(CA)(A) NH Flashcards
NICE recommendations regarding artificial feeding in people with severe dementia
NICE recommendations regarding artificial feeding in people with severe dementia:
* Shouldn’t be routinely offered
* Could be offered short term if dementia related feeding issues (eating, drinking or swallowing) will be resolved and oral feeding can resume
* Treatable reasons for loss of appetite (constipation, sore mouth, indigestion, swallowing difficulties etc.) should be addressed to improve oral intake
* If dysphagic: texture modified meals & drinks (SALT input needed)
* Offering food person enjoys even if they don’t want/cannot eat much
* Dry sore mouth: fruit juice/water offered to maintain moisture
Why don’t NICE recommend routine artificial feeding in people with severe dementia? (COCHRANE Review Sampson et al., 2009)
Reasons why NICE don’t recommend routine artificial feeding in people with severe dementia:
* 1 study from review suggests that people living with severe dementia are MORE likely to get aspiration pneumonia (food/liquid in lungs) than people E+D normally (Cochrane review Sampson et al., 2009: study in care home residents 58% enteral feeding got asp pneumonia, only 17% E+D got it )
* Cochrane review Sampson et al., 2009: found no evidence of increased survival in patients receiving enteral tube feeding.
* **No evidence of benefit in nutritional status or the prevalence of pressure ulcers. **
* However studies didn’t investigate benefits on QOL.
What are the ETHICAL CONSIDERATIONS of artificial feeding in patients living with dementia?
ETHICAL CONSIDERATIONS of artificial feeding in patients living with DEMENTIA:
* Autonomy, what would the individual actually want?
* Tube feeding is a MEDICAL INTERVENTION: risks and benefits must be considered
* Goals & outcomes need to be documented
* Monitoring is needed to evaluate if goals are being met
* Communicate early to get patient’s wishes
* Will QOL be improved?
* Trial feed for a set period could be used to monitor goals
What is Clinically Assisted Nutrition and Hydration?
Clinically Assisted Nutrition and Hydration (CANH) is ALL forms of tube feeding but does not include oral feeding e.g. ONS.
ALL forms of CANH are deemed to be ? ? and are treated in the same way as all other ? interventions.
ALL forms of CANH are deemed to be medical treatment and are treated in the same way as other medical interventions.
Other reasons why NICE don’t recommend CANH in people with severe dementia
Other reasons why NICE don’t recommend CANH in people with severe dementia
* NG insertion could be distressing and uncomfortable
* PEG insertion has risk of complications due to anaesthia/sedative
* Risk of infection at site of tube insertion
* Tube presence may be distressing. Patient may attempt to remove it: particularly harmful if it is a PEG
* Being admitted to hospital for PEG could be distressing and could limit patient activities once inserted
* Pain during recovery
All reasons why NICE don’t recommend CANH in people with severe dementia
ALL reasons why NICE don’t recommend routine artificial feeding in people with severe dementia:
* 1 study from review suggests that people living with severe dementia are MORE likely to get aspiration pneumonia (food/liquid in lungs) than people E+D normally (Cochrane review Sampson et al., 2009: study in care home residents 58% enteral feeding got asp pneumonia, only 17% E+D got it )
* Cochrane review Sampson et al., 2009: found no evidence of increased survival in patients receiving enteral tube feeding. **No evidence of benefit in nutritional status or the prevalence of pressure ulcers. **
* However studies didn’t investigate benefits on QOL.
* NG insertion could be distressing and uncomfortable
* PEG insertion has risk of complications due to anaesthia/sedative
* Risk of infection at site of tube insertion
* Tube presence may be distressing. Patient may attempt to remove it: particularly harmful if it is a PEG
* Being admitted to hospital for PEG could be distressing and could limit patient activities once inserted
* Pain during recovery
Limitations to the Cochrane Review NICE cite for recommendations regarding CANH in dementia
Limitations to the Cochrane Review NICE cite for recommendations regarding CANH in dementia
* **Many of the studies included only mentioned albumin as a marker of nutritional status **but albumin isn’t a marker of nutritional status it can be used with CRP to indicate inflammation. Albumin reduces regardless of nutritional status (Evans et al.,)
* The studies included in the review only investigate the use of NG & PEG
* None of the studies were randomised control trials: which increases the risk of bias
* Only 1 of the studies used a validated diagnostic criteria of dementia
* Participants in studies: some didn’t have dementia. Some had varying levels of dementia, some were undefined. How did NICE interpret this for application in SEVERE dementia?
* The authors stated that results were inconclusive but NICE said there was no “good” evidence.
* NICE state NO evidence of ENT having positive effect on pressure ulcers **but1 study found fewer PUs in tube fed **and this was statistically significant.
* Study that found greater PUs in ENT fed was not a statistically significant finding.
Although recent Cochrane review supports that greater PUs in ENT fed has moderate evidence
Pros to the Cochrane Review NICE cite for recommendations regarding CANH in dementia (Sampson et al., 2009)
Pros to the Cochrane Review NICE cite for recommendations regarding CANH in dementia (Sampson et al., 2009):
* Various sources scoured for evidence: databases/theses etc.
* Authors of studies were contacted when information was missing
* Authors were transparent about their search methods
What are some of the unwanted effects that enteral tube feeding can have on a patient with dementia?
Unwanted effects that enteral tube feeding can have on a patient with dementia:
* discomfort/pain
* pneumonia
* worsen bowel or bladder control
* bleeding
* swelling
* infection
* Severe dementia: may be confused or distressed by the tube and may try to remove it
Why is CANH considered in people living with dementia?
Reasons why CAMH is considered in people living with dementia:
* People with dementia often have difficulties E+D
* ** Early stages of dementia: **
1. may forget to eat
2. chew food without swallowing
3. be confused at mealtimes.
4. may experience changes in the taste and smell of food.
* ** Later stages of dementia:**
1. people often have difficulties swallowing: can be difficult to ensure they receive appropriate food and fluids. (texture modification could combat this)
Main findings from Cochrane Review about ENT feeding in dementia (Davies et al., 2021)
Main findings from Cochrane Review about ENT feeding in dementia (Davies et al., 2021)
* PEG may make no difference to how long people live (4 studies, 36,816 people)
* PEG leads to a small increase in the chance of developing pressure sores (1 study, 4421 people).
* PEG or nasogastric tube feeding may increase the length of time people live (4 studies, 1696 people)
* PEG or NG tube feeding may slightly increase the chance of developing pressure sores (3 studies, 351 people)
* ENT feeding may increase caregiver burden
Limitations:
* Moderate confidence: pressure ulcers were more common in people who were fed with a PEG tube.
* Little to very little confidence for other findings.
Reasons for confidence ratings:
* Participants not randomly placed into different treatment groups. This means that differences between the groups could be due to differences between people rather than between the treatments.
* However: ethical considerations would make it very difficult to do this in future studies.
* Results were very inconsistent across the different studies
* Some studies were very small.
Limitations and reasons for confidence ratings (Davies et al., 2021:Cochrane review) ENT feeding in dementia
Limitations and reasons for confidence ratings (Davies et al., 2021:Cochrane review) ENT feeding in dementia
Limitations:
* Moderate confidence: pressure ulcers were more common in people who were fed with a PEG tube.
* Little to very little confidence for other findings.
Reasons for confidence ratings:
* Participants not randomly placed into different treatment groups. This means that differences between the groups could be due to differences between people rather than between the treatments.
* However: ethical considerations would make it very difficult to do this in future studies.
* Results were very inconsistent across the different studies
* Some studies were very small.
Where is more research needed regarding ENT feeding in dementia patients?
Regarding ENT feeding in patients with dementia. More research is needed about:
* QOL
* Effect on behaviour
* Effect on psychological symptoms of dementia
What is the definition of palliative care?
Palliative care definition:
* Improving QOL of patients and their families when dealing with issues associated with life threatening/terminal illness
* prevention and relief of suffering
* treatment of pain
* treatment of physical/psychosocial/spiritual needs
via early and impeccable assessment
* aims to improve the quality of life of patients experiencing a life-limiting illness. It also involves offering support to families and carers.
What are the 3 issues to consider in palliative care?
The 3 issues to consider in palliative care are:
* Physiological/metabolic
* Family & friends
* Psychological
Name some of the physiological & metabolic issues of PALLIATIVE CARE
Physiological & metabolic issues of PALLIATIVE CARE:
* Neurological conditions: increased swallowing difficulty
* COPD: breathing difficulties
* Cancer: side effects of treatment (nausea, taste changes, dry mouth)
* Cancer: altered metabolism. Cachexia.
* Ketone bodies: impact on hunger
* Absorption: reduced GI absorption
* Delayed gastric emptying
How do ketone bodies affect hunger?
Ketone bodies affect hunger by:
* Reducing appetite
via:
1. potentially lowering ghrelin levels (hunger stimulating hormone) (studies suggest it doesn’t have an effect)
What issues might arise between palliative patients and their family regarding nutrition?
Issues might arise between palliative patients and their family regarding nutrition:
* Decreased appetite is common
* Patient may perceive food differently
* Family may want patient to eat more/force them to eat more
Psychological issues of the patient
Psychological issues of the patient
* The patient with advanced illness may well perceive food differently depending on the present stage of their disease
* Depression – anorexia: due to being diagnosed with a progressive/incurable illness
* Anger
* Guilt
* Pain
Cycle of psychological issues in palliative care-family
Cycle of psychological issues in palliative care-family
1. Patient getting weaker, frailer, not eating
2. Try harder with getting them to eat
3. Thoughts: “We can’t let them starve”
4. Conflict between
patient/family/HCP
5. Frustration and anger from patient and family
Dietitians role in palliative care
Dietitians role in palliative care
* Identify & address nutritional factors that impair a patient’s physical & psychological wellbeing
* Assess the nutrition needs and problems of the patient
* Establish the most appropriate nutrition support measures
* Suggest appropriate strategies to alleviate nutrition related problems caused by physical or psychological effects of the disease and its treatment
* Provide support for families and carers
* Liaise with catering providers to provide a flexible approach to food provision/meet patient wishes
* Provide education, training and support
* Act on patient’s wishes, but support family/carers
* Maintain/improve the quality of life for the patient
* Identify need for eating aids to assist with independent eating
The patient with advanced illness may well perceive food ? depending on the present stage of their disease
The patient with advanced illness may well perceive food differently depending on the present stage of their disease
What is the primary objective of nutrition support in palliative care?
The primary objective of nutrition support in palliative care:
* maintain/improve quality of life
How long does the palliative stage last?
The palliative stage lasts months-years. It is difficult to quantify/estimate
Where might palliative care take place?
Palliative care may occur at home, day-care centres, hospitals, hospices, nursing/care homes or palliative care units.
It is important that palliative care is patient focused, considering an individual’s needs and choices are considered but to also?
It is important that palliative care is patient focused, considering an individual’s needs and choices are considered but to also provide support to carers.
ALL HCPs should know when to ?
ALL HCPs should know when to refer patients to palliative care
What are the benefits of nutritional support in palliative care?
Benefits of nutritional support in palliative care:
* Increase energy
* Resistance to infection
* Minimise muscle wastage/prevention of pressure sores
* May allow some control over illness
* maintain a sense of normality
* Improve quality of life and a sense of wellbeing
* Better tolerance to medication/treatments
Why might palliative patients that are struggling to eat be fearful?
Palliative patients that are struggling to eat may have feelings of fear and despair as eating is usually associated with health and wellbeing. This might lead to social isolation and depression
How might progressive/incurable illness impact nutritional status? (Manual of Dietetic Practice)
How might progressive/incurable illness impact nutritional status? (Manual of Dietetic Practice)
* Psychological effect: depression/anxiety/hopelessness> reduced intake
* Worsening symptoms of the disease e.g. fatigue, dysphagia
* Medication side effects e.g. n&v&d, drowsiness, opioids
* Treatment side effects e.g. chemotherapy: dry mouth
* Increased nutritional requirements due to physiological effects of illness e.g. pyrexia, increasing tumour mass
* Final phase of illness: delayed gastric emptying, decline in persitalsis etc. Appetite and the ability to tolerate food decreases.
