1. Chapter 17: Dysphagia and Malnutrition

2. Learning Objectives Assess for dysphagia at the bedside.
Develop a plan to meet the nutritional and hydration needs of a patient with dysphagia.
Differentiate between anorexia of aging and malnutrition.
Describe the steps necessary to adequately assess an older adult for malnutrition.
Develop a plan to meet the nutritional needs of a homebound older adult suffering from weight loss and malnutrition.

3. Dysphagia Prevalence Implications 25% and 30% of hospitalized patients
40–60% of persons in nursing homes
Swallowing problems increase with age
Implications
Greater risk for nutritional deficiencies and respiratory problems: aspiration pneumonia
Dehydration and malnutrition predispose persons to many medical problems

4. Dysphagia Warning signs/risk factors (p. 625, table 17-2)
Oropharyngeal dysphagia usually related to neuromuscular impairments affecting the tongue, pharynx, and upper esophageal sphincter
Coughing or choking with
swallowing
Difficulty initiating swallowing
Inability to control food or
saliva, Sialorrhea
Food sticking in the throat
Unexplained weight loss
Change in dietary habits
Recurrent pneumonia
Change in voice or speech
(wet voice)
Nasal regurgitation

5. Dysphagia Warning signs/risk factors (p. 625, table 17-2)
Esophageal dysphagia results from motility problems, neuromuscular problems, or obstruction that interferes with the movement of the food bolus through the esophagus into the stomach
Sensation of food sticking in the chest or throat
Oral or pharyngeal regurgitation
Change in dietary habits
Recurrent pneumonia

6. Dysphagia
Assessment
Clinical evaluation of swallowing skills in patients with conditions that predispose to dysphagia or who voice complaints that suggest a swallowing disorder should be a priority for nursing
80% of dysphagia can be diagnosed through a history- “how often do you cough after eating?”
Physical assessment involves Cognitive, neuromuscular, and respiratory assessment, plus medications

7. Dysphagia Interventions/strategies for care Diet modifications
Dysphagia diet (pudding, honey thick, nectar thick..): p. 629 table 17-3, p.630 Table 17-4
Oral hygiene
Adaptive equipment

8. Interventions/strategies for care
Managing Gastroesophageal Reflux Disease
Avoid food or fluids associated with heartburn or discomfort (coffee, spicy foods, fatty foods, citrus fruits, alcohol, and smoking)
Sitting up for at least an hour after eating and/or raising the head of the bed 4 to 6 inches.
Administer an oral proton pump inhibitor 60 minutes before a meal. (Lansoprazole, Omeprazole, Pantoprazole)

9. Interventions/Strategies for Care:
Compensatory eating techniques
Positioning - upright
Establish arousal and attention
Assist with head positioning
Chin slightly tucked
Do not rush
Use small amounts of food - 1/2 teaspoons
Place food on unaffected side
Assist with lip closure if needed
Provide adaptive equipment as needed.

10. Interventions/Strategies for Care:
Compensatory eating techniques (Cont.)
Avoid use of straws (unless recommended by speech therapist)
Provide frequent verbal cues
Use thickener for liquids as recommended (honey, nectar, thin)
Stimulate the swallowing reflex – oral care, menthol, cold food, black pepper,…
Educate person and family
Thermal stimulation - cold stimulates the swallow response
Follow recommendations of speech therapist (may have multiple steps)

11. Non-oral interventions:
G-tubes
PEG tubes
Percutaneous Endoscopic Gastrostomy (PEG) tube
Check abdominal girth for distension
Check residual volumes
Keep upright after feedings
Monitor continually for aspiration
Treat GERD

12. Malnutrition Prevalence
Anorexia of aging is a physiological process that occurs with older age
Increases the risk of developing malnutrition and weight loss with a physical or psychological illness
Malnutrition: a state of being poorly nourished
Sarcopenia
Syndrome of progressive and generalized loss of skeletal muscle mass and strength
Cachexia
Associated with terminal illness

13. Malnutrition Implications Malnutrition can lead to
Delayed wound healing
Pressure ulcers,
Susceptibility to infections
Functional decline
Cognitive decline
Depression
Delayed recovery from acute
illness
Difficulty in swallowing\
dehydration
Decreased lean body mass
Lessened muscular strength
and aerobic capacity, leading
to chronic fatigue
Alterations in gait and balance,
increasing risk for falls and
fractures
Deterioration in their overall
quality of life and
dependence on others

14. Malnutrition Factors influencing nutritional risk Social Psychological
Isolation
Loneliness
Poverty
Dependency
Psychological
Depression
Anxiety
Dementia
Bereavement

15. Malnutrition Factors influencing nutritional risk (cont’d) Biological
Dentition
Loss of taste or smell
Gastrointestinal disorders
Muscle weakness
Dry mouth
Olfaction
Renal disease
Physical disability
Infections
Chronic obstructive pulmonary disease (COPD)
Drug interactions

16. Malnutrition Assessment
Clinical screening tools: Mini Nutritional Assess (MNA)
Anthropometric and body composition measures: Body Mass Index (BMI), serial body weight
Laboratory assessments: Albumin (<3.5g/dl) and prealbumin (<11mg/dl) level
Clinical data review: current meds, oral problem, GI problems, …
Diet history review: check food consumed a day.

18. Malnutrition Evidence-based strategies to improve nutrition
Dietary supplements only for symptomatic nutrient deficiency disease
Real food is better than meal replacements when possible
USDA MyPlate method (figure 17-1, p. 641)
Refer to other health care providers depending on results of nutritional assessment

19. Summary
Malnutrition in older adults is multifaceted and complex. No single tool or clinical marker accurately predicts nutritional status.
A validated nutrition screening tool with anthropometric and laboratory data can give a more accurate picture of nutrition status.
When reversible causes of malnutrition are identified, evidence-based approaches should be used, including referral to other disciplines.