Geriatrics Interhospital Meeting 3/2015

Eating problems in patient with advanced dementia

Dr. Ho Ka Shing

Higher physician trainee

Tuen Mun Hospital

Ms Chang, 88 years old

Elderly home resident, chairbound, non-communicable since 10/2013

Past medical history :

Major neurocognitive disorder, Alzheimer’s type

Hypertension

Open cholecystectomy with history of adhesive intestinal obstruction resolved with conservative treatment

3 admissions for poor oral intake and dehydration in recent 6 months, some episodes were precipitated by urinary tract infection

History of Present Illness

Fluctuate oral intake for 6 months

Reduced urine output for few days

No fever

No vomiting / diarrhea

Drug regimen just before admission :

Aqueous cream, urea cream, emulsifying ointment, piriton tds prn, dulcolax

Initial management by admitting medical officer :

Water swallowing test failed as patient could not anticipate and refuse intake -> intravenous fluid given

Empirical augmentin given

Foley inserted for monitoring

H’stix BD (H’stix 4.5 in AED)

Physical Examination the next day

Emaciated ( Body weight 26.3kg, dropped by 4kg in 1 month, BMI 11.4 by fibular length )

Eye contact to verbal stimulation, mute Not in distress except itchy scaly lesion over right

forearm, no burrows over finger webspace / armpits, on mitten

Dry oral mucosa Blood pressure / pulse / saturation stable Chest clear, abdomen soft, not distended, bowel

sound present Spontaneous movement over 4 limbs No pressure sore

Investigations

CXR : no focal consolidation AXR : fecal loaded, no dilated bowels ECG : sinus rhythm, no acute ischaemic changes First catheterized volume 20ml Catheterized urine multistix : not suggestive of urinary

tract infection WCC 6, normal differentials Na 166 Cr 114, urea 19 Hb 12.5, MCV 103, platelet normal (TSH / folate / B12

normal in 1/2015) Albumin 36 RG 6.2

Impression

Feeding problem with severe dehydration and malnutrition in patient with underlying advance stage dementia

Possible precipitating events

Constipation

? Scabies / fungal infection over right forearm

Sedative side effects from piriton

Management

Continue cautious intravenous fluid replacement Off antibiotics Off foley Off H’stix checking Anti-fungal cream to right forearm, skin scrapping Try off mitten over right hand Urea cream, piriton to nocte prn Dulcolax stat, senna alternative day for constipation Refer speech therapist, dietician Invite relatives to try feeding patient

Initial progress :

Speech therapist : poor oral anticipation, delayed swallow, no choking on syringe trial of medium thick liquid, spit out oral food

Dysphagia with behavioural problem

Dietician : add ensure at breakfast and lunch, fortijuice 8pm

Relatives feeding : no significant difference when being fed by relatives / staff

Family members showed concerns on the nutritional status and ways to ensure oral intake for patients

Eating problems in patient with

advanced dementia

85.8% of nursing home resident with advanced dementia got eating problem1

90.4% who died during the follow up period experienced eating problem in the last 3 months of life 1

The adjusted 6-month mortality after the development of eating problem is 38.6% 1

n=323

1. Mitchell SL et.al. The clinical course of advanced dementia. N Engl J Med. 2009, 15;361(16):1529-38.

Swallowing difficulties (dysphagia )

Food refusal by verbal rejection, physical rejection, oral defensiveness

Oral spitting and spillage

Food retention

Eating problems in patient with

advanced dementia

Volicer L. Quality of life in dementia. Prague: Charles University; 2011.

Common reasons for food refusal in

patients with advanced dementia

Taste and smell dysfunction 1

Agnosia, apraxia, attention deficits, disorientation, dysphagia with choking 2

Unsuppressed primitive oro-motor reflexes3 Depression, psychotic features

Acute event / discomfort like sepsis, stroke, pain,

electrolytes imbalance, hyper/hypoglycaemia, hypothyroidism e.t.c.

Side effects of medications Gastrointestinal tract : dental problem, peptic ulcer,

constipation Urinary retention

1. Morris J. et. al. Nutritional management of individuals with Alzheimer’s disease and other progressive dementias. Nutr Clin Care. 2001;4:148–55. 2. Volicer L. et. al. Eating difficulties in patients with probable dementia of the Alzheimer type. J Geriatr Psych Neurol. 1989;2:188–95. 3. van Boxtel MP et. al. Prevalence of primitive reflexes and the relationship with cognitive change in healthy adults: a report from the Maastricht Aging Study. J Neurol 2006;253:935-41

Management

Look out for acute event, correct any reversible components Medication review :

Stop unnecessary medications

Modification of diet : Remove any dietary restriction Increase nutritional density, alter the texture of food, offer finger foods,

smaller portions, favorite foods, off unnecessary restriction, schedule meals at times of greatest alertness and function

Modification of environment : Provide adequate lighting, assistive feeding utensils, optimize patient

positioning

Cognitive behavioural strategies ? Appetite stimulants ? Tube feeding Review for any advance care planning / advance directives,

communication with relatives / elderly home staff for prognosis, expectations e.t.c.

Increase nutritional density

High calorie supplements consistently promotes weight gains of 0.5–2.0 kg (moderate strength evidence) 1

1. Laura CH. et. al. Oral Feeding Options for Patients with Dementia: A Systematic Review. J Am Geriatr Soc. 2011 ; 59(3): 463–72.

Oral nutritional support

Stratton RJ et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev. 2005;4(3):422-50.

Cognitive behavioural strategies

For physical refusal behavioural modification using music,

calming and rhythmical patting

For oral defensiveness oral desensitisation with teat soothing,

slow icing and brushing, bottle feeding oral stimulation by alternation of

appetisers with specific taste and temperature in the diet

For verbal refusal selected feeding carers, verbal

prompting

Chan CPH, Kwan YK. Feeding-swallowing issues in older adults with dementia. Asian J Gerontol Geriatr 2014; 9: 80–4

Cognitive behavioural strategies

Chan CPH, Kwan YK. Feeding-swallowing issues in older adults with dementia. Asian J Gerontol Geriatr 2014; 9: 80–4

Appetite stimulants

Laura CH. et. al. Oral Feeding Options for Patients with Dementia: A Systematic Review. J Am Geriatr Soc. 2011; 59(3): 463–72.

Oral feeding options

Sparse but consistent evidence showed that oral feeding options do not improve function, cognition, or mortality for people with moderate to severe dementia 1

But yet these strategies may help to maintain patients’ pleasure on eating, interaction between patient and carers, relieve family’s worries, avoid necessary discomfort by artificial feeding e.t.c

1. Laura CH. et. al. Oral Feeding Options for Patients with Dementia: A Systematic Review. J Am Geriatr Soc. 2011; 59(3): 463–72.

Tube feeding : pros

? prolong life

? prevent aspiration

? improve malnutrition and its sequelae (e.g. pressure sores)

? alleviate symptoms of hunger or thirst

Jaul 2006 Alvarez-Fernandex 2005

Mitchell 1997 Nair 2000 Kuo 2009 Teno 2012

Study populat-ion

Psychogeri. patient with high Disability Rating Scale, n = 88

Advanced dementia patient in community, n = 67

Nursing home residents with Cognitive Performance Scale >= 6 n = 1386

Dementia patient ( control group ? with dementia), n = 88

Nursing home residents with Cognitive Performance Scale >= 6 and PEG insertion n = 5209

Nursing home residents with dementia and Cognitive Performance Scale >= 6 n = 36492

Study design

Prospective cohort

Prospective cohort

Prospective cohort

Prospective cohort

Prospective cohort

Prospective cohort

Compar-able ?

No Unclear Unclear Unclear - Adjustment done

Interven-tion

NG vs oral NG vs oral PEG/NG vs oral PEG vs oral PEG PEG vs oral

Follow up 17 months 30 months (median)

24 months 6 months 12 months 12 months

Mortality N.S.D. Mortality higher in patient with NG, (RR 3.5, P = 0.003)

N.S.D Mortality higher in patient with PEG (44% vs 26%, p = 0.03)

Mortality 64.1%, median survival 56 days post insertion.

N.S.D. (AHR 1.03 95% CI 0.94 – 1.13)

Summarized from Sampson EL et. al. Enteral tube feeding for older people with advanced dementia. Cochrane Database of Systematic Reviews 2009 (4) Teno JM et al. Does feeding tube insertion and its timing improve survival? J Am Geriatr Soc 2012;60:1918–21.

NG = nasogastric tube feeding ; N.S.D. = no statistically difference ; PEG = percutaneous endoscopic gastrostomy

Peck 1990 Jaul 2006 Alvarez-Fernandex 2005

Nair 2000 Teno 2012

Study population

Nursing home resident with MMSE 0 (control not all are demented), n = 104

Psychogeri. in-patient with high Disability Rating Scale, n = 88

Advanced dementia (FAST at least 7A) patient in community, n = 67

Dementia patient ( control group ? with dementia), n = 88

Nurse home resident with newly developed CPS score 6 with PEG inserted, n = 6340

Study Design

Retrospective cohort

Prospective cohort

Prospective cohort

Prospective cohort

Propensity-matched cohort

Comparable ? No No Unclear Unclear Yes

Intervention PEG/ NG vs oral NG vs oral NG vs oral PEG vs oral PEG vs oral

Follow up 6 month 17 months 30 months 6 months 12 months

Weight ↑48% vs ↑ 17% , p <0.01)

N.S.D. - - -

Albumin g/L

- N.S.D. 32.9 vs 36.6 p = 0.043

28.6 vs 33.2 p = 0.001

-

Pressure ulcer

- Mean number of pressure ulcer / patient 0.97 vs 1.92 p = 0.03

- - new stage 2 ulcer: adj. OR 2.27 (95% CI, 1.95-2.65) Healing ulcer: Adj. OR 0.70 (95% CI, 0.55-0.89)

Summarized from Sampson EL et. al. Enteral tube feeding for older people with advanced dementia. Cochrane Database of Systematic Reviews 2009 (4) Teno JM et. al. Feeding tubes and the prevention or healing of pressure ulcers. J Am Geriatr Soc 2012;172:697–701.

NG = nasogastric tube feeding ; N.S.D. = no statistically difference ; PEG = percutaneous endoscopic gastrostomy

1. Peck A. et. al. Long term enteral feeding of aged demented nursing home patients. Journal of the American Geriatrics Society 1990;38:1195-8 2. Finucane TE et. al. Use of tube feeding to prevent aspiration pneumonia. Lancet. 1996;348 (9039):1421 3. Grunow JE, et. al. Gastroesophageal reflux following percutaneous endoscopic gastronomy in children. J Pediatr Surg. 1989;24:42-45.

Aspirate of saliva and gastric content

gastrostomy tube placement may reduce lower esophageal sphincter pressure and increase the risk of gastroesophageal reflux3

Peck 1990 Feinberg 1996

Study population Nursing home resident with MMSE 0 vs randomly selected non-intubated controls, n = 104

Nursing home resident referred for video swallowing exam, n = 32/152 with dementia

Study Design Prospective cohort Prospective cohort

Comparable ? No Unclear

Intervention PEG/ NG vs oral PEG > NG vs oral

Follow up 6 month 36 months

Aspiration Aspiration pneumonia 58% vs 17%, p <0.01

Major aspiration/ oral feeding month 1.3% vs Major aspiration / artificial feeding month 4.4% p < 0.01

Tube feeding : cons Discomfort / risk during insertion Dislodgement, blockage, migration, leakage Agitation, physical and chemical restrain ->

development of pressure ulcer Diarrhoea, vomiting, aspiration,

gastrointestinal bleeding Electrolytes disturbance Earlier institutionalisation Reduced function and quality of life. Breach to dignity, autonomy ? non-maleficence

Comfort oral feeding vs tube feeding

- views from general population

Comfort oral feeding vs tube feeding

- views from professional bodies

Various professional bodies like the American Geriatrics Society, the Canadian Geriatrics Society, the American Board of Internal Medicine’s Choosing Wisely Campaign recommended ongoing hand feeding rather than tube feeding as the preferred approach to nutritional support in patients with advanced dementia

Aim to provide food and drink to the extent that it is enjoyable and comfort for the patient. The objective of providing a prescribed daily caloric intake is abandoned in favor of palliation

American Geriatrics Society Feeding Tubes in Advanced Dementia Positional Statement. J Am Geriatr Soc 2014 ; 62:1590–3

Barrier to oral feeding

Labor intensive

Choking / suffocation ‘ 因噎廢食 ? !’

Lack of awareness of the previously stated wish from patient

Lack of awareness of the evidence surrounding the benefits, risks, and burdens of tube feeding

? Higher risk of recurrent admission due to dehydration

Decision aid for

Progress of Ms Chang

Mitchell SL. et. al. Prediction of 6-month survival of Nursing Home Residents with Advanced Dementia Using ADEPT vs Hospice Eligibility Guidelines. JAMA. 2010;304(17):1929-35

Progress of Ms Chang

Intake gradually improved after relieving constipation, skin itchiness and reducing dose of piriton

Intake ~500ml/day, fruit juice was one of her favourite food

Electrolytes imbalance corrected Clinical course and prognosis of advance dementia

explained to family Advance care planning

Family opted for comfort oral feeding after thorough discussions

DNACPR if patient arrest

No re-admission yet since discharge in late 1/2015

Bring home message

Eating problems are common in patients with advanced dementia, and are associated with a substantial 6-month mortality

Always look out for any acute cause for eating problems and review for the medication regimen

After ruling out reversible components, careful hand feeding is preferred over tube feeding

Review for any advance care planning / advance directives, communication with relatives for prognosis and expectations

Thank you and welcome for questions !

Watson, R. et. al. A longitudinal study of feeding difficulty and nursing intervention in elderly patients with dementia. Journal of Advanced Nursing, 1997 ; 26(1), 25-32.

Royal Brisbane Hospital Outcome

Measure for Swallowing

Stage Level Description Characteristics

A. Nil by mouth 1 Aspirate secretions Wet phonation, pooling of saliva in oral cavity

2 Difficulty managing secretions but able to protect airway

Moist phonation, protective cough,

3 Coping with secreations No pooling/ droopling

B. Commencing oral intake

4 Tolerates small amounts of thickened/thin fluids only

= Sips

C. Establishing oral intake

5 Modified diet with supplementation

non-oral supplementation for requirements

6 Modified diet without supplementation

meets all fluid and/or food requirements orally

7 Upgrading of modified diet progression in diet towards normal diet consistencies

D. Maintaining oral intake

8 Optimal level independent in use of compensatory techniques

9 Pre-morbid /preadmission level

10 Better than premorbid /preadmission level

Modified from : Speech Therapy Department, Royal Brisbane Hospital. Royal Brisbane Hospital Outcome Measure for Swallowing: technical and administrative manual. Brisbane: Brisbane Hospital; 1998.

Meier 2001

Mitchell 1997

Murphy 2003

Nair 2000 Kuo 2009 Teno 2012

Study populat-ion

Advanced dementia with surrogate decision maker, n = 99

Nursing home residents with Cognitive Performance Scale >= 6 n = 1386

Advanced dementia, n = 41

Dementia patient ( control group ? with dementia), n = 88

Nursing home residents with CPS >= 6 and PEG insertion n = 5209

Nursing home residents with dementia and newly developed CPS score 6, n = 36492

Study design

Prospective cohort

Prospective cohort

Prospective cohort

Prospective cohort

Prospective cohort

Prospective cohort

Compar-able ?

Unclear Unclear Unclear Unclear - Adjustment done

Interven-tion

PEG > NG vs oral

PEG/NG vs oral

PEG vs oral

PEG vs oral PEG PEG vs oral

Follow up 5 years 24 months 2 years 6 months 12 months 12 months

Mortality N.S.D. (stepwise logistics regression)

N.S.D (RR 0.90, 95% CI 0.67 – 1.21)

N.S.D. (median survival 59 vs 60 days, P = 0.37)

Mortality higher in patient with PEG (44% vs 26%, p = 0.03)

One-year mortality 64.1%, median survival 56 days post insertion.

N.S.D. (AHR 1.03 95% CI 0.94 – 1.13)

Summarized from Sampson EL et. al. Enteral tube feeding for older people with advanced dementia. Cochrane Database of Systematic Reviews 2009 (4)

NG = nasogastric tube feeding ; N.S.D. = no statistically difference ; PEG = percutaneous endoscopic gastrostomy