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Managing Dysphagia in Dementia: A Timed Snack Protocol

September 1, 2004
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Mini-meals help residents with dysphagia maintain weight and nutritional balance by Faerella Boczko, MS, CCC/SLP

Managing dysphagia in dementia: A timed snack protocol

Recent pilot studies indicate that appropriate snacks attentively provided can produce needed weight gain Documentation clearly shows that acute and chronic ailments associated with advancing age place nursing home residents at increased risk for swallowing disorders. Recent studies have demonstrated that swallowing disorders may affect from 30 to 60% of residents.1,2 Swallowing issues predispose these individuals to malnutrition and its concomitant harmful effects. With weight loss and protein energy undernutrition shown to be strongly correlated with morbidity and mortality in the nursing home population, malnutrition and hydration are considered to be all-too-common problems.1,3

Numerous studies4-6 have evidenced that there is a general decline in food intake with aging that parallels physiological changes in body composition, as well as progressive decreases in the basic functioning of organ systems. Effects of severe weight loss are also evidenced in findings of increased incidence of decubitus ulcers and poor wound healing. The respiratory system is also disturbed, with decreased maximal breathing capacity observed in undernourished residents. Finally, impact on the central nervous system is evidenced in decreased cognition and increased delirium.

In addition to neural and muscular losses, sensory changes that accompany the aging process further affect food intake. A decreased sense of taste and/or olfaction may diminish the palatability of certain foods, resulting in poor appetite; this decline in taste and smell may be compounded by the administration of varied medications.4 Decreased flexibility in physical structures related to swallowing and overall declinations in muscle physiology may also reduce maximal strength and pressure within the oral, pharyngeal, and esophageal systems.6 These physiologic changes may place the elderly at greater risk for developing dysphagia.

The long-term care resident who presents with both dementia and dysphagia poses a unique therapeutic challenge. The pronounced negative effects resulting from the varied number of influences detailed above clearly threaten residents' nutritional status. This led us to undertake our study, the purpose of which was to explore a plan of care that would keep weight loss in this population to a minimum.

We initiated a pilot study at a long-term care facility one year ago aimed at providing a more comprehensive approach to improving residents' nutritional status and encouraging weight gain. Pivotal to this study was the concept of handheld, highly spiced or sweetened snacks treated as a "medication protocol" to ensure both regular delivery and consumption. It was hypothesized that approaching snack intake as medication administration would ensure reliable delivery by staff and promote resident cooperation.

It was also hypothesized that handheld, highly spiced or sweetened snacks would be successfully consumed by this population for a variety of reasons: (1) residents' self- feeding leads to their increased awareness of food; (2) snacks based on residents' preferences (e.g., for sweet or spicy foods) are better tolerated; and (3) consumption of discrete, small amounts of food may serve to satisfy appetite without overloading the system.

The interdisciplinary team members specific to the initial pilot study were identified to include food and nutrition services, nursing, and speech-language pathology (SLP). Food and nutrition services were required to provide handheld, highly spiced or sweetened snacks while maintaining records regarding caloric content. Nursing was responsible for obtaining the pre- and poststudy weights and weekly indications; nursing also provided an in-service to define ways to apply a medication protocol to the distribution of snacks, and was charged with compiling logs to record distribution times and the percentage of food consumed. SLP was required to select the appropriate subjects for the study, provide and collect the daily logs, and coordinate weekly interdisciplinary meetings, as well as problem-solve for instances of resident noncompliance.

Six residents were selected for the first pilot study conducted over a period of four weeks. Participants included three women and three men, ranging in age from 81 to 101 years of age (mean age: 89.5 years). Each individual was presented with three handheld, highly spiced or sweetened snacks per day to be taken as "medication" at specifically timed intervals: two hours post breakfast, two hours post lunch, and two hours post dinner. The snacks were pureed/soft-for example, pureed salami with pureed pickle was spread on white bread with the crust removed; the bread was cut into triangles which were placed in the resident's hand and the hand directed to the mouth. Our purpose was to bombard the oral cavity with increased taste; directing the hand was needed at times because of resident forgetfulness in self-feeding. Residents were weighed at the beginning of the study and then at one-week intervals for its duration to determine if the snacks were successful in increasing body weight. We also sought to determine which method of providing and dispensing the snacks was most efficient.