Artificial Nutrition and Hydration in Advanced Dementia (ANH)

Artificial Nutrition and Hydration in Advanced Dementia (ANH)

It is estimated that up to one-third of nursing home patients with severe cognitive impairment in the United States have feeding tubes. A systematic review showed that the primary reason for use of Artificial Nutrition and Hydration (ANH) was to prolong life. However, evidence indicates that ANH in advanced dementia does not prolong survival or improve quality of life. Studies have shown, despite the conventional wisdom that artificial nutrition would mitigate the risks of aspiration and help with wound healing, that the opposite is true: risk of aspiration and the development of pressure ulcers in fact increase with the initiation of tube feeding. Although dry mouth may be common during end of life, IV fluids do not seem to help the symptom. In addition, enteral feeding might worsen sensation of hunger. Both hunger and thirst at end of life are treated with small amounts of food, fluids, and artificial saliva, as well as good mouth care.

Education of ANH for Health Care Professionals

There is evidence of a knowledge gap among physicians who, for example, often incorrectly cite aspiration pneumonia as being an important indication for feeding tube insertion in patients with dementia. In addition, many speech-language pathologists believe that tube feeding in advanced dementia and dysphagia improves nutritional status and prolongs survival. In addition, patients under the care of subspecialists are also more likely to receive feeding tubes compared with those cared for by generalists. The reason for this is unclear but it could be due to generalists having a more wide-angled view of patient care.

Cost Dilemmas of ANH

Guidelines put forth by the American Geriatrics Society discourage the use of feeding tubes in patients with advanced dementia and promote instead the use of careful hand feeding. However, it can be difficult for dementia patients to get this one-on-one feeding time that they need. An American study demonstrated that day-to-day costs for residents with feeding tubes were lower than costs for residents without. In addition, medicare billings showed that patients with feeding tubes get higher reimbursements. This puts nursing homes in a difficult situation, trying to balance costs while also considering the well-being of the patient.

Consulting with Patients and Family

There are special circumstances where parenteral hydration can have more benefits than risks for the patient such as cases of peripheral edema, opioid toxicity, or hypercalcemia. In the end, ANH should be a decision made with the family, physician, and patient, weighing the benefits against the harms. Decisions to be made for the patient would ideally be completed before dementia is progressed. However, the legal representative, family, or best interest of the patient would be used if advanced directives are not established prior. In addition, establishing a relationship with the family can greatly help ease decisions associated with palliative care and give them all of the information that they need to make their decision. It may be helpful to consider the help of social work when supporting the family on decisions at end of life care. It may also be helpful to speak to religious leaders regarding risks associated with ANH if the family has a religious or cultural preference that is influencing their decision that may not be in the best interest of the patient.

Sources:

Ying, I. (2015). Artificial nutrition and hydration in advanced dementia. Canadian Family Physician, 61(3), 245-248.