Lecture 3/18

Question 1

Malnutrition

Answer 1

• Loss of body composition (e.g., fats, proteins)
• Primary Malnutrition: decrease in nutrient intake in the absence of underlying disease process (e.g. inadequate food supply or inability to ingest nutrients)
• Secondary Malnutrition: Underlying organic disease process (e.g. malabsorption, due to GI tract or lier disease; excessive secretion)

Question 2

Example of risk for inadequate nutrition and hydration

Answer 2

Cancer and cancer treatments can cause barriers to oral intake.
- Chemotherapy: nausea and vomiting; decreased
appetite; mouth sores and ulcers; diarrhea; transient
dysphagia (e.g., transient cranial nerve damage or
muscle weakness)
- Radiation: xerostomia; inflammation of oral cavity;
esophagitis; hypogeusia or ageusia; odynophagia
- Premature babies, strokes, and surgery

Question 3

Alternative means of nutrition and hydration

Answer 3

• Safe and adequate nutrition and hydration cannot be met by mouth

Successful feedings is crucial for:
 Healthy physical and cognitive development
 Restoration of health following disease and interventions
 Maintenance of health (e.g. GI tract: malnutrition-malabsorption cycle)
 Healthy immune system (malnutrition causes immunodeficiency)

Options:
 Enteral nutrition
 Parenteral nutrition

Question 4

Orogastric Tube

Answer 4

• Tube through oral cavity, pharynx, and esophagus

May be preferred for:
- Infants to prevent even partial obstruction of the nasal
airway (Arvedson & Brodsky, 2002)
- Facial trauma
- Sinusitis

Question 5

Nasogastric (NG) tube

Answer 5

• Tube through nose, pharynx, and esophagus

Example:
- Dobhoff: small bore feeding tube; narrow diameter to minimize irritation in pharynx, UES

Question 6

Disadvantages: Orogastric and NG tubes

Answer 6

Disadvantages:
- removed by patient
- irritation to nose, pharynx, and esophagus
- risk for reflux
- Unsightly
- uncomfortable

• temporary solution

-other tubes: nasoduodenal and nasojejunal

Question 7

Percutaneous Endoscopic Gastrostomy (PEG) Tube

Answer 7

• Surgery requiring local anesthetic creates opening in abdomen into stomach
• Advantage: avoid nasal pharyngeal irritation associated with NG tube
• Disadvantages: more invasive, risk for infection at stoma site, risk for reflux

Question 8

Percutaneous Endoscopic Jejunostomy (PEJ) Tube

Answer 8

Surgery requiring local anesthetic that creates an opening in the abdomen into the small intestine.

Disadvantages:
- more invasive
- risk for reflux remains

Fundoplication: surgery to twist the top of stomach around the LES in reinforce LES in prevent reflux.

Question 9

Cautions

Answer 9

• None alleviate risk of reflux and may even increase
  rate of reflux
• Sites need to be cleaned, monitored for infection and
  leakage
• All can be temporary

Question 10

Weaning

Answer 10

• To induce hunger, hold feedings 1 hour before meal
  or infuse feedings at night only
• End feedings when patient can ingest 65-75% of
  nutrients over 2-3 days via oral feeding
• Dietician should be involved in this process

Question 11

Parenteral nutrition

Answer 11

Total parenteral nutrition (TPN)
- Circumvent gastrointestinal tract
- Intravenous delivery

Indications:
- Very small premature babies
- Short-term intensive nutrition
- Obstruction in or deformation of GI tract
- Inability to absorb nutrients (chronic disease; intractable vomiting; diarrhea; intestinal disease)

Question 12

Disadvantage: Parenteral Nutrition

Answer 12

Total parenteral nutrition (TPN)
Disadvantage: Risk for (bacterial) infection; Premature babies: atrophy of the GI tract

Question 13

Total Parenteral Nutrition

Answer 13

Peripherally Inserted Central Catheter (PICC) line; Inserted via peripheral vein and through to central vein

Question 14

Examples of Risk for Inadequate Nutrition and Hydration

Answer 14

Thickened liquids provide the same amount of free
water as thin water

BUT intake may be limited by
- Dislike of taste (few naturally occurring thick liquids)
- Limited availability

Question 15

Fluids

Answer 15

• Fluid is anything that is in a liquid state at room temperature (includes jello, ice chips and ice cream)
• Non-fluids can contain fluids (e.g. fruit)

Amount of fluid needed is determined by:
- Height
- Weight
- Age
- Gender
- Physiologic activity
- Medical diagnosis
- Medications

Question 16

Aging and fluid balance

Answer 16

• Fluid and electrolyte imbalance is common
• Reduced total body water (45-50%) (reduction in lean
  muscle) and reserve capacities
• Reduced ability to regulate water balance in response
  to changes in condition
• Increased likelihood of onset of disease
• Increased use of medications
• Reduced fluid intake (e.g. due to bladder dysfunction)
• Morbidity and hospitalization

Question 17

Withholding thin liquids results in…

Answer 17

1. Increased risk for dehydration
   Recommendation: 6-8 cups of fluid
   Prevalence: Common in health care especially in elderly (35-85% NH residents) and is often underdiagnosed
   Consequences: Increased risk for morbidity and mortality; Increased risk for UTI, lethargy, constipation, renal failure, development of sores, poor healing of sores
2. Reduced likelihood of “compliance”
3. Reduced quality of life: Unable to quench thirst effectively

Question 18

Aspiration

Answer 18

• Aspiration can be problematic since it is often colonized with pathogens
• It constitutes 5%-15% of the 4.5 million cases of community-acquired pneumonia per year with a mortality rate as high as 21%.5
• Clave et al. (1996) studied patients with stroke/TBI or neurodegenerative diseases, and healthy volunteers using MBSS while swallowing liquid, nectar, and pudding boluses
  ** 21.6% of stroke/TBI had aspiration of liquid into the airway, but was reduced to 10.5% and 5.3% when the diet was modified to nectar and pudding.
  ** 16.2% of neurodegenerative patient had aspiration of liquid into the airway, which was reduced to 8.3% and 2.9% when given nectar and pudding boluses
  ** Thus, thickened liquids significantly improved the MBSS results, leading to a presumptive decrease in the rate of respiratory complications.

But thickening liquids is not always the answer!

Question 19

So, what is so bad about thickening liquids??

Answer 19

• Evidence supporting other forms of treatment (over
  thickening) goes back to the 1990s.
• Depippo et al. (1994) found family instruction on appropriate compensatory swallowing techniques without the use of thickened liquids carried no increased risk of pneumonia, dehydration, malnutrition, or death when compared with thickened liquids.
• Some studies reveal the harm of thickening liquids
• In one study, patients assigned to thickened liquids
  had a higher rate of dehydration (6%-2%), fever (4%-
  2%), and UTIs (6%-3%) than those assigned to thin
  liquids (Robbins et al., 2008)

Question 20

Thickened Liquids and QOL

Answer 20

• Patients perceived QOL is also lower when on
  thickened liquids
• One study found that those started on thickened
  liquids had a significant reduction in their SWAL-
  QOL score by nearly 14 points (Carlaw et al.,
  2012). Patient compliance has been reported to be
  as low as 35% at five days, likely due to this
  impact on QOL (Leiter, 1996).

Question 21

When can thick liquids be helpful?

Answer 21

• In patients who have extreme choking with water intake
• In end-of-life situations, if coughing is so bothersome to
  patients as to be inconsistent with goals of care, then
  thickened liquids for comfort measures may be
  reasonable.
• One study found that combining thickened liquids with
  texture modified diets and intensive training sessions
  with SLPs who focused on swallowing techniques led to
  a reduced risk for aspiration pneumonia during the first
  seven days following stroke
• Since risk reduction did not persist after seven days,
  prolonged modification is likely not helpful.

Question 22

What can we do instead of thickening liquids?

Answer 22

• Access to free water is important for hydration &
  QOL
• Collaborate with patient, team members/family to focus on strategies to prevent aspiration pneumonia via positioning, oral hygiene, and patient and family education

Question 23

Water and Aspiration Pneumonia

Answer 23

• Aspiration of different materials presents different risks for developing aspiration pneumonia
• Aspiration of water is less harmful than water plus
  glucose in rabbits.
• Aspiration of thick liquids and solids results in a
  greater risk for aspiration pneumonia and death than
  aspiration of water
• Aspiration pneumonia may result from aspiration if
  material is pathogenic to lungs and resistance to
  material is compromised

Question 24

Frazier Free Water Protocol

Answer 24

Study by Garon, Engle & Ormiston (1997)

Participants
- 20 patients
- Post CVA
- Aspirated on thin liquids per MBS
- Randomly assigned to 2 groups

Procedure
- Experimental group received thin liquids between meals after rinsing their mouth, thick liquids with meals over 30 days
- Control group received thick liquids between meals and with meals over 30 days
- All participants were monitored for development of aspiration pneumonia

Results
- No participants developed aspiration pneumonia
- Experimental group had significantly greater overall
intake of fluids
- Experimental group reported higher degree of
satisfaction

Limitations
- Small sample size
- Relatively healthy participants

Question 25

Frazier Free Water Protocol (Continued)

Answer 25

Bedside and instrumental swallow study
- If impulsive require supervision
- No water if choking or strict NPO per MD

Water allowed between meals
- Provide aggressive oral care
- At least 30 minutes after a meal if eat by mouth
- Any time if NPO
- Unrestricted quantity
- Use any recommended swallow strategies
- No medication with thin liquid

Question 26

Aspiration, health status and pneumonia

Answer 26

• Dysphagia does not imply aspiration pneumonia
• Why do some patients with dysphagia succumb to
  aspiration pneumonia while others do not’?

Should we focus on
- Aspiration?
- Prevailing health status?
- Both?

Question 27

Predictors of Aspiration PNA (Langmore study)

Answer 27

“Dysphagia by itself is not sufficient to cause
pneumonia” (Langmore, 1998, p.76).

Among the significant predictors of pneumonia
were
- feeding dependency
- oral care dependency
- number of decayed teeth
- more than one medical diagnosis
- number of medications
- presence of smoking

Question 28

Three Pillars of PNA

Answer 28

Pneumonia from Aspiration
- Impaired Health Statues
- High Prevalence of Dysphagia Signs
- Poor oral health status.

**Must consider the presence and severity of all three when determining if your patient is at risk for pneumonia from aspiration or not

Question 29

International Dysphagia Diet Standardization Initiative (IDDSI)

Answer 29

• Provides a level of consistency in terminology
  used to describe dysphagia diets/textures and
  viscosities
• New framework standardized terminology and
  definitions for food textures and liquid thicknesses
• Designed to avoid the confusion created by the
  different names used throughout world to describe
  texture-modified foods and thickened liquids, so as
  to ensure patient safety
• Includes characteristics and examples of food or liquid at each level, testing methods, as well as photos and videos of the testing methods.

Question 30

Tips for Implementation of IDDSI Framework

Answer 30

• Become familiar with IDDSI. (Free app available.)
• Decide who will participate on the implementation/leadership team(s). Typically, head of SLP dept. and the head of clinical nutrition. In others, food service controls new programs (or can be all three).
• Identify who the administrator is who will approve
  commencement of the IDDSI framework implementation at your facility/network.
• Identify the leadership team and then decide who else can support implementation In many settings, SLPs and registered dietitians might fill this role. Some places rely on food service managers for overseeing the process.
• Begin “mapping process’ where you match your menus to IDDSI framework