Dysphagia, Dementia and Nutrition
When you go to the movies and buy a box of popcorn, you don't stop watching the show to eat it. Putting food in your mouth, chewing and swallowing are things most people do without thinking approximately 600 times each day throughout their lives.
While eating seems like a basic, even automatic act, it actually requires attention, initiation, conceptualization, visual-spatial activities and planning -- a combination of cognitive skills that present a variety of challenges for persons who have mental and functional deficits caused by a dementing illness. But the most common cause of impaired eating in dementia patients, and one with serious implications, is a condition known as dysphagia -- difficulty, pain or the inability to swallow.
Dysphagia, which makes it problematic to take in enough calories and fluids to maintain body weight and stay healthy, can be seen in persons with cancer, Parkinson's disease, cerebral palsy, multiple sclerosis and stroke as well as dementia. In its mild form, dysphagia can cause occasional coughing, increased colds and some weight loss, plus frustration and depression. Severe dyspahgia may lead to significant weight loss, dehydration, malnutrition and pneumonia, which can have dire consequences for someone whose health is already compromised.
Nourishing the Dysphagia Patient
Food texture is a very important factor when someone has a swallowing problem. However, determining and delivering the proper texture of foods and liquids can be frustrating for caregivers. That's because the concern for hydration, nourishment and patient gratification must be balanced with caution over aspiration and choking.
At the John Douglas French Center for Alzheimer's Disease in Los Alamitos, CA, this complex assignment is the responsibility of Genetha Thomas, registered dietician and director of food services, and her dietary staff of 20.
"Dementia care is very different from hospital or acute care in that we are often trying to add calories to prevent the weight loss that may occur in the progression of the disease," Thomas explains. "I want our residents to stay healthy, happy and calm -- even if this means liberalizing their diets and letting them get to the upper range of their ideal body weight. For example, most dementia patients love chocolate, so, if putting chocolate syrup on their pancakes or breakfast cereal means they'll eat more, that's acceptable."
When a swallowing problem is detected, Thomas first observes how the resident handles liquids and various textured foods and what percentage is eaten at each meal. Then, tests may be ordered to determine if the swallowing mechanism is working properly. "Based on these findings, we structure a diet that reflects the individual's feeding abilities, cultural background, eating patterns, food preferences and allergies that, at the same time, provides the necessary protein, calories and fluids," she says.
Residents eat six times a day (three meals and three snacks) in a quiet and relaxed atmosphere, where they are encouraged to sit upright, eat slowly and pause between bites and sips. "Dietary patterns are adjusted to reflect high-density foods such as cereals, mashed potatoes and soups," says Thomas. "And the bulk of their nutrients are served at breakfast, which tends to be their best meal of the day because they are less tired."
Fluids are harder to control in the mouth and more likely to cause aspiration than semi-solid or solid food, according to Thomas. Some patients who aspirate on thin liquids can swallow carbonated beverages because the effervescence can heighten their awareness of the liquid, resulting in an increased initiation of the swallow reflex. Adding powdered milk, powdered eggs, gelatin or commercial thickening agents can change almost any liquid to nectar, honey or pudding consistency and make it easier to consume. "Of course, thickening agents are not particularly pleasant because they alter both appearance and consistency, so we use them only when necessary," she said.
When chewing and swallowing solids are a problem, Thomas will first try grinding up foods in a blender. "We try to avoid pureeing foods to baby-food consistency because it also alters the taste," she says. "Imagine a pureed Big Mac. It doesn't look, taste or smell like a hamburger -- now that would be an 'unhappy' meal!"
Thomas also keeps patient satisfaction in mind when modifying diets. She uses spices liberally to enhance the flavor; molds to make pureed foods more eye-appealing; and garnishes -- such as dill weed, kale, parsley, endive, apple rings and orange or lemon wedges -- to give foods a fresh look from meal to meal. Serving food at the appropriate temperature is important, too. "A good temperature for eating hot foods is 120-140 degrees, while cold foods should be served at 35-40 degrees to help trigger the swallow," she notes.
Thomas sometimes has to work within a very limited menu to get an individual through a health crisis. "I had a resident who survived for a time on peanut butter milkshakes and is now able to eat a variety of foods," she explains. "Another would accept only egg salad sandwiches; and there was one who would take just frozen liquids for breakfast, lunch and dinner."
Nutritional strategies don't always last long -- what is successful one year (or one month) may not work the next, especially as the disease process changes a patient's behavior and functioning.
No matter what foods are served, Thomas believes that all meals -- and especially liquid meals -- should never be boring, bland or unappealing. "It is critical to maintain an individual's dignity and morale during dining," she stresses. "The bottom line for successfully treating dementia patients with dysphagia requires teamwork and doing whatever it takes in the kitchen to keep them nourished and hydrated."
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Contributed by The John Douglas French Center for Alzheimer's Disease, Los Alamitos, CA.
Adapted from its Journal magazine, and used by permission
