Blogs to Boards: Question 12a

Mrs. A is an 88 year old with advanced dementia who lives in a nursing home.  She has at baseline some difficulty with eating as she pockets food in her mouth and occasionally coughs after swallowing.  She is now hospitalized for an aspiration pneumonia.  In addition to the antibiotics she is on in the hospital, her only other medications include HCTZ for hypertension and a baby aspirin.  She has never taken a cholinesterase inhibitor.

What is the best next step?

  1. A trial of both a cholinesterase inhibitors and memantine
  2. Feeding tube insertion
  3. Careful hand feeding and good oral care
  4. Addition of olanzapine to treat her pocketing of food behavior

Discussion: Correct answer is (c)

  1. Acetylcholinesterase  inhibitors, such as donepezil, galantamine, and rivastigmine, and the N-methyl-D-aspartate  (NMDA) antagonist memantine have some evidence for a statistically significant improvement in cognitive, functional, and behavioral outcomes in indivudals with moderate-to-severe  dementia. However, these improvements have marginal clinical significance.  Adverse events are common with these agents, most commonly nausea, vomiting, and diarrhea.  There is no evidence to suggest that they decrease eating problems or risk for aspirations.
  2. Placement of PEG tubes often occur after transfer to an acute care facility for eating problems or pneumonia, despite the fact that feeding tubes have not been shown to improve survival for individuals with dementia.  There is also no evidence that tube feeding prevents aspiration pneumonia, decreases the risk for pressure ulcers, improves patient comfort, or prolongs life.
  3. Oral care has been shown to decrease incidence of pneumonia, number of febrile days, and death from pneumonia in nursing home residents.
  4. Antipsychotics have not been shown to improve eating behaviors in dementia.  There is a moderate short-term efficacy when treating agitation, serious side effects that include risk of stroke and death limit their clinical use.

References:

  • http://www.geripal.org/2011/07/decisions-on-feeding-tubes-in-advanced.html
  • Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. Oct 13 1999;282(14):1365-1370.
  • Yoneyama T, Yoshida M, Ohrui T, et al. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc. Mar 2002;50(3):430-433.
  • Schneider LS, Tariot PN, Dagerman KS, et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease. N Engl J Med. Oct 12 2006;355(15):1525-1538