ESPEN guideline on nutrition and hydration in dementia - Update 2024.

BACKGROUND & AIMS: Dementia is accompanied by a variety of changes that result in an increased risk of malnutrition and low-intake dehydration. This guideline update aims to give evidence-based recommendations for nutritional care of persons with dementia in order to prevent and treat these syndromes. METHODS: The previous guideline version was reviewed and expanded in accordance with the standard operating procedure for ESPEN guidelines. Based on a systematic search in three databases, strength of evidence of appropriate literature was graded by use of the SIGN system. The original recommendations were reviewed and reformulated, and new recommendations were added, which all then underwent a consensus process. RESULTS: 40 recommendations for nutritional care of older persons with dementia were developed and agreed, seven at institutional level and 33 at individual level. As a prerequisite for good nutritional care, organizations caring for persons with dementia are recommended to employ sufficient qualified staff and offer attractive food and drinks with choice in a functional and appealing environment. Nutritional care should be based on a written care concept with standardized operating procedures. At the individual level, routine screening for malnutrition and dehydration, nutritional assessment and close monitoring are unquestionable. Oral nutrition may be supported by eliminating potential causes of malnutrition and dehydration, and adequate social and nursing support (including assistance, utensils, training and oral care). Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Routine use of dementia-specific ONS, ketogenic diet, omega-3 fatty acid supplementation and appetite stimulating agents is not recommended. Enteral and parenteral nutrition and hydration are temporary options in patients with mild or moderate dementia, but not in severe dementia or in the terminal phase of life. In all stages of the disease, supporting food and drink intake and maintaining or improving nutrition and hydration status requires an individualized, comprehensive approach. Due to a lack of appropriate studies, most recommendations are good practice points. CONCLUSION: Nutritional care should be an integral part of dementia management. Numerous interventions are available that should be implemented in daily practice. Future high-quality studies are needed to clarify the evidence.

Ketogenic Diet for the Treatment and Prevention of Dementia: A Review.

Dementia (major neurocognitive disorder) is an increasingly common syndrome with a significant burden on patients, caregivers, the health-care system, and the society. The prevalence of dementia will certainly continue to grow as the US population ages. Current treatments for dementia, though, are limited. One proposed nonpharmacologic approach for the delay or prevention of dementia is the use of a ketogenic diet. The ketogenic diet was originally employed to treat refractory epilepsy and has shown promise in many neurologic diseases. It has also gained recent popularity for its weight loss effects. Several preclinical studies have confirmed a benefit of ketosis on cognition and systemic inflammation. Given the renewed emphasis on neuroinflammation as a pathogenic contributor to cognitive decline, and the decreased systemic inflammation observed with the ketogenic diet, it is plausible that this diet may delay, ameliorate, or prevent progression of cognitive decline. Several small human studies have shown benefit on cognition in dementia with a ketogenic diet intervention. Future, large controlled studies are needed to confirm this benefit; however, the ketogenic diet has shown promise in regard to delay or mitigation of symptoms of cognitive decline.

Effects of probiotics supplementation on dementia and cognitive impairment: A systematic review and meta-analysis of preclinical and clinical studies.

BACKGROUND: Dementia is a chronic syndrome characterized by cognitive and behavioral symptoms, which may include short-term memory impairment and problems related to orientation, language, attention and perception. Although cognitive impairment (CI) is increasingly considered the main geriatric condition predisposing to dementia, its early management could still promote symptomatic relief and delay disease progression. Recently, probiotics treatment has been studied as a potential new therapeutic approach to attenuate dementia-related decline and mild cognitive impairment (MCI). Therefore, we conducted a systematic review and meta-analysis to review and analyse the available evidence on the effect of probiotics on MCI and dementia. METHODS: A systematic search and meta-analysis were performed on Cochrane Library, ProQuest, Web of Science, PubMed-Medline, The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, ScienceDirect and Open Grey. Search terms included diagnoses of interest (dementia and MCI) and the intervention of interest (probiotic, lactobacillus and bifidobacterium). Original articles reporting the use of probiotics supplementation for the treatment of dementia and MCI were screened and studied independently by two researchers. After that, a random and fixed effects model was used at the meta-analysis stage of the results to determine its effect size. RESULTS: A total of 16 articles (10 preclinical and 6 clinical) that met the inclusion criteria for the systematic review, and 15 articles (10 preclinical and 5 clinical) for meta-analysis were finally included. In humans, the administration of probiotics improved general cognitive function after the treatment period. Similarly, an improvement in memory and spatial/non-spatial learning was identified in the probiotic group of animals compared to the control group. On the other hand, the results showed an increase in the levels of the brain-derived neurotrophic factor, an improvement in the inflammatory profile and regulation of cellular biomarkers after probiotics administration. CONCLUSION: Probiotics supplementation could be an adequate therapeutic strategy both in dementia and CI based on clinical and preclinical evidence. However, it is therefore important to translate preclinical data into clinical data where the evidence is more limited.

Efficacy of Mealtime Interventions for Malnutrition and Oral Intake in Persons With Dementia: A Systematic Review.

Malnutrition and weight loss are highly prevalent in persons with Alzheimer's disease and related dementias. Oral intake is an important interventional target for addressing these nutritional consequences. However, the efficacy of interventions remains poorly understood as prior syntheses have failed to examine the impact of intervention approaches on malnutrition and hypothesized mechanisms of action in persons with dementia. This review aimed to determine the efficacy of mealtime interventions to improve oral intake and nutritional outcomes in persons with dementia. Four databases yielded 1712 studies, resulting in 32 studies that met inclusion criteria. Studies included education, environmental modifications, feeding, oral supplementation, and other pharmacologic/ecopsychological interventions. While the majority of studies reported statistically significant improvements in at least 1 nutritional outcome, study design and outcome measures were heterogenous with many lacking adequate statistical power or blinding. Collectively, we found moderate evidence to suggest the efficacy of oral supplementation, and preliminary evidence to suggest that feeding interventions, education, and environmental modifications may confer improvements. Findings clarify the state of existing evidence regarding various interventional strategies for improving malnutrition in persons with dementia. While some approaches are promising, adequately powered and rigorously designed multidimensional intervention trials are needed to inform clinical decision-making in real-world contexts.

Diet modulates brain network stability, a biomarker for brain aging, in young adults.

Epidemiological studies suggest that insulin resistance accelerates progression of age-based cognitive impairment, which neuroimaging has linked to brain glucose hypometabolism. As cellular inputs, ketones increase Gibbs free energy change for ATP by 27% compared to glucose. Here we test whether dietary changes are capable of modulating sustained functional communication between brain regions (network stability) by changing their predominant dietary fuel from glucose to ketones. We first established network stability as a biomarker for brain aging using two large-scale (n = 292, ages 20 to 85 y; n = 636, ages 18 to 88 y) 3 T functional MRI (fMRI) datasets. To determine whether diet can influence brain network stability, we additionally scanned 42 adults, age < 50 y, using ultrahigh-field (7 T) ultrafast (802 ms) fMRI optimized for single-participant-level detection sensitivity. One cohort was scanned under standard diet, overnight fasting, and ketogenic diet conditions. To isolate the impact of fuel type, an independent overnight fasted cohort was scanned before and after administration of a calorie-matched glucose and exogenous ketone ester (d-ß-hydroxybutyrate) bolus. Across the life span, brain network destabilization correlated with decreased brain activity and cognitive acuity. Effects emerged at 47 y, with the most rapid degeneration occurring at 60 y. Networks were destabilized by glucose and stabilized by ketones, irrespective of whether ketosis was achieved with a ketogenic diet or exogenous ketone ester. Together, our results suggest that brain network destabilization may reflect early signs of hypometabolism, associated with dementia. Dietary interventions resulting in ketone utilization increase available energy and thus may show potential in protecting the aging brain.

Probiotics, prebiotics, and synbiotics for the treatment of dementia: Protocol for a systematic review.

BACKGROUND: The number of dementia patients in the world is large, and the number of dementia patients will continue to rise in the future, which will bring a heavy social and economic burden. No interventions have been found to cure dementia. Medication can delay the progression of the disease and impose an economic burden. Some non-drug therapies often require the care of the caregiver. Probiotics, prebiotics, and synbiotics may intervene in dementia through microbiota-gut-brain axis (MGBA). However, their effectiveness and safety are still obscure and deserve further investigation. The purpose of this study is to assess the effect and safety of probiotics, prebiotics, and synbiotics in treating dementia. METHODS: We will summarize and meta-analyze randomized controlled trials (RCTs) of probiotics, prebiotics, and synbiotics for the treatment of dementia. RCTs comparing probiotics, prebiotics, and synbiotics with blank control, placebo or conventional therapies will be included. RCTs comparing probiotics, prebiotics, and synbiotics plus conventional therapies with conventional therapies alone will also be included. The following electronic databases will be searched: PubMed, Cochrane Library, EMBASE, CNKI, CBM, VIP, and WAN FANG DATA. The methodological quality of RCTs will be assessed using the Cochrane risk assessment tool. All trials included will be analyzed according to the criteria of the Cochrane Handbook. Review Manager 5.3, R-3.5.1 software will be used for publication bias analysis. Grading of Recommendations Assessment, Development and Evaluation (GRADE) pro-GDT web solution will be used for evidence evaluation. RESULTS: This review will evaluate the effects of probiotics, prebiotics, and synbiotics on cognitive function, behavioral and psychological symptoms of dementia, quality of life (QOL), functional performance in activities of daily living, and compliance with the intervention and safety in patients with dementia. CONCLUSIONS: This review will provide clear evidence to assess the effectiveness and safety of probiotics, prebiotics, and synbiotics for dementia.OSF registration number: DOI 10.17605/OSF.IO/2Q3AK.

Attending to difference: enacting individuals in food provision for residents with dementia.

In the face of warnings about total institutions and growing concern about the quality of care, healthcare professionals in Western Europe and North America have increasingly been exhorted to tailor their services to individuals in their care. In this article, we invite our readers to become more interested in the kinds of differences care is being tailored to, and with what effects. Focusing on food provision for residents with dementia, we present three repertoires through which care workers attend to, and enact different sets of differences between individuals: providing choice allows residents to express fleeting preferences; knowing residents places emphasis on care providers' familiarity with a person; and catering to identities brings to the fore the tastes which make up part of who someone is. The analysis brings attending to difference to the fore as a practical process and suggests that tailoring care requires sensitivity to the different kinds of individuals enacted when attending to difference.

Demencia y problemas de alimentación: ¿sonda PEG o no? / Dementia and feeding problems: PEG feeding tube or not?

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B Vitamins and Fatty Acids: What Do They Share with Small Vessel Disease-Related Dementia?

Many studies have been written on vitamin supplementation, fatty acid, and dementia, but results are still under debate, and no definite conclusion has yet been drawn. Nevertheless, a significant amount of lab evidence confirms that vitamins of the B group are tightly related to gene control for endothelium protection, act as antioxidants, play a co-enzymatic role in the most critical biochemical reactions inside the brain, and cooperate with many other elements, such as choline, for the synthesis of polyunsaturated phosphatidylcholine, through S-adenosyl-methionine (SAM) methyl donation. B-vitamins have anti-inflammatory properties and act in protective roles against neurodegenerative mechanisms, for example, through modulation of the glutamate currents and a reduction of the calcium currents. In addition, they also have extraordinary antioxidant properties. However, laboratory data are far from clinical practice. Many studies have tried to apply these results in everyday clinical activity, but results have been discouraging and far from a possible resolution of the associated mysteries, like those represented by Alzheimer's disease (AD) or small vessel disease dementia. Above all, two significant problems emerge from the research: No consensus exists on general diagnostic criteria-MCI or AD? Which diagnostic criteria should be applied for small vessel disease-related dementia? In addition, no general schema exists for determining a possible correct time of implementation to have effective results. Here we present an up-to-date review of the literature on such topics, shedding some light on the possible interaction of vitamins and phosphatidylcholine, and their role in brain metabolism and catabolism. Further studies should take into account all of these questions, with well-designed and world-homogeneous trials.

Dietary interventions in mild cognitive impairment and dementia.

Dietary intervention is an enticing approach in the fight against cognitive impairment. Nutritional supplements and dietetic counseling are relatively easy and benign interventions, but research has not yet yielded irrefutable evidence as to their clinical utility. Heterogeneity in the results of available clinical studies, as well as methodological and practical issues, does not allow replication and generalization of findings. The paper at hand reviews only randomized clinical trials of single nutrients, multi-nutrient formulations and dietary counseling in mild cognitive impairment and dementia of the Alzheimer's type focusing on both cognitive and functional outcomes. Thus far, folate, vitamin E, Ω-3 fatty acids, and certain multi-nutrient formulations have shown some preliminary promising results; larger, well-designed trials are needed to confirm these findings before nutritional elements can be incorporated in recommended clinical guidelines.

Nutrición enteral domiciliaria en el paciente con patología neurológica de un área de salud del sureste español / Home enteral nutrition in patients with neurological disease in an area of the southeast of Spain

Introducción: la desnutrición en el paciente neurológico presenta una alta prevalencia, aumentando las complicaciones y disminuyendo la calidad de vida. La nutrición artificial minimiza el riesgo de malnutrición. En los últimos años, en Murcia, se pone en marcha una vía clínica de adecuación a la Guía Nacional de Nutrición Enteral Domiciliaria (NED) para optimizar este recurso y reducir la variabilidad de prescripción. Objetivo: analizar las características de la NED en el paciente neurológico, de un área de salud de Murcia, antes y después de la adecuación a las directrices nacionales. Método: diseño observacional de corte transversal. Análisis y comparación de las muestras NED de adultos del Área 1 de salud de Murcia, en 2010 y 2014. Resultados: la patología más asociada a las prescripciones de NED fue la neurológica. La vía de administración más utilizada fue la oral, aunque desciende en la muestra de 2014 a favor de la sonda de nutrición y ostomía. El tipo de fórmula más usado en 2010 fue la no específica. Tras la vía clínica se reduce el uso de fórmulas específicas, disminuyendo especialmente las fórmulas hiperproteicas y/o hipercalóricas. Conclusiones: la implementación de una vía clínica de adecuación a la Guía Nacional NED ha provocado un cambio en la realidad de este tipo de nutrición artificial en el Área 1 de salud del Servicio Murciano de Salud, consiguiendo normalizar su uso bajo criterios unificados y profesionales especializados. Finalmente, estos logros se han generalizado a toda la región

Introduction: malnutrition in patients with neurological disease is very prevalent, worsening their complications and diminishing their quality of life. For that reason, nutritional support can provide a reduction in comorbidities. Over the past years, in Murcia (southeast of Spain), a clinical pathway has been stablished in accordance to the National Home Enteral Nutrition guide (HEN) to optimize this resource and reduce the prescription gap. Objective: to analyze the HEN characteristics in neurological patients in an area of Murcia, before and after the adequacy of the national recommendations. Method: observational cross-sectional study. Analysis and comparison of HEN in health area no. 1 in Murcia in 2010 and 2014. Results: the most prevalent cause for HEN was neurological disease. In 2010, oral nutrition was the most used way compared with 2014, when it had changed to enteral nutrition through feeding tube or ostomy. Non-specific formula was the most frequently used in 2010. However, after the establishment of the clinical pathway there was a reduction in specific enteral formula use, specially hypercaloric and hyperproteic. Conclusions: the implementation of a clinical pathway according to the National HEN guide has caused a change in the reality of artificial nutrition in health area no. 1 in Murcia (Spain), which means a standardization of its use under unified criteria made by specialized professionals. Finally, due to these results, this clinical pathway has been generalized to the rest of the region

Nutritional Interventions for Persons With Early-Stage Dementia or Alzheimer's Disease: An Integrative Review.

Persons with Alzheimer's disease and related dementias (ADRD) are at particular risk of malnutrition and weight loss. Clinical research concerning the role and impact of nutritional intervention in early-stage ADRD, specifically on cognition and key symptoms such as behavior, is less straightforward. Thus, an integrative review was conducted to examine the literature pertaining to nutritional interventions for persons with ADRD and to make recommendations for priority areas for future research and practice. Findings from the studies reviewed highlight multiple potential opportunities for improving nutritional status and support for persons with ADRD living in the community. Despite the small amount of evidence, the six studies identified in the current review suggest a broad benefit may be conferred through educational approaches and nutritional supplementation. [Res Gerontol Nurs. 2019; 12(5):259-268.].

Manejo nutricional de la demencia avanzada: resumen de recomendaciones del Grupo de Trabajo de Ética de la SENPE / Nutritional management of advanced dementia: summary of recommendations of the SENPE Ethic Group

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Adherence to multidomain interventions for dementia prevention: Data from the FINGER and MAPT trials.

INTRODUCTION: Multidomain interventions, targeting multiple risk factors simultaneously, could be effective dementia prevention strategies, but may be burdensome and not universally acceptable. METHODS: We studied adherence rates and predictors in the Finnish Geriatric Intervevntion Study to Prevent Cognitive Impairment and Disability and Multidomain Alzheimer Preventive Trial prevention trials, for all intervention components (separately and simultaneously). Finnish Geriatric Intervevntion Study to Prevent Cognitive Impairment and Disability participants received a 2-year multidomain lifestyle intervention (physical training, cognitive training, nutritional counseling, and cardiovascular monitoring). Multidomain Alzheimer Preventive Trial participants received a 3-year multidomain lifestyle intervention (cognitive training, physical activity counseling, and nutritional counseling) with either an omega-3 supplement or placebo. RESULTS: Adherence decreased with increasing intervention complexity and intensity: it was highest for cardiovascular monitoring, nutritional counseling, and the omega-3 supplement, and lowest for unsupervised computer-based cognitive training. The most consistent baseline predictors of adherence were smoking and depressive symptoms. DISCUSSION: Reducing participant burden, while ensuring that technological tools are suitable for older individuals, maintaining face-to-face contacts, and taking into account participant characteristics may increase adherence in future trials.

Enhancing the decision-making process when considering artificial nutrition in advanced dementia care.

BACKGROUND: Nutritional problems often manifest during late-stage dementia, and some families may request to instigate artificial nutrition and hydration (ANH) therapies. In the US, an estimated one-third of nursing home patients with a severe cognitive impairment have artificial feeding tubes inserted. Fear that a relative could experience extreme hunger or thirst if they are not mechanically fed tends to be the main driver behind family's requests to implement artificial or enteral feeding methods. In contrast, artificial hydration is rarely given to older people with dementia in the UK and this practice of non-intervention tends to apply across all healthcare and hospice type environments. AIM: This literature review aims to evaluate the evidence to support the use and non-use of ANH. METHOD: A literature review was undertaken to examine the evidence around ANH for patients with dementia to offer support to families or carers contemplating feeding choices. CONCLUSION: This paper challenges the implementation of invasive ANH worldwide. It highlights how resorting to ANH does not necessarily lead to improvements in comfort, survival or wound healing. The risk of aspiration does not appear to significantly alter either.

Japanese, Mediterranean and Argentinean diets and their potential roles in neurodegenerative diseases.

Environmental factors are responsible of cellular senescence and processes found in the development of cognitive disorders. The aim of this paper is to compare benefits of the Japanese, Mediterranean, and Argentinian Diet on the onset or prevention of senile dementia (SD) and Alzheimer's Disease (AD). Special focus was on the effects of specific compounds such as polyunsaturated fatty acids (PUFAs), antioxidants, and saturated and trans fatty acids. A high adherence to diets rich in PUFAs, monounsaturated fatty acids (MUFAs) and antioxidants may decrease the risk of developing neurodegenerative diseases; while the predominance of saturated and trans fatty acids possibly rises it.

Enteral versus oral feeding in advanced dementia.

The global population is aging, and with this demographic shift, the incidence and prevalence of dementia are expected to increase. According to the World Health Organization, an estimated 50 million people are living with dementia worldwide, and this number is expected to triple to 150 million by 2050. Dementia initially affects the brain, eventually affecting the entire body culminating in death, commonly from the complications and comorbidities. People with dementia often experience eating difficulties in addition to a severe decline in cognitive, verbal, and functional abilities secondary to gradual neurodegenerative process, leading to weight loss, malnutrition, and dehydration. When eating difficulties and weight loss occur, health care providers and families often feel obligated to decide to either continue the oral feeding or opt for feeding tube placement. Primary care clinicians, both nurse practitioners and physicians, are presented with challenges when facilitating the decision regarding the feeding options in patients with advanced dementia. This narrative review aims at evaluating the impact of enteral nutrition versus oral feeding by comparing the rates of survival and adverse events in older adults with advanced dementia. It also highlights the best approaches to optimizing nutrition for this frail population.

Effect of monosodium L-glutamate (umami substance) on cognitive function in people with dementia.

BACKGROUND/OBJECTIVES: This study assessed the effect of continuous ingestion of monosodium L-glutamate (MSG) on cognitive function and dietary score in dementia patients. SUBJECTS/METHODS: This was a single-blind, placebo-controlled trial involving 159 subjects with dementia residing in a hospital or nursing home. We assigned the subjects to a group that ingested MSG thrice daily (0.9 g/dose) (MSG group; n = 79) or a group that ingested NaCl thrice daily (0.26 g/dose) (Control group; n = 80). This study consisted of a 12-week intake period, followed by a 4-week follow-up period without the ingestion of MSG or NaCl. We performed physical examination, cognitive symptom tests (the Touch Panel-type Dementia Assessment Scale (TDAS) and Gottfries-Bråne-Steen Scale (GBSS)), palatability and behaviour questionnaires, and blood tests before and after the intervention and after the follow-up period. RESULTS: There were no significant differences in the TDAS and GBSS total scores between the groups before and after the intervention. However, regarding the TDAS sub-items, "the accuracy of the order of a process" did not deteriorate in the MSG group compared with that observed in the Control group (p < 0.05). At the follow-up assessment, the TDAS total scores in the MSG group showed significant improvement compared with those reported in the Control group (p < 0.05). Furthermore, there was a correlation of changes from pre-intervention to post-intervention between the TDAS and enjoyment of the meal (r = -0.299, p = 0.049). CONCLUSIONS: Our results suggest that continued ingestion of MSG has an effect on cognitive function. Furthermore, the patients with improved questionnaires about palatability survey showed greater improvement in cognitive function.

Validation study of a Spanish version of the modified Telephone Interview for Cognitive Status (STICS-m).

OBJECTIVE: To compare the Spanish version of the modified Telephone Interview of Cognitive Status (STICS-m) with the Mini-Mental State Examination (MMSE) and predict its ability to detect the development of dementia. METHOD: 106 participants in a dietary intervention trial underwent face-to-face evaluation with the MMSE, and phone interview with the STICS-m. The correlation between STICS-m and MMSE was assessed with the intraclass correlation coefficient (ICC) of consistency. Secondly, 932 participants over 55 years old from the "Seguimiento Universidad de Navarra" cohort were evaluated with the STICS-m and data on dementia diagnosis were gathered (median follow-up time of 6.5 years). A logistic regression model evaluated the association between STICS-m score or 2-year changes in STICS-m score and risk of developing dementia, adjusting for ApoE, age and years of university education. RESULTS: The ICC between the MMSE and the STICS-m was 0.31 (95% confidence interval [95%CI]: 0.13-0.48). The adjusted odds ratio (OR) for the development of dementia for each additional point in the baseline STICS-m score was 0.85 (95%CI: 0.72-1.02; p=0.084). When considering the 2-year change in the STICS-m score as exposure, the OR for the development of dementia was 0.79 (95%CI: 0.67-0.93; p=0.006). CONCLUSIONS: The weak correlation between the STICS-m and the MMSE reflects moderate-low concurrent validity. Even so, the STICS-m can be regarded as an useful tool in the epidemiological setting since increasing scores appear to be able to predict a lower risk of developing dementia.