Enhancing the Mealtime Experience Presented by: Heather Jacobson, Speech-Language Pathologist Madeleine Kunzler, Clinical Dietitian Lynda Wolf, Occupational Therapist Contributions by: Andrea Bellamy, Occupational Therapist Carole Hamel, Clinical

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Enhancing the Mealtime ExperiencePresented
byHeather Jacobson, Speech-Language
Pathologist Madeleine Kunzler, Clinical
Dietitian Lynda Wolf, Occupational
TherapistContributions by Andrea Bellamy,
Occupational TherapistCarole Hamel, Clinical
Nurse Specialist
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Overview

• Safety and Swallowing
• Supportive Eating Environment
• Techniques for Enhancing Mealtimes

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What is required for successful mealtimes?

• Ability to swallow safely
• Preferred food texture
• Attention to eating
• Ability to get food from plate to mouth
• Supportive environment that facilitates
  independent feeding

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Whats the big deal? A Few Stats

• Approx 60 of institutionalized elderly
  individuals experience some form of swallowing
  problems
• For those being fed, 90 have swallowing problems
• Risk/Complications
• Mealtime distress such as choking, painful
  swallowing
• Malnutrition
• Dehydration
• Aspiration Pneumonia

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SAFETY AND SWALLOWINGA Definition of Dysphagia

• Difficulty swallowing Difficulty moving
  food/liquid from mouth to stomach
• The difficulty may involve the mouth, throat,
  voice box, and/or esophagus

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Normal Swallowing

• Automatic
• Frequent
• Necessary

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Three Swallowing Stages

• Oral
• Pharyngeal
• Esophageal

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The Effect of Aging on Swallowing

• Reduced saliva
• Reduced thirst
• Reduced sweet salty taste buds
• Increased likelihood of reflux
• Reduced muscle bulk/strength of tongue, facial
  muscles
• Reduced cough reflex

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Dementia and Swallowing

• Persons with dementia forget how to swallow
• This is a thinking problem, not a physical problem

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Things you may notice

• Distorted perception of food
• Sorts food and spits out
• Chews food longer
• Holds food on tongue or in cheeks
• Prefers liquids
• Does not open mouth to accept food

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Physical Problems

• Three places where problems can happen
• Mouth
• Throat
• Esophagus
• Symptoms of Dysphagia
• Coughing/clearing throat at meals
• Pocketing food in mouth after swallowing
• Poor ability to chew
• Sensation of food being stuck
• Painful swallowing
• No swallowing at all
• Wet, gurgly voice or breathing sounds after
  swallowing

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How to Make Feeding Safer

• Here are the 8 Steps
• Check for swallowing care plans
• Proper Resident Position
• Food Check
• Proper Feeder Position
• Appropriate Rate and Amount
• Oral Care
• Proper Resident Position After Eating
• Reporting to the staff

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Step 1 Check for Silver Spoons Club symbol
SAFE SWALLOWING GUIDE PATIENT NAME   DIET
Pureed with Thick 2 (Honey) liquids SUCKERS OK
if directly supervised by family/staff POSITION
Upright at 90? in bed at 60? for 30 minutes
after meals.   FEEDER POSITION Sit/stand beside
bed at her eye level SPECIAL INSTRUCTIONS þ  
Approach from RIGHT SIDE. þ   Feed slowly watch
adams apple move up down þ   Reduce
distractions and noise. þ   To encourage mouth
opening swallow o      Light pressure on her
tongue o      Touch food to her lips o     
Alternate between liquids and solids o     
Gently massage throat o      Use cold spoon
(dipped in cup of ice) þ   WAIT if coughing
happens - make sure voice is clear sounding
before continuing to feed. ORAL CARE Remove
food with moist toothette
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Step 2 Proper Resident Position

• Remember the song Head and shoulders, knees and
  toes
• Seated hips at 90o
• Head forward, chin down
• Body aligned in mid-line position
• Knees, ankles at 90o
• Feet and arms supported

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Wheelchair Positioning

• Standard Wheelchair
• May need a support behind the back to achieve
  most upright position
• Knees bent feet supported
• Tilt-in-Space Wheelchair
• Back at 90o to seat (no recline or tilt)
• Headrest supporting head in midline with chin
  somewhat forward
• Knees bent feet supported

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Wheelchair Positioning

• Use of Wheelchair Tray
• Use with small wheelchairs to bring tray where
  person can see and reach
• If chair too short for person to eat from table
• If person cannot reach food at table
• Use of Overbed Table
• Also brings tray closer
• Make sure person still eats with others

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Wheelchair Repositioning

• Be sure that person is sitting upright in chair
• Repositioning must be done by two staff members

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Step 3 Food Check

• Before feeding, check to confirm all food and
  fluids match diet order ticket

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Step 3 Food Check

• Before feeding, check to confirm all food and
  fluids match diet order ticket
• There is no one dysphagia diet
• Individualized
• Proper food order never
• exceeds persons ability to swallow

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Whats for supper?

• Texture - What are the choices?
• Soft
• Soft/Minced
• Minced
• Total Minced
• Puréed
• Blenderized
• No Mixed Consistency
• Thickened Liquids

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Texture of Food

• Adjusting food texture helps decrease
• Excessive chewing
• Spitting out of food particles
• Holding of food in mouth
• Method of service
• Serve foods in cup instead of plate
• Provide straw instead of cup drinking
• Finger foods instead of utensils

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When People Refuse to Eat

• Specially made milkshakes
• Sprinkle artificial sweetener or syrup over foods
• Give ice cream or pudding with main entrée
• Finger foods for pacers
• Placement of food
• Food available 24 hrs a day

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High Risk Foods!

• Foods That May Cause Obstruction in the Airway
• Sticky Foods
• Stringy Foods
• Foods with small pits
• Foods That May Increase the Risk of Aspiration
• Foods that DO NOT easily form a bolus
• Foods of 2 or more consistencies
• Thin liquids (risky only if resident restricted
  to thickened liquids)
• Jell-O ice cream?

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Step 4 Proper Feeder Position

• Sit facing patient, at eye level
• Give spoonfuls from below

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Step 5 Appropriate Rate and Amount

• Give one teaspoon at a time and observe or feel
  for swallow before more food or fluid is given.

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Ask Yourself

• What are mealtimes like here?
• Does the dining room experience look and feel
  normal or does it feel like a big confusing
  institution?
• Do mealtimes provide an opportunity for the
  person with dementia to be successful?
• Are mealtimes pleasantly social?
• Are residents eating with people they like or are
  they distracted or upset by others?
• Are staff engaging residents and calling them by
  name during mealtimes?
• Is this a place where I would want to eat my
  meals for the rest of my life?

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Supportive PhysicalEnvironment

• Noise
• Light
• Aroma
• Heights and Distances
• Simplify

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Supportive SocialEnvironment

• Preferred companions
• Sitting as equals
• Clear communication
• Providing enough time
• Promoting dignity

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Supportive Techniques

• Ask persons permission to assist
• Opening containers
• Use the simplest cutlery
• Promote finger foods if utensils not used
• Place food where seen
• Provide assistance as needed
• Hand-Over-Hand
• Priming the Pump
• Provide encouragement

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What if the person is not swallowing?

• Press gently with the spoon on tongue
• Increase distinctness in food flavours, textures
  and temperatures
• If person is holding food in mouth
• tap front of chin or stroke throat
• use verbal cueing (e.g. open, eat, swallow)
• gently massage side of jaw
• model an open mouth
• tap lips gently with spoon
• stroke face with damp cloth

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Step 6 Oral Care

• Remove particles of food
• from patients mouth after
• each meal.
• Breathing in the contents of an unclean mouth is
  the fastest route to pneumonia because the person
  will have introduced ready-made bacteria into the
  lungs.

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Oral Care and Dementia

• Understanding the challenge
• resistance does not mean that individual does
  not want their mouth cleaned
• high risk for oral disease due to challenging
  behaviour
• dental work is important

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Step 7 Proper Resident Positioning After Eating

• Have person remain upright for at least 30
  minutes after the meal (if in bed, lower the head
  of bed to 60o).

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Step 8 Reporting to Staff

• Report observations, unusual incidents, and/or
  amount of food/liquids

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Managing Coughing/Choking Incidents

• Choking
• Partial or complete obstruction of the airway
• If person can speak or cough,
• Stand by and reassure, but dont interfere
• Encourage coughing
• Do NOT hit the person on the back
• If person is unable to speak or make any sounds,
  is clutching his/her throat, and having extreme
  breathing difficulty, weak or ineffective cough,
  they are choking
• CALL FOR HELP!