The Peg Decison - When Elderly can't Swallow

The PEG stands for percutaneous endoscopic gastronomy. A surgically emplaced feeding tube. My little one had one emplaced at age 104 (her decision) and she is doing fine at 108. At home with her son and private aides. Many elderly are reluctant to have a feeding tube and I will offer some comments. Many people, contrary to popular belief, tolerate them very well with little discomfort. My little one is in that universe of people. They have to be replaced every six months to eighteen months, primarily because the feeding tube becomes clogged with residue. There are several types available. Consult your physician. These are prescribed for those who cannot swallow (dysphagia), often secondary to a stroke. If swallowing resumes they can be removed. A patient can eat soft pureed foods while on a peg as the swallowing returns. Nutrition is provided either by bolus or continuous feed. You can do both. Bolus feed one day and continuous feed the next or at night. Or continuous feed at night and give a bolus feed at noon. Bolus feeding is best.  With bolus feeding the patient can be taken outdoors or on trips and not be attached to a machine. The bolus feeding is, however more labor intensive, and in a nursing home they invariably select continuous feeding, which means the patient will not move in the bed, and is likely to develop bedsores and clots. Furthermore they will not permit you or anyone else to come in and "bolus feed". "Insurance regulations", they say. If you have insurance home-care the home-care agencies will refuse to service the peg, forcing you to call in a registered nurse. This is often an unaffordable option. I trained home-care aides with no experience to perform the servicing, and they are paid for by the family. The "fiction" is that the son does the feeding. Think three to four man (or woman) hours a day for bolus feeding. That's an hour or so three times a day. The key to bolus feeding is to always clean and service the tube and flush it. A bit of seven-up and then a squire of saline. And to care for the dressing to prevent infection. I use an ultraviolet filter and HEPA unit in the room to insure it is dust free. You don't want infection to end up in the opening. The bolus syringes are meant to be one-time use. Nevertheless people re-use them.  If re-used insure they are sterilized. This means dust filters on open windows and a freshly-painted dust free room. Keep a digital camera in the room and when the aides change the dressing take a   photo of the opening. You can review this and e-mail it to a physician. This way you can watch for inflamation (inflammation).

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Elderly patients with swallowing disorders often have symptoms that are circadian in nature. That is to say regulated by the "body clock". With my little one at age 102, she could swallow at night, but not during the afternoon. Scheduling meals at 9 P.M. was helpful.  I cannot explain the reason for this, but it was meticulously documented. Thus any "test" for swallowing, before considering a PEG,  should be repeated several times during a 24 hour cycle. A swallow test should include a variety of liquids. As an example, another one of my little ones "failed" her swallow test because the doctor tested her (I wasn't there) with cranberry juice, which she detests and is allergic to. She swallowed lemonade quite well.