Sociodemographic and Linguistic Disparities in Tube Feeding Among Canadian Nursing Home Residents With Advanced Dementia

Difficulty eating is the most common complication of advanced dementia, and observational studies show no benefits of tube feeding [1-3]. Between 2000 and 2014, feeding tube insertions among US nursing home residents with advanced dementia decreased by approximately 50% (11.7%–5.7%), yet disparities existed across race, socioeconomic status, and geography [4]. We analyzed contemporary rates of tube feeding among Canadian nursing home residents with advanced dementia and characterized differences across sociodemographic and linguistic factors.

We conducted a repeated cross-sectional study from January 1, 2006 to December 31, 2022 examining the annual prevalence of tube feeding among Canadian nursing home residents with advanced dementia. In Canada, the two official languages are English and French, and all nursing home residents receive publicly funded personal support, nursing care, and subsidized accommodation. We used interRAI Minimum Data Set (MDS) 2.0 data from the Provinces of British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, and Newfoundland and Labrador (2021 population of 26.5 million). We included all nursing home residents with advanced dementia (Cognitive Performance Scale score of 6) and total dependence on eating [5]. We selected each resident's most recent MDS 2.0 assessment and fit a multivariable logistic regression to model sociodemographic (age, sex, and marital status), linguistic, clinical, and facility factors associated with feeding tube prevalence [5]. In a supplementary analysis, we modeled changes in feeding tube prevalence by resident primary language over time (Data S1). This study followed the RECORD reporting guideline and statistical analysis was conducted in SAS version 9.4 (Cary, NC). The University of Waterloo's Research Ethics Board approved our study.

We identified 114,769 Canadian nursing home residents with advanced dementia (29.8% males; median age = 87 years, interquartile range = 81–91 and 16.9% non-English or non-French speaking), of whom 2.6% were tube-fed from 2006 to 2022. The annual prevalence of tube feeding decreased from 3.5% (95% confidence interval [CI]: 2.7%–4.3%) in 2006 to 1.7% (95% CI: 1.5%–1.9%) in 2022, and was highest among nursing home residents who were non-English and non-French speakers (Figure 1). Among all 2934 residents with feeding tubes, 69.8% were identified on the first MDS 2.0 assessment following acute care hospitalization.

Annual feeding tube prevalence was greater among residents who were male (adjusted odds aatio [aOR] 1.18, 95% CI: 1.09–1.28), of younger age (aOR 1.33, 95% CI: 1.32–1.35 per 5-year decrement), living in large nursing homes of ≥ 100 beds (aOR 1.49, 95% CI: 1.33–1.66) situated in urban areas (aOR 1.89, 95% CI: 1.58–2.27), and in the lowest income quintile neighborhoods (aOR 1.21, 95% CI: 1.06–1.37). Compared to English speakers, French-speaking residents had lower odds of tube feeding (aOR 0.42, 95% CI: 0.28–0.63), whereas non-English and non-French speakers had higher odds (aOR 3.26, 95% CI: 3.02–3.52) (Table 1). Relative to English-speaking residents, the time trend for feeding tube prevalence was similar among French-speaking (p = 0.53) and other language-speaking (p = 0.47) residents (Data S1).

The annual prevalence of tube feeding among Canadian nursing home residents with advanced dementia is low and declined between 2006 and 2022. There was a higher prevalence among men, and residents of larger homes situated in urban areas and lower-income neighborhoods. Similar disparities exist among US nursing home residents with advanced dementia [4, 6]. Our findings add to the growing body of literature documenting sociodemographic disparities for persons living with dementia and for the end-of-life care of nursing home residents [7, 8].

The reasons for these sociodemographic disparities are likely multifactorial. In the United States, lower-resourced nursing homes have the highest rates of tube feeding, likely because of inadequate resources to educate staff and to have sufficient staff to support oral assisted feeding for residents living with advanced dementia [9]. For residents and their substitute decision-makers who are observant followers of Judaism and Islam, the “sanctity of life” often takes precedence over the more secular construct of “quality of life”, and providing artificial nutrition and hydration through tube feeding has the same moral and cultural imperatives as oral intake [10]. Analogous features in many Asian cultures, distinct from religion, value eating and avoidance of hunger at all costs, while caregivers of people living with dementia from ethnic minorities in the United Kingdom identify food as an expression of culture [11, 12].

We also documented a higher prevalence of feeding tubes among non-English and non-French language-speaking nursing home residents. Notably, this linguistic disparity persisted over the study period. Our findings highlight that improving healthcare equity for nursing home residents living with advanced dementia will require addressing language barriers. These efforts include creating more languageaccessible healthcare systems, developing standards for linguistic and culturally competent care, and expanding the multilingual workforce to reflect the linguistic diversity of residents [13].

Our study was limited to nursing home residents, and did not capture community-dwelling people living with advanced dementia or residents of other congregate care settings, including assisted living facilities. We neither had data on residents' goals of care nor race, with previous studies reporting that Black nursing home residents in the United States experience higher rates of tube feeding [4, 6]. Further, since language often intersects with race, immigration status, religion, and socioeconomic position, these factors may have influenced goals of care and decisions about tube feeding [14]. Overall, our findings underscore the need for renewed stewardship efforts to address sociodemographic and linguistic disparities in tube feeding for nursing home residents with advanced dementia, with a focus on acute care where most feeding tubes are inserted.

Nathan M. Stall and Luke A. Turcotte conceived and designed the study, with input from all other co-authors. Luke A. Turcotte conducted the analysis. All authors contributed to interpreting the results. Nathan M. Stall drafted the manuscript; all co-authors provided intellectual content, critical revisions, and approval of the final draft.

The authors declare no conflicts of interest.