1. Enhancing the Mealtime Experience 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

2. Overview Safety and Swallowing Supportive Eating Environment Techniques for Enhancing Mealtimes

3. 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

4. What’s the big deal? A Few Stats… Approx 60% of institutionalized elderly individuals experience some form of swallowing problems For those being fed, 90% have swallowing problems Risk/Complications: Mealtime distress – such as choking, painful swallowing Malnutrition Dehydration Aspiration Pneumonia

5. SAFETY AND SWALLOWING: A Definition of Dysphagia Difficulty swallowing = Difficulty moving food/liquid from mouth to stomach The difficulty may involve the mouth, throat, voice box, and/or esophagus

6. Normal Swallowing Automatic Frequent Necessary

7. Three Swallowing Stages Oral Pharyngeal Esophageal

8. The Effect of Aging on Swallowing Reduced saliva Reduced thirst Reduced sweet & salty taste buds Increased likelihood of reflux Reduced muscle bulk/strength of tongue, facial muscles Reduced cough reflex

9. Dementia and Swallowing Persons with dementia forget how to swallow This is a thinking problem, not a physical problem

10. 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

11. Physical Problems Three places where problems can happen: –Mouth –Throat –Esophagus Symptoms of Dysphagia –Coughing/clearing throat at meals –Pocketing food in mouth after swallowing –Poor ability to chew –Sensation of food being “stuck” –Painful swallowing –No swallowing at all –Wet, gurgly voice or breathing sounds after swallowing

12. 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

13. SAFE SWALLOWING GUIDE 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 SPECIAL INSTRUCTIONS:  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 1: Check for “Silver Spoons Club” symbol

14. Step 2: Proper Resident Position Remember the song “Head and shoulders, knees and toes…” –Seated – hips at 90 o –Head forward, chin down –Body aligned in mid-line position –Knees, ankles at 90 o –Feet and arms supported

15. 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 90 o to seat (no recline or tilt) –Headrest supporting head in midline with chin somewhat forward –Knees bent & feet supported

16. 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

17. Wheelchair Repositioning Be sure that person is sitting upright in chair Repositioning must be done by two staff members

18. Step 3: Food Check Before feeding, check to confirm all food and fluids match diet order ticket

19. 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

20. What’s for supper? Texture - What are the choices? –Soft –Soft/Minced –Minced –Total Minced –Puréed –Blenderized –No Mixed Consistency –Thickened Liquids

21. 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

22. When People Refuse to Eat… Specially made milkshakes Sprinkle artificial sweetener or syrup over foods Give ice cream or pudding with main entrée Finger foods for pacers Placement of food Food available 24 hrs a day

23. High Risk Foods! Foods That May Cause Obstruction in the Airway –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?

24. Step 4: Proper Feeder Position Sit facing patient, at eye level Give spoonfuls from below

25. 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.

26. 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?

27. Supportive Physical Environment Noise Light Aroma Heights and Distances Simplify

28. Supportive Social Environment Preferred companions Sitting as “equals” Clear communication Providing enough time Promoting dignity

29. 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

30. What if the person is not swallowing…? 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

31. 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.

32. 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 behaviour –dental work is important

33. 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 60 o ).

34. Step 8: Reporting to Staff Report observations, unusual incidents, and/or amount of food/liquids

35. Managing 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 –CALL FOR HELP!