The refusal of food in the elderly patient: identification of the causes of rejection of the meal in senior age and hypotheses of intervention to prevent, treat and rehabilitate malnutrition

Malnutrition can derive from causes that are independent of the patient's desire to feed themselves or which manifest themselves with the refusal of the meal; while for the former the strategies for solving and compensating the problem are more predictable, for the latter it is not always easy to have effective and prompt intervention procedures available. T he importance of a method that investigates the causes of food refusal and provides rehabilitative pathways to accepting the meal, designed to intervene on fasting in a structured way, lies in the timeliness and clarity of the roles. I.R.M.I.E. (Investigation of the Rejection of Meal in the Institutional Elderly) analyzes the refusal of the meal and the consequent malnutrition linked to it, in the elderly subject institutionalized and not. It is thought of as a trace to identify the causes that lead the fasting patient to a condition of vital risk and to propose strategies of compensation and resolution to the problem. It is the premise of an individualized plan. It should be discussed as a team in the case and also given to the family member by the same or alternatively by a professional elected to the role, with a subsequent comparison. T he planning of an intervention plan will follow, according to the procedures proposed in the manual that includes it, related to the identified Qeios, CC-BY 4.0 · Article, October 9, 2018 QN 433183 · https://doi.org/10.32388/433183 1/40 causes, and of the resources exploitable in the service.

the age of 50, and have less response to the treatment of malnutrition [2] . From this we can deduce that, besides lowering the quality of life and the effectiveness of the therapeutic / rehabilitative procedure, malnutrition can be an important cause of death but also a prognostic element to other causes of death. In fact: "the mortality statistics based on the only initial cause of death allow to observe only a part of a more complex morbid picture. T his is true the more the mortality profile is characterized by long-term chronic diseases" [3] . RELAT  T he importance of malnutrition by defect is relevant: in elderly malnourished mortality at 14 months was 63%, compared with 9% in normonutritoned people [4] .
Malnutrition is associated with decreased nutrient intake (most common mode in the elderly) is recorded in different percentages depending on your frame of reference: -1-15% of outpatients; -25-60% of institutionalized subjects; facilities, and it was said that in elderly malnourished sub mortality that is 63% at 14 months, in the worst malnutrition is the cause of 53,55% of deaths of institutionalized elderly: more than half. Regarding the correlation between rejection of the meal and other causes to it divorced that lead to malnutrition, there are still no statistics in the literature that can give an accurate measurement. Nevertheless, on an empirical level, you can understand that the refusal of the meal is due to an important part of the causes of malnutrition identified in research and epidemiological studies related to it, and that is what we are going to deal with in the next chapter.

T H E REFUSAL OF T H E M EAL: AN UN CERT AIN ROLE OF IN T ERVEN T ION AN D T H E REFUSAL OF T H E M EAL: AN UN CERT AIN ROLE OF IN T ERVEN T ION AN D T H E IM PORT AN CE OF A M ET H OD T H E IM PORT AN CE OF A M ET H OD
When a guest refuses a meal at a nursing home, several actions may be followed by the event. Surely the fact is noted, as it is common practice (and legally obligatory) to keep diaries and reports on each patient by the staff members, each in their own area of competence respectively. T he single episode of rejection of the meal, in the absence of a guideline, could be overlooked and considered a moment of fasting "granted" to the person, underestimating that inappetence can be a symptom or manifestation of an important discomfort and can have dangerous consequences. However, if repeated over time, fasting is unlikely to be considered a problem, as it makes it difficult to guarantee the adequate nutritional intake for the refusing guest, up to malnutrition. T he first indication is assumed to start in most cases by those who assist the patient more closely and more frequently over time; the socio-health worker, who except in special cases administers and monitors the meals of each patient, highlights the difficulty in feeding the patient, who through the referent / coordinator is brought to the attention of the team.
T he composition of the team depends on the regional legislation, but generally the figures involved in the health-care-rehabilitation in the nursing home are: doctor, nurse responsible health, coordinator Oss of the nucleus, social worker, psychologist, physiotherapist, speech therapist and professional educator . T he refusal of the meal, although it may be said as a dangerous alarm bell, will surely be perceived as an important problem when it involves malnutrition, putting the guest's life at risk. At that moment, there is no clarity on which professional figure has the task of taking charge of investigating the issue and proposing solutions. After a brainstorming, the hypotheses of intervention can be very many: the doctor, visiting the patient, can exclude drug-related side effects and the presence of discomforts that imply lack of appetite; the psychology service will be able to verify if there is depression with apathy towards the meal, or if present dementia, how much it is going to affect the ability / desire / rituality to feed itself; the speech therapist can evaluate hypotheses of dysphagia and resort to a dietician to draw up a diet if there is a quantity of nutrients actually taken and yet if there are sores in the mouth and dental congruence, and so on. If the problem does not resolve, the only solution that will be proposed by the team to the family will be that of an artificial nutrition.
In terms of time, the weight loss of a fasting elderly person can be sudden and rapid: if he is immobilized, the resting compacasa of decubitus injuries in the absence of sufficient caloric and water intake can go down even under 36 hours, independently from posture and medication and other attentions to prevent them. In the walking guest, the fact of not eating will weaken, weaken it and reduce its autonomy, and so saying can be reported other dozens of prognosis in which it is understandable that the refusal of the meal leads to accelerate the decay and trigger a vicious circle in the what is the growing difficulty of making it reversible, due to the accentuation of problems and problems related to it.
T he importance of a method lies in the timeliness and clarity of the roles, which investigates the causes of food rejection ad-personam and proposes rehabilitative paths to the acceptance of the meal, designed to intervene on fasting in a structured way.
Even if you are spending a lot of attention on how to identify and intervene on the problem, we must not neglect the aspect of prevention. "T o screen or not to screen for adult malnutrition" is the title of an article by Marinos Elia [7] published in 2005 which states that the inability to recognize and treat malnutrition is unacceptable, especially where it is more frequent, therefore it is recommended the routine use of simple screening tools for malnutrition or nutritional risk. Elia also concludes by stating that in every place of care and assistance transparent policies should be adopted for the use of nutritional screening, policies that should vary according to the setting, available resources and characteristics of the subjects to be evaluated. Early identification of individuals with nutritional risk through screening tools, followed by adequate nutritional interventions, can in fact contribute to preserving muscle function, preventing or at least restraining sarcopenia and therefore maintaining physical self-sufficiency, quality of life, and the increase in the probability of survival.

CAUSES OF M ALN UT RIT ION CAUSES OF M ALN UT RIT ION
Malnutrition in the institutionalized elderly: a consequence and / or manifestation also of the refusal of the meal Malnutrition can derive from causes that are independent of the patient's desire to feed themselves or which manifest themselves with the refusal of the meal; while for the former the strategies for solving and compensating the problem are more predictable, for the latter it is not always easy to have effective and prompt intervention procedures available.

CAUSES OF M ALN UT RIT ION RET URN AB LE OR LESS T H AN T H E M EAL'S CAUSES OF M ALN UT RIT ION RET URN AB LE OR LESS T H AN T H E M EAL'S REFUSAL REFUSAL
In the scientific literature, both historically and internationally, there is still no homogeneous and definitive cataloging that collects all possible causes of malnutrition.
T he malnutrition itself does not have as its sole cause those that derive or that manifest themselves with a refusal of the meal. If we mean malnutrition that has arisen or has been treated in a nursing home as obstinate, chronic, continuous and / or non-reversible weight loss by the health care work team, we must distinguish the causes in two categories: -Causes that are manifested in avulsed way the willingness and host expressiveness, which is unable to eat or whose weight loss is independent of the amount of taken meal; -Causes due to refusal of the meal and / or arising from the rejection of the meal itself.
T he "National guidelines for hospital food and assistance" [8] [10] ) were identified as:  "T he assistance picky guest" (the table WORKING ASL BRESCIA -RESPONSIBLE FOR HEALT H OF RSA / RSD PROT OCOL POWER in RSA / RSD -Protocol [11] ), is the case with the same key reading but by slightly alternative views previous article, and describe it as follows.
A situation of loss of appetite (anorexia and) is common among the elderly, particularly if hospitalized in a RSA. In many situations it is secondary to physical illness (gastrointestinal tract but also heart, lung, kidney, etc.), T o mental illnesses (depression, dementia), the use of drugs that suppress the appetite, to ' combined effect of aging and disease. T here are however a number of causes that can be corrected and whose early detection can help the host to maintain or recover an adequate dietary intake; in particular, it is always necessary to check: "T he condition of the oral cavity: edentulism (lack of teeth), presence of dental roots causing irritation of the gums, malfunctioning prostheses, poor hygiene of the teeth and mouth, oral infections / intolerance for some foods / constipation (constipation) obstinate / the presence of fever, dehydration, confusion (delirium). In other cases we are, in fact, faced with an inability for the person to take food properly due to: reduced manual dexterity; vision impairment; overall reduction in vision, but also inability to discriminate different shades of the same color (it may be difficult for a demented person to identify white mash or stracchino on a white plate); inability to "see" food placed in one half of the dish as a consequence of a brain injury; apraxia: inability to organize a series of movements in a complex action, such as picking up a cutlery, collecting food and bringing it to the mouth (in this case it may be useful to "guide" the beginning of the movements); agnosia: incapacity for the person (mostly affected by dementia) to understand the situation and the meaning and the use, for example, of a cutlery (also in this case it may be helpful to help the person to start the action); incorrect posture, which makes it more difficult to autonomously take food and / or compromises Lack of assistance or pre-existing malnutrition entrance Malnutrition can be observed as a framework that already exists at the entrance of the host, therefore, for unknown reasons or due to lack of previous interventions to RSA context. Where then the autonomy to be very low, the power must be delayed (eg. Gastrectomizzati) and / or if the meal times are long, the assistance deficiency can lead to an insufficient amount of food intake.
Despite the reasons that follow, related and / or manifested with the refusal of the meal, the prognosis and the possible resolution of the problems described here it is much more intuitive. You can resort to healthcare pathways such as: Choice of specific supplements and a high-calorie diet ad personam, when the appetence is low and you need a higher nutritional value, as a result of the higher need for calorie intake dictated by the disease; T o reduce the nutrient malabsorption, diarrhea and vomiting, drowsiness and increase alertness, wellbeing and harbored a desire, it is appropriate to establish a drug treatment plan, or revisit the same if the causes of malnutrition are secondary to side effects of the same treatment in progress ; When the dysphagia is so serious as to make possible a rehabilitative treatment, compensatory to new strategies, caloric and water intake may be introduced into the body with artificial feeding (which bypasses the respiratory apparatus Provide more support, even with the help of assistants and caregivers, when the host needs more time to enjoy your meal (lack of partial or total autonomy, general slowness or acceptance of a dish but that requires chewing higher), or needs frequent meals and deferred or at different times from those canonical (eg if you have exams in meal times).

T OGET H ER IN T ERSECT ION T OGET H ER IN T ERSECT ION
Given the complexity of the issue, will be reported between the two lists respective descriptions with an excursus on the 'between intersection"; it represents the list of the causes of malnutrition "hybrid", that are manifested in the refusal albeit from a problem previously treated in the last part of this chapter.
-Health-pathological level: T he malabsorption of nutrients related to impairment of digestive organs, may cause weight loss and malnutrition not only directly since there is a sufficient caloric intake, but also due to a secondary consequence, represented a no-hungry condition for physical discomfort. As we will see in particular in cases of treatments, once it resolved the cause of the illness there is good chance that the hunger reappear. In this case, the part evaluative of this manual may serve as a starting point to suggest greater attention in the patient's screening towards pathological inferences such as: compression for ulcers organs, air and masses, pain during chewing, swallowing and / or digestion and finally pain distal undervalued or not expressed (pressure ulcers, hemorrhoids, diverticulosis, more suffering etc.). T he same diarrhea, vomiting and constipation not only affect food absorption, but they create poor appetite due to pain and quite uncomfortable sense that they create, leading the host to reject the meal and hydration, into a spiral where over not to digest what has already assumed, it does not integrate as lost or necessary.
-T herapeutic drug level: T he damage that can cause a drug at the wrong dosage is due to malnutrition in possible side effects not only for interaction with the assimilation / metabolism and drowsiness / lowering of vigilance. It can interfere behavioral bringing out atypical emotional aspects compared to historic patient in which it could refuse the food. In these cases, it may have been stimulated aggression, direct or secondary disorientation at times dementing (vascular in particular) and confabulation. In addition, the drug can lead all'inappetenza if inhibits hunger or taste perception.
-Grade of care assistance: As already said, when the needs of a customer requiring a higher level of care on powerup, it is necessary to comply with them. If assistance does not fulfill these needs, besides the fact that caloric intake is insufficient, there is a risk of developing mortification, T he causes that lead to the refusal of food or that occur in this event with regard to the institutionalized elderly, are addressed only to fasting patients with stretches of vigilance.
As explained in the previous paragraphs, it would not be permissible to define those who are vegetative, coma and stupefied, or who accept food but whose absorption is affected by pathological, iatrogenic or morphological causes. in Lido di Venezia (Venice) and "Residenza Gruaro".
T he research work [12] was embellished by personal experiences or provided by those who wanted to collaborate in the project, from home treatments in collaboration with "PrivatAssistenza" of Jesolo, from the availability in nursing homes mentioned to access departments specific in dementia as the S.a.p.a. but also trasvecasa of rest like Psychiatric Points, Hospice, C.Sla and HIV, and finally from the precious experiences with disability at "Bellinato-Zorzetto" and "Amici Insieme" of Mestre and "Ass. Our Family "of Padua.
By limiting the observed sample to the geriatric field, the 3-year observational training always involved at least 2 facilities simultaneously for no less than 6 months each, with an average of 102 guests per location. In total, more than 1150 guests were assessed (number accentuated compared to the expected average due to deaths and transfers). T he elder, therefore, can refuse the meal because: 1. T he patient eats less with age Senility leads to inappetence and imbalance of the organic picture (examples of imbalances that reduce hunger are zinc deficiency and reduced production of hormones processed by corticosurrene).

T he patient has a sense of satiety and fullness faster
Because of age, greater digestion time or fasting that reduces the volume of the stomach, the elderly can feel full while not having taken a sufficient caloric intake.
3. T hey are missing that "fatigue" and that movement that are "hungry" T he patient is not appetite because it reduces his movement and physical consumption.
4. T he patient has difficulty perceiving the appetite T he patient has never been a "glutton": he has a history in which he has not been accustomed to striving to consume a fair portion of food, tending to weight loss and defect in quantities in an "innate" way, due to causes not related to aspects related to old age.
5. T he patient does not accept the structure and condition of institutionalized T he patient may not accept himself in his condition of necessary assistance. He can refuse the meal as a form of provocation and protest, but also as a consequence of mortification and loss of self-esteem, as well as feeling "prisoner" in a place and in a social-health condition that he is not congenial to. 8. T he meal times are insufficient compared to the needs As mentioned, where more time is required for meal consumption and assistance is not sufficient to compensate for the problem, the patient can refuse the meal due to a sense of defeat, lack of self-esteem or protest.
9. T he patient reports to perceive odor and / or have unpleasant vision during the meal T he elderly may not feel comfortable in the community environment and develop lack of appetite for unpleasant stimuli; when they are perceived in the dining room, they penalize in an important way the acceptance and consumption of what is proposed.

T he diet is monotonous
T he lack of a good presentation and the variety of foods can cause them to be rejected.
11. T he patient has sensorial olfactory / gustatory disability: he feels less the flavors T he inability to feel the flavors is going to undermine the pleasure of the meal.
12. T he patient has health food limitations: diabetes, allergies, treatment diarrhea, diverticula etc.
T he dietary limitations related to the treatment of a disease or a disorder can make the meal less tasty or exclude dishes judged important and particularly pleasing to the patient, who may perceive the food tasteless or develop waste as provocation.
13. T he dental prosthesis is incongruent or is edentulous and the consistency is not chewable T he refusal may derive from the difficulty or even the inability to chew food, which can mortify and lead to "surrender" to the consumption of the meal.
14. T he taste and / or consistency of food has varied and is perceived as disgusting T he patient may not like the dishes, perhaps used to experience other flavors, or when a variation in the consistency of liquids / solids has been necessary, it may be unpleasant or even lead to rejection as provocation.
15. Mastication and swallowing require physical effort, the patient is lazy and / or has reduced autonomy Although respecting times, physical fatigue in praxis and oral acts can create a negative reinforcement of food, reducing pleasure and hedonism.
16. T he patient presents pain during chewing, swallowing and / or digestion Cause of rejection towards the meal can derive from a pain that appears directly in the alimentary act, therefore during the chewing (involving the oral cavity), swallowing (high respiratory tract) and digestion.
17. T he patient has distal pain (bedsores, other sufferings, etc.) Also a pain of another tissue removed from the role of food is a cause of distraction and lack of appetite, as it is perceived as a more urgent discomfort to be solved compared to hunger. 18. T he patient is affected by the chronicity of organic discomforts (constipation, nausea, diarrhea, infections, etc.) T he feeling of crushing of the intestine, diaphragm and stomach can result from constipation which makes the bowels full; even the chronicity of discomfort can lead to an "a priori" refusal of the meal.
19. T he patient has a compromise / compression of organs (ulcers, air, masses, etc.) A feeling of crushing and malaise that deceptively gives a sense of satiety can also derive from the compromise of the digestive organs due to inflammation, meteorism and neoformations.
20. T he patient has a feeling of crushing / incoordination due to restraint Physical restraint can create a crush on the abdomen (intestine, diaphragm, stomach) creating the illusion of a fullness, until it becomes a real obstacle to digestion.
21. T he patient has communicative deficits (aphasia, dysphonia, dysarthria, hearing disability) T he inability to communicate one's needs, as well as being mortifying, can be a direct cause of inappetence or secondary to the impossibility of communicating a discomfort.

T he patient suffers from hypothetical side effects of drug therapy (eg Sleepiness)
Drug treatment can cause a change in the patient's behavior, which may become unable to feed due to fatigue or drowsiness even if he renounces the task, or bring out a refusal related to cognitive impairment. 25. T he patient has serious temporal disorientation T he elderly with significant temporal disorientation can "live in a past time", refusing food to supply it with hypothetical young children. Even the doll of "Doll T herapy" can be confused for them.
26. T he patient does not recognize food as subsistence due to dementia T he patient may forget the function of food as sustenance due to cognitive impairment, and the loss of short-term memory can make him lose the task during the act of eating, or make him forget whether he ate or not and how long perpetuate a fast.

T he patient forgets the bolus in the mouth due to dementia
Short-term memory loss can also make the patient forget to have a bolus in the mouth as soon as it is introduced, resulting in an apparent refusal (consequences may be rejection or passivity).
28. T he patient presents hallucinations that disturb him (he pursues, he feels bodies in his mouth, etc.) During the meal, the elderly person may be affected by hallucinations (which may involve all 5 senses, secondarily to cognitive, psychiatric and / or iatrogenic disorders) and therefore may be distracted and inappetent. A particular delirium can make him believe that food is poisoned and harmful, creating a very strong waste.
29. T he patient presents childish regression: he refuses out of spite or as a child's scheme Cognitive impairment can bring out patterns of rejection similar to child behavior.
30. T he patient has a constant urge to go to the toilet but he is unable to do it by himself T he feeling of having to discharge (evacuation or urination), real or secondary to a moment of cognitive decompensation linked perhaps to a dementia base, certainly distracts from hunger, since the problem is naturally perceived as a more important need.
31. T he patient presents wandering, has difficulty staying still during the meal T he necessity of perpetrating the continuous motion without a purpose, of a demented with wandering, is primary with respect to hunger and makes the staticity and concentration required in taking the meal difficult, which can be refused.

T he patient is afraid of suffocating after an episode of negative reinforcement
Following an episode of aspiration or penetration of the bolus in the airways, the patient may be frightened (of the sensation and the discomfort that can be followed, such as apnea, fever and cough) and refuse the meal for fear that it may happen again.
33. T he patient has sadness for the loss of the home and rhythms and habits are consolidated in it T he bad mood generated by the abandonment of one's own home can cause inappetence and apathy towards the pleasure of feeding oneself, until reaching the depression. Also the variation of one's own rhythms and habits, the decrease of activity and the variation of the times in which the patient usually consume the food, can be a cause of rejection.
34. T he patient has lost self-esteem: he is mortified in being fed T he patient may not accept the reduction of his / her autonomy, feel downcast and humiliated until he / she wants to avoid, through opposition and passivity, the situations in which he / she perceives this sensation most.

Depression and stressful events have meant apathy behavior towards meal pleasure
Aspects of depression are the apathy and loss of pleasure, even inherently to nutrition.
Depression can also be transitory as a physiological phase of mourning of various kinds, not only due to the death of a loved one. Finally, some other stressful events not previously mentioned may cause loss of appetite.
36. T he patient chosen to "reject life" wants to speed up the departure Although lexically it would not be correct to speak of "suicide" or "euthanasia", the refusal of the meal may be for the patient a conscious choice to decide to die.
37. Previous or current anorexia nervosa or psychiatric illness is found Malnutrition due to rejection of the meal can be dictated by some disturbances not previously mentioned of a psychiatric nature or anorexia nervosa, in which (not due to dementia) the patient is afraid of getting fat and appearing "imperfect". Usually this behavior has a history and re-emerges after having already appeared in the experience of the person in question.

T he patient presents drug abstinence or previous dependence on psychotropic substances and alcohol
Substances such as topiramate, amphetamine, exenatide, methylphenidate and methamphetamine reduce appetite both during consumption and during withdrawal. T he same signs of abstinence can be found for stimulants such as coffee, nicotine and cocaine, as well as during detoxification from any form of addiction (alcohol in the first place). Finally, food may not be satisfying in reducing the consumption of pharmacological therapies linked to some antidepressants or clearly after the sudden suspension of essences that increase appetite.
39. T he patient is suffering from "Node in the throat" or vomiting due to psychogenic esophageal dysphagia Esophageal dysphagia in the elderly, if not secondary to mechanical obstructions, ongoing pathology of the digestive organs or iatrogenic reaction, can be compared to a true form of bulimia and has been defined in some Italian articles in 2017 as "inexplicable", probably a psychogenic basis.

T he patient carries PEG / SNG but can not assimilate what is expected in the stomach
Artificial nutrition that reaches the digestive tract bypassing the respiratory system may not be assimilated for various reasons often linked to the enteral medium or to the state of the organ that receives it. In reality, bulimia-like rejection forms without explicit causes are observable, which can be traced back to an anxiety state similarly to the psychogenic type of esophageal dysphagia described above. It should be discussed as a team in the case and also given to the family member by the same or alternatively by a professional elected to the role, with subsequent comparison.
T he planning of an intervention plan will follow, according to the procedures proposed in the manual that includes it, related to the identified causes, and of the resources exploitable in the service.  In both cases, the will to not feed is a frequent behavior, attributable respectively to a form of protest, resistance to help or abandonment of the self. Of particular importance is the pre-entry home visit and the accompaniment in the structure, moments in which part of the professionals guided by the social worker explain the advantages of life in a retirement home to stimulate interest and concretization. Once accepted, it is a good idea to approach the patient with gentlecare and validation, in order to apply an environmental and naturalistic restraint that makes him feel understood, next to a In light of this it is necessary to build a diet that guarantees the health of the patient and however fulfills its expectation, proposing strategies such as sweetening with products that do not increase glycemia in diabetes and overweight, or deprive the food of waste for the patient who suffers from diverticula. T here are also specific products that can be purchased for these types of patients as well as for others affected by food intolerances (for example, lactose or celiac disease). In the elderly, the refusal of food can be linked to a sense of apparent satiety, linked to crushing, compression and / or impairment of the digestive organs (esophagus, stomach, diaphragm, intestine, etc.). T he causes can be inflammation, tissue lesions, meteorism and neoformations (for example, ulcers, air in the bowels, masses ...).
Although causing symptoms similar to cases of pain during swallowing / digestion and constriction from constipation or eventual restraint, the circumstances discussed here often provide a more complex solution to the problem, and therefore must be treated differently, in the awareness that nutrition and therapy pharmacology can only reduce the malaise. T herefore, parallel to the clinical procedures, we recommend the administration of selected foods to give relief with respect to the specific disorder and absorption capacity, with the aim of preventing malnutrition and establishing a collaboration that allows the patient's confidence to return to the fasting and unhappy patient. be able to take specific foods that do not accentuate their physical pains, but rather are pleasant, analgesic, easily digestible and preferably caloric. refusal, which it is good to know how to deal with to interpret the needs of the patient.
When a patient refuses the meal for reasons unrecognizable due to a severe deficit both in production and in non-rehabilitative comprehension (eg serious pictures of global aphasia or dementia), we invite to provide extremely simple forms of CAA to enter into a relationship, after a cognitive therapy training in the psycho-linguistic-environmental field.
T he same can be applied in the Augmentative Alternative Communication, next to the speech therapy rehabilitation, in cases in which the refusal of the meal appears in non communicating receptive patients (eg motor aphasia, deaf-mutism, dysarthria and dysphonia).
On the other hand, when a patient refuses the meal for unrecognizable reasons and his speech, intelligible, is apragmatic (eg, Frontal, Fronto-temporal and Alzheimer dementia, T he elderly with dementia can refuse the meal due to hallucinations that disturb him, making him believe for example that the food is poisoned or has foreign bodies in the mouth. T o solve the problem in these cases, some strategies have proved to be effective, including preparing the meal with the gentleman in order to create a situation that does not allow food manipulation by third parties and acts as a "test" to reassure the goodness and harmlessness of the food to be taken. If it is necessary to use a supplement, it is possible to supply it as a mouthwash to be swallowed during oral hygiene. It is good practice to elect a figure to whom the patient puts unconditional trust (a family member, the parish priest who comes to Mass etc.), to be placed side by side in the act of nutrition.  contact of the oral cavity, for example through hygiene. We can continue, with a view to a "Validation" approach (which validates and legitimates the behavior of the patient through empathy) with the attempt to facilitate and cautious feeding, explaining the effectiveness of the precautions taken. In this cognitive-behavioral psychotherapy, an examination of reality that can lead to reflection on the consequences of fasting and incentives to face the phobia may be useful. As a positive reinforcement, the resumption of feeding is allowed in frequent and continuous rehabilitation training for dysphagia, to   T o this may be associated a tactile stimulation, sensory and affective, which includes contacts, relaxing massages and caresses designed to pursue the well-being of the patient, encouraging a sense of reassurance. T he search for a goal to be pursued and a rewarding role at the employment level, such as feeding and manual activities, proved to be very useful. Finally, it is possible to find pleasing and evocative foods for the patient, which he can help to prepare, involved in a cooking laboratory.
T he whole is applicable when no signs of psychogenic esophageal dysphagia appear, often frequent evolution.
On the other hand, in the elderly with dementia, the pharmacological therapy of an If the meal is partially accepted, it is important to supplement the intake with high-calorie products to make it sufficiently nutritious. T o this may be associated a tactile stimulation, sensory and affective, which includes contacts, relaxing massages and caresses designed to pursue the well-being of the patient, encouraging a sense of reassurance.
T he search for a goal to be pursued and a rewarding role at the employment level, already mentioned, turned out to be very useful. Finally, it is possible to find pleasing and evocative foods for the patient, which he can help to prepare, involved in a cooking laboratory.
T he whole is applicable when no signs of psychogenic esophageal dysphagia appear, often frequent evolution.
T his type of process is suggested for lucid people, because in the elderly with dementia, on the contrary, it is very difficult to interpret a certain rejection of the meal as a In some cases the polished elder can refuse the meal due to a disturbance of his body image, fearing to gain weight and to make himself more "imperfect". In the absence of dementia or other cognitive decays, this behavior is due to psychiatric / affective disorders or anorexia nervosa, sometimes present in the patient's history.
In these cases, similarly to eating disorders, it is possible to treat fasting with pharmacological therapy and psychotherapy (cognitive-behavioral and dynamic), which will focus on the acquisition, processing and acceptance of one's body scheme and the replacement of food rejection with acquisition of a reduced (but sufficient) diet.
T o make the meal initially accepted, counseling aimed directly at the patient is also useful, explaining and demonstrating the importance of the fluids to maintain the state of health and the impossibility of gaining weight following a balanced diet. T he elderly person can refuse the meal due to a sensation of "lump in throat" and nausea, symptoms that, in the absence of infectious, obstructive-morphological, mechanical-motor or neurological / neuromuscular causes, can be traced back to a Psychogenic type of Esophageal Dysphagia. , in which an unconscious anxiety-producing state seems to re-emerge.
In an attempt to resolve the disorder and prevent malnutrition, it is necessary to set up an antidepressive or antipsychotic drug therapy as appropriate, and to investigate any disruptive factors present in the environment to be adapted to the patient, associating a relaxation and reassurance training to it. which can start from gentle body contact.
In the sufficiently lucid and collaborating patient the psychotherapeutic treatment is invited, while in the subject with more pronounced cognitive deterioration it is necessary to administer the meal in a Snoezeln Chamber, conceived with elements able to capture the attention of the gentleman and distract him from his anguish, reducing it.
At food level, as the difficulty of the esophageal passage of the bolus and vomit is reduced, a specific diet must be identified that guarantees sufficient water and calories in the moments when feeding is possible. Parenteral Artificial Nutrition will be valid to compensate for fasting before any benefits of interdisciplinary treatment (eg CVC, Midline, infusion for drip), while the long-term efficacy prognosis (eg PEG) may be affected by vomiting , if not reduced, would lead to rejecting what was introduced. Similarly to this, in an attempt to resolve the disorder and prevent malnutrition, it is necessary to set up an antidepressive or antipsychotic drug therapy as appropriate, and to investigate any disruptive factors present in the environment to be adapted to the patient, associating it with a training of relaxation and reassurance that can start from gentle body contact.
In the sufficiently lucid and collaborating patient the psychotherapeutic treatment is invited, while in the subject with more pronounced cognitive deterioration the activation of the Artificial Nutrition medium in a Snoezeln Chamber is necessary, conceived with elements able to capture the attention of the gentleman and distract him from the own anguish, reducing it.
In both cases, the most advantageous strategy turned out to be enteral infusion during moments of deep sleep that alternate with wakefulness, in a cyclicity guaranteed by therapy.