Managing dysphagia in dementia: a timed snack protocol; Recent pilot studies indicate that appropriate snacks attentively provided can produce needed weight gain.

Documentation clearly shows that acute and chronic ailments associated with advancing age place nursing home residents at increased risk for swallowing disorders. Recent studies have demonstrated that swallowing disorders may affect from 30 to 60% of residents. (1,2) Swallowing issues predispose these individuals to malnutrition and its concomitant harmful effects. With weight loss and protein energy undernutrition shown to be strongly correlated with morbidity and mortality in the nursing home population, malnutrition and hydration are considered to be all-too-common problems. (1,3)

Numerous studies (4-6) have evidenced that there is a general decline in food intake with aging that parallels physiological changes in body composition, as well as progressive decreases in the basic functioning of organ systems. Effects of severe weight loss are also evidenced in findings of increased incidence of decubitus ulcers and poor wound healing. The respiratory system is also disturbed, with decreased maximal breathing capacity observed in undernourished residents. Finally, impact on the central nervous system is evidenced in decreased cognition and increased delirium.

In addition to neural and muscular losses, sensory changes that accompany the aging process further affect food intake. A decreased sense of taste and/or olfaction may diminish the palatability of certain foods, resulting in poor appetite; this decline in taste and smell may be compounded by the administration of varied medications. (4) Decreased flexibility in physical structures related to swallowing and overall declinations in muscle physiology may also reduce maximal strength and pressure within the oral, pharyngeal, and esophageal systems. (6) These physiologic changes may place the elderly at greater risk for developing dysphagia.

The long-term care resident who presents with both dementia and dysphagia poses a unique therapeutic challenge. The pronounced negative effects resulting from the varied number of influences detailed above clearly threaten residents' nutritional status. This led us to undertake our study, the purpose of which was to explore a plan of care that would keep weight loss in this population to a minimum.

We initiated a pilot study at a long-term care facility one year ago aimed at providing a more comprehensive approach to improving residents' nutritional status and encouraging weight gain. Pivotal to this study was the concept of handheld, highly spiced or sweetened snacks treated as a "medication protocol" to ensure both regular delivery and consumption. It was hypothesized that approaching snack intake as medication administration would ensure reliable delivery by staff and promote resident cooperation.

It was also hypothesized that handheld, highly spiced or sweetened snacks would be successfully consumed by this population for a variety of reasons: (1) residents' self-feeding leads to their increased awareness of food; (2) snacks based on residents' preferences (e.g., for sweet or spicy foods) are better tolerated; and (3) consumption of discrete, small amounts of food may serve to satisfy appetite without overloading the system.

The interdisciplinary team members specific to the initial pilot study were identified to include food and nutrition services, nursing, and speech-language pathology (SLP). Food and nutrition services were required to provide handheld, highly spiced or sweetened snacks while maintaining records regarding caloric content. Nursing was responsible for obtaining the pre- and poststudy weights and weekly indications; nursing also provided an in-service to define ways to apply a medication protocol to the distribution of snacks, and was charged with compiling logs to record distribution times and the percentage of food consumed. SLP was required to select the appropriate subjects for the study, provide and collect the daily logs, and coordinate weekly interdisciplinary meetings, as well as problem--solve for instances of resident noncompliance.

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Six residents were selected for the first pilot study conducted over a period of four weeks. Participants included three women and three men, ranging in age from 81 to 101 years of age (mean age: 89.5 years). Each individual was presented with three handheld, highly spiced or sweetened snacks per day to be taken as "medication" at specifically timed intervals: two hours post breakfast, two hours post lunch, and two hours post dinner. The snacks were pureed/soft--for example, pureed salami with pureed pickle was spread on white bread with the crust removed; the bread was cut into triangles which were placed in the resident's hand and the hand directed to the mouth. Our purpose was to bombard the oral cavity with increased taste; directing the hand was needed at times because of resident forgetfulness in self-feeding. Residents were weighed at the beginning of the study and then at one-week intervals for its duration to determine if the snacks were successful in increasing body weight. We also sought to determine which method of providing and dispensing the snacks was most efficient.

The purpose of the second pilot study was to determine the efficacy of snack recommendations without the benefit of using a medication protocol to ensure their achievement. Six different residents from the first study were chosen. Criteria for selection by the SLP included a diagnosis of concurrent dementia and dysphagia, as well as a significant weight loss triggering an initial evaluation. Participants included four women and two men, ranging from 80 to 96 years of age (mean age: 88.5 years). Snack recommendations continued to include handheld, highly spiced or sweetened snacks.

During this second pilot study, a medical chart review by the SLP was undertaken six weeks postrecommendation to: (1) determine when and how snack recommendations were initiated by the nutrition team, since they were not on a medication protocol, and (2) confirm the residents' weights at time of the dysphagia evaluation and their weights following two months of intervention. In addition, whether daily snacks were indeed delivered routinely to each individual was assessed.

Results

Results of the first pilot study revealed that four residents gained weight, one maintained pre-study weight, and one lost weight. A review undertaken two weeks poststudy indicated weight gains were maintained. These findings were a positive indicator for continued consideration of the benefits of a timed provision of snacks. In addition, according to a staff survey conducted at the conclusion of the study, most of the nursing staff found that the prescribed protocol for administration of snacks was not excessively time-consuming.

Investigation during the second pilot study revealed that only one of the six patients actually received the recommended snacks as requested: a half sandwich and 4 oz juice daily at 2 pm along with a diet health shake. A weight gain of 1 lb was recorded during the period covered by the study. One other resident demonstrated a weight gain of 2 lbs; this appeared to be related to a diet change made at the time of the dysphagia evaluation, downgrading the resident's diet from a chopped to a ground consistency for improved mastication and bolus control. Of the four remaining residents who received neither snacks nor a diet change, three showed continued weight loss while one individual's weight remained constant.

The fact that the one resident confirmed as receiving snacks on a routine basis during the second pilot study did gain weight is reason to suggest that more must be done to encourage between-meal intake. This finding is also consistent with the earlier pilot study that revealed weight gain for the majority of participants. Comparison of the two studies is nonetheless striking for the significant breakdown in delivery of snacks during the second study and its apparent impact on the results: Without the input of the interdisciplinary team in conjunction with a concerted effort to provide snacks with the deliberateness of a medication protocol, follow-through was critically lacking, and residents lost the opportunity for improved nutritional status and potential weight gain.

The current study supports the following conclusions: An interdisciplinary team is essential to ensure complete follow-through of all nutritional recommendations. In approaching the concept of snacks as "medication," intake can be prescribed by medical personnel to ensure its delivery, as well as encourage a different perspective on the part of the resident who refuses meals. It is critical that the medical and nursing staffs continue to learn about the benefits of maintaining nutrition in this population. In dealing with dysphagia, the SLP must be vigilant in examining all options available to encourage a positive meal experience. While self-feeding as an aspect of positive ADL independence represents an ideal scenario, creative methods must be explored to encourage food intake when self-feeding possibilities are compromised. A need exists for future research to determine appropriate intervention measures that will yield measurable outcomes regarding improvement in the self-feeding ability in residents with dementia. In addition, the weight gain noted in the resident having undergone a diet change supports the importance of offering less-restrictive dietary choices.

Further study should include a larger subject base from which to draw, possibly enlisting several long-term care facilities to participate. An interdisciplinary team should be assembled to ensure complete cooperation and follow-through of all recommendations, with the clear mission and understanding that improved nutritional status is ultimately an integral factor in enhancing quality of life for the elderly.

References

1. Hudson HM, Daubert CR, Mills RH. The interdependency of protein-energy malnutrition, aging, and dysphagia. Dysphagia 2000;15:31-8.

2. Mendez L, Friedman LS, Castell DO. Swallowing disorders in the elderly. Clinics in Geriatric Medicine 1991;7:215-30.

3. Smithard DG, O'Neill PA, Parks C, Morris J. Complications and outcome after acute stroke. Does dysphagia matter? Stroke 1996;27:1200-4.

4. Thomas DR, Morley JE. Anorexia and weight loss in elderly outpatients. Clinics in Geriatric Medicine (supplement) 2000:1-7.

5. Silver AJ, Morley JE, Strome LS, et al. Nutritional status in an academic nursing home. Journal of the American Geriatric Society 1988;36:487-91.

6. McCullough GH. Normal swallowing in the geriatric population. Swallowing and Swallowing Disorders 2001:14-17.

BY FAERELLA BOCZKO, MS, CCC/SLP

Faerella Boczko, MS, CCC/SLP, is Director of Speech-Language Pathology at the Jewish Home and Hospital Life Care System, Bronx, New York. Aresearcher and author, Boczko has 28 years' experience working with the geriatric population. For further information, phone [phone]. To comment on this article, send e-mail to [e-mail]. For reprints in quantities of 100 or more, call [phone].