Download FeedingandSwallowing.GRS9

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FEEDING AND
SWALLOWING
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OBJECTIVES
Know and understand:
• Age-related changes in swallowing
• The fundamental clinical approach to
difficulties with feeding
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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
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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
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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
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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
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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)
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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
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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
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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.
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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
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
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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
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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.
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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
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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
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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
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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.
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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
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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
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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.
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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.
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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
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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
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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:
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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.
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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.
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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
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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
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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