Annals of Long Term Care

Best Practices in Nursing Care to Older Adults
From The Hartford Institute for Geriatric Nursing
New York University, College of Nursing

Issue Number 20, Revised 2007
Series Editor: Marie Boltz, MSN, APRN, BC, GNP
Managing Editor: Sherry A. Greenberg, MSN, APRN, BC, GNP
New York University College of Nursing

WHY: Aspiration (the misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract) is common in older adults with dysphagia and can lead to aspiration pneumonia. In fact, it has been suggested that dysphagia carries a sevenfold increased risk of aspiration pneumonia and is an independent predictor of mortality (Singh & Hamdy, 2006).

TARGET POPULATION: Dysphagia is common in persons with neurologic diseases such as stroke, Parkinson’s disease, and dementia. The older adult with one of these conditions is at even greater risk for aspiration because the dysphagia is superimposed on the slowed swallowing rate associated with normal aging. Conditions that suppress the cough reflex (such as sedation) further increase the risk for aspiration.

BEST PRACTICES: ASSESSMENT AND PREVENTION ASSESSMENT
Aspiration: Although aspiration during swallowing is best detected by procedures such as video-fluoroscopy or fiberoptic endoscopy, clinical observations are also important. Symptoms to look for include:
•Sudden appearance of respiratory symptoms (such as severe coughing and cyanosis) associated with eating, drinking, or regurgitation of gastric contents.
•A voice change (such as hoarseness or a gurgling noise) after swallowing.
•Small-volume aspirations that produce no overt symptoms are common and are often not discovered until the condition progresses to aspiration pneumonia.
Aspiration Pneumonia:
•Older persons with pneumonia often complain of significantly fewer symptoms than their younger counterparts; for this reason, aspiration pneumonia is under-diagnosed in this group (Marrie, 2000).
•Delirium may be the only manifestation of pneumonia in elderly persons (Marrie, 2000).
•An elevated respiratory rate is often an early clue to pneumonia in older adults; other symptoms to observe for include fever, chills, pleuritic chest pain and crackles (Marrie, 2002).
•Observation for aspiration pneumonia should be ongoing in high-risk persons.

PREVENTION OF ASPIRATION DURING HAND FEEDING:
There is little research-based information regarding specific strategies to prevent aspiration during the feeding of dysphagic individuals (Loeb, et al, 2003). However, the following actions may be of some benefit:
•Provide a 30-minute rest period prior to feeding time; a rested person will likely have less difficulty swallowing.
•Sit the person upright in a chair; if confined to bed, elevate the backrest to a 90-degree angle.
•Slightly flexing the person’s head to achieve a ‘chin-down’ position is helpful in reducing aspiration in some types of dysphagia (Shanahan, et al, 1993). Swallowing studies may be needed to determine which individuals are most likely to benefit from this position.
•Adjust rate of feeding and size of bites to the person’s tolerance; avoid rushed or forced feeding.
•Alternate solid and liquid boluses.
•Vary placement of food in the person’s mouth according to the type of deficit. For example, food may be placed on the right side of the mouth if left facial weakness is present.
•Determine the food viscosity that is best tolerated by the individual. For example, some persons swallow thickened liquids more easily than thin liquids. A recent study showed that increasing food viscosity greatly improved swallowing in neurological patients (Clave, et al, 2006). That is, aspiration was significantly lower when nectar or pudding was swallowed (as compared to when liquids were swallowed).