Articles

Intermittent Oro-Esophageal Tube Feeding of an Alzheimers Patient with Dysphagia: A Case Study

Hua Yongling¹, Yang Ling ¹, Sha Jinguo¹, Li Xucheng^1, Mohammad Abbas Uddin^2*
1Dali University First Affiliated Hospital, Dali, Yunnan- 671000.
²Directorate General of Nursing and Midwifery, Dhaka, Bangladesh.

Article Info

Received Date: 28 January 2025, Accepted Date: 07 February 2025, Published Date: 13 February 2025

*Corresponding author: Mohammad Abbas Uddin, Directorate General of Nursing and Midwifery, Dhaka, Bangladesh.

Citation: H Yongling, Y Ling, S Jinguo, L Xucheng, Md Abbas Uddin. (2025). Intermittent Oro-Esophageal Tube Feeding of an Alzheimers Patient with Dysphagia: A Case Study. Journal of International Surgery Case Reports, 1(1); DOI: http;/02.2025/JISCR/001.

Copyright: © 2025 Mohammad Abbas Uddin. This is an open-access article distributed under the terms of the Creative Commons Attribution 4. 0 international License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Introduction: Intermittent Oro-Esophageal Tube (IOET) feeding has been widely used in patients with dysphagia to maintain their nutritional status and treat dysphagia.

Objective: To evaluate the effects of IOET feeding of an Alzheimers disease patient with dysphagia.

Methods: The participant was a patient diagnosed with Alzheimers disease with dysphagia and severe malnutrition, admitted to Dali University First Affiliated Hospital in June 2024. An assessment of the patients swallowing function and nutritional status was performed. The geriatric nursing team and IOET feeding experts designed an IOET feeding plan that was administered for 26 days.

Results: The patients nutritional status improved, their malnutrition was corrected, and their swallowing function was enhanced.

Conclusion: IOET feeding in Alzheimers patients with dysphagia and malnutrition leads to gradual improvement of nutritional status, correction of malnutrition, and enhanced swallowing function.

Keywords: IOET feeding; Alzheimers disease patients; swallowing dysfunction.

Introduction

Advancements in modern science and technology have contributed to socioeconomic development and longer human lifespans. However, consequently, chronic diseases have become more prevalent. In the elderly aged 65 or older, the prevalence of Alzheimers disease has increased [1]. In the last stages of Alzheimers disease, changes in patients brains begin to undermine physical functions, including the ability to swallow; this difficulty in swallowing is known as dysphagia [2]. It may cause severe complications, including dehydration, undernourishment, infections, and aspiration pneumonia, and even asphyxia death [3]. Nutritional interventions, however, can alleviate the consequences of subsequent energy or protein deficits [4]. IOET feeding is a method of nutritional intervention that ensures safe and quick feeding and, as a result, increases patients and caregivers satisfaction [5]. IOET feeding also acts as an intervention for the management of dysphagia and contributes to improved nutritional status and swallowing function for patients. A combination of positive pressure from the oral cavity and negative pressure from the stomach pushes liquid food into the stomach [6]. Studies have reported on IOET feeding used with post-stroke dysphasic patients [7], critically ill patients [8], cerebral small vessel disease patients with dysphagia [9, 10], post-stroke elderly patients [11], intensive care unit patients who cannot eat [12], stroke patients with dysphagia [13], and patients with bulbar palsy after ischemic strokes [14]. However, there are few studies on IOET feeding of Alzheimers patients with dysphagia. Therefore, this study aims to investigate the effects of IOET feeding in an Alzheimers patient with dysphagia.

Case Information

The participant was an 81-year-old female patient, 155 cm tall, weighing 40 kg, who had completed high school education. She was admitted at Dali University First Affiliated Hospital on June 29th, 2024 and discharged on July 25th, 2024. She had been suffering from recurrent fatigue and poor appetite for over two months, which had worsened in the ten days before admission. The patient had been diagnosed with Alzheimers disease more than two years earlier. She took one tab of Donepezil daily and 5 mg/d of Amlodipine besylate tab to control blood pressure.

The patient had been admitted to a state hospital two months earlier for poor appetite, frequent choking during meals, fatigue, and fever. After returning home, the patient had continued to experience poor appetite and frequent choking while eating, along with fatigue and altered consciousness for over ten days.

The initial assessment at Dali University First Affiliated Hospital in June 2024 found that the patient was suffering from hypotension, lactic acidosis, and electrolyte imbalance. She was placed in the geriatric ward. The patient was bedridden, seemed malnourished, exhibited significant weight loss (about 4 kg over the previous two months), presented with an altered mental status and unclear speech, and was non-cooperative during the physical examination.

On admission, the patients blood pressure was 86/63 mmHg. Initial laboratory investigations found procalcitonin (PCT) at 0.329 ng/ml, interleukin-6 (IL-6) at 74.58 pg/ml, fibrinogen (FIB) at 3.74 g/L, blood gases with pH 7.343, PCO2 18.3 mmol/L, HCO3- 9.9 mmol/L, base excess -13.4 mmol/L, lactate 3.4 mmol/L, thyroid function tests (FT3) at 2.44 Pmol/L, total T3 (TT3) at 1.0 nmol/L, immunoglobulin (IgG) at 6.25 g/L, total cholesterol (TC) at 2.44 mmol/L, BNP for myocardial infarction at 111 pg/ml, and D-dimer at 841 ng/ml.

A complete blood count found WBC at 3.88 x 10^9/L, neutrophil percentage 85.2%, RBC at 3.36 x 10^12/L, hemoglobin at 108 g/L; liver and kidney function tests results were TP at 44.1 g/L, ALT at 22.0 g/L, globulin at 22.1 g/L, urea at 16.74 mmol/L, creatinine at 150 umol/L, uric acid at 454 umol/L, electrolyte levels were found potassium at 3.17 mmol/L, sodium at 149 mmol/L, chloride at 121.3 mmol/L, and phosphorus at 0.28 mmol/L.

An imaging report identified a cystic lesion in the liver, multiple stones in the right kidney, and aortic calcification. A CT scan of the chest revealed bronchitis and emphysema with scattered interstitial infections. A CT scan of the head showed an old lacunar infarction in the left basal ganglia and multiple demyelinating changes in the white matter near the bilateral lateral ventricles and centrum semiovale.

An ECG showed occasional square-shaped premature beats with left anterior fascicular block and low voltage in limb leads. The Barthel Index activities of daily living score was 10 points, indicating severe dependency. The Braden scale pressure ulcer risk score was 9 points, indicating extremely high risk. The Morse scale for fall risk score was 60 points, indicating high danger. The catheter dislodgment risk score was 9 points, indicating medium risk. The VTE risk (Padua score) was 4 points, indicating high risk. Finally, the aspiration risk score was 16 points, indicating moderate danger.

The diagnoses included severe protein-energy malnutrition, severe pneumonia, lactic acidosis, shock state, old cerebral infarction, age-related brain atrophy, aortic calcification, grade II hypertension (very high-risk group), chronic bronchitis with emphysema, right kidney stones, hyperuricemia, and Alzheimers disease.

After informing the family of the critical need for enteral nutrition support to restore gut function and enhance nutrition, the advantages of IOET feeding were explained. The family consented to the treatment and the IOET therapy consent form was signed. IOET therapy commenced on the day of admission.

Nursing Issues

The patient was suffering from severe malnutrition caused by swallowing problems due to Alzheimers, resulting in weight loss (4 kg).

Nursing Strategies

The usefulness of IOET feeding was explained to the patient and family members and their support for this intervention was sought.

A team was formed to monitor the patient and observe the intervention process. This team consisted of specialized geriatric nurses, attending physicians, a consultant from the hospital nutrition department, and expert nurses in IOET feeding.

The following IOET insertion and removal procedures were explained to the patient and family members to reduce tube insertion fears:

Procedures: The patient is kept in a semi-sitting position. Wearing gloves, nurses measure the predetermined length of the tube and lubricate it in warm water. They ensure the patient opens their mouth and they guide the tube insertion. When inserting the tube into the pharynx (14-16 cm for oral insertion and 20 cm for nasal), the patient is asked to swallow, facilitating the tubes advancement. The patient is encouraged to breathe deeply. To ensure the required length is reached, a distance through the mouth to the esophagus 30–35 cm or 35–40 cm for oral insertion. After placement, gentle rotation is performed while observing the patient for any discomfort. Correct placement is checked by immersing the tube end in water: if there are no bubbles, placement is correct. 10-20 ml of lukewarm water is slowly administered to check tube clearance before feeding begins. After completing feeding, the tube is flushed and gently removed.

Nutritional interventions: Based on the nutritionists advice, nutritional staff supplied liquid meals (at 38-40 °C) to feed the patient. Each feeding took about 10 minutes. The first days meals were between 500 and 600 ml. The meal was increased by 50 ml with each subsequent feeding. Three feedings were given a day (at 7 am, 12 pm, and 5 pm). Snacks (milk or juice) were given between 10 am and 2 pm. The tube was flushed with 20 ml of lukewarm water before and after each feed. Inter-meal liquids (milk or juice) were given 1 or 2 times in required amounts to ensure adequate hydration. Before each feeding, stomach emptying was assessed. The patient maintained a semi-sitting position (30-60 degrees) during feeding and for the following 30 to 60 minutes. To avoid the risk of vomiting, nebulization was given two hours after each meal.

Usual care measures included: monitoring the ECG and blood oxygen saturation, pressure ulcer preventive care, catheter care, assisted sputum clearance care, oral care, nebulized inhalation, low-flow continuous oxygen supplementation, and central venous catheter care. Therapeutic measures included: acid suppression and gastric protection, rehydration maintenance, electrolyte disturbance correction, intravenous nutritional support, anti-infection assistance, and thrombus prevention treatments.

Outcomes 

Patients response to IOET feeding: During the initial feedings, tube insertion was adjusted until the patient reported less discomfort and became familiar with the process.

Effects of IOET feeding: In the first week, the patient gained 0.8 kg with increased TP: 44.6 g/L, ALT: 29.8 g/L, GLB: 14.8 g/L, Hb: 124 g/L. In the second week, the patient gained a further 1.1 kg with increased TP: 51.3 g/L, ALT: 35.3 g/L, GLB: 15.8 g/L, Hb: 126 g/L. In the third week, the patient gained a further 1.4 kg with increased TP: 65.1 g/L, ALT: 45.8 g/L, GLB: 19.3 g/L, Hb: 118 g/L. At the discharge assessment, the patient had gained a further 0.4 kg with normal TP: 66.8 g/L, ALT: 46.0 g/L, GLB: 20.8 g/L, Hb: 114 g/L. In total, the patient gained 3.7 kg during hospitalization.

Dysphagia: The patients swallowing function improved from Grade V to Grade IV. The patient remained unable to eat independently and required continued IOET feeding and swallowing rehabilitation.

Conclusion

Alzheimers patients are predominantly elderly people. In the last stages of this disease, brain changes affect physical function. Dysphagia (problems swallowing) is one possible consequence of this. Dysphagia may create several further problems, including decreased nutritional status and malnutrition. IOET feeding was used as an intervention to improve a patients nutritional status, manage their malnutrition, and improve their swallowing problems. This study found that IOET feeding is a suitable therapy to improve Alzheimers patients nutritional status. IOET can correct malnutrition, assist weight gain, and improve swallowing function. This evidence can contribute to the management of Alzheimers patients with dysphagia by clinical nurses. Further studies with larger sample sizes and in different settings are recommended.

Acknowledgements

The authors express special appreciation to the hospital authority and team members including specialized geriatric nurses, attending physicians, a consultant from the hospital nutrition department, and expert nurses in IOET feeding, patient and patients relatives. Authors are grateful to Andy Babb for his editing support.

Funding
No funding support has been taken from any organization.

Conflicts of Interest
No conflict of interest has been declared by the authors.

Ethical Considerations
Data collection permission was obtained from hospital authority. Informed consent was obtained from patient and relative.