The use of percutaneous endoscopic gastrostomy in 161 consecutive elderly patients - PEG

Age and Ageing,  March, 1994  by Sandip K. Raha,  Ken Woodhouse

• E-mail
• Print
• Link

SANDIP K. RAHA, KEN WOODHOUSE

Over the period 1 April 1990 to 31 December 1992, a total of 179 PEG procedures were performed on 161 elderly patients, mean age 79 years (range 53-99). In most (141) patients, the indication was neurological dysphagia (usually stroke), but in 20 the tube was inserted to attain adequate nutritional support.

Thirty-day fatality was 20% overall, but in those who underwent PEG only for nutritional support, survival was poor--only 20% at 30 days. Almost all deaths were a result of progression of the original illness. Only one procedure-related death occurred. Fifty-six complicating episodes occurred in 20 (12%) patients, the majority being minor. The commonest adverse event was PEG site infection.

PEG is a useful and in general well tolerated procedure in geriatric practice, but careful patient selection is essential; in particular its use as a nutritional adjunct in frail patients needs careful evaluation.

Introduction

Artificial hydration and nutritional support are widely practised in British hospitals. In geriatric units the enteral route, particularly by nasogastric tube, is most frequently used. The majority of elderly patients receive tube feeding for swallowing disorders and a significant proportion need this on a long-term basis.

Swallowing disorders following acute cerebrovascular accident are well recognized and up to 30% of stroke victims experience dysphagia (1). Some studies, using video fluoroscopy, have shown 'silent' aspiration in as many as 40% of these patients (2). In elderly people, figures may be even higher as co-existing illness contributes to swallowing disorders and associated poor nutrition. However, few British geriatric units have a comprehensive swallowing and feeding policy, and, compared with the USA, percutaneous endoscopic gastrostomy (PEG) is not widely practised.

PEG was described over a decade ago (3) and has since been proposed as a safe and effective alternative to long-term nasogastric feeding in dysphagic patients (4)(6). We describe 161 elderly individuals, requiring prolonged enteral nutrition, who underwent 179 PEG procedures, in a large University Department of Geriatric Medicine, covering three major General Hospitals in South Wales.

Patients

Details of the subjects are given in Table I. Mean age was 79 years; with a range of 53-99 years. Most procedures were carried out for neurological dysphagia, the commonest cause being stroke. Twenty frail, malnourished patients with other illnesses, predominantly orthopaedic, underwent PEG as an adjunct to nutritional support. Patients were followed up either until death, or until the gastrostomy tube was no longer required and was removed. Mean duration of follow-up was 152 days (range 1-1106 days).

Table I. Patient characteristics

Diagnosis                 Number (%)
Dysphagia (total)         141 (88)
Stroke                    130 (81)
Parkinson's disease         5 (3)
Motor neurone disease       3 (2)
Other                       3 (2)
Nutritional support        20 (12)
Total                     161 (100)

The interval between onset of dysphagia and PEG insertion averaged 44 days, but the range was wide, 6-200 days. Only one PEG-related death occurred, in a confused man who pulled the tube out through the abdominal wall, causing peritonitis. Thirty-day fatality was 20%, and 90-day fatality 39%. Almost all of the medium-term deaths were due to progression of the original illness, or a direct complication thereof. The outcome was especially poor in those undergoing PEG purely as a method of supplementary nutrition. Of 20 such patients, only four were still alive at 30 days, reflecting the very frail pre-procedure condition of these individuals.

Complications are shown in Table II. Fifty-six adverse episodes occurred in 20 patients (12%). The majority of events were minor, the commonest being infection at the gastrostomy site. Some events (for example non-PEG site contamination with MRSA, or Clostridium difficile diarrhoea) were probably related to the original pathology, rather than the presence of a gastrostomy.

[TABULAR DATA OMITTED]

One hundred and twenty-five tubes were in situ for more than 1 month (77%); 74 for over 3 months (46%); and 47 for more than 6 months (29%). Nineteen tubes were removed electively after a mean of 199 days (range 45-365), because swallowing had been regained. Sixteen patients required 18 replacements because of tube blockage, intractable infection or tube breakage.

Discussion

Adequate nutrition is a basic necessity of life, but is unfortunately all too often neglected in hospitalized elderly patients. PEG has been strongly advocated as a safe, reliable, and acceptable form of enteral nutrition, particularly in those with neurological dysphagia (5). In general, our series would confirm this, but several important points emerge.

First, the target population is, by definition, markedly disabled, usually with severe underlying disease. This is reflected in the high 1 and 3-month fatality. None the less we believe that providing these patients with a comfortable route of hydration and nutrition significantly improved their quality of life during their final weeks, and unquestionably made their nursing care much easier.