Rethinking Dysphagia Management in Dementia Care
George Barnes MS, CCC-SLP, BCS-S
I recently watched a fascinating course by Jennifer Brush, MA, CCC/SLP, titled “Shifting Our Perspective: Dementia and Dysphagia.” I've been following her work for a while now, and she has blazed a trail in this area. Her insights on patient-centered care for people with dementia have transformed my approach to dysphagia management with this unique population. Below are some BIG takeaways, which are simple, cheap, and can be utilized quickly and easily in your practice. And it'll make a big difference for your patients. We are well-positioned to help this vulnerable population. The content below is based on her career dedicated to researching and adopting evidence-based practices.
The Problem with Thickened Liquids
Jennifer shared her journey, which began with a reluctance to adapt to the status quo of geriatric care and evolved into a passionate advocacy for patient-centered care. She highlighted the limitations of traditional dysphagia practices, particularly the overreliance on thickened liquids. Her background resonates strongly with my experience and is a big motivating factor leading to my career in managing dysphagia in older adults.
As I've written with Dr. Ianessa Humbert, thickened liquids, often seen as a quick fix for swallowing difficulties, can have significant drawbacks. They can be unpalatable, leading to reduced fluid intake and potential dehydration. Additionally, they can impact medication absorption and may not always be the most effective solution for preventing aspiration pneumonia.
Patient-Centered Care: A Holistic Approach
Jennifer emphasized the importance of patient-centered care, particularly for individuals with dementia. Before recommending thickened liquids, we must consider our patients' preferences, needs, and individual goals. We must ask ourselves: Will they drink thickened liquids? Are they at risk for dehydration? What are their quality-of-life priorities?
Beyond Thickened Liquids: Exploring Other Options
Modifying diet consistencies should be the last step, not the first. Here are some other, often more effective options for managing dysphagia:
- Postural changes: head positions or propping the patient upright can help improve swallow safety and efficiency.
- Compensatory strategies: Can we utilize a 3-second oral hold or the Mendelsohn maneuver? How about the supraglottic swallow? Or the SUPER supraglottic swallow? What about something simple like drinking slowly or swallowing twice for each bolus?
- Swallowing exercises: Strengthening the muscles can be a great way to rehabilitate the swallow directly and pave the way for continued progress.
- Assistive devices: Can help patients with limited mobility or coordination eat and drink more independently.
The Impact of Lighting
Older, healthy adults need THREE TIMES of light to see effectively. Can we blame patients for not eating if they can't know where the food is on their plate? Lighting can be a quick, easy, and cheap fix to this problem. Jennifer conducted her study on this issue and found that increasing lighting levels resulted in a statistically significant increase in food intake for people with dementia. What can be easier than that? Change out some of the bulbs and turn on a switch. This will make a huge difference for everyone eating in the dining room. This highlights the importance of considering the environment as an integral part of dementia care. While we can't always improve function, especially when the condition is degenerative, we can consider how to adapt the patient's environment to fit their needs best. It's like being stuck in a rainstorm. Sure, having an off switch would be wonderful, but until we figure that out, let's invest in a good umbrella to keep us dry.
Spaced Retrieval: An Effective Memory Intervention
For the longest time, I thought working on memory for patients with dementia was unethical. I was told there is no chance of recovery, so we shouldn't consider providing the service. But that couldn't be further from the truth. People with dementia can improve and, at the very least, can maintain the function they do have. When working directly on memory, Jennifer advocates for research-based intervention, such as spaced retrieval. This technique involves practicing recalling information over progressively longer intervals, helping individuals with dementia improve their memory and cognitive function. The strategy utilized in the research consists of doubling the time between the reminder and the recall every time they can successfully recall the information. People with dementia can learn and grow toward their goals. One good way to implement this intervention is with safety strategies during and outside meals to improve a patient's ability to live a relatively independent life. That's a goal worth striving towards.
The Importance of Choice and Control
People need control. They want and deserve some level of independence and choice in their lives. For many, without this independence, life would be stale and colorless. Jennifer highlights the significance of providing choices and control to individuals with dementia. She gives the phenomenal example of a nursing home talking to the residents and figuring out their favorite food, obtaining the recipe, and then cooking each person's favorite meal a few times to get everyone excited about eating. This gives people a sense of control in their lives and a sense of meaning. Research has shown that offering choices in daily routines and activities can improve quality of life, reduce agitation, and increase engagement. For instance, allowing residents to choose their meals, dining times, and who they eat with can significantly enhance their dining experience. Remember going to school as a kid? Could you imagine if you had assigned seating in the lunch room and had to sit next to the smelly kid who constantly called you names? We wanted control then, and we still like it now. We wish to have it and will have earned it when we grow older.
Minimizing Background Noise
Recently, I went to dinner inside a crowded restaurant playing loud music. I literally could not hear what my wife was trying to say to me. I couldn't even hear what I was trying to tell her. This is not my idea of a good time; honestly, it led to a pretty terrible dining experience. It's hard to have an appetite for your food when your food is bumping to the beat of Taylor Swift. What you may not know is that one out of three older adults has hearing loss, and hearing loss is a risk factor for dementia. Creating a calm and quiet environment is crucial for individuals with dementia. Excessive background noise can increase confusion and agitation, especially during mealtimes. Minimizing distractions can help individuals focus on eating and enjoy a more relaxed dining experience.
Conclusion
Jennifer Brush's course has inspired me to rethink my approach to dysphagia management. By embracing patient-centered care and utilizing simple techniques, we can help our patients with dementia live their lives to the fullest. I hope you benefit from her research and experience as much as I have.
