Geriatrics Interhospital Meeting 3/2015

Transcription

1 Geriatrics Interhospital Meeting 3/2015 Eating problems in patient with advanced dementia Dr. Ho Ka Shing Higher physician trainee Tuen Mun Hospital

2 Ms Chang, 88 years old Elderly home resident, chairbound, noncommunicable 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 3 admissions for poor oral intake and dehydration in recent 6 months, some episodes were precipitated by urinary tract infection

4 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

5 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)

6 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

7 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

8 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

9 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

10 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

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

12 Eating problems in patient with advanced dementia 85.8% of nursing home resident with advanced dementia got eating problem % 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= Mitchell SL et.al. The clinical course of advanced dementia. N Engl J Med. 2009, 15;361(16):

13 Eating problems in patient with Swallowing difficulties (dysphagia ) Food refusal by verbal rejection, physical rejection, oral defensiveness Oral spitting and spillage Food retention advanced dementia Volicer L. Quality of life in dementia. Prague: Charles University; 2011.

14 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 reflexes 3 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: Volicer L. et. al. Eating difficulties in patients with probable dementia of the Alzheimer type. J Geriatr Psych Neurol. 1989;2: 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

15 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.

16 Increase nutritional density High calorie supplements consistently promotes weight gains of kg (moderate strength evidence) 1 1. Laura CH. et. al. Oral Feeding Options for Patients with Dementia: A Systematic Review. J Am Geriatr Soc ; 59(3):

17 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):

18 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

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

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

21 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):

22 ? prolong life Tube feeding : pros? prevent aspiration? improve malnutrition and its sequelae (e.g. pressure sores)? alleviate symptoms of hunger or thirst

23 Study design Study population Comparable? Intervention Jaul 2006 Psychogeri. patient with high Disability Rating Scale, n = 88 Prospective cohort Alvarez- Fernandex 2005 Advanced dementia patient in community, n = 67 Prospective cohort Mitchell 1997 Nair 2000 Kuo 2009 Teno 2012 Nursing home residents with Cognitive Performance Scale >= 6 n = 1386 Prospective cohort Dementia patient ( control group? with dementia), n = 88 Prospective cohort Nursing home residents with Cognitive Performance Scale >= 6 and PEG insertion n = 5209 Prospective cohort Nursing home residents with dementia and Cognitive Performance Scale >= 6 n = Prospective cohort No Unclear Unclear Unclear - Adjustment done NG vs oral NG vs oral PEG/NG vs oral PEG vs oral PEG PEG vs oral Follow up 17 months 30 months (median) Mortality N.S.D. Mortality higher in patient with NG, (RR 3.5, P = 0.003) 24 months 6 months 12 months 12 months N.S.D Mortality higher in patient with PEG (44% vs 26%, p = 0.03) Mortality 64.1%, median survival 56 days post insertion. NG = nasogastric tube feeding ; N.S.D. = no statistically difference ; PEG = percutaneous endoscopic gastrostomy N.S.D. (AHR % CI ) 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:

24 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. inpatient 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 Propensitymatched 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 vs 36.6 p = vs 33.2 p = Pressure ulcer - Mean number of pressure ulcer / patient 0.97 vs 1.92 p = new stage 2 ulcer: adj. OR 2.27 (95% CI, ) Healing ulcer: Adj. OR 0.70 (95% CI, ) NG = nasogastric tube feeding ; N.S.D. = no statistically difference ; PEG = percutaneous endoscopic gastrostomy 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:

25 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 Aspirate of saliva and gastric content gastrostomy tube placement may reduce lower esophageal sphincter pressure and increase the risk of gastroesophageal reflux 3 1. Peck A. et. al. Long term enteral feeding of aged demented nursing home patients. Journal of the American Geriatrics Society 1990;38: Finucane TE et. al. Use of tube feeding to prevent aspiration pneumonia. Lancet. 1996;348 (9039): Grunow JE, et. al. Gastroesophageal reflux following percutaneous endoscopic gastronomy in children. J Pediatr Surg. 1989;24:42-45.

26 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

27 Comfort oral feeding vs tube feeding - views from general population

28 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

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

30 Labor intensive Barrier to oral feeding 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

31 Decision aid for

32 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):

33 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

34 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

35 Thank you and welcome for questions!

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37 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),

38 Modified from : Speech Therapy Department, Royal Brisbane Hospital. Royal Brisbane Hospital Outcome Measure for Swallowing: technical and administrative manual. Brisbane: Brisbane Hospital; 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 C. Establishing oral intake D. Maintaining oral intake 4 Tolerates small amounts of thickened/thin fluids only 5 Modified diet with supplementation 6 Modified diet without supplementation = Sips non-oral supplementation for requirements meets all fluid and/or food requirements orally 7 Upgrading of modified diet progression in diet towards normal diet consistencies 8 Optimal level independent in use of compensatory techniques 9 Pre-morbid /preadmission level 10 Better than premorbid /preadmission level

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40 Study design Study population Comparable? Intervention Meier 2001 Advanced dementia with surrogate decision maker, n = 99 Prospectiv e cohort Mitchell 1997 Nursing home residents with Cognitive Performanc e Scale >= 6 n = 1386 Prospective cohort Murphy 2003 Advanced dementia, n = 41 Prospectiv e cohort Nair 2000 Kuo 2009 Teno 2012 Dementia patient ( control group? with dementia), n = 88 Prospective cohort Nursing home residents with CPS >= 6 and PEG insertion n = 5209 Prospective cohort Nursing home residents with dementia and newly developed CPS score 6, n = Prospective cohort Unclear Unclear Unclear Unclear - Adjustment done 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 ) 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 % CI ) NG = nasogastric tube feeding ; N.S.D. = no statistically difference ; PEG = percutaneous endoscopic gastrostomy Summarized from Sampson EL et. al. Enteral tube feeding for older people with advanced dementia. Cochrane Database of Systematic Reviews 2009 (4)

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