1. EATING AND FEEDING PROBLEMS
Suggestions for Lecturer
-1-hour lecture
-Use GNRS slides alone or to supplement own teaching materials.
-Refer to GNRS and Geriatrics At Your Fingertips for further content.
-For strength of evidence (SOE) levels, see related chapter.
-The GNRS Teaching Slides reflect care that can be provided to older adults in all settings. The words patient, resident, and older adult have been used interchangeably, as have the words provider, clinician, and primary care provider. Given the continually ongoing changes in health care today, some of the guidelines around reimbursement may have changed since publication.

2. OBJECTIVES
Know and understand:
Age-related changes in nutritional health
The fundamental clinical approach to difficulties with feeding

3. TOPICS COVERED
Oral Health
Dysphagia
Feeding and PEG Tubes

4. EATING AND NORMAL AGING
Taste sensation but not discrimination is diminished:
Tendency to add more salt and sweetener (especially sugar) to food
Can still discriminate sweet from salty
Diminished olfactory function further impairs taste sensation
Complaints of taste and smell dysfunction are common in older adults
Drugs may further impair smell and taste

5. COMMON BUT NOT NORMAL
Xerostomia (but salivary function not significantly reduced with aging)
Common medication side effect
Reduced chewing efficiency and efficacy with loss of multiple teeth
Esophageal dysmotility

6. ORAL CAVITY
Dysfunction and disease in the mouth may be important risk factors for nutritional impairment
Increasing age and history of prior restorative dentistry make teeth less sensitive, thereby predisposing to unnoticed and possibly irreparable tooth destruction
Dry mouth, decay, missing teeth, and periodontal disease are common but do not represent normal aging

7. THREE PHASES OF SWALLOWING
Preparatory or oral phase: Voluntary; includes the complex activities of mastication and propelling the food bolus to the back of the mouth toward the pharynx
Pharyngeal phase: Involuntary initiation of the swallow reflex; food propelled into the esophagus
Esophageal phase: Food propelled down the esophagus by the action of skeletal muscle proximally and smooth muscle distally; regulated by its own intrinsic innervation

8. DYSPHAGIA
Oral dysphagia: Difficulty with voluntary transfer of food from mouth to pharynx (eg, due to xerostomia or apraxia in dementia)
Pharyngeal dysphagia: Difficult reflexive transfer of food bolus from pharynx to initiate the involuntary esophageal phase while simultaneously protecting the airway (eg, after stroke)
Esophageal dysphagia: Sensation of food being “stuck” after swallow (eg, in esophageal motility disorder or with mechanical obstruction)

9. Defined as misdirection of pharyngeal contents into the airway
ASPIRATION
Defined as misdirection of pharyngeal contents into the airway
Aspiration pneumonia occurs when an inoculum of bacteria large enough to overcome host defenses arrives in the lung
Normal, healthy people of all ages frequently aspirate small amount, especially during sleep

10. Oral and oropharyngeal fauna
SOURCES OF ASPIRATION
Oral and oropharyngeal fauna
Exacerbated in case of salivary hypofunction, when intrinsic antimicrobial defenses are diminished
Gastric contents (Mendelson’s syndrome)
Usually results in a chemical pneumonitis
Usefulness of prophylactic antibiotics questionable
Most often, local host defenses clear the lung of offending aspirate without serious clinical impact
Aspiration is not prevented by feeding tubes (in fact, tube feeding is a risk for aspiration).

11. ASSESSMENT OF OROPHARYNGEAL DYSPHAGIA
Full bedside evaluation
Videofluoroscopic deglutition examination (VDE) by a speech-language pathologist
A variant of the modified barium swallow
Data conflict regarding the use of VDE and whether subsequent treatment actually reduces the occurrence of aspiration pneumonia or prolongs survival

12. INTERVENTIONS FOR DYSPHAGIA
Swallow therapy:
Compensatory (eg, turn head toward weaker side while swallowing)
Indirect (eg, exercises to improve the strength of the involved muscles)
Direct (eg, exercises to perform while swallowing, such as swallowing multiple times per bolus)
Diet modification: altering bolus size or consistency

13. CHARACTERISTICS OF ALTERED DIET CONSISTENCIES
Prescribed consistency
Description
Solids
Regular or whole foods
Food served as it would be at a restaurant
Cut up
No pieces larger than ½″ cubes
Chopped*
Food chopped into pea-sized pieces no larger than ¼″ cubes
Ground*
Size/consistency of cottage cheese, moist, soft
Pureed*
Smooth, like yogurt or very thick soup
Liquids
Unrestricted
Also known as “thin” liquids with the consistency of water
Nectar
Consistency of tomato juice (usually some thickening agent added)
Honey
Liquid can be poured but slowly (most liquids require addition of thickening agent)
Pudding
Liquids cannot be poured and must be spooned
*Avoid foods that are tough to chew (eg, nuts, seeds, bacon, meat with casing, bagels, popcorn, dried fruits) for any consistency other than regular or cut-up.

14. FEEDING
When older adults experience difficulty eating, the two main approaches are:
Careful feeding by hand: Labor-intensive
Tube feeding: Invasive intervention with its own risks
Data about either are limited; no randomized controlled trials have compared the two directly

15. PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) TUBES
Low procedure-related complication rates; however, long-term studies reveal substantial mortality
No studies demonstrate improved survival, reduced incidence of pneumonia or other infections, improved symptoms or function, or reduced incidence of pressure sores
Median survival after PEG is <1 year
Complications include  risk of aspiration pneumonia, metabolic disturbances, local cellulitis, diarrhea, diminished social contact
A 2009 Cochrane review of tube feeding in patients with advanced dementia found no evidence of a decrease in mortality.
Tube feedings may interfere with the absorption of some medications, eg, levodopa/carbidopa and phenytoin. Time-released medications cannot be crushed for administration through the tube. The only condition for which feeding tubes have been shown to be of clinical benefit to the patient is esophageal obstruction, such as from malignancy.
Consideration of the use of feeding tubes requires careful examination of the data, with a focus on whether there is evidence of clinical benefit to support this invasive and potentially burdensome approach.

16. APPROACH TO FEEDING PROBLEMS
Evaluate for depression
Eliminate unduly restrictive diets and consider individual food preferences
Consider the eating environment to improve socialization and reduce disruptive stimuli
Examine the oral cavity
Determine need for personal assistance with feeding
Reduce or eliminate medications that can cause inattention, xerostomia, movement disorders, or anorexia
Small studies have documented improved clinical outcomes in nursing home residents with the use of flavor enhancers, increased food variety, and attention to the meal ambiance.

17. SUMMARY
Oral health and changes of aging may affect many aspects of health and disease in older adults
Swallowing is an important and complex task that can be affected by both normal aging and diseases that are common in older adults
The use of feeding tubes requires careful examination of the data, with a focus on whether there is evidence of clinical benefit to support this approach

18. CASE (1 of 3)
A 73-year-old man experienced a left hemispheric stroke 2 days ago and has moderate right hemiparesis.
He is alert and able to speak, but his speech is somewhat garbled.
He has been receiving intravenous fluids for hydration, and he indicates that he is hungry.

19. CASE (2 of 3)
Which of the following is the most appropriate initial step in assessing this patient’s ability to eat?
Trial of feeding
Bedside assessment of swallowing function
Videofluoroscopy
Fiberoptic endoscopic evaluation
Trial of neuromuscular electrical stimulation

20. CASE (3 of 3)
Which of the following is the most appropriate initial step in assessing this patient’s ability to eat?
Trial of feeding
Bedside assessment of swallowing function
Videofluoroscopy
Fiberoptic endoscopic evaluation
Trial of neuromuscular electrical stimulation
ANSWER: B
Stroke guidelines recommend assessment of swallowing function in all patients before beginning feeding. A standardized bedside swallowing test has been shown to detect dysphagia after stroke with a sensitivity of 97% and a specificity of 90%. A trial of feeding without prior assessment of swallowing function would increase the risk of aspiration.
Videofluoroscopy and fiberoptic evaluation may be useful if results from the bedside swallowing evaluation are equivocal, but they are expensive and expose the patient to radiation in the first case, and require specialty consultation in the second case. Neuromuscular electrical stimulation may improve swallowing in patients with dysphagia. However, it would be used only after identification of dysphagia in a patient by a bedside assessment and subsequent evaluation by videofluoroscopy.

21. Copyright © 2014 American Geriatrics Society
GNRS4 Teaching Slides Editor: Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF GNRS4 Teaching Slides modified from GRS8 Teaching Slides based on chapter by Colleen Christmas, MD and questions by Daniel Mendelson, MD Managing Editor: Andrea N. Sherman, MS
Copyright © 2014 American Geriatrics Society
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