Older Adults Dysphagia and Nursing Care
Dysphagia
Dysphagia is a symptom exhibited by either difficulty swallowing or pain on swallowing that is experienced on a continuum from the inability to move food back in the mouth to a total inability to take nourishment. While the prevalence of dysphagia in the general population is unknown, the risk has been estimated in adults over 50 from 16% to 22%.
The number of nursing home residents requiring extensive to total assistance with eating, sometimes an indicator of swallowing problems, ranges between 17% to 43% pending on the state (Centers for Medicare and Medicaid, 2001; Lindgren & Janzon , 1991 ).
Generally, persons most
likely to be at high risk for dysphagia include persons with head injuries,
stroke, Parkinson's disease, and malignancy of the head and neck (Lind, 2003).
Persons with severe cognitive impairments may simply forget how to eat or may
have accompanying neurological compromise affecting the swallow.
Phases of Swallowing
Swallowing has both voluntary and involuntary phases; the oral stage, where food is masticated and moved back to the pharynx, is under conscious control, and the pharyngeal and esophageal stages, where food is automatically moved through coordinated reflexive actions, is under involuntary control.
Thus, depending on an individual's health problem, such as impairment of the neuro-muscular pathways, structural or connective tissue diseases, or mental disorders ranging from Alzheimer's disease to psychogenic dysphagia, dysphagia may occur anywhere along the route food and fluid take to the stomach .
While aging has been
suggested as a risk factor for dysphagia, there is currently no evidence to
substantiate this claim among healthy older adults and the reasons it is seen
are more likely related to other factors such as poor oral health or adverse
effects of medications .
Diagnosis of Dysphagia
Identification of persons with dysphagia can be a critical assessment that the nurse needs to make early to prevent further problems and start effective treatment for a potentially occult disease.
Accompanying symptoms (Palmer, 2002) associated with all stages of dysphagia include weight loss, dehydration, complaints of food, "sticking" in the throat, change in dietary habits, and drooling, while oral and pharyngeal dysphagia includes a change in voice, coughing, Difficulty initiating a swallow, and coughing or choking with swallow.
Persons with esophageal dysphagia experience recurrent pneumonia. For
some individuals, dysphagia may be temporary and with aggressive rehabilitation
may reverse, for example in the acute stroke victim. However, for persons with
progressive diseases such as dementia and Parkinson's disease, the goal of care
is to maintain functional and safe swallowing for as long as possible.
Ethical Issues In Dysphagia
Ethical issues in dysphagia increased dramatically within the past 5 years as results from large studies began to demonstrate the medical futility of tube feeding in persons with severe cognitive impairments.
As providers of information and counseling to families and caregivers regarding end-of-life decision making, nurses need to be familiar with these findings. While the ethical arguments of "sanctity of life" versus "quality of life" are often at the core of debates regarding use of tube feeding for persons with dementia, the issue may initially present as a safety. problem:
Should someone with a severe cognitive impairment with an ineffective swallow who is losing weight be tube fed? A review of the literature concerning the use of enteral feeding in persons with severe cognitive impairments by Finucane, Christmas, and Travis (1999) demonstrated that much of the justification for use of tubes was not supported by well designed studies: the prevention of the consequences of malnutrition, improved survival, change in pressure ulcer status, decline in risk of infection, improvement of functional status and comfort.
By using a national nursing home database, the Minimum Data Set (MDS), researchers found wide regional variation in use of tube feeding in this impaired population ( Aronheim , Mulvihill , Sieger , Park, & Fries, 2001) and that select organizational characteristics, eg, larger, for-profit homes in urban areas lacking a nurse practitioner, influenced the rate of tube feeding (Mitchell, Teno , Roy, Kabu -moto, & Mor , 2003).
Several national organizations, including the Hospice and Palliative Nurses Association (HPNA) (2003), developed a position statement on the use of artificial nutrition and hydration in which they addressed the point at the end of life when persons are unable to take foods cause of dysphagia or other problems, or resistant foods.
While not advocating for either using or not using tube feedings, the HPNA recommended counseling patients, families, and caregivers concerning the benefits and burdens of this intervention as well as advocating for advance care planning concerning this issue.
Nursing Care
Thus, nurses need to consider causes of dysphagia, the individual's capacity for rehabilitation, prior declarations regarding end-of-life care, and put possible treatments into an evidence-based perspective when they consider this issue in persons with severe cognitive impairments ( Amella , 2003).
Assessment of dysphagia can be accomplished by the nurse through the use of psychometrically sound instruments; two instruments were developed in the past 5 years, the McGill Ingressive Skills Assessment (MISA) (Lambert, Gisel , Groher , & Wood - Dauphinee , 2003) and the Massey Bedside Swallowing Screen (MBSS) (Massey & Jedlicka , 2002).
The MISA addresses a range of criteria positioning, texture management, feeding skills, liquid and solid ingestion, and has. good interrater reliability and internal consistency. However, the testing of the MBSS was criticized for having too broad inclusion criteria, small sample size, and questionable screening criteria (Sasaki & Leder , 2003).
Nurses should not only be assessing who is at risk for dysphagia, but once this is known, who will develop complications. Using MDS data from three states (n=102,842), Langmore , Kimberly, Skarupski , Park, and Fries (2002) sought to determine predictors of aspiration pneumonia, one of the assumed consequences of dysphagia.
In this descriptive study, the researchers found that of the 3% of the residents who had pneumonia (n = 3,118), 18 factors predicted aspiration using a logistic regression model: the highest were suctioning, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), tube feeding, bedfast, case mix index, indicators of delirium, weight loss, and dysphagia/swallowing problems, while interestingly, cerebrovascular accident (CVA) was actually protective (OR=83).
Results of this large study support and refute an earlier 5th year study led by the same author ( Langmore et al., 1998) that examined predictors of aspiration: tube feeding was found to be a predictor of aspiration in both studies, dysphagia was not found to be a predictor in the earlier study while feeding dependence was the strongest predictor in the earlier study but was only mildly predictive in the larger.
Researchers sought to determine if persons who had experienced a stroke were aware of their swallowing problems and would alter theorian, small sample size, and questionable screening criteria (Sasaki & Leder , 2003).
Nurses should not only be assessing who is at risk for dysphagia, but once this is known, who will develop complications. Using MDS data from three states (n=102,842), Langmore, Kimberly, Skarupski , Park, and Fries (2002) sought to determine predictors of aspiration pneumonia, one of the assumed consequences of dysphagia.
In this descriptive study, the researchers found that of the 3% of the residents who had pneumonia (n = 3,118), 18 factors predicted aspiration using a logistic regression model: the highest were suctioning, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), tube feeding, bedfast, case mix index, indicators of delirium, weight loss, and dysphagia/swallowing problems, while interestingly, cerebrovascular accident (CVA) was actually protective (OR=83).
Results of this large study support and refute an earlier 5th year study led by the same author (Lang more et al., 1998) that examined predictors of aspiration: tube feeding was found to be a predictor of aspiration in both studies, dysphagia was not found to be a predictor in the earlier study while feeding dependence was the strongest predictor in the earlier study but was only mildly predictive in the larger.
Researchers sought to determine if persons who had experienced a stroke were aware of their swallowing problems and would alter their eating patterns, thus decreasing complications.
In a descriptive study of 27 persons who were determined to be dysphagic by a speech pathologist, only 3 had awareness of their problem when asked directly (Parker, C., et al., 2004). Poor awareness of swallowing problems also was a predictor at 3 months for persons with more complications.
Westergren, Ohlsson, and Rahm Hallberg (2001) found that among
patients who were admitted to a facility after stroke with swallowing
difficulties (n = 24) and received individualized nursing interventions, the
level of alertness and the energy level of the patients was most predictive of
increased ability to eat and swallow and development of further complications.
Nursing Challenges
It is critical for nurses to examine quality-of-life issues for all persons with impairment in eating and swallowing problems. Several studies (Perry & McLaren, 2003; Merca dante , Casuccio , & Fulfaro , 2000; Sjostrom, Holmberg, & Strang, 2002) showed that among persons with stroke and progressive cancer, dysphagia can be both painful as well as a barrier to the enjoyment of previous activities.
Nursing interventions should facilitate the
social as well as nutritional aspects of meals so that the one of the critical
factors to eating the pleasure of a good meal and good company is not lost.
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