Transcript Enhancing the Mealtime Experience SWALLOWING

Enhancing the Mealtime
Experience
Presented by:
Heather Jacobson, Speech-Language Pathologist
Madeleine Kunzler, Clinical Dietitian
Lynda Wolf, Occupational Therapist
Contributions by:
Andrea Bellamy, Occupational Therapist
Carole Hamel, Clinical Nurse Specialist
Overview
• Safety and Swallowing
• Supportive Eating Environment
• Techniques for Enhancing Mealtimes
What is required for
successful mealtimes?
– Ability to swallow safely
– Preferred food texture
– Attention to eating
– Ability to get food from plate to mouth
– Supportive environment that facilitates
independent feeding
What’s the big deal?
A Few Stats…
• Approx 60% of institutionalized elderly
individuals experience some form of swallowing
problems
• For those being fed, 90% have swallowing
problems
• Risk/Complications:
• Mealtime distress – such as choking, painful
swallowing
• Malnutrition
• Dehydration
• Aspiration Pneumonia
SAFETY AND SWALLOWING:
A Definition of Dysphagia
• Difficulty swallowing = Difficulty
moving food/liquid from mouth to
stomach
• The difficulty may involve the mouth,
throat, voice box, and/or esophagus
Normal Swallowing
• Automatic
• Frequent
• Necessary
Three Swallowing Stages
• Oral
• Pharyngeal
• Esophageal
The Effect of Aging on
Swallowing
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Reduced saliva
Reduced thirst
Reduced sweet & salty taste buds
Increased likelihood of reflux
Reduced muscle bulk/strength of tongue,
facial muscles
• Reduced cough reflex
Dementia and Swallowing
• Persons with dementia forget how to
swallow
• This is a thinking problem, not a physical
problem
Things you may notice…
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Distorted perception of food
Sorts food and spits out
Chews food longer
Holds food on tongue or in cheeks
Prefers liquids
Does not open mouth to accept food
Physical Problems
• Three places where
problems can happen:
– Mouth
– Throat
– Esophagus
•
Symptoms of Dysphagia
– Coughing/clearing throat at meals
– Pocketing food in mouth after
swallowing
– Poor ability to chew
– Sensation of food being “stuck”
– Painful swallowing
– No swallowing at all
– Wet, gurgly voice or breathing
sounds after swallowing
How to Make Feeding Safer
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Here are the 8 Steps:
1.
2.
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4.
5.
6.
7.
8.
Check for swallowing “care plans”
Proper Resident Position
Food Check
Proper Feeder Position
Appropriate Rate and Amount
Oral Care
Proper Resident Position After Eating
Reporting to the staff
Step 1:
Check for “Silver Spoons Club” symbol
SAFE SWALLOWING GUIDE
PATIENT NAME
DIET:
Pureed with Thick 2 (Honey) liquids
SUCKERS – OK if directly
supervised by family/staff
POSITION: Upright at 90 in bed & at 60
for 30 minutes after meals.
FEEDER POSITION: Sit/stand beside bed at her
eye level
SPECIAL INSTRUCTIONS:
 Approach from RIGHT SIDE.
 Feed slowly – watch adam’s apple move up & down
 Reduce distractions and noise.
 To encourage mouth opening & swallow:
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Light pressure on her tongue
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Touch food to her lips
o
Alternate between liquids and solids
o
Gently massage throat
o
Use cold spoon (dipped in cup of ice)
 WAIT if coughing happens - make sure voice is clear
sounding before continuing to feed.
ORAL CARE: Remove food with moist toothette
Step 2:
Proper Resident Position
• Remember the song “Head and shoulders,
knees and toes…”
– Seated – hips at 90o
– Head forward, chin down
– Body aligned in mid-line position
– Knees, ankles at 90o
– Feet and arms supported
Wheelchair Positioning
• Standard Wheelchair
– May need a support behind the back to
achieve most upright position
– Knees bent & feet supported
• Tilt-in-Space Wheelchair
– Back at 90o to seat (no recline or tilt)
– Headrest supporting head in midline with chin
somewhat forward
– Knees bent & feet supported
Wheelchair Positioning
• Use of Wheelchair Tray
– Use with small wheelchairs to bring tray
where person can see and reach
• If chair too short for person to eat from table
• If person cannot reach food at table
• Use of Overbed Table
– Also brings tray closer
• Make sure person still eats with others
Wheelchair Repositioning
• Be sure that person is sitting upright in
chair
• Repositioning must be done by two staff
members
Step 3:
Food Check
• Before feeding,
check to confirm
all food and fluids
match diet order
ticket
Step 3:
Food Check
• Before feeding, check to confirm all food
and fluids match diet order ticket
• There is no one dysphagia diet
– Individualized
– Proper food order never
exceeds person’s ability to swallow
What’s for supper?
• Texture - What are the choices?
– Soft
– Soft/Minced
– Minced
– Total Minced
– Puréed
– Blenderized
– No Mixed Consistency
– Thickened Liquids
Texture of Food
• Adjusting food texture helps decrease:
– Excessive chewing
– Spitting out of food particles
– Holding of food in mouth
• Method of service:
– Serve foods in cup instead of plate
– Provide straw instead of cup drinking
– Finger foods instead of utensils
When People Refuse to Eat…
• Specially made milkshakes
• Sprinkle artificial sweetener or syrup over
foods
• Give ice cream or pudding with main
entrée
• Finger foods for pacers
• Placement of food
• Food available 24 hrs a day
High Risk Foods!
• Foods That May Cause Obstruction in the
Airway
– Sticky Foods
– Stringy Foods
– Foods with small pits
• Foods That May Increase the Risk of Aspiration
– Foods that DO NOT easily form a bolus
– Foods of 2 or more consistencies
– Thin liquids (risky only if resident restricted to
thickened liquids)
• …Jell-O & ice cream?
Step 4:
Proper Feeder Position
• Sit facing patient, at eye level
• Give spoonfuls from below
Step 5:
Appropriate Rate and Amount
• Give one teaspoon at a time and observe
or feel for swallow before more food or
fluid is given.
Ask Yourself…
• What are mealtimes like here?
• Does the dining room experience look and feel “normal”
or does it feel like a big confusing institution?
• Do mealtimes provide an opportunity for the person with
dementia to be successful?
• Are mealtimes pleasantly social?
• Are residents eating with people they like or are they
distracted or upset by others?
• Are staff engaging residents and calling them by name
during mealtimes?
• Is this a place where I would want to eat my meals
for the rest of my life?
Supportive Physical
Environment
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Noise
Light
Aroma
Heights and Distances
Simplify
Supportive Social
Environment
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Preferred companions
Sitting as “equals”
Clear communication
Providing enough time
Promoting dignity
Supportive Techniques
• Ask person’s permission to assist
– Opening containers
• Use the simplest cutlery
– Promote finger foods if utensils not used
• Place food where seen
• Provide assistance as needed
– “Hand-Over-Hand”
– “Priming the Pump”
• Provide encouragement
What if the person is not
swallowing…?
• Press gently with the spoon on tongue
• Increase distinctness in food flavours, textures
and temperatures
• If person is holding food in mouth:
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tap front of chin or stroke throat
use verbal cueing (e.g. “open, eat, swallow”)
gently massage side of jaw
model an open mouth
tap lips gently with spoon
stroke face with damp cloth
Step 6:
Oral Care
• Remove particles of food
from patient’s mouth after
each meal.
• Breathing in the contents of an unclean mouth is
the fastest route to pneumonia because the
person will have introduced ready-made bacteria
into the lungs.
Oral Care and Dementia
• Understanding the challenge:
– “resistance” does not mean that individual
does not want their mouth cleaned
– high risk for oral disease due to challenging
behaviour
– dental work is important
Step 7:
Proper Resident Positioning
After Eating
• Have person remain upright for at least 30
minutes after the meal (if in bed, lower the
head of bed to 60o).
Step 8:
Reporting to Staff
• Report observations, unusual incidents,
and/or amount of food/liquids
Managing
Coughing/Choking Incidents
• Choking:
– Partial or complete obstruction of the airway
• If person can speak or cough,
– Stand by and reassure, but don’t interfere
– Encourage coughing
– Do NOT hit the person on the back
• If person is unable to speak or make any sounds, is
clutching his/her throat, and having extreme breathing
difficulty, weak or ineffective cough, they are choking
– CALL FOR HELP!