"It Doesn't Taste Good": A Practical Approach to Eating and ...
Transcript of "It Doesn't Taste Good": A Practical Approach to Eating and ...
“It Doesn’t Taste Good”: A Practical Approach to Eating and Nutrition in the Elderly
Wednesday, April 1, 2009
Heidi Wierman, MD
Kimberly Bassett, MS, CCC/SLP
Outline Review Normal Aging changes, Disease
effect, Medication Effects Nutritional Needs Swallowing Changes Food Preparation/Texture Environmental Considerations Quality of Life Considerations
Appetite/desire, smell
Access to (appropriate, tasty) food
Ability to feed self or be fed
Mouth function: chew, taste
Swallowing
Absorption
Transport of food/waste through body
Normal Nutrition
Nutritional Requirements Individual variation…watch the weight and adjust. Guideline for calories:
Harris-Benedict Equation WHO Estimated Energy Requirement
Guideline for fluid 30 ml/kg/day
Guideline for protein: 1g/kg/day
Varied diet, consider MVI, Calcium/vit D.
Risk Factors for Undernutrition Alcohol or substance abuse Cognitive Dysfunction Decreased activity, functional limitations Depression Low income, limited education Lack of Transportation Medical Problems/Chronic Diseases, Medications Teeth Problems Restricted diet, poor eating habits Social Isolation
Normal Aging Changes Alteration in body composition Thinning of tooth enamel Change in fit of dentures Decrease in saliva production Decrease in gastrointestinal motility Diminished thirst
Normal Changes in Swallow with Age “Presbyphagia”
Oral phase changes are related to changes in muscle strength of face, tongue Decreased lip seal for cup drinking Reduced masticatory strength Piecemeal swallow
Feeding performance does not seem to be significantly affected by these oromotor changes as older adults effectively compensate by changing diet consistency and meal duration
Normal Changes in Swallow with Age Pharyngeal phase changes can be of greater
clinical significance for the oldest old (80+) and include:
Delay in pharyngeal swallow
Reduced pharyngolaryngeal sensory discrimination
Normal Changes in Swallow with Age Esophageal Phase
Studies of age related changes to UES function have been inconclusive
Primary esophageal peristalsis is preserved in the elderly, however, secondary peristalsis is less frequent or absent
Normal Changes in Swallow with Age: 60-80 Years Old Swallow Timing
Longer oral transit times Elderly are more often “dippers” Reduced tongue pressure Longer pharyngeal delay times Inconsistent findings of slower pharyngeal
wall contraction
Normal Changes in Swallow with Age: 60-80 Years Old Safety and Efficiency of Swallow
Penetration occurs more frequently Aspiration occurs no more frequently in
healthy elders Pharyngeal residue is slightly greater in
elderly compared to young adults
Normal Changes in Swallow with Age: 80+ Year Olds Reduced reserve, especially in men
Hyoid and laryngeal maximum vertical movement significantly reduced in oldest old (80+)
Reduced Flexibility Cricopharyngeal opening durations across
volumes reduced in oldest old Cricopharyngeal opening diameter across
volumes reduced in oldest old
Normal Changes in Swallow with Age: 80+ Year Olds
Other Findings in Healthy Dentate Elderly Piecemeal swallowing Premature loss of liquid Oral and pharyngeal residues Penetration
Normal Changes in Swallow with Age:Research Conclusions An older adult’s swallow is not necessarily an
impaired swallow
Healthy older adults exhibit a highly safe and efficient swallow
Older adults are more vulnerable to the effects of acute illnesses and medications and can cross the line from having a normal older swallow to being dysphagic
Effect of Disease on Swallow
It is the increased incidence of cerebrovascular disease and degenerative neurologic disease with aging that is strongly associated with dysphagia in the elderly
Effect of Disease on Swallow Stroke
Type and severity of dysphagia depends on size and location of lesion
Parkinson’s Disease Dysphagia develops in approximately 50% of
patients Alzheimer’s Disease
Primary issue is eating / food management secondary to cognitive decline
Effect of Disease on Swallow ALS
Swallowing deficits emerge when the disease enters the bulbar phase
Muscular Dystrophy Myotonic Occulopharyngeal
Myasthenia Gravis Characterized by global fluctuating muscle fatigue
Multiple Sclerosis Factors most closely related to dysphagia are bulbar
involvement and severity of illness
Effect of Disease on Swallow Head and Neck Cancer
Swallow dysfunction is related to surgical and radiation treatment
Prolonged Mechanical Ventilation Etiology of swallowing dysfunction is
multifactorial
Medication Effects
Diseases/Medication Effects Dryness Decrease in acid production Taste Changes Nausea/Anorexia Speed of eating Ability to feed self Chewing ability Dysphagia
Associated with Dry Mouth (also Constipation)
Drugs used to treat: Depression, Diarrhea/nausea, Hypertension
(diuretics) Anxiety, Asthma (certain bronchodilators), Allergies
and colds (antihistamines and decongestants) Pain, Psychotic disorders, Parkinson's disease Epilepsy Urinary incontinence
Diseases: Sjogren’s Syndrome, Xerostomia, Parkinson’s Disease
Treatment of Dry Mouth Limiting medications that cause, decreasing doses Sucking on sugar-free candy or chewing sugar-free
gum Drinking plenty of water to help keep mouth moist Protecting teeth by brushing with a fluoride
toothpaste, using a fluoride rinse, and visiting your dentist regularly
Breathing through nose, not mouth Using a room vaporizer to add moisture to the air Using an over-the-counter artificial saliva
substitute.
Impairment of Taste Dryness Destruction of taste buds (burn, radiation) Bell’s palsy or surgical destruction of CN VII Sinusitus, Upper Respiratory Tract Infection Head injury Gingivitis Smoking
Medications that alter smell and taste Antibiotics
Ampicillin, Azithromycin, Ciprofloxacin, Clarithromycin, Griseofulvin, Metronidazole, Ofloxacin, Tetracycline
AnticonvulsantsCarbamazepine, Phenytoin
Antidepressants/Mood StabilizerAmitriptyline, Clomipramine, Desipramine, Doxepin, Imipramine, Nortriptyline
Antihistamines and decongestantsChlorpheniramine, Loratadine, Pseudoephedrine
Antihypertensives/CardiacAcetazolamide, Amiloride, Betaxolol, Captopril, Diltiazem, Enalapril, Hydrochlorothiazide, Nifedipine, Nitroglycerin, Propranolol, Spironolactone
Anti-inflammatory agentsColchicine, Dexamethasone, Gold, Hydrocortisone, Penicillamine
AntineoplasticsCisplatin, Doxorubicin, Methotrexate, Vincristine
Antiparkinsonian agentsLevodopa, Sinemet
AntipsychoticsClozapine , Trifluoperazine
Antithyroid agentsMethimazole, Propylthiouracil
Lipid-lowering agentsFluvastatin, Lovastatin, Pravastatin
Muscle relaxantsBaclofen, Dantrolene
ACE inhibitors one of the most common offenders
How to address alterations in taste Re-evaluate medications Treat diseases of the mouth Stop smoking Use spices…salt, herbs, pepper Extra attention to texture, color,
temperature of food.
Individuals with impaired taste, should avoid cooking by taste
Food Preparation and Texture Meals that Appeal
Vary color, texture, temperature Consider offering meals in “courses”, so food
temperatures are maintained for slower eaters Use moulds to improve presentation of blended foods
Small meals The elderly may benefit from being offered frequent
small servings of foods that they like throughout the day Garnish
Add parsley, lemon slices – provides visual appeal
Food Preparation and Texture Food that is easy to eat
Finger foods allow those with cognitive impairments to be more independent
When needed, cut food up into bite sized portions prior to serving
Add flavor enhancers that amplify the intensity of food odor Appealing odors can help to enhance appetite These may be useful for elderly adults with decreased
smell / taste
Environmental Considerations Make Eating a Social Event
For seniors who live alone: Encourage family to bring food to or invite elderly
family member over or out for dinner Take advantage of local “bean suppers”
Set a nice table Establish good lighting Limit distractions
Environmental Considerations For Seniors Who Live in Assisted Living/Nursing
Home Dining room and ambiance Attend to proper seat positioning, access to adaptive
equipment Have a positive attitude toward those with feeding and
swallowing difficulties Take it slow…
Encourage Family members to assist Time of day
Environmental Considerations Attend to Cultural Concerns / Needs
Observe Rituals
Handwashing Saying a blessing
How to improve Appetite Treat depression, constipation, other
issues Encourage physical activity & fluids Consider medications to stimulate
appetite: Remeron Megace (800 mg/day) Dronabinol
Quality of Life Considerations Restrictions: salt, caloric, textures Feeding Tubes Desires versus nutritional needs
Case discussion 82 year old retired physician diagnosed with
Parkinson’s disease in 1989, hospitalized in 1999 for pneumonia: required intubation
MBS 2/19/99 revealed severe oropharyngeal dysphagia characterized by significant pharyngeal pooling and frank aspiration
Underwent PEG placement and was transferred to a SNF for rehabilitation
Received intensive speech therapy and taught to use chin tuck
Case discussion, continued Follow-up MBS 3/26/99 revealed improved
swallow function and started on a blended diet with thin liquids
Transferred to an assisted living facility from SNF
Eventually returned to a regular diet and PEG tube was removed
Ate 2 meals/day in dining room of assisted living facility – enjoyed the social contact
Case discussion, continued Stable for 3 years - returned for an MBS on
4/30/02 due to increased concerns and episodes of choking
Showed a moderate decline in swallowing function with an episode of silent aspiration on thin liquids
Started intensive outpatient speech therapy addressing both swallowing and voice
CASE STUDY, continued Diet consistency modified to soft, moist
consistencies Advised to drink nectar liquids Advised to make sure her sinemet dose
corresponded well with meals and that she try smaller, more frequent meals / day
Continued to go to the dining room – intake and ability to tolerate diet highly variable
Began to lose weight
CASE STUDY, continued Underwent surgery in 2003 and was put on clear
liquids post-operatively Developed an aspiration pneumonia and required
intubation Discharged back to assisted living; suffered
significant weight loss and worsening of dysphagia PEG replaced and received intensive speech therapy
to try to improve swallowing function Transferred to adjacent nursing home
References Bromley, Steven. Smell and Taste Disorders: A Primary Care Approach American Family Physician, Jan 15, 2000 Simmons, Sandra et al. Prevention of Unintentional Weight Loss in Nursing Home Residents: A Controlled Trial of
Feeding Assistance Journal of the American Geriatric Society 56:1466-1473, 2008 www.healthinaging.org/aginingintheknow AGS Foundation for Health in Aging, Chapters on Nutrition, Disorders of the
Mouth, Disorders of the Digestive System. American Geriatric Society Clinical Guideline: Feeding Tube Placement in Elderly Patients with Advanced Dementia Fucile, Sandra et al. Functional Oral-Motor Skills: Do They Change With Age? Dysphagia 13: 195-201 (1998) Youmans, Scott et al. Differences in Tongue Strength Across Age and Gender: Is There a Diminished Strength Reserve?
Dysphagia 24: 57-65 (2009) Leslie, Paula et al. Swallow Respiratory Patterns and Aging: Presbyphagia or Dysphagia? Journal of Gerontology Vol.
60A, No. 3, 391-395 (2005) Yoshikawa, Mineka et al. Aspects of Swallowing in Healthy Dentate Elderly Persons Older Than 80 Years Journal of
Gerontology Vol 60A, No4, 506-509 (2005) Logemann, Jeri et al. Temporal and Biomechanical Characteristics of Oropharyngeal Swallow in Younger and Older Men
Journal of Speech, Language and Hearing Research Vol. 43, 1264-1274 (October 2000) Logemann, Jeri et al. Oropharyngeal Swallow in Younger and Older Women: Videofluoroscopic Journal of Speech,
Language and Hearing Research Vol. 45, 434-445 (June 2002) Achem, Sami et al. Dysphagia in Aging Journal of Clinical Gastroenterology Vol. 39, No 5 (May/June 2005) Schindler, Joshua et al. Swallowing Disorders in the Elderly Laryngoscope 112: April 2002 Wright, l et al. eating Together is Important; Using a Dining Room in and Acute Elderly Medical Ward Increases Energy
Intake Journal of Human Nutrition Dietetics 19: 23-26 (2006)