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Swallowing and dementia – practical solutions for a highly emotive problem?

Matthew Kurien and David S Sanders
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DOI: https://doi.org/10.7861/clinmedicine.10-3-305a
Clin Med June 2010
Matthew Kurien
Department of Gastroenterology Royal Hallamshire Hospital, Sheffield
Roles: Specialty registrar in gastroenterology
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David S Sanders
Department of Gastroenterology Royal Hallamshire Hospital, Sheffield
Roles: Consultant gastroenterologist and honorary professor in gastroenterology
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Editor – we read with interest the review by Smith et al (Clin Med December 2009 pp 544–8). We would like to contribute to this debate with important clinical information that supports this practical approach. A recent report by Mitchell et al was the first prospective observational study of patients in nursing homes with dementia (n=323).1 The investigators reported that over an 18-month period 85.8% of patients developed an eating problem and that the mortality in this cohort was 54.8%. Many clinicians consider dysphagia as an end-stage event in patients with dementia – nevertheless it remains a common indication for gastrostomy insertion in secondary care. How can we improve the care for patients with feeding difficulties and dementia? We have previously reported a high mortality in patients with dementia who have a percutaneous endoscopic gastrostomy (PEG) tube inserted (54% died at 30 days).2 As a result of this observation we devised a pragmatic strategy to try to improve all aspects of our selection process for insertion of the tube (Table 1). By implementing this strategy and critically engaging carers in this decision-making process (as well as providing data on prognosis) we were able to show a reduction in the number of PEG tubes inserted in patients with dementia.3 We believe that our data (and pragmatic approach), coupled with Smith et al's recent report, allows clinicians to have an evidence-based discussion about feeding with all interested parties. It also allows clinicians within the UK to have local, or at least UK, data, which are possibly relevant to their own practice. Perhaps this is a practical solution to a highly emotive problem?4

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Table 1.

Strategy to try to improve all aspects of selection process for insertion of the percutaneous endoscopic gastrostomy (PEG) tube.

Footnotes

  • Please submit letters for the Editor's consideration within three weeks of receipt of the Journal. Letters should ideally be limited to 350 words, and sent by email to: Clinicalmedicine{at}rcplondon.ac.uk

  • © 2010 Royal College of Physicians

References

  1. ↵
    1. Mitchell SL,
    2. Teno JM,
    3. Kiely DK,
    4. et al
    . The clinical course of advanced dementia. N Engl J Med 2009; 361: 1529–38.doi:10.1056/NEJMoa0902234doi:10.1056/NEJMoa0902234
    OpenUrlCrossRefPubMed
  2. ↵
    1. Sanders DS,
    2. Carter MJ,
    3. D'Silva J,
    4. et al
    . Survival analysis in percutaneous endoscopic gastrostomy: a worse outcome in patients with dementia. Am J Gastroenterol 2000; 95: 1472–5.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Sanders DS,
    2. Carter MJ,
    3. D'Silva J,
    4. et al
    . Percutaneous endoscopic gastrostomy: a prospective audit of the impact of guidelines in 2 district general hospitals in the United Kingdom. Am J Gastroenterol 2002; 97: 2239–45.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Sanders DS,
    2. Anderson AJ,
    3. Bardhan KD
    . Percutaneous endoscopic gastrostomy: an effective strategy for gastrostomy feeding in patients with dementia. Clin Med 2004; 4: 235–41.
    OpenUrlAbstract/FREE Full Text
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Swallowing and dementia – practical solutions for a highly emotive problem?
Matthew Kurien, David S Sanders
Clinical Medicine Jun 2010, 10 (3) 305-306; DOI: 10.7861/clinmedicine.10-3-305a

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Swallowing and dementia – practical solutions for a highly emotive problem?
Matthew Kurien, David S Sanders
Clinical Medicine Jun 2010, 10 (3) 305-306; DOI: 10.7861/clinmedicine.10-3-305a
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