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At the last NYCLTCEN meeting in September, I was asked by many in the audience to provide a copy of the assessment instruments that I and co-workers had developed, to classify behaviors which hinder of prevent effective oral nutrition in late stage dementia patients. The Board suggested that the Newsletter seemed to be an appropriate forum for this. By way of background, it should be understood and recognized that a major management problem in late stage and end stage dementia is the patient's dependence on others for feeding and finally failure to accept adequate nutrition and hydration even when fed. This failure is characterized by many different behaviors that obstruct the feeding process. All of these may be attributable to the brain damage caused by the underlying disease process. Our work has shown that there are several different groups of behavior and that each group, when present, suggests a management approach. The attached Aversive Feeding Behavior Inventory (AFBI) and Aversive Feeding Dependency Scale (AFDS) can help care providers identify those at risk (AFDS) and then develop a management strategy (AFBI). Restoration of nutritional status does not alter the underlying behaviors which progress and change with the progression of the underlying brain pathology.

Interpretations of Aversive Feeding Behavior Inventory in Dementia

Global aversive behaviors

Confusion and in- coordination hinder or prevent many different activities, including eating. Indicates global brain pathology.

1. Resistive behaviors

May indicate reflex protective responses to being physically disturbed. Often actively resist other activities (e.g., bathing and dressing).

Recommend

A quiet environment and a coaxing, non-threatening approach. Repeated efforts are usually needed. Favorite foods may enhance feeding efforts.

Dyspraxia/agnosia

Demonstrate neglect or failure to recognize food, or the ability to use utensils. Initially precede and then accompany oropharyngeal dysphagia.

Recommend

A non-distracting environment, continuous prompting, coaxing and/or cueing, favorite foods, and frequent small meals.

Oral aversive feeding behaviors

Affect only the act of eating. Probably indicate localized mesotemporal or basal brain pathology.

1. Selective behaviors

May represent early oropharyngeal dysphagia because of unconscious need to change food consistency (thinken liquids and puree solids). May be associated with speech impairment. Potentially the most amenable to enhanced feeding strategies.

Recommend

Frequent small meals, change food consistencies, offer favorite foods.

2. Oropharyngeal dysphagia

Indicate impairment of chewing and bolus formation. Patients lack speech, ambulation, volition, and/or continence. Indicates pre-terminal/terminal stage dementia.

Recommend

Limited therapeutic options. Continue efforts at spoon feeding. Time trial of artificial nutrition and hydration for an acute change of eating status. Consider palliative care if no recovery within set time.

3. Pharyngoesophageal dysphagia

Permits laryngeal penetration by liquids and/or bolus.

Recommend

Requires speech and swallow examination. Strategies to minimize aspiration. Trial of tube feeding for an acute change in feeding status. If problem and complications persist consider gastrostomy feeding or palliative care.

For further information contact Dr. Blandford at (718) 920-4696 or by e-mail at DrGB@aol.com. For copy of chart on assessing aversive feeding behavior, which was included in the newsletter, contact the ethics network at (718) 796-2444.

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