Tube-feeding older adults with advanced dementia: Considerations from the Social Ecological Model

Background: Alzheimer’s disease is the 6^th leading cause of death in the US and the most common form of dementia, afflicting 5.2 million Americans in 2014.  Alzheimer’s and other forms of advanced dementia often yield severe weight loss with feeding tubes as the intervention. However, this practice is ineffective and causes a myriad of problems. The purpose of this review is to examine the use of feeding tubes in elderly patients with dementia from a social ecological perspective.

Methods:  A systematic literature review was conducted. Articles were included if they addressed the use of feeding tubes in patients with dementia and pertained to the levels of the Social Ecological Model (SEM).

Results:  At the individual level, feeding tubes often cause physical discomfort, medical complications, increased emergency room admissions, social exclusion, depression and/or anxiety.  Family members experienced additional unneeded distress as they lacked information to make informed decisions. Healthcare professionals lack knowledge of evidence-based guidelines.  At the organizational level, corporate culture influences feeding tube rates; Medicaid patients are most likely to receive tube feedings. Regarding public policy, reimbursement structures encourage the use of feeding tubes; facilities are reimbursed at higher rates for patients with tube feedings.

Conclusions: The use of feeding tubes in patients with advanced dementia is a serious and complex issue, warranting approaches that target each level within the Social Ecological Model.  Educating individuals and family members, as well as providing the healthcare team with current evidence-based guidelines are recommended.  Organizational norms and healthcare policies need to be revisited.