common practices of assessing and managing...
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Common Practices of
Assessing and Managing
Dysphagia for Persons with
Dementia
Simon CHAN, Speech Therapist
Prince of Wales Hospital
New Territories East Cluster
12 October 2018
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Dysphagia
Dysphagia means difficulty in swallowing.
Any abnormality in the swallowing process can be defined as
dysphagia.
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Swallowing
Food/liquid mouth pharynx stomach
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Dementia
A syndrome caused by a number of progressive disorders that
affect memory, thinking, behavior, and the ability to perform
activities of daily living (World Alzheimer’s Report, 2010).
Prevalence in Hong Kong (aged 65+): 7.2% (Wu et al., 2018)
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Dementia & dysphagia
Common in moderate dementia (Garon, Sierzant et al. 2009, Suh,
Kim et al. 2009, Humbert, McLaren et al. 2010)
Eating problem: hallmark of end-stage dementia [the ability to eat
independently is generally the last activity of daily activity to be lost
(Mitchell, et al., 2009)]
As dementia progresses, dysphagia becomes more pronounced
[the result of behavior (cognition), sensory, motor problems (or
combination)].
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Seven stages of dementia
Global Deterioration Scale for Assessment of Primary Degenerative
Dementia (GDS)/Reisberg Scale (Reisberg, et al., 1982)
Stages Diagnosis
1: no cognitive decline ---
2: very mild cognitive decline Forgetfulness/age related memory
decline
3: mild cognitive decline Early confusional/mild cognitive
impairment
4: moderate cognitive decline Late confusional
5: moderately severe cognitive
decline
early dementia
6: severe cognitive decline
(Middle dementia)
Middle dementia
7: very severe cognitive decline
(late dementia)
Late dementia
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Dementia & dysphagia
Early dementia: (stage 5 to stage 6)
Taste & smell dysfunction, medication/depression
appetite (Morris & Volicer, 2001)
Advanced dementia: (stage 6 to stage 7)
Problem with self-feeding and dysphagia (Volicer, et al., 1989)
Consequence:
Eating problem with dysphagia malnutrition, weight loss &
aspiration pneumonia (Mitchell et al. 2009; Hoffer, 2006)
Need to decide: careful hand feeding vs tube feeding
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Prevalence of Dysphagia in Dementia
Moderate to severe AD: 84% - 93% (Affoo, Foley et al. 2013)
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Signs of dysphagia
Choking
Drooling/cannot tolerate oral secretion
Pocking of food in cheeks
Delay swallow
Effortful swallow
Multiple swallow for each mouthful
Complaint of food sticking in throat
Prolonged mealtime
Refuse oral feeding
On & off low grade fever
Lots of sputum
Weight loss
Repeated pneumonia
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Dementia & dysphagia
Most frequent feeding problem/dysphagia
Tactile agnosia for food – failure to recognize food as something to swallow
in the mouth
Absent or continuous chewing
Pocketing of food
Spitting food
Multiple swallow
Food refusal
Delayed and impaired pharyngeal swallow
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Management of dysphagia
Speech therapist is responsible for:
Determine presence or absence of dysphagia
Determine underlying causes
Assess severity
Make recommendations, design and implement
rehabilitation plan
Need to achieve a balance between aspiration risk and
QOL
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Assessment of swallowing
Bedside swallowing examination
Instrumental examination:
FEES/FEESST
VFSS
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Bedside swallowing examination
Case/medical history taking
Communication ability/cognitive status screening
Oro-motor structures & functions examination
Swallowing ability with
Different consistencies
Different compensatory strategies
Different delivery system
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Information from bedside examination
Risk of aspiration/silent aspiration
Signs of swallowing dysfunction
Suspected underlying physiology
Means of feeding
Feeding precautions
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Instrumental examination
Purposes:
Objective measures of presence of aspiration
Determine pathophysiology of swallowing
Guide management and rehabilitation
Patients/relatives/staff education
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FEES/FEESST
Fiberoptic Endoscopic Evaluation of Swallowing (with
Sensory Testing)
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FEES/FEESST17
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FEES/FEESST18
photo
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FEES/FEESST19
video
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VFSS
Videofluoroscopic Studies of Swallowing
photo
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VFSS21
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VFSS22
video
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Recommendations
Mode of feeding
Feeding precautions
Swallowing therapy (early stage dementia)
Refer to other specialties if needed
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Mode of feeding
Oral feeding (diet types)
Non-oral feeding
Partial oral feeding
Careful hand feeding/comfort feeding
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American Geriatrics Society Feeding Tubes
in Advanced Dementia Position Statement
(2014)
Feeding tubes are not recommended for older adults with dementia.
Careful hand feeding should be offered.
Efforts to enhance oral feeding by altering the environment and creating
individual centered approaches to feeding should be part of usual care for
older adults with advanced dementia.
Tube feeding is a medical therapy that an individual’s surrogate decision-
maker can decline or accept in accordance with advance directives,
previously stated wishes, or what is thought to individual would want.
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American Geriatrics Society Feeding Tubes
in Advanced Dementia Position Statement
(2014)
It is the responsibility of all members of the healthcare team caring for the
residents in long-term care settings to understand any previous expressed
wishes of the individual.
Institutions should promote choice, endorse shared and informed decision-
making, and honor individuals’ preferences regarding tube feeding.
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Careful hand feeding/Comfort feeding
Definition (2 folds)
Feeding so long as it is not distressing
Goals of feeding are:
Comfort oriented
Least invasive
Potentially most satisfying way of attempting to
maintain nutrition through careful hand feeding.
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Careful hand feeding
Feeding precautions
Flexibility in feeding
Promote comfort rather than adding pain
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Feeding precautions
Before feeding:
oral hygiene
dentures
diet types/thickened liquid
feeding utensils
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Feeding precautions
Before feeding:
proper position
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Feeding precautions
During careful hand feeding: (Li 2002, DiBartolo 2006)
Reminders to swallow
Use of cueing, environment modification and minimizing
distraction
Multiple swallows
Gentle cough after swallow
Bolus size < 1 tsp
Judicious use of thickener
Avoid distraction
Observe for food pocketing
Observe for aspiration signs
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Feeding precautions
After feeding:
Clear food residue
Sit-up x 30min after feeding
Maintain good oral hygiene
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3 hand feeding techniques
Direct hand feeding (DH)
Over hand feeding (OH)
Under hand feeding (UH)
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3 hand feeding techniques
Which is better?
Time spent during meal: similar
DH & UH produced greater intake with less feeding
behaviors observed.
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Feeding technique to promote oral
feeding/maintain nutrition
Provide sensory stimulation over the oromotor area before
and during meal with the use of iced cotton swab or spoon
pressing on tongue
Apply gum massage to normalize sensation for those with oral defensiveness
Assist lip closure during feeding to avoid food spillage and
facilitate oral food manipulation
Use of syringe feeding for those with poor mouth opening for feeding in order to facilitate food delivery to mouth
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Feeding technique to promote oral
feeding/maintain nutrition
Apply light touch to calm down patient’s emotion during
feeding
Alternate feeding of meal with favourite food taste
Provide patients with their favourite food and taste
Small amount and frequent meals
Provide high calorie food
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Dementia feeding program in Shatin
Hospital
A multidisciplinary feeding
program for advanced dementia
patients
Collaboration of Doctors, Nurses,
Dietitians, Speech Therapists, and
Carers
Team members:
Doctor
Nurse
Dietitian
Speech Therapist
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Role of Speech Therapist
Feeding & swallowing assessment, recommend feeding mode and
diet type, advise on feeding techniques/feeding utensils
Identify patient’s food preference
Regular review on patient progress
Share information among the team
Provide caregivers/families education
Weekly team meeting for case management
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Findings:
70 patients recruited (mid-2016 to mid-2018)
Subjects: advanced dementia patients with <50% usual intake for 3
days
Results:
Most patients maintain oral feeding upon discharge (2 resume
tube-feeding)
Improved nutrition (calorie, protein & fluid)
>90% patient’s families/caregivers satisfied with the feeding Mx
(satisfaction survey)
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Conclusions:
Dementia patients are prone to have dysphagia.
Besides oral, non-oral & partial oral feeding, comfort feeding/careful hand feeding can be considered in suitable patients.
Dysphagia management should be patient centered and a team decision making.
The decision-making process regarding oral and non-oral feeding provokes difficult ethical decisions for professionals and patients.
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References:
Affoo, R. H., N. Foley, J. Rosenbek, J. K. Shoemaker and R. E. Martin (2013).
“Swallowing dysfunction and autonomic nervous system dysfunction in
Alzheimer’s disease: a scoping review of the evidence.” J Am Geriatr Soc
61(12): 2203-2213.
American Geriatrics Society Ethics, C., P. Clinical and C. Models of Care
(2014). “American geriatrics society feeding tubes in advanced dementia
position statement.” J Am Geriatr Soc 62(8): 1590-1593.
Batchelor-Murphy MK, McConnell ES, Amella EJ, Anderson RA, Bales CW,
Silva S, Barnes A, Beck C5, Colon-Emeric CS (2017). Experimental
Comparison of Efficacy for Three Handfeeding Techniques in Dementia. J
Am Geriatr Soc. Apr;65(4):e89-e94.
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References:
DiBartolol MC. 2006. Careful hand feeding: a reasonable alternative to PEG
tube placement in individuals with dementia. J Gerontol Nurs 32(5):25-33.
Elanie N.M. Human anatomy & phygiology, 5th ed (2001). Benjamin
Cummings – an imprint of Addison Wesley Longman.
Garon, B. R., T. Sierzant and C. Ormiston (2009). “Silent aspiration: results of
2,000 video fluoroscopic evaluations.” J Neurosci Nurs 41(4): 178-185; quiz
186-177.
HA guidelines on life-sustaining treatment in terminally ill (2015).
Hoffer LJ. Tube feeding in advanced dementia: The metabolic perspective.
BMJ 2006;333:1214-5.
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References:
Humbert, I. A., D. G. McLaren, K. Kosmatka, M. Fitzgerald, S. Johnson, E.
Porcaro, S. Kays, E. O. Umoh and J. Robbins (2010). “Early deficits in cortical
control of swallowing in Alzheimer’s disease.” J Alzheimers Dis 19(4): 1185-
1197.
Li I. 2002. Feeding tubes in patients with severe dementia. Am Family
Physician 65(8):1605-1611.
Mitchell SL, Teno JM, Keily DK, et al. The clinical course ofadvanced
dementia. N Engl J Med 2009;361:1529-38.
Hoffer LJ. Tube feeding in advanced dementia: The metabolic perspective.
BMJ 2006;333:1214-5.
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References:
Morris J, Volicer L. Nutritional management of individuals with Alzheimer’s
disease and other progressive dementias. Nutr Clin Care. 2001; 4:148–155.
Reisberg B et al. The Global Deterioration Scale for Assessment of Primary
Degenerative Dementia. American Journal of Psychiatry.1982;139(9):1136-
1139.
Suh, M. K., H. Kim and D. L. Na (2009). “Dysphagia in patients with dementia:
Alzheimer versus vascular.” Alzheimer Dis Assoc Disord 23(2): 178-184.
Volicer L, Seltzer B, Rheaume Y, et al. Eating difficulties in patients with
probable dementia of the Alzheimer type. J Geriatr Psych Neurol. 1989;
2:188–195.
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References: Yu-Tzu Wu Gemma-Claire Ali Maë lenn Guerchet A Matthew Prina Kit
Yee ChanMartin Prince Carol Brayne. Prevalence of dementia in
mainland China, Hong Kong and Taiwan: an updated systematic
review and meta-analysis. International Journal of Epidemiology,
Volume 47, Issue 3, 1 June 2018, Pages 709–719.
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Thank you!!46