An 88-year-old nursing home resident is admitted to the hospital for fever and confusion. She was recently discharged after an episode of aspiration pneumonia, which entailed a prolonged and complicated hospitalization course. She has lost 20 lbs (9 kg) over the past 6 months. She suffers from dementia and requires constant assistance with her activities of daily living. She frequently does not recognize her caregivers and is regularly found to be incontinent of urine and stool. Her other medical problems include hypertension, atrial fibrillation, type 2 diabetes mellitus, and mild residual left-sided hemiparesis from a previous ischemic stroke.
Her temperature is 38.3 C (101 F) , blood pressure is 144/87 mm Hg, pulse is 92/min, and oxygen saturation is 92% on 2 L/min O₂ via nasal canula. Her BMI is 18.5 kg/m². Examination reveals dry mucous membranes. Coarse rhonchi are heard over the right lower lung. She has a stage 3 coccygeal pressure ulcer.
Blood cultures are sent and she is started on broad-spectrum antibiotics. Her daughter inquires about nutritional support because her mother is losing weight and "needs to get stronger to fight this infection."
Which of the following statements would best address the daughter's concerns?

Question

Quizplus · Accepted Answer

Unfortunately, failure to thrive and malnutrition may be inevitable in patients with advanced dementia due to the terminal nature of the disease. It has been surmised that tube feedings may provide adequate nutrition and hydration in these patients, possibly improving functional status and survival. In fact, it is estimated that approximately 30% of all PEG tubes are placed in patients with dementia. Unfortunately, feeding tubes have not been demonstrated to prolong survival in patients with dementia, nor have they been shown to provide comfort, afford adequate nutrition, or prevent pressure ulcers or aspiration pneumonia. In addition, there can be complications with feeding tube placement (e.g., cellulitis, leakage, ileus), and feeding tubes are associated with worsening of urine and fecal incontinence, increased oral and pulmonary secretions, and gastroesophageal reflux. These can increase the risk of aspiration pneumonia and pressure ulcer infection (Choices A and C). Instead of placing feeding tubes, caretakers should be encouraged to hand-feed patients if possible and maintain aspiration precautions (e.g., upright while eating, small boluses, restricting thin liquids). The patient's oral intake should be stimulated by providing favorite foods and by varying flavors, amounts, consistencies, and increasing the availability of food. If this fails or is not feasible, caretakers and their families should be made aware that advanced dementia is a terminal disease and that there should be realistic goals for PEG feeding (e.g., hydration, nutrition, and/or medications for comfort care) and not to expect improvements in functional status or survival. (Choice D) Thin liquids are the easiest to aspirate, and restricting liquids to thickened liquids is necessary in all patients at risk for aspiration. Solid foods do not need to be avoided, but they should be soft and easy to chew (e.g., mashed potatoes). High-calorie supplements (solids or liquids) can help patients gain weight, but they are still unlikely to improve functional outcome or prolong life. (Choice E) There is little evidence that appetite stimulants (e.g., megestrol acetate) can promote weight gain in patients with severe dementia. Educational objective: Feeding tubes have not been demonstrated to provide adequate nutrition, prevent pressure ulcers or aspiration pneumonia, afford comfort, improve functional status, or prolong life in patients with advanced dementia. __________ References: Feeding tubes in patients with severe dementia. (http://www.ncbi.nlm.nih.gov/pubmed/11989637)

An 88-Year-Old Nursing Home Resident Is Admitted to the Hospital