Download involuntary weight loss in the elderly

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
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.
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.
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; 30:671674.
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 mildmoderate AD White et al J Am Geriatr Soc 1996;44:265-272
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.
CAUSES OF WEIGHT LOSS IN THE ELDERLY
_____________________________________________
• REVERSIBLE
• Assessment
• Diagnosis
• Treatment
• IRREVERSIBLE
•
•
•
•
•
Frustrating
Painful
Emotionally draining
Expensive
Fruitless
CAUSES OF WEIGHT LOSS IN THE ELDELY
_____________________________________________
•
•
•
•
•
PHYSIOLOGICAL
MEDICAL
FUNCTIONAL
PSYCHOLOGICAL
SOCIAL
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.
CAUSES OF WEIGHT LOSS IN THE ELDELY
PHYSIOLOGICAL FACTORS
ANOREXIA IN AGING
Hays and Roberts Phys and Behavior 2006; 88:257-266.
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
MEDICATION SIDE EFFECTS THAT CAN
CONTRIBUTE TO WEIGHT LOSS
Side effect
Drug
Anorexia
Antibiotics, anticonvulsants, digoxin,
Dry mouth
Anticholinergics, antihistamines,
diuretics, clonidine
Dysgeusia/dysosmia
ACEI, antibiotics, anticholinergics,
calcium channel blockers, etc.
Nausea/vomiting
Antibiotics, digoxin, hormone
replacement, iron, potassium,
SSRIs, statins, etc.
Carr-Lopez et al.Drugs Aging 1996;9:221-5
metformin, SSRIs,etc.
CAUSES OF WEIGHT LOSS IN THE ELDELY
FUNCTIONAL CAUSES
•
•
•
•
•
•
•
Immobility
Arthritis
Stroke
Parkinson’s
Dental
Vision
Hearing
CAUSES OF WEIGHT LOSS IN THE ELDELY
PSYCHIATRIC/PSYCHOLOGICAL CAUSES
•
•
•
•
•
•
•
Depression
Psychosis
Grief/Bereavement
Intentional
Alcoholism
Dementia
Anorexia nervosa/anorexia tardive
CAUSES OF WEIGHT LOSS IN THE ELDELY
SOCIAL CAUSES
•
•
•
•
•
Poverty
Isolation
Neglect
Abuse
Caregiver fatigue
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
TREATMENT
_____________________________________
• NON-PHARMACOLOGIC
• PHARMACOLOGIC
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
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
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)
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.
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
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
PROTEIN AND ENERGY SUPPLEMENTATION
SAMPLE OF ORAL SUPPLEMENTS
Boost plus
Carnation VHC 2.25
Resource Diabetic
Enlive
NuBasics Fruit Bev.
Gatorade
Ensure pudding
Benefiber
Procel
Thicken-up
High cal., high protein
Very high cal., high protein
Diabetic, high protein
Clear liquid supplement
Clear liquid supplement
Clear liquid supplement
Consistency modified
Fiber supplement
Modular protein
Powder thickener
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.
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
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 cancerrelated 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
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
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.
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
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
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
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 appetiteenhancing 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.
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
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.
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.
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.
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
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.
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
o Facilitate transfer to LTC facilities
o Increase caregiver convenience
o Comply with LTC facilities policies
Which of the following reasons are true when evaluating the potential
placement of a feeding tube in a severely demented patient:
a
b
c
d
e
f
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
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.
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 perioperative 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.
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
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.
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
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.
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
DECISION MAKING: NEW YORK STATE LAW
DNR (in the event of
cardiopulmonary arrest)
Withholding or withdrawing
life-sustaining treatment
Patient with Capacity
yes
yes
Health Care Proxy
available (HCP)
yes
yes
Artificial nutrition and
hydration
yes
Only with clear and
convincing evidence of
patient’s wishes
Surrogate (courtappointed 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
Only with clear and
convincing evidence of
patient’s wishes
Only with clear and
convincing evidence of
patient’s wishes
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
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
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
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
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.
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.
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.
--- Remember: You don't stop
laughing because you grow old, You
grow old because you stop laughing
thanks.