Undernutrition in frail elderly people is a pathological condition that needs to be recognized and addressed early. Neurological dysphagia is among the most frequent causes of this condition in the elderly but should be considered a terminal event in Alzheimer-type dementias. Tube feeding is an important resource for facilitating metabolic recovery in cachectic patients and is particularly successful in “bridging” and stabilizing therapies prior to major treatment able to cure the patient. Clinical management of tube feeding in “incurable” conditions is complex and becomes part of the palliative care and comfort provided in the terminal stages of illness. Non-specialized physicians are often unfamiliar with the theory and practice of end-of-life interventions, and the resulting decisions are in many cases actually contrary to patient comfort. These problems deserve to be more carefully addressed when the patient is unable to cooperate or express his/her preferences and needs. The success of percutaneous endoscopic gastrostomy has led to increasingly frequent referrals for placement in critically ill elderly patients. Endoscopists therefore become a key figure in stimulating rational, correct treatment of these patients.