CHAMPCHAMPDementia in the Hospitalized Dementia in the Hospitalized Older AdultOlder Adult

Caroline Harada, M.D.Caroline Harada, M.D.

University of ChicagoUniversity of Chicago

OutlineOutline

• Dementia 101Dementia 101• 2 topics you can teach:2 topics you can teach:

– Decision making capacityDecision making capacity– Tube feedingTube feeding

ObjectivesObjectives

Learners will:Learners will:• Be familiar with the diagnostic criteria for Be familiar with the diagnostic criteria for

dementia dementia • Understand the steps in assessing decision Understand the steps in assessing decision

making capacity making capacity • Feel ready to teach the basics of decision Feel ready to teach the basics of decision

making capacity on the wardsmaking capacity on the wards• Be able to teach others the arguments for Be able to teach others the arguments for

why tube feeding not useful in end stage why tube feeding not useful in end stage dementiadementia

Dementia 101: Dementia 101: Facts you can use on the wardsFacts you can use on the wards

Dementia is commonDementia is common

• Prevalence in general populationPrevalence in general population– 4 million currently; 14-16 million by 4 million currently; 14-16 million by

20502050– Affects 5-10% of people over 65Affects 5-10% of people over 65– May affect up to 50% of people over May affect up to 50% of people over

age 85age 85

Kennedy GJ. Geriatric Medicine, an Evidence Based Approach, 2003.

Dementia is commonly Dementia is commonly overlookedoverlooked

• Dementia is often not mentioned in Dementia is often not mentioned in the medical record of patients with the medical record of patients with dementiadementia– 64% overlooked in Canadian Study of 64% overlooked in Canadian Study of

Health and AgingHealth and Aging– 79% overlooked in Indiana study79% overlooked in Indiana study

• 40% of vulnerable elders in ACOVE 40% of vulnerable elders in ACOVE had cognition assessed at allhad cognition assessed at all

Sternberg SA et al. JAGS, 2000

Boustani M. et al. JGIM, 2005

When to suspect dementia? When to suspect dementia?

If you suspect dementia…If you suspect dementia…

ScreeningScreening• MMSEMMSE• MiniCogMiniCog

DiagnosisDiagnosis• Diagnostic criteriaDiagnostic criteria

Diagnostic criteriaDiagnostic criteria

Rule out delirium & psychiatric disordersRule out delirium & psychiatric disorders

Two of five domains impaired: Two of five domains impaired: • MemoryMemory• LanguageLanguage• Visuospatial (Spatial ability /orientation Visuospatial (Spatial ability /orientation

/agnosia)/agnosia)• Handling complex tasksHandling complex tasks• Judgment/reasoningJudgment/reasoning

Decline from cognitive baselineDecline from cognitive baseline

Decline in function Decline in function Diagnostic and Statistical Manual of Mental Disorders- 4th edition, 1994.

Executive functionExecutive function

PrognosisPrognosis

Average life expectancy Average life expectancy

from time of diagnosis:from time of diagnosis:

6 years6 years

Knopman DS et al. Mayo Clin Proc, 2003.

PrognosisPrognosis

Comparison of Life Expectancy by Quartiles (Men age 70)

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Comparison of Life Expectancy by Quartiles (Women age 70)

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Why does dementia matter in an Why does dementia matter in an inpatient hospitalization? inpatient hospitalization?

• Affects other diseasesAffects other diseases• Bounce backs (d/c planning)Bounce backs (d/c planning)• Capacity for decision makingCapacity for decision making• DeliriumDelirium• End of life issuesEnd of life issues

A B C D E

Brauner DJ et al. JAMA, 2000.

Decision Making CapacityDecision Making Capacity

Karlawish JHT & Pearlman RA. Geriatric Medicine, an Evidence Based Approach, 2003.

Competence vs. Competence vs. CapacityCapacity

CapacityCapacity

• Task specificTask specific• Sliding scale Sliding scale • DynamicDynamic• Dementia does not have to Dementia does not have to

mean lack of decision making mean lack of decision making capacitycapacity

• 90 million adults have fair to 90 million adults have fair to poor literacypoor literacy

Drane JF. JAMA 1984; Safeer RS & Keenan J. Am Fam Physician, 2005

Key StepsKey Steps

• See what the patient already knowsSee what the patient already knows• Provide all the information neededProvide all the information needed• Give a recommendation (if Give a recommendation (if

appropriate)appropriate)• Ask the patient to reiterateAsk the patient to reiterate

Key information to provide: Key information to provide:

• Medical condition and prognosisMedical condition and prognosis• Recommended interventions and Recommended interventions and

alternatives (including no alternatives (including no intervention)intervention)

• Risks and benefits of the optionsRisks and benefits of the options• Consequences of decisionConsequences of decision

Geriatrics at Your Fingertips, Online Edition. (accessed January 9 2006).

How to determine DMC:How to determine DMC:

• Ask the patient to rephrase:Ask the patient to rephrase:– ““Tell me in your own words…”Tell me in your own words…”– ““What are the alternatives?”What are the alternatives?”– ““What are the risks of that What are the risks of that

intervention?intervention?– ““What would happen without this What would happen without this

procedure?”procedure?”

Appelbaum PS, Grisso T. N Engl J Med 1988

Appelbaum PS, Grisso T. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. 1998.

• Iterative process: Iterative process: – If they don’t get it, correct or explain, If they don’t get it, correct or explain,

then ask the patient to re-rephrasethen ask the patient to re-rephrase

• Optimize the circumstances Optimize the circumstances – Reduce stressors, distractionsReduce stressors, distractions– Treat delirium, depression, painTreat delirium, depression, pain– Optimize time of dayOptimize time of day

Appelbaum PS, Grisso T. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. 1998.

Formal standardsFormal standards

• Ability to communicate a choiceAbility to communicate a choice– Unimpaired level of consciousness, willingness to Unimpaired level of consciousness, willingness to

express a choice, reasonable stability of choiceexpress a choice, reasonable stability of choice

• Ability to understand (and retain) relevant Ability to understand (and retain) relevant informationinformation

– Patient can recapitulate: current condition, plans being Patient can recapitulate: current condition, plans being discussed, potential consequences of the various discussed, potential consequences of the various optionsoptions

• Ability to appreciate the situation and Ability to appreciate the situation and consequences of a decision consequences of a decision for oneselffor oneself

– Patient acknowledges illness (when present) & general Patient acknowledges illness (when present) & general probabilities of risks and benefits as they apply to him probabilities of risks and benefits as they apply to him or herselfor herself

• Ability to manipulate information rationallyAbility to manipulate information rationally– Patient reaches conclusions that are logically consistent Patient reaches conclusions that are logically consistent

with the starting premiseswith the starting premises

Appelbaum PS, Grisso T. N Engl J Med 1988, 319(25), 1635-1638.

Role Play: a DMC ConversationRole Play: a DMC Conversation

Why does dementia matter in an Why does dementia matter in an inpatient hospitalization? inpatient hospitalization?

• Affects other diseasesAffects other diseases• Bounce backs (d/c planning)Bounce backs (d/c planning)• Capacity for decision makingCapacity for decision making• DeliriumDelirium• End of life issuesEnd of life issues

A B C D E

Tube Feeding in End-stage Tube Feeding in End-stage DementiaDementia

Not eating? Not eating?

• Anorexia vs Anorexia vs

dysphagia vs dysphagia vs

agnosia/apraxia vsagnosia/apraxia vs

agitationagitation

• Acute vs ChronicAcute vs Chronic– acute (then can treat underlying cause?)acute (then can treat underlying cause?)– chronic (due to dementia itself?)chronic (due to dementia itself?)

FAST stagesFAST stages

©1984 by Barry Reisberg, M.D. All rights reserved.Reisberg, B. Functional Assessment Staging (FAST). Psychopharmacology Bulletin. 1988:24: 653-659.                     

1.1. No difficultiesNo difficulties2.2. Subjective complaints Subjective complaints 3.3. Decreased job functioning Decreased job functioning 4.4. Needs assistance with IADLs Needs assistance with IADLs 5.5. Requires assistance in choosing Requires assistance in choosing

proper clothing to wear for the dayproper clothing to wear for the day6.6. Needs assistance with ADLsNeeds assistance with ADLs7.7. Stops talking, walking, sitting, Stops talking, walking, sitting,

smilingsmiling

Why put in a tube? Why put in a tube?

Prevent aspiration? Prevent aspiration?

• No study has shown decrease in risk of No study has shown decrease in risk of aspiration pneumonia from PEG placementaspiration pneumonia from PEG placement

• Doesn’t prevent aspiration of oral Doesn’t prevent aspiration of oral secretionssecretions

• Refluxed gastric contents can still be Refluxed gastric contents can still be aspiratedaspirated– Enteral feeding may increase risk of aspiration Enteral feeding may increase risk of aspiration

(data mixed)(data mixed)– LES pressure is decreased in tube fed patientsLES pressure is decreased in tube fed patients– J tubes may not be better than G tubesJ tubes may not be better than G tubes

Finucane TE. JAMA, 1999; Dharmarajan TS. Am J Gastroenterology, 2001

Improved Survival?Improved Survival?

• Observational studies:Observational studies:– NH patients show no survival advantage with NH patients show no survival advantage with

tube feedingtube feeding– 1 retrospective review of 41 consults for PEG 1 retrospective review of 41 consults for PEG

• survival without PEG 60 days, with PEG 59 dayssurvival without PEG 60 days, with PEG 59 days

• Mortality is high after G-tube placementMortality is high after G-tube placement– 6-28% in first 30 days6-28% in first 30 days– 50% in first year50% in first year

Murphy LM. Arch Int Med, 2003; Dharmarajan TS. Am J Gastroenterology, 2001; Mitchell SL. Arch Int Med, 1997

Survival after PEG Survival after PEG placementplacement

Dharmarajan TS. Am J Gastroenterology, 2001

Patient Comfort?Patient Comfort?

• Studies of dying cancer or ALS Studies of dying cancer or ALS patients with anorexia:patients with anorexia:– Little hunger or thirstLittle hunger or thirst

• Any thirst can be treated with mouth swabs Any thirst can be treated with mouth swabs and ice chipsand ice chips

– Sense of euphoria (endorphins)Sense of euphoria (endorphins)• Goes away if fedGoes away if fed

– Patients were left alone morePatients were left alone more

Gillick MR. NEJM, 2000

• Artificial nutrition and hydration may Artificial nutrition and hydration may prolong the dying processprolong the dying process

McCann RM, JAMA, 1994

Comfort?Comfort?

• Eating is pleasant!Eating is pleasant!– depriving a person (who wants to depriving a person (who wants to

eat) of the pleasure of eating eat) of the pleasure of eating does not increase comfortdoes not increase comfort

• Restraints are not Restraints are not

comfortablecomfortable

Help wound healing/prevent Help wound healing/prevent pressure ulcers? pressure ulcers?

• Very little dataVery little data• One observational study failed to One observational study failed to

show an associationshow an association• Common sense:Common sense:

– More likely to be immobileMore likely to be immobile– More likely to be restrainedMore likely to be restrained– More often wet skin (sweat, stool, urine)More often wet skin (sweat, stool, urine)

Finucane TE, JAMA, 1999; Dharmarajan TS, Am J Gastroenterology, 2001

Other benefits of tube Other benefits of tube feeding? feeding?

• Observational studies show:Observational studies show:– No recovery of functionNo recovery of function– No decrease in risk of infectionNo decrease in risk of infection

Finucane TE, JAMA, 1999

Other considerationsOther considerations

• Pulling out the tubePulling out the tube– Return trips to GI or IRReturn trips to GI or IR– RestraintsRestraints

• Increased stool and urine outputIncreased stool and urine output– Caregiver burdens highCaregiver burdens high

Slow hand feedingSlow hand feeding

• Survival can be substantial despite Survival can be substantial despite emaciation and poor po intakeemaciation and poor po intake

• Human, nurturing, time for closeness Human, nurturing, time for closeness with loved oneswith loved ones

Finucane TE, JAMA, 1999

Feeding tipsFeeding tips

• Multiple swallows after each bolusMultiple swallows after each bolus• Gentle coughs after each swallowGentle coughs after each swallow• Small bolus (less than teaspoon)Small bolus (less than teaspoon)• Sit upSit up• Liquid supplementsLiquid supplements• Decrease distractionsDecrease distractions• Feed finger foods, thick liquids (gravy, ice Feed finger foods, thick liquids (gravy, ice

cream, add cream & butter to things), hot cream, add cream & butter to things), hot or cold foods, strong flavors, favorite foodsor cold foods, strong flavors, favorite foods

Finucane TE, JAMA. 1999

Tube feedingTube feeding

• No evidence that tube feeding:No evidence that tube feeding:– Decreases risk of aspirationDecreases risk of aspiration– Prolongs survival (60% mortality at 6 Prolongs survival (60% mortality at 6

months, perhaps 90% at one year)months, perhaps 90% at one year)– Improves comfortImproves comfort– Decreases pressure sore riskDecreases pressure sore risk

• Recommend slow hand feedingRecommend slow hand feeding

Finucane TE, JAMA. 1999; Gillick MR. N Engl J Med. 2000

SummarySummary

• Dementia is common, Dementia is common,

but commonly overlookedbut commonly overlooked• Diagnosis is by clinical criteriaDiagnosis is by clinical criteria• Prognosis is poorPrognosis is poor• Determining decision making capacityDetermining decision making capacity

• Requires a dialogue with the patientRequires a dialogue with the patient• Formal standards available to guide youFormal standards available to guide you

• Tube feeding vs. slow hand feedingTube feeding vs. slow hand feeding

ReferencesReferences1. Kennedy, GJ. Dementia in Geriatric Medicine, an Evidence Based Approach,

4th Ed. Cassel et al, Eds. 2003. p.10792.2. Boustani M, Callahan CM, Unverzagt FW, Austrom MG, Perkins AJ, Fultz BA, Boustani M, Callahan CM, Unverzagt FW, Austrom MG, Perkins AJ, Fultz BA,

Hui SL, Hendrie HC. Implementing a screening and diagnosis program for Hui SL, Hendrie HC. Implementing a screening and diagnosis program for dementia in primary care. J Gen Intern Med. 2005 Jul;20(7):572-7. dementia in primary care. J Gen Intern Med. 2005 Jul;20(7):572-7.

3.3. Sternberg SA, Wolfson C, Baumgarten M. Undetected dementia in Sternberg SA, Wolfson C, Baumgarten M. Undetected dementia in community-dwelling older people: the Canadian Study of Health and Aging. community-dwelling older people: the Canadian Study of Health and Aging. J Am Geriatr Soc. 2000 Nov;48(11):1430-4. J Am Geriatr Soc. 2000 Nov;48(11):1430-4.

4.4. Knopman DS, Boeve BF, Petersen RC. Essentials of the proper diagnoses Knopman DS, Boeve BF, Petersen RC. Essentials of the proper diagnoses of mild cognitive impairment, dementia, and major subtypes of dementia. of mild cognitive impairment, dementia, and major subtypes of dementia. Mayo Clin Proc. 2003 Oct;78(10):1290-308.Mayo Clin Proc. 2003 Oct;78(10):1290-308.

5.5. Larson EB, Shadlen MF, Wang L, McCormick WC, Bowen JD, Teri L, Kukull Larson EB, Shadlen MF, Wang L, McCormick WC, Bowen JD, Teri L, Kukull WA. Survival after initial diagnosis of Alzheimer disease.WA. Survival after initial diagnosis of Alzheimer disease.Ann Intern Med. 2004 Apr 6;140(7):501-9. Ann Intern Med. 2004 Apr 6;140(7):501-9.

6.6. Brauner DJ, Muir JC, Sachs GA. Treating nondementia illnesses in patients Brauner DJ, Muir JC, Sachs GA. Treating nondementia illnesses in patients with dementia. JAMA. 2000 Jun 28;283(24):3230-5.with dementia. JAMA. 2000 Jun 28;283(24):3230-5.

7. Karlawish JHT & Pearlman RA. Determination of Decision-Making Capacity, in Geriatric Medicine, an Evidence Based Approach, 4th Ed. Cassel et al, Eds. 2003. p.1233.

8. Drane JF. Competency to give an informed consent. A model for making clinical assessments. JAMA 1984, 252(7), 925-927.

9. Safeer RS & Keenan J. Health literacy: the gap between physicians and patients.Am Fam Physician. 2005 Aug 1;72(3):463-8.

10. Geriatrics at Your Fingertips, Online Edition. http://www.geriatricsatyourfingertips.org/ebook/gayf_2.asp#c2s4_INFORMED_DECISION_MAKING (accessed January 9 2006).

11. Appelbaum PS, Grisso T. Assessing patients' capacities to consent to treatment. N Engl J Med 1988, 319(25), 1635-1638.

12. Appelbaum PS, Grisso T. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. 1998, New York: Oxford University Press. 31-60, 77-126.

13. Reisberg, B. Functional Assessment Staging (FAST). Psychopharmacology Bulletin. 1988:24: 653-659.     

14.14. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. 1999 Oct 13;282(14):1365-70.dementia: a review of the evidence. JAMA. 1999 Oct 13;282(14):1365-70.

15.15. Dharmarajan TS., et al. Percutaneous endoscopic gastrostomy and outcome in Dharmarajan TS., et al. Percutaneous endoscopic gastrostomy and outcome in dementia. Amer J Gastroenterology. 2001; 96:2556-2563.dementia. Amer J Gastroenterology. 2001; 96:2556-2563.

16.16. Murphy LM, Lipman TO. Percutaneous endoscopic gastrostomy does not Murphy LM, Lipman TO. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia. Arch Int Med. 2003; 163:1351-prolong survival in patients with dementia. Arch Int Med. 2003; 163:1351-1353. 1353.

17.17. Mitchell SL et al. The risk factors and impact on survival of feeding tube Mitchell SL et al. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment.placement in nursing home residents with severe cognitive impairment.Arch Intern Med. 1997 Feb 10;157(3):327-32. Arch Intern Med. 1997 Feb 10;157(3):327-32.

18.18. Gillick MR. Rethinking the role of tube feeding in patients with advanced Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med. 2000 Jan 20;342(3):206-10.dementia. N Engl J Med. 2000 Jan 20;342(3):206-10.

19. McCann RM et al. Comfort care for terminally ill patients. The appropriate use of et al. Comfort care for terminally ill patients. The appropriate use of nutrition and hydration. JAMA. 1994 Oct 26;272(16):1263-6. nutrition and hydration. JAMA. 1994 Oct 26;272(16):1263-6.