Careful hand feeding reduces pneumonia risk vs nasogastric tube feeding in advanced dementia patients

In advanced dementia patients with feeding problems, careful hand feeding (CHF) is associated with a 40 percent lower risk of pneumonia and similar 1-year survival rate vs nasogastric tube feeding (NGF), a retrospective cohort study in Hong Kong has shown.

The study, led by researchers from the Division of Geriatrics, the University of Hong Kong, included 764 patients (mean age, 88.8 years; female, 61 percent; residential care home residents, 74 percent) with advanced dementia with an indication for tube feeding who were admitted to two geriatric convalescent hospitals in Hong Kong between January 2015 and June 2019. The primary types of feeding problems were dysphagia (50 percent), behavioural feeding problem (33 percent), or both (17 percent). [J Am Med Dir Assoc 2022;23:1541-1547.e2]

Among these patients, 464 (60.7 percent) were initiated on NGF and 300 (39.1 percent) were put on CHF, based on consensus feeding mode decision made between the treating physician and the family surrogate. Patients in the NGF group were younger than those in the CHF group (mean age, 88.2 years vs 89.8 years; p<0.001), more likely to have dysphagia (59.1 percent vs 37.0 percent) or both dysphagia and behavioural feeding problem (20.0 percent vs 11.3 percent), had higher severity of dysphagia (moderate-severe, 18.1 percent vs 11.3 percent; severe, 43.7 percent vs 31.1 percent), and more likely to have a diagnosis of aspiration pneumonia (64.6 percent vs 35.4 percent; p=0.02).

Among 577 patients (76 percent) who survived to discharge, the rate of pneumonia was significantly lower in the CHF vs NGF group at 1 year (48.0 percent vs 60.3 percent; p=0.004). In subgroup analyses, NGF was associated with increased pneumonia risk in patients with both dysphagia and behavioural feeding problem, but not in those with either alone. “After adjusting for cofounders, NGF was found to be a significant risk factor for pneumonia [adjusted hazard ratio (aHR), 1.41; 95 percent confidence interval (CI), 1.08–1.85],” the researchers reported.

At 1 year, mortality rates were similar between the NGF and CHF groups (64.0 percent vs 62.7 percent; p=0.55). Median survival was 125 days vs 145 days. No difference in survival was found between patients with different types of feeding problems. “NGF was not a significant predictor for survival [aHR, 1.15; 95 percent CI, 0.94–1.39],” the researchers noted.

Feeding tubes are commonly inserted due to perceived benefits of reducing aspiration pneumonia risk and improving survival. However, given the lack of conclusive evidence on benefit and the treatment burden associated with tube feeding, several guidelines have recommended CHF as an alternative. [JAMA 1999;282:1365-1370; Cochrane Database Syst Rev 2009;2:CD007209; J Am Med Dir Assoc 2021;22:357-363; J Am Geriatr Soc 2014;62:1590-1593; Clin Nutr 2015;34:1052-1073; Clin Med (Lond) 2010;10:3; Australas J Ageing 2011;30:98-103]

“This study, the first to examine effects of NGF vs CHF on survival and pneumonia risk in hospitalized advanced dementia patients and to compare the effects by feeding problem type, provides evidence to support CHF practices in hospitals and residential care homes not only for quality of life considerations, but also for feasibility and the potential to reduce pneumonia risk in this population,” the researchers noted.

Postulated mechanisms for the increased risk of aspiration pneumonia from NGF include impairment of lower oesophageal sphincter with the tube’s presence across the gastric cardia, reduced frequency of oesophageal body contractions, desensitization of the pharyngoglottal adduction reflex, and reflux of gastric content into the pharynx, especially when patients are fed in a supine position. [World J Gastroenterol 2014;20:8505-8524; Curr Opin Clin Nutr Metab Care 2003;6:327-333] “CHF may reduce the risk of aspiration pneumonia due to modified food textures, as well as the patient’s erect position and the caregiver’s careful observations during feeding, with cession of feeding on noting the first signs of choking or respiratory distress,” the researchers hypothesized.