1. Prognosis Life expectancy from the time of diagnosis:
Alzheimer Disease years
Vascular Dementia 4 years
Dementia with Lewy Bodies 4 years

2. 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

3. Weight loss

4. 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: ; Aziz NA et al, J Neurol 2008 4 4

5. 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: 5 5

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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