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As Molina et al. reported, advanced dementia is one of the main reasons for placing a PEG tube,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> although there is no evidence pointing to a survival and nutritional status improvement or that the incidence of bronchoaspiration pneumonia or pressure ulcers decreases. Its use is associated with a greater use of physical and pharmacological containment measures and worsening pressure ulcers.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">For this reason, various scientific societies (<span class="elsevierStyleItalic">American Geriatrics Society</span>,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleItalic">American Society for Parenteral and Enteral Nutrition</span>,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleItalic">European Society for Parenteral and Enteral Nutrition</span><a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>), or initiatives like Choosing Wisely<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> or NICE<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> advise against the use of the PEG tube in patients with advanced dementia. Instead they indicate careful assisted oral feeding, with results similar to PEG regarding mortality, aspiration pneumonia, functional status and patient well-being.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Therefore, considering the available evidence, initiation of tube feeding at the advanced stage of dementia should be uncommon.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> But there are barriers that hinder the implementation of this “do not do” practice, including the values, expectations, knowledge and beliefs of the patient and family members and of the professionals who care for them.</p><p id="par0020" class="elsevierStylePara elsevierViewall">As healthcare professionals we can propose several areas of improvement:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0025" class="elsevierStylePara elsevierViewall">Since the severity of dementia will determine its approach, it would be advisable to use objective validated scales (<span class="elsevierStyleItalic">Global Deterioration Scale</span> [GDS], <span class="elsevierStyleItalic">Functional Assessment Staging</span> [FAST] or <span class="elsevierStyleItalic">Clinical Dementia Rating</span> [CDR]), recording the stage of dementia in the medical history. Dementia is considered advanced when the GDS or FAST score is 6–7 or the CDR score is 3.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0030" class="elsevierStylePara elsevierViewall">Information should be improved to the patient and family, explaining that the natural progression of dementia includes difficulties for intake near the end of life, the poor prognosis of advanced dementia and the absence of clinical benefit with the use of the PEG tube.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a> Actually, food and water rejection is a natural, non-painful, part of the dying process.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Choosing Wisely and NICE provide information to help patients, family members, caregivers and health professionals discuss options, with an evidence-based approach and shared decision making.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0035" class="elsevierStylePara elsevierViewall">After adequate information, each patient should be evaluated individually with respect to the following questions: 1. Is PEG likely to improve or maintain the quality of life of this patient? 2. Is PEG likely to improve or maintain this patient's functionality? 3. Is PEG likely to prolong survival in this patient? 4. Is the prolongation of life desirable from the patient's perspective? 5. How do the risks of PEG tube insertion and enteral nutrition compare to the expected benefits?</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0040" class="elsevierStylePara elsevierViewall">It is recommended that each decision for or against PEG in patients with dementia be taken individually, assessing the overall prognosis and patient preferences.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> Artificial tube feeding is a medical procedure, which like any other medical procedure may not be initiated or interrupted if a beneficial effect is not expected or observed. With the evidence that tube feeding does not prolong survival in the final stage of dementia, the argument that it is unacceptable not to initiate or interrupt it for fear of potentially accelerating the death process would be ignored.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> Other complementary tools have been proposed, such as the use of a checklist for decision making, applying the principles of informed consent, consulting with a palliative care unit, establishing an order of adaptation/limitation of therapeutic effort<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> or request ethical advice before starting feeding by PEG in advanced dementia.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">In summary, the decision to place a PEG tube should be individualized, taking into account not only the needs, preferences and expectations of the patient and relatives, but also the available scientific evidence.</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: Sánchez-Muñoz LA, Silvagni-Gutiérrez H, Usategui-Martín I. Demencia y problemas de alimentación: ¿sonda PEG o no? Med Clin (Barc). 153;2019:e59–e60.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gastrostomía endoscópica percutánea. Indicaciones, cuidados y complicaciones" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Molina Villalba" 1 => "J.A. Vázquez Rodríguez" 2 => "F. 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Patient decision aid on enteral (tube) feeding for people living with severe dementia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "National Institute for Health and Care Excellence" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "WWW" => array:2 [ "link" => "https://www.nice.org.uk/guidance/ng97/resources/enteral-tube-feeding-for-people-living-with-severe-dementia-patient-decision-aid-pdf-4852697007" "fecha" => "2018" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015300000011/v1_201911300659/S2387020619304942/v1_201911300659/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015300000011/v1_201911300659/S2387020619304942/v1_201911300659/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020619304942?idApp=UINPBA00004N" ]
Journal Information
Vol. 153. Issue 11.
Pages e59-e60 (December 2019)
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Vol. 153. Issue 11.
Pages e59-e60 (December 2019)
Letter to the Editor
Dementia and feeding problems: PEG feeding tube or not
Demencia y problemas de alimentación: ¿sonda PEG o no?
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11
Luis Angel Sánchez-Muñoz
, Hana Silvagni-Gutiérrez, Iciar Usategui-Martín
Corresponding author
Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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