The present study found that old age, male gender and certain diagnoses were associated with higher in-hospital mortality after PEG placement in a geriatric population. The data shows no influence of the functional components of a basic geriatric assessment on mortality.
Hospital mortality in the described patient population was 12.8%, which is within the range of mortality rates observed in other studies of PEG-placement in geriatric patients
Our finding that old age is predictive of decreased survival is supported by several studies in elderly patients conducted with different time frames for follow-up ranging from 1 to 36 months
]. However, the increased risk was very small in our study; thus, age per se
should have no impact on clinical decision making regarding whether a feeding tube should be placed or not.
The increased risk for in-hospital mortality observed in men is noteworthy and has been shown in other studies of the elderly
]. Women in our population were generally more dependent, but diagnosis groups did not seem to differ between sexes. One possible explanation could be a more generous prescription of feeding tubes for men because they were significantly younger and had a higher functional status and lower care level, which possibly made them seem more promising as candidates with benefit from PEG placement. Even though we did not detect any gender differences in regards to the main diagnosis, men could have been sicker overall. Also, men comprised 40% of the present study population, but they account for 30% of the general GEMIDAS (years 2002 to 2008) population, supporting the previously mentioned hypothesis of a more generous prescription in men. We think this should not lead to any impact on decision-making, but it is an interesting finding prompting further research.
While patients in the pneumonia and miscellaneous groups had a statistically increased risk for in-hospital mortality it remains important to carefully evaluate indication and timing for PEG placement in every patient. Taking into account the prognosis and usefulness of the intervention in acutely ill patients have to be underlined. This is supported by studies that found patients with acute illness to be at a high risk of serious adverse events after PEG insertion
]. Abuksis et al. suggested for instance the use of a nasogastric feeding tube during the first 30 days and then deciding on PEG insertion
PEG placement in patients with a very low Barthel index and high cognitive impairment as is often the case in patients with advanced dementia is not supported by the literature; whether patients profit in terms of survival and improved nutritional or functional status or quality of life is questionable
]. In our analysis, the Barthel index was not predictive of in-hospital mortality. However, the mean Barthel index value was extremely low, which could be the reason for not being able to detect an influence. The index values of patients in this study were similar to those of patients receiving PEG in an earlier study using GEMIDAS data (9.5
13.0 vs. 8.2
14.6), whereas the mean Barthel index value of the general GEMIDAS population is significantly higher (44.6
]. Other studies investigating PEG placement in geriatric patients found very low functional status in patients receiving PEG feeding
]. In our study, impaired functional status was not associated with increased in-hospital mortality. Thus, not functional status per se
, but diagnosis and general prognosis should support the decision-making process.
Several studies and meta-analyses have emerged that question the practice of feeding tube placement in patients with dementia
] Mitchell et al. for instance observed nursing home residents with advanced dementia and found that 40.7% of residents underwent burdensome interventions including aggressive nutrition therapy in the last 3 months of life
]. Sanders et al. on the other hand compared the 30-day mortality after PEG placement in patients with dementia to other patient subgroups and found a significantly higher mortality in cognitively impaired patients (54% mortality vs. 28% mortality entire cohort, p <0,0001)
]. In our study we were not able to find an influence of cognitive status on short-term survival in regards to hospital mortality. However, this conclusion is of limited value as cognitive status has only been available in approximately half of the patients and the origin of cognitive dysfunction (dementia, delirium, or other) could not be traced back. Taken together, our data indicate that cognitive impairment as a functional measure does not increase the risk of short-term mortality after PEG insertion.
The limitations of this study are the retrospective nature of the database analysis and the lack of information concerning several known risk factors such as for example secondary diagnoses, inflammatory markers, etc. that have been found to be significant predictors of decreased survival in patients with PEG placement
Mini Mental Status Examination is used for cognition screening in the GEMIDAS-database. It has to be mentioned that the test is limited in differentiating between mild to no dysfunction of cognitive status and is of limited use in inpatients with dysphasia. It remains to discuss whether another instrument for more precise cognition screening should be used in the future.
Certainly it has to be mentioned that advanced directives play a certain role in patient selection, this however, could not be displayed by our study.