Weight Loss in Advanced Alzheimer's Disease Part II: Interventions

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Weight loss is a common occurrence in advanced Alzheimer's disease. Part II of this two-part article discusses effective interventions to prevent or improve weight loss in patients with Alzheimer's disease. Certain factors in the progression of the disease may promote weight loss and nutritional decline, such as abnormal eating behaviors, behavioral disturbances, dysphagia, taste and smell dysfunction, the effects of proinflammatory cytokines, or medication effects. Appropriate nutritional care for the Alzheimer’s patient with weight loss begins with identification of all contributing factors, a review of medications, medical history, and a thorough physical examination. Other members of the care team, especially the nutritionist and speech therapist, can also identify factors contributing to weight loss and help to develop and implement a care plan. All interventions to avoid or rectify weight loss and promote nutritional well-being should be based on careful assessments, frequently evaluated for effectiveness, and should reflect the overall goals of care for the individual patient.

This article is the second in a two-part series. Part I appeared in the May issue of the Journal.


Heidi K. White, MD, MHS. Weight Loss in Advanced Alzheimer’s Disease Part II: Interventions. Annals of Long-Term Care: Clinical Care and Aging: 2004;12[6]:34-38


INTRODUCTION

Effective nutritional interventions for patients with advanced Alzheimer’s disease (AD) in nursing care facilities must begin with a thorough assessment of the factors that may be contributing to weight loss or nutritional compromise. This initial assessment along with the development and implementation of a plan to improve nutrition will involve not only the physician but also the nutritionist, speech therapist, nurses, nursing assistants, and family members. Appropriate goals should be set that are consistent with the patient’s overall medical condition, with the wishes of the patient and with the likelihood that the nutritional condition is reversible. Each intervention that is initiated should be assessed for effectiveness. Periodically, both the goals and the plan of care should be reassessed as the patient’s condition changes. Within this framework specific nutritional interventions can be most effectively implemented (Table I).


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Table I: Framework for Effective Nutritional Intervention

Facility-wide Nutrition Program
- Staff training for hand-feeding and minimizing aspiration risk, accurate weight measurement, practical procedures for promoting hydration and nutrition

Individual Assessment
- Medical history, medication review, physical examination, include physician, nurses, nutritionist and speech therapist

Individual Nutritional Goals
- Consider medical conditions and patient wishes

Evaluate Effectiveness of Nutrition Interventions
- Careful monitoring with feedback from caregivers, reassess goals as the patient’s condition changes
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INTERVENTIONS FOR WEIGHT LOSS

Vigilance in monitoring weight and watching for changes in eating behavior are probably the most important steps that allow for swift intervention before serious malnutrition and complications result. In noninstitutionalized subjects with Alzheimer’s disease (AD) a combination of nutrition education and health promotion to prevent weight loss and malnutrition was effective in maintaining weight. [1]

For the most part, getting patients with dementia to eat is a process of trial and error. It is important to make sure that food is available not just at mealtimes but whenever the patient is inclined to eat. Many patients need supervision, constant reminders, and simple directions to complete a meal. Providing finger foods can be helpful for patients who are challenged by the use of utensils. [2] Appetite and alertness may be better early in the day so that breakfast and lunch become more substantial meals. Providing preferred foods can also increase intake. [3] Simplifying the environment so that there are fewer distractions during mealtime may be helpful as well.

Researchers have demonstrated that improving the ambiance during mealtime in a nursing facility by manipulating social and environmental aspects of mealtime improves food consumption and nutritional status. The intervention included manipulating factors such as decorations in the dining room, improving the presentation of food by taking it off of trays, and providing more staff to interact with patients at mealtime. They found a significant difference between groups with regard to weight change, with more intervention group subjects maintaining or gaining weight. [4] Studies that have implemented soothing dinner music for patients with dementia demonstrate that this intervention can improve mealtime agitation and food intake. [5,6] Taken together, these studies—although few in number and scope of intervention—suggest that a nutritional intervention that seeks to enhance the hedonic reward during mealtime may significantly benefit AD patients who are at risk for nutritional decline.


Maximize Taste and Smell

Flavor enhancement has been shown to increase food intake and maintain weight in nursing home residents. In one study, flavor enhancers were sprinkled over the food of the flavor group, but not over the meals of the control group. [7] The main finding was that repeated consumption of flavor-enhanced meals led to an increase in body weight of the flavor group, while the control group lost weight. [7]

Caregivers should take advantage of aromatous foods that stimulate the physiologic responses that prepare the individual for food intake and stimulate appetite. Foods that are flavorful and appealing should be served. Dietary restrictions such as low sodium and low cholesterol that limit aroma, flavor, and calories should be avoided. In addition to mealtimes, activities such as baking bread or popping popcorn can stimulate appetite and provide needed calories.


Nutrition Supplements

Oral liquid supplements should be given between meals to boost calorie consumption. [8] Previous interventions using nutritional supplements in older adults have met with mixed success. Liquid supplements should not replace food intake; they can result in decreased calorie consumption. [9]

Involving a nutritionist in the care of the patient will facilitate appropriate assessment, individualized interventions, and evaluation of these interventions. When liquid supplements are used without adequate assessment of the nutritional problem and without evaluation of their effectiveness, the results are disappointing. [10]

A routine vitamin/mineral supplement should be considered for all patients with moderate-to-advanced AD, because inadequacies in micronutrient intake are very common among eating-dependent nursing home residents. [11] Like all older adults, most patients with AD will require calcium and vitamin D supplementation. Several studies indicate that even subtle deficits in nutritional status can impact cognitive performance in older adults without dementia. [12,13] For example, Goodwin et al [14] showed that healthy elderly subjects who had subclinically low blood concentrations or intakes of folate, vitamin B [12], vitamin C, and riboflavin scored lower on tests of memory and abstract thinking. Even if nutritional supplementation does not improve cognitive symptoms, nutritional interventions (eg, multivitamin with minerals, calcium supplements, liquid calorie and nutrient supplements) may help to maintain muscle and bone mass necessary for continued independent physical function, and in more disabled patients can prevent challenging complications such as pressure ulcers.


Appetite Stimulants

Orexigenic agents are often considered in the treatment of end-stage dementia with nutritional decline. None have been studied for their effectiveness in patients with advanced Alzheimer’s disease. Megestrol acetate was studied in a group of Veterans Affairs nursing home patients with anorexia and cachexia who weighed less than 20% of the ideal body weight. [15] It did provide an improved sense of well-being and appetite. At the end of 3 months of treatment there was no significant change in weight compared to the placebo group. However, 3 months after treatment was discontinued there was a significant weight gain in the treatment group compared to the placebo group. A reduction in cytokine levels was also noted in the treatment group. [16] This study highlights the possibility that the effects of megestrol may be related to changes that take several months to have an effect on appetite and weight status. Careful studies of megestrol acetate in other patient populations, such as those with cancer and AIDS, have found an increase only in fat mass but no significant increase in lean body mass. No survival advantage has been demonstrated. Side effects include adrenal suppression, fluid retention, deep vein thrombosis, confusion, and impotence. Other agents that have been used to stimulate appetite, but for which there are little or no data regarding their use in advanced dementia, include cyproheptadine, dronabinol, testosterone, growth hormone, oxandrolone, and steroids.

When considering the use of an orexigenic agent, the etiology of the weight loss and the goals of care need to be carefully defined. Ifdysphagia is the primary issue hindering caloric intake then appetite stimulation may only serve to make the patient’s condition more uncomfortable. However, if agitation and distractibility are hindering intake, a greater sense of appetite may help the patient to focus attention on eating. The goals of care are also important to consider when making this decision since benefits may be even less in advanced dementia than in other disease processes. In other disease processes an improved sense of well being has been a meaningful and measurable outcome with orexigenic agents. However,patients with advanced dementia are not likely to experience an improved sense of well-being, since they cannot appreciate the importance of their nutritional health.


Antidepressants

In the situation of otherwise unexplained weight loss, even when symptoms of depression have not been clearly identified, a trial of an antidepressant may be reasonable. Although tricyclic antidepressants frequently result in weight gain for younger patients who consider this an unpleasant side effect, they may not produce this same effect in frail institutionalized patients. Side effects that include constipation, dry mouth, orthostatic hypotension, and urinary retention make these agents less desirable with the advent of selective serotonin reuptake inhibitors ([SSRIs] eg, sertraline, citalopram). Initial concern that SSRIs may produce weight loss in older adults has not been substantiated. [17] Mirtazepine, a multireceptor agonist, has been associated with increased appetite and weight gain in younger patients in comparison to SSRIs. However, effectiveness of this agent in producing significant weight gain in frail older adults or patients with dementia is unknown. In many instances weight gain may represent improvement in depression.


Tips for Hand Feeding

Caregivers should realize that feeding a patient who can no longer feed himself or herself can be very time-consuming. In the institutional setting, some patients may respond better to a particular caregiver, and specific techniques that are particularly effective in feeding a patient should be shared and mimicked by other caregivers. Research indicates that the quality of the relationship between the person being fed and the feeder is an important predictor of food intake. [18] Even patients with severe dementia respond best to caregivers who are personal, interested, involved, flexible, calm, cooperative, and more willing not to seek control in the relationship (Table II).

Patients who are dependent in feeding should be encouraged to drink fluids, since they are not able to regulate fluid intake according to thirst on their own. If they refuse or have difficulty with liquids, then foods with a high water content should be utilized such as ice cream, gelatin, and applesauce.


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Table II: Tips for Hand-Feeding

- Share feeding techniques that work

- Remain flexible, calm and cooperative

- Make the most of breakfast

- Remove distractions

- Maintain a pleasant eating environment
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Minimizing Aspiration Risk

A speech therapist can be helpful not only in diagnosing dysphagia and other eating problems, but can participate in developing the treatment plan and provide staff education for implementation. Altering food and liquid consistency can minimize the risk of aspiration. Semi-solid consistencies are generally tolerated better than liquids. Potentially helpful techniques to minimize the risk of aspiration include upright positioning of the patient during meals and for 30 minutes after meals, tucking the chin during swallowing, swallowing multiple times with each bolus, and keeping the bolus less than 1 teaspoon (Table III).


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Table III: Minimizing Aspiration Risk

- Only feed individuals in an upright position

- Maintain an upright posture for 30 minutes after meals

- Keep bolus size less than 1 teaspoon

- Provide good oral care

- Consider a swallowing evaluation by a speech therapist
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Good oral hygiene reduces the bacterial load in the mouth that can be aspirated and may decrease the risk of pneumonia. A growing number of studies indicate that angiotensin-converting enzyme inhibitors may elevate substance P levels and in so doing, stimulate cough and improve oral sensation, thus decreasing the risk of aspiration and pneumonia. [19]


Feeding Tubes

The time and effort necessary to feed patients with advanced AD can be overwhelming, and even with diligent care weight loss may continue and malnutrition ensue. Families, physicians, or nurses often consider feeding tubes as a possible intervention. Both physicians and patients’ surrogate decision makers tend to have high expectations for feeding tube placement to improve nutrition, functional status, and quality of life. [20] These high expectations for improved nutritional and health status are not supported by current research.

There have been no randomized clinical trials comparing tube feeding with oral feeding in patients with severe dementia. A review of existing literature by Finucane and colleagues [21] found no evidence to support that tube feeding prevents aspiration pneumonia. In fact, tube feeding does nothing to prevent the aspiration of oral secretions, nor can it prevent aspiration from regurgitated gastric contents. Jejunostomy, which places the feeding tube past the gastric outlet, is not associated with lower rates of pneumonia than gastrostomy. [22,23] Furthermore, Finucane and colleagues [21] found no evidence to support prevention of other infections, the consequences of malnutrition, or pressure ulcers. They found no evidence to support a survival benefit, improved functional status, or greater patient comfort. Adverse events associated with feeding tubes include aspiration pneumonia, tube occlusion, leakage, and local infection. The mortality during percutaneous endoscopic gastrostomy tube placement is low (0-2%), but perioperative mortality ranges from 6-24%.

In circumstances where careful hand feeding has not provided adequate nutrition and has resulted in pneumonia or other complications of malnutrition, the possibility of providing food and liquid as tolerated but allowing a natural death to occur should be considered. For the patient with severe dementia, the decision of whether or not to institute a feeding tube ultimately lies with the patient’s family or guardian. However, families and physicians are often aided by advance directives that allow patients with dementia to convey their wishes regarding this issue either before or during the early stages of disease. It is important for health care providers to initiate these conversations with the patient regarding care at the end of life when cognitive abilities will still allow a meaningful discussion. The decision of whether or not to institute a feeding tube should be made knowing that current research does not support the belief that a feeding tube will help the patient’s condition. Patients and their families should receive appropriate guidance and recommendations from their physicians. In most cases, given the current evidence the recommendation is likely to be against tube feeding in favor of careful hand feeding. Federal regulations should not be seen as a barrier to this course of action as long as the eating problems are identified and properly assessed, and reasonable efforts to hand feed are being made. [24] Careful documentation by the physician and other care providers should indicate that nutritional decline is not preventable because of the patient’s advanced dementia diagnosis.


SUMMARY RECOMMENDATIONS

A physician should evaluate the patient with advanced AD who is losing weight, has a low body mass index, or has unmet nutritional needs (eg, pressure ulcers). A thorough medical history and physical examination should be done. The physician, nutritionist, speech therapist, nurse, direct care worker, and family should contribute to the process of evaluation and the implementation of the nutrition care plan. All of these individuals must work together to ensure that weight loss and malnutrition are recognized, evaluated, and treated. The effectiveness of each intervention must be evaluated. Maintaining nutritional health will not always be possible. The goals of care must be clear to all involved, which may range from expected improvement in nutritional status to supportive and palliative care in the face of an advanced and terminal condition. The goals of care are likely to evolve as assessments are made and interventions evaluated. The nursing home medical director and primary care physicians of individual patients must provide leadership to this process, especially when alternatives to oral feeding are considered. The leadership within individual nursing facilities should discuss and determine their evaluation and implementation process for recognizing and intervening to prevent weight loss and nutritional decline. Certain interventions such as improving the dining environment or careful hand feeding are best implemented through a facility-wide nutrition program. Nutritional policies and procedures need to include not only the recognition and treatment of weight loss, but also a plan for palliative and supportive care when end-stage dementia precludes our ability to overcome nutritional decline.


References

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15. Yeh SS, Wu SY, Lee TP, et al. Improvement in quality-of-life measures and stimulation of weight gain after treatment with megestrol acetate oral suspension in geriatric cachexia: Results of a double-blind, placebo- controlled study. J Amer Geriatr Soc 2000;48(5):485-492.

16. Yeh SS, Wu, SY, Levine DM, et al. The correlation of cytokine levels with body weight after megestrol acetate treatment in geriatric patients. J Gerontology Series A-Biological Sciences & Medical Sciences 2001;56(1):M48-54.

17. Rigler SK, Webb MJ, Redford L, et al. Weight outcomes among antidepressant users in nursing facilities. J Am Geriatr Soc 2001;49:49-55.

18. Amella EJ. Factors influencing the proportion of food consumed by nursing home residents with dementia. J Am Geriatr Soc 1999;47: 879-885.

19. Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest 2003;124:328-336.

20. Cox CE, Lewis CL, Carey TS, et al. Expectations and outcomes of feeding tube placement from the perspective of patients’ surrogates and physicians. J Gen Intern Med 2002;17(S1):187.

21. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: A review of the evidence. JAMA 1999; 282(14):1365-1370.

22 Lazarus BA, Murphy JB, Culpeper L. Aspiration associated with long-term gastric versus jejunal feeding: A critical analysis of the literature. Arch Phys Med Rehabil 1990;71:46-53.

23. Fox KA, Mularski RA, Sarfati MR, et al. Aspiration pneumonia following surgically placed feeding tubes. Am J Surg 1995;170:564-566.

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