Dysphagia is a serious problem and contributes to weight loss, malnutrition, dehydration, aspiration pneumonia, and death. Careful assessment of risk factors, observation for signs and symptoms, and collaboration with speech-language pathologists on interventions are essential.
Dysphagia, or difficulty swallowing, is a common problem in older adults. The prevalence of swallowing disorders is 16% to 22% in adults older than 50 years of age, and up to 60% of nursing home residents have clinical evidence of dysphagia (Aslam & Vaezi, 2013).
Dysphagia can be the result of behavioral, sensory, or motor problems and is common in individuals with neurological disease and dementia.
Dysphagia is a serious problem and has negative consequences, including weight loss, malnutrition, dehydration, aspiration pneumonia, and even death.
Aspiration (the misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract) is common in older adults.
Risk Factors for Dysphagia
• Cerebrovascular accident
• Parkinson's disease
• Neuromuscular disorders (ALS, MS, myasthenia gravis)
• Dementia
• Head and neck cancer
• Traumatic brain injury
• Aspiration pneumonia
• Inadequate feeding technique
• Poor dentition ALS
Amyotrophic lateral sclerosis; MS, multiple sclerosis.
Implications for Gerontological Nursing and Healthy Aging.
Assessment
It is important to obtain a careful history of the older adult's response to dysphagia and to observe the person 136during mealtime. Symptoms that alert the nurse to possible swallowing problems are presented in Box 10.4. Patients referred for a dysphagia evaluation (“swallowing study”) must be assumed to be dysphagic and at risk for aspiration. Nothing-by-mouth (NPO) status should be maintained until the swallowing evaluation is completed. During this period, if necessary, nutrition and hydration needs can be met by intravenous, nasogastric, or gastric tubes. A comprehensive evaluation by a speech-language pathologist (SLP), usually including a video fluoroscopic recording of a modified barium swallow, should be considered when dysphagia is suspected.
Symptoms of Dysphagia or Possible Aspiration must present:
• Difficult, labored swallowing
• Drooling
• Copious oral secretions
• Coughing, choking at meals
• Holding or pocketing of food/medications in the mouth
• Difficulty moving food or liquid from mouth to throat
• Difficulty chewing
• Nasal voice or hoarseness
• Wet or gurgling voice
• Excessive throat clearing
• Food or liquid leaking from the nose
• Prolonged eating time
• Pain with swallowing
• Unusual head or neck posturing while swallowing
• Sensation of something stuck in the throat during swallowing; sensation of a lump in the throat
• Heartburn
• Chest pain
• Hiccups
• Weight loss
• Frequent respiratory tract infections, pneumonia
Interventions
After the swallowing evaluation, a decision must be made about the potential for functional improvement of the swallowing disorder and the safety in swallowing liquid and solid food.
The goal is safe oral intake to maintain optimal nutrition and caloric needs. Nurses work closely with speech-language pathologists and the dietitian to implement interventions to prevent aspiration. Compensatory interventions include postural changes, such as chin tucks or head turns while swallowing, and modification of bolus volume, consistency, temperature, and rate of presentation. Diets may be modified in texture from pudding-like to nearly normal-textured solids.
Liquids may range from spoon-thick to honey-like, nectar-like, and thin. Commercial thickeners and thickened products are also available (Mathew & Jacobs, 2014).
Neuromuscular electrical stimulation has received clearance by the U.S. Food and Drug Administration for treatment of dysphagia. This therapy involves the administration of small electrical impulses to the swallowing muscles in the throat and is used in combination with traditional swallowing exercises (Shune & Moon, 2012).
Aspiration is the most profound and dangerous problem for older adults experiencing dysphagia. It is important to have a suction machine available at the bedside or in the dining room in the institutional setting.
Research on the appropriate management of swallowing disorders in older people, particularly during acute illness and in long-term care facilities, is very limited, and additional study is essential.
Tips for Best Practice Preventing Aspiration in Patients With Dysphagia
:
Hand Feeding
• Provide a 30-minute rest period before meal consumption; a rested person will likely have less difficulty swallowing.
• The person should sit at 90 degrees during all oral (PO) intake and remain in this position for at least 1 hour after intake.
• Adjust rate of feeding and size of bites to the person's tolerance; avoid rushed or forced feeding.
• Alternate solid and liquid boluses.
• Have the person swallow twice before the next mouthful.
• Stroke under chin downward to initiate swallowing.
• Follow speech therapist's recommendation for safe swallowing techniques and modified food consistency (may need thickened liquids, pureed foods).
• If facial weakness is present, place food on the nonimpaired side of the mouth.
• Avoid sedatives and hypnotics that may impair cough reflex and swallowing ability.
• Keep suction equipment ready at all times.
• Supervise all meals.
• Monitor temperature.
• Observe color of phlegm.
• Visually check the mouth for pocketing of food in cheeks.
• Check for food under dentures.
• Provide mouth care every 4 hours and before and after meals, including denture cleaning.
Info Adapted from Metheny N, Boltz M, Greenberg S: Preventing aspiration in older adults with dysphagia, Am J Nurs 108(2):45–46, 2008.
Implications for Gerontological Nursing and Healthy Aging
Maintenance of adequate nutritional health as a person ages is extremely complex. Knowledge of nutritional needs in later years and of the many factors contributing to inadequate nutrition is essential for the gerontological nurse and should be a part of every assessment of an older person. Working with members of the interprofessional team in appropriate assessment and development of therapeutic interventions is a major role in community, hospital, and long-term care settings. Use of evidence-based practice protocols is important in determining nursing interventions to support and enhance nutritional status.
Prevention of undernutrition and malnutrition and the maintenance of dietary needs and food are also ethical responsibilities. No older person should be hungry or thirsty because he or she cannot shop, cook, buy and prepare food, or eat independently. Nor should any older person have to suffer because of a lack of assistance with these activities in whatever setting the person may reside.
References
BOOK:
Ebersole and Hess' Gerontological Nursing and Healthy Aging 5th
Author: Theris A. Touhy; Kathleen F. Jett. Edition: 5th, Fifth, 5e Year: 2017 .
Other references to review from from:
· Aslam M, Vaezi M. Dysphagia in the elderly. Gastroenterol Hepatol. 2013;9(12):784–795.
· Metheny M, Boltz M, Greenberg S. Preventing aspiration in older adults with dysphagia. Am J Nurs. 2008;108(2):45–46.
· Shune S, Moon J. Neuromuscular electrical stimulation in dysphagia management: Clinician use and perceived barriers. Contemp Issues Commun Sci Disord. 2012;39:55–68.
Resources for Best Practice
· American Heart Association: DASH diet, Mediterranean diet.
· Capezuti E, Zwicker D, Mezey M, et al., editors: Evidence-based geriatric nursing protocols for best practice, ed 4, New York, 2012, Springer.
· HelpGuide.com: Eating well after 50. Nutrition and diet tips for healthy eating as you age. National Institute on Aging: What's on your plate? Smart food choices for healthy aging. Pioneer Network: New Dining Practice Standards (LTC).
· The American Geriatrics Society: Position statement: Feeding tubes in advanced dementia.
· The Hartford Foundation for Geriatric Nursing: Assessing nutrition in older adults (includes a video of administration of MNA), Mealtime difficulties, preventing aspiration in older adults with dysphagia (includes video).
samvera
Agingchapter10Nutrition-Dysphagia.docx
0
