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INVOLUNTARY WEIGHT LOSS IN THE ELDERLY _____________________________

INVOLUNTARY WEIGHT LOSS IN THE ELDERLY _____________________________. Beatriz Korc MD, PhD. The Brookdale Department of Geriatrics And Adult Development Mount Sinai School of Medicine March 3 rd , 2009. OBJECTIVES. To recognize the importance of involuntary weight loss in the elderly

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INVOLUNTARY WEIGHT LOSS IN THE ELDERLY _____________________________

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  1. INVOLUNTARY WEIGHT LOSS IN THE ELDERLY_____________________________ Beatriz Korc MD, PhD. The Brookdale Department of Geriatrics And Adult Development Mount Sinai School of Medicine March 3rd, 2009

  2. OBJECTIVES • To recognize the importance of involuntary weight loss in the elderly • To identify the factors associated with weight loss in the elderly and their investigation • To become familiar with non-pharmacological and pharmacological management options • To discuss artificial nutrition in end-stage dementia.

  3. Case of Ms. FB • 85 year old woman with history of severe dementia, L sided CVA with R hemiplegia, hypertension and an approx. 6 month history of decline and weight loss. • The patient was admitted with one week history of progressive weakness, mental status changes and decrease oral intake • Exam showed BP 110/55, HR 90. Lethargic, non-verbal, does not follow commands. R sided hemiplegia. No other findings • Labs: Normal CBC with diff. Chem-7: Na 168 and Creatinine 1.3 (baseline 0.8-0.9) • 24/7 private paid HHA. Large family and very supportive. No advanced directives.

  4. WHAT IS CLINICALLY IMPORTANT INVOLUNTARY WEIGHT LOSS?__________________________________________ • 5% weight loss over a 1 year period Wallace J et al. J Am Geriatr Soc 1995; 43:329-337 • More than 10 pounds in 6 monthsSeltzer MH et al J Parenter Enteral Nutr 1982;:218-221 • >5% in 30 daysRyan et al South Med J 1995; 88:721-724 • 10% in 180 daysChang et al J Fam Pract 1990; 30:671-674.

  5. PREVALENCE_____________________________________ • 1.3-8% of adults seeking outpatient health care Marton et al Ann Intern Med 1981;95:568-574 • 27% of free-living frail elderly receiving community services Payette et al J Clin Epidemiol 2000;53:579-587. • 50% of institutionalized patients with dementia • 30% of non-institutionalized patients with mild-moderate AD White et al J Am Geriatr Soc 1996;44:265-272

  6. EFFECTS OF INVOLUNTARY WEIGHT LOSS • Increased frailty and mortality (9-38% within 1-3years) • Increased hospital admissions and increased risk of in-hospital complications • Increased falls and injuries from falls • Impaired cell-mediate and humoral immune response with increased rate of infections • Loss of lean body mass with impaired skeletal muscle, cardiac muscle and respiratory function • Delayed wound healing • Decreased functional ability and ADLs • Higher rates of admission to an institution • Poorer quality of life Launer et al. JAMA 1994;271:1093-1098 Fine et al JAMA 1999;282:2136-2142. Landi et al J Am Geriatr Soc 1999;47:1072-1076 Tayback et al Arch Inter Med 1990;150:1065-1072.

  7. CAUSES OF WEIGHT LOSS IN THE ELDERLY_____________________________________________ • REVERSIBLE • Assessment • Diagnosis • Treatment • IRREVERSIBLE • Frustrating • Painful • Emotionally draining • Expensive • Fruitless

  8. CAUSES OF WEIGHT LOSS IN THE ELDELY_____________________________________________ • PHYSIOLOGICAL • MEDICAL • FUNCTIONAL • PSYCHOLOGICAL • SOCIAL

  9. CAUSES OF WEIGHT LOSS IN THE ELDELYPHYSIOLOGICAL FACTORSANOREXIA IN AGING • Chemosensory changes • Diminished sensory-specific satiety • Change in taste and smell • Increase threshold for salt and other specific tastes • Decrease taste sensitivity due to decrease taste receptor turnover; taste buds number does not change. • Medications alter senses of taste and smell • Gastrointestinal factors • Delayed gastric emptying • Prolonged antral distension • Increased absorption time • Gut Hormones • Elevated levels of Glucagon (GLP-1), CCK and Leptin • Decreased levels of Ghrelin Hays and Roberts Phys and Behavior 2006; 88:257-266.

  10. CAUSES OF WEIGHT LOSS IN THE ELDELYPHYSIOLOGICAL FACTORSANOREXIA IN AGINGHays and Roberts Phys and Behavior 2006; 88:257-266.

  11. CAUSES OF WEIGHT LOSS IN THE ELDELY MEDICAL CAUSES • Malignancy • Infectious • Bacterial,Tb, fungal,parasitic • Inflammation • Autoimmune diseases • Endocrine • DM, hypo/hyperthyroid, Adrenal Insufficiency • Organ Failure • CHF, CRI, COPD, etc • Medication Side Effects • Deficiencies • B12, Folate, Iron, Thiamine, Vit.C, Zn

  12. Side effect Anorexia Dry mouth Dysgeusia/dysosmia Nausea/vomiting Carr-Lopez et al.Drugs Aging 1996;9:221-5 Drug Antibiotics, anticonvulsants, digoxin, metformin, SSRIs,etc. Anticholinergics, antihistamines, diuretics, clonidine ACEI, antibiotics, anticholinergics, calcium channel blockers, etc. Antibiotics, digoxin, hormone replacement, iron, potassium, SSRIs, statins, etc. MEDICATION SIDE EFFECTS THAT CAN CONTRIBUTE TO WEIGHT LOSS

  13. CAUSES OF WEIGHT LOSS IN THE ELDELYFUNCTIONAL CAUSES • Immobility • Arthritis • Stroke • Parkinson’s • Dental • Vision • Hearing

  14. CAUSES OF WEIGHT LOSS IN THE ELDELYPSYCHIATRIC/PSYCHOLOGICAL CAUSES • Depression • Psychosis • Grief/Bereavement • Intentional • Alcoholism • Dementia • Anorexia nervosa/anorexia tardive

  15. CAUSES OF WEIGHT LOSS IN THE ELDELYSOCIAL CAUSES • Poverty • Isolation • Neglect • Abuse • Caregiver fatigue

  16. EVALUATION OF WEIGHT LOSS IN THE ELDERLY • Weigh the patient • Calculate body mass index (undernutrition <22) • Careful H&P with emphasis in pharmacologic and psychosocial factors • Basic screening tests including UA, CBC, electrolytes, LFTs, TFTs, renal function, stool occult blood, CXR; upper and lower endoscopies (high diagnostic yields) • Indicators of poor nutrition: Albumin <3.4 g/dL, Cholesterol < 160 mg/dL, Transferrin <180, Hb < 12g/dL, triceps skin fold thickness

  17. TREATMENT_____________________________________ • NON-PHARMACOLOGIC • PHARMACOLOGIC

  18. NON-PHARMACHOLOGIC TREATMENT • Minimize dietary restrictions • Optimize energy intake • High energy foods at the best meal of the day • Smaller meals more often (eat with the clock not your appetite) • Favorite foods and snacks • Optimize and vary dietary texture • Avoid gas-producing foods • Ensure adequate oral hygiene and health • Take nutritionally dense supplements • Eat in company or with assistance, hand-feed the patient • Use flavor enhancers, maximize taste and smell • Participate in regular exercise • Take a multiple vitamin supplement daily • Use community nutritional support services • Minimize aspiration risk

  19. NUTRITIONAL NEEDS IN THE ELDERLY • Energy intake • Declines significant with aging • reduction in basal energy expenditure • decline in physical activity • Goal: 25 kcal/kg/day • Macro nutrients • Protein intake: 0.8-1.2 gm/kg/day (higher in patients with pressure ulcers) • Carbohydrates: minimum of 130 g/day, 50% complex; 20-30 g of fiber • Fat: less than 30% of total calories; less than 10% saturated • Micronutrients: vitamins and minerals • Water soluble vitamins • Fat soluble vitamins NHANES 3 Baltimore Longitudinal Study of Aging Framingham

  20. NUTRITIONAL NEEDS IN THE ELDERLY Water-soluble vitamins • Folate RDA 400µg/day • No evidence of increased requirement in the elderly • Low levels more common in elderly alcoholics (poor intake and decreased absorption) • Risk for over-supplementation (>1mg) mask Vit B12 deficiency. • Cyanocobalamine (B12) RDA 2.4 µg/day in adults>51y • 10-15 % elderly have B12 deficiency (achlorhydria, antacid use, H.Pylori) • Thiamine (B1) Mandatory enrichment of food ensures that the RDA is met. • Low levels most common in elderly alcoholics (poor intake and decreased absorption)

  21. NUTRITIONAL NEEDS IN THE ELDERLY Fat-soluble vitamins • Vitamin A: RDA 700 RE in women and 900 in men • requirement does not increase with age; • the clearance is reduced. • Hypervitaminosis: significant toxicity with chronic ingestion (headaches, leukopenia, hypercalcemia, etc) • Vitamin D : RDA>70 600-800 IU • requirement increases with age due to reduced skin photosynthesis, reduced sun exposure, reduced absorption, reduced 1 hydroxylation of 25(OH)D • Vitamin E: • Deficiency is limited to cases of severe , long-standing fat malabsorption. Amount in diet is usually adequate.

  22. NUTRITIONAL NEEDS IN THE ELDERLY WATER : FORGOTTEN NUTRIENT • Elder patients have • Decreased thirst response • Reduced concentration capacity by the kidneys • Water needs • 1 ml/kcal or 30ml/kg of body weight

  23. PROTEIN AND ENERGY SUPPLEMENTATION • Objective: to examine evidence from trials for improvement in nutritional status and clinical outcomes when extra protein and energy food were provided, usually in the form of commercial ‘sip-feeds’ • Results: 31 trials with 2464 randomised participants were included in the review. Most studies were poor in quality. • The RR indicated lower mortality in the supplemented group. • Small weight gain • The risk of complications (e.g. number of infections) showed no significant difference • Little evidence of benefit to functional outcomes from individual studies • Some indication of shorter length of stay for the supplemented groups (-3.4 days) • Conclusions: Supplementation appears to produce a small but consistent weight gain. There was a statistical significant beneficial effect on mortality and a shorter length of hospital stay Milne et al Cochrane Database of Systematic Reviews. 1. 2005

  24. PROTEIN AND ENERGY SUPPLEMENTATION SAMPLE OF ORAL SUPPLEMENTS Boost plus High cal., high protein Carnation VHC 2.25 Very high cal., high protein Resource Diabetic Diabetic, high protein Enlive Clear liquid supplement NuBasics Fruit Bev. Clear liquid supplement Gatorade Clear liquid supplement Ensure pudding Consistency modified Benefiber Fiber supplement Procel Modular protein Thicken-up Powder thickener

  25. WHEN TO CONSULT THE NUTRITIONIST? • Enteral/parenteral support • Unintentional weight loss >5% • N/V/D > 3 days • Poor oral intake, <50% of meals >3 days • Difficulties chewing, swallowing, aspiration precautions diet • NPO>3 days • Albumin<3.4 • Wound/Pressure ulcer (any stage) • Transplant patients • Newly diagnosed or uncontrolled diabetic/CHF/ESRD.

  26. PHARMACOLOGIC TREATMENTAPPETITE STIMULANTS = OREXIGENIG AGENTS • MEGESTROL ACETATE • DRONABINOL • ANABOLIC AGENTS • ANTIDEPRESSANTS • GASTROPROKINETIC AGENTS • OTHER EXPERIMENTAL DRUGS Morley, EM Clin Geriatr Med 2002;18:853-866

  27. PHARMACOLOGIC TREATMENT MEGESTROL ACETATE • Progestational agent that produces an increase in food intake • Mechanism unclear: • alteration of CNS neurotransmitters involved in the regulation of food intake • antagonizes cytokine production (potent anorectic agents) • Weight gain has been reported in numerous patients with cancer-related anorexia and wasting Nelson et al J Clin Oncol 1994;12:213-225 • Patients with AIDS reported increase caloric intake, weight gain and increased sense of well-being. Fat mass increased but there was no increase in body water or lean body mass Oster et al Ann Intern Med 1994;121:400-408

  28. PHARMACOLOGIC TREATMENT MEGESTROL ACETATE (cont.) • NH patients showed increased appetite, greater enjoyment of life, stronger sense of well being; statistical significant increase in body weight was shown only if medication was provided longer than 12 weeks. Yeh et al 2000; 48:485-492. • Doses range from 80-800 mg/day. • Consumer price: $4,750 per year for the 800 mg suspension • Most common side effects include: thromboembolism, fluid retention, flushing, erectile dysfunction, vaginal bleeding, adrenal insufficiency, diabetes, decrease in testosterone levels

  29. PHARMACOLOGIC TREATMENT MEGESTROL ACETATE (cont.) • Recommendations: • Avoid M.A. in bed-bound patients – increased incidence of DVTs • If the patient is scheduled for urgent surgery or has an infection during M.A. treatment (longer than 8-12 weeks) the patient should be given a stress dose of steroids Morley, EM Clin Geriatr Med 2002;18:853-866 Golden AG et al Am J of Therapeutics 2003;10:292-298.

  30. PHARMACOLOGIC TREATMENT DRONABINOL • Cannabis was already used as an appetite stimulant in ancient Arabic medicine • It increases the desire for food, improves taste, makes substances smell richer, decreases pain, and improves mood • Effective appetite stimulant in patients with AIDS and cancer • FDA approved as an appetite stimulant and antiemetic in HIV patients • Doses used 2.5-20 mg/day (5-7.5 mg at hs for older demented patients) • Major side effects include: delirium, abdominal pain, nausea, ataxia at high dose. Morley, EM Clin Geriatr Med 2002;18:853-866

  31. PHARMACOLOGIC TREATMENT DRONABINOL • One study in patients with Alzheimer’s disease (n=12) placebo-controlled cross-over design Int J Geriat Psychiatry 1997;12:913-919 • Mean weight gain of 9.3lbs in the treated group vs. 6.3 lbs in the placebo group • Treatment decreased severity of disturbed behavior • Most common side effects noted: euphoria, somnolence and tiredness. One patient had a seizure. To limit the occurrence of delirium in older patients, Dronabinol should be given in the evening at a low starting dose of 2.5 mg. Appetite stimulation usually occurs at 5-7.5 mg dose. Morley, EM Clin Geriatr Med 2002;18:853-866

  32. PHARMACOLOGIC TREATMENTANABOLIC AGENTS • Testosterone: replacement in older men increase muscle mass, decreases fat mass and increases bone mineral density. Higher Hct (>54%), leg edema, exacerbation of prostate cancer are major side effects. Sih et al J Clin Endocrinol Metab 1997;82:1661-1667 • Anabolic steroids: oxandrolone, nandrolol have improved weight in AIDS patients. Liver toxicity, fluid retention and renal failure are major side effects. Romeyn & Gunn.JAMA 2000;284;176. • Growth hormone and IGF-1 might be useful in treating severely ill, malnourished patients resulting in nitrogen retention and weight gain. Glucose intolerance/insulin resistance, peripheral edema, gynecomastia are major side effects Chu et el. J Clin Endocrinol Metab 2001;86:1913-1920. • Glucocorticoids have been widely used in hospice patients. Improve appetite and mood but have minimal impact on weight gain or function

  33. PHARMACOLOGIC TREATMENT ANTIDEPRESSANTS: MIRTAZAPINE • Depression is the most common treatable cause of anorexia and weight loss • Some antidepressant are more orexigenic than others • Mirtazapine enhances noradrenergic and serotoninergic neurotransmission. This combination suggests appetite-enhancing effects Halikas JA Hum Psychopharmacol 1995;10:S125-S133 • Mirtazapine increases appetite and more weight gain than SSRIs Schatzberg et al Am J Geriatr Psychiatry 2002;10:541-550. • It could be used as the antidepressant of choice for older depressed patients with weight loss • There is no data of mirtazapine as a appetite stimulant in the elderly non-depressed patient. Golden AG et al Am J of Therapeutics 2003;10:292-298.

  34. TO PEG OR NOT TO PEG “If a man be sensible and one fine morning, while he is lying in his bed, counts at the tips of his fingers how many things in this life truly will give him enjoyment, invariably he will find food is the first one” Lin Yutang

  35. CAUSES OF EATING PROBLEMS IN ADVANCED DEMENTIA • Oral dysphagia: absent or continuous chewing with tendency to pocket or spit food • Pharyngeal dysphagia: delayed swallowing initiation, multiple swallows, and aspiration • Loss of the ability to perform the task of eating • Loss of the ability to interpret the sensation of hunger • Disinterest in food due to depression • Refusal to eat. Volicer L, Clin Geriatr Med. 2001;17(2):377-391 Langmore et al. Arch Neurol.2007; 64(1):58-62.

  36. INDICATIONS • The American Gastroenterological Association (AGA) endorses PEG tube placement for prolonged tube feeding (>30 days) when: • The patient cannot or will not eat • The gut is functional • The patient can tolerate the placement of the device.

  37. SOME FACTS • PEG tubes were introduced in 1979 to provide enteral nutrition in children and young adults • In 2000 more than 216,000 PEG tubes were placed nationally most of them in older adults. • PEG is the second leading indication for upper gastrointestinal tract endoscopy • Dementia patients account for 30% of all PEG tubes placement • One third of all NH patients are being tube fed • Patient characteristics consistently associated with with a higher likelihood of being tube fed included: younger age, nonwhite race, and lack of advanced directives. Gauderer Gastrointest Endosc 1999;50:879-883. Cervo et al. Geriatrics 2005;61:30-35 Mitchell et al. 2003 JAMA 290(1):73-80 Mitchell et al 1997 Arch Intern Med ; 157(3):327-332.

  38. Percutaneous Endoscopic Gastrostomy • Success rate: 95% • Procedure-related morbidity: 9.4% • Procedure related mortality: 0.53% • Major complications: 1-3% cases Larson et al Gastroenterology 1987; 93:48-52 Wollman et al Radiology 1995;197:699-704

  39. Percutaneous Endoscopic Gastrostomy Complications • Major • Aspiration pneumonitis/pneumonia • Peritonitis • Hemorrhage: puncture of gastric wall vessel • Buried bumper syndrome: migration of the tube into the gastric wall and epithelization of the ulcer site. • Gastrocolocutaneous fistula • Wound infection • Necrotizing fasciitis • Inadvertent removal of PEG tube • Minor • Tube leakage (58-78% of patients with long-term PEG) • Tube blockage (16-31% during 18-month follow up) Potack & Chokhavatia, Medscape J Med. 2008; 10(6): 142.

  40. PEG PLACEMENT IN PATIENTS WITH DEMENTIA Decision by physicians and caregivers to place a PEG tube is motivated by goals of: • Provide nutrition and hydration • Reduce risk of aspiration pneumonia • Improve pressure ulcers • Improving nutrition parameters • Improve survival • Facilitate transfer to LTC facilities • Increase caregiver convenience • Comply with LTC facilities policies

  41. Which of the following reasons are true when evaluating the potential placement of a feeding tube in a severely demented patient: • It will provide adequate nutrition • It will prolong the patient’s life • It will eliminate suffering • It will prevent aspiration pneumonia • It will improve skin integrity by increasing protein intake • It will improve functional status and/or quality of life 1. Only a,c and e are true 2. Only b and f are true 3. Only a and d are true 4. All the statements are true 5. None of the statements are true

  42. SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) Provide nutrition • Nutritional markers (Hb, Alb, Cholesterol) have not shown improvement after PEG placement • “Despite administration of apparently adequate formula, micronutrient deficiency exist in chronically-ill patients” (LTC) • Tube feedings do not prevent the clinical consequences of malnutrition such as pressure ulcers Li et al Am Fam Physician 2002;65:1605-1610; Callahan et al J Am Geriatr Soc 2000;48:1048-54. Finucane et al JAMA 1999;282:1365-70 Finucane TE 1995 J Am Geriatr Soc. 43(4):447-451.

  43. SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) Prolongation of life • Available data does not show survival advantage to PEG use • Mortality during PEG tube placement ranges from 0-2% and peri-operative mortality ranges from 6-24% • No difference in mortality rates among PEG vs. hand-fed demented patients • In all patients fed by gastrostomy tube, there is an high initial mortality of 28% at 30 days. Patients with dementia have a worse prognosis, with 54% having died at 1 month and 90% at one year. Gillick MR N Engl J Med 2000;342:206-210 Finucane et al JAMA 1999;282:1365-70 Meier et al Arch Intern Med 2001;161:594-9 Sanders et al Amer J of Gastroenterol 2000 95(6):1472-1475.

  44. SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) Elimination of suffering • There is no data to suggest that patient with end stage dementia suffer due to eating problems • Studies from non-demented terminally ill patients with anorexia suggest no discomfort from these symptoms • There is significant suffering due to • surgical/wound-related issues: infection, bleeding, leakage, abscess, peritonitis • increase use of restrains and subsequent pressure sores • need for pharmacological sedation • Electrolyte disturbance • Aspiration pneumonia after placement • increase urine and stool production, diarrhea or constipation, vomiting • decrease contact with care-givers • deprivation of the joy of eating • Increased # of transfers to acute care facilities due to tube dislodgement or leakage. Finucane et al JAMA 1999; 282:1365-70 Callahan et al J Am Geriatr Soc 2000; 48:1048-54. Pek et al J Am Geriatr Soc 1990; 38(11):1195-1198

  45. SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) Prevention of aspiration pneumonia • There are no published studies suggesting that tube feeding reduces the risk of aspiration • Tube feeding does not reduce the risk of aspiration from regurgitated gastric content or oral secretions. • Gastrostomy tubes may reduce lower esophageal sphincter tone increasing the risk of GERD. • Several case-controlled studies identified tube feeding as a risk factor for aspiration pneumonia with increased rate of pneumonia and death • Prospective cohort with oropharingeal dysphagia: tube fed patients had more aspiration than orally fed • The most common adverse effect associated with tube feeding is aspiration pneumonia (0%-66%) Finucane et al JAMA 1999;282:1365-70 Pick et al J Am Geriatr Soc 1996;44:763-768 Finucane et al Lancet 1996;348:1421-24.

  46. SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) • There are no studies showing improvement of function • A retrospective study in NH patients showed no improvement in bladder or bowel function, mental status, speech, ADLs or ambulation during the 18 months after PEG tube placement. • Feeding tubes are ineffective in the prevention or treatment of pressure ulcers • There is positive correlation between pressure ulcers and long term tube feeding. Bedfast, incontinent, dementia patients are more likely to be restrained with increased risk for pressure ulcer formation Cervo et al. Geriatrics 2005;61:30-35 Finucane et al JAMA 1999;282:1365-70

  47. SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) PEG placement does not seem to improve quality of life in patients with end stage dementia: • Questionnaire to caregivers 5 weeks after PEG placement: only 19% thought the QOL had improved McNabney et alJ Am Geriatr Soc 1994;42:161-168 • PEG placement has been associated with social isolation and denial of oral feeding Finucane et al JAMA 1999;282: 1365-1370 • Increased agitation and use of restraints Peck et al J Am Geriatr Soc 1990;38:1195-1198.

  48. BARRIERS TO LIMITING THE PRACTICE OF FEEDING TUBE PLACEMENT IN ADVANCED DEMENTIA • Economic incentives/NH issues • Path of less resistance • State law • Family concerns over starving • Religious beliefs • Lack of understanding of terminal nature of advanced dementia • Physician’s beliefs

  49. DECISION MAKING: NEW YORK STATE LAW

  50. BARRIERS TO LIMITING THE PRACTICE OF FEEDING TUBE (FT) PLACEMENT IN ADVANCED DEMENTIA Shega et al. J Pall. Med 2003;6:885-893 • 76.4% believe that FT reduce aspiration pneumonia • 74.6% believe that FT improve pressure ulcer healing • 61.4% believe that FT improves survival • 93.7% believe that FT improves nutritional status • 27.1% believe that FT improves functional status • Most physicians underestimate 30-day mortality post FT placement • 51% of the physicians believe that FT are the standard of care • Most physicians believe that speech therapists, nurses and nutritional support teams recommend FT (70%), which influences their decision to recommend the FT (66%) and influence families about FT placement (95%) • 47% had a NH request a FT placement and 65% thought that the HN concerns influenced their decision to recommend it The authors found and notable discord between physician opinion, reported practice and the literature regarding PEG tube placement in advanced dementia

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