The most common form of dementia is Alzheimer's Disease representing between 50 to 80 percent of all dementia cases. The Alzheimer's Association characterizes it as a progressive--and ultimately fatal--disease that destroys brain cells, causing memory loss and problems with thinking and behavior. Alzheimer's Disease is projected to affect as many as one in every 45 people by the time the next generation reaches senior age. Malnutrition is a significant concern, raising ethical and efficacy discussions regarding the best way to provide nutrition and hydration in deeply demented patients.
Malnutrition
According to the Dementia Education and Training Program, during the earliest stages of the disease, depression can rob people of their desire to eat. As the disease progresses, people need assistance to do even basic tasks. Dental problems, lack of interest or refusal to eat, increased physical movement and swallowing safety all impact nutritional status at this stage. During the end stages, the disease erodes the person's ability to chew and swallow safely. At this point, people are generally completely dependant on others.
PEG Tubes
Percutaneous endoscopic gastrostomy tubes--or PEG tubes--are feeding tubes that are placed in the stomach for long-term feedings. Originally invented by a pediatrician for children with swallowing problems, approximately one-third of all dementia patients have a PEG today. Malnutrition is very distressing for caretakers. Over time, the placing of a PEG has been associated with caring for the patient while declining one has been categorized as a form of neglect. Studies have shown no improved benefits for the patient from the use of such tubes, and the risk of complications and need for restraints can be high. Without the eating experience, the patient is denied another one of the small joys of life.
Benefits
Assisted oral feeding has significant advantages. It allows the person to enjoy the process of eating and the companionship of a meal. Nursing staff, dietitians, volunteers and caretakers can all play a vital role by implementing mealtime programs and educating families about how to maximize calories and by keeping the patient engaged while minimizing the impact of poor swallowing control.
Features
The earliest stages are the best time to assess patients' capabilities and nutritional status. Practical suggestions discussed in American Family Physician include offering consistent meals and nutritionally dense snacks. Have patience as it often takes extra time to finish a meal, and patients may need reminders to chew and swallow. When they are hungry, double portions if appropriate, use plain white plates and a single-eating utensil to limit confusion. Have them dine with a zesty eater. If needed, serve one food at a time, offer finger foods, regular drinks and soup in mugs. Concentrated nutritional supplements are good between meals.
Expert Insight
The best plan is communication. Having a living will and choosing a surrogate while the person is still competent makes decisions easier. Consult the advice of your physician and a licensed speech-language pathologist for swallowing safety. A registered dietitian would likely recommend pureed foods and foods thickened with a commercial thickener as the dementia progresses. You will find most commercial thickeners clump up in nutrition supplements; consider the pudding consistency for better tolerance. Consider assigning family members specific mealtime visits throughout the day.
References
- alz.org: What is Alzheimer's Disease?
- "Projections of Alzheimer's disease in the United States and the public impact of delaying disease onset"; Am J Public Health; R. Brookmeyer, et. al.; 1998.
- "Feeding Tubes in Patient's with Severe Dementia"; American Family Physician; Ina Li, MD; 2002.
- "Lack of evidence about tube feeding"; Journal of the American Medical Association; R. McCann; 1999.
- "Tube Feeding and Advanced Progressive Dementia"; The Hasting's Center Report; Stephen G. Post; 2001
