Advanced Dementia and Feeding Tubes: Do Physician Factors Contribute to State Variation?

To the Editor: We have read with interest the article by Keller et al. on the prevention of weight loss in demented patients living in special care units (SCUs). Results show that body weight can be maintained in demented patients living in SCUs, where malnutrition is a frequent condition. We would like to contribute to the discussion with our own data, obtained from a prospective observational study of demented patients living in two SCUs. We determined the prevalence of malnutrition through biochemical and anthropometric data, evaluating nutritional changes with 6 and 18 months of follow-up after a nutritional intervention program. Study was performed on 40 elderly residents in SCUs (part of the Alzheimer Care Plan of Regione Lombardia, Italy); 31 were affected by Alzheimer’s disease (AD), four had vascular dementia (VD), four had mixed AD-VD, and one had Lewy Body disease. Patients were mainly female (72%), with severe cognitive impairment (mean Mini-Mental State Examination score standard deviation55.1 5.9), moderate to severe behavioral disturbances (neuropsychiatric inventory535.7 15.3), and functional impairment (Barthel Index, activities of daily living5 45.9 22.3); they were affected by multiple comorbid diseases (number of diseases54.9 2.9, burden of disease57.4 2.9) and experienced clinical adverse events the year before the study (number of infections52.3 1.6). A low number of neuroleptic drugs and antidepressants was prescribed (0.5 0.5 and 0.7 0.5, respectively), with behavioral interventions preferred over pharmacological treatment of behavioral and psychological symptoms of dementia. Nutritional status was analyzed using anthropometric (weight, body mass index) and biochemical (albumin, transferrin (total iron body capacity (TIBC)), cholesterol, and hemoglobin serum levels) indexes. An albumin level of 3.5 g/dL was used as the cutoff for malnutrition, as previously done in another study. To understand the characteristics of feeding difficulties, the Eating Behavioral Scale was introduced (range 0–18). This scale includes variables potentially influencing feeding, such as the ability to begin the meal and keep attention on food, the use of a knife, and the ability to chew and swallow without difficulty. Higher scores indicate greater levels of independence. Dental status, feeding time, and percentage of food eaten were also assessed for each patient (visual staff evaluation). At the beginning of the study, 19 of 40 patients (47.5%) were judged to be malnourished. Those patients underwent a nutritional program that consisted of modifications of diet composition and quality and consistency of food based on a patient’s preferences or ability to chew, swallowing difficulties, and dental status (soft diets). Time spent by nurses for feeding was increased, as was help feeding, ranging from stimulation to supervision to assisted feeding. Environmental modifications were performed to find the most comfortable place for each patient. Finally, nutritional supplements were prescribed for patients whose daily caloric intake was low (hypercaloric and hyperproteic diets). Nutritional oral supplement prescription was reviewed monthly. Nutritional parameters were assessed at 6 and 18 months of follow-up. After a 6-month intervention trial, the number of malnourished patients fell to 10 (25%). Baseline malnourished patients had a statistically significant improvement of albumin levels and a trend, still not significant, toward improvement of other nutritional parameters: cholesterol, TIBC, and hemoglobin (Table 1). Weight and body mass index did not show significant changes. At 18 months of follow-up, data confirmed the previous evaluation by showing a substantial stability in albumin levels. Similar results were obtained for TIBC and cholesterol, whereas body weight did not change significantly (Table 1). Survival rates at 18 months of follow-up were not different from those reported in the study by Keller et al.