Nutritional Care, Support Key for Dementia Patients

Abstract

Balancing potential benefit and burden of nutritional interventions and providing support should be an integral part of dementia management, according to experts from the European Society of Clinical Nutrition and Metabolism (ESPEN). In new evidence-based guidelines, the panelists recommended screening and monitoring of body weight as well as adequate nursing support around eating and a pleasant dining environment for patients with the condition. Published in Clinical Nutrition (Clin Nutr 2015;34:1052–73) the guidelines on nutrition and dementia were written by a panel that was made up of 86 physicians, nutritionists, and dietitians experienced in treatment and nutritional therapy in patients with dementia. They assessed reports from a systematic literature search of PubMed and the Cochrane Library to arrive at a grading of the evidence and strength of recommendation. That scoring then was subject to a discussion by the experts who took into consideration risk/benefit ratios, costs, and a review of supportive evidence, which concluded when consensus was reached. The resulting guidelines span 26 recommendations, from screening and monitoring of weight through provision of meals and use of appetite stimulants, supplements, and artificial nutrition. For all individuals with dementia, regardless of the disease state, the experts recommended screening for malnutrition and close monitoring of body weight. To encourage oral nutrition, sufficient food should be available in an attractive, pleasant environment and with adequate nursing support. The panel noted that weight loss is common in patients with dementia, for a variety of reasons, such as brain atrophy and pathological changes in the olfactory system. Issues with shopping for and preparing of food may occur with early-stage disease, whereas behavioral problems and oral dysphagia are common in more advanced disease. In individuals with dementia, weight loss is associated with increased risk of mortality, hence the need for a focus on nutrition. For screening, the experts recommend using the validated Mini Nutritional Assessment-Short Form (MNA-SF) and having relatives or professional caregivers answer the six questions about a patient with dementia to ensure that the information obtained is reliable. Tools to identify specific eating disorders include the Aversive Feeding Behavior Inventory, the Edinburgh Feeding Evaluation in Dementia Questionnaire, and the Eating Behavior Scale. Weighing patients at 3-month intervals and under consistent conditions is suggested, except in patients with end-stage disease because the practice may do them more harm than good. In an LTC setting, serving meals family-style, in a home-like setting, with adequate lighting and relaxing background music, has been found to have a positive impact on nutrition in patients with dementia. The panelists also recommended that staff bring residents to tables and sit down and talk with residents as they eat, offering prompts and encouragement to promote self-feeding. An adequate diet for individuals with dementia, the experts said, should include fruits, vegetables, legumes, and unrefined cereals with moderate amounts of dairy products, low intake of meat, and regular intake of fish. Snacks should be available to supplement regular meals. In some observational studies, use of high-energy/protein foods has been shown to have a positive impact on dietary intake and body weight in patients with dementia in LTC settings. Reviewing the literature on use of appetite stimulants in patients with dementia, the panelists found only limited evidence. They also did not recommend use of omega-3-fatty acids or of vitamins B1, B6, B12, or folic acid supplements 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. Systematic use of special medical foods such as lyophilized foods or nutraceutical formulations have potential to affect cognitive function, the experts said, and may be effective under certain conditions, but current evidence is too weak to support their general use. Artificial nutrition can be used for a short period of time to overcome a crisis situation in a patient with mild or moderate dementia who has markedly insufficient oral intake. The panelists did not, however, recommend artificial nutrition in patients with severe dementia or who are terminally ill. Judith M. Orvos, ELS, is a freelance medical writer and president of Orvos Communications in Washington, DC.