Older Adults, Neuroplasticity

Question 1

WHO-ICF

Answer 1

Aspiration Pneumonia, dehydration, malnutrition, choking + contextual factors

(swallowing impairment - mealtime performance - social/professional experiences)
*Impacts QOL

Question 2

A Triad of Inter-Related Factors Compromise Mealtime Function and Lead to Poor QOL

Answer 2

Medical Frailty Presbyphagia (normal age related slowing down of swallowing) w/ de-compensation –>

Dementia: Cognitive impairments w/ problem mealtime behaviours –>

Dependent on environmental supports: structured routines & re-direction –>

(In middle: anxiety, frustration, social isolation, apathy)

Question 3

The Medically Fragile Patient

Answer 3

• “At risk”, have one or more chronic diseases w/ at least 1 being terminal.
• those w/ low resistance to infection who lack robustness may be more likely to be dx w/ aspiration pneumonia

Question 4

Common Xtics of Medically Fragile Adult

Answer 4

Malnutrition
Dementia
Depression (mod/severe)
Incontinence
Decreased ability to perform 1 or more ADLs
Difficulty w/ ambulation/coordination
History of falls (>1 in 3 months)
One or more disease processes

Question 5

Medical frailty consists of ______ and _____

Answer 5

Inactivity - reduced energy intake (calories) leading to weight loss

Weight loss - probable malnutrion and dehydration

Question 6

The ability to adapt to stress is called:

Answer 6

Functional reserve

• decreases w/ age
• risk factor for dysphagia when combined w/ poor medical conditions, chronic or acute illness
• Common for older adults to “decompensate” and develop swallowing problem when they are trying to recover from an illness*

Question 7

Sarcopenia:

Answer 7

Age-related loss of muscle mass
-decreased mass = decreased function, decreased reserve
-^ risk of dysphagia and nutritional decline
“use it or lose it principle”

Question 8

4 Major Contributors to Muscle Weakness in Older Adults

Answer 8

1. Age-related muscoloskeletal changes
2. Accumulation of chronic diseases and medications
3. Disuse atrophy
4. Under nutrition

Question 9

Physiologic Impact of Aging on swallowing (risk factor for dysphagia):

Answer 9

PRESBYPHAGIA

• Decreased swallow rates
• Posterior positioning of bolus
• Delayed initiation of swallow (pyriform residue)
• Delayed transit though oral cavity and pharynx
• UES takes longer to relax
• Diminished cough reflex
• Alterations in oral stage (decreased sensory receptions, dentition, etc)

Question 10

Fungal infections (e.g., _____) may be painful and interfere w/ normal swallow.

Answer 10

Oral candidiasis “thrush”
-easily treatable w/ topical antibiotic (important part of differential dx)
Systemic factors: antibiotics, xerostomia, diabetes, irradiation, malnutrition, immunosuppression

-dentures, poor oral hygiene

Question 11

Differential DX of Dysphagia

Answer 11

• swallow decompensated?
• new events (neurologic -sudden [fluids & semi-solids], obstructive - progressive[solids affected])
• psychosocial factors
• combination
• medication changes
• acute infections?

Question 12

Decompensated Swallow

Answer 12

• not severe
• usually for thin fluids only
• compensates once metabolic state normalizes
• ST management
• May require periodic follow up for s/s

Question 13

Respiratory Triad

Answer 13

• ->Respiratory compromise
• -> Dysphagia
• -> Protein Energy Malnutrition (PEM)

*Vicious cycle commonly seen in older adults

Question 14

PEM

Answer 14

Poor nutrition, decreased immune response, decreased metabolic rates, decreased activity level

• -> accelerates weight loss, reduces lean mass
• -> depression, stress reaction, poor QOL
• -> pneumonia, UTIs, bedsores, chronic infection
• -> DEATH (if 20-30% lean muscle mass)

Question 15

Seating and Positioning

Answer 15

Feet on floor
Upright, chin slightly downward
90 degrees in knees and hips
Chair/table should be 13-16 inches from ground for older adult women, most chairs in LTC use 18” (height appropriate for most men)

Question 16

Preventing Pneumonia: Factors Beyond Aspiration

Answer 16

Good oral care
Good feeding techniques
Proper positioning
Overuse of antibiotics
Diet manipulation/thickened liquids
Consistently hand washing by staff
Level of physical activity/mobility
Bed Elevation/Alertness

Question 17

Neuroplasticity:

Answer 17

Set of processes by which the healthy brain encodes experience & learns new behaviours and the damaged brain relearns lost behaviours or learns compensatory bevrs (encompasses both synaptic plasticity and non synaptic plasticity)

Question 18

10 Principles of Neuroplasticity

Answer 18

1. Use it or lost it
2. Use it and improve it
3. Repetition matters
4. Intensity matters
5. Specificity
6. Salience matters
7. Transference
8. Interference
9. Time matters
10. Age matters

Question 19

Principle 1 - Use it or lose it and swallowing

Answer 19

• if NPO after stroke may lose volitional swallowing motor patterns or require “warm up” times
• aspiration is NOT alleviated by tube feeding
• not using their swallowing mechanism can decrease it’s cortical representation
• systematic swallowing drills without a bolus can improve rehab outcomes (dry or saliva only - can use thermal tactile stimulation)

Question 20

Principle 10 - Age matters

Answer 20

Training induced plasticity occurs more readily in younger brains (>65 less plastic)

Question 21

Effective instructional planning includes consideration of:

Answer 21

• generalizable features
• personal factors
• WHO ICF foundations
• environmental factors

Question 22

Effective instructional practice can enhance plasticity by providing:

Answer 22

Intensive practice of functional targets