy and achieve its initial aims and to ensure that the principles of beneficence and nonmaleficence are respected.
Authors: Eduardo Sánchez-Sánchez; María Araceli Ruano-Álvarez; Jara Díaz-Jiménez; Antonio Jesús Díaz; Francisco Javier Ordonez Journal: Nutrients Date: 2021-05-06 Impact factor: 5.717