International Journal of Gerontology
Volume 5, Issue 3 , Pages 135-138, September 2011

Percutaneous Endoscopic Gastrostomy in the Enteral Feeding of the Elderly☆

  • Huan-Lin Chen

      Affiliations

    • Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Mackay Medicine, Taitung-Branch, Taipei, Taiwan
    • ,
  • Shou-Chuan Shih

      Affiliations

    • Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
    • Mackay Medicine, Nursing and Management College, Taipei, Taiwan
    • ,
  • Ming-Jong Bair

      Affiliations

    • Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Mackay Medicine, Taitung-Branch, Taipei, Taiwan
    • Corresponding Author InformationCorrespondence to: Ming-Jong Bair, Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taitung Branch, No. 1, Lane 303, Changsha Street, Taitung, Taiwan.
    • ,
  • I.-Tsung Lin

      Affiliations

    • Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Mackay Medicine, Taitung-Branch, Taipei, Taiwan
    • ,
  • Chia-Hsien Wu

      Affiliations

    • Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Mackay Medicine, Taitung-Branch, Taipei, Taiwan

Received 28 May 2010; received in revised form 18 April 2011; accepted 14 June 2011. published online 28 November 2011.

Article Outline

Summary 

Today we are faced with an aging society that may develop malnutrition because of dysphagia related to dementia, stroke, and malignancy seen often in the elderly. The preferred form of nutritional supplementation for this group is enteral nutrition, and the most appropriate long-term method is by use of a gastrostomy. Percutaneous endoscopic gastrostomy (PEG) was first introduced in 1980 as an alternative to the traditional operative procedure and rapidly became the preferred procedure. In geriatric patients, the principal indications are neurological dysphagia and malnutrition, related to an underlying disease or anorexia-cachexia in very elderly. PEG is contraindicated in the presence of respiratory distress, previous gastric resection, total esophageal obstruction, coagulation disorders and sepsis in the elderly. Common complications include wound infection, leakage, hemorrhage, and fistula in the general population, but aspiration pneumonia is the major case of death in this group. Risks and complications of PEG must be discussed with patients and their families; and the decision for percutaneous endoscopic gastrostomy insertion should only be made after careful consideration and discussion between managing physicians, allied health professionals, and the patient and/or family. Four ethical principles may help make feeding decisions: beneficence, non-maleficence, autonomy and justice. Attentive long-term care after tube replacement is mandatory. Acceptance of percutaneous endoscopic gastrostomy placement by patients and their families tends to increase once favorable outcomes are offered.

Keywords: elderly, enteral feeding, geriatric patient, nutrition, percutaneous endoscopic gastrostomy

 

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1. Introduction 

As evidenced by worldwide population trends, today we are faced with an aging society. Dementia, stroke, and malignancy are common problems among the elderly that may lead to malnutrition because of dysphagia associated with these diseases. Alternate means of feeding then becomes a consideration when the demented or diseased patient is unable to ingest food for any reason. Nutritional supplementation may be enteral or parenteral, and enteral nutrition is the preferred route if the gut is functional1.

Enteral feeding can be accomplished through nasogastric, nasojejunal, gastrostomy or jejunostomy tubes. Nasogastric tubes have the advantage of being simple to insert, but are often poorly tolerated by the patient. They are difficult to maintain in position and have a significant associated risk of aspiration pneumonia. Nasojejunal tubes are better tolerated, but are easily blocked. Similar to nasogastric tubes, they are also difficult to keep in position2. The most appropriate method for long-term enteral feeding is by use of a gastrostomy or occasionally a jejunostomy. Gastrostomy can be created surgically, radiologically or endoscopically.

Surgical gastrostomy is technically simple, but it does involve an abdominal incision under general anaesthesia. As most elderly patients are malnourished, often in the presence of multiple medical problems, the operative risk is high. The gastrostomy site may heal poorly, leading to leakage and increased morbidity. Hence, it has been a less popular option because of the higher rate of complications than percutaneous gastrostomy3. Another method, the percutaneous nonendoscopic or radiological gastrostomy, was first performed in 1981 by Preshaw4, a Canadian surgeon; using this technique, the tube is placed with fluoroscopic guidance rather than by means of endoscopy or surgery. Just prior to this, in 1980, Gauderer et al5 had introduced a new technique into clinical practice with the creation of a feeding gastrostomy that used a percutaneous technique under endoscopic guidance. Since then, percutaneous endoscopic gastrostomy (PEG) has rapidly become the preferred method of delivering long-term enteral nutrition to those with swallowing difficulties6. More than 216,000 tubes were placed in 20007, up from 15,000 tubes in 1989, with as many as 10% of institutionalized older patients being tube-fed8. It is now the most commonly used method in both children and adults, much more widely used than surgical or radiological insertion. While much has been published specifically about PEG feeding, articles about tube feeding in general have been reviewed only where these seem to be of relevance.

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2. Indications for percutaneous endoscopic gastrostomy in elderly patients 

The most common reasons shown for using PEG in a recent American series among elderly adults were stroke (40.7%), neurodegenerative disorders (34.7%), and cancer (13.3%)9. Another 168-patient study in Australia revealed different reasons, including recent cerebrovascular accident in 97 patients (58%); other neurological impairment in 25 (15%); pharyngeal or esophageal obstruction in 16 (9%); and general debility with difficulty swallowing in 30 patients (18%)10. Although neurological dysphagia in the most common indication, another principal indication in the elderly is refusal of oral intake in a context of anorexia-cachexia from a 59-patient study11. Thus, frequent indications for PEG placement include impaired swallowing associated with neurological conditions (stroke and neurodegenerative disorders), anorexia-cachexia ‘wasting’ and neoplastic diseases of the oropharynx, larynx and oesophagus. Less commonly, PEG placement is performed in patients with head, facial or neck trauma, in those with miscellaneous catabolic conditions, and in those with benign or malignant gastrointestinal tract obstruction, who need sustained gastric decompression (the so-called ‘venting PEG’). However, PEG appears not to be appropriate in patients with rapidly progressive and incurable disease.

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3. Contraindications for percutaneous endoscopic gastrostomy in elderly patients 

Before PEG insertion, patients should be carefully screened for contraindications. Most elderly patients who need PEG are likely to have more medical comorbidities, which are vital in determining the suitability and timing of a PEG insertion. In the general, elderly patients with severe respiratory disease are too frail for the sedation necessary for endoscopy. Another absolute contraindication for PEG placement is the inability to bring the anterior gastric wall in apposition to the abdominal wall, which may be the result of prior gastric resection, ascites, hepatomegaly or obesity10. Other conditions, including bleeding tendency, peritonitis, pharyngeal or esophageal obstruction, and acute severe illness, are also absolute contraindications12. Relative contraindications to PEG include neoplastic, inflammatory and infiltrative diseases of the gastric and abdominal walls, and immune system deficiencies.

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4. Procedure for percutaneous endoscopic gastrostomy in the elderly patient 

The procedure of PEG in the elderly is the same as other groups. The PEG procedure can be performed in the operating room, in the endoscopy suite, or at the patient’s bedside. Prophylactic antibiotics in the geriatric group are administered before endoscopy and continued for 72 hours, usually a cephalosporin or a quinolone. In general, moderate sedation is used to perform a PEG procedure. If an elderly patient is at risk of respiratory compromise because of a comorbid disease state, the use of an anesthesiologist or a nurse anesthetist to provide sedation and to monitor the patient’s cardiorespiratory status is warranted. In addition, sometimes intubation for airway protection may be necessary in the elderly. The patient may be placed in the supine position, which does not need to be changed after endoscope insertion. Some elderly can not lie in the supine position due to kyphosis, which may be risky for this procedure. Before PEG placement, a full examination of the esophagus, stomach, and duodenum are performed (Fig. 1A). If a stricture or mass is encountered in the esophagus or the oral cavity, conditions may be not suitable for this procedure. Besides, paralytic ileus is a common problem in the elderly, which affects bowel movement and results in distension of the bowel loop. The physician should correct this problem first, and the patients should have an abdominal X-ray before PEG placement.

  • View full-size image.
  • Fig. 1 

    The procedure of percutaneous endoscopic gastrostomy. (A) A full examination of the esophagus, stomach, and duodenum should be performed before the PEG procedure. (B) The plastic outer sheath (introducer catheter) in the gastric cavity is noted. (C) A guidewire is threaded through the introducer catheter into the gastric cavity, and the PEG bumper can be inserted into the stomach. (D) The PEG bumper is in the appropriate position within the stomach.

The usual PEG entry site is in the left upper quadrant of the abdomen. It may be necessary to use the ‘high light intensity’ feature of the light source to determine an appropriate PEG entry site, especially in patients who are obese or of darker skin tone. Injection of 3–5cm3 of anesthetic and 1% lignocaine intradermally is required. After a 1cm incision of the entry site, the needle catheter should be rapidly pushed through the incision on the abdominal wall into the gastric cavity. The inner needle is removed, leaving the plastic outer sheath (introducer catheter) in the gastric cavity (Fig. 1B). A guidewire is threaded through the introducer catheter into the gastric cavity (Fig. 1C). The remaining part of the procedure is dependent on ‘push technique’ or ‘pull technique.’

In the ‘push’ PEG technique, the guidewire is pulled out of the oral cavity so that a PEG tube can be threaded over it and pushed into position. The PEG tube is pushed into the patient until the dilating tip exits the abdominal wall. This dilating tip of the PEG tube is grasped and the PEG tube is subsequently pulled into position (Fig. 1D). Otherwise, in the ‘pull’ PEG procedure, the loop guidewire that exits the patient’s mouth is attached to a loop guidewire on the end of the PEG tube by creating a square knot. The abdominal wall end of the looped guidewire is grasped and pulled, moving the PEG tube down the esophagus, through the stomach and out the PEG entry site on the abdominal wall into position. A final check for excessive tightness is made. After PEG placement, it is routine practice to keep the patients ‘nil by PEG’, and water flushes carried out 3 to 4 hours after placement. Afterwards the initial tube feeding and medication delivery are performed. The patient’s PEG tube site dressing is changed daily until there is no drainage or minimal drainage. The wound can be cleansed daily, or as needed, with soap and water.

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5. Complications for percutaneous endoscopic gastrostomy in elderly patients 

Generally speaking, PEG tube insertion is a safe procedure and it should not lead to mortalities in any age group. Nevertheless, a procedure-related mortality rate of 1–2% and morbidity of 3–12% was reported in the largest reported series13. Furthermore, it is recommended not to use PEG during periods of severe disease or severe immunosuppression. Death has been reported post-PEG insertion when it has been attempted during such periods14. Reported complications may include localized, gastrointestinal, and other types of complications15, 16. Local complications include wound infection, peristomal leakage, bleeding, necrotizing fascitis, and buried bumper syndrome17. Gastrointestinal complications include diarrhea, vomiting, bowel perforation, pneumoperitoneum and gastrocolic or colicocutaneous fistulae. Pneumoperitoneum occurs commonly after PEG and is of little clinical significance unless accompanied by signs of peritonitis18. Other complications may include aspiration pneumonia, septicemia, and metastastic lesion from gastrostomy, device dislodgement, accidental tube removal, and electrolyte imbalance. In a Japanese study of 931 elderly patients aspiration pneumonia was the major case of death19. Prolong prophylactic antibiotics, delay feeding, and tube decompression after the procedure may be helpful.

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6. Functional status and quality of life 

The evidence base for PEG tube use is conflicting, particularly in geriatric patients. Generally speaking, the functional status of patients who need PEG insertion is very poor. In one 6629-patient study in the UK, including new adult registrations of home enteral tube feeding of which half were housebound or bed-bound, more than 80% of patients had some limitation in activity level6. Hence, Callahan’s prospective observational study of 150 patients aged 60 years and older who received PEG tubes found no improvement in functional status, nutritional status, or subjective health status of patients at 1-year follow-up9. Another previously published review article reported no improvement in aspiration pneumonia, mortality, pressure sores, function, or palliation in PEG-fed patients with advanced cognitive impairment20.

Considering other aspects of PEG feeding, comfort and quality of life are often not easy to assess because many elderly patients receiving enteral tube feeding have advanced dementia and therefore cannot narrate their subjective feelings. Bannerman et al21 reported a cohort study of 215 patients, which revealed that health-related quality of life data were available for only 30 patients. Only 45% (10 out of 22) felt that PEG had an overall positive effect on their quality of life, but the data may not be representative. In one 5-week follow-up study of 58 caregivers of patients with new PEG insertion, 64% said there was no change in their patient’s quality of life, 19% thought it had improved, and 17% felt it had worsened22. In this particular survey, most surrogates felt that their decision was correct and would have acted similarly given a second chance, but were unsure if the patient would have made the same decision. In another study, Verhoef et al23 found that 67% of PEG patients surviving 1 year were not managing their own self-care, but the majority of patients and caregivers still did not regret the decision to PEG feed.

Why does PEG have unwanted results, even though it has become the most popular method of enteral feeding? In the report of Bannerman et al21, fewer than half of the patients appeared to suggest they had a positive impression of the gastrostomy, which did not necessarily translate into a better nutritional state. Most patients and caregivers had hoped for more improvement of functional status after PEG insertion, and some of them also wanted to change to oral nutrition after that. However, PEG is only one of the methods available to provide nutritional support; it is not intended as curative management. Moreover, gastrostomy tubes can contribute to patient discomfort. Because of dementia, some patients may try to pull the tube out, resulting in self-injuries and increasing the need for restraints. A restraint rate of up to 71% has been noted in studies24. Other sources of patient discomfort or injury have been noted including PEG wound care, wound infection, or tube dislocation. These conditions may result in behavioral changes, such as agitation, requiring the addition of sedative-hypnotics or antipsychotics. In addition, depressive moods appear frequently in these patients, especially with Parkinson’s disease, which has a negative impact on activities of daily living, cognitive performance, and quality of life25. Consequently, the decision for PEG insertion should only be made after careful consideration and discussion between the managing physicians, allied health professionals and the patient and/or the family.

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7. Ethical issues 

The ethical issues surrounding the withdrawing and withholding of artificial nutrition have been recently reviewed. In a study exploring the appropriate use of PEG in the elderly, Dr. Robert Skelly suggests that applying four ethical principles, beneficence, non-maleficence, autonomy and justice, may be helpful in making appropriate feeding decisions26. Beneficence means essentially that we ‘do good’ by initiating tube feeding in the elderly demented patients, providing benefits, such as prolonging life, improving functional status, avoiding hunger, improving comfort, preventing nutritional decline and its consequences, preventing aspiration and reducing the incidence of pressure sores and infections. Nonmaleficence means to ‘do no harm’ for the patients, and careful patient selection and avoiding procedure-related side effects are therefore necessary. Autonomy refers to allowing the patient to participate in the feeding decision and to express the method he or she prefers; however, since elderly patients who require enteral feeding often have advanced dementia or severe dysphasia, they may be unable to express their views, and only a minority of patients can actually contribute to decision-making regarding PEG placement. A 253-patient study found that 65% would prefer tube feeding if the chance of recovery was good, but only 4.5% would want long-term tube feeding in the context of significant cognitive impairment27. Therefore, family members usually play important roles in making decisions for elderly patients. ‘Justice’ refers to the elderly having equal access to treatments from which they can benefit. This means that elderly patients should not be denied tube feeding when it may offer them benefits, such as prolonging life, improving functional status, preventing hunger and nutritional decline, improving comfort and other benefits as mentioned above. Equally important, elderly patients should not be denied high quality palliative care when in the terminal stages of debilitating disease.

Applying these four ethical principles described above allows the managing physicians, allied health professionals, caregivers and the patient and/or the family to better discuss the related details of PEG feeding and to make the appropriate decision for the individual patient.

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8. Conclusion 

Percutaneous endoscopic gastrostomy placement is a safe procedure and an effective enteral feeding method in the elderly when oral feeding is not possible and the gastrointestinal tract is functionally intact. However, everyone should be doing ‘good’ for the patients, even the patients themselves. PEG is one of the methods for nutritional support in the elderly. PEG should not be used as a matter of administrative convenience and is not a substitute for nursing attention. If the patient can swallow safely, including multiple swallows per bolus, small food bolus, thickened fluids, or cream, and achieve the protein and calorie intake of a healthy senior, then PEG is not needed. After careful consideration and discussion between allied groups, the managing physicians should assess safety of the procedure and suitability of the candidate. In addition, long-term care of PEG and nutritional support is more important for the patient. We should enhance patient care by providing education that enables caregivers to become familiar with alternative feeding techniques, correctly manage these devices initially and long-term, and understand the long-term implications of tube feeding for the individual. In these respects, PEG would be beneficial for the elderly who can not eat by mouth.

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References 

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☆ All contributing authors declare no conflict of interest.

PII: S1873-9598(11)00111-6

doi:10.1016/j.ijge.2011.09.040

International Journal of Gerontology
Volume 5, Issue 3 , Pages 135-138, September 2011

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