5 fundamental issue: reduce the risk of aspiration in patients with dementia and dysphagia | Clinical

introduction

As people get older, the muscles involved in swallowing often become weaker. This may explain why swallowing difficulties are relatively common among older people (Rogus-Pulia et al, 2015). Some will be able to handle certain textures and consistencies of foods and liquids, while others will choke with what they eat or drink. Dysphagia (difficulty swallowing) often develops in people with chronic diseases such as dementia. Food, drinks and even saliva can enter the bronchial pathways, potentially resulting in:

• choking;
• Aspiration pneumonia.

The consequences of dysphagia on the health of an individual include:

• Malnutrition;
• Dehydration.

The number of frail elderly people with dysphagia, especially those> 80 years of age, is increasing (Leder and Suiter, 2009). The consequence is an increase in the number of hospitalizations and an increased demand for the health system.

This article discusses the role of the Multidisciplinary Team (MDT) in helping people with dementia and dysphagia to eat and drink, while reducing their risk of aspiration. This involves the implementation of five recommendations – the 5 Fundamental Ms – that I have developed to provide a framework for health professionals working with people with dementia and dysphagia.

Effects of aging and dementia

With age, physiological changes affect all aspects of swallowing, including:

• A reduction of proprioception (perception and awareness of the position and movement of the body);
• Decreased muscle tone and body mbad (muscle weight) in the tongue and lips, reducing the ability to identify texture and viscosity (Hiss et al, 2001);
• Alteration of saliva production;
• Modification of sensory functions of taste and smell;
• Inability to adapt to physiological stressors (eg, infection) due to reduced functional reserve (Smithard, 2016).

Factors such as poor oral health (Razak et al, 2014), loose and / or painful teeth, and poorly fitting prostheses can help reduce oral intake in older adults.

The process of consumption and swallowing requires cognitive awareness, visual recognition of food, physiological response, motor planning and execution, as well as a structured sensorimotor response (Rogus-Pulia et al, 2015) . People with dementia experience apraxia and deficits in attention, initiation, orientation, recognition, executive function, and decision-making; which affects the diet and swallowing. Box 1 highlights the signs of dysphagia to be monitored in people with dementia.

Choose the path of nutrition

Decision making

National guidelines recommend that people with advanced dementia and dysphagia continue to eat and drink, rather than receiving non-oral nutritional support, as this is considered better for their quality of life (Royal College of Physicians, 2010). . Enteral feeding – for example, by nasogastric tube or percutaneous endoscopic gastrostomy tube (PEG) – is intended to reduce the risk of aspiration pneumonia and malnutrition and its sequelae, including starvation and malnutrition. death. However, in 2009, a Cochrane review highlighted the lack of data suggesting that enteral feeding would be beneficial for people with advanced dementia (Sampson et al, 2009).

Existing nonoral nutritional data, based on observational studies, suggest that this does not improve survival or reduce the risk of aspiration. People receiving non-oral nutrition may still develop chest infections due to positioning problems and strong addictions, such as the need to help eat, drink and care for the mouth (Hibberd et al, 2013 Langmore et al, 2002). When PEG tube feeding can be indicated in people with dementia, it is essential to refer to the guidelines, to adopt a multidisciplinary approach when selecting patients and to discuss quality of life (Sanders et al, 2004). In people with advanced dementia, Palecek et al (2010) advocated a "comfort diet" of careful manual feeding, which is a clear alternative to parental feeding.

The choice of the nutrition route should also take into account the badociated risks, such as the surgical risks badociated with the insertion of a gastrostomy and the risk of thoracic infection (which can lead to death). The patient's diagnosis, condition, and personal preferences are also critical to the decision-making process.

Risk of food

The use of oral nutrition despite the risk of aspiration pneumonia may be called "risky feeding". The decision whether to use risk-based feeding should involve discussing the risks and benefits with the individual, his relatives and the PCT. In 2011, a risk management protocol was developed to coordinate and formalize these discussions in the context of acute care (Hansjee, 2018). It provides a person-centered framework for facilitating nutrition decisions, outlines why a person may be a candidate for risky eating, addresses mental capacity and quality of life, and guides discussions. with the PCT, the patient and / or his family.

After discussions, a management plan authorized by the consultant and a speech therapist is put in place. The plan includes recommendations to reduce risk, including an badessment of swallowing performed to determine the safest and least painful diet for the patient.

L & # 39; study

In January 2018, I conducted a small-scale study in a London acute care hospital to determine the preferences of nine patients with mild dementia regarding their nutrition pathway. The severity of their cognitive impairment was established using the abbreviated mental test score (they scored 6 to 8 points) and the mini-mental state exam (they scored 18 to 23 points). ). The mental capacity of participants to make a decision about their nutrition path was established in accordance with the Mental Capacity Act 2005, which is recognized for all.

All participants had some degree of swallowing. They had undergone a swallowing badessment, following which recommendations had been made for diet and fluids.

Participants had the choice to eat and drink with risk of aspiration or being void by mouth and being fed through an enteral tube. They were informed of the risks badociated with both options. All made it clear that they preferred oral nutrition to tube feeding.

Table 1 summarizes the data from the study, including participant comments, which show their willingness to maintain their quality of life.

The 5 fundamental Madame

For people with dementia and dysphagia, the goal of at-risk eating is to maintain their quality of life. Five recommendations – the five basic recommendations (Fig. 1) – provide a framework that can help reduce the risk of aspiration in these patients:

• MDT's participation;
• Moximetry posture;
• Mpreparation before the time;
• Mambulatory care;
• Mcommunication management.

Involvement of the multidisciplinary team

Treating dysphagia in people with dementia involves a problem-solving approach from the various professionals involved in nutritional management and care. This is where a risk-eating protocol and an accompanying policy can help coordinate and formalize team discussions. The wishes of the individual must remain at the forefront of all decisions.

Speech-language pathologists identify the safest and least arduous foods and drinks for each individual. Dietitians work closely with speech therapists to determine if oral intake is sufficient or supplements are needed. Food and fluid recommendations and strategies are disseminated to nurses and support personnel involved with feeding or badisting those meals. Because people at risk are at risk for frequent chest infections, physiotherapists communicate with their physician colleagues to determine the level of thoracic management and the ceiling of care. Pharmacists are alerted to make sure that any medication is provided in a form that is easy to swallow.

Documentation of current and future nutritional management and care decisions is accurate when transferred to another hospital team, general practitioner, nursing home, or health and social services.

Maximize posture

When taking oral food, people should be encouraged to sit in a chair rather than in bed. Indeed, a lying position in the bed can affect the ability to breathe and expectorate. Taking the time to optimize the person's position before eating and drinking is essential. According to Alghadir et al (2017), correct positioning improves the speed and safety of swallowing. A physiotherapist can be consulted on how to improve positioning and posture. The goal is usually to obtain a 90 ° angle at the hips, knees and ankles. The person's head, feet and arms should be supported appropriately.

Beakers are beneficial for some people, but should only be used when recommended by the TLS; they should not be used regularly. Beaker beakers require greater inclination to access the fluid, which can alter the positioning of the neck and cause stress; they can also increase the risk of choking if the person is unable to control the amount of fluid absorbed.

Preparation of the meal

A good meal experience can have a positive impact on a person's nutritional intake and social well-being (Alzheimer Society, 2016). Before meals, food and fluid recommendations should be checked to ensure that appropriate foods and fluids are available. Volunteers do not normally feed people at high risk of aspiration, but they can contribute to the preparation of the environment and / or meal – as such, they must be informed of the needs of the patient. 39, individual and precautions to take.

Patients should be informed of the time and meal that they will take. If they are able to self-feed, the food should be placed in front of them, where it can be seen and reached. The sight and smell of food will stimulate the olfactory and optic nerves, which is the first step in the swallowing process.

People with dementia can take a long time to eat. The staff who helps them to eat needs to keep pace with each person and establish the proper feeding rate and size. Helping hand in hand implies that the caregiver puts his hands on the person's hands and triggers the movement or action, prompting the person to complete it. The technique can be used, where appropriate, to help people self-feed.

People with dementia can become dehydrated because they forget to drink. Placing a cup in front of them is not always enough because they may not know what to do with it. Some people will have to be encouraged to drink; support staff can encourage liquid consumption through social interaction.

Colored cups have been shown to attract the attention of people with dementia (Dementia UK, 2016). However, it is best to avoid dark opaque plastic cups because liquid levels will not be visible. cups made of translucent material and light color shades are preferable. Similarly, colorful plates can increase oral food consumption in people with dementia. According to Chaudhury and Cooke (2014), a red plate consumes 25% more food than a white plate. Occupational therapists may recommend the use of objects such as anti-slip mats, plate guards and utensils tailored to increase their independence.

People with advanced dementia may have difficulty communicating their needs and preferences, which will result in behavior; for example, they may refuse to eat or spit food or drink. It is essential that staff be aware of these issues in order to provide the necessary badistance, supervision and encouragement. Most SLT departments in hospitals offer tailor-made training to caregivers, often tasked with helping patients to feed themselves.

Care of the mouth

The absence of quality oral care (including brushing twice daily) may contribute to ingestion difficulties and exacerbate dehydration, malnutrition and frailty (National Institute for Health and Safety). the excellence of care, 2016). Fragile older people are often dependent on others for oral health care because of functional limb limitations, impaired motor skills, neglect, apraxia and cognitive deficits (Willumsen et al, 2012). Beyond oral deficiencies related to the structure and function of the mouth, mastication, swallowing and saliva control can also be affected (Smithard, 2016). Since oral pathogens are the most likely cause of pneumonia, adequate oral care is essential to reduce the risk of pneumonia (Seedat and Penn, 2016).

A study by Durgude and Cocks (2011) found a lack of nurses' knowledge of the link between oral hygiene, dysphagia and pneumonia, highlighting the need for further training of nurses and caregivers. Good oral hygiene not only improves quality of life and nutrition, but also reduces the occurrence of aspiration pneumonia and, hence, the risk of death (Rosenblum, 2010).

Medication Management

Staff may be tempted to facilitate the ingestion of the tablets by crushing, melting or dispersing their contents, but the modified medication may not be absorbed by the body as it should, with subsequent risks badociated with it. Reduced efficacy and / or increased frequency effects (Royal Pharmaceutical Society, 2011). A qualitative study of drug-related care for people with dysphagia living in health-care facilities revealed that staff were poorly aware of the impact of fraudulent drug handling, reinforcing the need for training in this area (Patients Association, 2015).

Before modifying a medicine, it is advisable to check directly with a pharmacist or general practitioner, or to consult the dashboard of the drug administration for specific instructions. The information must be communicated to other health and care institutions at the time of admission, transfer or discharge.

According to Kelly et al (2011), medication errors are three times more likely to occur in dysphagic patients than in those who do not. In its guidelines on oral health in health care facilities, NICE (2016) recommends identifying ingestion problems as part of the drug review process, which is an integral part of secure drug administration among residents of health care facilities (Morris et al, 2018).

Conclusion

The 5 fundamental questions highlight the need to pay attention to the fundamental areas of care that can improve the quality of life of people with dementia and dysphagia. It is incumbent upon the multidisciplinary team, both in acute care facilities and in communities, to take the initiative to put in place an individualized approach to reduce the risk of aspiration in this area. population.

References:

Alghadir AH et al (2017) Effect of posture on swallowing. Health Sciences in Africa; 17: 1, 133-137.

Alzheimer Society (2016) Eat and drink.

Chaudhury H, Cooke H (2014) Design matters for the treatment of dementia: the role of the physical environment in dementia treatment facilities. In: Downs M, Bowers B (eds) Excellence in dementia care: from research to practice Maidenhead: Open University Press.

Dementia United Kingdom (2016) Tips for eating and drinking with dementia.

Durgude Y, Roosters N (2011) Nurses' knowledge of providing oral care to dysphagic patients. British Journal of Community Nursing; 16: 12, 604-610.

Hansjee D (2018) A model of acute care to guide decisions about food and alcohol consumption in frail elderly people with dementia and dysphagia. Geriatrics; 3: 4, 65.

Hibberd J et al (2013) Can we use influencing factors to predict aspiration pneumonia in the UK? Multidisciplinary respiratory medicine; 8: 1, 39.

Hiss SG et al (2001) Effects of Age, Sex, Bowel Volume, and Trial on Swallowing Duration and Swallowing-Respiratory Phase Relationships in Swallowing Apnea normal adults. dysphagia; 16: 2, 128-135.

Kelly J et al (2011) Medication Delivery Errors in Dysphagic Patients Second Line: Multicenter Observational Study. Journal of Advanced Nursing; 67: 12, 2615-2627.

Langmore SE et al (2002) Predictors of aspiration pneumonia among nursing home residents. dysphagia; 17: 4, 298-307.

Leder SB, Suiter DM (2009) An epidemiological study on aging and dysphagia in the hospitalized population in acute care: 2000-2007. Gerontology; 55: 6, 714-718.

Morris JE et al (2018) Pilot project of a charter to improve medication management and oral care for residents with dysphagia in nursing homes. Geriatrics; 3: 4, 78.

National Institute for Excellence in Health and Care (2016) Oral health for adults in nursing homes.

Palecek EJ et al (2010) Comfort Food Only: A proposal to clarify the decision-making process regarding eating difficulties for people with advanced dementia. Journal of the American Geriatrics Society; 58: 3, 580-584.

Patient Association (2015) Survey of Drug Care for Residents with Dysphagia in Nursing Homes.

Razak PA et al (2014) Oral oral health: an article of synthesis. Journal of International Oral Health; 6: 6, 110-116.

Rogus-Pulia N et al (2015) Understanding dysphagia in dementia: the present and the future. Current reports of Physical Medicine and Rehabilitation; 3: 1, 86-97.

Rosenblum R Jr (2010) Oral hygiene can reduce the incidence and mortality resulting from pneumonia and respiratory tract infection. Journal of the American Dental Association; 141: 9, 1117-1118.

Royal College of Physicians (2010) Difficulties and dilemmas related to oral nutrition: Guide to practical care, especially at the end of life.

Royal Pharmaceutical Society (2011) Pharmaceutical Problems in Crushing, Opening or Splitting Oral Dosage Forms.

Sampson EL et al (2009) Enteral feeding for older people with advanced dementia. Cochrane Database of Systematic Reviews; 2: CD007209.

Sanders DS et al (2004) The placement of PEG in patients with dementia: a controversial ethical and clinical dilemma? [letter]. Gastrointestinal endoscopy; 60: 3, 492.

Seedat J, Penn C (2016) Implementation of oral care to reduce aspiration pneumonia in dysphagic patients in a South African context. South African Journal of Communication Disorders; 63: 1.

Smithard DG (2016) Dysphagia: a geriatric giant? Medical and clinical examinations; 2: 1, 5.

Willumsen T et al (2012) Do nurses or patients have barriers to good oral hygiene in nursing homes? Gerodontology; 29: 2, e748-e755.