Managing Dysphagia in Residents With Dementia

SKILLED INTERVENTION FOR A COMMON-AND T ROUBLING-DISORDER

BY SUE CURFMAN, MA, CCC

Adapted with permission from an or iginal article published at www.speechpathology.com.

Research and statistics clearly indicate that dehydration and malnutrition are prevalent and seriou s concerns with skilled nursing facility (SNF) residents. Studies indicate that 54% of all newly admitted SNF r esidents are malnourished; the prevalence of malnourished elderly in SNFs has been reported to range from 20 to 87%. In addition, 60% of all residents experience an initial weight loss following admission.

Many of t he residents in these statistics had a dementia diagnosis, which places them at higher risk for weight loss and dehydration. In addition, current statistics estimate that 60 to 80% of all residents in long-term care have a dementia diagnosis. Thus, adequate nutrition and hydration in a resident with dementia is a central concern fo r all members of the family and healthcare team.

The effect of dementia on nutrition and hydration chang es throughout the course of the degenerative disease process. In the early stage, the individual with de mentia may forget to eat, may become depressed and not want to eat, or may become distracted and leave the tabl e without eating. In the middle stage, the individual with dementia may be unable to sit long enough to eat, yet at this stage may require an additional 600 calories per day because of wandering and motor restlessne ss. In the late stage, the individual with dementia does not have intact oral motor skills for chewing a nd swallowing, thus becoming subject to malnourishment and “wasting away.”

This is one reason a facility can benefit from the involvement of a speech-language pathologist (SLP). The role of the SLP will change over time because of the progressive nature of the dementia disease process and its effect on swallowing function an d nutrition. The SLP’s goal is the same as Medicare’s number one goal in these residents: “facilitating and mai ntaining safety for the resident during swallowing and p.o. intake” (Medicare Transmittal No. 597, Medicare Hos pital Manual). It is imperative that the SLP, as well as the director of nursing and other key members of the c aregiving team, have a solid understanding of dysphagia and appropriate treatment and management techniques spe cific to the disorder. Administrators and other nursing home professionals will also benefit from a general und erstanding of the complexities of caring for these residents.

Ass essment
The goal of assessment for an individual with dysphagia and dementia is to identif y the nature of the dysphagia, identify the contributing factors, differentiate the physiologic impairment and/ or cognitive dysfunction aspects, identify capacity for improved safety, and identify the potential benefit fro m skilled intervention. Specific components of the initial assessment include chart review, resident/caregiver/ nursing interview, sensory function, head and neck positioning, oral motor skills, pattern of mastication, sali vation, and laryngeal elevation. Each of the swallow assessment components are individually reviewed below.

Chart review. The course of recovery or progressive decline found in t he diseases and surgical procedures linked to dysphagia vary widely. Once the disease process contributing to t he dysphagia is identified, the clinician should determine the resident’s course of anticipated recovery or dec line. Fortunately, the effect of progressive dementia on swallow function can be fairly predictable. Chart revi ew takes on an even more primary role when the resident’s recall or ability to provide information is limited b ecause of memory impairment, dementia, or other language deficits. Therefore, the following information in the medical record should be sought:

• diagnoses
• current weight
• recent weight change s
• current and historic therapeutic/altered diets
• current eating habits, including food types an d amounts consumed at scheduled and unscheduled times
• self-feeding skills throughout the course of the meal
• eating and chewing difficulties
• signs/symptoms (from nursing notes) of congestion, coughin g, choking with drinking or taking medications, fever, and lethargy
• x-ray results (e.g., chest and modi fied barium swallow)
• history of pneumonia

Resident/caregiver/nursing inte rview. Two key questions for the resident are: (1) “What are your problems with eating, drinking, an d swallowing?” and (2) “Why do you think you are having a problem with swallowing?” Besides valuable informatio n about the resident’s perception of the illness, you can get a sense of the resident’s overall cognitive statu s and ability to attend to and follow directions and learn new information. This will influence the nature of t he treatment program.

Many residents with dysphagia as a result of neurologic impairment will be unable to participate in the interview process because of expressive and/or receptive communication problems or cognit ive dysfunction. If so, the necessary information can be obtained from a caregiver or family member who is fami liar with the resident.

Sensory function. It is important to determi ne whether the resident’s sensory pathways are intact, intermittently intact, or absent. The following six anat omic sites are assessed to determine this, in this order:

• tongue (anterior two-thirds)
• tongue (posterior one-third)
• hard palate
• soft palate
• posterior pharyngeal wall
• laryngeal region

Sample sensory deficits that may be discovered include decreased p.o. intake secondary t o altered/absent perception of taste; diminished safety mechanism for sensing hot food, with potential/actual i ntraoral injuries; and/or profound sensory deficits in the later stages of the disease that eliminate any funct ional mastication pattern.

Head and neck positioning. Assessment con siders both habitual body position and habitual head position. Note whether the resident is able to complete in dependent positioning on instruction or is at least able to assist in positioning. Three common head/neck posit ions occur in the later stages of dementia: chronic head/neck flexion, variable head/neck flexion/extension cau sed by a lack of positioning management, and chronic head/neck hyperextension. The only appropriate goal of int ervention at this late stage is to improve the resident’s functional behaviors through the use of adaptive equi pment or assistive devices; no rehab potential remains because of the bilateral brain destruction.

Oral motor skills. The clinician will: (1) visually inspect and assess ROM, stre ngth, and coordination of individual oral structures, including lips, tongue (anterior, middle, and posterior), and soft palate; and (2) assess the functional movement patterns required for the oral stage of swallowing, in cluding food bolus manipulation during chewing, cohesive food bolus formation, anterior-to-posterior transit of cohesive food bolus, and transfer or dropping of food bolus into pharynx.

Patt ern of mastication. The clinician will assess both the muscles associated with mastication and the p attern of mastication. The oral motor function will determine the pattern of mastication, which deteriorates in a predictable fashion with the progression of dementia. The progressive deterioration in the mastication patte rns below reflects a transition from higher level reflex integration to lower level reflex integration during t he course of dementia:

• rotary chew pattern
• lateral chew/chomping pattern and jaw-jerk reflex
• suck-swallow pattern
• absent oral motor function for chewing

< b>Salivation. Assessment of salivary function includes three components: (1) visual inspection of th e oral mucosa to determine adequacy of salivary flow, (2) medication review, and (3) medical history review. Co mmon drug classes that reduce salivation include anticholinergic, antidepressant, and antipsychotic drugs. If s alivary flow is adequate, the oral cavity will appear wet; if hyposalivation is present, the oral cavity will b ecome dry. Symptoms of dry mouth (xerostomia) include mouth pain; difficulty chewing; difficulty swallowing; we ight loss; mouth infections; tooth decay; a dry, cracked tongue; bleeding gums; cracked corners of the mouth; b adly fitting dentures; and dryness in the eyes, nose, skin, and throat. If complaints or visual inspection indi cate a dry mouth, the resident should be assessed for other signs/symptoms of dehydration, including dry mucous membranes; loss of skin turgor; intense thirst; flushed skin; oliguria (decreased urine output in relation to fluid intake); dark, yellow urine; and/or possible elevated temperature.

Analyz ing volitional swallows and laryngeal elevation. Once initiated, the swallow should occur briskly. T he clinician will also assess laryngeal elevation during dry and/or bolus swallows. The components of laryngeal elevation would include the speed of laryngeal elevation, the movement of the structures involved, and the int egrity of their movement.

Assessment AnalysisThe information from the chart review, interview, clinical swallow assessment, and instrumental assessment is reviewed and analyzed to determine the presence of dysphagia, as well as level, severity, and primary etiology of contributing factors. The question then is whether the resident demonstrates dysphagia secondary to a physi ologic deficit and/or a cognitive deficit. Many swallowing and eating impairments are secondary to the primary dementia diagnosis, which is the focus of the remainder of this article.

Dysphagia of Dementia
The resident may demonstrate the following secondary conditio ns related to the primary dementia diagnosis:

• absent oral motor pattern for mastication
  poor sensory awareness/integration
• negative reaction to food textures and consistencies
• suc k-swallow mastication pattern
• significant irreversible pharyngeal dysphagia
• reduced p.o. intak e secondary to behavioral issues possibly related to dementia

Treatme nt Recommendations
Dysphagia treatment can be divided into direct treatment and indirect treatment. In direct treatment, the clinician works directly with the resident, teaching him or he r compensatory strategies. Examples of direct dysphagia treatment interventions include sensory stimulation, di et modification, muscle strengthening, ROM exercises, and caregiver training in feeding assistance.

With indirect treatment, the clinician sets up an individualized plan of care incorporating environmental modificat ions, adaptive equipment/assistive devices, safety strategies, etc., that are used by a designated caregiver. E xamples of indirect dysphagia treatment interventions include addition of sweetener to food items (if only swee t taste receptors remain); use of alternative nutritional systems, such as enteral feeding; and/or oral care/se nsory stimulation provided by nursing.

Treatment recommendations may include:

• sensory s timulation and/or integration, such as increasing texture variation (dry crackers or crisp cookies), increasing mouth sensation, and facilitating mastication pattern;
• diet management (as prescribed), development o f an individualized plan of care/functional maintenance program (FMP), and caregiver training for implementatio n. An FMP is a detailed program of strategies and instruction carried out by the caregiver that maximizes resid ent skills to maintain the highest level of functional independence;
• providing oral care from nursing before meals with a citric swab to increase salivation;
• offering the resident six small meals daily;
• offering the resident calorie-loaded finger foods throughout the day to increase p.o. intake of calories;
• involving the resident in a facility hydration program; and
• evaluating the resident by PT/OT f or appropriate positioning to expedite safe, effective swallow function and meal completion.

< font color=”#509197″>Enteral Feeding and End-of-Life Decisions
More than one-third of s everely cognitively impaired residents in U.S. nursing homes have feeding tubes. However, studies by Murphy and Lipman, as well as Finucane et al, conclude that there are no documented changes in nutritional status, pressu re sores, or other functional status following gastrostomy tube placement in these residents.^1,2 Tub e feeding is not proven to prevent “wasting away,” and there is no survival benefit in residents with dementia who receive enteral feeding. Issues related to enteral feeding to sustain life in the end stage of dementia sho uld be discussed with the resident and family early in the disease process. It is optimal for the person to sta te his/her own preference regarding enteral feeding before losing the ability to communicate such complex ideas . If the resident cannot do this, it is important to provide caregivers with adequate information regarding ava ilable treatment options and the consequences related to nutritional intake.