Tube Feeding Versus Assisted Oral Feeding for Persons With Dementia: Using Evidence to Support Decision-Making: Page 2 of 2

January 17, 2013


The literature supports the view that PEG tube feeding in patients with dementia is not beneficial in terms of forestalling morality or improving quality of life; however, it appears that assisted oral feeding is better accepted both by patients and by their families during the patients’ waning months of life. After reviewing this body of evidence, it is advisable for clinicians to provide effective counseling to the families of persons with advanced dementia, helping to support the choice of assisted oral feeding in the late stage of this disease.


  1. World Health Organization. Dementia: A Public Health Priority. United Kingdom: World Health Organization Press, 2012.

  2. Reisberg B, Ferris SH, De Leon MJ, Crook T. The Global Deterioration Scale for assess- ment of primary degenerative dementia. Am J Psychiatry. 1982;139(9):1136-1139.

  3. Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529-1538.

  4. Ritchie CS, Wilcox CM, Kvale E. Ethical and medicolegal issues related to percutaneous endoscopic gastrostomy placement. Gastrointest Endoscopy Clin N Am. 2007;17(4):805-815.

  5. Casarett D, Kapo J, Caplan A. Appropriate use of artificial nutrition and hydration–fundamental principles and recommendations. N Engl J Med. 2005;353(24):2607-2612.

  6. Givens JL, Kiely DK, Carey K, Mitchell SL. Healthcare proxies of nursing home residents with advanced dementia: decisions they confront and their satisfaction with decision-making. J Am Geriatr Soc. 2009;57(7):1149-1155.

  7. Lewis CL, Hanson LC, Golin C, et al. Surrogates’ perceptions about feeding tube placement decisions. Patient Educ Couns. 2006;61(2):246-252.

  8. Carey TS, Hanson LC, Garrett JM, et al. Expectations and outcomes of gastric feeding tubes. Am J Med. 2006;119(6):527.e11-16.

  9. Shega JW, Hougham GW, Stocking CB, et al. Barriers to limiting the practice of feeding tube placement in advanced dementia. J Palliat Med. 2003;6(6):885-893.

  10. Hanson LC, Garrett JM, Lewis C, Phifer N, Jackman A, Carey TS. Physicians’ expectations of benefit from tube feeding. J Palliat Med. 2008;11(8):1130-1134.

  11. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. 1999;282(14):1365-1370.

  12. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev. 2009;2:CD007209.

  13. Garrow D, Pride P, Moran W, Zapka J, Amella E, Delegge M. Feeding alternatives in patients with dementia: examining the evidence. Clin Gastroenterol Hepatol. 2007;5(12):1372-1378.

  14. Kuo S, Rhodes RL, Mitchell SL, Mor V, Teno JM. Natural history of feeding-tube use in nursing home residents with advanced dementia. J Am Med Dir Assoc. 2009;10(4):264-270.

15. Tokunaga T, Kubo T, Ryan S, Tomizawa M, Yoshida S, Takagi K, Furui K, Gotoh T. Long-term outcome after placement of a percutaneous endoscopic gastrostomy tube. Geriatr Gerontol Int. 2008;8(1):19-23.

16. Callahan CM, Haag KM, Weinberger M, Tierney WM, Buchanan NN, Stump TE, Nisi R. Outcomes of percutaneous endoscopic gastrostomy among older adults in a community setting. J Am Geriatr Soc. 2000;48(9):1048-1054.

17. Higaki F, Yokota O, Ohishi M. Factors predictive of survival after percutaneous endoscopic gastrostomy in the elderly:is dementia really a risk factor? Am J Gastroenterol. 2008;103(4):1011-1016.

18. Gaines DI, Durkalski V, Patel A, DeLegge MH. Dementia and cognitive impairment are not associated with earlier mortality after percutaneous endoscopic gastrostomy. J Parenter Enteral Nutr. 2009;33:62-66.

19. Rimon E, Kagansky N, Levy S. Percutaneous endoscopic gastrostomy; evidence of different prognosis in various patient subgroups. Age Ageing. 2005;34(4):353-357.

20. Sanders DS, Carter MJ, D’Silva J, James G, Bolton RP, Bardhan KD. Survival analysis in percutaneous endoscopic gastrostomy feeding: a worse outcome in patients with dementia. Am J Gastroenterol. 2000;95(6):1472-1475.

21. Peck A, Cohen CE, Mulvihill MN. Long-term enteral feeding of aged demented nursing home patients. J Am Geriatr Soc. 1990;38(11):1195-1198.

22. Bourdel-Marchasson I, Dumas F, Pinganaud G, Emeriau JP, Decamps A. Audit of percutaneous endoscopic gastrostomy in long-term enteral feeding in a nursing home. Int J Qual Health Care. 1997;9(4):297-302.

23. Mitchell SL, Kiely DK, Lipsitz LA. The risk factors and impact on survival of feeding tubes in nursing home residents with advanced dementia. Arch Intern Med. 1997;157(3):327-332.

24. Mitchell SL, Kiely DK, Lipsitz LA. Dose artificial enteral nutrition prolong the survival of institutionalized elders with chewing and swallowing problems? J Gerontol. 1998;53(3):M207-M213.

25. Rudberg MA, Egleston BL, Grant MD, Brody JA. Effectiveness of feeding tubes in nursing home residents with swallowing disorders. JPEN J Parenteral Enteral Nutr. 2000;24(2):97-102.

26. Nair S, Hertan H, Pitchumoni CS. Hypoalbuminemia is a poor predictor of survival after percutaneous endoscopic gastrostomy in elderly patients with dementia. Am J Gastroenterol. 2000;95(1):133-136.

27. Meier DE, Aronheim JC, Morris J, Baskin-Lyons S, Morrison RS. High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding. Arch Intern Med. 2001;161(4):594-599.

28. Tokuda Y, Koketsu H. High mortality in hospitalized elderly patients with feeding tube placement. Intern Med. 2002;41(8):613-616.

29. Murphy LM, Lipman TO. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia [published correction appears in Arch Intern Med. 2003;163(19):2397.] Arch Intern Med. 2003;163(11):1351-1353.

30. Jaul E, Singer P, Calderon-Margalit R. Tube feeding in the demented elderly with severe disabilities. IMAJ. 2006;8(12):870-874.

31. Arinzon Z, Peisakh A, Berner YN. Evaluation of the benefits of enteral nutrition in long-term care elderly patients. J Am Med Dir Assoc. 2008;9(9):657-662.

32. Stratton RJ, Ek AC, Engfer M, et al. Enteral nutritional support in prevention and treat- ment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev. 2005;4(3):422-450.

33. Teno JM, Gozalo P, Mitchell SL, Kuo S, Fulton AT, Mor V. Feeding tubes and the prevention or healing of pressure ulcers. Arch Intern Med. 2012;172(9):697-701.

34. Teno JM, Mitchell SL, Kuo SK, et al. Decision-making and outcomes of feeding tube insertion: a five-state study. J Am Geriatr Soc. 59(5):881-886.

35. Hanson LC, Ersek M, Gilliam R, Carey TS. Oral feeding options for patients with dementia: a systematic review. J Am Geriatr Soc. 2011;59(3):463-472.

36. Palecek EJ, Teno JM, Casarett D, Hanson LC, Rhodes RL, Mitchell SL. Comfort feeding only: a proposal to bring clarity to decision making regarding difficulty with eating for persons with advanced dementia. J Am Geriatr Soc. 2010;58(3):580-584.

37. Kayser-Jones J, Schell ES, Porter C, Barbaccia JC, Shaw H. Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision. J Am Geriatr Soc. 1999;47(10):1187-1194.

38. Mitchell SL, Buchanan J, Littlehale S, Hamel MB. Tube-feeding versus hand-feeding nursing home residents with advanced dementia: a cost comparison. J Am Med Dir Assoc. 2004;5(suppl 2):S22-S29.

39. Monteleoni C, Clark E. Using rapid-cycle quality improvement methodology to reduce feeding tubes in patients with advanced dementia: before and after study. BMJ. 2004;(7464):491-494.

40. Hanson LC, Carey TS, Caprio AJ, et al. Improving decision-making for feeding options in dementia care: a randomized, controlled trial. J Am Geriatr Soc. 2011;59(11):2009-2016. 



The author reports no relevant financial relationships.


Address correspondence to:

Laura C. Hanson, MD, MPH

CB 7550 Division of Geriatric Medicine

University of North Carolina

Chapel Hill, NC 27599