Feeding Tubes for Elderly: Pros and Cons

“Feeding Tubes for Elderly” was written by Rachel Blowers. Rachel works Asante Three Rivers Medical Center in Grants Pass, OR as an inpatient clinical dietitian. Reviewed/edited by Katie Dodd, MS, RDN, CSG, LD, FAND.

Feeding tubes for elderly can be a tricky topic. This article dives into the pros and cons of using feeding tubes in older adults.

What is a Feeding Tube? 

A feeding tube is a way for someone to get nutrition from a liquid formula rather than through food. Tube feeds can be either short term or long term. Each situation is unique. And depends on what the individual may need. 

Types of Tube Feeds 

There are two ways to receive a tube feed. It can be either through the nose or abdomen. Feedings through the abdomen require surgical intervention. And these are typically for those who need a long term tube feed.

The first three tube feeds listed below are inserted through the nose, and the last two are inserted through the abdomen (1). 

1. Nasogastric: A tube is inserted through the nose and ends in the stomach. 
2. Nasodudenal: A tube is inserted through the nose and ends in the first portion of the small intestine called the duodenum. 
3. Nasojejunal: A tube is inserted through the nose and ends in the second part of the small intestine called the jejunum. 
4. Percutaneous Endoscopic Gastrostomy (PEG): Through surgical intervention, a tube is inserted through the abdomen wall and into the stomach.
5. Percutaneous Endoscopic Jejunostomy (PEJ): Through surgical intervention, a tube is inserted through the abdomen wall and into the second part of the small intestine, the jejunum. 

Why Someone May Need a Tube Feed

There are various reasons that a person may need a tube feed.

Certain medical conditions may require a tube feed. For example, when a person is having difficulty swallowing. Or when a person is unable to eat enough food by mouth.

As previously mentioned, tube feeds can be either short term or long term. Short term is typically less than 4 weeks. And nasal tubes are most commonly used for this type of feeding. 

Examples of why a nasal tube feed may be used:

• Unable to meet nutritional needs by mouth AND are experiencing:
  • significant weight loss
  • cancer
  • certain bowel conditions
  • stroke
  • some neurological disorders
  • etc.

If a person’s nose or esophagus is not accessible or functioning properly, then the use of PEG or PEJ tube can be used. A PEG or PEJ provides nutrition through the abdomen wall. These types of tube feeds are also used for those who need a tube feed long term.

Examples of why a PEG or PEJ tube feed may be used:

• need for long-term tube feed
• throat cancer
• esophagus removal
• swallowing difficulty (known as dysphagia(
• etc. 

There are other reasons feeding tubes in the elderly may be needed. Always work with your healthcare team to address your individual needs and situation.

Is a Tube Feed the Right Decision for my Loved One?

Deciding whether a tube feed is the best choice for the care of a loved one can be overwhelming to family members. Older adults often experience inadequate nutrition and dehydration. This can play a big role in the functional status and their overall quality of life.

A tube feed provides both adequate nutrition and hydration to a patient. However, there are many considerations to make in this population.

Weight Loss in the Elderly 

Typically as we age, our appetite decreases leading to weight loss. There are situations where weight loss can be necessary and help improve a person’s health status. However, in the elderly population weight loss is a big concern. 

Weight loss in the elderly can be caused by:

• social isolation
• depression
• certain medications
• certain illnesses
• cognitive problems
• etc. 

Weight loss in the elderly puts them more at risk for malnutrition.

ASPEN defines malnutrition as, “An acute, subacute or chronic state of nutrition, in which a combination of varying degrees of overnutrition or undernutrition with or without inflammatory activity have led to a change in body composition and diminished function.” (2)

Simply put, malnutrition is deficiencies or imbalances in a person’s overall diet that can lead to decreased energy and unable to utilize nutrients efficiently.

Malnutrition can put the elderly more at risk for a compromised immune system, slower healing time, muscle weakness, and decreased bone mass all of which can lead to decreased health.

A tube feed provides all nutritional needs to meet recommended caloric needs calculated by a registered dietitian. Some patients with a tube feed, depending on their condition, are still able to take food by mouth in addition to the tube feeding formula.

If the patient’s appetite begins to increase, and the patient is eating more by mouth, then the tube feed can often be discontinued. 

Hydration in the Elderly

Fluid status is important in all ages to help carry out normal daily functions throughout the body.

The elderly population are more susceptible to dehydration.

Our bodies are able to hold a certain amount of water. And as we age, our ability to store water decreases. This can, in turn lead to a decrease in thirst. 

Causes of dehydration in elderly:

• Inadequate fluid intake
• certain medications
• illnesses that cause diarrhea and/or vomiting
• sweating
• etc.

Symptoms of dehydration in elderly include:

• low blood pressure
• dry mouth
• dry or scaly skin
• confusion
• difficulty walking/balancing
• less energy
• etc.

All of these symptoms could be reasons that someone may end up in the hospital.

Tube feed formulas provide a specific amount of fluid in the formula itself. However, rarely does the fluid from the tube feed formula meet a patient’s estimated fluid needs (calculated by a registered dietitian).

With a tube feed, you are able to provide something called a water flush. This allows additional water to the patient through the tube.

Just like with food, if feasible, the patient can still take liquids by mouth and then the fluid flush amount may decrease. 

Feeding Tubes for Elderly with Advanced Dementia

Dementia can be termed as the general loss of memory, language, and thinking abilities that are severe enough that it interferes with the daily tasks of a person’s life (3).

Tube feeding in those with dementia can be helpful. However, sometimes (especially in those with advanced dementia) it may not be the best solution. It can be difficult for families to come to a consensus for their loved one when that loved is unable.

Risk of Surgery

Tube feeding in those with advanced dementia would likely have to be administered through a PEG tube, which requires surgical intervention.

Anytime a person undergoes surgery there is always a potential risk. However, as we age the risk of surgery increases which leads to another consideration when placing a tube feed. 

Research on Tube Feeds with Dementia

Research shows that there is insufficient evidence that suggests tube feeding is more beneficial in those with dementia (4).

Some risks to tube feeds in elderly with advanced dementia(5):

• Tube feeding have not been shown to prevent aspiration risk, heal pressure ulcers, improve nutritional status, improve cognitive status, or decrease mortality 
• Risk of recurrent and new‐onset aspiration, infections related to tube feeds, increased oral secretions, and tube malfunction
• Agitation and discomfort can also be associated with tube feeds. This may lead to a patient trying to pull at their tube feed
• Nutrition received through a tube feed may not necessarily mean that a patient will gain weight and get better to increase quality of life

The American Geriatric Society guidelines state that hand feeding can be as beneficial as tube feeding. Research has shown that administering a tube feed in those with advanced dementia has shown little to no benefit in prolonging end of life compared to intake of food by mouth. 

You can learn more at our article on Dementia and Eating Issues. Particularly the section on Tube Feeding in Older Adults with Advanced Dementia.

Dysphagia and Feeding Tubes for Elderly

Dysphagia is a condition that occurs when a person has difficulty swallowing food or liquid. 

IDDSI for Dysphagia

Sometimes changing diet texture can help older adults with dysphagia. For example, using different textures such as pureed, minced and moist, soft and bite-sized, easy to chew, and regular food textures. These are all standardized diet textures from the International Dysphagia Standardisation Initiative (IDDSI) (6).

Older adults with dysphagia should work with their healthcare team to get a swallow study. A speech therapist will help to determine which food and liquid textures are needed.

Tube Feeds for Dysphagia

In the event that a person’s dysphagia is severe enough where different diet textures are unable to resolve the issue, a tube feed can be used. A nasogastric tube is an option if it is for short term use. Otherwise a PEG tube should be used if there is a long term need.

However, having a tube feed does not guarantee that a person will not aspirate (food goes into lungs). Always work with your healthcare team to find the best options for your situation.

Circling back to older adults with advanced dementia, we know this population can be at risk for dysphagia. However, studies have found that there is no significant evidence that proves the use of a PEG tube will improve survival rates of those with dysphagia (7).

Tube Feeding at End of Life

As mentioned before, it can be a very burdensome task when it comes to trying to decide if a tube feed may be the best solution for a family member and friend. When a person approaches their end of life, it is never an easy decision to come to terms with or to have a conversation about. 

It’s All About Comfort

At the end of the day, it all comes down to the patient and their comfort at end of life care. While we would do anything in our power to prolong their life to spend extra moments with them, sometimes the best thing we can do is to simply be there in the moment with the people we care about.

End of Life Nutrition

We associate food and drink as a way of bringing people together and as another way to show love to someone.

When our loved ones begin to eat less, it can be stressful on family members, friends and caretakers. This is when someone may consider a tube feed as a source of nutrition to assist in the care of a geriatric patient. 

If the patient is of sound mind and able to make decisions for themselves, one important thing you can do is listen to their thoughts and feelings on the initiation of a tube feed.

It is also important to try and not push or guilt trip a patient into getting a tube feed if they do not wish to have one.

You can learn more about this topic at our article on End of Life Nutrition.

Conclusion: Feeding Tubes for Elderly

There are many options to consider when a loved one is having difficulty obtaining nutrition.

Learning as much as you can from a geriatric dietitian is an important part of this decision-making process. It is also important to make that loved one a part of the conversation and decision. Working together, will help lead to a solution all parties can agree upon.

Best of luck!

References

1. Enteral and Parenteral Nutrition. American College of Gastroenterology. https://gi.org/topics/enteral-and-parenteral-nutrition/. Accessed April 28, 2021.
2. Definitions: Malnutrition. ASPEN. American Society for Parenteral and Enteral Nutrition. https://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Toolkits/Malnutrition_Toolkit/Definitions/. Accessed April 28, 2021.
3. Alzheimer’s and Dementia. What Is Dementia. alzheimer’s association.  https://www.alz.org/alzheimers-dementia/what-is-dementia. Accessed April 30, 2021.
4. Ijaopo EO, Ijaopo RO. Tube Feeding in Individuals with Advanced Dementia: A Review of Its Burdens and Perceived Benefits. J Aging Res. 2019;2019:7272067. Published 2019 Dec 19. doi:10.1155/2019/7272067
5. Clinical, Practice, and Models of Care Committee. American Geriatrics Society feeding tubes in advanced dementia position statement. Journal of the American Geriatrics Society. Published 2014 July 17. Doi.org/10.1111/jgs.12924
6. The IDDSI Framework. International Dysphagia Diet Standardisation Initiative. https://iddsi.org/Framework. Accessed May 3, 2021.
7. Goldberg LS, Altman KW. The role of gastrostomy tube placement in advanced dementia with dysphagia: a critical review. Clin Interv Aging. 2014; 9: 1733–1739. Published online 2014 Oct 14. doi 10.2147/CIA.S53153