Nutrition in dementia

Robert E. Lam; Peter J. Lam

doi:10.1503/cmaj.141217

Eating difficulties are a part of the natural progression of advanced dementia

A large prospective cohort study showed that 85% of patients with advanced dementia (Mini-Mental State Examination score ≤ 5.1) had eating difficulties.¹ The six-month mortality for such patients was almost 40%.¹

Feeding tubes do not enhance survival or quality of life

Examining the evidence from observational controlled studies involving nasogastric tubes, percutaneous endoscopic gastrostomy tubes or a combination of types of feeding tubes, a Cochrane review found insufficient evidence that feeding tubes enhance survival or quality of life, or that they reduce pneumonia or pressure ulcers.² Feeding tubes may increase the need for restraints, thereby possibly worsening pressure ulceration (Box 1).²

Box 1:

Choosing Wisely Canada recommendation

Do not recommend percutaneous feeding tubes for patients with advanced dementia; instead, offer oral feeding.

Careful hand-feeding for patients with severe dementia is at least as good as tube-feeding for the outcomes of death, aspiration pneumonia, functional status and patient comfort. Food is the preferred nutrient, but nutritional supplements may be beneficial. Tube-feeding is associated with agitation, increased use of restraints and worsening pressure ulcers.

Source: Canadian Geriatrics Society: Five things physicians and patients should question. Choosing Wisely Canada; 2014. Available: www.choosingwiselycanada.org/recommendations/canadian-geriatrics-society-2/

Careful hand-feeding may be preferable to tube-feeding

Although a direct comparison is not available, evidence suggests that careful hand-feeding is as good as tube-feeding in terms of complications and survival (Box 1).³ Hand-feeding may be best received by patients with advanced dementia if small quantities are given frequently to minimize choking. Patients at the end of life may feel only transient hunger and thirst.⁴ Although it can be time-consuming, hand-feeding provides caregivers a way to express care and allows the patient to enjoy the sensation of eating.⁵

Before recommending tube-feeding, physicians should clarify the presence and severity of underlying dementia

Most feeding tubes (68%) are given to residents of nursing homes during an admission to hospital for acute care,⁶ a situation in which the extent of the patient’s underlying dementia may be unclear to staff. Feeding tubes should not be recommended for patients with advanced dementia.⁵ Once a feeding tube is inserted, deciding on its removal can be difficult for a substitute decision-maker.

Feeding decisions are best discussed with the patient or substitute decision-maker well before an admission to hospital

A randomized controlled trial showed that substitute decision-makers had more knowledge and less decisional angst after watching a video about feeding options (http://decisionaid.ohri.ca/tools.html#feedingoptions).⁷ A decision aid of this type may enhance the quality of subsequent discussions.

CMAJ is collaborating with Choosing Wisely Canada, with support from Health Canada, to publish a series of articles describing how to apply the Choosing Wisely Canada recommendations in clinical practice.

Footnotes

See references, Appendix 1, www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.141217/-/DC1
Competing interests: Robert Lam is the secretary-treasurer of the Canadian Geriatrics Society, which supports the Choosing Wisely Canada campaign; he has received a grant from Pfizer Canada to develop a continuing medical education course for physicians. No other competing interests were declared.
This article has been peer reviewed.