Chapter 17: Dysphagia and Malnutrition

Learning Objectives Assess for dysphagia at the bedside. Develop a plan to meet the nutritional and hydration needs of a patient with dysphagia. Differentiate between anorexia of aging and malnutrition. Describe the steps necessary to adequately assess an older adult for malnutrition. Develop a plan to meet the nutritional needs of a homebound older adult suffering from weight loss and malnutrition.

Dysphagia Prevalence Implications 25% and 30% of hospitalized patients 40–60% of persons in nursing homes Swallowing problems increase with age Implications Greater risk for nutritional deficiencies and respiratory problems Dehydration and malnutrition predispose persons to many medical problems

Dysphagia Warning signs/risk factors Oropharyngeal dysphagia usually related to neuromuscular impairments affecting the tongue, pharynx, and upper esophageal sphincter Coughing or choking before, during, or after a swallow Difficulty placing food in the mouth Inability to control food or saliva Food sticking in the throat Unexplained weight loss Change in dietary habits Recurrent pneumonia Change in voice or speech (wet voice)

Dysphagia Warning signs/risk factors Esophageal dysphagia results from motility problems, neuromuscular problems, or obstruction that interferes with the movement of the food bolus through the esophagus into the stomach Oral or pharyngeal regurgitation Change in dietary habits

Dysphagia Assessment Clinical evaluation of swallowing skills in patients with conditions that predispose to dysphagia or who voice complaints that suggest a swallowing disorder should be a priority for nursing 80% of dysphagia can be diagnosed through a history Cognitive, neuromuscular, and respiratory assessment, plus medications

Dysphagia Interventions/strategies for care Diet modifications Dysphagia diet (pudding, honey thick, nectar thick..) Oral hygiene Adaptive equipment

Interventions/strategies for care Managing Gastroesophageal Reflux Disease Avoid food or fluids associated with heartburn or discomfort (coffee, spicy foods, fatty foods, citrus fruits, alcohol, and smoking) Sitting up for at least an hour after eating and/or raising the head of the bed 4 to 6 inches. Administer an oral proton pump inhibitor 60 minutes before a meal. (Lansoprazole, Omeprazole)

Interventions/Strategies for Care: Compensatory eating techniques Positioning - upright Establish arousal and attention Assist with head positioning Do not rush Use small amounts of food - 1/2 teaspoons Place food on unaffected side Assist with lip closure if needed

Interventions/Strategies for Care: Compensatory eating techniques (Cont.) Avoid use of straws (unless recommended by speech therapist) Provide frequent verbal cues Use thickener for liquids as recommended (honey, nectar, thin) Stimulate the swallowing reflex Avoid milk and milk products Educate person and family Thermal stimulation - cold stimulates the swallow response Follow recommendations of speech therapist (may have multiple steps)

Non-oral interventions: G-tubes PEG tubes Percutaneous Endoscopic Gastrostomy (PEG) tube Check abdominal girth for distension Check residual volumes Keep upright after feedings Monitor continually for aspiration Treat GERD

Malnutrition Prevalence Anorexia of aging is a physiological process that occurs with older age Increases the risk of developing malnutrition and weight loss with a physical or psychological illness Malnutrition: a state of being poorly nourished Sarcopenia Syndrome of progressive and generalized loss of skeletal muscle mass and strength Cachexia Associated with terminal illness

Malnutrition Implications Malnutrition can lead to Delayed wound healing Pressure ulcers, Susceptibility to infections Functional decline Cognitive decline Depression Delayed recovery from acute illness Difficulty in swallowing\ dehydration Decreased lean body mass Lessened muscular strength and aerobic capacity, leading to chronic fatigue Alterations in gait and balance, increasing risk for falls and fractures Deterioration in their overall quality of life and dependence on others

Malnutrition Factors influencing nutritional risk Social Psychological Isolation Loneliness Poverty Dependency Psychological Depression Anxiety Dementia Bereavement

Malnutrition Factors influencing nutritional risk (cont’d) Biological Dentition Loss of taste or smell Gastrointestinal disorders Muscle weakness Dry mouth Olfaction Renal disease Physical disability Infections Chronic obstructive pulmonary disease (COPD) Drug interactions

Malnutrition Assessment Clinical screening tools: Mini Nutritional Assess (MNA) Anthropometric and body composition measures: Body Mass Index (BMI) Laboratory assessments: Albumin (<3.5g/dl) and prealbumin (11mg/dl) level Clinical data review: current meds, oral problem… Diet history review: check food consumed a day.

Malnutrition Evidence-based strategies to improve nutrition Dietary supplements only for symptomatic nutrient deficiency disease Real food is better than meal replacements when possible USDA MyPlate method (figure 17-1, p. 641) Refer to other health care providers depending on results of nutritional assessment

Summary Malnutrition in older adults is multifaceted and complex. No single tool or clinical marker accurately predicts nutritional status. A validated nutrition screening tool with anthropometric and laboratory data can give a more accurate picture of nutrition status. When reversible causes of malnutrition are identified, evidence-based approaches should be used, including referral to other disciplines.