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Susan L. Mitchell, MD, MPH, Discussant

JAMA. 2007;298(21):2527-2536.

More than 5 million Americans have dementia, a leading cause of death among persons older than 65 years in the United States. Eating problems typically develop during the advanced stage of dementia, which requires decision making to direct care toward either palliation or more aggressive measures, such as tube feeding. The case of Mr P, a 93-year-old man with end-stage dementia and recent hip fracture, illustrates the issues involved in this challenging crossroads when his daughter is confronted with his failure to orally maintain adequate hydration and nutrition. The discussion reviews the epidemiology and natural history of advanced dementia, the barriers to providing palliative care to patients with this condition, the role of pharmacotherapy, and the treatment options for feeding problems and the advantages and disadvantages of each option, and suggests an approach to help clinicians provide effective and compassionate decision support to patients with advanced dementia and their family members.

Author Affiliation: Dr Mitchell is Associate Professor of Medicine, Harvard Medical School and Department of Medicine, Beth Israel Deaconess Medical Center, and Senior Scientist, Hebrew Senior Life Institute for Aging Research, Boston, Massachusetts.

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