P rognosis
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Transcript of P rognosis
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Prognosis
Life expectancy from the time of diagnosis:
Alzheimer Disease 5-10 years
Vascular Dementia 4 years
Dementia with Lewy Bodies 4 years
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What is an advance directive??
DNRLiving willDPOA HC
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Weight loss
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Anorexia and Weight Loss
Common in patients with dementiaEspecially AD
Possible causes Forgetting to eat Inability to prepare and eat foods Impaired olfaction and taste Behavior problems (restlessness, etc) Depression Comorbid medical illness Medications (esp ACh-I, Antidepressants) Inflammatory abnormalities (anorexia, procatabolic
state)
Wang et al, J Neurol 2004, 251:314-320; Aziz NA et al, J Neurol 2008
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Controlled study of 51 AD pts and 27 non-demented controls AD pts were thinner and less active Pts with AD actually ate the same or MORE than
controls Presence of AD was a risk factor for weight loss
even if other factors were controlled
Wang et al, J Neurol 2004, 251:314-320
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AD pts have increased serum levels of: Glucagon Ammonia Lactate Cortisol Interleukins 1 and 6 TNF alpha
• AD pts have greater insulin resistance• All of above is similar to cancer patients
Knittweis J, Medical Hypotheses, 1999
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Strategies
Diet- liberalize it! No special diets!
Environment Eat with others Pleasant, quiet
setting Music may help
Tamura BK et al. Nutrition and the Institutionalized Elderly. 2007
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Strategies
Food Modifications Single items, presented one
at a time Contrast color of food with the dish Make food and setting look attractive Make food portable for those who are restless Sweet, hot/cold, juicy
Eating Schedule AD pts ate more at breakfast than other meals Frequent, small meals Eat with others
Tamura BK et al. Nutrition and the Institutionalized Elderly. 2007
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Limited Data on Pharmacologic Strategies
Nutritional supplements between mealsMicronutrients (MVI) probably not needed
Megestrol acetate (Megace)Dronabinol (Marinol)Methylphenidate (Ritalin)Mirtazepine (Remeron)
Tamura BK et al. Nutrition and the Institutionalized Elderly. 2007
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Feeding tubes
When are theyappropriate?
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Improved Survival?
Observational studies: NH patients show no survival advantage with tube
feeding 1 retrospective review of 41 consults for PEG
survival without PEG 60 days, with PEG 59 days
Mortality is high after G-tube placement 6-28% in first 30 days 60% mortality at 6 months, perhaps 90% at one year
Murphy LM. Arch Int Med, 2003; Dharmarajan TS. Am J Gastroenterology, 2001; Mitchell SL. Arch Int Med, 1997; Gillick MR. N Engl J Med. 2000