Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
1 FEEDING AND SWALLOWING 2 OBJECTIVES Know and understand: • Age-related changes in swallowing • The fundamental clinical approach to difficulties with feeding 3 TOPICS COVERED • Swallowing in Health and Disease • Swallowing and Aging • Dysphagia • Aspiration • Assessment of Oropharyngeal Dysphagia • Feeding • Hand Feeding Versus Tube Feeding • Approaches to Nondysphagia Feeding Problems 4 THREE PHASES OF SWALLOWING • 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 5 EATING AND NORMAL AGING • 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 6 COMMON BUT NOT NORMAL • Reduced chewing efficiency and efficacy with loss of multiple teeth; only partially ameliorated by dental prostheses • Sarcopenia can contribute to loss in chewing efficiency and pharyngeal muscle weakness • It is controversial whether aging alone contributes to esophageal dysmotility = Prolonged duration of each swallow 7 DYSPHAGIA • Oral dysphagia: Difficulty with voluntary transfer of food from mouth to pharynx (eg, due to apraxia in dementia) • Pharyngeal dysphagia: Problem with 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) 8 ASPIRATION • Defined as misdirection of oral or gastric contents into the airway • Aspiration pneumonia occurs when an inoculum of bacteria large enough to overcome host defenses arrives in the lung Many healthy individuals episodically aspirate without any important clinical consequences 9 PREVENTION OF ASPIRATION • Aspiration is not prevented by feeding tube placement • In fact, tube feeding is a risk factor for aspiration • It is unclear whether hand feeding is safer than tube feeding • A single nonrandomized prospective comparison showed that hand feeding resulted in lower rates of pneumonia in patients with oropharyngeal dysphagia • No prospective randomized trials have been published ASSESSMENT OF OROPHARYNGEAL DYSPHAGIA • Full bedside evaluation • Videofluoroscopic deglutition examination (VDE) by a speech-language pathologist A variant of the modified barium swallow Therapist may recommend swallow therapy, diet modifications, or both based on results • Nasopharyngeal laryngoscopy by an otolaryngologist 10 11 INTERVENTIONS FOR DYSPHAGIA • 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 CHARACTERISTICS OF ALTERED 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. 12 13 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 PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) TUBES • 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 14 APPROACH TO NONDYSPHAGIA 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 15 16 CHOOSING WISELY • Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding. • Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, provide feeding assistance and clarify patient goals and expectations. 17 SUMMARY • With aging, chewing becomes less efficient, and swallowing is slowed for most healthy 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 18 CASE 1 (1 of 5) • A 75-year old man has gradually lost 4.5 kg (10 lb) over the last 4 months; he was unaware that he had been losing weight • History Ketosis-prone diabetes Esophageal rupture >1 year ago that required creation of a spit fistula (esophagus to chest wall). (Anastomosis of esophagus to stomach was not possible.) Hospital stay included prolonged immobility • Discharged from hospital to nursing home, and has lived there since. Can now propel himself in a wheelchair and ambulate 100 ft with 1 assistant 19 CASE 1 (2 of 5) • Nutrition Bolus of commercially available solution via gastrostomy tube 4 times daily (unchanged since admission to nursing home) With each tube feeding, he has uncomfortable sensation of fullness and fecal urgency, and passes loose, non-bloody stool Never skips a feeding, but often ends it before completion because of fecal urgency 20 CASE 1 (3 of 5) • He reports no palpitations, night sweats, heat or cold intolerance, anxiety, or depression. • Physical examination: unremarkable, beyond weight loss • Lab findings: mild anemia, mild renal insufficiency, hemoglobin A1c is 7.6%. No blood in stool. 21 CASE 1 (4 of 5) Which one of the following is the most likely cause of the patient’s weight loss? A. Inadequate caloric intake B. Malabsorption C. Occult malignancy D. Inadequate control of diabetes 22 CASE 1 (5 of 5) Which one of the following is the most likely cause of the patient’s weight loss? A. Inadequate caloric intake B. Malabsorption C. Occult malignancy D. Inadequate control of diabetes 23 CASE 2 (1 of 4) • A 79-year-old woman has lost approximately 10% of body weight over last 3 months. • History: Alzheimer disease (diagnosed 6 years ago), bowel and bladder incontinence • Medications: senna 2 tablets at bedtime • Has lived in nursing facility for 12 months; primarily wheelchair bound but can transfer with assistance; requires assistance with bathing and dressing • Speech is dysarthric and limited to single words. Demeanor is typically pleasant, and she is often observed to be humming or singing. 24 CASE 2 (2 of 4) • Nutrition Food intake has declined significantly despite modifications to consistency and content of her diet. Family has provided foods that she previously enjoyed. Staff have set up her tray to facilitate her ability to eat. 25 CASE 2 (3 of 4) Which one of the following is the most appropriate next step in managing the patient’s weight loss? A. Program of careful hand feeding B. Referral for placement of gastrostomy tube C. Addition of oral nutritional supplements D. Evaluation for occult malignancy 26 CASE 2 (4 of 4) Which one of the following is the most appropriate next step in managing the patient’s weight loss? A. Program of careful hand feeding B. Referral for placement of gastrostomy tube C. Addition of oral nutritional supplements D. Evaluation for occult malignancy 27 CASE 3 (1 of 4) • An 81-year-old man vomited overnight and has since had a nonproductive cough, rapid breathing, and fever • History: severe intellectual disability and schizophrenia; gastrostomy tube because of severe dysphagia • Lives in a nursing home and is dependent for all activities of daily living. He does not speak. • Physical examination: Appears thin and chronically ill; no sign of respiratory distress Temperature: 38.5°C (101.3°F) Heart rate: 85 bpm Blood pressure: 115/70 mmHg Respiratory rate: 24 bpm O2 saturation 91% on room air Cardiac auscultation: regular rhythm and rate, no murmur. Lung sounds are coarse throughout. 28 CASE 3 (2 of 4) Laboratory findings: WBC 19.2/µL, with 77% neutrophils and 9% bands Hemoglobin10.1 g/dL Hematocrit 31% Platelets 258,000/µL Sodium 139 mEq/L Potassium 3.9 mEq/L Chloride 100 mEq/L Carbon dioxide 26 mEq/L BUN 29 mg/dL Creatinine 0.44 mg/dL Chest radiography shows diffuse mild interstitial prominence, unchanged from prior examinations. 29 CASE 3 (3 of 4) Which one of the following is the most appropriate first-line treatment? A. Ceftriaxone 1 g IM and azithromycin 500 mg via gastrostomy tube B. Clindamycin 450 mg three times daily via gastrostomy tube C. Prednisone 60 mg via gastrostomy tube D. Supplemental oxygen 30 CASE 3 (4 of 4) Which one of the following is the most appropriate first-line treatment? A. Ceftriaxone 1 g IM and azithromycin 500 mg via gastrostomy tube B. Clindamycin 450 mg three times daily via gastrostomy tube C. Prednisone 60 mg via gastrostomy tube D. Supplemental oxygen 31 GRS9 Slides Editor: Tia Kostas, MD GRS9 Chapter Author: Colleen Christmas, MD GRS9 Question Writer: Ian M. Deutchki, MD Managing Editor: Andrea N. Sherman, MS Copyright © 2016 American Geriatrics Society