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

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

Table 1.

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