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Recognizing dysphagia at meals

October 1, 2007
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Swallowing problems affect residents' health and quality of life. Can your staff identify dysphagia?

Most of us look forward to mealtime. It is, of course, an opportunity to eat, but it is also a chance to socialize with others and relax from the day's work or routine. However, for many older adults, eating—and swallowing—is a struggle. Swallowing is mostly an involuntary process that is hardly thought about. On average, a person swallows more than 600 times a day—imagine if you experienced pain with every swallow. Mealtime can be an uncomfortable experience for older adults because of poor dentition, ill-fitting dentures, pain, or dysphagia, a term used to describe a swallowing problem. Approximately 15 million Americans are affected by dysphagia1, which can dramatically influence a person's nutritional status.

Common Eating Problems

Dysphagia is not unusual among older adults living in long-term care facilities. One study2 recorded the presence of mealtime difficulties in nursing home residents and found that nearly 90% had impairments that included dysphagia, poor oral intake, positioning problems, or challenging behaviors. Furthermore, 68% of the residents experienced dysphagia, compromising their ability to enjoy meals, let alone consume the necessary calories to meet nutritional requirements. Dysphagia can lead to aspiration, choking, dehydration, malnutrition, and pneumonia. In fact, aspiration pneumonia is the fifth leading cause of death in people over 60 years of age and the third leading cause of death in people over 80.1 Clearly, food intake is crucial to many residents' health and quality of life.

Residents with dysphagia often require modified diet consistencies, such as thickened liquids or pureed foods. In addition, nursing assistants must often comply with specialized feeding techniques, such as placing food in the non-impaired side of the mouth, limiting the use of straws, or facilitating the use of adaptive feeding equipment. In the dining room, nursing assistants who provide help to, monitor, or feed residents must follow the techniques for the residents' safety and nutritional health. Failure to successfully comply with swallowing and feeding recommendations can cause inadequate hydration and nutrition and unsafe feeding.

Through therapy, a speech-language pathologist can help many residents with dysphagia learn compensatory swallowing techniques. Researchers have found that poor staff training and a lack of understanding about feeding recommendations can cause malnutrition and dehydration in long-term care.3,4McGillivray and Marland conducted a review of the literature on assisting people with dementia during meals.5 Their review found that mealtime assistance is often stressful for residents and staff because feeding becomes task centered and staff have not been sufficiently educated or trained.

As part of their general training, nursing assistants receive education on mealtime atmosphere, techniques to help residents maintain independence, therapeutic diets, how to feed residents, how to identify a choking victim, and the importance of adequate hydration and nutrition. If the swallowing process is addressed at all, it is usually covered briefly. Nursing assistants need to have basic knowledge of how swallowing mechanisms work so that charge nurse can be notified and stop feeding assistance if the process goes awry. Educating nursing assistants about the phases of swallowing and the signs and symptoms of dysphagia is clearly in the residents' best interest.

An in-depth discussion on eating and swallowing should take place after the nursing assistants have had a chance to assist residents with eating and observe those with dysphagia. Then, the staff can apply the new information in a meaningful way to resident care.

The Science of Swallowing

Although swallowing is a complex process that moves food and liquids from the mouth to the stomach (figure 1), it can be simplified and discussed in four phases of activity. Keep in mind that the four phases are not distinct, but rather overlap one another, as many movements occur simultaneously when we chew and swallow. A person can experience a problem during one or all of the phases.

Anatomy of the head and neck

During the oral preparatory phase (figure 2), a person sees, smells, and recognizes the food before opening his or her mouth to take a bite or sip. So before the food even enters the person's mouth, a potential for difficulty with the process exists. This is crucial to remember when working with residents who have a cognitive deficit or who are unable to feed themselves. If someone is not cognitively prepared for food, it could spill back into an unprotected airway before the person realizes that anything is in his or her mouth. As a result, the resident could choke. Once food is recognized, it is placed in the mouth, chewed, and mixed with saliva in preparation for the swallow. During the chewing process, the tongue scoops up the food and places it back on the teeth. It is amazing that we have such a great feedback process that we don't bite our tongues while eating.