Problem Identification
The problem lies in the rising cases of dementia patients and the prevalence of malnutrition in the elderly segment of the population. The following study reveals the significance of malnutrition in dementia, emphasizing the issue in aged care
Introduction
According to 1995 medical statistics of all Australian population an estimated 130,000 people suffered from dementia. A projected estimate is that by the year 2041 Australia will have 460,000 of its 25 million population suffering from the disorder (Jorn A, 2001). Percentages of people suffering from dementia in Australia residing in residential set up are almost fifty percent of the total dementia population in Australia (Beer C, Viewed on 23rd Sep 2008)
Dementia as a study needs to be undertaken as; it is one of the major health challenges in the 21st century and is one of the biggest neurodegenerative diseases as well. Australia, in general, has a high birth rate and also a high death rate, better sanitation, better living conditions, and immunization, which have helped in augmenting the life span but also has increased problems affecting old age. Dementia is one of the biggest health problems faced in Australia at the current time, hence it becomes of utmost importance to address the health problem of dementia.
Dementia is a disease affecting the brain, which leads to a constant decline in the functioning of the brain cells which leads to problems such as the ability to think, act, retain, reason, or adapt oneself to the environment. (Alzheimer’s Australia, July 2005). The most eminent areas affected areas in the case of dementia are memory, language, and attention. Disorientation of time, place, and person is one of the common symptoms of the disease (Alzheimer’s Australia, July 2005)
The common occurrence at any stage of dementia is prominent weight loss and malnutrition due to an imbalance between energy consumption and energy expenditure Underweight and weight loss are important factors in detecting malnutrition. Research conducted by Mamhidir AG, Ljunggren G, Kihlgren M, Kihlgren A, Wimo A (2006) delves deeper into underweight, weight loss, and related nutritional factors. 719 older people were undertaken among which 503 remaining chronically ill individuals with cognitive and functional disabilities. Twenty-seven percent of older adults suffered a weight loss of 5%, out of which 14% dementia and Parkinson’s cases showed 10% weight loss. Based on single item analysis, constipation and eating dependencies were observed as the strongest risk factors.
Ensuring adequate nutritional status in individuals helps in avoiding malnutrition and balancing energy consumptions. In old age, dementia patients do not have any will to eat or drink; hence they require regular assistance from others. Dementia can be backed by depression and generally arises due to a lack of hunger and difficulty in feeding (Alzheimer’s Australia, July 2005). The issue can be resolved by providing sip, hand, and tube feeding. However, Tube and other feeding in dementia do not result in an increased life span or prevention of infection (Cunningham C, Viewed on 23rd September, 2008)
The causes responsible to trigger dementia are severe high blood pressure, strokes, advanced Parkinson’s disease, changed personality, etc. Dementia might also lead to diseases such as Creutzfeldt-Jakob, a viral infection that spreads up at a great pace or Huntington’s disease resulting in mental deterioration (Boulevard R, 2008).
Dementia care is a rapidly advancing healthcare issue having a considerable impact on the economic and medical grounds. Nutritional intake can explore positive prospects for better future conditions. Areas such as behavioral manifestations of pain, wandering, falls, are few highlighted areas of concern (Cotter VT, 2007)
Research Details
Inclusion criteria
- The criteria for including the literature mainly focused on the relevance of the topic, link to malnutrition in dementia.
- As well the indirect causes which may hinder the nutritional aspects of dementia patients in a residential setting.
Exclusion criteria
- It may be noted that few articles did support malnutrition but had no inclusion for dementia.
- Older without dementia.
- Other on community.
Search strategy
Three major databases, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Proquest, and Medline were searched using the search term “malnutrition”, “dementia”, “feeding” within the time period of 1992-2008. In the beginning, approximately 50 literatures were found having link to the topic but afterwards only 32 were finally used.
Aging is a process which displays very prominent signs of low energy intake, malnutrition due to inappropriate protein consumption in regard to energy applied or because of inadequate energy intake in regard to protein requirement of the body. Malnutrition is an eminent cause of the occurrence of dementia mostly found in the old age but again the frequency under which the old age categorization could be made is 5-12% in community residing older people, 30-61% hospitalized old age people and 40-85% old people requiring long term medical care (Thomas DR, 1999).
Establishment of adult daycare centers, nursing homes etc is a positive step for providing proper care to the dementia patients as they render meals, health care, recreational activities to the sufferers but past data highlights the fact that such patients under the supervision of external sources are severely affected by the malnutrition problem. though it is a proven fact that a high ratio of malnutrition old age cases are often related to patients under nursing care but other factors such as constant weight loss etc are also responsible for the same (Thomas, 1999).
Reasons such as eating difficulties, physical inability to feed oneself, low salt and low cholesterol food intake, social problems like depression, isolation, lack of care are also responsible for the growing number of malnutrition cases, major cause of dementia. Malnutrition affects the quality of life which is neglected in the dementia patients (Brayne C, Gao L, Michael Dewey M, Matthews F E, 2007)
According to the Alzheimer’s society, more than 7, 50,000 people can be affected with dementia in Australia upto 2050 and are under the risk of getting trapped by signs of malnutrition due to overeating, under eating, dehydration, unsafe and stale food, expired food (AP, 2008). A People with dementia are found with the indignity and discomfort due to inadequate eating and drinking stuff (Amella EJ, 2004). Studies actually showed the extent to which the old age people affected with dementia suffer at home as well under medical care.
In old age, people who are not capable to look after themselves, care is medicalized and demoted to an insignificant event without dignity or regard for customized needs (Amella EJ, 2004). One can imagine the increase in number of such patients in the past years, 31% people did not receive enough food to eat in the hospital, and 58% old aged people were not treated properly or assisted while eating. 33% of the people in care homes were not getting enough feed. (Hannaford R, 2000)
Many factors are responsible for the development of a disorder, particular dementia such as nutrition, education, socio economic factors, lifestyle etc however studies have revealed that a healthy physical, balanced social and active life style could certainly help in non occurrence or reduced threat of dementia (Phung TK; Andersen K; Kessing LV; Waldemar G, 2006)
Weight loss is a genuine problem found in elderly people with dementia (Barratt J, 2004). The study undergone by Wang SY, 2002, comprehends data from different sections such as cross-sectional and longitudinal studies of weight fluctuations, physiologic changes and treatment strategies to restrict the weight loss in dementia patients.
Findings
Development of major complication affecting health
The latest research and the knowledge gained in the past couple of years have enabled the medical field to implement numerous interventions to prevent dementia and to some extent even delay the occurrence of it. For instance in an article by Brayne C; Gao L; Dewey M; E. Matthews E F (2007), focus on quality of life, healthy aging, longitudinal studies, cognitive decline, risk in the populations etc, have been revealed.
The age limit set for the new interventions include time period from prenatal phase to old age stage. Refinements in the cardiovascular risk factors can also help in the reduction of risk of dementia as per the latest research by Phung TK; Andersen K; Kessing LV; Waldemar G, (2006). Research has proved that enhanced aspiration pneumonia and choking could aggravate the patient’s condition which can further show signs of unhealthy nutritional status of the patient ultimately leading to Dementia (Cunningham C, Viewed on 23rd Sep, 2008).
Excessive Support and Intense care
In the Reuters Health, (2007), specific type of residential care and assisted living facility for elderly people has been identified for early detection of dementia. To further support a proper nutritional care, professional caregivers have researched that 34% of medical and 44% of surgical consultants firmly supported the fact that feeding and hydration should always be intervened to the dementia patients (Solomon MZ, 1993). Holm B; Söderhamn O (2003) support that poor nutritional status lead to lost learned practices and dry mouth. Caring interventions must consider support at meals and proper oral care. Amella AJ (2004) also highlights the social interaction issues regarding the feeding and hydration issues for older adults with dementia.
However few of the researches also reveal no significant changes among the demented and non demented patients as far as the food intake is concerned. According to the study conducted by (Molaschi M, Scarafiotti C, Ponzetto M, Raspo S, Bo M, Massaia M, Fabris F, 2003), to assess the effects of the nutritional level of proper care in food intake especially in demented patients, it was found that same levels of caloric consumption could be observed in demented and non demented patients with almost negligible differences in nutritional status apart from consideration in the extent of care required in food intake for dementia patients (Biernacki C, Barratt J, 2001).
This research was conducted on 96 patients falling under the age bracket of 75 to 103 years with no signs of severe illnesses and diseases, however almost 70% people under observation were suffering from dementia.
Researchers have also pointed out that dementia is an independent risk cause for injury falls due to weak body constitution. As per the experiment conducted by Doorn V C, Gruber-Baldini, Zimmerman , Hebel R, , Cynthia L. Port, Baumgarten M, Charlene C. Taler G, Magaziner J, 2003 the fall rate for dementia patients admitted in nursing homes was almost 4.05 per year in comparison to non affected patients which was only 2.33 per year.
Malnutrition in Dementia patient observed as a major cause for the loss of body function and coordination, thereby aggravating the fear and discouragement symptoms further. Ill-treatment, high treatment costs, mechanical restraints are also among the few specific reasons explored during the phase of the study for deteriorating health of the patient.
Social and Family Support Related To Depressive Symptoms
Studies have also correlated other factors exhibited in case of dementia rather than cognitive and behavioral issues such as weight loss and nutrition problems. 59 people with memory dysfunctioning were assessed through three assessment tools along with a structured questionnaire. The results revealed that patients under observation were eating in small chunks and partially lost the previous learned practices. The major emphasis was laid on providing extra support during meals to such patients in hand with a proper oral health care for prevention of further complications in patient’s health (Holm B; Söderhamn O, 2003).
To add on further, a research conducted by Keller HH; Smith D; Kasdorf C; Dupuis S; Schindel Martin L; Edward G; Cook C; Genoe R, 2008 involved interviews with 14 formal providers to determine the extent of nutrition concerns, however most of the resources extended to the clients did not match up with the nutrition concerns observed by the formal providers due to substandard quality.
The critical issue of the study under process is concerned with the old age people who cannot take care for themselves. Kayser-Jones has conducted an extensive study exploring the multi-factorial issues in imparting effective medical care to suffering patients (Amella EJ, 2004). In her findings she pointed out that inadequate staff, disregard for personal and cultural priorities, dysphagia, and improper oral care are responsible for the soaring number of malnutrition and dehydrated resident patients (Amella EJ, 2004).
Generally nutrition is undermined due to other aspects of health care. One of the prime areas of research in the past years has been the nutritional needs of elder people under hospital care. The care givers responsible for assisting patients suffering from dementia face varied difficulties in responding to the nutritional needs including emotional and over dependence as few of the factors for food refusal by the patients (Archibald C, 2006).
Studies clearly indicate that excessive weight loss in dementia could increase mortality rates and risk of pressure ulcers, weak immune system. Only good care can prevent future complications (Dorner B, 2005)
Abundant care and improved quality of life
As per the study undertaken by Biernacki C, Barratt J, 2001, malnutrition was proved to be a reversible action. Patients who were in their advanced stage of dementia could actually mark an improvement in their nutritional structure. The fact was realized after considering a sample of 20 residents of Southern Derbyshire on a long stay ward for a period of 6 years under the care of specialized experts from various fields.
The outcome was successful in drafting a standard nutritional chart for older people suffering from dementia. They succeeded in developing a frame work where adequate and proper and good nutritional aid could be provided to the elderly.
Alternatives for high quality care
Patients with advanced dementia are considered to be the most difficult patients because they are purely bedridden and depended on the external source for the day to day operations of life. In such cases feeding tubes is a useful option to prevent malnutrition but till date not many studies have supported the alternative as the option does not help in providing any comfort, increased survival rate (Mitchell SL, Tetroe JM. J Gerontol A, 2000) or improved functional ability in the condition of the patient as researched by Murphy LM, Lipman TO (2003) instead it adds on to the distress level of the patient and the care giver as well, hence studies suggests that tube feeding must be replaced with hand feeding, though it doesn’t contributes in solving the problem of malnutrition but certainly aids in warm and intimate patient care (Jefferson T, 2002).
40 severe tubes fed patients were taken under consideration with highly affected cognitive and functional stand; however the results showed a further detriment in the weight of the patient, no improvement in the hemoglobin or cholesterol level was observed during or after the tube feeding (Jefferson, 2002). Park RH (1992) also explored that NG tubes frequently blocked and were able to pass on only a fraction of the food delivered by PEG tube. Rimon E (2005) supported through his observational studies a poor survival in PEG fed dementia patients where the ratio revealed 25% mortality at 1 month and 50% at 6/12.
As far as tube fed process is concerned, various studies have been undertaken in order to find out its cost perspectives also. (Mitchell SL; Buchanan JL, Littlehale S; Hamel MB, 2003), found out that tube fed dementia patients have to bear a high cost. In the study costs comparison were observed for six month duration among the patients who underwent tube placement and patients did not went through the process. Costs including time, assessments, food, hospitalization, tests and treatment and other aspects were monitored. 22 objects were made a part of the study out of which 11 were tube fed. The results revealed that the daily costs of nursing home were much higher in comparison to the residents not on feeding tubes (Mitchell SL; Buchanan JL, Littlehale S; Hamel MB, 2003).
Advantages of tube feeding certainly include ease of feeding to the patients so that further deterioration of health due to lack of nutrition can be controlled. Apart from being a critical issue, hospital do add Positive inducements for tube feeding as large chunk of financial incentive is earned by them due to which tube feed processes are encouraged. (Mitchell SL; Buchanan JL, Littlehale S; Hamel MB, 2003).
No survival positive outcomes are recorded in patients with dementia who were feeded through a PEG tube (Percutaneous Endoscopic Gastrostomy). In a study initiated by (Murphy LM; Lipman TO, 2003) 41 consultations were intervened for PEG tube placement, out of which 23 patients were actually underwent PEG tube placement which were further evaluated by authorized nutrition support nurses along with gastroenterology expert staff for a duration of 2 years.
A further interview with patients was also undertaken so comprehend a wider perspective on the issue imparting knowledge about the entailed risks and advantages of PEG tube. The results confirmed that no major changes were noticed in the survival rate of the dementia patients, the median survival rate for patients who took up PEG placement was 59 days whereas who didn’t went through it comprised of 60 days, hence negligible difference in both the readings (Murphy LM; Lipman TO, 2003)
Complementary and alternative medical therapies can also be used for the patients suffering from gastrointestinal symptoms. Herbals and probiotics supplements may be used to gain health benefits (Lipman O T, 2007)
As per the nutritional assessment in demented patients undergone by Magri F; Borza A; del Vecchio S; Chytiris S; Cuzzoni G; Busconi L; Rebesco A; Ferrari E, 2003, 174 patients were taken under observation with different types of dementia such as vascular, degenerative, generative dementia etc. each individual was assessed through conventional tools and techniques for all aspects including functional, behavioral assessments as well, both initially at the time of admission and at the end time of hospitalization to compare the differences in the results especially focusing on vitamin, protein and care components. When compared, it was found that demented patients show a high rate of malnutrition and cognitive imbalances but at the same time proper nutritional intervention during meals resulted in favorable and improved state of dementia.
Ethics and medical Practices
To support the views of the above study, further past findings by Barratt J, 2004, strengthen the issue in focus. Studies relate to major decisions regarding the ethics involved in the non oral feeding in dementia patients. The past researches have supported the fact that proper and effective interventions in dementia have helped the patients to regain the lost weight. Helping the patients with eating and drinking is a challenge which can be cracked through incorporating evidence based practice into the daily operation conduction for the dementia patients (Wang SY, 2002)
Reversible dementia was initially sponsored by the National Institute of Ageing back in 1980, where the assigned task force obtained information about 10-12% of reversible dementia cases in the older adult segment especially under interventions for metabolic nutritional, drugs, infections, disorders etc.76 patients suffering from different dementia types such as vascular dementia which is caused by blockages in the brain’s blood supply and affects people between the age group 60 and 75 (Belmont J, 2007).
Alzheimer’s disease etc were chosen for the study. MRI was taken as an important tool in the diagnosis of dementia which was responded with sensitivity towards lacunes. The reversible dementia included a significant rate of infections almost 14.47 %, metabolic nutritional count again 14.47% and autoimmune disease which turned out to be 3.94%; however a four month follows up of MMSE in the selected group marked remarkable improvements in the nutritional group (Sundar U; Sharma A; Yeolekar ME, 2004).
The review generated by Salerno-Kennedy R; Cashman KD, 2005 highlights the kinds of dementia and focuses on the current approach towards the link between malnutrition in dementia. Nutrition has an imperative role on the progression of dementia, however a balanced intake of nutritional food does not protect people completely from the disease but certainly imbalanced intake increases the chances of development of age related complications. Deficiency of vitamins, proteins, minerals etc can result in future impairments in old age such as hypertension, diabetes etc. timely intervention may help in the cure of the disease in more productive manner.
Social Care and Quality of life
Research printed by the Reuters Health care reported that patients under residential care or nursing homes would be able to detect undiagnosed dementia by the use of using the Minimum Data Set Cognition Scale. New study states that better lighting condition generally during the day time lighting may help in the improvement of cognitive and other behaviour conditions in dementia patients (Jeffrey S, 2008)
Recommendations for Practice, Education and Research
So far there is no such cure available for the treatment of dementia, the only practical approach for the curbing of the peril is to prevent it from developing. An active life, strong mental and physical body structure along with the medications available to prevent the trigger such as anti diabetic or hypertension drugs can help in controlling of dementia in the early stages. Nurses should adopt a proactive approach rather than a reactive approach to control the undesired behaviour of dementia patients. The Progressively Lowered Stress Threshold Model can assist the care givers to carry on the nursing practice effectively and improving the quality of life of the old adults (David E, Vance, Barbara S. Moore, Struzick T, 2008)
To facilitate the dementia old aged adults few practices such as limiting distractions, obstructions from the dining area, applying strategic seating, time consciousness, encouraging independent eating along with regular supervision and direction, adequate staffing at all meal times for assistance can help to focus on a positive nutritional impact , trimming down the chances of malnutrition.
It becomes utmost important for the health experts to follow a structured approach to cure and prevent dementia in malnutrition. There is a dire need to address the social factors such as poverty; lack of means for proper meals etc, to resolve such social issues, community programmes like meals on wheels could be initiated on a larger extent (Thomas, D R, 1999).
To study the effect of malnutrition, meal time observation of dementia patients needs to be recorded so as to remove the obstacles and explore effective and innovative methods that ease out the difficulty in the in intake of nutritional diet in old age making the latter years a little comfortable and enjoyable. It could be well suggested for the future researches to emphasize upon the enhanced knowledge requirements of the nursing staff about the needs of patients with dementia, new assessing (Archibald C, 2006)
Looking at the current status of the research in the highlighted area of science and medical arena, there exists a significant translation gap around nutrition and dementia which can be a solid platform for future study in the nutrition education resources (Keller HH; Smith D; Kasdorf C; Dupuis S; Schindel Martin L; Edward G; Cook C; Genoe R, 2008).
Increased energy intake levels from healthy food supplements, ways to overcome aversive behaviour of the patients are few areas were future study may be extended for obtaining positive results. Further research is required to determine whether the financial motives affect the tube-feeding decisions in medical practice.
Creation of advanced nutrition screening tools for early identification of dementia could help in proper customized intervention for specific individual requirements. More number of staff must be added for special care of dementia patients in order to address the complexities of the bodily changes. Environment where normalized social care can be promoted should be encouraged, to further the empathy for people whose behavioral conduct might not be acceptable as per society norms. The challenge in future is to create an atmosphere around the patients where dignity and comfort are taken to be as the utmost priority. Policy developments in future must address the needs of individuals who may combat the treat of dementia due to a prolonged life span.
Appendix: Summary of studies included in the review.
Bibliography
Alzheimer’s Australia, (2005), Living with Dementia, What is Dementia? Web.
AAP, 2008. Dementia ‘set to treble in Australia’. Web.
Archibald C. (2006). Meeting the nutritional needs of patients with dementia in hospital. Nurs Stand, 20(45), 41-45.
Amella EJ. (2004). Feeding and hydration issues for older adults with dementia. Nurs Clin North Am, 39(3), 607 -23.
Barratt J. (2004). Practical nutritional care of elderly demented patients. Curr Opin Clin Nutr Metab Care, 7(1):35-8.
Beer C, NHMRC – Department of health and ageing dementia research grants program. Web.
Biernacki C; Barratt J. (2001).Improving the nutritional status of people with dementia. J Nurs, 10(17), 1104-1114.
Belmonte J. 2007, Vascular Dementia: Signs, Symptoms, Prognosis and Support. Web.
Boulevard R. (2008). FACTS on mental health of the elderly, Friends Behavioral Health System. Web.
Brayne C; Gao L; Dewey M; E. Matthews E F. (2006). Dementia before death in ageing societies — The promise of prevention and the reality, PLoS Med, 3(10).
Cotter VT. (2007). The burden of dementia, Am J Manag Care, 13 suppl 8, 193-197.
Cunningham C. Tube feeding in Dementia, Ethics and Evidence. 2008. Web.
Commentary on Dewing J & Traynor V. (2005) Admiral nursing competency project: practice development and action research. Journal of Clinical Nursing 14, 695-703.
David E, Vance, Barbara S. Moore, Struzick T.Posted on 06/17/2008 , Procedural memory and emotional attachment in alzheimer disease: Implications for meaningful and engaging activities, J Neurosci Nurs.40(2), 96-102.
Dorner B. (2005).Nutrition for the dementia resident: how to handle common challenges. Web.
Doorn V C, Gruber-Baldini, Zimmerman, Hebel R,, Cynthia L. Port, Baumgarten M, Charlene C. Taler G, Magaziner J. (2003). Dementia as a risk factor for falls and fall injuries among nursing home residents. J Am Geriatr Soc 51(9, 1213-1218.
Hannaford R, BBC News, 2000, Health, malnutrition risk for dementia sufferers. Web.
Holm B; Söderhamn O. (2003). Factors associated with nutritional status in a group of people in an early stage of dementia. Clin Nutr, 22(4), 385:389.
Jefferson T, Posted on 15th April, 2002, Feeding Tubes in patients with severe dementia. Web.
Jorn A, 2001. Dementia: A major Health problem in Australia. Web.
Keller HH; Smith D; Kasdorf C; Dupuis S; Schindel Martin L; Edward G; Cook C; Genoe R. (2008). Nutrition education needs and resources for dementia care in the community. Am J Alzheimer’s Dies Other Demen, 23(1), 13:22.
Lipman O T. (2007). The Role of herbs and probiotics in GI wellness for older adults. Geriatrics Aging, 10(3), 182-191.
Magri F; Borza A; del Vecchio S; Chytiris S; Cuzzoni G; Busconi L; Rebesco A; Ferrari E. (2003). Nutritional assessment of demented patients: a descriptive study. Aging Clin Exp Res. 2003, 15(2), 148-153.
Murphy LM; Lipman TO. (2003). Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia. Arch Intern Med, 163(11), 1351-1353
Mitchell SL; Buchanan JL; Littlehale S; Hamel MB. (2003). Tube-feeding versus hand-feeding nursing home residents with advanced dementia: a cost comparison, J Am Med Dir Assoc, 2003, 4(1), 27-33.
Mitchell SL, Tetroe JM. (2000). Survival after percutaneous endoscopic gastrostomy placement in older persons. J Gerontol A Biol Sci Med Sci. ;55(12),M735-9.
Molaschi M, Scarafiotti C, Ponzetto M, Raspo S, Bo M, Massaia M, Fabris F.( 2003), Malnutrition and dementia: importance of care during food intake. Recenti Prog Med, 92(2), 61-65.
Moprley JE, Silver AJ. (1995). Nutritional issues in nursing home care. Ann Int Med 1995; 123:850-859.
Mamhidir AG, Ljunggren G, Kihlgren M, Kihlgren A, Wimo A.2006. Underweight, weight loss and related risk factors among older adults in sheltered housing–a Swedish follow-up study. J Nutr Health Aging. 10(4):255-62 (ISSN: 1279-7707).
Phung TK; Andersen K; Kessing LV; Waldemar G. (2006). Lifestyle-related risk factors for dementia. Ugeskr Laeger, pg 168, Vol 40, 3401-5.
Park RH, Allison MC, Lang J, Spence E, Morris AJ, Danesh BJ, et al (1992). Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia. Bmj. 1992 30;304(6839):1406-9.
Rimon E, Kagansky N, Levy S. (2005) Percutaneous endoscopic Gastrostomy. Evidence of different prognosis in various patient subgroups. Age Ageing, 34(4):353-7.
Solomon MZ, O’Donnell L, Jennings B, Guilfoy V, Wolf SM, Nolan K. (Jan 1993). Decisions near the end of life: professional views on life-sustaining treatments. Am J Public Health. ; 83(1), 14-23.
Salerno-Kennedy R; Cashman KD. (2005). Relationship between dementia and nutrition-related factors and disorders: an overview. Int J Vitam Nutr Res, 75(2), 83-95.
Susan Jeffrey, 2008, Brighter lighting improves symptoms in patients with dementia. Web.
Reuters Health Information. (2007). Elderly in care facilities can be simply screened for dementia. J Am Geriatr Soc, 55, 1349-1355.
Rose M. Mccloskey. (2004). Caring for patients with dementia in the acute care environment, Geriatr Nurs 25(3), 139-144.
Thomas DR. (1999). Causes of protein-energy malnutrition. Protein –energy malnutrition in elderly, Z Gerontol. Geriat 32 7, S38-S44.
U Sundar, A Sharma, M E Yeolekar.(2004). Presenile dementia etiology, clinical profile and treatment response at four months follow up. Physicians India, Vol 52, 953-958.
Wang SY. (2002). Weight loss and metabolic changes in dementia. J Nutr Health Aging, 6(3), 201 – 205.
Summary of studies included in the review.