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Recomendações em Alzheimer 2011

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The Personal Health Navigator is available to all Canadian patients. Questions about your doctor, hospital or how to navigate the health care system can be sent to AskPaul@Sunnybrook.ca.
Question: My mother has advanced dementia and lives in a nursing home. She is now having problems swallowing her food. I've asked the staff at the home if she can get nourishment through a feeding tube. But they say there are risks involved with artificial nutrition. I don't want her to starve to death. What are the pros and cons of feeding tubes?

Answer: Feeding tubes are sometimes used for people who can't swallow or are at risk of choking.

The main goal is to prevent food or liquid from going down the wrong way and accidentally ending up in the lungs. If foreign materials are inhaled into the airways, the patient may develop a serious lung infection known as aspiration pneumonia.

To insert a feeding tube, the patient is mildly sedated and a doctor makes a cut in the belly to put the tube directly into the stomach. The tube then becomes the regular pathway for delivering liquid nourishment.

It seems like an easy solution, and not so long ago, some patients with severe cognitive impairment were routinely fed this way.

In recent years, however, there's been a growing recognition that feeding tubes may do more harm than good for people with dementia, says Dr. Irene Ying, a palliative-care physician at Sunnybrook Health Sciences Centre.

For starters, the use of a tube can cause discomfort and may fail to dampen feelings of hunger or thirst.

There's also a risk that the stomach's contents will "reflux" - or back up - into the throat and enter the lungs. This means feeding tubes don't provide 100 percent protection against aspiration pneumonia.

In some cases, a feeding tube may supply more fluid and nutrition than the patient actually needs. This can lead to edema, in which watery fluids build up in tissues or body cavities - including the lungs - causing discomfort and making breathing difficult.

What's more, artificial feeding can boost the amount of stool - often as diarrhea, increasing the risk of bedsores and infections.

Ying says feeding tubes are often started with the intention of prolonging a person's life. Yet, "there is no evidence to show they help with survival," she says. In fact, the possible complications from this feeding method may hasten the death of a cognitively-impaired individual.

To make matters worse, a patient with dementia is unlikely to understand why a feeding tube has been put in place and could try to pull it out. In response, the patient's movements may be restricted by the use of a sedating medication or physical restraints.

"It's really sad when this happens to people with dementia," says Dr. Peter Tanuseputro, a physician scientist at the Bruyère Research Institute and Ottawa Hospital.

"They can't express their wishes, so they are more vulnerable to getting care they wouldn't want."

Tanuseputro notes that dementia tends to be a gradually advancing disease which eventually results in death. That's why it's important for patients to talk to their families about their end-of-life wishes while they still have the ability to do so.

Tanuseputro is the lead author of a recent study that looked at spending on end-of-life care in Ontario.

The findings revealed that $4.7-billion annually - 10 percent of the province's health-care budget - goes to the cost of caring for people in their last year of life. That works out to $54,000 per person - and the lion's share represents hospital expenditures in the final few months or weeks of life.

As many as half of all terminally-ill Canadians die in hospital, partly because there's a lack of palliative care and other supports in the community, Tanuseputro says.

Once they are admitted to hospital, patients are likely to receive treatments aimed at increasing survival. "But when someone is dying, there is often nothing that we can do to prolong life." In other words, some of those final medical interventions may be unhelpful and even counter-productive because the treatment's side effects can contribute to patient suffering.

"I think the majority of end-of-life care should be focused on improving their quality of life, and providing a comfortable and meaningful dying experience," he adds.

"The unfortunate thing is that we are not recognizing that people with advanced dementia are at the end of life and should be receiving palliative care." He says hospitalization "contributes to them getting aggressive treatment when they shouldn't be."

Ying points out that many expert groups - including the American Geriatrics Society - discourage the use of feeding tubes in patients with advanced dementia. Instead, they recommend careful hand feeding by healthcare staff or family members. This is known as "comfort feeding" and it's done only when the patient is alert and receptive to food.

The use of a tube, by contrast, amounts to "forced feeding" which isn't in the best interest of the patient, Ying says.
Sunnybrook's Patient Navigation Advisor provides advice and answers questions from patients and their families. His blog, Personal Health Navigator, is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Follow Paul on Twitter @epaultaylor.

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Why palliative care, not feeding tubes, is best for advanced dementia patients

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The Personal Health Navigator is available to all Canadian patients. Questions about your doctor, hospital or how to navigate the health care system can be sent to AskPaul@Sunnybrook.ca. Question: My mother has advanced dementia and lives in a nursing home. She is now having problems swallowing her food.

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Feeding Tubes for People with Alzheimer's Disease: When you need them - and when you don't

Most people in the last stage of Alzheimer's disease have difficulty eating and drinking. At this time, families may wonder if a patient needs a feeding tube.

Families want to do everything possible for someone who is ill. But they often get little information about feeding tubes. And they may feel pressure from doctors or nursing home staff, because feeding is simpler with a feeding tube.

But feeding tubes sometimes do more harm than good. Here's why:
Feeding tubes usually aren't helpful for severe Alzheimer's disease.
People with severe Alzheimer's disease can no longer communicate or do basic things. Chewing and swallowing is often hard. This can cause serious problems, such as weight loss, weakness, and pressure sores. Or food can get into the lungs, and cause pneumonia. So people often need help to eat.

In many cases, a decision is made to use a feeding tube. The tube may be put down the throat. Or it may be put through a small cut in the abdominal wall, into the stomach. The patient is then given liquid nutrition through the tube.

But tube feeding is not better than careful hand feeding-and it may be worse. It does not help people live longer, gain more weight, become stronger, or regain skills. And it may increase the risk of pneumonia and pressure sores.

Hand feeding gives human contact and the pleasure of tasting favourite foods.
When death is near and patients can no longer be fed by hand, families often worry that the patient will "starve to death." In fact, refusing food and water is a natural, non-painful part of the dying process. There is no good evidence that tube feeding helps these patients live longer.
Feeding tubes can have risks.
Tube feeding has many risks.

It can cause bleeding, infection, skin irritation, or leaking around the tube.

It can cause nausea, vomiting, and diarrhea.

The tube can get blocked or fall out, and must be replaced in a hospital.

Many people with Alzheimer's disease are bothered by the tube and try to pullit out. To prevent that, they are often tied down or given drugs.

Tube-fed patients are more likely to get pressure sores.

Tube-fed patients are more likely to spit up food, which may lead to pneumonia a term called "aspiration pneumonia".

At the end of life, fluids can fill the patient's lungs, and cause breathing problems.

So when are feeding tubes a good idea?
Feeding tubes can be helpful when the main cause of the eating problem is likely to get better. For example, they can help people who are recovering from a stroke, brain injury, or surgery.

The tubes also make sense for people who have problems swallowing and are not in the last stage of an illness that can't be cured. For example, they can help people with Parkinson's disease or amyotrophic lateral sclerosis (Lou Gehrig's disease).
Caring for a person with severe Alzheimer's disease:
When caring for a person with severe Alzheimer's disease, these steps can help with eating problems and other end-of-life concerns:

Treat conditions that cause appetite loss, such as constipation, depression, or infection.

Feed by hand. Ask the health care provider about the best kinds of foods to offer and the best ways to feed by hand.

Stop unneeded medicines. Some drugs can make eating problems worse, including:

antipsychotics such as quetiapine (Seroquel and generic)

sleeping pills or anti-anxiety drugs such as lorazepam or Zopliclone

bladder-control drugs such as oxybutynin (Ditropan and generic)

some drugs for osteoporosis such as alendronate (Fosamax and generic)

drugs for Alzheimer's disease such as donepezil (Aricept and generic)

Schedule dental care. Badly fitting dentures, sore gums, and toothaches can make eating hard or painful.

Consider hospice care. Many people with advanced Alzheimer's disease qualify for hospice care if they have difficulty drinking and eating enough to keep their weight up. Hospice eases suffering and pain in the last six months of life. Hospice can be given in the patient's home.

Plan ahead. Every adult should have an advance directive. It lets you say what kind of care you want and who can make decisions for you if you cannot speak for yourself. You can print your province's advance directive form at Speak Up.

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Feeding Tubes for People with Alzheimer's Disease: When you need them - and when you don't - Choosing Wisely Canada

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Most people in the last stage of Alzheimer's disease have difficulty eating and drinking. At this time, families may wonder if a patient needs a feeding tube. Families want to do everything possible for someone who is ill. But they often get little information about feeding tubes.

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Manejo ulceras traumaticas e neurotroficas MS 2002

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Manejo ulceras traumaticas e neurotroficas MS 2002

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Consenso 2016 sobre medicamentos potencialmente inapropriados para idosos