Yeah. The interesting thing about Alzheimer's disease is how does it play into the final years, how does it play into the final months of life and do people actually die of Alzheimer's disease? What’s interesting, Alzheimer's disease used to never be found on a death certificate. Then, a few years ago, physicians started writing Alzheimer's disease as a cause of death because what usually happens in people with Alzheimer's disease if they don’t have a heart attack or die from an injury is that they lose the ability to swallow.
Once they lose the ability to swallow, a couple of bad things happen. One is that they become very undernourished and they can die of what we sometimes called adult failure to thrive. It’s basically a malnutrition because they’re not able to eat or they have enough trouble swallowing it that they get pneumonias over and over again, aspiration pneumonia. They are also more susceptible to infections like really severe urinary tract infections where the infection spreads through the bloodstream, so usually, the adult failure to thrive, aspiration pneumonia or some sort of infection, skin breakdown, those kinds of things.
The interesting question that’s always raised about that is that if a person’s not able to swallow anymore, then why don’t we just give them tube feedings? Why don’t we put tube through the skin and to the stomach and feed them that way? It’s an important philosophical question, even a religious question for a lot of people but what we know medically is yes, we can make their nutritional values look better but we don’t change their cognition. We don’t change the fact that they’re becoming bedbound, that they often don’t communicate at all with their family anymore, that their quality of life may not be what they want.
This takes us back to why it’s important to have the discussion about end of life when a person’s still able to be able to participate because most people will say, that I see in my office anyway, “I don’t want to be tube-fed. Don’t let them put a tube in me. If I can’t get to the table, don’t feed me.” I've heard that phrase so many times in so many different ways but it’s very hard for a family to do that at the end. It’s very hard for them to say, “No, we’re not going to do the tube feeding,” in part because the whole social context of eating, of sharing a meal, of breaking bread is such an integral part of our humanity that it’s very hard to say no tube feeding but it’s artificial. A lot of advanced care directives say, “I don't want any artificial feeding.”
