A Double-Edged Sword and Swinging Pendulum: The Evolving Role of Percutaneous Endoscopic Gastrostomy Tubes in Patients with Advanced Dementia

Abstract

Percutaneous Endoscopic Gastrostomy (PEG) tubes have been increasingly utilized
in recent decades accompanying the rise in prevalence of disorders that require long-term nonoral
enteral feeding such as Cerebrovascular accident (CVA), head and neck cancer and most
notably advanced dementia.1,2 The population of patients with dementia is expected to increase
worldwide due to shifts in aging demographics leading to an estimate of 81 million people with
this condition by 2040.3
A commonly encountered challenge in adults with advanced dementia is the
development of difficulty with mastication and swallowing leading to weight loss, malnutrition
and risk of aspiration pneumonia.4,5 One long-term intervention to manage such malnutrition
and risk of aspiration is the provision of enteral feeding through a percutaneous endoscopic
gastrostomy (PEG) tube given the proposed nutritional, medication administration, and quality
of life benefits.6 However such benefits are controversial given lack of randomized controlled
data as well as conflicting evidence regarding the prevalence of complications of PEG tubes
compared to the actual benefit received with respect to morbidity and mortality from malnutrition
and dysphagia. Multiple studies have revealed that PEG tubes in nursing home residents with
advanced dementia do not in fact improve survival, nor prevent or help heal decubitus ulcers
in this group of patients.7-10 Additionally, risks of aspiration are not eliminated by PEG tube
placement.11,12 Finally, PEG tube insertion is associated with procedure-related complications
such as bleeding, wound infection, aspiration events, tube leakage and dislodgment, buriedbumper
syndrome, necrotizing fasciitis and peritonitis.1,13-15 Of note, certain factors have been
shown to predict the occurrence of complications following PEG insertion including low body
mass index, malignancy, low serum albumin and neurologic diseases.