INVOLUNTARY WEIGHT LOSS IN THE ELDERLY _____________________________ hello INVOLUNTARY WEIGHT LOSS IN THE ELDERLY _____________________________ Beatriz Korc MD, PhD. The Brookdale Department of Geriatrics And Adult Development Mount Sinai School of Medicine March 3rd, 2009 goodbye

hello OBJECTIVES To recognize the importance of involuntary weight loss in the elderly To identify the factors associated with weight loss in the elderly and their investigation To become familiar with non-pharmacological and pharmacological management options To discuss artificial nutrition in end-stage dementia. goodbye

hello Case of Ms. FB 85 year old woman with history of severe dementia, L sided CVA with R hemiplegia, hypertension and an approx. 6 month history of decline and weight loss. The patient was admitted with one week history of progressive weakness, mental status changes and decrease oral intake Exam showed BP 110/55, HR 90. Lethargic, non-verbal, does not follow commands. R sided hemiplegia. No other findings Labs: Normal CBC with diff. Chem-7: Na 168 and Creatinine 1.3 (baseline 0.8-0.9) 24/7 private paid HHA. Large family and very supportive. No advanced directives. goodbye

>5% in 30 days Ryan et al South Med J 1995; 88:721-724 hello WHAT IS CLINICALLY IMPORTANT INVOLUNTARY WEIGHT LOSS? __________________________________________ 5% weight loss over a 1 year period Wallace J et al. J Am Geriatr Soc 1995; 43:329-337 More than 10 pounds in 6 months Seltzer MH et al J Parenter Enteral Nutr 1982;:218-221 >5% in 30 days Ryan et al South Med J 1995; 88:721-724 10% in 180 days Chang et al J Fam Pract 1990; 30:671-674. Although there is no clinical consensus the most accepted definition of clinically important weight loss is 5% over a period of 6-12 months. 4-5% weight loss at one year is associated with increased mortality >10# in 6 m Increased in mortality in a study of patients admitted for elective surgery Weight loss also predicts mortality in the NH. Patients losing >5% of the body weight over one month were 4.6 times more likely to die within a year. Those losing 10% or more over 6 months had 62% mortality over the next 3 years (42% when weigh was stable) 5% in 30 d or 10% in 180 days or intake thatn <75% of meals triggers a change in the MDS in NH goodbye

PREVALENCE _____________________________________ hello PREVALENCE _____________________________________ 1.3-8% of adults seeking outpatient health care Marton et al Ann Intern Med 1981;95:568-574 27% of free-living frail elderly receiving community services Payette et al J Clin Epidemiol 2000;53:579-587. 50% of institutionalized patients with dementia 30% of non-institutionalized patients with mild-moderate AD White et al J Am Geriatr Soc 1996;44:265-272 It has been reported as many as 50% of ….. And up to 30% of noninstitutionalized pat with mild-mod AD goodbye

EFFECTS OF INVOLUNTARY WEIGHT LOSS hello EFFECTS OF INVOLUNTARY WEIGHT LOSS Increased frailty and mortality (9-38% within 1-3years) Increased hospital admissions and increased risk of in-hospital complications Increased falls and injuries from falls Impaired cell-mediate and humoral immune response with increased rate of infections Loss of lean body mass with impaired skeletal muscle, cardiac muscle and respiratory function Delayed wound healing Decreased functional ability and ADLs Higher rates of admission to an institution Poorer quality of life Launer et al. JAMA 1994;271:1093-1098 Fine et al JAMA 1999;282:2136-2142. Landi et al J Am Geriatr Soc 1999;47:1072-1076 Tayback et al Arch Inter Med 1990;150:1065-1072. goodbye

hello CAUSES OF WEIGHT LOSS IN THE ELDERLY _____________________________________________ REVERSIBLE Assessment Diagnosis Treatment IRREVERSIBLE Frustrating Painful Emotionally draining Expensive Fruitless goodbye

PHYSIOLOGICAL MEDICAL FUNCTIONAL PSYCHOLOGICAL SOCIAL hello CAUSES OF WEIGHT LOSS IN THE ELDELY _____________________________________________ PHYSIOLOGICAL MEDICAL FUNCTIONAL PSYCHOLOGICAL SOCIAL goodbye

Gastrointestinal factors hello CAUSES OF WEIGHT LOSS IN THE ELDELY PHYSIOLOGICAL FACTORS ANOREXIA IN AGING Chemosensory changes Diminished sensory-specific satiety Change in taste and smell Increase threshold for salt and other specific tastes Decrease taste sensitivity due to decrease taste receptor turnover; taste buds number does not change. Medications alter senses of taste and smell Gastrointestinal factors Delayed gastric emptying Prolonged antral distension Increased absorption time Gut Hormones Elevated levels of Glucagon (GLP-1), CCK and Leptin Decreased levels of Ghrelin Hays and Roberts Phys and Behavior 2006; 88:257-266. There is a decline in appetite and food intake common in the elderly described as “anorexia of aging”. Energy intake and expenditure declines steadily in the elderly Decrease in pleasantness of food as it consumed probably related to a decline in taste and smell sensitivity related to aging. Reason for these changes are still not well determined.Hypothesis suggest…. Overall impaired taste and smell reduce the cephalic phase of digestion, decreases the pleasure provided by a meal with consequent anorexia. ……..Reduced hunger and increase satiety ……..energy substrates remain in circulation for longer periods In addition to its effects on chemos… and Gi factors, age also influence the production and or detection of several hormones thought to be involved in satiety and hunger Glucagon: increased satiety; Increased CCK: correlates with decrease hunger, Increased leptin correlates with reduces feeding and increases energy expenditure Gherlin is a growth hormone produced by the stomach that increases appetite and food intake goodbye

hello CAUSES OF WEIGHT LOSS IN THE ELDELY PHYSIOLOGICAL FACTORS ANOREXIA IN AGING Hays and Roberts Phys and Behavior 2006; 88:257-266. A variety of peripheral satiety signals may be related to central mechanisms responsible for coordination of energy regulation signals. One potential candidate is the neuropepetide Y NPY that integrate mechanisms that modulate feeding behavior and energy expenditure. NPY gene expression is increased in the hypothalamus of older women and anorectics goodbye

CAUSES OF WEIGHT LOSS IN THE ELDELY MEDICAL CAUSES hello CAUSES OF WEIGHT LOSS IN THE ELDELY MEDICAL CAUSES Malignancy Infectious Bacterial,Tb, fungal,parasitic Inflammation Autoimmune diseases Endocrine DM, hypo/hyperthyroid, Adrenal Insufficiency Organ Failure CHF, CRI, COPD, etc Medication Side Effects Deficiencies B12, Folate, Iron, Thiamine, Vit.C, Zn goodbye

MEDICATION SIDE EFFECTS THAT CAN CONTRIBUTE TO WEIGHT LOSS hello MEDICATION SIDE EFFECTS THAT CAN CONTRIBUTE TO WEIGHT LOSS Side effect Anorexia Dry mouth Dysgeusia/dysosmia Nausea/vomiting Carr-Lopez et al.Drugs Aging 1996;9:221-5 Drug Antibiotics, anticonvulsants, digoxin, metformin, SSRIs,etc. Anticholinergics, antihistamines, diuretics, clonidine ACEI, antibiotics, anticholinergics, calcium channel blockers, etc. Antibiotics, digoxin, hormone replacement, iron, potassium, SSRIs, statins, etc. goodbye

CAUSES OF WEIGHT LOSS IN THE ELDELY FUNCTIONAL CAUSES hello CAUSES OF WEIGHT LOSS IN THE ELDELY FUNCTIONAL CAUSES Immobility Arthritis Stroke Parkinson’s Dental Vision Hearing goodbye

CAUSES OF WEIGHT LOSS IN THE ELDELY PSYCHIATRIC/PSYCHOLOGICAL CAUSES hello CAUSES OF WEIGHT LOSS IN THE ELDELY PSYCHIATRIC/PSYCHOLOGICAL CAUSES Depression Psychosis Grief/Bereavement Intentional Alcoholism Dementia Anorexia nervosa/anorexia tardive goodbye

CAUSES OF WEIGHT LOSS IN THE ELDELY SOCIAL CAUSES hello CAUSES OF WEIGHT LOSS IN THE ELDELY SOCIAL CAUSES Poverty Isolation Neglect Abuse Caregiver fatigue goodbye

EVALUATION OF WEIGHT LOSS IN THE ELDERLY hello EVALUATION OF WEIGHT LOSS IN THE ELDERLY Weigh the patient Calculate body mass index (undernutrition <22) Careful H&P with emphasis in pharmacologic and psychosocial factors Basic screening tests including UA, CBC, electrolytes, LFTs, TFTs, renal function, stool occult blood, CXR; upper and lower endoscopies (high diagnostic yields) Indicators of poor nutrition: Albumin <3.4 g/dL, Cholesterol < 160 mg/dL, Transferrin <180, Hb < 12g/dL, triceps skin fold thickness Despite its frequency there is no clear guidelines on how to evaluate weight loss in the elderly Albumin has a half life of 18 days and it is afected by inflammation, liver disease, nephrosis Pre albumin half life 2d Better measure of acute nutritional changes and is valuable in nutritional recovery Cholesterol has prognostic value but may not be nutritionally mediated goodbye

TREATMENT _____________________________________ hello TREATMENT _____________________________________ NON-PHARMACOLOGIC PHARMACOLOGIC goodbye

NON-PHARMACHOLOGIC TREATMENT hello NON-PHARMACHOLOGIC TREATMENT Minimize dietary restrictions Optimize energy intake High energy foods at the best meal of the day Smaller meals more often (eat with the clock not your appetite) Favorite foods and snacks Optimize and vary dietary texture Avoid gas-producing foods Ensure adequate oral hygiene and health Take nutritionally dense supplements Eat in company or with assistance, hand-feed the patient Use flavor enhancers, maximize taste and smell Participate in regular exercise Take a multiple vitamin supplement daily Use community nutritional support services Minimize aspiration risk goodbye

NUTRITIONAL NEEDS IN THE ELDERLY hello NUTRITIONAL NEEDS IN THE ELDERLY Energy intake Declines significant with aging reduction in basal energy expenditure decline in physical activity Goal: 25 kcal/kg/day Macro nutrients Protein intake: 0.8-1.2 gm/kg/day (higher in patients with pressure ulcers) Carbohydrates: minimum of 130 g/day, 50% complex; 20-30 g of fiber Fat: less than 30% of total calories; less than 10% saturated Micronutrients: vitamins and minerals Water soluble vitamins Fat soluble vitamins NHANES 3 Baltimore Longitudinal Study of Aging Framingham There are very few studies comparing dietary intake of elderly to indications of their nutritional needs The recommended dietary allowances (RDA) have several limitations :they extrapolate from data of younger population and they do not address nutritional needs in disease, stressed states or polypharmacy effects Only a select number of vit will be mentioned here goodbye

NUTRITIONAL NEEDS IN THE ELDERLY hello NUTRITIONAL NEEDS IN THE ELDERLY Water-soluble vitamins Folate RDA 400µg/day No evidence of increased requirement in the elderly Low levels more common in elderly alcoholics (poor intake and decreased absorption) Risk for over-supplementation (>1mg) mask Vit B12 deficiency. Cyanocobalamine (B12) RDA 2.4 µg/day in adults>51y 10-15 % elderly have B12 deficiency (achlorhydria, antacid use, H.Pylori) Thiamine (B1) Mandatory enrichment of food ensures that the RDA is met. Low levels most common in elderly alcoholics (poor intake and decreased absorption) Folate: coenzyme for the metabolism of nucleic acids and amino acids. Its deficiency is associated with impaired cell division and protein synthesis B12: coenzyme essential for methyl transfers Thyamine key coenzyme in the metabolism of sugars by the pentose phosphate pathway its requirements depend on the caloric intake…..with the classic thiamine deficiency triad: confusion, ataxia and ophthalmoplegia characteristic of the Wernicke –Korsakoff syndrome…… And large proportion of elderly population suffer from alcoholism , so high suspicion for thiamine deficiency must be mantained Vitamin A important in the maintenance of normal dark-adapted vision and mucosal membranes; the deficiency causes night blindness, dry skin and dry mucous membranes goodbye

NUTRITIONAL NEEDS IN THE ELDERLY hello NUTRITIONAL NEEDS IN THE ELDERLY Fat-soluble vitamins Vitamin A: RDA 700 RE in women and 900 in men requirement does not increase with age; the clearance is reduced. Hypervitaminosis: significant toxicity with chronic ingestion (headaches, leukopenia, hypercalcemia, etc) Vitamin D : RDA>70 600-800 IU requirement increases with age due to reduced skin photosynthesis, reduced sun exposure, reduced absorption, reduced 1 hydroxylation of 25(OH)D Vitamin E: Deficiency is limited to cases of severe , long-standing fat malabsorption. Amount in diet is usually adequate. RE retinol equivalents goodbye

NUTRITIONAL NEEDS IN THE ELDERLY hello NUTRITIONAL NEEDS IN THE ELDERLY WATER : FORGOTTEN NUTRIENT Elder patients have Decreased thirst response Reduced concentration capacity by the kidneys Water needs 1 ml/kcal or 30ml/kg of body weight goodbye

PROTEIN AND ENERGY SUPPLEMENTATION hello PROTEIN AND ENERGY SUPPLEMENTATION Objective: to examine evidence from trials for improvement in nutritional status and clinical outcomes when extra protein and energy food were provided, usually in the form of commercial ‘sip-feeds’ Results: 31 trials with 2464 randomised participants were included in the review. Most studies were poor in quality. The RR indicated lower mortality in the supplemented group. Small weight gain The risk of complications (e.g. number of infections) showed no significant difference Little evidence of benefit to functional outcomes from individual studies Some indication of shorter length of stay for the supplemented groups (-3.4 days) Conclusions: Supplementation appears to produce a small but consistent weight gain. There was a statistical significant beneficial effect on mortality and a shorter length of hospital stay Milne et al Cochrane Database of Systematic Reviews. 1. 2005 goodbye

PROTEIN AND ENERGY SUPPLEMENTATION hello PROTEIN AND ENERGY SUPPLEMENTATION SAMPLE OF ORAL SUPPLEMENTS Boost plus High cal., high protein Carnation VHC 2.25 Very high cal., high protein Resource Diabetic Diabetic, high protein Enlive Clear liquid supplement NuBasics Fruit Bev. Clear liquid supplement Gatorade Clear liquid supplement Ensure pudding Consistency modified Benefiber Fiber supplement Procel Modular protein Thicken-up Powder thickener goodbye

WHEN TO CONSULT THE NUTRITIONIST? hello WHEN TO CONSULT THE NUTRITIONIST? Enteral/parenteral support Unintentional weight loss >5% N/V/D > 3 days Poor oral intake, <50% of meals >3 days Difficulties chewing, swallowing, aspiration precautions diet NPO>3 days Albumin<3.4 Wound/Pressure ulcer (any stage) Transplant patients Newly diagnosed or uncontrolled diabetic/CHF/ESRD. goodbye

PHARMACOLOGIC TREATMENT APPETITE STIMULANTS = OREXIGENIG AGENTS hello PHARMACOLOGIC TREATMENT APPETITE STIMULANTS = OREXIGENIG AGENTS MEGESTROL ACETATE DRONABINOL ANABOLIC AGENTS ANTIDEPRESSANTS GASTROPROKINETIC AGENTS OTHER EXPERIMENTAL DRUGS Morley, EM Clin Geriatr Med 2002;18:853-866 A number of drugs have been used to stimulate appetite and produce weight gain in older persons. Two agents are the most widely used to stimulate appetite: megestrol acetate and dronabinol. Others are also used with less frequency. What is the evidence of their effectiveness? goodbye

PHARMACOLOGIC TREATMENT hello PHARMACOLOGIC TREATMENT MEGESTROL ACETATE Progestational agent that produces an increase in food intake Mechanism unclear: alteration of CNS neurotransmitters involved in the regulation of food intake antagonizes cytokine production (potent anorectic agents) Weight gain has been reported in numerous patients with cancer-related anorexia and wasting Nelson et al J Clin Oncol 1994;12:213-225 Patients with AIDS reported increase caloric intake, weight gain and increased sense of well-being. Fat mass increased but there was no increase in body water or lean body mass Oster et al Ann Intern Med 1994;121:400-408 goodbye

PHARMACOLOGIC TREATMENT hello PHARMACOLOGIC TREATMENT MEGESTROL ACETATE (cont.) NH patients showed increased appetite, greater enjoyment of life, stronger sense of well being; statistical significant increase in body weight was shown only if medication was provided longer than 12 weeks. Yeh et al 2000; 48:485-492. Doses range from 80-800 mg/day. Consumer price: $4,750 per year for the 800 mg suspension Most common side effects include: thromboembolism, fluid retention, flushing, erectile dysfunction, vaginal bleeding, adrenal insufficiency, diabetes, decrease in testosterone levels goodbye

PHARMACOLOGIC TREATMENT hello PHARMACOLOGIC TREATMENT MEGESTROL ACETATE (cont.) Recommendations: Avoid M.A. in bed-bound patients – increased incidence of DVTs If the patient is scheduled for urgent surgery or has an infection during M.A. treatment (longer than 8-12 weeks) the patient should be given a stress dose of steroids Morley, EM Clin Geriatr Med 2002;18:853-866 Golden AG et al Am J of Therapeutics 2003;10:292-298. goodbye

PHARMACOLOGIC TREATMENT hello PHARMACOLOGIC TREATMENT DRONABINOL Cannabis was already used as an appetite stimulant in ancient Arabic medicine It increases the desire for food, improves taste, makes substances smell richer, decreases pain, and improves mood Effective appetite stimulant in patients with AIDS and cancer FDA approved as an appetite stimulant and antiemetic in HIV patients Doses used 2.5-20 mg/day (5-7.5 mg at hs for older demented patients) Major side effects include: delirium, abdominal pain, nausea, ataxia at high dose. Morley, EM Clin Geriatr Med 2002;18:853-866 active ingredient of cannabis is delta 9- tetrahydrocannabinol Dronabinol (Marinol) is the synthetic form goodbye

PHARMACOLOGIC TREATMENT hello PHARMACOLOGIC TREATMENT DRONABINOL One study in patients with Alzheimer’s disease (n=12) placebo-controlled cross-over design Int J Geriat Psychiatry 1997;12:913-919 Mean weight gain of 9.3lbs in the treated group vs. 6.3 lbs in the placebo group Treatment decreased severity of disturbed behavior Most common side effects noted: euphoria, somnolence and tiredness. One patient had a seizure. To limit the occurrence of delirium in older patients, Dronabinol should be given in the evening at a low starting dose of 2.5 mg. Appetite stimulation usually occurs at 5-7.5 mg dose. Morley, EM Clin Geriatr Med 2002;18:853-866 goodbye

PHARMACOLOGIC TREATMENT ANABOLIC AGENTS hello PHARMACOLOGIC TREATMENT ANABOLIC AGENTS Testosterone: replacement in older men increase muscle mass, decreases fat mass and increases bone mineral density. Higher Hct (>54%), leg edema, exacerbation of prostate cancer are major side effects. Sih et al J Clin Endocrinol Metab 1997;82:1661-1667 Anabolic steroids: oxandrolone, nandrolol have improved weight in AIDS patients. Liver toxicity, fluid retention and renal failure are major side effects. Romeyn & Gunn.JAMA 2000;284;176. Growth hormone and IGF-1 might be useful in treating severely ill, malnourished patients resulting in nitrogen retention and weight gain. Glucose intolerance/insulin resistance, peripheral edema, gynecomastia are major side effects Chu et el. J Clin Endocrinol Metab 2001;86:1913-1920. Glucocorticoids have been widely used in hospice patients. Improve appetite and mood but have minimal impact on weight gain or function goodbye

PHARMACOLOGIC TREATMENT hello PHARMACOLOGIC TREATMENT ANTIDEPRESSANTS: MIRTAZAPINE Depression is the most common treatable cause of anorexia and weight loss Some antidepressant are more orexigenic than others Mirtazapine enhances noradrenergic and serotoninergic neurotransmission. This combination suggests appetite-enhancing effects Halikas JA Hum Psychopharmacol 1995;10:S125-S133 Mirtazapine increases appetite and more weight gain than SSRIs Schatzberg et al Am J Geriatr Psychiatry 2002;10:541-550. It could be used as the antidepressant of choice for older depressed patients with weight loss There is no data of mirtazapine as a appetite stimulant in the elderly non-depressed patient. Golden AG et al Am J of Therapeutics 2003;10:292-298. goodbye

hello TO PEG OR NOT TO PEG “If a man be sensible and one fine morning, while he is lying in his bed, counts at the tips of his fingers how many things in this life truly will give him enjoyment, invariably he will find food is the first one” Lin Yutang Eating problems are a hallmark of end-stage dementia because the ability to eat independently is generally the last ADL to be lost prior to death. However patients with advanced dementia can live for a relatively long time despite poor oral intake. One theory posits that patients with advanced dementia have an altered state of homeostasis, characterized by a reduced metabolic rate and lower caloric requirements. Volicer L 2001, Clin Geriatr Med.;17(2):377-391 Chen J Wang SY Hoffer LJ goodbye

CAUSES OF EATING PROBLEMS IN ADVANCED DEMENTIA hello CAUSES OF EATING PROBLEMS IN ADVANCED DEMENTIA Oral dysphagia: absent or continuous chewing with tendency to pocket or spit food Pharyngeal dysphagia: delayed swallowing initiation, multiple swallows, and aspiration Loss of the ability to perform the task of eating Loss of the ability to interpret the sensation of hunger Disinterest in food due to depression Refusal to eat. Volicer L, Clin Geriatr Med. 2001;17(2):377-391 Langmore et al. Arch Neurol.2007; 64(1):58-62. goodbye

hello INDICATIONS The American Gastroenterological Association (AGA) endorses PEG tube placement for prolonged tube feeding (>30 days) when: The patient cannot or will not eat The gut is functional The patient can tolerate the placement of the device. For patients with severe dementia the decision to use or withhold artificial nutrition and hydration can be difficult. As the prevalence of dementia increases , this problem will arise with still greater frequency. Physicians in ACE units care for demented patients with eating problems. Artificial nutrition is considered in many of these patients using PEG tubes, that are often placed because of unrealistic and inaccurate expectations of what they can accomplish. Thus is very important that hospitalists understand the scientific and ethical issues surrounding the use of PEG tubes. Eating is usually the last ADL to become impaired indicating that the patient has entered the final stages of the illness. So, in this situation is PEG feeding beneficial? goodbye

hello SOME FACTS PEG tubes were introduced in 1979 to provide enteral nutrition in children and young adults In 2000 more than 216,000 PEG tubes were placed nationally most of them in older adults. PEG is the second leading indication for upper gastrointestinal tract endoscopy Dementia patients account for 30% of all PEG tubes placement One third of all NH patients are being tube fed Patient characteristics consistently associated with with a higher likelihood of being tube fed included: younger age, nonwhite race, and lack of advanced directives. Gauderer Gastrointest Endosc 1999;50:879-883. Cervo et al. Geriatrics 2005;61:30-35 Mitchell et al. 2003 JAMA 290(1):73-80 Mitchell et al 1997 Arch Intern Med ; 157(3):327-332. A randomized controlled trial of tube feeding in advanced dementia has not been conducted and would be difficult to justify ethically. Therefore it is impossible to definitely know the outcomes of this intervention. The highest quality data are derived from observational studies and limited by selection bias. Mitchell S 2007 JAMA 298(21):2527-2536 goodbye

Percutaneous Endoscopic Gastrostomy hello Percutaneous Endoscopic Gastrostomy Success rate: 95% Procedure-related morbidity: 9.4% Procedure related mortality: 0.53% Major complications: 1-3% cases Larson et al Gastroenterology 1987; 93:48-52 Wollman et al Radiology 1995;197:699-704 goodbye

Percutaneous Endoscopic Gastrostomy Complications hello Percutaneous Endoscopic Gastrostomy Complications Major Aspiration pneumonitis/pneumonia Peritonitis Hemorrhage: puncture of gastric wall vessel Buried bumper syndrome: migration of the tube into the gastric wall and epithelization of the ulcer site. Gastrocolocutaneous fistula Wound infection Necrotizing fasciitis Inadvertent removal of PEG tube Minor Tube leakage (58-78% of patients with long-term PEG) Tube blockage (16-31% during 18-month follow up) Potack & Chokhavatia, Medscape J Med. 2008; 10(6): 142. goodbye

PEG PLACEMENT IN PATIENTS WITH DEMENTIA hello PEG PLACEMENT IN PATIENTS WITH DEMENTIA Decision by physicians and caregivers to place a PEG tube is motivated by goals of: Provide nutrition and hydration Reduce risk of aspiration pneumonia Improve pressure ulcers Improving nutrition parameters Improve survival Facilitate transfer to LTC facilities Increase caregiver convenience Comply with LTC facilities policies goodbye

hello Which of the following reasons are true when evaluating the potential placement of a feeding tube in a severely demented patient: It will provide adequate nutrition It will prolong the patient’s life It will eliminate suffering It will prevent aspiration pneumonia It will improve skin integrity by increasing protein intake It will improve functional status and/or quality of life 1. Only a,c and e are true 2. Only b and f are true 3. Only a and d are true 4. All the statements are true 5. None of the statements are true ‘None of the statements are true’ (option 5) is the correct answer goodbye

SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) hello SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) Provide nutrition Nutritional markers (Hb, Alb, Cholesterol) have not shown improvement after PEG placement “Despite administration of apparently adequate formula, micronutrient deficiency exist in chronically-ill patients” (LTC) Tube feedings do not prevent the clinical consequences of malnutrition such as pressure ulcers Li et al Am Fam Physician 2002;65:1605-1610; Callahan et al J Am Geriatr Soc 2000;48:1048-54. Finucane et al JAMA 1999;282:1365-70 Finucane TE 1995 J Am Geriatr Soc. 43(4):447-451. Loss of appetite and dysphagia result in in abnormal markers for nutrition While these results may seem counterintuitive, as with other end-stage illnesses, people with advanced dementia may be too debilitated to demonstrate increased survival or nutrition benefits. goodbye

SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) hello SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) Prolongation of life Available data does not show survival advantage to PEG use Mortality during PEG tube placement ranges from 0-2% and peri-operative mortality ranges from 6-24% No difference in mortality rates among PEG vs. hand-fed demented patients In all patients fed by gastrostomy tube, there is an high initial mortality of 28% at 30 days. Patients with dementia have a worse prognosis, with 54% having died at 1 month and 90% at one year. Gillick MR N Engl J Med 2000;342:206-210 Finucane et al JAMA 1999;282:1365-70 Meier et al Arch Intern Med 2001;161:594-9 Sanders et al Amer J of Gastroenterol 2000 95(6):1472-1475. There is a perception that gastrostomy insertion is safe and simple. However, goodbye

SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) hello SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) Elimination of suffering There is no data to suggest that patient with end stage dementia suffer due to eating problems Studies from non-demented terminally ill patients with anorexia suggest no discomfort from these symptoms There is significant suffering due to surgical/wound-related issues: infection, bleeding, leakage, abscess, peritonitis increase use of restrains and subsequent pressure sores need for pharmacological sedation Electrolyte disturbance Aspiration pneumonia after placement increase urine and stool production, diarrhea or constipation, vomiting decrease contact with care-givers deprivation of the joy of eating Increased # of transfers to acute care facilities due to tube dislodgement or leakage. Finucane et al JAMA 1999; 282:1365-70 Callahan et al J Am Geriatr Soc 2000; 48:1048-54. Pek et al J Am Geriatr Soc 1990; 38(11):1195-1198 Physician autonomy in decision making about PEG tubes is manipulated by a variety of external forces (families, speech therapists, nurses, nutritionists, NH administrators) goodbye

SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) hello SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) Prevention of aspiration pneumonia There are no published studies suggesting that tube feeding reduces the risk of aspiration Tube feeding does not reduce the risk of aspiration from regurgitated gastric content or oral secretions. Gastrostomy tubes may reduce lower esophageal sphincter tone increasing the risk of GERD. Several case-controlled studies identified tube feeding as a risk factor for aspiration pneumonia with increased rate of pneumonia and death Prospective cohort with oropharingeal dysphagia: tube fed patients had more aspiration than orally fed The most common adverse effect associated with tube feeding is aspiration pneumonia (0%-66%) Finucane et al JAMA 1999;282:1365-70 Pick et al J Am Geriatr Soc 1996;44:763-768 Finucane et al Lancet 1996;348:1421-24. No randomized trials of the intervention have been done There are no studies showing improvement of function and feeding tubes are ineffective in the prevention or treatment of pressure ulcers goodbye

SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) hello SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) There are no studies showing improvement of function A retrospective study in NH patients showed no improvement in bladder or bowel function, mental status, speech, ADLs or ambulation during the 18 months after PEG tube placement. Feeding tubes are ineffective in the prevention or treatment of pressure ulcers There is positive correlation between pressure ulcers and long term tube feeding. Bedfast, incontinent, dementia patients are more likely to be restrained with increased risk for pressure ulcer formation Cervo et al. Geriatrics 2005;61:30-35 Finucane et al JAMA 1999;282:1365-70 goodbye

SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) hello SUGGESTED REASONS WHY PEG TUBE FEEDING MIGHT BE BENEFICIAL (cont.) PEG placement does not seem to improve quality of life in patients with end stage dementia: Questionnaire to caregivers 5 weeks after PEG placement: only 19% thought the QOL had improved McNabney et al J Am Geriatr Soc 1994;42:161-168 PEG placement has been associated with social isolation and denial of oral feeding Finucane et al JAMA 1999;282: 1365-1370 Increased agitation and use of restraints Peck et al J Am Geriatr Soc 1990;38:1195-1198. goodbye

Economic incentives/NH issues Path of less resistance State law hello BARRIERS TO LIMITING THE PRACTICE OF FEEDING TUBE PLACEMENT IN ADVANCED DEMENTIA Economic incentives/NH issues Path of less resistance State law Family concerns over starving Religious beliefs Lack of understanding of terminal nature of advanced dementia Physician’s beliefs goodbye

DECISION MAKING: NEW YORK STATE LAW hello DNR (in the event of cardiopulmonary arrest) Withholding or withdrawing life-sustaining treatment Artificial nutrition and hydration Patient with Capacity yes Health Care Proxy available (HCP) Only with clear and convincing evidence of patient’s wishes Surrogate (court-appointed guardian, spouse, adult child, parent, sibling or other relative or friend a. Terminal illness (<12 months) b. Permanently unconcious c. Resuscitation would impose an extraordinary burden d. Medical futility Patient w/o capacity, w/o HCP, no evidence or prior wishes Only if medically futile: documented by 2 physicians: “CPR will be unsuccessful in restoring cardiac and respiratory function or that the patient will experience repeat arrest in a short time period before death occurs” Use the following guidelines: a. Prolong life. Presume that the patient wants to be treated and to live as long as possible b. Do not initiate or continue ineffective treatment c. Do not do anything where the burden clearly exceeds the benefit d. Appropriate treat disstressing symptoms goodbye

hello BARRIERS TO LIMITING THE PRACTICE OF FEEDING TUBE (FT) PLACEMENT IN ADVANCED DEMENTIA Shega et al. J Pall. Med 2003;6:885-893 76.4% believe that FT reduce aspiration pneumonia 74.6% believe that FT improve pressure ulcer healing 61.4% believe that FT improves survival 93.7% believe that FT improves nutritional status 27.1% believe that FT improves functional status Most physicians underestimate 30-day mortality post FT placement 51% of the physicians believe that FT are the standard of care Most physicians believe that speech therapists, nurses and nutritional support teams recommend FT (70%), which influences their decision to recommend the FT (66%) and influence families about FT placement (95%) 47% had a NH request a FT placement and 65% thought that the HN concerns influenced their decision to recommend it The authors found and notable discord between physician opinion, reported practice and the literature regarding PEG tube placement in advanced dementia Survey of 416 eligible participants PCPs from the AMA Masterfile. 195 completed the survey (46.9%response rate)These are the results: goodbye

hello OBSTACLES TO ETHICAL DECISION MAKING Casarett et al N Engl J Med 2005;35324:2607-12 All clinicians should be better educated to engage patients and families in meaningful discussions State laws should allow the same standard of evidence of a patient’s preferences for decisions about artificial nutrition and hydration as they do for other decisions Attorneys, physicians and other health care providers should encourage and help patients to complete advanced directives including preferences on artificial hydration and nutrition Health care facilities should ensure that preferences are respected; information transfer between institutions should be optimized Decision making about artificial nutrition and hydration should be shielded from financial and regulatory pressures NH are reimbursed at higher rate for residents receiving TF Cost for the NH is less of the patient is receiving TF than feeding by hand. NH should not be cited when patient loses weight after deciding to withdraw ANH. goodbye

Suggested approach to counseling about PEG use in demented patients hello Suggested approach to counseling about PEG use in demented patients Educate decision makers that eating problems are a sign of the final stages of dementia. Families need to know that if the patient truly is no longer able to eat, this signifies the final phase of illness Determine if the patient’s wishes about artificial nutrition are known. Contact patient’s PCP or family members if necessary. Elicit specific decision-maker concerns about eating problems, identify issues to emphasize and misconceptions to correct when informing about risks, benefits, and alternatives. goodbye

hello Suggested approach to counseling about PEG use in demented patients (cont.) Inform about the risks of providing nutrition via PEG Inform about lack of evidence to support benefits Inform about alternatives: hand feeding, easy-to swallow high energy foods, elimination of sedating medications, improvement of dental hygiene, swallowing cues Recognize that if the PEG is pursued, it can be discontinued in the future if complications arise. goodbye

hello TAKE HOME MESSAGES Involuntary weight loss and malnutrition are prevalent in the frail elderly population Aging is associated with physiologic changes that contribute to decline in appetite and early satiety Work up for involuntary weight loss should include medical, functional, psychological as well as social factors Non-pharmacological treatment strategies are varied and usually successful Pharmacological appetite stimulants have not been well studied in this population In demented patients, PEG tubes have not been shown to have any objective benefits. goodbye

--- Remember: You don't stop laughing because you grow old, You hello --- Remember: You don't stop laughing because you grow old, You grow old because you stop laughing thanks. goodbye