I would like to weigh in on a few issues raised in the Opinion piece “Dementia caregivers’ dilemma: ‘No tube feeding? Am I killing him?’” (Dec 5).
Dementia arising from stroke or Parkinsonism can present with swallowing difficulties earlier in the disease where tube feeding is a viable treatment.
Even in patients with advanced dementia, feeding problems may not always be due to progressive dementia but arise from potentially treatable and reversible causes such as delirium, depression and infections.
The treatment approach is then to elucidate and treat the underlying cause. Hence, tube feeding may be needed to administer the necessary medication and basic sustenance while awaiting recovery.
Moreover, dementia patients with conditions such as pressure sores would need more nutrition for wound-healing. Hence tube feeding boosts nutrition to aid healing if the patient is unable to consume nutrients adequately.
One must have sound reasons for instituting tube feeding and should define the treatment goals clearly. Tube feeding needs to be appropriate and proportionate to the ends.
An area of concern arises from the notion that tube feeding worsens the patient’s quality of life. This is, however, not always the case. In the PISCES study cited, even as 50 per cent of the caregivers reported diminished quality of life for tube-fed patients, the other half did not. This is true to what we observe in practice.
There is also an impression that a patient’s quality of life is compromised by the use of physical hand restraints to prevent the patient from removing the tube from the nose.
Although the nasogastric feeding tube is commonly used here, a feeding gastrostomy tube inserted directly into the stomach is a mainstay for long-term feeding in most developed Western countries. As gastrostomy tubes are unobtrusive and can be hidden under garments, they are less liable to be removed by the patient, thus avoiding the use of restraints that compromise patient dignity and quality of life.
Tube feeding in dementia is a nuanced issue that demands careful consideration of the medical and situational factors, as well as the multivalent views of the family, healthcare professionals and the patient’s previous expressed wishes. Shared decision-making is best and where there is uncertainty, a trial of tube feeding can lend greater clarity.
Philip Yap
Chairman
Dementia Singapore
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