End-of-life issues in advanced dementia

Objective To answer frequently asked questions about management of end-stage pneumonia, poor nutritional intake, and dehydration in advanced dementia.

Sources of information Ovid MEDLINE was searched for relevant articles published until February 2015. No level I studies were identified; most articles provided level III evidence. The symptom management suggestions are partially based on recent participation in a Delphi procedure to develop a guideline for optimal symptom relief for patients with pneumonia and dementia.

Main message Feeding tubes are not recommended for patients with end-stage dementia. Comfort feeding by hand is preferable. Use of parenteral hydration might be helpful but can also contribute to discomfort at the end of life. Withholding or withdrawing artificial nutrition and hydration is generally not associated with manifestations of discomfort if mouth care is adequate. Because pneumonia usually causes considerable discomfort, clinicians should pay attention to symptom control. Sedation for agitation is often useful in patients with dementia in the terminal phase.

Conclusion Symptomatic care is an appropriate option for end-stage manifestations of advanced dementia. The proposed symptom management guidelines are based on a literature review and expert consensus.