CHAMP Dementia in the Hospitalized Older Adult

1. CHAMPDementia in the Hospitalized Older Adult Caroline Harada, M.D. University of Chicago

2. Dementia 101 2 topics you can teach: Decision making capacity Tube feeding Outline

3. Learners will: Be familiar with the diagnostic criteria for dementia Understand the steps in assessing decision making capacity Feel ready to teach the basics of decision making capacity on the wards Be able to teach others the arguments for why tube feeding not useful in end stage dementia Objectives

4. Dementia 101: Facts you can use on the wards

5. Prevalence in general population 4 million currently; 14-16 million by 2050 Affects 5-10% of people over 65 May affect up to 50% of people over age 85 Dementia is common Kennedy GJ. Geriatric Medicine, an Evidence Based Approach, 2003.

6. Dementia is often not mentioned in the medical record of patients with dementia 64% overlooked in Canadian Study of Health and Aging 79% overlooked in Indiana study 40% of vulnerable elders in ACOVE had cognition assessed at all Dementia is commonly overlooked Sternberg SA et al. JAGS, 2000 Boustani M. et al. JGIM, 2005

7. When to suspect dementia?

8. Screening MMSE MiniCog Diagnosis Diagnostic criteria If you suspect dementia…

9. Rule out delirium & psychiatric disorders Two of five domains impaired: Memory Language Visuospatial (Spatial ability /orientation /agnosia) Handling complex tasks Judgment/reasoning Decline from cognitive baseline Decline in function Diagnostic criteria Executive function Diagnostic and Statistical Manual of Mental Disorders- 4th edition, 1994.

10. Average life expectancy from time of diagnosis: 6 years Prognosis Knopman DS et al. Mayo Clin Proc, 2003.

11. Prognosis US population AD Larson EB et al. Ann Intern Med, 2004

12. Affects other diseases Bounce backs (d/c planning) Capacity for decision making Delirium End of life issues Why does dementia matter in an inpatient hospitalization? A B C D E Brauner DJ et al. JAMA, 2000.

13. Decision Making Capacity

14. Competence vs. Capacity Karlawish JHT & Pearlman RA. Geriatric Medicine, an Evidence Based Approach, 2003.

15. Task specific Sliding scale Dynamic Dementia does not have to mean lack of decision making capacity 90 million adults have fair to poor literacy Capacity Drane JF. JAMA 1984; Safeer RS & Keenan J. Am Fam Physician, 2005

16. See what the patient already knows Provide all the information needed Give a recommendation (if appropriate) Ask the patient to reiterate Key Steps

17. Medical condition and prognosis Recommended interventions and alternatives (including no intervention) Risks and benefits of the options Consequences of decision Key information to provide: Geriatrics at Your Fingertips, Online Edition. (accessed January 9 2006).

18. Ask the patient to rephrase: “Tell me in your own words…” “What are the alternatives?” “What are the risks of that intervention? “What would happen without this procedure?” How to determine DMC: Appelbaum PS, Grisso T. N Engl J Med 1988 Appelbaum PS, Grisso T. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. 1998.

19. Iterative process: If they don’t get it, correct or explain, then ask the patient to re-rephrase Optimize the circumstances Reduce stressors, distractions Treat delirium, depression, pain Optimize time of day Appelbaum PS, Grisso T. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. 1998.

20. Ability to communicate a choice Unimpaired level of consciousness, willingness to express a choice, reasonable stability of choice Ability to understand (and retain) relevant information Patient can recapitulate: current condition, plans being discussed, potential consequences of the various options Ability to appreciate the situation and consequences of a decision for oneself Patient acknowledges illness (when present) & general probabilities of risks and benefits as they apply to him or herself Ability to manipulate information rationally Patient reaches conclusions that are logically consistent with the starting premises Formal standards Appelbaum PS, Grisso T. N Engl J Med 1988, 319(25), 1635-1638.

21. Role Play: a DMC Conversation

22. Affects other diseases Bounce backs (d/c planning) Capacity for decision making Delirium End of life issues Why does dementia matter in an inpatient hospitalization? A B C D E

23. Tube Feeding in End-stage Dementia

24. Anorexia vs dysphagia vs agnosia/apraxia vs agitation Acute vs Chronic acute (then can treat underlying cause?) chronic (due to dementia itself?) Not eating?

25. No difficulties Subjective complaints Decreased job functioning Needs assistance with IADLs Requires assistance in choosing proper clothing to wear for the day Needs assistance with ADLs Stops talking, walking, sitting, smiling FAST stages ©1984 by Barry Reisberg, M.D. All rights reserved.Reisberg, B. Functional Assessment Staging (FAST). Psychopharmacology Bulletin. 1988:24: 653-659.

26. Why put in a tube?

27. No study has shown decrease in risk of aspiration pneumonia from PEG placement Doesn’t prevent aspiration of oral secretions Refluxed gastric contents can still be aspirated Enteral feeding may increase risk of aspiration (data mixed) LES pressure is decreased in tube fed patients J tubes may not be better than G tubes Prevent aspiration? Finucane TE. JAMA, 1999; Dharmarajan TS. Am J Gastroenterology, 2001

28. 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 50% in first year Improved Survival? Murphy LM. Arch Int Med, 2003; Dharmarajan TS. Am J Gastroenterology, 2001; Mitchell SL. Arch Int Med, 1997

29. Survival after PEG placement Dharmarajan TS. Am J Gastroenterology, 2001

30. Studies of dying cancer or ALS patients with anorexia: Little hunger or thirst Any thirst can be treated with mouth swabs and ice chips Sense of euphoria (endorphins) Goes away if fed Patients were left alone more Patient Comfort? Gillick MR. NEJM, 2000

31. Artificial nutrition and hydration may prolong the dying process

32. McCann RM, JAMA, 1994

33. Eating is pleasant! depriving a person (who wants to eat) of the pleasure of eating does not increase comfort Restraints are not comfortable Comfort?

34. Very little data One observational study failed to show an association Common sense: More likely to be immobile More likely to be restrained More often wet skin (sweat, stool, urine) Help wound healing/prevent pressure ulcers? Finucane TE, JAMA, 1999; Dharmarajan TS, Am J Gastroenterology, 2001

35. Observational studies show: No recovery of function No decrease in risk of infection Other benefits of tube feeding? Finucane TE, JAMA, 1999

36. Pulling out the tube Return trips to GI or IR Restraints Increased stool and urine output Caregiver burdens high Other considerations

37. Survival can be substantial despite emaciation and poor po intake Human, nurturing, time for closeness with loved ones Slow hand feeding Finucane TE, JAMA, 1999

38. Multiple swallows after each bolus Gentle coughs after each swallow Small bolus (less than teaspoon) Sit up Liquid supplements Decrease distractions Feed finger foods, thick liquids (gravy, ice cream, add cream & butter to things), hot or cold foods, strong flavors, favorite foods Feeding tips Finucane TE, JAMA. 1999

39. No evidence that tube feeding: Decreases risk of aspiration Prolongs survival (60% mortality at 6 months, perhaps 90% at one year) Improves comfort Decreases pressure sore risk Recommend slow hand feeding Tube feeding Finucane TE, JAMA. 1999; Gillick MR. N Engl J Med. 2000

40. Dementia is common, but commonly overlooked Diagnosis is by clinical criteria Prognosis is poor Determining decision making capacity Requires a dialogue with the patient Formal standards available to guide you Tube feeding vs. slow hand feeding Summary

41. Kennedy, GJ. Dementia in Geriatric Medicine, an Evidence Based Approach, 4th Ed. Cassel et al, Eds. 2003. p.1079 Boustani M, Callahan CM, Unverzagt FW, Austrom MG, Perkins AJ, Fultz BA, Hui SL, Hendrie HC. Implementing a screening and diagnosis program for dementia in primary care. J Gen Intern Med. 2005 Jul;20(7):572-7. Sternberg SA, Wolfson C, Baumgarten M. Undetected dementia in community-dwelling older people: the Canadian Study of Health and Aging. J Am Geriatr Soc. 2000 Nov;48(11):1430-4. Knopman DS, Boeve BF, Petersen RC. Essentials of the proper diagnoses of mild cognitive impairment, dementia, and major subtypes of dementia. Mayo Clin Proc. 2003 Oct;78(10):1290-308. Larson EB, Shadlen MF, Wang L, McCormick WC, Bowen JD, Teri L, Kukull WA. Survival after initial diagnosis of Alzheimer disease.Ann Intern Med. 2004 Apr 6;140(7):501-9. Brauner DJ, Muir JC, Sachs GA. Treating nondementia illnesses in patients with dementia. JAMA. 2000 Jun 28;283(24):3230-5. Karlawish JHT & Pearlman RA. Determination of Decision-Making Capacity, in Geriatric Medicine, an Evidence Based Approach, 4th Ed. Cassel et al, Eds. 2003. p.1233. Drane JF. Competency to give an informed consent. A model for making clinical assessments. JAMA 1984, 252(7), 925-927. Safeer RS & Keenan J. Health literacy: the gap between physicians and patients.Am Fam Physician. 2005 Aug 1;72(3):463-8. References

42. Geriatrics at Your Fingertips, Online Edition. http://www.geriatricsatyourfingertips.org/ebook/gayf_2.asp#c2s4_INFORMED_DECISION_MAKING (accessed January 9 2006). Appelbaum PS, Grisso T. Assessing patients' capacities to consent to treatment. N Engl J Med 1988, 319(25), 1635-1638. Appelbaum PS, Grisso T. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. 1998, New York: Oxford University Press. 31-60, 77-126. Reisberg, B. Functional Assessment Staging (FAST). Psychopharmacology Bulletin. 1988:24: 653-659. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. 1999 Oct 13;282(14):1365-70. Dharmarajan TS., et al. Percutaneous endoscopic gastrostomy and outcome in dementia. Amer J Gastroenterology. 2001; 96:2556-2563. Murphy LM, Lipman TO. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia. Arch Int Med. 2003; 163:1351-1353. Mitchell SL et al. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment.Arch Intern Med. 1997 Feb 10;157(3):327-32. Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med. 2000 Jan 20;342(3):206-10. McCann RM et al. Comfort care for terminally ill patients. The appropriate use of nutrition and hydration. JAMA. 1994 Oct 26;272(16):1263-6.