Percutaneous endoscopic gastrostomy in geriatric patients with dysphagia

Abstract

Background: Orofaryngeal dysphagia (OD) is common in geriatric patients and a risk factor for malnutrition and prolonged in-hospital stay. Nutritional assessment is essential in these patients and documentation should be performed. Enteral nutrition (EN) by percutaneous endoscopic gastrostomy (PEG) is a common treatment to ensure nutrition status for patients with OD.

Aim: The overall aim of this thesis was to increase the knowledge of the process of geriatric patients receiving PEG regarding indication, survival, documentation of nutrition assessment and complications. Aim study I. To examine the indications for and survival in a consecutive group of elderly individuals who had received PEG. Aim study II. To describe to what extent nutritional assessment were performed and documented in the records of older patients with stroke treated with EN by PEG. A secondary aim was to identify documented post-procedural complications after PEG insertion during hospital stay.

Methods: Both study I and study II were retrospective. Data were collected consecutively from records of patients 65 years and older, who received PEG, admitted to the hospital during a 4-year period. For Study I collected data included age, gender diagnosis, indication for PEG, operating time, removal time, or time of death. Data were analyzed and presented with descriptive statistics as mean (±SD) and median. For survival analysis the Kaplan Meier curves were used. For Study II data were collected from three stroke units. Collected data included patient characteristics, nutritional status, multimorbidity, post-procedural complications and pressure ulcers. Data were analyzed and presented with descriptive statistics as mean (± SD) except LOS and number of days from hospital admission to PEG insertion which were presented as median (range). For correlation analyses, Spearman correlation coefficients were calculated. Ethics. Both studies were performed according to the Helsinki declaration guidelines.

Results: In study I records of 201 patients 79 ±7 years were included and in study II patient records of 161 patients 82,2 ±7 years were included. The main findings of this thesis are the following, in study I OD was an indication for PEG in the 86% of geriatric patients. The median survival in this group was about 4 months and the 30-day mortality was 22%. The patients were categorized into seven diagnosis groups. Patients with stroke and other neurological diseases as well as patients with malignancies had the shortest survival rate. Almost 80% of the patients in study II fulfilled the European Network criteria for multimorbidity. Morbidity and multimorbidity correlated to the length of stay (p = < 0.0005). Postprocedural complications occurred in 69% of the patients. More than one complication occurred in 33% of the patients. The number of complications was related to weight loss (p = < 0.046) and Body Mass Index (BMI) change (p = <0.018). One of the major findings was that pressure ulcers (PU) was identified in 50 % of the patients as documented in the patient records.

Conclusions: OD in patients with neurological disease constituted a majority of the patients who received PEG in study I. Survival after PEG insertion varied for patients in the seven different diagnose groups. Furthermore, in study I the severity of the patient’s diseases are unknown. It is also unknown whether the severity of the disease could have had an impact of the mortality of the patients. In study II essential information of the patient’s nutritional status was missing which could have had an impact the patient’s nutritional treatment during the hospital stay. The identified frequency of pressure ulcers which was an unexpected complication and indicates that there is a need for further research. This study indicates that implementation of nutritional guidelines in the health care of geriatric patients with PEG is needed.