44
Part I Introduction to Nutrition Care in Older Adults
entire task (23). Consistency is crucial when working with older adults with cognitive deficits. It is important that all who assist the individual follow the same pro- cedures. It can be confusing when different team members give conflicting or different advice. By fol- lowing specific instructions developed by the appropri- ate therapist, the same sequence of movement should be followed. When assisting older adults with cognitive deficits, the goal is to help them be autonomous in spite of lost abilities (21).
Cerebrovascular Accidents A cerebrovascular accident is caused by an interruption in the blood flow in the brain (24). Depending on the part of the brain affected, a CVA can result in multiple deficits that may affect dining. In addition to the cogni- tive deficits discussed above, CVA can result in motor dysfunction, including paralysis of a limb or one side of the body, which affects positioning for dining and the ability to grasp and use utensils. Motor dysfunction may result in difficulty coordinating the lips and tongue and musculature involved in swallowing (24,25). Apraxia, or motor planning, may also be affected (26). An older adult with ideomotor apraxia may not be able to pick up a cup and take a drink when asked to do so but may reach out for and drink from a
cup automatically if he or she sees a cup and is thirsty (24). Visual field cuts and unilateral neglect may limit independent dining, as the older adult may not see items on one side or may ignore the affected limb and the affected side of space (24). Older adults who have had a CVA may have decreased sensation to tempera- ture, placing them at risk of injury from hot foods and beverages. Impulsivity or poor judgment are often factors for persons who have had a CVA affecting the left side of the body. This may place an older adult at risk of choking due to taking large bites or eating and drinking at a rapid pace (24,25). CVA can also result in aphasia—a loss of lan-
guage skills (24). Older adults with aphasia may be unable to comprehend verbal speech, including direc- tives and cues, or they may have difficulty with expressing or be unable to express their wants and needs.
Interventions for deficits associated with CVA should be based on an individualized approach and should involve the entire care team, including the older adult. The older adult should be evaluated for difficulty with swallowing (dysphagia), should eat or be assisted slowly, and should be encouraged not to lie flat immediately after meals. (See Box 4.4.)
BOX 4.4 Intervention for Dysphagia and Deficits Associated with Cerebrovascular Accident ●
Impulsivity and poor judgment: supervise the older adult, put utensils down between each bite, provide small-bowled spoon to limit bite size, provide flow-control cups or cups with lids and small openings, present one food item at a time in individual bowls or on small plates (25).
● Decreased attention: provide a quiet environment, limit excess noise and visual stimulation (21,25). ●
Unilateral neglect or visual field cut: position food and utensils within the older adults’ available visual field—that is, place all items to the right of midline for an older adult with left neglect, sit on the affected side, and provide verbal and physical prompts to direct attention to the affected side; monitor for pocketing of food and drooling (25).
● Aphasia: consult with speech therapy to establish and utilize available communication strategies. ●
Hemiplegia: consult with occupational therapy and physical therapy for proper positioning; incorporate the affected arm by using the affected hand to stabilize the plate; utilize a two-handed technique (if deemed appropriate by therapy) to grasp cups and mugs; place the affected arm forward on the table, next to the place setting to assist in maintaining an upright symmetrical posture (24); encourage the older adult to use available active movement by using the affected hand to bring finger foods to the mouth.
●
Facial weakness: provide appropriate consistency foods such as pureed or ground foods with sauces and appropriate thickness for liquids to increase control, place food on the stronger side, tilt head to the stronger side, and assist the older adult with lip closure (25); experiment with temperature, as cold tem- peratures increase muscle tone (12).
● ●
Pocketing of food: stroke the older adult’s cheek where pocketing is occurring, stroking back and up toward the older adult’s ear, use verbal or gesture cues to prompt a tongue or finger sweep (12).
Slow oral transit or swallow delay: offer no thin liquids, do not use straws, cue the older adult to tuck the chin to increase airway protection, cue the older adult to double swallow, cue the older adult to rotate the head to the weaker side, use hot or cold foods vs warm foods (12,25).
●
Coughing after swallowing: if permitted by the diet order, alternate between solids and liquids, cue the older adult to chin tuck and double swallow or to clear the throat immediately after each swallow (12).
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