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Microsoft PowerPoint - Speech Pathology June 17 2008

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Microsoft PowerPoint - Speech Pathology June 17 2008 Powered By Docstoc
					Swallowing and feeding issues
        in the elderly
                 Leora Benjamin
              Speech Pathologist
Normal/Disordered Swallow
Role of the Speech Pathologist
Assessment & Management of Swallowing
Diet/Fluid Modification
Free Fluid Protocol
         The Normal Swallow
Chewing and swallowing are complex functions involving:

  Higher Cortical Functioning
  Approximately 26 muscles in the mouth, pharynx and
  Several muscle sphincters
  6 Cranial Nerves:
                   Trigeminal (5th)
                   Facial (7th)
                   Glossopharyngeal (9th)
                   Vagus (10th)
                   Spinal Accessory (11th)
                   Hypoglossal (12th)
       The Normal Swallow
Swallowing is usually described in three stages:

Oral Stage
Chewing and movement of the material in preparation for
  swallowing reflex initiation

Pharyngeal Stage
Swallowing reflex initiation. Safe passage of the material
  through the pharynx and the cricopharyngeal sphincter
  into the oesophagus. It is at this level aspiration can occur

The Oesophageal Stage
Safe passage of the material through the oesophagus and
  the gastro-oesophageal sphincter into the stomach
          Risks of dysphagia
Weight loss

Malnutrition – Failure to thrive, low energy levels


Aspiration – Chest Infection


Loss of enjoyment of eating/drinking
  Medications and Swallowing
Medication             Examples           Effect
Drugs with anti-       Antidepressants    May delay the swallow reflex
cholinergic activity   Antipsychotics     Tends to dry the mouth throat
                       Antihistamines     and nose
Drugs which impair     Benzos             May cause disorientation,
alertness              Antidepressants    drowsiness and confusion
Anti spastic agents    Buclofen           Impact on muscle function

Antipsychotics         Haliperidol        May interfere with initiation and
                                          control of movements
Role of the Speech Pathologist
SP provides comprehensive evaluation and management for
individuals with Dysphagia. Recommendations and services
are directed toward the prevention, or minimisation, of clinical
risk, including, chest infection.

Speech Pathology Services are provided in conjunction with
the Medical Team including, Doctor, Nurse and Nutrition.

Speech Pathology Management includes:
   Education for patients and carers
   Advice regarding dietary texture and fluid consistency
   Recommendations for safe swallowing/eating including
     exercises & compensatory strategies
             SP Assessment
Holistic assessment eg attention to patient’s communication
skills, cognitive state, insight

Bulbar Examination including status of the reflexes: Cough,
Gag and Swallow

Completion of Videofluoroscopy/FEES as required

Completion of controlled oral intake trials and meal time
evaluation as appropriate
     SP Ax - Videofluoroscopy
Radiological assessment requiring the patients to swallow
  different consistencies of food and fluid with barium added

  Close analysis and diagnosis

  Identification of laryngeal penetration or aspiration

  Trial and analysis of postural strategies

  Identification of structural abnormalities e.g Pouch

  Teaching tool for use with patient / carers
                  SP Ax - FEES
Fiberoptic Endoscopic Evaluation of Swallowing
   FEES is an endoscopic assessment performed by an ENT in
   conjunction with the Speech Pathologist.
   It involves passing a fiberoptic laryngoscope transnasally to
   visualise the hypopharynx, larynx, and proximal trachea.
   Can be used for assessment and treatment
Speech Pathology Management
 Management and Recommendations may include:
      Commencement for oral intake
      Thickened Fluids
      Free Fluid Protocol
      Dietary Texture Modification e.g.
                Smooth Pureed Diet
                Minced and Moist Diet
                Combination Diets
      Safe Swallowing Strategies
      Consideration for NG/P.E.G insertion
      Quality of life Intake
 Patient and Carer Education
 Safe Discharge Planning
Why are patients/residents
 given thickened fluid?
Patients/residents with dysphagia are at risk of developing
aspiration pneumonia because they have poor airway
protection during swallowing

Thickened fluids prevent or reduce the risk of aspiration
because they move through the pharynx more slowly than thin
fluids allowing impaired muscles more time to respond
  Why are patients/residents
   given thickened fluid?
assessment of swallowing
supports this practice
Patients/residents having
thickened liquids complain that
their thirst is not quenched by
thickened fluids. They also
complain the drinks are claggy
in their mouth
Lack of patient, staff, carer and family compliance
Already being done intuitively, especially in settings
where quality of life issues predominate e.g. long
term care and palliative care
Experience demonstrates that when patients
/residents have thin fluid they often don’t develop
    Aspiration pneumonia
Development of aspiration pneumonia may depend on the
features of aspirate
   particulate v’s liquid1
   infective v’s sterile1
   thick fluid v’s thin2
   hypotonic v’s hypertonic solutions3
   amount of aspirate1

1 Johnson & Hirsh 2003 2 Holas et al 1994 3 Effros et al 2000
No strong evidence related to the

efficacy of thickened fluids and the

reduction of aspiration pneumonia
Why consider free water policy?
 Patients/residents don’t want to have, or only want to have
 small amounts of, the types of drinks usually available as
 thickened fluids, eg. fruit juices or milk drinks.

 Many Patients/residents, their families and carers, feel that
 denial of favourite drinks, such as tea or water, impacts
 negatively on the quality of life.
Poor Intake of Fluids
Loss of fluid by conversion to thickened fluids
Thickened fluid recipe inaccuracy
Inability to reach fluids or self feed.
Reduced amount of fluids offered to inpatients prescribed
thickened fluids
Time constraints of nursing staff and oral intake assistance
Evidence related to dehydration
& provision of thickened fluids
 A study of patients admitted to hospital from a Residential
 Care Unit with an acute illness, found that 34% were
 diagnosed as dehydrated
                                      Lavizzo Mourey et al 1988

 In similar study of patients over 70 years old, who were
 admitted to hospital, found that 23% were dehydrated
                                                 Eaton et al. 1994
Evidence related to dehydration
& provision of thickened fluids
 Patients receiving thickened fluids and dysphagia diets failed
 to meet their fluid requirements, whereas patients given IV
 fluids and enteral feeds had enough fluids.
                                            Finestone et al. 2001
 A review of the fluid intake of 40 nursing home residents
 found that while all residents received adequate fluids for
 each day on their meal trays, the fluid intake of many
 residents was inadequate. This problem was more
 pronounced for those given thickened fluids.
                                             Chidester et al. 1997
Evidence related to dehydration
& provision of thickened fluids
 Whelan (2001) looked the fluid intake of patients with
 dysphagia resulting from acute stroke. The results confirmed
 that the intake of thickened fluids was inadequate:
    no patient was able to achieve their daily intake of fluid
    requirement via oral intake alone.
    The mean intake approximated only 2 1/2 hospital cups of
    fluid per day.

 A study by Philip and Greenwood (2000) found that patients
 on thickened fluids were offered approximately 50% less fluid
 than those on free fluid.
Evidence for free water protocol
 A one year randomized-control prospective study by Garon et
 al (1997) compared 2 groups of stroke patients who were
 known to aspirate on thin fluids. The control group of 10 had
 only thickened fluids and the study group of 10 had thickened
 fluids plus free water according to guidelines based on the
 Frazier Rehabilitation Centre “Free Water Policy.’

 They found that there were no instances of pneumonia,
 dehydration or complications in either group. However patient
 satisfaction much better in the study group but only one
 person in the control group was happy with the thickened
     The Free Water Protocol
The following free water protocol has been in use at the Frazier
  Rehabilitation Centre in America, since 1984.

  Any patient on a dysphagic diet may have water.
  All patients are screened with water. Patients who are
  impulsive or cough excessively will be restricted to water
  under strict supervision. Patients with extreme
  choking/discomfort may not be allowed water.
  The water is only permitted between meals (NOT DURING
  MEALS) and allowed half an hour after a meal. This allows
  spontaneous swallows to clear pooled material. Thickened
  fluids are provided with meals.
   The Free Water Protocol
Water is offered to patients throughout the day as long as
they are alert, sitting upright, co-operative.
Strict oral hygiene must be provided so that pathogenic
bacteria are less likely to contaminate secretions.
Medications are never given with water but are given in a
teaspoonful of puree or thickened fluid.
All staff and family members must be educated on the
rationale for allowing water intake.
The evidence regarding the development of aspiration
pneumonia is unclear and there is a need to also consider:
   The range of factors contributing to the development of
   aspiration pneumonia

Decisions regarding the provision of thickened fluids need to
consider safety and quality of life
Artificial/Nutrition & Hydration
 Increased medical knowledge
 Increased technology in artificial nutrition/hydration
 May prolong life in some
 At what cost?
 When is it harmful to the patient?
        Risk/Benefit Analysis
ANH can be potentially harmful

Little or no benefit to patient

Natural decline in metabolic function: body can not utilize
nutrition & hydration
           Literature Review
Terminally ill patients stop wanting food/fluids (Schmitz ’91,
Printz ’88,Zerwekh ’83)
Pts don’t die of starvation but of dehydration (Smith &
Andrews 2000)
Pts report dehydration has an analgesic effect and increases
pt comfort (Post 2001, Smith & Andrews 2000)
2005 Study by Pasman et al
Looked at discomfort in NH pts with severe dementia where
no ANH
Prospective longitudinal study of 178 NH pts
Discomfort measured with the observational Discomfort
Scale- dementia of AD type
Conc. Forgoing ANH in pts with severe dementia who have
reduced oral intake: Not associated with high levels of
  Clinical Case Against Tube
  Feeding in Palliative Care of
the Elderly (I. Campbell-Taylor)
  Pts who are elderly, dysphagic & terminal phase of disease
  NG or PEG poses significant hazards
  Risk of aspiration may be equal or greater than in careful
  spoon feeding
  1. Reflux
  2. Poor oesophageal peristalsis
  3. Incompetent oesophageal sphincters
  4. Slow gastric emptying
  5. Problems with delivery of nutrition
 Pegs in Advanced Dementia
    (Finucane et al 1999)
  Pegs still inserted in pts with advanced dementia
  Aims are to prolong life, provide nutrition, improve functional
  status including skin integrity, prevent aspiration pneumonia
  & reduce suffering
This is not the case:
  1. Invasive procedure with possible complications
  2.Pts did not increase weight or stop LOW
  3.No data to suggest it prevents asp pneumonia
  4. No data to support it improves pressure sores
  5.No data to suggest survival advantage
  6. May increase suffering eg tube leaks, blockages, cellulitis,
  GERD, diarrhea, use of restraints
  7. Adversely effects natural processes such as terminal
Palliative Care in End Stage
Emphasis on symptom control
Dehydration and lack of nutrition rarely causes increased
distress for these types of patients
Generally peaceful deaths
Families need reassurance/education about dying process
Support for families becomes high priority
Clinical category         Clinical           Ethical rationale
                          Guideline          For guideline
                                             Patient unable to
                    Yes   Do not offer PEG   make use of


                          Offer &            Patient unable to
                    Yes   recommend          experience any
vegetative state
                          against PEG        quality of life


Dysphagia without         Offer and
                    Yes                      unequivocally
complications             recommend PEG
                                             benefits from PEG


                                             Patient equivocally
Dysphagia with            Discuss no PEG     benefits from PEG
complications             vs trial of PEG    and potential exists
                                             for loss of QOL
Thank you

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Description: Microsoft PowerPoint - Speech Pathology June 17 2008