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5/23/2005 Dysphagia and Nutrition Management In Patients With Dementia: The Role of the SLP Sue Curfman, M.A., CCC | |
| Research and statistics clearly indicate that dehydration and malnutrition are prevalent and serious concerns with our residents in skilled nursing facilities (SNF). Studies indicate that 54% of all SNF admissions are malnourished; the range of malnourished elderly in SNFs range from 20-87%. In addition, 60% of all residents experience an initial weight loss following admission. The financial impact of dehydration and malnutrition are illustrated with the following statistic in that $1.3 billion spent in 1996 by CMS for acute hospital care with primary diagnosis of dehydration. Many of these residents quoted in these statistics have a dementia diagnosis, which places them at higher risk for weight loss and dehydration. Current statistics estimate that 60-80% of all residents in long-term care have a dementia diagnosis. Adequate nutrition and hydration in an individual with dementia is a central concern for all members of the family and healthcare team. The impact of dementia on nutrition and hydration changes throughout the course of the degenerative disease process. In the early stage, the individual with dementia may forget to eat, may become depressed and not want to eat, or become distracted and leave the table 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 due to wandering and motor restlessness. In the late stage, the individual with dementia does not have intact oral motor skills for chewing and swallowing, thus becomes subject to malnourishment and “wasting away.” The role of the SLP will change over time due to the progressive nature of the dementia disease process and its impact on swallowing function and nutrition. The goal of the SLP is the same as Medicare’s # 1 goal, which is “facilitating and maintaining safety for the resident during swallowing and p.o. intake.” It is imperative that the SLP has a solid understanding of dysphagia and appropriate treatment and management techniques specific to the disorder. Assessment The goal of assessment for an individual with dementia is to identify the nature of dysphagia, identification of the contributing factors, differentiate the physiological impairment and/or cognitive dysfunction aspects, capacity for safety improvement, and potential to benefit from skilled intervention. Specific components of the initial assessment include chart review, sensory assessment, head and neck positioning, oral-motor skills, pattern of mastication, salivation, and laryngeal elevation. Each of the swallow assessment components are individually reviewed with specific areas identified for review: Chart Review Review of the medical record is absolutely essential for determining the disease process or combination of factors that are related to the presence of dysphagia. The course of recovery or progressive decline found in the diseases and surgical procedures linked to dysphagia vary widely. Once the disease process contributing to the dysphagia is identified, the clinician should determine the patient’s course of anticipated recovery or decline. The impact of progressive dementia on swallow function can be fairly predictable. Chart review takes on a more primary role when the patient’s recall or ability to provide information is limited due to memory impairment, dementia or other language deficit. The following information in the medical record should be referenced:
Two key questions that the SLP would ask the patient are (1) “What is are reported problems with eating, drinking, swallowing,” and (2) “Why do you think you are having this problem with swallowing?” The patient’s responses can provide valuable information about his or her perception of the illness. In addition, as the interviewer, you can get a sense of the patient’s overall cognitive status, ability to attend and follow directions, and learn new information. This will influence the nature of the treatment program that is established. Many of the patients that present with dysphagia as a result of neurological impairment will be unable to participate in the interview process due to expressive and/or receptive communication problems or cognitive dysfunction. The information can be obtained from a caregiver or family member that is familiar with the patient. Sensory Assessment  Sample sensory deficits include decreased p.o. intake secondary to altered/absent perception of taste, diminished safety mechanism for detecting hot food with potential/actual intra-oral injuries, and/or profound sensory deficits in the later stages of the disease eliminate any functional mastication pattern. Head and Neck Positioning Assessment considers both habitual body position and habitual head position. It should be noted if the patient is able to complete independent positioning on instruction or is able to assist in positioning. In the later stages of dementia, there are three common head-neck positions including chronic head/neck flexion, variable head/neck flexion/extension in the absence of positioning management, and chronic head/neck hyperextension. The only appropriate goal of intervention at this late stage is to improve functional behaviors through adaptive equipment or assistive devices; there is no rehab potential due to bilateral brain destruction. Oral Motor Skills The clinician will complete (1) visual inspection and assessment of ROM, strength and coordination of individual oral structures including lips, tongue (anterior, middle, posterior), soft palate and (2) assess the functional movement patterns required for oral stage of swallowing including 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 Pattern of Mastication The clinician will assess both the muscles associated with mastication and the pattern of mastication. The oral motor function will determine the pattern of mastication, which will deteriorate in a predictable fashion with the progression of the dementia. The progressive deterioration in mastication patterns reflects a transition from higher level reflex integration to lower level reflex integration.
Assessment of salivary function includes three components: (1) visual inspection of the oral mucosa to determine adequacy of salivary flow, (2) medication review, and (3) medical history. If salivary flow is adequate, the oral cavity appears wet and if hyposalivation, the oral cavity will become dry. Symptoms of dry mouth, or xerostomia, includes mouth pain, difficulty chewing, difficulty swallowing, weight loss, mouth infections, tooth decay, dry cracked tongue, bleeding gums, cracked corners of mouth, badly fitting dentures, dryness in eyes, nose, skin and throat. If complaints or visual inspection indicates a dry mouth, the individual 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. Volitional Swallows and Laryngeal Elevation The clinician will assess laryngeal elevation during dry and/or bolus swallows. Once initiated, the swallow should occur briskly. The components of laryngeal elevation would include the speed of laryngeal elevation, the movement of the structures, and the integrity of the movement. Assessment Analysis and Conclusions The information from the chart review, interview, clinical swallow assessment, and instrumental assessment, is reviewed and analyzed to determine the presence of dysphagia, level, severity, and primary etiologic contributing factors. The question to be answered is whether the individual demonstrates a dysphagia secondary to a physiological deficit and/or cognitive deficit. Many of the swallowing and eating impairments are secondary to the primary dementia diagnosis, which is the focus of the remainder of this paper. The individual may demonstrate the following secondary conditions related to the primary dementia diagnosis:
Dysphagia treatment can be divided into direct treatment and indirect treatment. In direct treatment, the clinician works directly with the patient with teaching compensatory strategies for resident implementation. Examples of direct dysphagia treatment interventions include sensory stimulation, compensatory strategies, diet modification, strengthening, ROM exercises, and caregiver training. With Indirect treatment, the clinician sets up an individualized plan of care that incorporates environmental modifications, adaptive equipment/assistive devices, safety strategies, etc. that is carried out by a designated caregiver. Examples of indirect dysphagia treatment interventions include addition of sweetener to food items if only sweet taste receptors remain, alternative nutritional systems, and/or oral care/sensory stimulation provided by nursing. Sample treatment recommendations may include the following:
From the earlier stages of forgetfulness and confusion to the end stage of impending death, provisions must be made by the caregivers and professionals to encourage adequate nutrition for people with dementia. The changes that occur during the progression of Alzheimer’s disease affect people cognitively, physically, and emotionally and present environmental challenges. Strategies for managing some of these changes are summarized in the following table.    Late Stage and Enteral Feeding Considerations If alternative nutritional systems are considered, it is critical that the SLP provide objective education on tube feeding in advanced cognitive impairments for physicians, family and caregivers. More than one-third of severely cognitively impaired residents in US nursing homes have feeding tubes. Studies by Murphy et al (2003) and Finucane et al (1999) conclude there are no documented changes in nutritional status, pressure sores, or other functional status following g-tube placement. Tube feeding is not proven to prevent “wasting away” and there is no survival benefit in patients with dementia who receive enteral feeding. The role of the SLP is to be informed, be familiar with your client’s advanced directive, recognize who will benefit from tube feeding and who will not, and communicates with physicians and family members. Summary In conclusion, careful attention needs to focus on effectively meeting the nutrition and hydration needs of the individual with dementia. The impact of progressive dementia, including Alzheimer’s disease, on swallowing function and independent eating/feeding will change over the course of the disease. The speech-language pathologist, in collaboration with the physician, plays a vital role as a member of the multi-disciplinary healthcare team in assessing the nature of the dysphagia and the contributing factors, developing an individualized plan of care to effectively manage the behaviors and strategies to ensure optimal nutrition and hydration, provide caregiver education in safe swallow strategies, and provide informed education regarding alternative nutritional systems. References Advisory Panel on Alzheimer’s Disease (1993). Fourth Report of the Advisory Panel on Alzheimer’s Disease, 1992 (NIH Publication No. 93-3520). Washington, D.C: Author. Allen, C., Earhart, C., & Blue, T. (1992). Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled. Bethesda, MD: The American Occupational Therapy Association, Inc Bayles, K.A., Tomeda, C.K. (1997). Improving Function in Dementia. Tucson, Arizona: Canyonlands Publishing. Hall, C.R. (1990, March/April). Eating: An Alzheimer’s activity. American Journal of Alzheimer’s Care and Related Disorders and Research, pg. 5-9. Finucane, T.E., Christmas, E., & Travis, K. (1999). Tube feeding in patients with advanced dementia: A review of the evidence. JAMA, 282, pg. 1365-1370. Kaplan, M., & Hoffman, S. (1998). Behaviors in Dementia, Best Practices for Successful Management. London: Health Professions Press. Murphy, L. & Lipman, T. (2003). Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia. Arch Intern Med, 163, pg. 1351-1353. Murray, Joseph. (1999). Manual of Dysphagia Assessment in Adults. San Diego, CA: Singular Publishing Group. Stefanakos, K., and Crouch, P. (2003). Dementia A to Z. A Comprehensive Training Resource Text for the Speech Pathologist. Tampa, Florida: The Speech Team, Inc. U.S. Congress, Office of Technology Assessment. (1992). Special Care Units for People with Alzheimer’s and Other Dementias (Report No. ITA-H-543). Washington, DC: U.S. Government Printing Office. Internet Citations: 2003 Progress Report on Alzheimer’s Disease: www.niapublications.org 2003 Progress Report on Alzheimer’s Disease: www.alzheimers.org/pr03/2003_Progress_Report_on_AD.pdf Alzheimer’s Disease: Nutritional challenges: www.mayoclinic.com/invoke.cfm?id=HQ00217 Anticipating end-stage needs of people with Alzheimer’s disease: www.mayoclinic.com/invoke.cfm?id=HQ00618 | |