Chapter 17: Dysphagia and Malnutrition

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Chapter 17 Dysphagia and Malnutrition
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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.

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Dysphagia

• Prevalence
• 25 and 30 of hospitalized patients
• 4060 of persons in nursing homes
• Swallowing problems increase with age
• Implications
• Greater risk for nutritional deficiencies and
  respiratory problems
• Dehydration and malnutrition predispose persons
  to many medical problems

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Dysphagia

• Warning signs/risk factors
• Oropharyngeal dysphagia usually related to
  neuromuscular impairments affecting the tongue,
  pharynx, and upper esophageal sphincter

Coughing or choking before, during, or after a swallow Difficulty placing food in the mouth Inability to control food or saliva Food sticking in the throat Unexplained weight loss Change in dietary habits Recurrent pneumonia Change in voice or speech (wet voice)
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Dysphagia

• Warning signs/risk factors
• 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
• Oral or pharyngeal regurgitation
• Change in dietary habits

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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
• Cognitive, neuromuscular, and respiratory
  assessment, plus medications

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Dysphagia

• Interventions/strategies for care
• Diet modifications
• Dysphagia diet (pudding, honey thick, nectar
  thick..)
• Oral hygiene
• Adaptive equipment

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• 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)

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• Interventions/Strategies for Care
• Compensatory eating techniques
• Positioning - upright
• Establish arousal and attention
• Assist with head positioning
• Do not rush
• Use small amounts of food - 1/2 teaspoons
• Place food on unaffected side
• Assist with lip closure if needed

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• 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
• Avoid milk and milk products
• Educate person and family
• Thermal stimulation - cold stimulates the swallow
  response
• Follow recommendations of speech therapist (may
  have multiple steps)

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• 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

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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

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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
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Malnutrition

• Factors influencing nutritional risk
• Social
• Isolation
• Loneliness
• Poverty
• Dependency
• Psychological
• Depression
• Anxiety
• Dementia
• Bereavement

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Malnutrition

• Factors influencing nutritional risk (contd)
• 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
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Malnutrition

• Assessment
• Clinical screening tools Mini Nutritional Assess
  (MNA)
• Anthropometric and body composition measures
  Body Mass Index (BMI)
• Laboratory assessments Albumin (lt3.5g/dl) and
  prealbumin (11mg/dl) level
• Clinical data review current meds, oral problem
• Diet history review check food consumed a day.

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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

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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.