Weight loss, dysphagia, and outcome in advanced dementia

ESPEN guideline on nutrition and hydration in dementia - Update 2024

BACKGROUND & AIMS

Dementia is accompanied by a variety of changes that result in an increased risk of malnutrition and low-intake dehydration. This guideline update aims to give evidence-based recommendations for nutritional care of persons with dementia in order to prevent and treat these syndromes.

METHODS

The previous guideline version was reviewed and expanded in accordance with the standard operating procedure for ESPEN guidelines. Based on a systematic search in three databases, strength of evidence of appropriate literature was graded by use of the SIGN system. The original recommendations were reviewed and reformulated, and new recommendations were added, which all then underwent a consensus process.

RESULTS

40 recommendations for nutritional care of older persons with dementia were developed and agreed, seven at institutional level and 33 at individual level. As a prerequisite for good nutritional care, organizations caring for persons with dementia are recommended to employ sufficient qualified staff and offer attractive food and drinks with choice in a functional and appealing environment. Nutritional care should be based on a written care concept with standardized operating procedures. At the individual level, routine screening for malnutrition and dehydration, nutritional assessment and close monitoring are unquestionable. Oral nutrition may be supported by eliminating potential causes of malnutrition and dehydration, and adequate social and nursing support (including assistance, utensils, training and oral care). Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Routine use of dementia-specific ONS, ketogenic diet, omega-3 fatty acid supplementation and appetite stimulating agents is not recommended. Enteral and parenteral nutrition and hydration are temporary options in patients with mild or moderate dementia, but not in severe dementia or in the terminal phase of life. In all stages of the disease, supporting food and drink intake and maintaining or improving nutrition and hydration status requires an individualized, comprehensive approach. Due to a lack of appropriate studies, most recommendations are good practice points.

CONCLUSION

Nutritional care should be an integral part of dementia management. Numerous interventions are available that should be implemented in daily practice. Future high-quality studies are needed to clarify the evidence.

Mortality risk factors among patients undergoing hemodialysis in a nursing home

AIM

This study aimed to verify the impact of low body mass index (BMI) on mortality in nursing home residents undergoing hemodialysis and to clarify other associated mortality risk factors.

METHODS

This retrospective study included patients admitted to a nursing home affiliated with Nagasaki Renal Center between April 2014 and March 2022. Medical data were collected on admission, and participants were divided into low and high BMI groups according to their median BMI values. The patients were followed up until March 2023. The association between survival and patient history was also analyzed.

RESULTS

Of the 106 patients (average age, 81.3 ± 7.9 years; male, 36.8%; median dialysis vintage, 32.5 [interquartile range (IQR), 13.8-79.3] months), 52 and 54 were classified into the low (median < 18.4 kg/m2 ) and high (≥18.4 kg/m2 ) BMI groups, respectively. Multivariable Cox proportional hazards analysis indicated that BMI (hazard ratio, 0.87; 95% confidence interval [CI]: 0.82-0.94; P < 0.001) was closely associated with survival. Multivariable logistic regression revealed that dementia was associated with low BMI (odds ratio: 2.89, 95% CI: 1.07-7.83, P = 0.03).

CONCLUSIONS

Low BMI was an important factor contributing to poor patient survival. Dementia was associated with low BMI. Therefore, the management of both nutrition and dementia is essential for nursing home residents undergoing hemodialysis. Geriatr Gerontol Int 2023; 23: 660-664.

Pharmacological Management of Dysphagia in Patients with Alzheimer's Disease: A Narrative Review

Alzheimer's disease (AD) and dysphagia are important health and socioeconomic problems in the aging population. Currently, the medical treatment of dysphagia in AD patients remains insufficient, and there are significant gaps in the management and clinical needs to postpone tube feeding. Literatures published over the last 30 years were searched in the PubMed and Embase databases. All relevant and promising pharmacological management studies were included. Because of the heterogeneity in design and methodology, only narrative reports were mentioned. Nine studies were included with two case reports, two case series, and two observational and three randomized controlled trials. The key approaches and clinical problems related to dysphagia include onset pattern, dementia stage, review of offending drugs and polypharmacy, and comorbidities (cerebrovascular disease, hypertension, parkinsonism, depression, and anorexia). The corresponding strategies of pharmacological treatments are further proposed and discussed comprehensively, with transient receptor potential channel modulators as promising treatment. With the integration of adequate and potential pharmacomanagement, AD patients with dysphagia can achieve a good prognosis and postpone tube feeding to maintain a better quality of life. More rigorous studies are needed to verify the effectiveness of innovative strategies and develop targets for neurostimulation.

Dysphagia in Alzheimer's disease: a systematic review

Dysphagia is described as a highly relevant comorbidity of Alzheimer's disease (AD). However, there is a scarcity of studies aiming at the characteristics and progression of dysphagia.

OBJECTIVE

The objective of this study was to identify the specific characteristics, progression, and prevalence of dysphagia in AD.

METHODS

Publications were searched in the PubMed (MEDLINE), EBSCO, ScienceDirect, and BASE databases. Critical appraisal and evidence-level analysis were conducted using the Joanna Briggs Institute and Effective Public Health Practice Project's (EPHPP) tools.

RESULTS

A total of 26 studies were reviewed. Symptoms begin in the early stage of AD, as oral phase impairments, and progress to pharyngeal symptoms and swallowing apraxia in the later stages of AD. Dysphagia progresses, as AD, along a continuum, with severity depending on individual variability. There were no studies found on prevalence.

CONCLUSIONS

Dysphagia is a complex and important comorbidity in AD that impacts the quality of life. No recent publications on prevalence may imply that is not being coded as a potential cause for pneumonia deaths in AD.

Evaluation of Swallowing Function according to the Stage of Alzheimer's Disease

BACKGROUND

Alzheimer's disease (AD) is a progressive neurodegenerative disease, and swallowing difficulties may occur as the disease progresses. Dysphagia has many consequences, such as aspiration and pneumonia. In particular, in the advanced stage, approximately 70% of the causes of death in AD involve aspiration pneumonia. Therefore, it is vital to assess the presence or absence of dysphagia in AD.

OBJECTIVE

This study aims to describe swallowing difficulty across the stages of AD.

METHODS

Thirty-five AD patients were evaluated. The Mini-Mental State Examination was conducted. A bedside water swallow test (BWST) and the Eating Assessment Tool (EAT-10) were administered. Finally, fiberoptic endoscopic evaluation of swallowing was used to evaluate residual, aspiration and penetration conditions.

RESULTS

EAT-10 scores, BWST results, and penetration-aspiration status were statistically significantly different according to AD stage (p < 0.05). Among all patients, 74.3% had residue, 25.7% had penetration, and 2.9% had aspiration.

CONCLUSIONS

This study has demonstrated that swallowing dysfunction begins at a mild stage and progressively worsens toward the advanced stage in patients with AD. At all stages of AD, residue was observed, and this poses a risk for the development of penetration-aspiration. Therefore, it is necessary to evaluate the early dysphagia of individuals.

Dysphagia Affecting Quality of Life in Cerebellar Ataxia-a Large Survey

Dysphagia is a common symptom in neurodegenerative disorders and is generally associated with increased mortality. In the clinical care setting of ataxia patients, no systematical and standardized assessment of dysphagia is employed. Its impact on patients’ health-related quality of life is not well understood. To assess the impact of dysphagia in ataxia patients on diet, body weight, and health-related quality of life. We conducted a large survey using self-reported questionnaires for swallowing-related quality of life (Swal-QOL) and a food frequency list in combination with retrospective clinical data of 119 patients with cerebellar ataxia treated in the neurological outpatient clinic of a large German university hospital. Seventeen percent of ataxia patients suffered from dysphagia based on the Swal-QOL score. Less than 1% of all patients reported dysphagia as one of their most disabling symptoms. Dysphagia was associated with unintentional weight loss (p = 0.02) and reduced health-related quality of life (p = 0.01) but did not affect individual nutritional habits (p > 0.05; Chi-squared test). Dysphagia is a relevant symptom in cerebellar ataxia. A systematic screening for dysphagia in patients with cerebellar ataxia would be desirable to enable early diagnosis and treatment.

A Nomogram for Prediction of Postoperative Pneumonia Risk in Elderly Hip Fracture Patients

Purpose

Pneumonia is one of the common complications of hip fracture. This study aimed to evaluate the risk factors and apply a nomogram to predict postoperative pneumonia in elderly hip fracture patients.

Materials and Methods

From August 2014 to October 2019, 1113 hip fracture patients who were older than 65 years and underwent surgical treatment in our hospital were subjects of this study. Univariate and multivariate Cox analyses were used to identify independent risk factors. A predictive nomogram model was built, and the discrimination and calibration were determined by receiver operating characteristic and calibration plot.

Results

A total of 166 patients developed pneumonia after operation (14.91%, pneumonia group) while the remaining 947 patients did not (85.09%, non-pneumonia group). According to the results, body mass index (OR, 0.76, 95% CI, 0.70 to 0.84, P<0.001), serum albumin (OR, 0.86, 95% CI, 0.79 to 0.93, P<0.001), c-reactive protein (OR, 1.01, 95% CI, 1.00 to 1.92, P=0.011), functional status (OR, 2.94, 95% CI, 1.69 to 5.10, P<0.001) and time to surgery (OR, 4.56, 95% CI, 2.64 to 7.88, P<0.001) were identified as independent risk factors of pneumonia. The area under the curve value for postoperative pneumonia risk was 0.905, and the P-value of the Hosmer-Lemeshow calibration test was 0.529.

Conclusion

Our nomogram model can be used to predict the risk of pneumonia in elderly hip fractures after surgery and provide clinicians with guidance for better perioperative intervention to improve prognosis and reduce mortality.

Risk factors and prognostic implications of aspiration pneumonia in older hip fracture patients: A multicenter retrospective analysis

AIM

The present study aimed to investigate the risk factors and prognostic implications of aspiration pneumonia in older hip fracture patients.

METHODS

A total of 394 female and 125 male hip fracture patients aged ≥60 years who underwent surgery between 2015 and 2018 were retrospectively analyzed. To identify risk factors of aspiration pneumonia, demographic factors, the American Society of Anesthesiologists classification, past medical history, known risk factors of aspiration and factors associated with surgery were compared between the aspiration pneumonia group and the control group. Regression analysis was also carried out. To assess the prognostic implications of aspiration pneumonia, hospital stay, frequency of the intensive care unit admission and in-hospital mortality rates were compared between groups.

RESULTS

Aspiration pneumonia was diagnosed in 8.8% of the hip fracture patients. Increased age, low body mass index, malnutrition, longer duration of surgery and delayed surgery were identified as risk factors of aspiration pneumonia. Regarding prognostic implications, hospital stay, the frequency of intensive care unit care and in-hospital mortality rates were significantly higher in the aspiration pneumonia group (P < 0.001, <0.001 and 0.001, respectively).

CONCLUSIONS

Older hip fracture patients with aspiration pneumonia showed worse prognostic outcome compared with patients without aspiration pneumonia. Longer duration of surgery and delayed surgery, as well as patient characteristics including increased age, low body mass index and malnutrition were identified as risk factors for aspiration pneumonia. Therefore, surgeons should try to reduce the operation time and the time interval between injury and surgery when treating older patients for hip fractures. Geriatr Gerontol Int 2019; 19: 119-123.

Doctors' Knowledge and Attitudes Regarding Enteral Feeding and Eating Problems in Advanced Dementia

BACKGROUND

The use of feeding tubes (FTs) in patients with advanced dementia does not yield positive health outcomes and can have a negative effect.

METHODS

A cross-sectional study assessed the knowledge and attitudes of physicians on the use of FTs for patients with advanced dementia.

RESULTS

201 of 240 doctors (83.8%) participated in the study; 61.7% of the doctors claimed that FTs prevent aspiration, 51.7% that they prevent pneumonia, and 38.8% that they prevent weight gain. Almost one-third (32.3%) said that the decision to use FTs could be taken by a hospitalist or a primary physician (28.9%).

CONCLUSION

We found large gaps in knowledge among doctors about the use of FTs and consequences in patients with advanced dementia.

Management of swallowing in thrombolysed stroke patients: Implementation of a new protocol

PURPOSE

There is a paucity of evidence regarding dysphagia management post-thrombolysis. The aim of this case-control study was to evaluate the impact of a dysphagia management protocol on patient outcomes. Thrombolysis has been completed at our metropolitan hospital since 2011 and a dysphagia management protocol was developed in 2012.

METHOD

Chart auditing was completed for 83 participants in three groups: pre-protocol (n = 12) (2011), post-protocol (n = 28) (2012-2014), and non-thrombolysed stroke patients (n = 43).

RESULT

Following the implementation of this clinical protocol, the average time patient remained nil by mouth reduced by 9.5 h, the percentage of patients who were malnourished or at risk reduced by 24% and the number of patients who developed aspiration pneumonia reduced by 11%. The cost of hospital stay reduced by $1505. Service compliance with best practice in dysphagia management in thrombolysed patients increased from 67% to 96% in the thrombolysed patient groups.

CONCLUSION

The outcomes suggest that a clinical protocol for dysphagia management in thrombolysed patients has the potential to improve service outcomes, reduce complications from dysphagia, have financial benefits for the hospital and increase service compliance. Furthermore, the results lend support for speech pathology services to manage dysphagia on weekends.

Tube Feeding Patients With Dementia

As the population ages, the incidence of dementia increases. All types of dementia, whether they are reversible or irreversible, lead to loss of intellectual function and judgment, memory impairment, and personality changes. The skills to feed oneself, use eating utensils, and consume items recognized as food, thereby maintaining nutrition status, may be lost as dementia progresses. Reports indicate that nutrition status may be maintained when patients are hand fed, but this is labor intensive and therefore expensive. Feeding via a percutaneous endoscopic gastrostomy tube is often chosen as an acceptable alternative. Research indicates that there is little benefit in this population when aggressive nutrition support is instituted. Providing tube feeding to patients with dementia does not necessarily extend life, increase weight, or reduce the incidence of pressure ulcers or aspiration. There are many legal and ethical issues involved in the decision to place a feeding tube in demented patients. The primary issue in patients with dementia may be autonomy and the right of an individual to decide whether or not a tube should be placed at all. Legally, there is clear precedent that the courts see the insertion of a feeding tube as extraordinary care that the patient has the right to refuse. However, much of case law is derived from cases of patients who were in a persistent vegetative state. Advance directives help to determine what the patient would want for himself. Considering all the options before the patient can no longer make decisions is the most desirable course.

Diagnostic Assessment and Management of Dysphagia in Patients with Alzheimer's Disease

A growing concern in patients affected by Alzheimer's disease (AD) is dysphagia, or swallowing impairment, which leads to malnutrition, dehydration, weight loss, functional decline and fear of eating and drinking, as well as a decrease in the quality of life. Thus the diagnostic assessment of dysphagia in patients with AD is imperative to ensure that they receive effective management, avoiding complications, and reducing comorbidity and mortality in such a growing population. Dysphagia management requires a multidisciplinary approach considering that no single strategy is appropriate for all patients. However, evidence for clinical diagnostic assessment, interventions, and medical management of dysphagia in these patients are still limited: few studies are reporting the evaluation and the management among this group of patients. Here we analyzed the most recent findings in diagnostic assessment and management of swallowing impairment in patients affected by AD.

ESPEN guidelines on nutrition in dementia

BACKGROUND

Older people suffering from dementia are at increased risk of malnutrition due to various nutritional problems, and the question arises which interventions are effective in maintaining adequate nutritional intake and nutritional status in the course of the disease. It is of further interest whether supplementation of energy and/or specific nutrients is able to prevent further cognitive decline or even correct cognitive impairment, and in which situations artificial nutritional support is justified.

OBJECTIVE

It is the purpose of these guidelines to cover these issues with evidence-based recommendations.

METHODS

The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds and accepted in an online survey among ESPEN members.

RESULTS

26 recommendations for nutritional care of older persons with dementia are given. In every person with dementia, screening for malnutrition and close monitoring of body weight are recommended. In all stages of the disease, oral nutrition may be supported by provision of adequate, attractive food in a pleasant environment, by adequate nursing support and elimination of potential causes of malnutrition. Supplementation of single nutrients is not recommended unless there is a sign of deficiency. Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Artificial nutrition is suggested in patients with mild or moderate dementia for a limited period of time to overcome a crisis situation with markedly insufficient oral intake, if low nutritional intake is predominantly caused by a potentially reversible condition, but not in patients with severe dementia or in the terminal phase of life.

CONCLUSION

Nutritional care and support should be an integral part of dementia management. In all stages of the disease, the decision for or against nutritional interventions should be made on an individual basis after carefully balancing expected benefit and potential burden, taking the (assumed) patient will and general prognosis into account.

A systematic review and meta-analysis examining pneumonia-associated mortality in dementia

BACKGROUND

Although it is generally accepted that deaths associated with pneumonia are more common in patients with dementia, no comprehensive reviews on the subject have previously been published.

SUMMARY

Relevant studies were identified through a literature search of the PubMed, EMBASE, Scopus, and ISI Web of Science databases for publications up to August 2013. Studies were included if (1) a group of adult subjects with dementia and a (comparison) group composed of subjects without dementia were included, (2) the cause(s) of death was/were reported, and (3) pneumonia was identified as one of the possible causes of death. The occurrence of death due to pneumonia associated with dementia was expressed as an odds ratio (OR) with 95% confidence interval (CI). Thirteen studies were included. The odds of death resulting from pneumonia were significantly increased for persons with any form of dementia compared with those without dementia (OR = 2.22, 95% CI 1.44-3.42, p < 0.001). In a subgroup analysis, using the results from 8 studies that restricted inclusion to persons with Alzheimer's disease, the odds of death resulting from pneumonia were also significantly higher (OR = 1.70, 95% CI 1.12-2.58, p = 0.013). Key Messages: The odds of pneumonia-associated mortality were increased more than 2-fold for patients with dementia.

Clinical Study of Respiratory Function and Difference in Pneumonia History between Alzheimer's Disease and Vascular Dementia Groups

[Purpose] This study compared respiratory function and differences in pneumonia history between Alzheimer’s disease and vascular dementia groups. [Subjects] Fifty-eight inpatients in the dementia treatment ward in a psychiatric facility were enrolled. [Methods] Patients underwent respiratory function testing twice using an 80-cm party horn. The Mini-Mental State Examination was also performed and motor functions were evaluated. Patient characteristics were obtained from medical records. [Results] Significant differences were noted between Alzheimer’s disease and vascular dementia groups in the ability to blow the party horn to full length, pneumonia history, and presence of impaired mobility. [Conclusion] Party horn evaluation may be useful for determining the risk of pneumonia in patients with dementia.

Malnutrition in care home residents with dementia

OBJECTIVES

To investigate the malnutrition prevalence in Dutch care home residents with dementia over the years. Secondly, to examine the relationship of malnutrition and dementia and the role of care dependency and co-morbidity within this relationship.

DESIGN

This study is a secondary analysis of data of the annual independent Dutch National Prevalence Measurement of Care Problems of Maastricht University. The design involves a cross-sectional, multicenter point prevalence measurement.

SETTING

Care homes.

PARTICIPANTS

75399 residents older than 65 years (4523 resident with dementia) participated over 5 years (2006-2010). Sixty organizations measured 4 times, 31 organizations 3 times, 68 organizations 2 times, 511 organizations 1 time.

MEASUREMENTS

A standardized questionnaire was used to register amongst others data of weight, height, nutritional intake, undesired weight loss, comorbidity, dementia, and care dependency.

RESULTS

The study was able to show that there is a significant decline in malnutrition prevalence in the group of non-demented residents over the years (Non-demented group p <0.001). The prevalence of malnutrition in the demented group showed no significant reduction over the years. GEE analysis showed that malnutrition and dementia are related and that care dependency and age are important influencing factors in this relation.

CONCLUSION

The results show that compared to the non-demented residents, the prevalence of malnutrition does not decline in demented care home residents over the years. Moreover, the findings of this study stress that malnutrition and dementia are related, while care dependency and age are confounding factors in this relationship.

Relationship between Swallowing Dysfunction and Decreased Respiratory Function in Dementia Patients

[Purpose] This study aimed to clarify whether respiratory function differed between dementia patients using and not using thickening fluids and texture-modifying foods for swallowing dysfunction management. [Subjects] Sixty-five inpatients in the dementia treatment ward in a psychiatric facility were enrolled. [Methods] The patients underwent respiratory function testing twice with an 80-cm party horn. Moreover, information about the patients' characteristics and use of thickening fluids and texture-modifying foods was obtained from their medical records. [Results] There was a significant difference in being able to blow the party horn to its full length between patients using and not using thickening liquids. [Conclusion] This result suggests that decreased respiratory function may reflect swallowing dysfunction in dementia patients.

Investigation of eating actions of people with dementia from the viewpoint of self-awareness

The key to improve the quality of life of people with dementia and caregivers is whether caregivers can understand the meanings of the puzzling words and deeds of people with dementia. Therefore, 2 of the authors observed and wrote down the puzzling words and deeds of 28 people with dementia in eating scenes, and these words and deeds were interpreted using our original model consisting of "theory of mind," "self-evaluation," and "self-consciousness." The results indicated that the bases for why caregivers perceive the words and deeds of people with dementia in eating scenes as puzzling are (1) those unable to pass the task of self-evaluation cannot evaluate their own eating situations in comparison with social standards, and the food culture collapses and (2) those unable to pass the task of self-consciousness cannot perceive through their senses.

Reduced limbic and hypothalamic volumes correlate with bone density in early Alzheimer's disease

Accelerated bone loss is associated with Alzheimer's disease (AD). Although the central nervous system plays a direct role in regulating bone mass, primarily through the actions of the hypothalamus, there is little work investigating the possible role of neurodegeneration in bone loss. In this cross-sectional study, we examined the association between bone mineral density (BMD) and neuroimaging markers of neurodegeneration (i.e., global and regional measures of brain volume) in early AD and non-demented aging. Fifty-five non-demented and 63 early AD participants underwent standard neurological and neuropsychological assessment, structural MRI scanning, and dual energy x-ray absorptiometry. In early AD, voxel-based morphometry analyses demonstrated that low BMD was associated with low volume in limbic grey matter (GM) including the hypothalamus, cingulate, and parahippocampal gyri and in the left superior temporal gyrus and left inferior parietal cortex. No relationship between BMD and regional GM volume was found in non-demented controls. The hypothesis-driven region of interest analysis further isolating the hypothalamus demonstrated a positive relationship between BMD and hypothalamic volume after controlling for age and gender in the early AD group but not in non-demented controls. These results demonstrate that lower BMD is associated with lower hypothalamic volume in early AD, suggesting that central mechanisms of bone remodeling may be disrupted by neurodegeneration.

End of life care for community dwelling older people with dementia: an integrated review

OBJECTIVE

To review the evidence for end-of-life care for community dwelling older people with dementia (including those resident in care homes).

DESIGN

An integrated review synthesised the qualitative and quantitative evidence on end-of-life care for community dwelling older people with dementia. English language studies that focused on prognostic indicators for end-of-life care, assessment, support/relief, respite and educational interventions for community dwelling older people with dementia were included. A user representative group informed decisions on the breadth of literature used. Each study selected was screened independently by two reviewers using a standardised check list.

RESULTS

Sixty eight papers were included. Only 17% (12) exclusively concerned living and dying with dementia at home. Six studies included direct evidence from people with dementia. The studies grouped into four broad categories: Dementia care towards the end of life, palliative symptom management for people with dementia, predicting the approach of death for people with dementia and decision-making. The majority of studies were descriptive. The few studies that developed dementia specific tools to guide end of life care and outcome measures specific to improve comfort and communication, demonstrated what could be achieved, and how much more needs to be done.

CONCLUSIONS

Research on end-of-life care for people with dementia has yet to develop interventions that address the particular challenges that dying with dementia poses. There is a need for investigation of interventions and outcome measures for providing end-of-life care in the settings where the majority of this population live and die.

Contribution of thickened drinks, food and enteral and parenteral fluids to fluid intake in hospitalised patients with dysphagia

BACKGROUND

Studies amongst older people with acute dysphagic stroke requiring thickened fluids have assessed fluid intakes from combinations of beverage, food, enteral and parenteral sources, but not all sources simultaneously. The present study aimed to comprehensively assess total water intake from food, beverages, enteral and parenteral sources amongst dysphagic adult in-patients receiving thickened fluids.

METHODS

Patients requiring thickened fluid following dysphagia diagnosis were recruited consecutively from a tertiary teaching hospital's medical and neurosurgical wards. Fluid intake from food and beverages was assessed by wastage, direct observation and quantified from enteral and parenteral sources through clinical medical records.

RESULTS

No patients achieved their calculated fluid requirements unless enteral or parenteral fluids were received. The mean daily fluid intake from food was greater than from beverages whether receiving diet alone (food: 807 +/- 363 mL, food and beverages: 370 +/- 179 mL; P < 0.001) or diet with enteral or parenteral fluid support (food: 455 +/- 408 mL, food and beverages: 263 +/- 232 mL; P < 0.001). Greater daily fluid intakes occurred when receiving enteral and parenteral fluid in addition to oral dietary intake, irrespective of age group, whether assistance was required, diagnosis and whether stage 3 or stage 2 thickened fluids were required (P < 0.05). After enteral and parenteral sources, food provided the most important contribution to daily fluid intakes.

CONCLUSIONS

The greatest contribution to oral fluid intake was from food, not beverages. Designing menus and food services that promote and encourage the enjoyment of fluid dense foods, in contrast to thickened beverages, may present an important way to improve fluid intakes of those with dysphagia. Supplemental enteral or parenteral fluid may be necessary to achieve minimum calculated fluid requirements.

Association of adiposity status and changes in early to mid-adulthood with incidence of Alzheimer's disease

Adiposity status and change are potential risk factors for Alzheimer's disease (AD). The authors used data on 2,322 participants in the Baltimore Longitudinal Study of Aging to analyze the relation between AD incidence and adiposity in Cox proportional hazards models, with adjustment for sociodemographic factors and smoking status. Body mass index (BMI; weight (kg)/height (m)(2)) and waist circumference at specific ages were predicted by empirical Bayes estimators from mixed-effects regression models. After a median of 23.4 years of follow-up between 1958 and 2006, 187 participants developed AD. Among men, being underweight (BMI <or=18.5) at age 30, 40, or 45 years increased the likelihood of AD (hazard ratio (HR) = 5.76, 95% confidence interval (CI): 2.07, 16.00); among women, being obese (BMI >or=30) at age 30, 40, or 45 years and jointly centrally obese (waist circumference >or=80th percentile) at age 30, 35, or 50 years increased AD risk (HR = 6.57, 95% CI: 1.96, 22.02). Women who lost weight (BMI change <10th percentile) between ages 30 and 45 years were also at increased risk (HR = 2.02, 95% CI: 1.06, 3.85). Weight gain among men (BMI change >90th percentile) between ages 30 and 50 years increased AD risk (HR = 3.70, 95% CI: 1.43, 9.56). Future studies should identify age- and gender-specific optimal weights and weight-loss strategies for preventing AD and investigate potential mechanisms.

Nutritional status and delirium in long-term care elderly individuals

Delirium is physiologically plausible in elderly individuals with a poor nutritional status. We explored body composition, serum protein levels, and delirium in a multicenter long-term care study using bioelectrical impedance analysis (BIA). Estimates from the BIA procedure included the body cell mass and fat-free mass (FFM) of nursing home elderly residents (N = 312). Increased delirium was identified in men and women who were leaner and had lower FFM. Clinical surveillance for delirium in frail elderly individuals with low serum albumin levels and polypharmacy is recommended because of their increased likelihood of having drug toxicities for medications with protein-binding properties.

Normal swallowing and functional magnetic resonance imaging: a systematic review

Unknowns about the neurophysiology of normal and disordered swallowing have stimulated exciting and important research questions. Previously, these questions were answered using clinical and animal studies. However, recent technologic advances have moved brain-imaging techniques such as functional magnetic resonance imaging (fMRI) to the forefront of swallowing neurophysiology research. This systematic review has summarized the methods and results of studies of swallowing neurophysiology of healthy adults using fMRI. A comprehensive electronic and hand search for original research was conducted, including few search limitations to yield the maximum possible number of relevant studies. The participants, study design, tasks, and brain image acquisition were reviewed and the results indicate that the primary motor and sensory areas were most consistently active in the healthy adult participants across the relevant studies. Other prevalent areas of activation included the anterior cingulate cortex and insular cortex. Review limitations and suggested future directions are also discussed.

[Relationship between eating dysfunction and life span and mortality in institutionalized elderly people]

AIM

The aim of this study was to evaluate the relationship between eating disorders and anticipated life span stage and mortality in institutionalized elderly people.

METHODS

Ninety-eight elderly residents (mean 86.3 +/- 5.9 years) at a nursing home were selected for investigation of the date and cause of death. Inclusion was limited to those who died within one week from admission to the institution/hospital. Data on 11 potential prognostic factors were analyzed: underlying disease, activity of daily living (ADL), disorder of anticipatory stage, swallowing function, need for feeding assistance, weight decrease rate in the part 6 months, body mass index (BMI), minimum nutritional assessment (MNA), occlusal status, age and sex. These 11 factors were analyzed by Kaplan-Meier survival curve, and either the log-rank or Wilcoxon test was used to analyze significant differences in survival days in subjects with and without the factors listed above. Moreover, the regression analysis was made using Cox proportional-hazards model, a nonlinear multivariate analysis, to extract factors contributing greatly to short survival days.

RESULTS

The survival days showed significant differences in six factors; ADL, disorder of anticipatory stage, swallowing function, need for feeding assistance, BMI and MNA. Three factors were shown to be related to a significantly shorter mortality by the Cox proportional-hazards model: disorder of anticipatory stage (hazard rate = 2.85, 95% CI = 1.04-7.83), swallowing function (hazard rate = 2.90, 95% CI = 1.06-7.91) and BMI (hazard rate = 2.54, 95% CI = 1.00-6.44) were involved in.

CONCLUSION

This study speculated that an appropriate response with a focus on feeding training may possibly contribute to prolong the mortality of elderly people.

Alzheimer's disease

BACKGROUND

The authors review the clinical features, epidemiology, pathophysiology, medical management, dental findings and dental treatment of patients with Alzheimer's disease (AD).

STUDIES REVIEWED

The authors conducted MEDLINE searches for 2000 through 2005 using the terms "Alzheimer's disease," "geriatric," "epidemiology," "pathophysiology," "treatment" and "dentistry." Reports selected for further review included those published in English in peer-reviewed journals. The authors gave preference to articles reporting randomized, controlled trials.

RESULTS

AD is a progressive and fatal neurodegenerative disorder characterized by cognitive dysfunctions, particularly in learning and memory, and the emergence of behavioral abnormalities. Deficiencies in the cells responsible for storage and processing of information underlie the cognitive, functional and behavioral changes seen in patients with the disorder.

CLINICAL IMPLICATIONS

As the elderly population grows, increasing numbers of Americans with AD will require dental treatment. The prevalence of dental disease likely will be extensive, because of diminished salivary flow and patients' inability to perform appropriate oral hygiene techniques. Preventive dental education for the caregiver and use of saliva substitutes and anticaries agents by the patient are indicated.

Effects of oral functional training for nutritional improvement in Japanese older people requiring long-term care

OBJECTIVES

The aim of this study was to evaluate the effect of oral functional training and nutrient supplements to improve the nutrition of malnourished elderly people in a nursing home.

BACKGROUND

Malnutrition is a frequent problem in the elderly requiring long-tem care; however, it is not clear whether oral functional training can be effective to improve nutrition.

SUBJECTS AND METHODS

Fourteen subjects of 82 residents (mean age 85.7+or-6.2 years) in a nursing home, who had a serum albumin level of <or=3.8 g/dl and understood the purpose of this study, were randomly divided into two groups of seven: one group served as the supplement group (mean age 87.0+/- 4.9 years) to which a high-calorie and high-protein diet was provided, and the other as the oral training plus supplement group (mean age 84.6+/- 10.1 years) to which oral functional training was given by a dental hygienist once a week as well as the above diet. Nutritional status was evaluated using serum biochemical values as indices at 4 months after the start of the intervention.

RESULTS

In the supplement group, serum albumin was 3.44+/- 0.36 g/dl at the start of the study (before intervention) and 3.24+/- 0.45 g/dl at 4 months after intervention. In the oral training plus supplement group, it was 3.56+/- 0.22 g/dl before intervention and significantly increased to 3.70+/- 0.33 g/dl after intervention (p<0.05: Wilcoxon signed-rank test).

CONCLUSION

Nutritional supplements alone were not adequate, but with oral functional training to maintain and improve feeding function, nutritional improvement in the elderly could be observed.

The McGill Ingestive Skills Assessment Predicts Time to Death in an Elderly Population with Neurogenic Dysphagia: Preliminary Evidence

The McGill Ingestive Skills Assessment (MISA) is a new assessment tool which quantifies the ingestive process by scoring a meal observation. The reliability and the construct validity of the MISA have been documented. However, establishment of the ability of the MISA to predict health outcomes related to feeding difficulties would support its applicability in research and in clinical settings. Seventy-three participants of a large-scale reliability and validity study were followed for up to 563 days following evaluation with the MISA. The date of the first pulmonary infection and the date and cause of death where applicable were obtained from medical records. Individuals with no incident of pulmonary infection and who were not deceased were "censored" at the date of followup. Survival analyses revealed that the MISA scores are predictive of death using a Cox proportional hazards model, and of time to pulmonary infection using a flexible model. Scores on the Solid Ingestion and Self-feeding scales are predictive of death using the Cox model, and the Texture Management scale is predictive of death using the flexible model. This effect remains statistically significant even when MISA scores are adjusted for the participant's age. These findings support the validity of the MISA for use with elderly individuals with neurogenic ingestive skill loss residing in long-term care facilities.

Survival-determining factors in patients with neurologic impairments who received home health care in Japan

BACKGROUND

The Japanese have become the longest-lived nation population in the world, and numbers of elderly who require medical and nursing care are increasing. The capacity of nursing homes and nursing institutions is sharply limited in Japan; further, as a group, elderly Japanese patients prefer home care to institutional care. For these reasons, the home health care system in Japan has been increasingly important.

OBJECTIVE

We sought to identify factors determining long-term survival in Japanese patients receiving home health care for neurologic disorders.

PATIENTS AND METHODS

We retrospectively evaluated 180 patients with neurologic disease, who received home health care conducted by our hospital between 1992 and 2001. Factors considered were age; gender; illnesses; prognosis; follow-up period; activities of daily living (ADL); behavioral, cognitive, and communicative functions; swallowing function; feeding method; serum nutritional values (total protein, albumin, and total cholesterol); hemoglobin concentration; and social care services provided at home.

RESULTS

Variables affecting long-term survival in 180 patients with neurologic disease were age (P<0.0002) and severity of dysphagia (P<0.04) by Cox's proportional hazard test.

CONCLUSION

Maintenance of swallowing function and adequate nutrition through a variety of feeding methods that can be provided by a home health care program are important for long-term survival of patients with stroke and also that of patients with other neurologic diseases.

Predictors of six-month survival among patients with dementia: an evaluation of hospice Medicare guidelines

The goal of the present study was to assess the validity of the Medicare hospice eligibility guidelines for dementia patients, as well as identify predictors that could more accurately identify prognosis in dementia patients referred to hospice. A retrospective chart review was conducted, including initial assessment and longitudinal follow-up of patients until the time of death. In addition, a second validation cohort was also followed. Participants consisted of 245 patients admitted to a large community-based hospice with a diagnosis of dementia, including a validation sample of 80 patients. The Kaplan-Meier estimation of survival and a Cox regression analysis (p > 0. 05) revealed no significant relationship between the Medicare guidelines or any component of the guidelines and survival at six months for the initial and validation samples. Significant multivariate predictors of shorter survival in both the initial and validation sample include greater age (p = 0. 02) and anorexia (p < 0. 001), as well as a combination of anorexia and greater functional impairment (p = 0.005). Overall, the results indicated that the Medicare guidelines were not valid predictors of survival in hospice patients with dementia and should be altered to include empirically valid predictors. Advanced age, as well as impaired nutritional and functional status, was associated with shortened survival in these patients. The predictor variables identified are an initial step toward providing improved prognoses for advanced dementia patients, their families, and practitioners. Broader issues in improving access to hospice care for dementia patients are discussed.

Treatment of protein-energy malnutrition in chronic nonmalignant disorders

Protein-energy malnutrition (PEM) is common in connection with chronic disease and is associated with increased morbidity and mortality. Because the risk of PEM is related to the degree of illness, the causal connections between malnutrition and a poorer prognosis are complex. It cannot automatically be inferred that nutritional support will improve the clinical course of patients with wasting disorders. We reviewed studies of the treatment of PEM in cases of chronic obstructive pulmonary disease, chronic heart failure, stroke, dementia, rehabilitation after hip fracture, chronic renal failure, rheumatoid arthritis, and multiple disorders in the elderly. Several methodologic problems are associated with nutrition treatment studies in chronically ill patients. These problems include no generally accepted definition of PEM, uncertain patient compliance with supplementation, and a wide range of outcome variables. Avail-able treatment studies indicate that dietary supplements, either alone or in combination with hormonal treatment, may have positive effects when given to patients with manifest PEM or to patients at risk of developing PEM. In chronic obstructive pulmonary disease, nutritional treatment may improve respiratory function. Nutritional therapy of elderly women after hip fractures may speed up the rehabilitation process. When administered to elderly patients with multiple disorders, diet therapy may improve functional capacity. The data regarding nutritional treatment of the conditions mentioned above is still inconclusive. There is still a great need for randomized controlled long-term studies of the effects of defined nutritional intervention programs in chronically ill and frail elderly with a focus on determining clinically relevant outcomes.

The selective vulnerability of brainstem nuclei to Alzheimer's disease

In a study of thioflavin S-stained serial sections from the entire brainstem, we found that the inferior and superior colliculi and the autonomic, monoaminergic, cholinergic, and classical reticular nuclei were affected with varying degrees of severity and frequencies in 32 patients with Alzheimer's disease, whereas no changes were seen in the brainstems of 26 control subjects. The majority of the affected nuclei in patients with Alzheimer's disease exhibit either neurofibrillary tangles or senile plaques, and only a few display both. However, when sections were immunostained with the antibodies 10D5 and AT8 or ALZ50, both beta-amyloid and hyperphosphorylated epitopes of tau protein were found to be present in various concentrations in all the affected nuclei. Our findings suggest that each brainstem nucleus has a distinct vulnerability to Alzheimer's disease-related pathological changes. Given that each nucleus has idiosyncratic neuroanatomical connections and prevailing neurochemical characteristics, the heterogeneous collection of brainstem nuclei can be considered a suitable anatomical ground for further investigation of selective vulnerability in Alzheimer's disease. The finding of severe pathological changes in some brainstem nuclei also raises the possibility that the dysfunction of these nuclei may contribute to the cognitive defects and increased rates of morbidity and mortality in patients with Alzheimer's disease.

Do nutrition indicators predict death in elderly Canadians with cognitive impairment?

This study describes the independent association between nutritional risk and death in older adults diagnosed with cognitive impairment. Canadian Study of Health and Aging participants who completed a clinical exam and were diagnosed with cognitive impairment and had complete data for regression analyses were included (n = 735). Nutritional risk was defined as the presence of at least one abnormal nutrition indicator identified during the clinical exam (history of weight loss, abnormal serum albumin, poor appetite, body mass index < 20). Other covariates believed to influence mortality were modelled with nutritional risk using logistic regression. There were 373 deaths during the five-year follow-up period in this sample. Nutritional risk was found to independently increase the likelihood of death (OR = 1.6, 95% CI 1.1, 2.2) in these older adults suffering from cognitive impairment. Further work is required to determine if interventions can improve nutritional status and quality of life of these older adults.

Severe pathological changes of parabrachial nucleus in Alzheimer's disease

In the first of a series of studies aimed at mapping brain stem pathological changes in patients with Alzheimer's disease (AD), we report a new finding regarding the parabrachial nucleus (PBN), a unit of paramount importance in the relay and integration of visceral and nociceptive information as well as in homeostatic control. The brains of 20 patients with AD were surveyed. The PBN contained pervasive neuropathological changes in 100% of the brains from those with early-onset dementia and in 80% from those with late-onset dementia. These changes were entirely absent in all 10 normal controls. The pathological changes of PBN, would cause autonomic dysfunction in patients with AD and perhaps contribute to the disproportionate mortality encountered in these patients.