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Koechl J, Banerjee A, Heckman G, Keller H. Factors Associated With the Initiation of Comfort-Focused Nutrition Care Orders for Long-Term Care Residents at End of Life. Int J Older People Nurs 2024; 19:e12634. [PMID: 39101230 DOI: 10.1111/opn.12634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 07/09/2024] [Accepted: 07/14/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Comfort-focused nutrition orders are recommended to manage eating changes among long-term care (LTC) residents nearing the end of life, though little is known about their current use. This investigation aims to describe current practices and identify resident-level and time-dependent factors associated with comfort-focused nutrition orders in this context. METHODS Data were retrospectively extracted from resident charts of decedents (≥65 years at death, admitted ≥6 months) in 18 LTC homes from two sampling frames across southern Ontario, Canada. Observations occurred at 6 months (baseline), 3 months, 1 month and 2 weeks prior to death. Extracted data included functional measures (e.g. cognitive performance, health instability) at baseline, formalised restorative and comfort-focused nutrition care interventions at each timepoint and eating changes reported in the progress notes in 2 weeks following each timepoint. Logistic regression and time-varying logistic regression models determined resident-level (e.g. functional characteristics) and time-dependent factors (e.g. eating changes) associated with receiving a comfort-focused nutrition order. RESULTS Less than one-third (30.5%; n = 50) of 164 participants (61.0% female; mean age = 88.3 ± 7.5 years) received a comfort-focused nutrition order, whereas most (99%) received at least one restorative nutrition intervention to support oral food intake. Discontinuation of nutrition interventions was rare (8.5%). Comfort orders were more likely with health instability (OR [95% CI] = 4.35 [1.49, 13.76]), within 2 weeks of death (OR = 5.50 [1.70, 17.11]), when an end-of-life conversation had occurred since the previous timepoint (OR = 5.66 [2.83, 11.33]), with discontinued nutrition interventions (OR = 6.31 [1.75, 22.72]), with co-occurrence of other care plan modifications (OR = 1.48 [1.10, 1.98]) and with a greater number of eating changes (OR = 1.19 [1.02, 1.38]), especially dysphagia (OR = 2.59 [1.09, 6.17]), at the preceding timepoint. CONCLUSIONS Comfort-focused nutrition orders were initiated for less than one-third of decedents and most often in the end stages of life, possibly representing missed opportunities to support the quality of life for this vulnerable population. An increase in eating changes, including new dysphagia, may signal a need for proactive end-of-life conversations involving comfort nutrition care options. IMPLICATIONS FOR PRACTICE Early and open conversations with residents and family about potential eating changes and comfort-focused nutrition care options should be encouraged and planned for among geriatric nursing teams working in LTC. These conversations may be beneficial even as early as resident admission to the home.
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Affiliation(s)
- Jill Koechl
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Albert Banerjee
- Department of Gerontology, St. Thomas University, Fredericton, New Brunswick, Canada
| | - George Heckman
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Heather Keller
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
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2
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Jan D, Kim KY. End-of-Life Care of Persons with Alzheimer's Disease and Other Dementias. Am J Hosp Palliat Care 2024:10499091241253838. [PMID: 38714329 DOI: 10.1177/10499091241253838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2024] Open
Abstract
End-of-life (EOL) care has been a common option for patients with terminal medical conditions such as cancers. However, the utilization of EOL care in Alzheimer disease and other dementing conditions have become available relatively recently. As the end-stage dementia approaches, the clinicians and caregivers become faced with numerous clinical challenges-delirium, neuropbehavioral symptoms, the patient's inability to communicate pain and associated discomfort, food refusal, and so on. In addition to providing quality clinical care to the EOL patients, clinicians should pay special attention to their families, assuring that their loved ones will receive supportive measures to improve quality of life (QOL).
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Affiliation(s)
- Darlon Jan
- Psychiatry Residency Program, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Center for Healthy Aging, Carilion Clinic, Roanoke, VA, USA
| | - Kye Y Kim
- Psychiatry Residency Program, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Center for Healthy Aging, Carilion Clinic, Roanoke, VA, USA
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3
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Alford H, Anvari N, Lengyel C, Wickson-Griffiths A, Hunter P, Yakiwchuk E, Cammer A. Resources to Support Decision-Making Regarding End-of-Life Nutrition Care in Long-Term Care: A Scoping Review. Nutrients 2024; 16:1163. [PMID: 38674853 PMCID: PMC11054792 DOI: 10.3390/nu16081163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/09/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Resources are needed to aid healthcare providers and families in making end-of-life nutrition care decisions for residents living in long-term care settings. This scoping review aimed to explore what is reported in the literature about resources to support decision-making at the end of life in long-term care. Four databases were searched for research published from 2003 to June 2023. Articles included peer-reviewed human studies published in the English language that reported resources to support decision-making about end-of-life nutrition in long-term care settings. In total, 15 articles were included. Thematic analysis of the articles generated five themes: conversations about care, evidence-based decision-making, a need for multidisciplinary perspectives, honouring residents' goals of care, and cultural considerations for adapting resources. Multidisciplinary care teams supporting residents and their families during the end of life can benefit from resources to support discussion and facilitate decision-making.
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Affiliation(s)
- Heather Alford
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada; (H.A.); (N.A.); (E.Y.)
| | - Nadia Anvari
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada; (H.A.); (N.A.); (E.Y.)
| | - Christina Lengyel
- Faculty of Agricultural and Food Sciences, University of Manitoba, Winnipeg, MB R3T 2N2, Canada;
| | | | - Paulette Hunter
- St. Thomas More College, University of Saskatchewan, Saskatoon, SK S7N 0W6, Canada;
| | - Erin Yakiwchuk
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada; (H.A.); (N.A.); (E.Y.)
| | - Allison Cammer
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada; (H.A.); (N.A.); (E.Y.)
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4
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Li S, Xiao X, Zhang X. Hydration Status in Older Adults: Current Knowledge and Future Challenges. Nutrients 2023; 15:nu15112609. [PMID: 37299572 DOI: 10.3390/nu15112609] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/28/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
Adequate hydration is essential for the maintenance of health and physiological functions in humans. However, many older adults do not maintain adequate hydration, which is under-recognized and poorly managed. Older adults are more vulnerable to dehydration, especially those living with multiple chronic diseases. Dehydration is associated with adverse health outcomes in older adults, and acts as an independent factor of the hospital length of stay, readmission, intensive care, in-hospital mortality, and poor prognosis. Dehydration is a prevalent health problem in older adults, accounting for substantial economic and social burden. This review attempts to provide current knowledge of hydration including patterns of body water turnover, the complex mechanisms behind water homeostasis, the effects of dehydration on the health of the body, and practical guidance for low-intake dehydration in older adults.
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Affiliation(s)
- Shizhen Li
- Department of Geriatrics, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Xun Xiao
- Department of Geriatrics, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Xiangyu Zhang
- Department of Geriatrics, The Second Xiangya Hospital, Central South University, Changsha 410011, China
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5
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Anantapong K, Sampson EL, Davies N. A shared decision-making model about care for people with severe dementia: A qualitative study based on nutrition and hydration decisions in acute hospitals. Int J Geriatr Psychiatry 2023; 38:e5884. [PMID: 36750227 PMCID: PMC10108087 DOI: 10.1002/gps.5884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/24/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To understand the decision-making processes regarding eating and drinking for hospital patients with severe dementia and use this data to modify a decision-making model about care for people with severe dementia. METHODS From January to May 2021, qualitative semi-structured interviews were conducted with 29 family carers and hospital staff in England who cared for people with severe dementia during hospital admissions. Interviews were transcribed verbatim and analysed using codebook thematic analysis. RESULTS We demonstrated a modified decision-making model consisting of six stages of the decision-making process: (i) identify a decision to be made; (ii) exchange information and recognise emotions; (iii) clarify values and preferences of all involved; (iv) consider feasibility of each choice; (v) share preferred choice and make a final decision; and (vi) deliver the decision, monitor outcomes and renegotiation. From this study, decision-making needed to be shared among all people involved and address holistic needs and personal values of people with dementia and family carers. However, hospital staff often made assumptions about the persons' ability to eat and drink without adequate consultation with family carers. The process was impacted by ward culture, professional practice, and legal framework, which might overlook cultural and personal beliefs of the persons and families. Treatment escalation plans could help inform stepwise treatments, create realistic expectations, and guide future decisions. CONCLUSIONS Our decision-making model provides clear stages of decision-making processes and can be used to guide clinical practice and policy around care decisions for eating and drinking, which is often poorly supported.
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Affiliation(s)
- Kanthee Anantapong
- Marie Curie Palliative Care Research DepartmentUCL Division of PsychiatryUniversity College LondonLondonUK
- Department of PsychiatryFaculty of MedicinePrince of Songkla UniversityHat YaiThailand
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research DepartmentUCL Division of PsychiatryUniversity College LondonLondonUK
- Department of Psychological MedicineRoyal London HospitalEast London NHS Foundation TrustLondonUK
| | - Nathan Davies
- Marie Curie Palliative Care Research DepartmentUCL Division of PsychiatryUniversity College LondonLondonUK
- Centre for Ageing Population StudiesResearch Department of Primary Care and Population HealthUniversity College LondonLondonUK
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6
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van Buuren CP, van der Steen JT, Olthof-Nefkens M, Bakker C, Koopmans RTCM, Perry M, Kalf JG. The Complexity of Nutritional Problems in Persons with Dementia: Expanding a Theoretical Model. J Alzheimers Dis 2023; 96:183-192. [PMID: 37742638 PMCID: PMC10657712 DOI: 10.3233/jad-230135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Persons with dementia are at risk of developing nutritional problems. Theoretical models on nutritional problems have been developed, but have not been evaluated with healthcare professionals. OBJECTIVE This study aimed to explore the comprehensiveness and applicability of a theoretical model of nutritional problems in persons with dementia for daily nursing home practice. METHODS A qualitative design employing a combined deductive and inductive approach was used. Healthcare professionals were eligible to participate if they 1) had expert knowledge of and experience with nutritional problems related to dementia, and 2) worked in a nursing home affiliated with an academic network covering the east and south of the Netherlands. Three focus group interviews with 20 healthcare professionals from seven professions were held. We conducted thematic analysis and we compared themes with existing theoretical models from the literature. RESULTS We identified six themes, four of which corresponded with the existing models (observing and analysing nutritional problems; consequences of nutritional problems; functioning of the person with dementia; environmental factors). Interprofessional collaboration and ethical factors were identified as new themes. The analyses indicated interactions within each theme, between themes, and a bidirectional connection between themes. CONCLUSIONS This study demonstrated the relevance of interprofessional collaboration and ethical considerations in nutritional problems related to dementia. It uncovered complex bidirectional relations within and between factors regarding nutritional problems. All aspects should be taken into account to minimize the consequences of nutritional problems for persons with dementia.
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Affiliation(s)
- Cornelia Pieternella van Buuren
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
- ‘Joachim en Anna’, Center for Specialized Geriatric Care, Nijmegen, The Netherlands
- Radboudumc Alzheimer Center, Nijmegen, The Netherlands
| | - Jenny Theodora van der Steen
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboudumc Alzheimer Center, Nijmegen, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Maria Olthof-Nefkens
- Radboudumc Alzheimer Center, Nijmegen, The Netherlands
- Department of Rehabilitation, Radboud University Medical Center, Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
- Zorggroep Maas & Waal, Beneden-Leeuwen, The Netherlands
| | - Christian Bakker
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboudumc Alzheimer Center, Nijmegen, The Netherlands
- Groenhuysen, Center for Geriatric Care, Roosendaal, The Netherlands
| | - Raymond Theodorus Catherina Maria Koopmans
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
- ‘Joachim en Anna’, Center for Specialized Geriatric Care, Nijmegen, The Netherlands
- Radboudumc Alzheimer Center, Nijmegen, The Netherlands
| | - Marieke Perry
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboudumc Alzheimer Center, Nijmegen, The Netherlands
- General Medical Practice, Velp, The Netherlands
| | - Johanna Gezina Kalf
- Radboudumc Alzheimer Center, Nijmegen, The Netherlands
- Department of Rehabilitation, Radboud University Medical Center, Donders Institute for Brain Cognition and Behaviour, Nijmegen, The Netherlands
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7
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Weaver MS, Geppert CMA. Sometimes a difficult decision to swallow: Ethical dilemmas when patients with dysphagia who lack capacity want to eat. J Pain Symptom Manage 2023; 65:e97-e102. [PMID: 36272543 DOI: 10.1016/j.jpainsymman.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Meaghann S Weaver
- VHA National Center for Ethics in Health Care (M.S.W., C.M.A.G.), Washington, District of Columbia, USA; Department of Pediatrics (M.S.W.), University of Nebraska Medical Center, Omaha, Nebraska, USA.
| | - Cynthia M A Geppert
- VHA National Center for Ethics in Health Care (M.S.W., C.M.A.G.), Washington, District of Columbia, USA; Departments of Psychiatry and Internal Medicine (C.M.A.G.), Ethics Education, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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8
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Anantapong K, Davies N, Sampson EL. Communication between the multidisciplinary team and families regarding nutrition and hydration for people with severe dementia in acute hospitals: a qualitative study. Age Ageing 2022; 51:afac230. [PMID: 36434801 PMCID: PMC9701106 DOI: 10.1093/ageing/afac230] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND When a person with severe dementia is in hospital and has eating and drinking difficulties, communication between the multidisciplinary team and families can be challenging and lead to suboptimal care. OBJECTIVE To gain in-depth understanding about the experiences, views and needs of family carers and hospital staff, regarding communication and conversations about nutrition and hydration, for hospital patients with severe dementia. DESIGN Qualitative semi-structured interview study. SETTING Acute hospital in England. METHODS From January to May 2021, semi-structured interviews were conducted with 29 family carers and hospital staff. Interviews were transcribed verbatim and analysed using reflexive thematic methods. RESULTS Four overarching themes were developed: (i) prerequisites to initiating communication about eating and drinking; (ii) communication aiming to develop agreed care plans; (iii) difficulty discussing palliative and end-of-life care; and (iv) needs of information and plans about future eating and drinking difficulties. Families tended to wait for hospital staff to initiate discussions but usually experienced frustration with delays and repeated conversations with different staff. Some staff felt unprepared to manage these conversations and found it challenging to work across the multidisciplinary team. During discharge processes, key information and care plans about eating and drinking were not regularly passed on to people involved to avoid unnecessary readmissions. CONCLUSIONS In acute hospitals, family carers and hospital staff can have disjointed communications and conversations about nutrition and hydration for persons with severe dementia. Timely reassurance, ongoing discussions and clear information sharing will support communication between those involved.
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Affiliation(s)
- Kanthee Anantapong
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Nathan Davies
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Department of Psychological Medicine, Royal London Hospital, East London NHS Foundation Trust, London, UK
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Donati E, Plotton C, Mainaud N, Gocko X. Arrêt de l’hydratation artificielle chez les patients en fin de vie : une revue systématique de la littérature. Bull Cancer 2022; 109:1073-1081. [DOI: 10.1016/j.bulcan.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/22/2022] [Accepted: 05/16/2022] [Indexed: 11/17/2022]
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10
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Experiences of Carers and People with Dementia from Ethnic Minority Groups Managing Eating and Drinking at Home in the United Kingdom. Nutrients 2022; 14:nu14122395. [PMID: 35745124 PMCID: PMC9230659 DOI: 10.3390/nu14122395] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/29/2022] [Accepted: 06/04/2022] [Indexed: 12/02/2022] Open
Abstract
Eating and drinking difficulties, such as loss of appetite and swallowing problems, are common in dementia, but little is known about the experiences of ethnic minority groups who are managing these difficulties at home. The purpose of our study was to explore the meaning of food, the impact of dementia on eating and drinking, and carers’ experiences of support. We undertook semi-structured interviews with 17 carers and people with dementia from ethnic minority backgrounds living in England, using thematic analysis to analyse the data. Food/drink had strong links to identity, culture and emotions. Providing culturally familiar foods, celebrating traditional festivals and supporting previous food-related roles promoted reminiscence, which encouraged the people living with dementia to eat and drink, as did social interactions, although these could lead to distress in those with more advanced dementia. Food choices were also influenced by carer strain, generational differences and the impact of health conditions. Despite a strong sense of duty to care for relatives at home, there was low awareness of community support services. The carers expressed a need for culturally tailored support for managing dementia-related eating and drinking difficulties at home. Healthcare professionals must provide contextually relevant advice to carers, being mindful of how cultural backgrounds can affect dietary choices.
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11
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Ke LS, Hu WY, Dai YT, Chen CY. The Differences and Perspectives Between Elderly Individuals and Their Surrogates Regarding End-of-Life Care: A Mixed Methods Study. Am J Hosp Palliat Care 2022; 39:1061-1070. [PMID: 35139645 DOI: 10.1177/10499091211052853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Family members often take the place of decision-making for elderly individuals. Previous studies showed that family members could not predict elderly individuals' thoughts about end-of-life care. Objectives: The aims are to understand the differences and perspectives between elderly individuals and surrogates regarding end-of-life care. Design: A mixed methods study comprising a cross-sectional survey and field notes analysis. Setting: Two geriatric wards in a veterans hospital located in northern Taiwan. Subjects: Fifty-five pairs of elderly individuals and their surrogates. Measurements: Life support preferences questionnaire and field notes. Results: The quantitative data showed that the elderly individuals and their surrogates had proper consistency in cardiopulmonary resuscitation and surgery. However, their consistency was poor in antibiotics and nasogastric tube feeding. Four themes were identified in qualitative data: recognizing old age, struggling with hope and peace, worries and concerns, and control of life. Recognizing old age for both elderly individuals and their surrogates was critical. Elderly individuals and their surrogates may seek a ray of hope among aggressive treatments and struggle with hope and peace. A lot of worries and concerns were mentioned, including contextual concerns. Elderly individuals need to depend on their ability to control their life. Conclusions: The study highlights elderly individuals' and their surrogates' considerations for antibiotics and nasogastric tube feeding. Furthermore, elderly individuals expressed that it is different for making decisions for themselves or others; thus, future studies can further explore whether elderly individuals allow their surrogates leeway from their wishes.
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Affiliation(s)
- Li-Shan Ke
- School of Nursing, 38028National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.,Department of Nursing, 46615Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yu Hu
- School of Nursing, College of Medicine, 33561National Taiwan University, Taipei, Taiwan.,Department of Nursing, 38006National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Tzu Dai
- School of Nursing, College of Medicine, 33561National Taiwan University, Taipei, Taiwan
| | - Ching-Yu Chen
- College of Medicine, 33561National Taiwan University, Taipei, Taiwan
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Barrado-Martín Y, Nair P, Anantapong K, Aker N, Moore KJ, Smith CH, Rait G, Sampson EL, Manthorpe J, Davies N. Family caregivers' and professionals' experiences of supporting people living with dementia's nutrition and hydration needs towards the end of life. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:307-318. [PMID: 33955630 DOI: 10.1111/hsc.13404] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/05/2021] [Accepted: 03/26/2021] [Indexed: 06/12/2023]
Abstract
The aim of this paper was to understand the needs of family caregivers and professionals supporting people living with dementia with eating and drinking difficulties towards the end of life and the strategies they use to overcome them. A total of 41 semi-structured interviews with family caregivers (n = 21) and professionals (n = 20) were conducted in London and surrounding areas of England. Interviews were audio-recorded and transcribed verbatim. Four themes were identified: caregivers accessing and seeking help, perceived priorities of care, professionals' supportiveness and educational role, and strategies. Caregivers often struggle as they are not aware of the eating and drinking difficulties associated with dementia's progression. Care can change over time with families prioritising a person's comfort towards the end of life rather than ensuring a particular level of nutrition. Mutual support is required by both professionals and caregivers to enhance the care of the person living with dementia. Cognitive difficulties are often behind initial eating and drinking challenges in dementia, whereas physical challenges take over towards the later stages. Flexibility and creativity are key to adapting to changing needs. There is a need to raise awareness of the eating and drinking challenges associated with the progression of dementia. Professionals can help caregivers embark on the transition towards focussing on comfort and enjoyment of eating and drinking near the end of life rather than nutrition. This is particularly relevant for those caring for a relative living at home. Caregivers' input is needed to tailor professionals' recommendations.
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Affiliation(s)
- Yolanda Barrado-Martín
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Pushpa Nair
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Kanthee Anantapong
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Narin Aker
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Kirsten J Moore
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Victoria, Australia
| | - Christina H Smith
- Language and Cognition, Division of Psychology and Language Sciences, University College London, London, UK
| | - Greta Rait
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, Edmonton, UK
| | - Jill Manthorpe
- NIHR Health and Social Care Workforce Research Unit and NIHR Applied Research Collaborative (ARC) South London, King's College London, London, UK
| | - Nathan Davies
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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13
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van Hamersveld-Kramer M, Perry SIB, Lodewijks E, Vasse E, de van der Schueren MAE. Decision-making regarding oral nutritional supplements for nursing home residents with advanced dementia: A cross-sectional pilot study. J Hum Nutr Diet 2021; 35:58-67. [PMID: 34694055 DOI: 10.1111/jhn.12955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/30/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surrogate decision-making regarding oral nutritional supplements (ONS) for nursing home residents with advanced dementia is a complex process. In this cross-sectional study, we assessed whether Dutch dietitians, elderly care physicians (physicians) and surrogate decision-makers (SDMs) differ in the factors that they regard important when considering ONS. We also investigated differences in opinion regarding whether or not ONS is a life-prolonging measure. METHODS Through an online survey, 90 dietitians, 53 physicians and 70 SDMs of nursing home residents (all aged ≥ 65 years old with advanced dementia) rated the level of perceived influence of 11 pre-defined factors on their decision-making, ranked factors in order of importance and stated whether they considered ONS a life-prolonging measure or not. By statistical analysis, we tested differences in the mean sum of ranks for perceived influence differing between groups. We also tested differences in proportions between groups of those who considered ONS a life-prolonging measure. RESULTS Rating of perceived influence significantly differed for six factors. Quality of life was ranked as the most influential factor by all groups. Dietitians significantly differed in their opinion on the life-prolonging effect of ONS from physicians (odds ratio = 0.29, 95% confidence interval = 0.13-0.65), as well as from SDMs (odds ratio = 0.22, 95% confidence interval = 0.10-0.45). CONCLUSIONS Although all groups proclaimed quality of life to be first priority in decision-making, we found that Dutch dietitians, physicians and SDMs differed in what they regarded important when considering ONS for nursing home residents with advanced dementia. Regarding the life-prolonging effect of ONS, dietitians differed in opinion from physicians, as well as from SDMs.
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Affiliation(s)
| | - Sander I B Perry
- Department of Epidemiology and Data Science, University of Amsterdam, Amsterdam, The Netherlands
| | - Eva Lodewijks
- Department of Dietetics, Florence Healthcare, Rijswijk, The Netherlands.,University Network for the Care Sector Zuid Holland, Leiden, The Netherlands
| | - Emmelyne Vasse
- Department of Dietetics, Gelderse Vallei Hospital, Ede, The Netherlands.,Dutch Malnutrition Steering Group, Amsterdam, The Netherlands
| | - Marian A E de van der Schueren
- Department of Nutrition, Dietetics and Lifestyle, HAN University of Applied Sciences, Nijmegen, The Netherlands.,Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
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14
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Davies N, Barrado-Martín Y, Vickerstaff V, Rait G, Fukui A, Candy B, Smith CH, Manthorpe J, Moore KJ, Sampson EL. Enteral tube feeding for people with severe dementia. Cochrane Database Syst Rev 2021; 8:CD013503. [PMID: 34387363 PMCID: PMC8407048 DOI: 10.1002/14651858.cd013503.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The balance of benefits and harms associated with enteral tube feeding for people with severe dementia is not clear. An increasing number of guidelines highlight the lack of evidenced benefit and potential risks of enteral tube feeding. In some areas of the world, the use of enteral tube feeding is decreasing, and in other areas it is increasing. OBJECTIVES To assess the effectiveness and safety of enteral tube feeding for people with severe dementia who develop problems with eating and swallowing or who have reduced food and fluid intake. SEARCH METHODS We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases and two trials registers on 14 April 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs), or controlled non-randomised studies. Our population of interest was adults of any age with a diagnosis of primary degenerative dementia of any cause, with severe cognitive and functional impairment, and poor nutritional intake. Eligible studies evaluated the effectiveness and complications of enteral tube feeding via a nasogastric or gastrostomy tube, or via jejunal post-pyloric feeding, in comparison with standard care or enhanced standard care, such as an intervention to promote oral intake. Our primary outcomes were survival time, quality of life, and pressure ulcers. DATA COLLECTION AND ANALYSIS Three review authors screened citations and two review authors assessed full texts of potentially eligible studies against inclusion criteria. One review author extracted data, which were then checked independently by a second review author. We used the 'Risk Of Bias In Non-randomised Studies of Interventions' (ROBINS-I) tool to assess the risk of bias in the included studies. Risk of confounding was assessed against a pre-agreed list of key potential confounding variables. Our primary outcomes were survival time, quality of life, and pressure ulcers. Results were not suitable for meta-analysis, so we presented them narratively. We presented results separately for studies of percutaneous endoscopic gastrostomy (PEG) feeding, nasogastric tube feeding and studies using mixed or unspecified enteral tube feeding methods. We used GRADE methods to assess the overall certainty of the evidence related to each outcome for each study. MAIN RESULTS We found no eligible RCTs. We included fourteen controlled, non-randomised studies. All the included studies compared outcomes between groups of people who had been assigned to enteral tube feeding or oral feeding by prior decision of a healthcare professional. Some studies controlled for a range of confounding factors, but there were high or very high risks of bias due to confounding in all studies, and high or critical risks of selection bias in some studies. Four studies with 36,816 participants assessed the effect of PEG feeding on survival time. None found any evidence of effects on survival time (low-certainty evidence). Three of four studies using mixed or unspecified enteral tube feeding methods in 310 participants (227 enteral tube feeding, 83 no enteral tube feeding) found them to be associated with longer survival time. The fourth study (1386 participants: 135 enteral tube feeding, 1251 no enteral tube feeding) found no evidence of an effect. The certainty of this body of evidence is very low. One study of PEG feeding (4421 participants: 1585 PEG, 2836 no enteral tube feeding) found PEG feeding increased the risk of pressure ulcers (moderate-certainty evidence). Two of three studies reported an increase in the number of pressure ulcers in those receiving mixed or unspecified enteral tube feeding (234 participants: 88 enteral tube feeding, 146 no enteral tube feeding). The third study found no effect (very-low certainty evidence). Two studies of nasogastric tube feeding did not report data on survival time or pressure ulcers. None of the included studies assessed quality of life. Only one study, using mixed methods of enteral tube feeding, reported on pain and comfort, finding no difference between groups. In the same study, a higher proportion of carers reported very heavy burden in the enteral tube feeding group compared to no enteral tube feeding. Two studies assessed the effect of nasogastric tube feeding on mortality (236 participants: 144 nasogastric group, 92 no enteral tube feeding). One study of 67 participants (14 nasogastric, 53 no enteral tube feeding) found nasogastric feeding was associated with increased mortality risk. The second study found no difference in mortality between groups. The certainty of this evidence is very low. Results on mortality for those using PEG or mixed methods of enteral tube feeding were mixed and the certainty of evidence was very low. There was some evidence from two studies for enteral tube feeding improving nutritional parameters, but this was very low-certainty evidence. Five studies reported a variety of harm-related outcomes with inconsistent results. The balance of evidence suggested increased risk of pneumonia with enteral tube feeding. None of the included studies assessed behavioural and psychological symptoms of dementia. AUTHORS' CONCLUSIONS We found no evidence that tube feeding improves survival; improves quality of life; reduces pain; reduces mortality; decreases behavioural and psychological symptoms of dementia; leads to better nourishment; improves family or carer outcomes such as depression, anxiety, carer burden, or satisfaction with care; and no indication of harm. We found some evidence that there is a clinically significant risk of pressure ulcers from enteral tube feeding. Future research should focus on better reporting and matching of control and intervention groups, and clearly defined interventions, measuring all the outcomes referred to here.
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Affiliation(s)
- Nathan Davies
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Yolanda Barrado-Martín
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Greta Rait
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Akiko Fukui
- Medical School, St George's, University of London, London, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Christina H Smith
- Division of Psychology and Language Sciences, University College London, London, UK
| | - Jill Manthorpe
- NIHR Policy Research Unit in Health and Social Care Workforce, Policy Institute at King's, King's College London, London, UK
| | - Kirsten J Moore
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Melbourne Ageing Research Collaboration, National Ageing Research Institute, Melbourne, Australia
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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15
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Wallin V, Omerov P, Mattsson E, Klarare A. Experiences of food and mealtime from the perspective of patients with chronic life-limiting disease: A mixed-method systematic review. J Adv Nurs 2021; 77:4400-4413. [PMID: 34133759 DOI: 10.1111/jan.14927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 04/08/2021] [Accepted: 05/24/2021] [Indexed: 01/07/2023]
Abstract
AIM To describe and synthesise experiences of food and mealtimes from the perspective of patients with chronic life-limiting disease. DESIGN A mixed-method systematic review. DATA SOURCES The databases Academic Search Complete, CINAHL, Nursing and Allied Health Database, PsycINFO, PubMed, Soc Index and Web of Science Core Collection were searched (January 2000 to March 2019). REVIEW METHODS Out of 3151 identified articles, 24 were included for appraisal and synthesis, using a data based convergent design. RESULTS Four themes were derived: 'understanding hampered eating-perhaps it is best to let nature run its course'; 'food and meals evoke distress-reducing joy, testing interim ways'; 'struggling with food and meals-eating to please others and to postpone death'; and 'food and meals as caring and love-flanked by social disconnecting'. CONCLUSION For patients with chronic life-limiting disease, food entailed potential to remain healthy, improve well-being and prolong life. Meanwhile, eating difficulties were experienced as fundamentally affecting social life and interactions; consequently, joy around food and meals was lost.
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Affiliation(s)
- Viktoria Wallin
- Department of Health Care Sciences, Palliative Research Centre, Ersta Sköndal Bräcke University College, Stockholm, Sweden
| | - Pernilla Omerov
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden
| | - Elisabet Mattsson
- Department of Health Care Sciences, Ersta Sköndal Bräcke University College, Stockholm, Sweden.,Department of Women's and Children's Health, Clinical Psychology in Healthcare, Uppsala University, Uppsala, Sweden
| | - Anna Klarare
- Department of Health Care Sciences, Palliative Research Centre, Ersta Sköndal Bräcke University College, Stockholm, Sweden.,Department of Women's and Children's Health, Clinical Psychology in Healthcare, Uppsala University, Uppsala, Sweden
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16
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Barrado‐Martín Y, Hatter L, Moore KJ, Sampson EL, Rait G, Manthorpe J, Smith CH, Nair P, Davies N. Nutrition and hydration for people living with dementia near the end of life: A qualitative systematic review. J Adv Nurs 2021; 77:664-680. [PMID: 33249602 PMCID: PMC7898342 DOI: 10.1111/jan.14654] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 09/01/2020] [Accepted: 10/28/2020] [Indexed: 11/28/2022]
Abstract
AIMS To synthesize the qualitative evidence of the views and experiences of people living with dementia, family carers, and practitioners on practice related to nutrition and hydration of people living with dementia who are nearing end of life. DESIGN Systematic review and narrative synthesis of qualitative studies. DATA SOURCES MEDLINE, Embase, PsycINFO, CINAHL. REVIEW METHODS Databases were searched for qualitative studies from January 2000-February 2020. Quantitative studies, or studies reporting on biological mechanisms, assessments, scales or diagnostic tools were excluded. Results were synthesized using a narrative synthesis approach with thematic analysis. RESULTS Twenty studies were included; 15 explored the views of practitioners working with people living with dementia in long-term care settings or in hospitals. Four themes were developed: challenges of supporting nutrition and hydration; balancing the views of all parties involved with 'the right thing to do'; national context and sociocultural influences; and strategies to support nutrition and hydration near the end of life in dementia. CONCLUSION The complexity of supporting nutrition and hydration near the end of life for someone living with dementia relates to national context, lack of knowledge, and limited planning while the person can communicate. IMPACT This review summarizes practitioners and families' experiences and highlights the need to include people living with dementia in studies to help understand their views and preferences about nutrition and hydration near the end of life; and those of their families supporting them in the community. The review findings are relevant to multidisciplinary teams who can learn from strategies to help with nutrition and hydration decisions and support.
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Affiliation(s)
- Yolanda Barrado‐Martín
- Centre for Ageing & Population StudiesResearch Department of Primary Care & Population HealthUniversity College LondonLondonUK
| | - Lee Hatter
- Centre for Ageing & Population StudiesResearch Department of Primary Care & Population HealthUniversity College LondonLondonUK
| | - Kirsten J. Moore
- Division of PsychiatryMarie Curie Palliative Care Research DepartmentUniversity College LondonLondonUK
- Melbourne Ageing Research CollaborationNational Ageing Research InstituteRoyal Melbourne Hospital VictoriaParkvilleVICAustralia
| | - Elizabeth L. Sampson
- Division of PsychiatryMarie Curie Palliative Care Research DepartmentUniversity College LondonLondonUK
- Barnet Enfield and Haringey Mental Health Trust Liaison TeamNorth Middlesex University HospitalLondonUK
| | - Greta Rait
- Centre for Ageing & Population StudiesResearch Department of Primary Care & Population HealthUniversity College LondonLondonUK
| | - Jill Manthorpe
- NIHR Policy Research Unit in Health & Social Care Workforce Research UnitNIHR Applied Research Collaborative (ARC) South LondonKing’s College LondonLondonUK
| | - Christina H. Smith
- Language and CognitionDivision of Psychology and Language SciencesUniversity College LondonLondonUK
| | - Pushpa Nair
- Centre for Ageing & Population StudiesResearch Department of Primary Care & Population HealthUniversity College LondonLondonUK
| | - Nathan Davies
- Centre for Ageing & Population StudiesResearch Department of Primary Care & Population HealthUniversity College LondonLondonUK
- Division of PsychiatryMarie Curie Palliative Care Research DepartmentUniversity College LondonLondonUK
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