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.
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:
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:
- Current weight
- Recent weight changes
- Current and historical therapeutic/altered diets
- Current eating habits including food types and amounts consumed at scheduled and unscheduled times of the day
- Self feeding skills throughout the course of the meal
- Eating and chewing difficulties
- Review of nursing notes for signs/symptoms of congestion, coughing, choking with drinking, taking medications, fever, lethargy.
- X-ray results - Chest, MBS
- History of pneumonia