Nutrition and Hydration

Meeting the nutritional needs of residents who are approaching the end-of-life is challenging for staff. Assisting residents with swallowing difficulties and behavioural or cognitive impediments to eat is a skillful and time consuming activity. There may be ethical and emotional issues for staff as well as the relatives of the resident to work through. There are standards of care to be met.

Potentially reversible causes of unexplained weight loss should be excluded. These may include:

  • pain
  • poor oral health
  • confusion
  • not recognising food
  • swallowing difficulties (dysphagia), and
  • need for increased physical assistance to eat.

An assessment of needs will include a review of:

  • oral health
  • pain
  • behaviours and cognition
  • mobility and dexterity
  • environmental factors - including dining arrangements, noise and distractions at meal times, and
  • individual food preferences.

A flexible approach to the timing of meals and snacks may be beneficial. This allows nourishment to be offered when the resident is most alert and receptive. Residents without dementia are more likely to benefit from nutritional supplements. Residents with dementia who are able to swallow safely may gain a small amount of weight from oral supplements. There is limited evidence for other benefits. [1]

Referral to other health services (Dentistry, Speech Pathology, Physiotherapy and Dietetics) should be considered. This is for assessment and management of problems identified, and for which treatment is deemed appropriate.

Weight loss is common in severe dementia and may be due to cachexia. This is a condition in which the body can neither absorb sufficient nutrients nor utilise energy from food. Family and staff may be concerned that the resident with cachexia is being starved. The use of artificial nutrition (tube feeding) for people with severe dementia has not shown any benefit. [2] Tube feeding may increase suffering.

It has been suggested that low body weight in end stage dementia is due to the dementia rather than starvation. They have a low requirement for food and a low metabolic rate. [3]

The recommended approach to residents with cachexia is to offer small amounts of food and fluids whenever they are alert enough to swallow, for comfort only. [4,5] This can be a very difficult concept for some families and care staff.
It is important that relatives are included in decision making and fully informed of the risks and lack of benefit from artificial nutrition and hydration.

A case conference may be useful in achieving consensus on care. Relatives may find forgoing artificial feeding easier to accept if the resident has previously given a health directive that he or she does not wish to receive artificial feeding when dying.

  1. Hanson LC, Ersek M, Gilliam R, Carey TS. Oral feeding options for people with dementia: a systematic review. J Am Geriatr Soc. 2011 Mar;59(3):463-72.
  2. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007209.
  3. Hoffer L. Tube feeding in advanced dementia: the metabolic perspective. BMJ. 2006 Dec 9;333(7580):1214-5.
  4. Australian Palliative Residential Aged Care (APRAC) Project. Guidelines for a Palliative Approach in Residential Aged Care, Enhanced Version - May 2006. Canberra: Commonwealth of Australia. 2006.
  5. Gove D, Sparr S, Dos Santos Bernardo AM, Cosgrave MP, Jansen S, Martensson B, et al. Recommendations on end-of-life care for people with dementia. J Nutr Health Aging. 2010 Feb;14(2):136-9.
Last updated 01 June 2018