Download GRS8EatingFeedingProblems

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EATING AND FEEDING
PROBLEMS
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OBJECTIVES
Know and understand:
• Age-related changes in nutritional health
• The fundamental clinical approach to
difficulties with feeding
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TO P I C S C O V E R E D
• Oral Health
• Dysphagia
• Feeding and PEG Tubes
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E AT I N G A N D N O R M A L A G I N G
• 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
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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
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O R A L C AV I T Y
• 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
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T H R E E P H A S E S O F S WA L L O W I N G
• 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
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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)
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A S P I R AT I O N
• 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
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S O U R C E S O F A S P I R AT I O N
• 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
ASSESSMENT OF
O R O P H A RY N G E A L D Y S P H A G I A
• 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
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I N T E RV E N T I O N S F O R D Y S P H A G I A
• 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
C H A R A C T E R I S T I C S O F A LT E R E D
DIET CONSISTENCIES
Prescribed consistency
Solids
Description
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
Honey
Consistency of tomato juice (usually some thickening agent
added)
Liquid can be poured but slowly (most liquids require addition of
thickening agent)
Pudding
Liquids cannot be poured and must be spooned
Nectar
*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.
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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
P E R C U TA N E O U S E N D O S C O P I C
G A S T R O S TO M Y ( P E G ) T U B E S
• 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
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A P P R O A C H 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
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S U M M A RY
• 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
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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.
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CASE (2 of 3)
Which of the following is the most appropriate initial step in
assessing this patient’s ability to eat?
A. Trial of feeding
B. Bedside assessment of swallowing function
C. Videofluoroscopy
D. Fiberoptic endoscopic evaluation
E. Trial of neuromuscular electrical stimulation
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CASE (3 of 3)
Which of the following is the most appropriate initial step in
assessing this patient’s ability to eat?
A. Trial of feeding
B. Bedside assessment of swallowing function
C. Videofluoroscopy
D. Fiberoptic endoscopic evaluation
E. Trial of neuromuscular electrical stimulation
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GRS8 Slides Editor:
Annette Medina-Walpole, MD, AGSF
GRS8 Chapter Author:
Colleen Christmas, MD
GRS8 Question Writer:
Daniel Mendelson, MD
Medical Writers:
Beverly A. Caley
Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2013 American Geriatrics Society