Advanced Dementia and Nutrition

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Advanced Dementia and Nutrition

• Dr Alex Brown
• Consultant Elderly Care
• Director of Medicine and Emergency Care
• Bradford Teaching Hospitals NHS Trust

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Bradford Nutrition Team

• Matron
• Specialist Nurse
• Consultant Gastroenterologist
• Consultant Elderly Care
• Dietician
• ? SALT

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• Enteral Nutrition (Tube feeding)
• NG tubes
• PEG feeding tubes
• RIG feeding tubes

• Parenteral Nutrition
• IV feeding

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NG tubes

• Short Term
• Uncomfortable
• Come out ( can use a bridle)

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PEG/RIG Tube

• Risks
• Bleeding
• Perforation
• Infection

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Question 1Old people often have grey hair

1. True
2. False

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Question 2If I(you) had advanced dementia.
Incontinent,Aphasic,Bed bound,No longer
recognised family.I would want to consider PEG
feeding.

1. Yes
2. No

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Question 3If my dearest closest relative had
advanced dementia. Incontinent----etc. I would
want them to be considered for PEG feeding.

1. Yes
2. No

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Alois Alzheimer

• Female gradual cognitive decline
• Feeding difficulties
• Autopsy

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Brain Atrophy
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• 2005 750,000 UK Dementia
• 2050 1,800,000

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Dementia Can Affect Anyone

• ?

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In USA

• 34 of 186,835 NH residents with advanced
  dementia tube fed

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Not just American Politicians
?
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Nutritional Problems

• 3 Stages
• Early
• Middle
• Late

Exclude Reversible Cause
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Early

• 75 dementia sufferers at home
• Reduced BMI compared to age related cohorts

Social Services Family / Informal carers OT /
Physio / GP Dietician
Poverty Social Isolation Lack of Skill Planning
and Preparation Co morbidities / Drugs Poor
Mobility
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Do not forget teeth
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Middle (? Institutional Care)
Exclude Reversible Cause
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Middle (? Institutional Care)

• Reduced Attention Span
• Sundowning
• Day / Night Reversal
• Feeding Difficulties
• Co morbidities / Drugs

• Environmental Factors
• Aids and Appliances
• Familiar Food
• Minimise Disturbance
• Flexibility
• Modified Diet / Supplements

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Flexibility

• Ward Routine
• Fixed Meal times
• Lack of Staff
• Food Stuffs
• Storage of Food

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Late
Exclude Reversible Cause
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Late

• Eating is last ADL lost
• Neuromuscular -lack of coordination
• Pocket or spit food
• Lack of Hunger

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What to do?

• Feed Orally
• Tube Feeding

• Treatment Goal
• Prolong life
• Comfort and quality of life in a terminal disease

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Oral Feeding

• Prolong Life
• May not meet needs
• Time consuming
• Resource heavy (in USA fewer staff increase PEG)
• Aspiration

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Oral Feeding

• Comfort / QOL
• Carers concern
• Hunger / Thirst
• Do not know capacity for hunger in dementia
• Cancer literature not a significant symptom
• Social Interaction-role for the carer

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PEG Feeding

• Prolong life
• No RCT observational studies only
• 54 mortality at 30 days
• 90 die within 1 year
• No difference mortality feeding tube or not
• 19 PEGs inappropriate NCEPOD
• Aspiration no reduction with tube feeding
• No evidence promoted healing of pressure sores
• Tube placement complications

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PEG Feeding

• Comfort / QOL
• Non compliant patient restraint
• Pressure sores no evidence of benefit ?
  Increased risk (diarrhoea)
• No improvement in functional status
• Tube complications cellulitis, leakage, fall
  out
• Guaranteed route for drugs

Chemical
Physical
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Cochrane Review 2009Enteral tube feeding for
older people with advanced dementia

• No conclusive evidence that tube feeding is
  effective in terms of prolonging survival,
  improving quality of life, or leading to better
  nourishment or decreasing the risk of pressure
  sores. It may actually increase the risk of
  pneumonia and even death.

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Which is best?
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Question 3If my dearest closest relative had
advanced dementia. Incontinent----etc. I would
want them to be considered for PEG feeding.

• A. Yes
• B. No

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Question 3If my dearest closest relative had
advanced dementia. Incontinent----etc. I would
want them to be considered for PEG feeding.

1. Yes
2. No

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Ros Levenson BMJ Volume 329 20th November 2004
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Take Home Message

• Exclude the reversible

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Types of Dementia

• Alzheimers Disease 55
• Vascular Dementia (MID) 20
• Lewy Body 15
• Picks Disease 5
• Other Dementia 5

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Prevalence
Age (years) Prevalence
40-65 1 in 1000
65-70 1 in 50
70-80 1 in 20
80 1 in 5
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• Neurofibrillary Tangles twisted bands of fibres
  
• Senile Plaques dense deposits outside and
  around nerve cell

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Summary

• Dementia is a terminal disease with predictable
  progression make plans
• PEG unlikely to meet treatment goals
• Ethics / Beliefs prolong life ? Paramount

Exclude Reversible Cause