Many residents in LTC have swallowing problems
Swallowing difficulties, also known as dysphagia, occur as a result of direct and indirect damage by numerous diseases to the swallowing muscles. These may be neurological or neuromuscular (28- 64% of persons with stroke, up to 81% with Parkinson’s disease, and 24-34% with MS), structural (tumours, salivary), immunological, environmental, psychological, or social. The severity can vary from mild to severe with any of these causes. Swallowing is complex and involves 26 muscles.
Dysphagia is an uncomfortable, frightening and potentially lifethreatening condition because it interferes with the oral intake of food and liquids; and can lead to aspiration, choking, suffocation, dehydration, malnutrition, decreased quality of life; and frustration for residents, family and staff. Swallowing, eating and chewing problems are common among LTC residents. Up to 70% of residents will have signs of swallowing problems. Signs of swallowing difficulties are usually obvious during meals.
• Coughing when eating or drinking
• Food or liquid spilling from the lips when eating or drinking
• Trouble moving food or liquid around in the mouth
• Prolonged chewing
• Trouble starting to swallow once food or liquid is in the mouth
• Clearing throat when eating or drinking
• Coughing or clearing throat shortly after a meal
• Has a wet or gurgly sounding voice
• Complains feeling that something is “stuck” after swallowing
• Shortness of breath during or right after mealtime
• Has frequent heartburn or bitter taste in the mouth
• Unexplained weight loss
• Recurrent chest infections
• Refusal to eat or reluctance to have food in the mouth
• Pocketing food or liquid in the cheeks or holding food in mouth
Thickened liquidsSome dysphagic residents may have difficulty swallowing thin liquids such as water, coffee , tea and juices. They may have difficulty controlling the liquid in their mouth before swallowing or clearing it during the swallow. Thin liquids may spill into the upper airway before they are ready to swallow, increasing the risk of “aspirating” fluids into the lungs. A cough usually clears the airway but for dysphagic residents their cough may be weak or absent. Aspiration of food may cause blockage in the lungs and could lead to an infection called “aspiration pneumonia”. Even non-dysphagic residents may aspirate when fed if they are tired, lethargic, inattentive or sedated. Thickened liquids often help prevent aspiration pneumonia because they flow slower and allow for the swallowing reflex to be triggered. Pre-thickened products are offered in nectar, syrup or thick texture consistencies. Thickened liquids take longer to digest and they don’t feel as thirst quenching but they do provide hydration as the body digests the product and absorbs almost all the water from it.
Food Aspiration = Aspiration Pneumonia
Aspiration of food or liquid means that residents are at greater risk of developing pneumonia. Aspiration pneumonia rates are highest in LTC homes, up to 44%. Residents dependent for feeding are 20 times more likely to develop aspiration pneumonia. Pneumonia is the second most common infection after urinary tract infection, most common reason for transfer to hospital and a leading cause of death from infection in LTC. Because dysphagic residents have problems starting to swallow or a weakened swallow causing spillage or incomplete clearing of food in the throat, food can then fall into the airway (aspirate) when they start breathing. These large-volume aspirations are of great concern, because chunks of food can block airways and if not cleared, can lead to infection. Pneumonia can also result from aspiration of saliva loaded with oral bacteria (100 million bacteria per 1ml); reflux; weakened immune system; dependency on staff for feeding; and reduced mobility. With recent information on oral hygiene and lower incidence of pneumonia in those receiving regular oral care, providing oral care to residents who are dependent on feeding or on tube feeds could significantly lower the incidence of aspiration pneumonia in LTC.
Other causes of aspiration pneumonia stems from tooth plaque, in those who cannot effectively brush their teeth. Bacteria grows in the plaque, and is inhaled into the bronchial tubes.
Tube feeds do not necessarily prolong life
For many without an appetite, tube feed may prolong a quality of life they may not want to experience. For these reasons, family members must the knowlege of what a loved one would want, expecially those with diseases that have predictable trajectories such as MS, dementia, or bone or stomach cancers.