P rognosis
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P rognosis. Life expectancy from the time of diagnosis: Alzheimer Disease 5-10 years Vascular Dementia 4 years Dementia with Lewy Bodies 4 years. What is an advance directive??. DNR Living will DPOA HC. W eight loss. Anorexia and Weight Loss. Common in patients with dementia

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P rognosis

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P rognosis

Prognosis

  • Life expectancy from the time of diagnosis:

    • Alzheimer Disease 5-10 years

    • Vascular Dementia 4 years

    • Dementia with Lewy Bodies 4 years


What is an advance directive

What is an advance directive??

DNR

Living will

DPOA HC


W eight loss

Weight loss


Anorexia and weight loss

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 (espACh-I, Antidepressants)

    • Inflammatory abnormalities (anorexia, procatabolic state)

Wang et al, J Neurol 2004, 251:314-320; Aziz NA et al, J Neurol 2008


P rognosis

  • 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, 251:314-320


P rognosis

  • 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


Strategies

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


Strategies1

Strategies

Food Modifications

  • 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


Limited data on pharmacologic strategies

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


Feeding tubes

Feeding tubes

When are they

appropriate?


Improved survival

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

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


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