Feeding tubes in patients with severe dementia

Patients with advanced dementia are among the most challenging patients to care for because they are often bedridden and dependent in all activities of daily living. Difficulty with eating is especially prominent and distresses family members and health care professionals. Health care professionals commonly rely on feeding tubes to supply nutrition to these severely demented patients. However, various studies have not shown use of feeding tubes to be effective in preventing malnutrition. Furthermore, they have not been demonstrated to prevent the occurrence or increase the healing of pressure sores, prevent aspiration pneumonia, provide comfort, improve functional status, or extend life. High complication rates, increased use of restraints, and other adverse effects further increase the burden of feeding tubes in severely demented patients. Feeding tubes should be avoided in many situations in which they are currently used. The preferable alternative to tube feeding is hand feeding. Though it may not be effective in preventing malnutrition and dehydration, hand feeding allows the maintenance of patient comfort and intimate patient care.     

Promoting good nutrition in patients with dementia

This article aims to raise awareness of good nutrition, the specific nutritional needs of individuals with dementia and the importance and implementation of protected mealtimes to prevent malnutrition in the hospital setting.     

Tackling dementia in patients with Parkinson's disease

Dementia more than one year after the onset of motor features associated with Parkinson's disease is defined as Parkinson's disease with dementia (PDD). If it develops within one year of the motor features, the term dementia with Lewy bodies (DLB) is used. Since clinical and pathological features are similar, it is generally accepted that both represent a continuum of the same disorder. PDD together with DLB account for around one fifth of all cases of dementia in the elderly. Studies suggest that most patients with Parkinson's disease would eventually develop dementia if they lived long enough. The diagnosis of PDD in the presence of long-standing pronounced motor features rarely poses a diagnostic dilemma. However, the diagnosis of DLB may be more difficult. It relies on the revised consensus clinical criteria which require the presence of at least two of the following three syndromes: persistent visual hallucinations, fluctuating defects in cognitive and functional ability, and parkinsonism. An early referral to a specialist clinic may not only help to confirm the diagnosis, but also to co-ordinate the group of professionals working with the patient. Well lit rooms and the use of glasses and hearing aids can help to reduce hallucinations. Cholinesterase inhibitors used in Alzheimer's disease have a role in DLB and PDD. Trials show moderate improvements in cognitive function in patients treated with rivastigmine. The greatest impact, however, seems to be on the psychotic features of the disease. Patients with DLB are less likely to have a good motor response from L-dopa than patients with Parkinson's disease or PDD.     

Understanding challenging behaviour in patients with dementia

The fifth and final article in the series on patients with dementia in acute care examines challenging behaviour. Hospital admission, combined with unfamiliar surroundings and memory problems, can be frightening and disorientating for those with dementia. This can lead to behaviour which is perceived as 'disruptive' or 'difficult'. Aspects of the hospital environment or care practice can contribute to problems that may be misinterpreted and lead to challenging behaviour. Staff should seek to understand the cause of challenging behaviour, assess the possible causes and use strategies to reinforce familiarity and minimise distress for these patients.     

Managing pain in patients with dementia in hospital

This is the fourth article in a series of five on dementia. Pain experienced by people with dementia is often poorly managed. Chronic pain can lead to further cognitive impairment, accidents and behavioural problems which can be minimised if the pain is properly assessed and managed. Patients with dementia receive fewer analgesics than any other patient group, but the likelihood of pain in this group is as high as in other older people. This article discusses the role of nurses in identifying and treating pain in patients with dementia. Approaches to assessment for improved detection and treatment of pain are outlined.     

End-of-life care for patients with dementia

Studies have shown that people with dementia receive sub-optimal end-of-life care (McCarthy et al, 1997; Morrison and Siu 2000; Mitchell et al, 2004). The National Institute of Clinical Excellence (NICE) and the National Council for Palliative Care (NCPC) have highlighted the importance of palliative care for people with dementia (NICE 2006; NCPC 2007). This article explores the palliative care needs of older people with dementia and considers how they may be addressed.     

Hospice care for patients with dementia

Dementia is a leading cause of death in the USA. Although guidelines exist to determine hospice eligibility for dementia, only a small percentage of patients dying with this condition receive hospice care. Hospice recipients with dementia have not been well characterized, and little is known about the quality of care they receive. The Family Evaluation of Hospice Care (FEHC) survey was adopted by the National Hospice and Palliative Care Organization (NHPCO) in 2003 as a standard benchmarking tool. The FEHC collects data from bereaved families regarding the quality of hospice care. An online repository of 2005 FEHC data was used to describe hospice recipients over 65 years of age who died with dementia and to examine their families' evaluation of hospice care. Decedents with cancer and chronic terminal conditions were also analyzed for comparison purposes. A total of 77,123 surveys submitted by 796 hospices nationwide met the study's eligibility criteria. Decedent diagnoses were as follows: dementia, n=8,686 (11.3%); cancer, n=35,693 (46.3%); and other chronic diseases, n=32,744 (42.4%). Decedents with dementia were more likely to be >85 years, female, and have length of stays >180 days. Evaluation of care in all FEHC domains did not significantly differ between groups. Approximately three-quarters of bereaved family members of decedents in all groups perceived the overall quality of care as excellent; however, opportunities to improve care were also identified. These data suggest that the evaluation of hospice care for older patients is generally high, and does not vary with respect to terminal diagnoses.     

Communicating with patients who have dementia

It was not until the 1980s that significant research was carried out on brain disorders. Lack of understanding of dementia has perhaps been the reason for the over-emphasis on physical care, and a failure to see these patients as people with feelings, beliefs and values. Three therapeutic techniques to help practitioners increase and improve communication with people who have dementia are described. It may be that communication is the key to understanding and resolving behaviour disturbances.     

Strategies for feeding patients with dementia

OVERVIEW: Despite the high prevalence of dementia among elderly patients in hospitals and nursing homes and the strong association between dementia and feeding difficulty, few sources adequately address effective feeding interventions. Basing their discussion on the conceptual model that grew out of a previously published systematic literature review, the authors address a wide range of assessment and intervention practices specific to various observed behaviors that may aid in feeding patients with dementia.     

Pain assessment in elderly patients with severe dementia

The purpose of this study was to assess the reliability and validity of facial expressions as pain indicators in patients with severe dementia. Based on interviews with patients who could report pain, we defined characteristics of decubitus ulcers associated with reports of pain during dressing changes. We then evaluated 9 patients who had ulcers with these characteristics but were unable to communicate verbally because of severe dementia. We videotaped their facial expressions before and during their decubitus ulcer dressing change. We showed the videotape segments, in random order, to 8 medical students and 10 nurses. The 18 viewers were asked to infer the presence or absence of pain based on their observations of the patients' facial expressions and vocalizations. The dressing change of decubitus ulcers extending beyond the subcutaneous tissue, covering an area of at least 9 cm(2), and with a moist surface, was always reported as painful by study patients able to report (95% confidence interval of 69-100%). The intraclass correlation coefficient for the answers of the 18 viewers evaluating each videotape segment for the presence of pain was 0.64. Sensitivity, specificity, and positive and negative predictive values of viewers' ratings of facial expressions and vocalizations as a measure of the presence of pain were: 0.70, 0.83, 0.90, and 0.81. The intraclass correlation coefficient for the answers rating pain intensity was only 0.10, indicating only slight agreement beyond chance. Assuming dressing changes of ulcers reported as painful by communicative patients are also painful in non-verbal severely demented patients, clinician observations of facial expressions and vocalizations are accurate means for assessing the presence of pain, but not its intensity, in patients unable to communicate verbally because of advanced dementia.     

Selegiline versus oxiracetam in patients with Alzheimer-type dementia

The efficacy and tolerability of the monoamine oxidase B inhibitor selegiline and of the nootropic agent oxiracetam were compared in a single-blind, controlled, parallel study. The trial involved 22 men and 18 women with mild-to-moderate senile and presenile dementia of the Alzheimer type. The treatments were administered for 90 consecutive days as follows: one 10-mg selegiline tablet once daily and one 800-mg oxiracetam tablet twice daily. Efficacy was evaluated by means of a complex battery of neuropsychological tests, administered monthly for three months, starting from baseline. Safety was evaluated by monitoring adverse drug reactions as well as any pathological changes in hematology, blood chemistry, or liver and kidney function, measured at baseline and again at the conclusion of the study. Analysis of the results demonstrates that, at the dosage used, selegiline is more effective than oxiracetam in improving higher cognitive functions and reducing impairment in daily living. In particular, short- and long-term memory, sustained concentration, attention, verbal fluency, and visuospatial abilities were, for the most part, positively affected by selegiline. Gastroenteric and systemic tolerability of both drugs was also very good.