Strategies for Improving Care for Patients with Advanced Dementia and Eating Problems (full title below)
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Strategies for Improving Care for Patients with Advanced Dementia and Eating Problems: Optimizing Care Through Physician and Speech Pathologist Collaboration
Problems with eating, swallowing, and poor caloric intake are common in patients with advanced dementia and often develop during an acute medical event when the immediate prognosis is unclear.1 For healthcare professionals, managing a patient with advanced dementia and swallowing problems and guiding caregivers through a process of decision making present enormous clinical challenges and require an interdisciplinary approach in order to provide optimal care. We present a pragmatic approach to managing eating and swallowing problems in persons with advanced dementia, emphasizing the importance of accurate clinical assessment, and effective communication and collaboration between physician(s), speech pathologist, other interdisciplinary team members, and family caregivers.
Dementia Progression and Eating Problems
As cortical function deteriorates with the progression of dementia, the patient’s ability to obtain adequate nutrition decreases. Some manifestations of this decline include impairment in independent use of utensils due to apraxia, food refusal, failure to recognize food or to understand the feeder’s approach due to agnosia, motoric impairment in chewing and swallowing, and weight loss. A survey of 71 residents of a Dementia Special Care Unit found that only 24% of residents were able to eat independently, 18% were hand-fed without any problem, but 58% had significant eating difficulties. These difficulties included isolated feeding refusal in 26%, isolated choking on food in 7%, and combination of feeding refusal and choking in 25% (Figure).2
Despite apraxia, many individuals can still feed themselves in the moderate stages of dementia by eating finger foods. With progression of dementia, patients ultimately become unable to eat or drink without assistance. In advanced dementia, patients may be unable or unwilling to open their mouths3 and may lose weight.
Clinical Evaluation
It is useful to consider problems with eating or swallowing as a clinical syndrome that triggers a medical assessment and work-up. Many contributing factors are potentially reversible, and thus warrant a careful search for causes that can be treated or managed.
Medical History
Concerns often arise from those involved with caring for and observing the patient at the bedside, including nursing staff, nursing assistants, or family members. History should be obtained from all current and previous caregivers familiar with the patient’s feeding behavior. A clear understanding of the patient’s baseline medical problems, functional status, mental status and stage of dementia, and baseline eating status should emerge, and is essential in assessing current eating problems. Vital information includes the timeframe of the eating problem, its nature (eg, coughing, choking, pocketing of food in mouth, resisting food), any attempts made to improve eating, and all coexisting acute medical issues. Descriptions of the patient’s baseline food consistencies, food preferences including ethnic foods, degree of independence in eating, and size and frequency of meals during the day are also essential.
A complete review of the patient’s medications is also indicated. Symptoms such as nausea or early satiety may manifest as poor oral intake in a patient with dementia, and medications are often a culprit. Older adults are particularly sensitive to many anticholinergic effects such as dry mouth or confusion, which may manifest as problems with eating. Removing an offending medication may offer a simple solution to the eating problem.
Target weight for those with advanced dementia should take into consideration functional impairment.
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