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Dementia is recognized as a progressive, irreversible, and terminal disease. Patients with severe dementia have a signifi cantly decreased life expectancy. Diffi culties with swallowing or lack of interest in eating frequently are part of the natural course of the disease. Despite consensus among geriatricians, ethicists, and neurologists that there is a lack of effi cacy of PEG tubes in prolonging or improving the quality of life for patients with end stage dementia, gastrostomy tubes are a common therapeutic intervention for this population. Discussion Feeding tubes are often initiated in patients with severe dementia prematurely or inappropriately. They are found in more than 35% of nursing home patients with advanced dementia even though they have not been proven to decrease mortality or reduce the risk of aspiration pneumonia. 1 Additionally, there is no evidence to indicate that artifi cial nutrition decreases infection, pressure ulcers, or improves qual- ity of life. 2-5 Prior to considering percutaneous endoscopic gastrostomy (PEG) tube placement, patients should be evaluated for reversible conditions that could cause weight loss or anorexia by assessing for infec- tion, constipation, depression, or other conditions. Loss of appetite is a common symptom in patients with advanced dementia. 6 Patients with advanced dementia also typically develop some degree of dysphagia and this was previously thought to be an appropriate indication for PEG placement. 7 However, over time small studies have shown that PEG placement does not improve the risk of aspiration pneumonia in patients with advanced dementia over oral feeding. 8-11 Adjusting the consistency of food and liquids can reduce the risk of aspiration and discomfort. 2 Additionally, assistance with feeding by soliciting the help of a family member, caregiver, or nursing aide can improve oral intake. The oral gratifi cation from food is thought to benefi t the patient's quality of life despite perhaps a lower total caloric intake. Patients with advanced dementia often refuse to eat and drink, which is a natural part of the dying process of this disease. Our best evidence has indicated this lack of appetite is not similar to the normal hunger and thirst experienced by healthy patients. 2,6 Studies have shown that there is no increased weight gain in demented patients after PEG placement and no improvement in their phys- ical function. 8,10 Counseling the patient's family about this end of life symptom may help alleviate

Revisiting the Use of Percutaneous Endoscopic Gastrostomy Tubes in Patients with Advanced Dementia