Table 1.

Summary of studies on the burdens of tube feeding in individuals with advanced dementia.

Article	Participants	Study design (follow-up)	Aim/objective	Outcome/conclusion
Jaul et al. [40]	88 patients (26 fed orally; 62 fed via NG tube)	Prospective survey study (17 months)	Compared the clinical course and outcome of elderly demented patients with severe disabilities via feeding mode	Tube feeding showed no beneficial effects on nutritional outcome in elderly patients with advanced dementia and does not aid the healing of pre-existing pressure sores as compared with oral feeding. The mean number of pressure ulcers in the tube and orally fed groups at the start to end of study were 1.05 to 0.97 vs. 2.28 to 1.92 (P=0.05 to 0.03), respectively
Ayman et al. [41]	392 patients	Retrospective analysis (48 months)	Compared rehospitalisation and mortality rates after PEG placement in dementia patients (165) versus stroke patients (124) and other patients' group with head and neck cancers and motor neuron disease (103)	PEG insertion did not reduce rehospitalisation rate at 6 months postprocedure in dementia patients compared with patients who had PEG for other condition (OR: 2.45 in the dementia group, 1.86 in the stroke group, and 1.65 in patients with oropharyngeal cancers and motor neuron disease; P < 0.05); also, mortality was higher in the dementia group (75%) within the first year after PEG placement compared with the stroke group (58%) and group C (38%) (P < 0.001)
Gieniusz et al. [43]	168 internal medicine physicians	Multicentre mixed-mode survey (none)	Evaluated physicians' knowledge and perceptions regarding PEG placement in individuals with advanced dementia	81% and 85% of physicians believed PEG placement does not increase survival nor reduce aspiration pneumonia, respectively; 71% and 61% of physicians claimed careful hand-feeding of advanced dementia people are nearly as good as tube feeding for the outcomes of comfort and functional status, respectively
Kuo et al. [45]	97,111 nursing home (NH) residents (5,209 had PEG; 91,902 had no PEG)	Secondary analysis of minimum data set (MDS) (2 years)	Assessed the natural history of feeding tube insertion in NH residents who followed-up for 2 years to measure their health care use and survival	Feeding tubes placement was associated with poor survival. 19.3% of residents who had feeding tube placement needed tube replacement or repositioning within 145 days after insertion, and the median survival was 54 days after replacement; also, one-year mortality after feeding tube insertion was 64.1% with a median survival of 56 days after insertion
Teno et al. [46]	4421 patients (1585 PEG-fed and 2836 Non-PEG-fed)	Propensity-matched cohort study (1 year).	Assessed benefits and risks of PEG feeding in the prevention and healing of a pressure ulcer in NH residents with advanced cognitive impairment (ACI)	NH residents who received PEG feeding were 2.27 times at higher risks of developing new pressure sores (95% CI 1.95–2.65) and had less odds of having their established pressure ulcer heal (OR 0.70, 95% CI 0.55–0.89)
Ticinesi et al. [47]	184 patients	Prospective observational study (18 months)	Compared survival rates and hospital readmissions in elderly demented patients who were PEG-fed versus those orally fed	At the follow-up, after adjustment for possible cofounders, mortality was higher in PEG-fed patients than orally fed patients, 70% vs. 40%, respectively (P=0.0002); however, hospital readmission rates during follow-up were insignificantly different in both groups (40% (PEG-fed) vs. 38% (orally fed), age- and sex- adjusted P=0.88)
Cintra et al. [48]	67 patients	Prospective nonrandomised observational study (6 months).	Compared hospital admissions, survival rates, and aspiration pneumonia incidence in dysphagic dementia patients on oral feeding versus alternative (mostly NG tubes) feeding route	No significant difference in number of hospital admissions in both groups (p=0.365); however, the incidence of aspiration pneumonia is twice as high in the alternative feeding group (RR: 2.32; 95% CI 1.22–4.40) Mortality at 3 months was 11.1% among the oral feeding group compared with 41.9% among the alternative feeding group (RR: 3.77; 95% CI 1.35–10.39) At 6 months, mortality was 27.8% in the oral feeding group versus 58.1% among the alternative feeding group (RR: 2.09; 95% CI 1.14–3.83)
Leibovitz et al. [54]	215 patients	Cross-sectional comparative study (not clear)	Compared the pathogenic oral floral colonisation risk in tube-fed elderly patients (n = 135) with their orally fed counterparts (n = 80) in skilled nursing facilities	Tube feeding is correlated with pathogenic organisms' colonisation of the oropharynx; Gram-negative bacteria were isolated in 81% of patients fed via the NG tube and from 51% of the PEG-fed patients as against 17.5% in the orally-fed patients (P < 0.0001); no correlation was found between the duration of tube feeding and bacterial isolations
Arinzon et al. [56]	261 patients	Prospective study (21 months before and after analysis)	Evaluated the effectiveness of enteral nutrition in improving survival, nutritional, and functional status of the very dependent demented elderly patients	Although the tube-fed group had improvements in blood count, renal function, and electrolyte and hydration status, the mortality rate was higher in the tube-fed group (42%) than in the control group (27%, P > 0.05). Also, nutrition-related complications were higher in the tube-fed group than in the orally fed (control) group, 61% and 34%, respectively