THE AMERICAN JOURNAL OF GASTROENTEROLOGY
1, 2000
© 2000 by Am. Coll. of Gastroenterology
Published by Elsevier Science Inc.
Hypoalbuminemia Is a Poor Predictor
of Survival After Percutaneous Endoscopic
Gastrostomy in Elderly Patients With Dementia
Satheesh Nair, M.D., Hilary Hertan, M.D., F.A.C.G., and C. S. Pitchumoni, M.D., F.A.C.G.
Division of Gastroenterology and Clinical Nutrition, Our Lady of Mercy Medical Center,
New York Medical College, Bronx, New York
OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) is
widely used for long-term enteral nutrition in patients with
dementia and inadequate oral intake, although its benefit in
prolonging the survival of the patient is not clear. Patients
are often referred for PEG placement after a significant
weight loss or fall in serum albumin. It is not known whether
this delay in referral adversely affects the survival. Our aim
was to determine the survival after PEG placement in pa-
tients with inadequate oral intake secondary to cognitive
impairment and to determine whether the nutritional param-
eters at the time of placement of PEG predict survival.
METHODS: After excluding patients with cancer, cerebro-
vascular accident (CVA), and anoxic encephalopathy, 56
consecutive patients with dementia and inadequate oral in-
take were included in the study. The following parameters
were analyzed to predict survival benefit: demographics,
reason for admission to the hospital, nutritional indices,
Karnofsky performance status before and after PEG, comor-
bid medical illnesses, and complications after PEG. A con-
trol group was selected from patients admitted to the geri-
atric division who did not receive PEG. Patients with CVA,
cancer, and anoxic encephalopathy were also excluded in
the control group. Both groups were followed-up for 6
months.
RESULTS: One patient was lost to follow-up and complete
data were available for 55 patients. The control group of 33
patients was comparable to the patients in age, gender, and
comorbid illnesses. During a 6-month follow-up period, the
mortality was 44% among patients and 26% among controls
(p ⫽ 0.03). The only factor that predicted poor survival in
patients at 6 months was a serum albumin of ⬍2.8 g/dl. The
predictive value of low serum albumin was higher in pa-
tients with sepsis on hospital admission and in patients
younger than 85 yr. The mean serum albumin of the patients
was significantly lower than the control group (p ⫽ 0.0001).
CONCLUSIONS: Only 50% of demented patients with inad-
equate oral intake are likely to survive beyond 6 months
after PEG placement. No improvement in performance sta-
tus is likely to occur in any patient. These limited benefits
should be realized before initiating PEG feeding. Since the
Vol. 95, No.
ISSN 0002-9270/00/$20.00
PII S0002-9270(99)00732-7
survival in the age-matched control group with a higher
mean serum albumin was better than in the patients who had
PEG, there may be some benefit in performing PEG before
the onset of severe hypoalbuminemia. (Am J Gastroenterol
2000;95:133–136. © 2000 by Am. Coll. of Gastroenterol-
ogy)
INTRODUCTION
Since its introduction in 1980, percutaneous endoscopic
gastrostomy (PEG) has emerged as a safe method of long-
term nutritional support (1, 2). Indications for PEG include
inability to eat as a result of major stroke, oropharyngeal
dysphagia secondary to neurological illnesses, anoxic en-
cephalopathy, or head and neck cancer (3). However, feed-
ing via gastrostomy is increasingly used to augment the
caloric intake of patients with cognitive impairment when
their intake is insufficient. There are few data regarding
survival benefit or improvement of performance status in
this subset of patients after PEG feeding. Previous studies
on survival after PEG included patients with cancer, major
stroke, and anoxic brain injury, making interpretation of
survival statistics difficult (4 –9). In addition, referral for
PEG in these patients is often prompted by significant
weight loss or fall in serum albumin. It is not clear whether
the delay in referral until the onset of severe malnutrition
affects survival. This prospective study was designed to
evaluate the survival, improvement in performance status,
and influence of nutritional status on survival after PEG in
cognitively impaired elderly patients.
MATERIALS AND METHODS
Patients and Controls
The study subjects were selected from patients referred for
PEG placement to the gastroenterology and clinical nutri-
tion division of a 600-bed university hospital in New York
City. The inclusion criterion was a documented inadequacy
of oral intake because of cognitive impairment. The under-
lying etiology of cognitive impairment was dementia of
Alzheimer type, multiinfarct dementia, and degenerative
134 Nair et al. AJG – Vol. 95, No. 1, 2000

diseases. Patients with life-threatening illnesses such as Table 1. Comparison of Demographic Data and Nutritional
major cerebrovascular accidents (CVA), cancer, and anoxic Factors at the Time of PEG for Survival Status at 6 Months
brain damage were excluded. Patients who were ventilator Dead Alive p
dependent and those on nasogastric feedings were not in- (n ⫽ 24) (n ⫽ 31) Value
cluded. Also excluded were those who underwent endo- Age, yr 82.8 ⫾ 11.9 83.8 ⫾ 7.9 0.94*
scopic reinsertion of a gastrostomy tube. The control group Gender 0.94
included patients from the geriatric division who did not Male 6 (25.0%) 8 (25.8%)
Female 18 (75.0%) 23 (74.2%)
have PEG. Residence
For each patient, the indication that prompted a referral Private home 3 (12.5%) 5 (16.1%) 0.70
by the primary care physician was noted. A list of comorbid Nursing home 21 (87.5%) 26 (83.9%)
conditions was recorded and scored as follows. Each pa- Weight (pounds) 107.9 ⫾ 22.9 111.0 ⫾ 23.4 0.58*
tient’s coexisting medical diseases were noted based on the Body mass index 19.1 ⫾ 3.5 19.9 ⫾ 4.1 0.45*
Body weight
organ system involved and each comorbid condition was Actual ⫺ ideal ⫺16.4 ⫾ 22.2 ⫺11.7 ⫾ 28.6 0.28*
scored as one point. A total count was taken as a co-morbid Total lymphocyte 1424.1 ⫾ 494.9 1562.8 ⫾ 646.4 0.61*
illness score (10). The performance status of each patient count (K)
was noted at the time of PEG placement by the Karnofsky Albumin (g/dl) 2.8 ⫾ 0.5 3.0 ⫾ 0.5 0.05*
performance scale (11). Triceps skinfold 11.3 ⫾ 3.8 12.5 ⫾ 4.4 0.24*
thickness (mm)
Nutritional Evaluation Mid-arm muscle 191.0 ⫾ 30.8 201.7 ⫾ 46.9 0.57*
Anthropometric assessment included weight (kg), height circumference
(cm), triceps skin fold thickness (an average of three mea- (mm)
Cholesterol (mg/dl) 152.1 ⫾ 41.4 161.6 ⫾ 45.8 0.37*
surements), and midarm circumference (average of three Albumin 0.04
measurements around a point midway between acromion ⱕ2.8 gm/dl 15 (62.5%) 11 (35.5%)
and olecranon process). Body mass index (BMI) and mi- ⬎2.8 gm/dl 9 (37.5%) 20 (64.5%)
darm muscle circumference were calculated for all patients * U test.
using standard formulas. The laboratory tests used in nutri-
tional screening were serum albumin, serum cholesterol, included in a forward, stepwise multiple logistic-regression
and total lymphocyte count. model to identify the most important risk factors for death
Procedure and Follow-Up within 6 months. If relevant data were missing, the patients
The PEG was placed by standard technique using a 20-F were excluded from the multivariate analyses. Cox propor-
Bard tube by a senior fellow under the direct supervision of tional-hazards analysis was used to determine the relative
a staff physician. All patients received parenteral antibiotics contribution of various factors to the risk of death. All p
against Gram-positive organisms 30 – 60 min before the values are two-tailed. Statistical analysis was performed
procedure. Patients were observed in the hospital for at least using the SPSS (SPSS, Chicago, IL).
72 h after the procedure. The feeding was initiated either 6 h
or 24 h after PEG, provided there were no complications. RESULTS
Any difficulty in initiating the feeding as a result of vom-
iting or abdominal distension was recorded. Complications Of 153 PEG placements performed in our institution from
of PEG such as cellulitis at the stoma site, bleeding, or July 1997 to April 1998, only 56 patients satisfied the
aspiration pneumonia were noted. Upon discharge, patients inclusion criteria. One was subsequently lost to follow-up
were followed once a week for the first month and once a and complete data were available in 55 patients (mean age,
month thereafter, for a total of 180 days. In addition, other 83.31 ⫾ 9.76 yr; 14 men, 41 women). The results are
caretakers provided clinical data regarding the patient’s tabulated in Tables 1 and 2. Of the thirty-six control sub-
condition and any complication or difficulty with gastros- jects, three were lost to follow-up. At the end of 180 days,
tomy feeding. Information about the status of the controls 24 patients were dead (44%) whereas only seven controls
was obtained at the end of 6 months. died (26%, p ⫽ 0.03). All 31 patients who survived ⬎6
months continued to use gastrostomy feeding. No improve-
Statistical Analysis ment in performance status by Karnofsky scale was noted in
When appropriate, the ␹2 test (without the Yates’ correc- these patients at the end of 6 months. The reasons for
tion) and Fisher’s exact test were used for comparisons of admission were sepsis in 35 patients, dehydration or elec-
categorical data. For ordinal variables (such as albumin trolyte disturbances in 17, upper gastrointestinal (GI) bleed
concentration grouped in quartiles), the Mantel-Haenszel in two, and cardiac failure in one.
test for linear association was used. Differences in the Immediate postprocedure complications noted were cel-
means of continuous measurements were tested by Stu- lulitis (7%), GI bleeding (⬎5%), drop in hematocrit (2%), or
dent’s t test and checked by the Mann-Whitney U test. ileus requiring interruption of feeding within 72 h of initi-
Significant predictors in the univariate analysis were then ation of feeding (2%). Fever (temperature ⬎100°F) was
AJG – January, 2000 Hypoalbuminemia After PEG in the Elderly 135

Table 2. Comparison of Admission Factors and Complications Control Subjects

From PEG for Survival Status at 6 Months In 33 control subjects (mean age, 80.4 ⫾ 8.02 yr; 21 women,
Dead Alive 12 men) a complete 6-month follow-up was obtained. The
(n ⫽ 24) (n ⫽ 31) p Value controls and patients were comparable by age and gender.
Karnofsky status 64.8 ⫾ 6.8 62.3 ⫾ 5.9 0.63 Mortality at 6 months was higher in patients who had PEG
(mean %) (44% vs 26%, p ⫽ 0.03). However, the mortality rates
Comorbid score 1.4 ⫾ 0.9 1.6 ⫾ 1.0 0.51 among controls and patients were not different when pa-
Initiation of feeding 0.96
tients with severe hypoalbuminemia (serum levels ⬍2.8
After 6 h 11 (45.8%) 14 (45.2%)
After 24 h 13 (54.2%) 17 (54.8%) g/dl) were excluded. The controls had a higher serum albu-
Sepsis on admission 17 (70.8%) 18 (58.1%) 0.32 min than the patients (3.32 ⫾ 0.44 g/dl vs 2.86 ⫾ 0.5 g/dl;
Diabetes 5 (20.8%) 9 (29.0%) 0.48 p ⫽ 0.001). Among the controls there was no significant
Complications from difference in the mean serum albumin between those who
the procedure died and those who survived (3.08 ⫾ 0.4 g/dl vs 3.39 ⫾ 0.4
Fever 8 (33.3%) 4 (12.9%) 0.06
Cellulitis 3 (12.5%) 1 (3.2%) 0.18 g/dl).
Hemorrhage 0 (0.0%) 1 (3.2%) 0.34
Ileus 0 (0.0%) 1 (3.2%) 0.34
DISCUSSION
Percutaneous endoscopic gastrostomy is a well-accepted
seen in 12 (21%) of patients within 72 h of PEG placement. method of long-term enteral feeding in patients unable to eat
The most common cause of fever was aspiration pneumonia as result of CVA, anoxia, and head and neck cancer. In
(14%). After PEG placement, 47 patients were in a skilled addition, PEG is performed to improve the caloric intake in
nursing facility and eight patients were at home. cognitively impaired elderly patients with reduced oral in-
The factors that did not influence the mortality within 6 take and malnutrition. Whether gastrostomy feeding in such
months were age, gender, place of residence subsequent to patients improves survival or not has not been prospectively
PEG placement, comorbid conditions, performance status, evaluated. It is also not clear whether the degree of malnu-
and immediate postoperative complications such as celluli- trition and hence the time of referral for PEG influence
tis, GI bleeding, and ileus. Presence of diabetes (25%) did survival. Previous studies included patients with malig-
not increase the rate of infectious complications or influence nancy, anoxic brain damage, postcardiorespiratory arrest,
survival. The presence of sepsis on admission, onset of and major stroke, all of which adversely affected the overall
sepsis in the hospital, type of sepsis, and choice of antibiotic survival (4 –9). Not surprisingly, these studies demonstrated
treatment had no influence on mortality at 1, 3, or 6 months. a reduced survival in patients with serious underlying ill-
nesses. They also noted that a serum albumin level ⬍3.5
Nutritional Status and Survival g/dl adversely affected survival (4). Our study was designed
At the time of PEG placement, there was no significant to evaluate the survival of patients referred for PEG place-
difference in weight BMI, triceps skin fold thickness, mi- ment for decreased nutritional intake, and to compare their
darm muscle circumference, serum cholesterol, or total lym- survival with that of hospitalized elderly patients (controls)
phocyte count between patients who would be alive or dead who did not receive PEG. The mortality in patients at the
at 6 months. end of 6 months was 44%, compared with 26% for the
The one nutritional parameter that adversely affected the controls. Hypoalbuminemia at the time of PEG predicted a
outcome was a low serum albumin at the time of PEG higher mortality for patients started on gastrostomy feeding.
placement. By logistic regression, there was a definite trend The mean serum albumin in patients was lower than that in
indicating that a low serum albumin at the time of PEG the control cohort.
predicted a higher short-term mortality (p ⫽ 0.05). An Even in the absence of life-threatening illnesses, the mor-
albumin level ⬎2.8 g% was the best predictor of survival tality rate of 44% we observed at the end of 6 months was
⬎6 months. In the subgroup of patients with low albumin surprisingly high. This higher mortality in patients than in
levels (⬍2.8 g/dl) a significant survival advantage was noted age- and gender-matched controls is probably a reflection of
when there was no sepsis (2.8 times higher than patients underlying neurological illness and functional impairment.
with sepsis; 83.3% vs 30%, p ⫽ 0.02; Fig. 1). In patients All 31 patients who survived were on gastrostomy feeding
admitted with sepsis, a higher albumin (⬎2.8 g/dl) offered at the end of 6 months and none had sufficient improvement
a 2.8-times higher survival benefit at the end of 6 months in their oral intake to enable discontinuation of gastrostomy
(80% vs 30%, p ⫽ 0.003). Among the patients with sepsis tube feeding. No improvement in performance status was
on admission, respiratory infection was seen in 15 patients noted in any survivors. Lack of prolonged survival and
and, in them, an albumin level ⬎2.8 g% was associated with improvement in performance status should be discussed
improved survival (100% vs 27.3%, p ⫽ 0.003). The influ- with the surrogate decision makers before initiating gastros-
ence of albumin as a predictor of early mortality seems to be tomy tube feeding in elderly patients with dementia.
higher in patients younger than 85 yr of age (p ⫽ 0.03). Low serum albumin at the time of PEG was the only
136 Nair et al.
parameter that predicted mortality. An albumin level of ⬍
2.8 g% indicated a higher mortality in these patients (Fig. 1)
within 6 months of gastrostomy tube placement. Interest-
ingly, the strength of hypoalbuminemia as a sole factor in
predicting early mortality was higher in the subgroup of
patients with sepsis at the time of admission. Friedenberg et
al., in a cohort of 64 patients with a mortality of 33% (21
patients) at 1 month, showed that serum albumin is an
independent predictor of survival beyond 30 days after PEG
placement (12). In our study, the immediate mortality within
30 days was not correlated with a low albumin (Fig. 1),
although mortality at 6 months was correlated with an
albumin of ⬍2.8 g/dl. The disparity in observation may be
due to differences in patient selection. The former study
included patients with underlying serious medical illnesses
and the low serum albumin might have been a reflection of
these underlying illnesses.
Among 55 patients in our study, 26 had severe hypoalbu-
minemia (⬍2.8 g/dl) at the time of PEG. The mortality
among them was 58%, which was much higher than in the
patients without severe hypoalbuminemia. Age-matched
controls in our study had a higher serum albumin and better
survival. When patients with severe hypoalbuminemia were
excluded, the mortality rate at 6 months among patients and
controls was not statistically different. In the absence of any
other disorder that leads to low albumin, severe hypoalbu-
minemia in these patients reflects a more severe underlying
malnutrition at the time of PEG placement. It is also likely
that there might be a delay in recognition of inadequate oral
intake and referral for PEG. Hence, to achieve a survival
benefit comparable to that of other hospitalized elderly
patients, a timely detection of insufficient oral intake and
early initiation of gastrostomy feeding should be encour-
aged.
CONCLUSIONS
When compared with age-matched controls, elderly patients
with cognitive impairment who have gastrostomy feeding
do not demonstrate improved survival. Patients who re-
ceived PEG had more severe hypoalbuminemia than con-
trols. Severe hypoalbuminemia (⬍2.8 g/dl) at the time of
PEG predicted poor survival. There may be some benefit,
AJG – Vol. 95, No. 1, 2000
therefore, in prolonging survival if gastrostomy feeding is
initiated before the onset of severe hypoalbuminemia.
Reprint requests and correspondence: C. S. Pitchumoni, M.D.,
F.A.C.P., Professor of Medicine, New York Medical College,
Chief, Division of Gastroenterology & Clinical Nutrition, Our
Lady of Mercy Medical Center, 600 East 233rd Street, Bronx, New
York, NY 10466.
Received Mar.10, 1999; accepted Aug. 17, 1999.
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