P rognosis

Prognosis

Life expectancy from the time of diagnosis:

Alzheimer Disease 5-10 years

Vascular Dementia 4 years

Dementia with Lewy Bodies 4 years

What is an advance directive??

DNRLiving willDPOA HC

Weight loss

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

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

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

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

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

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

Feeding tubes

When are theyappropriate?

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