SKILLED INTERVENTION FOR A COMMON-AND T ROUBLING-DISORDER
BY SUE CURFMAN, MA, CCC
Adapted with permission from an or iginal article published at www.speechpathology.com.
Research and statistics clearly indicate that dehydration and malnutrition are prevalent and seriou s concerns with skilled nursing facility (SNF) residents. Studies indicate that 54% of all newly admitted SNF r esidents are malnourished; the prevalence of malnourished elderly in SNFs has been reported to range from 20 to 87%. In addition, 60% of all residents experience an initial weight loss following admission.
Many of t he residents in these statistics had a dementia diagnosis, which places them at higher risk for weight loss and dehydration. In addition, current statistics estimate that 60 to 80% of all residents in long-term care have a dementia diagnosis. Thus, adequate nutrition and hydration in a resident with dementia is a central concern fo r all members of the family and healthcare team.
The effect of dementia on nutrition and hydration chang es throughout the course of the degenerative disease process. In the early stage, the individual with de mentia may forget to eat, may become depressed and not want to eat, or may become distracted and leave the tabl e without eating. In the middle stage, the individual with dementia may be unable to sit long enough to eat, yet at this stage may require an additional 600 calories per day because of wandering and motor restlessne ss. In the late stage, the individual with dementia does not have intact oral motor skills for chewing a nd swallowing, thus becoming subject to malnourishment and "wasting away."
This is one reason a facility can benefit from the involvement of a speech-language pathologist (SLP). The role of the SLP will change over time because of the progressive nature of the dementia disease process and its effect on swallowing function an d nutrition. The SLP's goal is the same as Medicare's number one goal in these residents: "facilitating and mai ntaining safety for the resident during swallowing and p.o. intake" (Medicare Transmittal No. 597, Medicare Hos pital Manual). It is imperative that the SLP, as well as the director of nursing and other key members of the c aregiving team, have a solid understanding of dysphagia and appropriate treatment and management techniques spe cific to the disorder. Administrators and other nursing home professionals will also benefit from a general und erstanding of the complexities of caring for these residents.
The goal of assessment for an individual with dysphagia and dementia is to identif y the nature of the dysphagia, identify the contributing factors, differentiate the physiologic impairment and/ or cognitive dysfunction aspects, identify capacity for improved safety, and identify the potential benefit fro m skilled intervention. Specific components of the initial assessment include chart review, resident/caregiver/ nursing interview, sensory function, head and neck positioning, oral motor skills, pattern of mastication, sali vation, and laryngeal elevation. Each of the swallow assessment components are individually reviewed below.
Chart review. The course of recovery or progressive decline found in t he diseases and surgical procedures linked to dysphagia vary widely. Once the disease process contributing to t he dysphagia is identified, the clinician should determine the resident's course of anticipated recovery or dec line. Fortunately, the effect of progressive dementia on swallow function can be fairly predictable. Chart revi ew takes on an even more primary role when the resident's recall or ability to provide information is limited b ecause of memory impairment, dementia, or other language deficits. Therefore, the following information in the medical record should be sought:
- current weight
- recent weight change s
- current and historic therapeutic/altered diets
- current eating habits, including food types an d amounts consumed at scheduled and unscheduled times
- self-feeding skills throughout the course of the meal
- eating and chewing difficulties
- signs/symptoms (from nursing notes) of congestion, coughin g, choking with drinking or taking medications, fever, and lethargy
- x-ray results (e.g., chest and modi fied barium swallow)
- history of pneumonia
Resident/caregiver/nursing inte rview. Two key questions for the resident are: (1) "What are your problems with eating, drinking, an d swallowing?" and (2) "Why do you think you are having a problem with swallowing?" Besides valuable informatio n about the resident's perception of the illness, you can get a sense of the resident's overall cognitive statu s and ability to attend to and follow directions and learn new information. This will influence the nature of t he treatment program.
Many residents with dysphagia as a result of neurologic impairment will be unable to participate in the interview process because of expressive and/or receptive communication problems or cognit ive dysfunction. If so, the necessary information can be obtained from a caregiver or family member who is fami liar with the resident.
Sensory function. It is important to determi ne whether the resident's sensory pathways are intact, intermittently intact, or absent. The following six anat omic sites are assessed to determine this, in this order: