Long-Term Care Survey Alert

Published on Sun Nov 23, 2008 PDF

5 savvy strategies put you on the right path for addressing this difficult issue.

Detecting and managing residents' swallowing problems is another one of those tough balancing acts in the clinical and survey arenas.

The problem: Overzealous use of thickened liquids and mechanically altered diets can lead to dehydration, weight loss, and a poor quality of life for residents. But lack of a systematic dysphagia management program leaves residents at higher risk for choking episodes and aspiration pneumonia.

Solution: A combination of practical, evidence-based strategies promotes optimal outcomes and gives your facility a sound rationale for defending its approach to surveyors and litigators.

Strategy 1: Screen all residents at admission and readmission. "If the person can't communicate a swallowing difficulty, look at hospital records, talk to his family members and perform staff observation," advises Robert Serianni, a speech language pathologist and VP of clinical services for Nyman Associates Inc. in Fort Washington, Pa.

If the person appears to have a swallowing problem, the SLP can perform a bedside swallowing test. "The test looks at the person's oral, motor, speech, language and cognitive function -- and also the person's ability to swallow different textures and liquid consistencies," says Serianni. The therapist might also listen with a stethoscope to the resident's upper airway for sounds signifying liquid penetration or aspiration, he says.

The focus also includes nutritional status, such as dehydration. If people choke a lot when they eat or drink, they may start self-restricting their intake, cautions Serianni.

When to take it to the next step: Serianni sees patients who he knows "without a shadow of doubt" are not at risk for aspiration while others are grossly aspirating. The 75 percent of people who fall in the middle may be candidates for video fluoroscopy, in his view. But timing of such studies is important, he adds. If Serianni thinks the resident has a good chance of failing, he may hold off on referring her for the testing until he sees how well she progresses in speech therapy and moves toward the least restrictive diet.

Strategy No. 2. Teach nursing to recognize residents with signs of swallowing problems. Nurses can identify key factors to trigger a bedside swallowing exam. "Coughing and wheezing during and after a meal is one sign," says Serianni.

Watch for this key clue: Pocketing meds (where a person with dementia tucks pills in his cheek and then hands them back to the nurse) can flag a swallow-cognitive dysfunction, says Serianni. When a cognitively impaired resident starts to do that, you may find she has difficulty with diet textures of a mixed consistently, such as soups, he cautions.

Strategy No. 3: Figure out what's causing or worsening a resident's swallowing problem. For instance, sometimes people have eating habits that worsen or cause swallowing problems, Serianni says.

Example: A resident now in a weakened state may have spent his life working third shift and gobbling up his food in 15 minutes, he says. If you can get the resident to slow down and eat over 30 minutes, he may be able to conserve his energy so he's not aspirating at the end of the meal, Serianni notes.

Positioning problems can also increase the risk of swallowing problems and aspiration. Occupational therapist Jody Niemann reports that sometimes the SLP in her facility finds that residents eating in the dining room have swallowing difficulties because they lean too much to the side or forward. Improving someone's ability to eat independently also helps prevent choking, adds Serianni.

Do a pharmacy review: Look for meds that cause dry mouth, psychotropic meds and anticonvulsants, advises Serianni.

Also make sure the resident with a swallowing difficulty gets appropriate medical evaluation. Geriatrician Daniel Haimowitz, MD, has seen patients develop a swallowing difficulty that's due to a medical problem, such as a tumor or infection. In some cases, specialists may have to get involved, such as a gastrointestinal specialist, or a neurologist, etc., he adds. It could be an ENT issue, or an esophageal Candida infection or a motility problem, says Haimowitz, in Levittown, Pa.

Strategy No. 4: Know the ins and outs of thickened liquids and the chin tuck maneuver. "Thickened liquids tend to decrease the number of episodes of aspiration, but they also decrease the person's water intake, which can lead to dehydration," David R. Thomas, MD, in St. Louis, Mo, tells Eli.

A safe, palatable alternative: Serianni advises using naturally thickened liquids, such as peach nectar and tomato juice. (See "Resident Refusing Thickened Liquids? Try These Simple Workarounds," in the April 2007 Long-Term Care Survey Alert.)

Beware: A person in a weakened state with an irregular swallowing pattern may not be able to tolerate thickened liquids if they cause the person to swallow faster than she can tolerate, thereby increasing the potential for aspiration, advises Joanne Wisely, a speech language pathologist and director of clinical services (SLP) for Genesis Rehabilitation Services in Kennett Square, Pa.

The evidence speaks: Aspiration of water alone is unlikely to cause aspiration pneumonia, Thomas notes. "Thus, allowing water is a new trend in the dysphagia literature," adds Thomas, who wrote an editorial on swallowing disorders in the September 2008 Journal of the American Medical Directors Association (http://www.jamda.com).

The chin tuck maneuver is a swallowing strategy that a person can use to help protect his airway during swallowing, says Serianni. "But you have to be careful to teach that strategy to someone who can learn the technique, and that the technique is appropriate for the difficulties the patient might be having -- it's not a catch-all technique."

Potential snag: One study found poor agreement among SLPs surveyed in the U.S. and Japan about how to define the chin tuck maneuver. "Developing a precise definition is important because various postures may have differing physiologic effects," the authors cautioned (Okada, S et al. Dysphagia. 2007 Jul; 22(3):204-9. Epub 2007 Apr 10).

Strategy No. 5: Focus on improving oral hygiene and dental health for all residents. Thomas notes that studies show that aspiration pneumonia may actually be caused by aspiration of saliva. And "there are good data showing that mouth care may reduce the severity of aspiration pneumonia."

Resource: Read "Improving Oral And Dental Health Can Pay Off In Unexpected Ways," in the Vol. 10, No. 9 issue of Long-Term Care Survey Alert in the free Online Subscription System.