BMJ  2004;329:917-918 (16 October), doi:10.1136/bmj.329.7471.917-b

Letter

Feeding tubes in dementia: is there an effective UK strategy?

EDITOR—In their quality improvement report Monteleoni and Clark showed a reduction in the number of gastrostomy tubes inserted (in patients with dementia) after specific quality interventions had been implemented.¹ We would like to add two points to the debate.

Firstly, how applicable is this observation to the United Kingdom? We have previously reported a high mortality in patients with dementia who have a percutaneous endoscopic gastrostomy (PEG) tube inserted.² As a result of this observation we devised a pragmatic strategy to try to improve all aspects of our selection process for insertion of the tube. Our quality interventions are not dissimilar to Monteleoni and Clark but also incorporated a one week, waiting list policy before the tube was inserted (box). We found that this additional quality intervention further improved selection of patients as it provided an opportunity for all those involved in the decision making process to reflect on the implications of PEG tube insertion. The nature and long term implications of a decision to feed mean that carers and relatives have to come to terms with the decision.

In addition, particularly ill patients may succumb during this cooling off period. Like Monteleoni and Clark (but in a UK setting) we were able to show a reduction in the number of PEG tubes inserted in patients with dementia.³

The final issue, which is perhaps harder to quantify, is the practice by nursing homes to accept preferentially patients with PEG tubes. This practice is linked to a greater amount of remuneration.^{4 5} In addition, the insertion of a PEG tube may potentially reduce the length of stay in hospital and alleviate the pressure on acute medical beds. However, these external economic and logistic forces may not be in the patient's best interest.^{4 5} In the United Kingdom at least, it is only when this practice is addressed that we will see a global decline in referral for gastrostomy insertion in patients with dementia.

Referral strategy for percutaneous endoscopic gastrostomy3 4 Standardise PEG referral form including concomitant disease Endoscopy nurse triage and dissemination of published evidence Gastroenterological review where necessary Holistic and multidisciplinary approach Advise against PEG feeding in patients with dementia One week waiting list policy

d.s.sanders28{at}btopenworld.com Royal Hallamshire Hospital, Sheffield S10 2JF

Rotherham District General Hospital, Rotherham S60 2UD

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See also News p 873

Competing interests: None declared.

References

1. Monteleoni C, Clark E. Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study. BMJ 2004;329: 491-4. (28 August.)[Abstract/Free Full Text]
2. Sanders DS, Carter MJ, D'Silva J, James G, Bolton RP, Bardhan KD. Survival analysis in percutaneous endoscopic gastrostomy: a worse outcome in patients with dementia. Am J Gastroenterol 2000;95: 1472-5.[CrossRef][ISI][Medline]
3. Sanders DS, Carter MJ, D'Silva J, James G, Bolton RP, Willemse PJ, Bardhan KD. Percutaneous endoscopic gastrostomy: a prospective audit of the impact of guidelines in 2 district general hospitals in the United Kingdom. Am J Gastroenterol 2002;97: 2239-45.[Medline]
4. Sanders DS, Anderson AJ, Bardhan KD. Percutaneous endoscopic gastrostomy: an effective strategy for gastrostomy feeding in patients with dementia. Clin Med 2004;4: 235-41.[Medline]
5. Tham TCK, Taitelbaum G, Carr-Lock DL. Percutaneous endoscopic gastrostomies: are they being done for the right reasons? Q J Med 1997;90: 495-6.

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