Lionel S. Lim, MD, MPH, FACP, FACPM
What are the benefits of oral feeding options for persons with dementia and feeding problems?
Included studies compared oral feeding options (prescribed high-calorie or high-protein supplements, modified diets, appetite stimulants, assisted feeding, or modified dining environments) with no intervention, usual care, or alternative feeding interventions in persons ≥ 50 years of age with dementia and a feeding problem (i.e., weight loss, dysphagia, reduced intake, or other evidence indicating risk for nutritional decline). Studies of supplements without caloric value (e.g., vitamins) were excluded. Studies had to report 1 major clinical outcome (survival, hospitalization, pneumonia, aspiration, functioning, quality of life, weight change, or wound healing) at ≥ 1 month follow-up.
MEDLINE, EMBASE/Excerpta Medica, Cochrane Library, CINAHL, and PsycINFO were searched from 1990 to October 2009 for randomized or nonrandomized controlled trials. Reference lists of included studies were hand-searched. 25 studies met the inclusion criteria: 19 were randomized controlled trials (RCTs) (n = 1591, sample size range 12 to 515, follow-up range 3 wk to 1 y). 4 RCTs had concealed allocation, and 11 were judged to have low risk for bias (5 of 7 criteria met). 17 RCTs involved nursing home residents or inpatients.
Meta-analysis was not done because of heterogeneity among trials in dementia severity, feeding problems, interventions, and outcome measures. The results of RCTs are reported here. Liquid supplements. 11 RCTs (n = 604) assessed high-calorie liquid supplements, alone or with various combinations of soup, fruit, dessert, or high-calorie bars. In 7 of 10 RCTs, supplements increased weight or body mass index (BMI). 3 of 3 RCTs (n = 172) showed no change in physical function, and 3 of 3 RCTs (n = 182) showed no change in cognition. Single RCTs showed that supplements improved pressure ulcer healing (n = 28) and reduced infections and bed-days (borderline significant) but not mortality (n = 99). Other interventions. 2 RCTs assessed appetite stimulants: Dronabinol, 2.5 mg twice daily (crossover study, n = 12), and megestrol, 800 mg/d (n = 68), each resulted in weight gain. Single studies showed that each of the following interventions increased weight: chocolate or hot chocolate, a homemade supplement, and exercise (n = 121); feeding assistance (n = 69); and lyophilized food, reconstituted to liquid or semisolid consistency (n = 56). Single studies found no difference in weight for buffet-style dining (n = 40) or high-carbohydrate meals (n = 34). 1 RCT (n = 515) comparing chin-down positioning with thickened liquids found no difference for pneumonia or mortality.
High-calorie supplements increase weight in persons with dementia and feeding problems, but there is no evidence that they affect other important clinical outcomes, such as functional status or death. Some evidence suggests that appetite stimulants, chocolate and exercise, feeding assistance, and lyophilized foods with modified texture may increase weight.
Lim LS. Review: High-calorie supplements increase weight in persons with dementia and feeding problems; no evidence exists for other outcomes. Ann Intern Med. ;155:JC2–5. doi: 10.7326/0003-4819-155-4-201108160-02005
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Published: Ann Intern Med. 2011;155(4):JC2-5.
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