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Advanced Dementia and Nutrition

Advanced Dementia and Nutrition. Dr Alex Brown Consultant Elderly Care Director of Medicine and Emergency Care Bradford Teaching Hospitals NHS Trust. Bradford Nutrition Team. Matron Specialist Nurse Consultant Gastroenterologist Consultant Elderly Care Dietician ? SALT.

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Advanced Dementia and Nutrition

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  1. Advanced Dementia and Nutrition Dr Alex Brown Consultant Elderly Care Director of Medicine and Emergency Care Bradford Teaching Hospitals NHS Trust

  2. Bradford Nutrition Team • Matron • Specialist Nurse • Consultant Gastroenterologist • Consultant Elderly Care • Dietician • ? SALT

  3. EnteralNutrition (Tube feeding) • NG tubes • PEG feeding tubes • RIG feeding tubes • ParenteralNutrition • IV feeding

  4. NG tubes • Short Term • Uncomfortable • Come out ( can use a bridle)

  5. PEG/RIG Tube • Risks • Bleeding • Perforation • Infection

  6. Question 1Old people often have grey hair • True • False

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

  8. Question 3If my dearest closest relative had advanced dementia. Incontinent----etc. I would want them to be considered for PEG feeding. • Yes • No

  9. Alois Alzheimer • Female gradual cognitive decline • Feeding difficulties • Autopsy

  10. Brain Atrophy

  11. 2005 750,000 UK Dementia 2050 1,800,000

  12. Dementia Can Affect Anyone ?

  13. In USA • 34% of 186,835 NH residents with advanced dementia tube fed

  14. Not just American Politicians ?

  15. Nutritional Problems 3 Stages: • Early • Middle • Late Exclude Reversible Cause

  16. 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

  17. Do not forget teeth

  18. Middle (? Institutional Care) Exclude Reversible Cause

  19. 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 Middle (? Institutional Care)

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

  21. Late Exclude Reversible Cause

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

  23. What to do? • Feed Orally • Tube Feeding • Treatment Goal • Prolong life • Comfort and quality of life in a terminal disease

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

  25. 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

  26. 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

  27. 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

  28. 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.’

  29. Which is best?

  30. 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

  31. Question 3If my dearest closest relative had advanced dementia. Incontinent----etc. I would want them to be considered for PEG feeding. • Yes • No

  32. Ros Levenson BMJ Volume 329 20th November 2004

  33. Take Home Message • Exclude thereversible

  34. Types of Dementia Alzheimer’s Disease 55% Vascular Dementia (MID) 20% Lewy Body 15% Picks Disease 5% Other Dementia 5%

  35. Prevalence

  36. Neurofibrillary Tangles – twisted bands of fibres • Senile Plaques – dense deposits outside and around nerve cell

  37. 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

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