CHF over NGF with lower pneumonia risk in advanced dementia patients

11 Jan 2023

Oral feeding difficulties occur in 86% of advanced dementia patients, with 41% also experiencing pneumonia, especially aspiration pneumonia.1 Nasogastric feeding (NGF) is commonly used due to its convenience and perceived benefits of overcoming dysphagia.2 Choosing an ideal feeding method for these patients could be complicated, as there is a need for the balance between comfort with oral feeding and minimizing the aspiration pneumonia risk, in addition to the comorbidities that patients are likely to have.3 A recent study by Yuen and her team has found a breakthrough in the feeding method of careful hand feeding (CHF) to minimize the pneumonia risk in advanced dementia patients.4

The 12-month retrospective cohort study in Hong Kong focused on 764 hospitalized patients, aged ≥60 years, with advanced dementia [i.e., stage 7 based on the Reisberg Global Deterioration Scale (GDS)] and documented indication for tube feeding.4 Feeding problems with these patients were assessed by speech therapists with bedside swallowing evaluations, including oropharyngeal dysphagia (50%), behavioral feeding problems, which refer to challenges such as food insertion into the mouth or food denial (33%), or both (17%).4 Patients who were comatose, had a feeding tube of any kind upon hospital admission, had an acute stroke, tracheostomy, or active cancer, and lacked data on feeding problem type were excluded from the study.4 The outcome of 1-year survival and pneumonia incidence were assessed.4 The latter was based on the treating physician’s clinical diagnosis of new pneumonia incident following the feeding mode selection.4

In the study, 464 (61%) patients were started on NGF and 300 (39%) on CHF, and within the group of discharged patients (n=577; 76%), a lower pneumonia rate was found in the CHF group (48% vs. 60%; p=0.004).4 NGF was also found to be a significant risk factor for pneumonia (aHR=1.41; 95% CI: 1.08-1.85) and was associated with increased pneumonia risk for patients with both dysphagia and behavioral feeding problems (p=0.01), but not in patients with dysphagia alone (p=0.30) or behavioral feeding problem alone (p=0.24).4 Concurrently, there was no significant difference in the 1-year survival rate comparing the NGF and CHF groups (36% vs. 37%; p=0.71), nor NGF was a significant risk factor for survival (aHR=1.15; 95% CI: 0.94-1.39).4

A reduction in the risk of pneumonia with CHF was hypothesized because of adjusted food textures, erect posture of patient and vigilance by the carer during feeding with caution for signs of respiratory distress or choking.4 Conversely, NGF may cause a dysfunction of the lower esophageal sphincter, less frequent contractions of the esophageal body, desensitization of the pharyngoglottal adduction reflex, and gastric reflux, especially when feeding in a supine position.4

Limitations of the study included a lack of randomized, controlled trial design or blinding due to ethical considerations, which could contribute to selection bias, among other differences between the NFG and CHF groups.4 Besides, the different types of dementia, of which were unaccounted for, might skew the results inappropriately, while pneumonia experienced by the patient might also not be specific to aspiration pneumonia, but owing to other causes.4

In summary, advanced dementia patients may benefit from CHF over NGF due to the lower pneumonia risk.4 Although survivability is not directly influenced, aspiration pneumonia may still be a risk of mortality and should be addressed with concern.4 While the study has a good overall generalizability, it provided evidence supporting that CHF practices in hospitals and residential care homes are not only for the quality of life considerations but also demonstrated the feasibility and potential to reduce the pneumonia risk in this population.4

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