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Part II Nutrition Assessment, Consequences, and Implications
(eg, the RDN, occupational therapist, speech-language pathologist).
Altering the consistency of solid and liquid foods is the primary intervention for individuals with dyspha- gia (37). However, diet modification is often associated with reduced acceptability and poor adherence. Therefore, the RDN must ensure that each individual receives the least restrictive diet to simultaneously minimize the risk of malnutrition/dehydration and maximize the pleasure of eating. The lack of evi- dence-based research regarding appropriate diet modi- fications and dysphagia and ultimately aspiration makes it extremely difficult to determine the best diet alterations in each case. In fact, as few as 5% of nursing home residents were shown to be on modified diets that correctly matched their swallowing ability (25).
In 2002, the National Dysphagia Diet (NDD) was the initial attempt to standardize dysphagia diets and improve the pairing of diet consistency and swallow ability (49). Unfortunately, since its release, there has been great variability in the use and interpretation of the diets (26,50). To reduce the inconsistencies of food and fluid delivery and the consequences associated with inadequate or unsafe food and fluid intake, Cichero et al recently proposed an international dys- phagia diet that would be consistent between all coun- tries and practice settings (51). However, improving the standardization of a dysphagia diet does not guar- antee that individuals will be provided the appropriate diet consistency. There are currently no data indicating that a standardized diet approach such as the NDD or proposed international diet has any benefit over an institution-specific modified diet. Providing those indi- viduals with modified foods and thickened liquids results in a decreased rate of pneumonia (52), yet it is associated with an increased rate of malnutrition and dehydration (51,53). To address the prevalence of dehydration, the Frazier Water Protocol was developed and has gained interest (54). This protocol allows for unlimited water prior to meals and includes aggressive oral care to minimize oral bacteria that may be associ- ated with the development of aspiration pneumonia. Though additional studies should be done to confirm the efficacy of this protocol, initial results show a low rate of dehydration and pneumonia (54). Additionally, proper training of staff who assist persons with dyspha- gia during mealtimes resulted in improved intake of both modified diet meals and supplements and should be considered a critical control point to all diet/dyspha- gia protocols (53).
Due to the controversial benefits and risks associ- ated with the use of modified diets, the current best practice is to maintain a good understanding of each
institution’s/practitioner’s interpretation of modified food/fluid consistency and provide the safest diet type possible. Policies and procedures should be written in conjunction with the speech therapist to optimize delivery of care. When an older adult’s living situation or source of food changes, it is imperative that com- munication regarding the individual’s nutritional status includes the amount of food and fluid he or she con- sumes, a detailed report of the types of foods/fluids the person tolerates, and adequate training of the individ- ual providing the diet.
ALTERNATIVE NUTRITION
When it has been determined that an individual cannot safely swallow any food or fluid, difficult decisions must be made to either continue to allow the individ- ual to eat foods after the risks associated with aspira- tion are explained, consider alternate routes of nutrition, or withhold nutrition. Placing a feeding tube has many ethical considerations that are best approached by the interdisciplinary team with the older adult and the family. Unfortunately, research does not show that persons are at less risk of aspira- tion or improved survival if enteral nutrition is initi- ated, especially for those with advanced dementia (55,56). One study demonstrated that hospitalized patients over age 65 with a percutaneous endoscopic gastrostomy (PEG) tube actually had mortality rates as high as 63% at 1 year (57). Additionally, depression and loss of social interaction is associated with the use of alternative routes of nutrition and should be addressed when developing the nutrition care plan (7).
SUMMARY
Considering that dysphagia is found in as many as 25% of healthy adults over the age of 50 and continues to increase in prevalence with advanced age and comor- bidities, the RDN working with older adults must be ever alert for the signs and symptoms of dysphagia. Once swallowing difficulty is diagnosed, effective nutrition interventions (if consistent with advance directives) must simultaneously maximize the safe consumption of food and fluid yet minimize the risks of malnutrition, dehydration, and aspiration. Until additional research is available to close the gap between the diagnosis of dysphagia and the provision of optimal nutrition interventions, the key to achieve this difficult balance is to individualize each person’s nutrition goal and to closely monitor progress for set- backs and adapt interventions accordingly.
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