Prognosis Life expectancy from the time of diagnosis: Alzheimer Disease 5-10 years Vascular Dementia 4 years Dementia with Lewy Bodies 4 years

What is an advance directive?? DNR Living will DPOA HC Bono has an advance directive- so should you! Living will- can be detailed or vague

Weight loss

Anorexia and Weight Loss Common in patients with dementia Especially AD Possible causes Forgetting to eat Inability to prepare and eat foods Impaired olfaction and taste Behavior problems (restlessness, etc) Depression Comorbid medical illness Medications (esp ACh-I, Antidepressants) Inflammatory abnormalities (anorexia, procatabolic state) Wang et al, J Neurol 2004, 251:314-320; Aziz NA et al, J Neurol 2008 4 4

Controlled study of 51 AD pts and 27 non-demented controls AD pts were thinner and less active Pts with AD actually ate the same or MORE than controls Presence of AD was a risk factor for weight loss even if other factors were controlled Wang et al, J Neurol 2004, 251:314-320 5 5

AD pts have increased serum levels of: Glucagon Ammonia Lactate Cortisol Interleukins 1 and 6 TNF alpha AD pts have greater insulin resistance All of above is similar to cancer patients Knittweis J, Medical Hypotheses, 1999 6 6

Strategies Diet- liberalize it! No special diets! Environment Eat with others Pleasant, quiet setting Music may help Tamura BK et al. Nutrition and the Institutionalized Elderly. 2007 7 7

Strategies Food Modifications Eating Schedule Single items, presented one at a time Contrast color of food with the dish Make food and setting look attractive Make food portable for those who are restless Sweet, hot/cold, juicy Eating Schedule AD pts ate more at breakfast than other meals Frequent, small meals Eat with others Tamura BK et al. Nutrition and the Institutionalized Elderly. 2007 8 8

Limited Data on Pharmacologic Strategies Nutritional supplements between meals Micronutrients (MVI) probably not needed Megestrol acetate (Megace) Dronabinol (Marinol) Methylphenidate (Ritalin) Mirtazepine (Remeron) Tamura BK et al. Nutrition and the Institutionalized Elderly. 2007 9 9

When are they appropriate? Feeding tubes When are they appropriate? In advanced stages people may stop eating altogther. Segue: So if you determine a patient is not eating because they have dementia, someone may suggest placing a feeding tube (either NG or G). Let’s go through the arguments FOR placing a tube: (Have the group give suggestions, write these on the board) Prevent aspiration Forestall malnutrition Help wound healing Prolong survival Provide comfort Prevent dehydration Segue to next slide: Unfortunately, there are no randomized controlled trials to prove to us that tube feeds can achieve these ends because of the complex ethical and cultural issues involved with feeding. Therefore, we are forced to use observational data to guide us. Let’s go through some of these reasons for tube feeding and discuss what evidence we do have. 10

Improved Survival? Observational studies: NH patients show no survival advantage with tube feeding 1 retrospective review of 41 consults for PEG survival without PEG 60 days, with PEG 59 days Mortality is high after G-tube placement 6-28% in first 30 days 60% mortality at 6 months, perhaps 90% at one year Elaboration: as in slide High mortality after PEG placement is usually because of the underlying illness, not complications of tube placement Highest mortality is seen for those 85 and older or those with dementia Murphy LM. Arch Int Med, 2003; Dharmarajan TS. Am J Gastroenterology, 2001; Mitchell SL. Arch Int Med, 1997; Gillick MR. N Engl J Med. 2000 11