This action might not be possible to undo. Are you sure you want to continue?
Laura C. Hanson, MD, MPH,Ã wz Mary Ersek, PhD, RN,§ Robin Gilliam, MSW,z and Timothy S. Carey, MD, MPHzk
OBJECTIVES: To review the beneﬁts of oral feeding options in people with dementia. DESIGN: Systematic literature search with review of potentially eligible studies by two independent investigators. SETTING: PubMed/MEDLINE, EMBASE, the Cochrane Library, CINAHL, and PsychINFO literature indices between January 1990 and October 2009. PARTICIPANTS: Clinical trials with random or nonrandom control groups were included if they reported on clinical outcomes of oral feeding interventions for people with dementia. MEASUREMENTS: Investigators abstracted data from included studies using a structured instrument. Studies were graded on quality and potential bias, and overall strength of evidence was summarized. RESULTS: Thirteen controlled trials provided data on use of supplements for people with dementia, and 12 controlled trials tested assisted feeding or other interventions. Studies provide moderate-strength evidence for high-calorie supplements, and low-strength evidence for appetite stimulants, assisted feeding, and modiﬁed foods to promote weight gain in people with dementia. The few studies measuring function or survival showed no difference. CONCLUSION: High-calorie supplements and other oral feeding options can help people with dementia with feeding problems to gain weight; they are unlikely to improve other outcomes. These treatments can be offered alone or in combination as an alternative to tube feeding. J Am Geriatr Soc 59:463–472, 2011.
Key words: dementia; oral feeding
From the ÃDivision of Geriatric Medicine, wCenter for Aging and Health, z Cecil G. Sheps Center for Health Services Research, and kDivision of General Internal Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and §School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania. Address correspondence to Laura C. Hanson, Division of Geriatric Medicine, Cecil B. Sheps Center for Health Services Research, CB 7550, University of North Carolina, Chapel Hill, NC 27599-7550. E-mail: lhanson@med. unc.edu DOI: 10.1111/j.1532-5415.2011.03320.x
ementia is a syndrome of decline in cognitive domains causing functional impairment. In the early stages of dementia, taste and smell dysfunction, medications, or depression may reduce intake.1 In advanced dementia, apraxia and attention deﬁcits interfere with self-feeding, and dysphagia causes choking or food avoidance.2 Feeding problems cause important health effects such as weight loss, dehydration, poor wound healing, and pneumonia. In the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life Study, 86% of persons with advanced dementia developed a feeding problem, and onset was associated with 39% mortality at 6 months.3 Treatments include medical feeding through a feeding tube and modiﬁcations of oral feeding such as high-calorie supplements, appetite stimulants, modiﬁed foods, enhanced dining environments, and personal assistance. The use of feeding tubes has increased for people with serious illness, particularly dementia and other neurological diseases.4–7 Controlled observational studies of persons with dementia provide evidence that tube feeding does not prolong life or promote wound healing.8–11 Physicians and families make choices about feeding in dementia. Interview studies suggest they expect beneﬁts from tube feeding that exceed actual outcomes.12,13 Consent for feeding tubes usually focuses on procedural risks, with limited information on outcomes and alternatives.14,15 If the choice is framed as opting for or against tube feeding, families may fear starvation without understanding other options. To enhance evidence-based decision-making, a systematic review of oral feeding options in dementia was conducted. The goal was to answer two important questions for dementia care: Does the addition of high-calorie supplements improve clinical outcomes, including weight gain, function, and survival? Do other oral feeding interventions such as appetite stimulants, assisted feeding, and modiﬁed diets improve outcomes?
JAGS 59:463–472, 2011 r 2011, Copyright the Authors Journal compilation r 2011, The American Geriatrics Society
it was planned to include only studies of dementia. appetite stimulants Exclusion: supplements without caloric value. dementia diagnosis and severity. Intervention. matched. pneumonia. and wound healing. Development and Evaluation criteria for overall strength of evidence. OR dementia. keywords. with concealed allocation. Participants could be in any settingFcommunity. weight change. hospitalization. those meeting three to four had medium risk. dysphagia. Data tables were created for summative assessment of evidence for each key question. MARCH 2011–VOL. risk of confounding bias. PICOT Criteria and Search Strategy Population of interest Inclusions: Adults aged 50 and older with any type or stage of dementia who have evidence of a feeding problem as deﬁned as weight loss. function. studies with ineligible interventions. time to follow-up. Intermediate outcomes such as serum proteins and amount of intake were excluded. Outcomes. e. A comparator group was required. The structured abstraction tool recorded study size. Reference lists of selected studies were hand searched for additional clinical trials. nonrandom comparison. including randomized control group.. methods of double or single blinding. NO. and potential sources of bias. Risk of bias was rated on type of controls. Outcomes.17 Strength of evidence was graded A if randomized. and studies excluding dementia. representing 912 unduplicated publications. were accepted. such as vitamins. type of controls. or wound healing) measured over followup of at least 1 month Exclusion: Study reports only intermediate outcomes such as serum protein levels or amount of intake Follow-up of 1 month or longer Intervention of interest Comparison Eligibility and Study Selection Investigators deﬁned eligibility before searches using the PICOT framework. OR feeding behavior. aspiration. multi-infarct Long-term care populationsFnursing homes OR long-term care OR institutionalized elders OR institutionalized seniors FeedingFmalnutrition OR weight loss OR inhalation OR dehydration OR eating problems OR decreased intake OR nutrition OR eating OR deglutition disorders. and Time frame. investigators searched the PubMed/MEDLINE. Studies had to address at least one major clinical outcome. OR anorexia.g. OR weight gain. Searches used a combination of medical subheadings. EMBASE. 59. Table 1. Outcomes Time frame PICOT 5 Population. assisted feeding. CINAHL. those that combined frail older persons with and without dementia were accepted. Initially. aspiration. modiﬁed diets. and methods indicative of study quality. including survival. Search terms for dementia and long-term care were used in combination with terms to identify interventions for nutrition or feeding problems (Table 1). or decreased intake or other evidence of risk of nutritional decline Inclusions: high-calorie or high-protein supplements. assistance in feeding. well-speciﬁed outcomes. B if randomized without clearly deﬁned concealment. ME). Two investigators (RG. study setting. enhanced dining programs. results. .147 potential studies and hand searches 65. modiﬁed diets. with follow-up of at least 1 month. outcome deﬁnitions and results. quality of life. OR airway obstruction OR choking OR energy intake. 3 JAGS METHODS Data Sources Assisted by an experienced health services librarian. Because some study populations varied in cognitive status. and those meeting zero to two had high risk of bias.464 HANSON ET AL. pneumonia. Comparison Groups. LCH. OR failure to thrive OR aspiration OR dysphagia OR dietary supplements Feeding methodsFfeeding methods OR hand feeding OR feeding programs OR assisted feeding OR dining program OR restorative dining OR feeding aide OR nutritional support OR supplementation Clinical trial or intervention study or systematic reviewFrandomized controlled trials OR single-blind method OR double-blind method OR random allocation OR systematic reviews OR evaluation studies OR program evaluation Data Abstraction and Quality Assessment Three investigators reviewed all full-text articles (RG.’’ or alternative feeding intervention including tube feeding Inclusions: One or more of the following outcomes (survival. quality of life. Search Terms Used for All Databases DementiaFdementia OR Alzheimer disease. Intervention. or hospital. with inadequate concealment. well-speciﬁed inclusion criteria.16 This framework designates Population. A third investigator settled cases of disagreement. intervention and control conditions. and modiﬁed dining environments. Study participants were aged 50 and older. Eligible studies were in English. studies that were not clinical trials. Studies meeting ﬁve to seven of these criteria were judged to have low risk. and intention-to-treat analysis. long-term care. and Time frame for outcomes (Table 2). but randomized or nonrandomized controlled studies. and PsychINFO literature indices between January 1990 and October 2009. Table 2. weight change. with dementia of any stage or etiology and evidence of a feeding problem. feeding aide programs. more than 75% complete outcome assessment. Eligible interventions included prescribed use of high-calorie or -protein supplements and other interventions such as appetite stimulants. Two investigators reached consensus on abstracted data on methods. Comparison groups. the Cochrane Library. LCH) reviewed all titles and abstracts and excluded duplicates. and text words. Evaluation terms were added to ensure that smaller studies were not missed. placebo-controlled. function.18–20 RESULTS Databases identiﬁed 1. study quality. hospitalization. type of feeding problems. Two investigators graded each included study on the strength of evidence and the risk of bias using the Cochrane rating approach. historical control. vitamin supplements Any comparison group. Supplements without caloric value. and C if not randomized. including pre–post design. pre– post design with subject as own control Comparison group may have received no intervention. were excluded. Investigators used the Preferred Reporting Items for Systematic reviews and MetaAnalyses Statement to guide reporting of evidence and Agency for Healthcare Research and Quality comparative effectiveness review guidelines and Grading of Recommendations Assessment. or ‘‘usual care.
Flow of information for systematic review of feeding interventions.33 Studies of Assisted Feeding and Other Interventions Twelve studies of diverse nutritional and environmental interventions that improved clinical outcomes for people with dementia were identiﬁed. with mixed results. Follow-up ranged from 3 to 12 months. two high-quality randomized clinical trials addressed the effectiveness of high-calorie supplements for people with dementia (Table 4). and physical and cognitive function (Table 3). One additional trial with possible inadequate randomization and one study using a pre–post design provided lower-quality evidence. Lower and higher quality studies had similar outcomes. Studies rarely reported potential harms from supplements. PICOT 5 Population. with a trend toward improving Additional studies identified through hand searches n=65 Studies after duplicates removed n=912 Studies excluded at abstract level n=802 Full-text articles assessed n=110 Full-text articles excluded n=85 Do not meet PICOT criteria: n=69 Not an intervention study: n=16 Studies included in full review n=25 Aim 1 13 Aim 2 12 Figure 1. and individualized nutritional care plans (n 5 4). Wound healing was more rapid in the intervention group over 12 weeks. Intervention. Nine additional randomized trials provided Grade B evidence for supplement use in dementia. and six demonstrated beneﬁt. six found positive effects (Table 3).005). Study populations varied in the severity of cognitive impairment and nutritional problems. high-protein supplement with micronutrients or usual diets.05). morbidity.8 kg over 12 weeks. leaving 110 articles for full-text review. . with mean reduction of wound size of 75%.23 Although this study met inclusion criteria.39 Three studies tested effects of feeding interventions on behaviors. whereas intervention participants gained 1. Ten studies used weight or BMI as outcomes.4 kg. and one measuring mortality found no differences with supplementation. P 5. Follow-up varied from 1 month to 1 year. particularly those with lower baseline weight.31 Controls lost an average of 0. Nine of 12 studies examining weight or BMI found improvement. 59. One found that dronabinol improved weight and reduced negative affect. Outcomes. including exercise (n 5 1). wound healing. yet weight gains were consistently 0. two-thirds of participants used tube feedStudies identified through database searching n=1. 3 REVIEW OF ORAL FEEDING IN DEMENTIA 465 Abstract and title review excluded 802.23 Four studies measuring function. Studies of High-Calorie Supplements for Dementia Thirteen original studies were identiﬁed that examined the effect of high-calorie supplements on clinical outcomes for feeding problems in people with dementia.45 Three studies tested appetite stimulants for people with dementia.21–33 Studies examined a variety of outcomes meeting the criteriaFchange in weight or body mass index (BMI). changes in environment with buffet-style dining (n 5 1) or music (n 5 1).0 kg. two trials using these outcomes found no beneﬁt. One study reported fewer infections at 1 year (47% vs 66%. Comparison Groups.43. One randomized 35 nursing home residents with moderate to severe dementia and low BMI to a micronutrient-enriched supplement or placebo. versus 45% (Po.36. In one study.JAGS MARCH 2011–VOL. The other enrolled 28 nursing home residents with Stage II to IV pressure ulcers to receive a high-calorie. three measuring cognition. and only one-third used oral nutrition for prescribed supplements.35. Function and mortality were rarely studied. Eighty-ﬁve studies failed to meet PICOT criteria (n 5 69) or did not test an intervention (n 5 16).25 Quality of Studies of High-Calorie Supplements for Dementia Between 1990 and 2009. thickened liquid or semisolid food (n 5 2).147 ing. leaving 25 studies for review (Figure 1). Ten studies found evidence of beneﬁt using at least one outcome. and Time frame. One study found better pressure ulcer healing with supplementation. mortality. NO. ﬁve of 31 (16%) participants.5 to 2. reduced their lunch intake after the supplement.34–45 Interventions included appetite stimulants (n 5 3).
2005 Simmons. and dessert Lauque. 2000 Young. homemade supplement. Summary of Evidence for Feeding Interventions and Major Outcomes Study Population.82 kg over 12 weeks. 2006 Planas. 2006 Young. and dessert Parrott. disruptive behaviors. 2001 47 Milk powder Lauque.43 Another randomized nursing home residents to megestrol acetate 800 mg or placebo. 43% of the intervention versus 18% of the placebo group gained more than 1. 2009 Gazzotti. 2003 66 46 28 80 99 Liquid supplement Liquid supplement Liquid supplement Liquid supplement and soup Liquid supplement Kwok. fruit. Analyzing participants with complete data. 2008 Volicer. 3 JAGS Table 3. 2003 Gil Gregorio. exercise Individualized nutrition therapy process and care plans Relaxing music played at lunchtime Enhanced dietitian time and menu Buffet-style dining program Chin-down posture vs thickened liquids Lyophilized foods Megestrol acetate and assistance Feeding assistance Dronabinol Weight Weight Pressure ulcer healing Weight BMI Morbidity Mortality Weight Cognition Physical function Weight BMI Grip strength Weight BMI Cognition Physical function BMI BMI Cognition Weight Weight Physical function Weight Weight BMI BMI Physical function Behaviors Weight Weight Pneumonia Mortality Weight Weight Weight BMI Weight Negative affect Disruptive behavior Weight Weight Cognition Behavior No Yes Yes Yes Yes Yes No No No No Yes No No Yes Yes No No Yes No No Yes Yes No Yes Yes Yes No No Yes Yes No No No Yes No Yes Yes Yes Yes No Yes No No No Yeh. 2006 Goddaer. n Intervention Type Major Outcomes Difference High-calorie supplement Beck. MARCH 2011–VOL. 2000 78 Liquid supplement. 2005 68 34 Megestrol acetate Meals high in carbohydrates BMI 5 body mass index. 2003 Remsburg. NO. 2002 Carver. 2008 Salas-Salvado. but those with advanced dementia were less likely to respond.466 HANSON ET AL. lyophilized foods with modiﬁed . including chocolate and exercise. 1995 Cereda. 59.44 A pilot study of megestrol demon- strated no change in weight. 2004 Other Feeding Interventions Beck. 2005 Simmons. 2004 91 Liquid supplement. enhanced dietitian time. soup. 1997 30 44 35 34 34 121 61 29 82 40 515 56 17 69 12 Liquid supplement and high-calorie bar Liquid supplement Micronutrient-enriched liquid supplement Liquid supplement Liquid supplement and high-calorie bar Chocolate.41 Four nonmedication interventions showed positive effects on weight. soup. 2001 Robbins. 2004 Wouters-Wessling. 1994 Keller. 2002 Wouters-Wessling. but secondary analyses suggested beneﬁt when combined with optimal assisted feeding. hot chocolate. 2008 Crogan.
2002 Carver. 2000 Nutritional supplements. 3 REVIEW OF ORAL FEEDING IN DEMENTIA 467 Table 4. 80 Æ 10 control group.3. weight gain of 1. 1995 Cereda.3–9.3.JAGS MARCH 2011–VOL.0) vs 1.1. fruit. NSD B Low 125-kcal enriched oral supplement RCT. Po. 1-year follow-up B Medium Kwok. 50% with vascular dementia or Alzheimer’s disease 80 patients on a geriatric ward in Belgium. mild to moderate cognitive impairment 46 older residents with dementia and pressure ulcers. 2004 91 patients from geriatric wards and day centers in France with Alzheimer’s disease and Oral supplements.4 Æ 0.1 Æ 2. mental function. Po. 300– 500 kcal.5 Æ 1. 68 Æ 7 control. P 5.0–3. 600 kcal RCT. 60 days follow-up Lauque.23 Æ 2.3 kg.7 vs À 3. dementia severity moderate to severe 78 malnourished nursing home residents in France. 2003 66 undernourished nursing home residents in Denmark. received in soup or a 500-kcal nutritional supplement RCT. 6 months follow-up Malnourished group. P 5. P 5. P 5. NSD Grip strength. 1 to 2 months follow-up Weight change: 1.05 Infection: 47% vs 66%. mean age: 81 Æ 10 intervention group. 81 Æ 10 control. Dietitian RCT. 2003 Gil Gegorio.4.7 to 46. 2001 Milk powder twice daily RCT.4 A Low 200 mL supplement. 9% control. controls received same foods as intervention B Medium Lauque.4 kg. or a liquid supplement.6 kg vs À 0. mean age 84 Æ 8 to 88 Æ 4. grip strength.5 kg. 12 weeks follow-up Weight change: 13.7 kg. dessert. dementia: 32% supplement group. 79 Æ 10 control. 59.4.0). dementia 47–91% in each group Homemade oral supplement. controls decreased from 46. mean age: men 68 Æ 9 intervention. intervention time 3 months.3 Æ 2.5 (À 2.5 Æ 6.3 kg vs 0. no change in weight BMI.9 to 44. mean age 84. disability measures. mean age 82 Æ 10 intervention.5 Æ 0.001 within-interventiongroup weight change. weight gain of 11.05 Days in bed: 7. dessert. 2 months follow-up Weight change: 10.5 vs 17. P 5. mean age 80 Æ 7. Methodological Characteristics and Quality of Included Studies Outcomes: Intervention vs Control Source Population Intervention Methods QualityÃ Bias Supplementation Beck.6 Æ 3. mean MMSE score 12.8 kg vs À 1.05 betweengroup comparison Weight change: 11. 500kcal enriched supplement RCT. 384 kcal RCT. or a liquid supplement Concurrent controls.7 Æ 3. 7 weeks follow-up.001 BMI change C Medium B Low (Continued ) . control group NSD B Low 30 kcal/kg per day nutritional supplement and two 400-mL. indicating moderate to severe dementia 47 nursing home residents with poor intake in China. NSD B High 200 mL oral supplement twice daily.5 kg. women: 80 Æ 10 intervention. NO.3 (À 1.8 kg vs 0. no indication of dementia severity 28 nursing home residents in Italy. NSD Control group. NSD Weight change 11. 12 weeks follow-up Pressure ulcer healing according to Pressure Ulcer Scale for Healing score: À 6.05 At-risk group.28 Æ 3.05 Mortality: NSD Weight change: intervention group increased from 42. 150–300 kcal: soup. 2009 Gazzotti.7 Æ 5. mean age 86.6 Æ 1. four different supplements offered: soup.5 kg. mean MMSE score 21 Æ 7 indicating mild cognitive impairment 99 malnourished nursing home residents in Spain.
NO. mean age 81.2) vs 0. group exercise.97 kg. 2006 risk of malnutrition. 1994 61 nursing home residents in the United States.) Outcomes: Intervention vs Control Source Population Intervention Methods QualityÃ Bias Parrott.6–0.6 kg/m to 26. P 5. or 150 mL of homemade milkbased supplement. mean age 79.8 to 24.0 Æ 3. and oral care twice a week 6 month individual nutrition prescription process with assessments. and interventions RCT. P 5.02 C Medium B Low A Low 200-mL liquid nutrition enriched supplement after prescription of antibiotics and diagnosis of acute infection 3/4 of a nutrition supplement bar and juice provided between breakfast and lunch RCT.5 Æ 4.4 Æ 4.6 kg/m2 in treatment and 26. A 5 no music.0) vs À 0.4 kg vs À 0. MARCH 2011–VOL. home residents with 2006 recent infection from a psychogeriatric unit in the Netherlands.4 to 26.97 Æ 0.38 kg/m2.1 kg/m2.1 to 25.29 Æ 1.4% (0– 1. Reduction in cumulative incidence of total agitated behaviors (63%).003 BMI change: 25.3 Æ 4.8 kg/m2 in controls. most with low BMI Assisted feeding and other interventions Beck.001 B Low Crogan.6–3. mean age 85 intervention.0 kg.468 HANSON ET AL.08 Æ 3. NSD Cognition: NSD Weight change: 1. (Contd. 10 weeks follow-up Planas. 12 weeks follow-up 10. and sustained 1 week after stopping intervention BMI change: 25. probable moderate to severe dementia.4 kg. mean age 83 Æ 7 Young. residents in the 2002 Netherlands. C Medium (Continued ) .001 Cognition: NSD Physical function: NSD BMI change 23. moderate cognitive impairment RCT.005 BMI change: 0. four phases lasting 21 days Weight change from baseline during intervention phases: 0. mean MMSE score 15 Æ 8. 5 weeks follow-up after onset of infection Weight change: 0.4 Æ 2.6% ( À 1.39 kg/m2 vs 0.5 kg/m2 vs 24. care planning. with probable moderate to severe Alzheimer’s made home visits and provided education Midmorning supplement (supplement bars or liquids) containing 250–258 kcal Oral liquid supplements 500 kcal/ d with or without micro-nutrient enhancement Pre–post study design. 2004 44 Alzheimer’s disease day center participants in Spain. 6 months follow-up C Medium Relaxing music played at lunchtime Pre–post study ABAB repeatedmeasures design. indicating moderate impairment 30 geriatric care facility residents in Canada. P 5.66 Æ 1. mean age 73 Æ 11 in study group and 77 Æ 6 in control group. 79 Æ 9 control group. 79 in comparison group.3% (0. with moderate to severe dementia and low BMI Wouters34 randomized nursing Wesseling. severe dementia 25 g of chocolate and 150 mL of hot chocolate. P 5. crossover with washout periods. Po. normal to moderately impaired cognition. at risk for malnutrition 29 nursing home residents in Belgium. Po. mean age 85 Æ 8 intervention group. 6 months follow-up Micronutrientenriched liquid nutrient of 125 mL twice a day between main daytime meals RCT. mild dementia and feeding problems Wouters35 nursing home Wesseling. 2008 121 nursing home residents in Denmark. mean age 87. NSD Function: no difference B Low Concurrent controls. 2004 34 geriatric care center Alzheimer’s unit residents in Canada.5 kg/m2. P 5. 2006 Goddaer. mean age 88 Æ 4.6).001.4 Æ 2.2%. 3 JAGS Table 4. 11 weeks follow-up Weight change: 1.7 Æ 3.8 kg vs À 0.04 Physical function: NSD B Low RCT. placebo controlled. 59.4 kg/m to 26. mean age 88 Æ 4.
45). mean age 80.5.7 Æ 2. enhanced menu with increased snack foods and highenergy and highprotein foods Buffet-style dining program (supper only) implemented daily Concurrent controls.8% Æ 0. and exhibiting food refusal Remsburg.) Outcomes: Intervention vs Control Source Population Intervention Methods QualityÃ Bias B 5 music. placebocontrolled crossover design. 1week intervals Keller. P 5. and at risk for malnutrition 515 residents from subacute residential facilities. 41–43% subjects with moderate dementia.001 27% intervention subjects gained weight vs 7% controls Weight change: À 0.3 lb and 1.84 (95% CI 5 0. moderate cognitive impairment. 12 weeks followup A Low Yeh. 50% with dementia. 24 weeks follow-up Weight change: À 2. 2003 82 nursing home residents with dementia. 84 control. mean age 80. (Contd.JAGS MARCH 2011–VOL. Po. mean MMSE score 4.3 Æ 3. P 5. median age 81. 25 weeks follow-up A Low (Continued ) . mean age 82 intervention. 41% with mild to moderate dementia 69 nursing home residents. 63 days follow-up Simmons. 70% with dementia and evidence for aspiration 56 patients with Alzheimer’s disease. agitated behavior was unchanged Weight change: 43% vs 18% gained 1. P 5. cluster design.009 BMI change: 0. 2000 68 nursing home residents with 45% weight loss or low body Megestrol acetate 800 mg daily RCT.0 kg Depression scores: NSD B Medium RCT.72 kg/ m2.0 Æ 1. and verbally agitated behaviors (75%).6 Æ 1.4.9%.7% vs À 4. moderate to severe cognitive impairment.009 Weight change: intervention group gained 7. controls received nutritional advice only.3 lb from baseline Intake improved only when combined with optimal feeding assistance Weight change difference: 4 lbs.8 kg or more.3 lb. 2001 Enhanced dietitian time and care planning. controls gained 4.32 Æ 0. 2005 Megestrol acetate 400 mg daily with vs without feeding assistance Pre–post study design.045). at risk for weight loss 12 patients from a Veterans Affairs hospital dementia study unit.0 Æ 7. 38% of intervention patients C Medium B Medium Volicer. moderate cognitive impairment.7 lb.5 lb and 2. hazard ratio 5 0. moderate to severe dementia. NSD Mortality: NSD Weight change: 2.9 vs 0.3 Æ 1.49–1.1 Æ 9.1 Æ 1.7 vs 0. 3 months follow-up physically nonaggressive behaviors (56%). NO. mean age 92.5 mg capsule twice a day RCT. moderate to severe nutritional risk 40 nursing home residents. 59.02 Behavior: Negative affect was reduced during intervention (P 5. 1997 Dronabinol 2. 2005 Drinking liquids in chin-down posture vs drinking thickened liquids (nectar thick and honey thick) in a head-neutral position Lyophilized food diet reconstituted to liquid or semisolid consistency with nutritional advice RCT. 2008 SalasSalvado. NSD C Medium B Medium Robbins.5% Æ 0. Weight change: 4. 3 months follow-up Incidence of pneumonia. and weight loss and requiring a liquid or semisolid diet 17 nursing home residents with low BMI or poor intake of food. 2008 Feeding assistance RCT. paralleldesign trial.11 Æ 0. mean age 73 Æ 5. 3 REVIEW OF ORAL FEEDING IN DEMENTIA 469 Table 4. 3 months follow-up B Medium Simmons. 30 months follow-up RCT.
High-calorie supplements are an evidencebased option to promote weight gain for people with dementia and feeding problems. nearly half of 17 participants reported new fatigue or loss of strength. concealed allocation.39 In a randomized trial comparing lyophilized food compared with nutritional advice. C 5 not randomized.39 Quality of Studies of Assisted Feeding and Other Interventions The two high-quality randomized trials in this group tested appetite stimulants and found beneﬁcial effects on weight (Table 4).42 One other study of enhanced dietitian care had no effect but enrolled less cognitively and nutritionally impaired participants. and increases in somnolence and euphoria marked the active treatment phase. and modiﬁed foods. (Contd. and effect size for supplements can be estimated at 0. Based on current evidence. use of calming music. in a placebo-controlled study of dronabinol.5 to 2. texture. mean age 88.12 kg in intervention group. and megestrol. but the combined outcome of fever or urinary infection or dehydration tended to be more common for the thickened liquid group (9% vs 5%. P 5.34.36 Æ 1.055).40 In the study of megestrol. and modiﬁed foods may also improve weight. placebo-controlled. but information on thrombotic disease was not provided.41 Finally. limiting clear conclusions about oral supplements and pressure ulcer . MMSE 5 Mini-Mental State Examination. Examining the quantity and quality of research. BMI 5 body mass index. NO. and ﬁve reported leg swelling. but rates did not differ between groups. one participant receiving the treatment had a seizure. specialized oral feeding interventions are unlikely to change how people with dementia function or how long they live. appetite stimulants.43 Overall Strength of Evidence for Oral Feeding Interventions in Dementia The evidence base for oral feeding options in people with dementia includes an encouraging number of randomized trials with low to medium risk of bias. MARCH 2011–VOL. and treatments can be used individually or in combination. there is moderate evidence to support the use of high-calorie supplements to improve weight for people with dementia and feeding problems and low evidence that these supplements promote wound healing and reduce infection risk. NSD Measures of cognition and behavior did not change B Medium Ã Quality Rating: A 5 randomization. B 5 randomization. most with low BMI High-carbohydrate meals. Four additional studies used nonrandom controls to test enhanced nutritional assessment. Assisted feeding. concealment not clearly deﬁned. Findings regarding weight gain are consistent between trials.35 Buffetstyle dining at one meal a day had no effect on weight. assisted feeding.470 HANSON ET AL.9. Four studies explicitly collected and reported data on harms. RCT 5 randomized controlled trial. current research offers low evidence for appetite stimulants. or mortality for people with moderate to severe dementia.40.0 kg of weight gain over 1 to 6 months.2 Æ 3. Six additional randomized trials of nonmedication interventions provided Grade B evidence with low to medium risk of bias. 84 days follow-up did not gain weight Advanced dementia associated with lack of gain Weight increase of 0. These results are consistent with a meta-analysis that found that protein energy supplementation improved nutrition and reduced morbidity and mortality for undernourished older hospitalized adults. DISCUSSION This systematic review summarizes research on oral feeding in dementia. probable moderate to severe Alzheimer’s disease. and feeding assistance. nearly all deaths or hospitalizations involved participants with more-advanced dementia.37. cognition. No correlation was fond between study quality and likelihood of positive results. investigators commented that a ‘‘usual care’’ control could not be used because of ethical concerns. The randomized trial comparing chin-down posture with thickened liquids as interventions to prevent aspiration pneumonia found that 23% of participants experienced an adverse event.08. Adverse events were equal between groups. nearly uniformly positive. received supplements in nonintervention phase RCT. 3 JAGS Table 4. concealment inadequate. Evidence is sparse but consistent in showing no effect of oral feeding options on function. P 5.) Outcomes: Intervention vs Control Source Population Intervention Methods QualityÃ Bias weight. 59. 30% incapable of consent Young.47 The single study in this review demonstrating wound healing included participants who were both tube fed and orally fed. 2005 34 nursing home residents in Canada. crossover design with four phases. NSD 5 nonsigniﬁcant difference.46 Another systematic review found moderate evidence to support use of supplements for healing of pressure ulcers. For the outcome of weight gain.38 A randomized trial comparing chin-down posture with thickened liquids found no differential effect for aspiration.
ethical. Garrett JM et al. J Am Geriatr Soc 2000. Arch Intern Med 2001. Cox CE.61:246–252. Meier DE. Given the progressive nature of dementia. Seltzer B. Patient Educ Couns 2006.e11–527. Rosenberg JC. function.119:527.JAGS MARCH 2011–VOL.161:594–599. Mitchell SL. Brett AS. Wray NP. Rheaume Y et al. Arch Intern Med 1997. J Geriatr Psych Neurol 1989. Carey TS. N Engl J Med 2009. Weinberger M et al.cochrane. Association between framing of the research question using the PICOT format and reporting quality of randomized controlled trials. Surrogates’ perceptions about feeding tube placement decisions. Enteral tube feeding for older people with advanced dementia [on-line]. or wound healing.163:1351– 1353. participants without tube feeding served as controls. Mitchell SL. 8. The clinical course of advanced dementia. Golin C et al. Nearly all people with advanced dementia develop feeding problems. 4. BMC Med Res Methodol 2010. and tastes and sips of food combined with mouth care may be used to promote comfort. NO. Morris J. Rabeneck L. Volicer L. and many may have received oral feeding treatments included in this review. Careful deﬁnition of dementia stage and feeding problems of the enrolled participants will strengthen future studies. Garrett JM. Lipsitz LA. or writing of this manuscript. The risk factors and impact on survival of feeding tubes in nursing home residents with advanced dementia.1186/1471-2288-10-11. and clinical controversy and remain emotionally difﬁcult for family caregivers. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia.html Accessed May 20. J Pall Med 2008. programmatic interventions make double-blinding difﬁcult. Teno JM. Available at http://www2. perhaps in combination with assisted feeding. Outcomes of percutaneous endoscopic gastrostomy among older adults in a community setting. Lewis CL. Arch Intern Med 2003. when interventions may be too late. Sponsor’s Role: The sponsor had no role in the design.19:1034–1038. single-blinding of outcome assessment and concealment of randomization allocation can avoid important sources of bias. Ersek.48:1048–1054.2:188–195. People with dementia and their families may rely heavily on medical advice to understand other treatment options. Lewis C et al. In these observational studies. Hanson LC. Investigators should be encouraged to design trials that view intake and weight gain as intermediate outcomes so as to provide stronger evidence of the effects on function. Kiely DK et al. 11. No randomized trials comparing tube feeding with oral feeding exist. and many set strict legal requirements. Many studies targeted moderate to severe dementia but were too small to stratify ﬁndings according to stage. Kiely DK.161:745–748. Garrett JM et al. Trends in the use of feeding tubes in North Carolina Hospitals: 1989 to 2000. data analysis and interpretation. Gilliam. Incomplete administration of supplements occurs in practice and is associated with weight loss in nursing home residents with dementia. Rios LP.10:11. 10. prescribed supplements must be ingested. JAMA 2003. 15. Author Contributions: Study concept. Lewis CL.11:1130–1134. Volicer L. Lipman TO. Nutritional management of individuals with Alzheimer’s disease and other progressive dementias. Petersen NJ. Haag KM. families should be counseled not to expect improvements in function or survival with any available form of feeding. 12. Am J Med 2006.48 This systematic review combined studies that were heterogeneous in the dementia status and feeding problems of enrolled participants.361:1529–1538. Manufacturers of nutritional supplements supported several studies that demonstrated positive results. 59. In end-stage dementia. J Gen Intern Med 1996. . oral feeding may no longer be possible. infection risk. and wound healing.4:148–155. To be effective. Variation in baseline dementia severity and nutritional status of study participants raises questions about optimal timing for nutritional interventions in the progression of dementia. and results may not extend to other populations with nutritional problems.e16. interventions. Sampson EL. 3 REVIEW OF ORAL FEEDING IN DEMENTIA 471 healing. including a randomized comparison of oral assisted feeding and tube feeding. Teno JM. 7. could be tested in multisite randomized trials. it is unclear whether reporting bias (failure to publish studies with negative ﬁndings) affected the available published literature. 2. and appetite stimulants can promote weight gain for several months. methods. participant recruitment. Eating difﬁculties in patients with probable dementia of the Alzheimer type. Ethical concerns about withholding feeding treatments may limit the range of possible control conditions.11:287– 293. 3.org/reviews/ en/ab007209. and outcome measures. 14. data collection. Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment. Physicians’ expectations of beneﬁt from tube feeding. J Gen Intern Med 2004. Hanson LC. Candy B. Mitchell SL. Nutr Clin Care 2001. 5. 6. Arch Intern Med 2001. behavior. Current evidence relies on numerous small single-site studies (average sample size. and combinations of promising interventions in comprehensive nutritional programs. to withhold or withdraw medical forms of nutrition and hydration. whereas others enrolled participants with clear indications of nutritional insufﬁciency. Some studies enrolled participants at risk for nutritional decline. 13. Jones L. Aronheim JC. 2009. Findings from individual studies suggest that interventions may be ineffective when initiated before nutrition is a major problem or for advanced dementia or low BMI. Carey. Expectations and outcomes of gastric feeding tubes. analysis. This review focused on dementia. ACKNOWLEDGMENTS Conﬂict of Interest: The editor in chief has reviewed the conﬂict of interest checklist provided by the authors and has determined that the authors have no ﬁnancial or any other kind of personal conﬂicts with this paper. High short-term mortality in hospitalized patients with advanced dementia: Lack of beneﬁt of tube feeding. Murphy LM. foods modiﬁed in taste or texture. preparation of manuscript: Hanson. This review identiﬁed several areas for improvement in this body of research. Future interventions. Hanson LC. Ye C. This research was funded by National Institute for Nursing Research Grant R01 NR009826. REFERENCES 1. such as health status or explicit evidence of patient wishes. Callahan CM. Study of more-complex.49 State laws reﬂect this controversy.50 Families and healthcare providers may improve the quality of informed decision-making using current evidence for oral feeding options in dementia. Roy J et al. but observational studies of people with dementia indicate that tube feeding is not superior for promoting survival. Thabane L. precluding meta-analysis. 9. Healthcare providers may conﬁdently advise families that high-calorie supplements. Morris J et al. Feeding treatment choices may cause great legal. doi: 10. Long-term outcomes of patients receiving percutaneous endoscopic gastrostomy tubes. n 5 73).290:73–80. Published online 2010 February 5. 16.157:327–332. The adequacy of informed consent for placement of gastrostomy tubes. design.
39. A pilot trial. Ann Intern Med 2009. Higgins JPT. Salas-Salvado J. The effect of megestrol acetate on oral food and ﬂuid intake in nursing home residents: A pilot study. Nursing home staff delivery of oral liquid nutritional supplements to residents at risk for unintentional weight loss. J Am Geriatr Soc 2006. Micronutrient supplementation in mild Alzheimer disease patients. Parello M et al. Pedrolli C et al. Osterweil D. Arnaud-Battandier F. Effects of relaxing music on agitation during meals among nursing home residents with severe cognitive impairment. NO. 35.cochranehandbook. Ann Intern Med 2006.336:924–926. versus standard.pdf Accessed July 13.51:945– 951. Parrott MD. Engfer M et al. body mass index. Clin Nutr 2005. Kwan M. 41. Greenwood CE. Improvement of weight and fat-free mass with oral nutritional supplementation in patients with alzheimer’s disease at risk of malnutrition: A prospective randomized study. Does low lactose milk powder improve the nutritional intake and nutritional status of frail older Chinese people living in nursing homes? J Nutr Health Aging 2001. 46. Gibbs AJ. Lohr KN. Young KW. Arnaud-Battandier F. J Am Geriatr Soc 2009. 38. J Hum Nutr Dietet 1995. 21. Damkjaer K. Multifaceted nutritional intervention among nursing-home residents has a positive inﬂuence on nutrition and function. Gazzotti C. Yeh SS. 40. 2009. 44. 2010. 18. 49.151:264–269. nutritional support for the treatment of pressure ulcers in institutionalized older adults: A randomized controlled trial. J Am Geriatr Soc 2004. MARCH 2011–VOL. 42.17:805–815. 22. Owens DK. Energy-containing nutritional supplements can affect usual energy intake postsupplementation in institutionalized seniors with probable Alzheimer’s disease. Goddaer J. J Am Geriatr Soc 2006. Volicer L. Beck AM. Lauque S. BMJ 2008.effectivehealthcare.25:89–103. Ritchie CS. Ramirez Diaz SP. Gensler G. Intervention study in institutionalized patients with Alzheimer disease.8:389–394. Green S. beneﬁcial to those with low body weight status. 47. Tetzlaff J et al. Available at http://www.18:70–74. Walker KA. Lee TP et al. Conde M. 36. Baran CR et al. A controlled trial. .12:913–919. Kleijer CN et al. Stelly M. Gini A. Atkins D et al Grading the strength of a body of evidence when comparing medical interventions. 52:1305–1312. Beck AM. J Am Geriatr Soc 2008.4:422–450. Robbins J. 28. Avenell A. 29. Boudreau LD et al. Beyer N. Prevention of weight loss in dementia with comprehensive nutritional treatment.24:390–397. Kleijer CN et al. Mansourian R et al. 3 JAGS 17. 24. crossover trial of high-carbohydrate foods in nursing home residents with Alzheimer’s disease: Associations among intervention response.56:245–251. 26. Kwok T. Enteral nutritional support in prevention and treatment of pressure ulcers: A systematic review and meta-analysis. Morris J et al. Comfort feeding only: A proposal to bring clarity to decision making regarding difﬁculty with eating for persons with advanced dementia. Arch Psych Nurs 1994. Torres M.101:1460–1463. Woo J. 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. The Cochrane Collaboration. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. Cereda E. Effects of dronabinol on anorexia and disturbed behavior in patients with Alzheimer’s disease. Luking A. 25.23:265–272. Age Ageing 2000.4:24–30. Simmons SF. 23.54:1372–1376. Young KWH. Prevention of unintentional weight loss in nursing home residents: A controlled trial of feeding assistance. J Am Geriatr Soc 2004. 50. Gil Gregorio P. Stratton RJ.8:150–158.14:212–215. Arnaud-Battandier F. J Am Geriatr Soc 2010. Planas M. 27. Comparison of two interventions for liquid aspiration on pneumonia incidence: A randomized trial. J Gerontol A Biol Sci Med Sci 2005. Prevention of malnutrition in older people during and after hospitalisation: Results from a randomised controlled clinical trial. Abraham IL. J Am Diet Assoc 2001. 2008 [on-line]. Potter J. Carver AD. van Reekum R et al. J Nutr Health Aging 2003. 37. Improving nutrition care for nursing home residents using the INRx process. Liberati A.5:17–21. Meta-analysis: Protein and energy supplementation in older people. Home-made oral supplement as nutritional support of old nursing home residents. eds.7:304–308. Casarett D et al. 60A:1039–1045. Mini Nutritional Assessment. 45. 19. Dobson AM. Age Ageing 2003. 32. J Am Geriatr Soc 2000. Ethical and medicolegal issues related to percutaneous endoscopic gastrostomy placement.144:37–48. Impact of a buffet-style dining program on weight and biochemical indicators of nutritional status in nursing home residents: A pilot study. Crogan NL. Ovesen L. Wilcox CM. Ribera Casado et al. Lauque S. Ek AC. Slump E.32:321–325. 20. Dementia and nutrition. Zhuo X et al. Ageing Res Rev 2005.56:1466–1473.48:485–492. Remsburg RE. Pasvogel A. GRADE: An emerging consensus on rating quality of evidence and strength of recommendations.gov/ehc/products/122/328/2009_0805_grading. Guyatt GH. Ann Intern Med 2008. Int J Geriat Psychiatry 1997. Effects of dietary supplementation of elderly demented hospital residents. Providing nutrition supplements to institutionalized seniors with probable Alzheimer’s disease is least 34. Simmons SF. Wouters-Wesseling W. Gillette S et al. 59. Keller HK. Planas M et al. Early nutritional supplementation immediately after diagnosis of infectious disease improves body weight in psychogeriatric nursing home residents. Alvine C. 48.54:1382–1387. Greenwood CE. 33. Available at http://www. ahrq.52:1702–1707. Milne AC. Aging Clin Exp Res 2002. Effect of oral administration of a shole formula diet on nutritional and cognitive status in patients with Alzheimer’s disease. Oxman ADGRADE Working Group et al.0. 31. Protein-energy oral supplementation in malnourished nursing-home residents.0. Greenwood CE. Schroll M. J Nutr Elder 2006.org Accessed December 10. Teno JM. Young KW. Disease-speciﬁc. Hind J et al. Wouters AE.57:1395–1402. Simmons SF.24:1073–1080. Agency for Healthcare Research and Quality [on-line].29:51–56. placebo-controlled study. J Am Med Dir Assoc 2004. Patel AV. Kvale E. Study of the effect of a liquid nutrition supplement on the nutritional status of psycho-geriatric nursing home patients. Cochrane Handbook for Systematic Reviews of Interventions version 5.472 HANSON ET AL. Clin Nutr 2004. Keeler E. Audivert S et al. Aging Clin Exp Res 2006. Gastrointest Endosc Clin North Am 2007.148:509–518. J Am Geriatr Soc 2003. Nutrition 2008. Eur J Clin Nutr 2002. Palecek EJ. and behavioral and cognitive function. who are undernourished or at risk of undernutrition based on the MNA. van Reekum R et al. 43. Moher D. A randomized.58:580–584. 30. Wu SU. Wouters-Wesseling W.