2a by xiaohuicaicai


									Enhancing the Mealtime
                     Presented by:
     Heather Jacobson, Speech-Language Pathologist
           Madeleine Kunzler, Clinical Dietitian
           Lynda Wolf, Occupational Therapist

                    Contributions by:
         Andrea Bellamy, Occupational Therapist
         Carole Hamel, Clinical Nurse Specialist

• Safety and Swallowing
• Supportive Eating Environment
• Techniques for Enhancing Mealtimes
        What is required for
       successful mealtimes?

– Ability to swallow safely
– Preferred food texture
– Attention to eating
– Ability to get food from plate to mouth
– Supportive environment that facilitates
  independent feeding
          What’s the big deal?
            A Few Stats…
• Approx 60% of institutionalized elderly
  individuals experience some form of swallowing

• For those being fed, 90% have swallowing

• Risk/Complications:
  • Mealtime distress – such as choking, painful
  • Malnutrition
  • Dehydration
  • Aspiration Pneumonia
     A Definition of Dysphagia
• Difficulty swallowing = Difficulty
  moving food/liquid from mouth to

• The difficulty may involve the mouth,
  throat, voice box, and/or esophagus
       Normal Swallowing
• Automatic
• Frequent
• Necessary
    Three Swallowing Stages
• Oral
• Pharyngeal
• Esophageal
      The Effect of Aging on
• Reduced saliva
• Reduced thirst
• Reduced sweet & salty taste buds
• Increased likelihood of reflux
• Reduced muscle bulk/strength of tongue,
  facial muscles
• Reduced cough reflex
    Dementia and Swallowing
• Persons with dementia forget how to
• This is a thinking problem, not a physical
     Things you may notice…

•   Distorted perception of food
•   Sorts food and spits out
•   Chews food longer
•   Holds food on tongue or in cheeks
•   Prefers liquids
•   Does not open mouth to accept food
                    Physical Problems
• Three places where
  problems can happen:
     – Mouth
     – Throat
     – Esophagus
•   Symptoms of Dysphagia
     – Coughing/clearing throat at meals
     – Pocketing food in mouth after
     – Poor ability to chew
     – Sensation of food being “stuck”
     – Painful swallowing
     – No swallowing at all
     – Wet, gurgly voice or breathing
       sounds after swallowing
    How to Make Feeding Safer
•    Here are the 8 Steps:
    1.   Check for swallowing “care plans”
    2.   Proper Resident Position
    3.   Food Check
    4.   Proper Feeder Position
    5.   Appropriate Rate and Amount
    6.   Oral Care
    7.   Proper Resident Position After Eating
    8.   Reporting to the staff
                                    Step 1:
Check for “Silver Spoons Club” symbol
                      PATIENT NAME
   DIET:    Pureed with Thick 2 (Honey) liquids
            SUCKERS – OK if directly
            supervised by family/staff
  POSITION: Upright at 90 in bed & at 60
            for 30 minutes after meals.

  FEEDER POSITION: Sit/stand beside bed at her
           eye level

   Approach from RIGHT SIDE.
   Feed slowly – watch adam’s apple move up & down
   Reduce distractions and noise.
   To encourage mouth opening & swallow:
     o    Light pressure on her tongue
     o    Touch food to her lips
     o    Alternate between liquids and solids
     o    Gently massage throat
     o    Use cold spoon (dipped in cup of ice)
      WAIT if coughing happens - make sure voice is clear
     sounding before continuing to feed.

  ORAL CARE: Remove food with moist toothette
              Step 2:
      Proper Resident Position
• Remember the song “Head and shoulders,
  knees and toes…”

  – Seated – hips at 90o
  – Head forward, chin down
  – Body aligned in mid-line position
  – Knees, ankles at 90o
  – Feet and arms supported
      Wheelchair Positioning
• Standard Wheelchair
  – May need a support behind the back to
    achieve most upright position
  – Knees bent & feet supported
• Tilt-in-Space Wheelchair
  – Back at 90o to seat (no recline or tilt)
  – Headrest supporting head in midline with chin
    somewhat forward
  – Knees bent & feet supported
       Wheelchair Positioning
• Use of Wheelchair Tray
  – Use with small wheelchairs to bring tray
    where person can see and reach
     • If chair too short for person to eat from table
     • If person cannot reach food at table
• Use of Overbed Table
  – Also brings tray closer
• Make sure person still eats with others
    Wheelchair Repositioning

• Be sure that person is sitting upright in
• Repositioning must be done by two staff
                Step 3:
              Food Check
• Before feeding,
  check to confirm
  all food and fluids
  match diet order
                  Step 3:
                Food Check
• Before feeding, check to confirm all food
  and fluids match diet order ticket

• There is no one dysphagia diet
  – Individualized
  – Proper food order never
    exceeds person’s ability to swallow
           What’s for supper?
• Texture - What are the choices?
   – Soft
   – Soft/Minced
   – Minced
   – Total Minced
   – Puréed
   – Blenderized
   – No Mixed Consistency
   – Thickened Liquids
            Texture of Food
• Adjusting food texture helps decrease:
  – Excessive chewing
  – Spitting out of food particles
  – Holding of food in mouth

• Method of service:
  – Serve foods in cup instead of plate
  – Provide straw instead of cup drinking
  – Finger foods instead of utensils
 When People Refuse to Eat…
• Specially made milkshakes
• Sprinkle artificial sweetener or syrup over
• Give ice cream or pudding with main
• Finger foods for pacers
• Placement of food
• Food available 24 hrs a day
             High Risk Foods!
• Foods That May Cause Obstruction in the
  – Sticky Foods
  – Stringy Foods
  – Foods with small pits
• Foods That May Increase the Risk of Aspiration
  – Foods that DO NOT easily form a bolus
  – Foods of 2 or more consistencies
  – Thin liquids (risky only if resident restricted to
    thickened liquids)
• …Jell-O & ice cream?
                Step 4:
         Proper Feeder Position
• Sit facing patient, at eye level
• Give spoonfuls from below
            Step 5:
 Appropriate Rate and Amount
• Give one teaspoon at a time and observe
  or feel for swallow before more food or
  fluid is given.
               Ask Yourself…
• What are mealtimes like here?
• Does the dining room experience look and feel “normal”
  or does it feel like a big confusing institution?
• Do mealtimes provide an opportunity for the person with
  dementia to be successful?
• Are mealtimes pleasantly social?
• Are residents eating with people they like or are they
  distracted or upset by others?
• Are staff engaging residents and calling them by name
  during mealtimes?
• Is this a place where I would want to eat my meals
  for the rest of my life?
          Supportive Physical
•   Noise
•   Light
•   Aroma
•   Heights and Distances
•   Simplify
           Supportive Social
•   Preferred companions
•   Sitting as “equals”
•   Clear communication
•   Providing enough time
•   Promoting dignity
       Supportive Techniques
• Ask person’s permission to assist
  – Opening containers
• Use the simplest cutlery
  – Promote finger foods if utensils not used
• Place food where seen
• Provide assistance as needed
  – “Hand-Over-Hand”
  – “Priming the Pump”
• Provide encouragement
       What if the person is not
• Press gently with the spoon on tongue
• Increase distinctness in food flavours, textures
  and temperatures
• If person is holding food in mouth:
  –   tap front of chin or stroke throat
  –   use verbal cueing (e.g. “open, eat, swallow”)
  –   gently massage side of jaw
  –   model an open mouth
  –   tap lips gently with spoon
  –   stroke face with damp cloth
                   Step 6:
                  Oral Care
• Remove particles of food
from patient’s mouth after
each meal.

• Breathing in the contents of an unclean mouth is
  the fastest route to pneumonia because the
  person will have introduced ready-made bacteria
  into the lungs.
     Oral Care and Dementia

• Understanding the challenge:
  – “resistance” does not mean that individual
    does not want their mouth cleaned
  – high risk for oral disease due to challenging
  – dental work is important
            Step 7:
   Proper Resident Positioning
          After Eating
• Have person remain upright for at least 30
  minutes after the meal (if in bed, lower the
  head of bed to 60o).
               Step 8:
           Reporting to Staff
• Report observations, unusual incidents,
  and/or amount of food/liquids
      Coughing/Choking Incidents
• Choking:
   – Partial or complete obstruction of the airway

• If person can speak or cough,
   – Stand by and reassure, but don’t interfere
   – Encourage coughing
   – Do NOT hit the person on the back

• If person is unable to speak or make any sounds, is
  clutching his/her throat, and having extreme breathing
  difficulty, weak or ineffective cough, they are choking

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