Chapter 17: Dysphagia and Malnutrition

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.

Dysphagia• Prevalence

– 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

– Dehydration and malnutrition predispose persons to many medical problems

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 swallowDifficulty placing food in the mouthInability to control food or salivaFood sticking in the throat

Unexplained weight lossChange in dietary habitsRecurrent pneumoniaChange in voice or speech (wet voice)

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

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

Dysphagia

• Interventions/strategies for care– Diet modifications

• Dysphagia diet (pudding, honey thick, nectar thick..)

– Oral hygiene

– Adaptive equipment

• 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)

• 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

• 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)

• 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

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

Malnutrition• Implications

– Malnutrition can lead toDelayed wound healingPressure ulcers,Susceptibility to infectionsFunctional declineCognitive declineDepressionDelayed recovery from acute illnessDifficulty in swallowing\ dehydration

Decreased lean body massLessened muscular strength and aerobic capacity, leading to chronic fatigueAlterations in gait and balance, increasing risk for falls and fracturesDeterioration in their overall quality of life and dependence on others

Malnutrition• Factors influencing nutritional risk

– Social

• Isolation• Loneliness• Poverty• Dependency

– Psychological

• Depression• Anxiety• Dementia• Bereavement

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

Malnutrition

• Assessment– Clinical screening tools: Mini Nutritional Assess

(MNA)

– Anthropometric and body composition measures: Body Mass Index (BMI)

– Laboratory assessments: Albumin (<3.5g/dl) and prealbumin (11mg/dl) level

– Clinical data review: current meds, oral problem…

– Diet history review: check food consumed a day.

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

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.