Influence of Appetite and Continuation of Meals on the Prognosis of Elderly Patients Who Have Lost Swallowing Function

Abstract

Dear Editor:

Tube feeding in elderly patients who have lost their swallowing function continues to be debated.^1,2 The number of elderly patients with a swallowing dysfunction who refuse tube feedings has been increasing in recent years.³ Medical professionals refrain from providing meals for such patients when the patient has a poor appetite. Meanwhile, professionals face a difficult struggle when elderly patients with severe swallowing disorders desire a meal, i.e., whether the medical professional should take away meals from elderly patients in order to prevent the risk of aspiration or rather should continue to provide meals, respecting the wishes of the patient. The prognosis of such patients from the viewpoint of appetite or the continuation of oral intake has not been reported to date. We therefore evaluated the impact of appetite and the continuation of providing meals on the prognosis of elderly patients with serious swallowing dysfunction who did not wish to be tube fed.

This was a retrospective observational study conducted at the Division of Internal Medicine, Tenshindo Hetsugi Hospital. Of the elderly patients 65 years of age or over who were admitted due to pneumonia between April 2012 and January 2013 (each patient was followed until October 2013), 28 patients with serious swallowing dysfunction who did not wish to be fed via a tube were included in this study. The study protocol was approved by the institutional ethics committee, and some of the subjects had been included in a previous study at our institute.⁴ The swallowing function was assessed by two speech/language therapists. As a result, approximately half of the elderly patients with a good appetite who continued to receive oral meals were still alive, whereas all of the elderly patients with a poor appetite and those with a good appetite who did not continue to receive oral meals had died (see Table 1). In addition, the median number of survival days in the elderly patients with a good appetite who received oral meals, except for those who continue to be alive, was higher than that of the patients who did not receive oral meals, although the difference was not statistically significant.

Table 1.

Prognosis of Elderly Patients Who Have Lost the Swallowing Function and Refused Tube Feeding

	Good appetite				Poor appetite
	Total^a	Discontinuation of meal	Continuation of meal ^c	P ^a	Discontinuation of meal	P ^b
Number	14	3	11		14
Age, year	85 (75–99)	86.0 (75–89)	85 (75–99)	0.756	82 (75–93)	0.491
Female	6 (43%)	1 (33%)	5 (45%)	0.615	5 (36%)	0.500
Underlying disease
Cerebral stroke	8 (57%)	2 (67%)	6 (55%)	0.615	6 (43%)	0.353
Dementia	8 (57%)	1 (33%)	7 (64%)	0.385	10 (71%)	0.347
Route of nutrition
Peripheral vein	13 (93%)	3 (100%)	10 (91%)	0.786	10 (71%)	0.163
Central vein	0 (0%)	0 (0%)	0 (0%)	-	4 (29%)	0.049
Oral intake only	1 (7%)	0 (0%)	1 (9%)	0.917	0 (0%)	0.500
Mortality	9 (64%)	3 (100)	6 (55%)	0.231	14 (100%)	0.020
Survival days in the dead, days	89 (18–251)	65 (60–96)	124 (18–251)	0.606	78 (18–195)	0.729

The data are expressed as the median (range) or number (%).

“Discontinuation of meal” compared with “Continuation of meal” in “Good appetite.”

“Total” in “Good appetite” compared with “Discontinuation of meal” in “Poor appetite.”

Consequently, these results suggest that continuing oral meals improves the prognosis of elderly patients with a good appetite, even among those with severe swallowing dysfunction. On the other hand, this study implies the difficulty in assessing the swallowing function at only one point. Therefore, continuing oral intake with tolerance for some degree of aspiration may result in an improvement in the swallowing function. Medical professionals could possibly offer the continuation of meals as an option to elderly patients and their families in place of tube feeding.

In conclusion, the continuation of oral meals in elderly patients with serious swallowing dysfunction does not worsen the prognosis. These data may be helpful for assessing the efficacy of the nutritional methods used in end-of-life care. Further well-designed studies are needed to verify the present results.

Footnotes

Acknowledgment

We thank Okabe, M.D., Nomura, S.T., and Takahashi, P.T. for their advice and expertise.

References

Finucane

, Christmas

, Travis

: Tube feeding in patients with advanced dementia: A review of the evidence. JAMA, 1999; 282:1365–1370.

Garrow

, Pride

, Moran

, et al.: Feeding alternatives in patients with dementia: Examining the evidence. Clin Gastroenterol Hepatol, 2007; 5:1372–1378.

Komiya

, Ishii

, Teramoto

, et al.: Medical professionals' attitudes toward tube feeding for themselves or their families: A multicenter survey in Japan. J Palliat Med, 2012; 15:561–566.

Komiya

, Ishii

, Kadota

: The prognosis of elderly patients who have lost the ability to receive oral intake and are treated with peripheral solution. J Palliat Med, 2013; 16:821.