Feeding and Alzheimer’s Disease

Feeding and Alzheimer’s Disease

Intervention and useful strategies with AD during meals  (Brush, J., Slominiski T., Boczko F., 2006)

• Visual cues and written reminders
• Cups and handles that are easy to grasp.  Try the Provale cup –  800-757-7579
  
• Serve larger portions at breakfast to maintain weight
  
• Seat patients according to compatibilities rather than disabilities
  
• Offer liquids and water consistently throughout the day
  
• Increase number of finger foods
  
• Patients can be tempted to eat more with sweetener added
  
• Provide ethnic or culturally appropriate food
  
• Alternate hot, cold, sweetener, and alternate  with spicy foods, add ketchup, mustard, salt, pepper (if medically appropriate)
  
• Tell concerned patients “their meal is paid for” and included in a  “meal club”
  
• Do not use garnishes or decorations or meal tray slips, as they are easy picked up and eaten.
  
• Limit the number of utensils
  
• Use one-step directives for cueing and encouraging PO
  
• Dining area should be in a home like environment – dining room etc.
  
• Use boundaries by using place mats or square tables to reduced interest in another persons meal
  
• Serve promptly after they are seated
  
• Increase lighting and contrast at dining table
  

Mealtimes can be a challenge on dementia units in long-term care facilities. The ability of someone with advancing dementia to maintain adequate nutrition and hydration by mouth can become quite compromised as the patient approaches end stage. Their eyes see food, but their brain may not know what to do with it. At this point the speech-language pathologist often is asked to get involved and do something to get the person to eat. The usual approaches well known among clinicians are reducing extraneous stimuli; alternating tastes, textures and temperatures; talking calmly and quietly to patients; and placing a cup or utensil in their hand. Other methods that complement these general strategies can be taught easily to and used by the nursing assistants who do the feeding. If a person you are feeding becomes agitated and resistant, stop!
Back off for a minute, give them time to re-orient to the meal in front of them, and then continue feeding. Patients with dementia can be highly distractible, which isn’t always bad. Sometimes a moment or two away from the task and their agitation and a gradual coming back may be all they need.
The Show and Tell method keeps patients involved in your presentation and approach as you feed them. As you get a bite ready, tell them what they need to do: “Okay, let’s take another bite” or “Try some vegetables; here you go.” Don’t ask them if they want the next bite; they’ll probably respond negatively.  Hold it up in front of them so they can see and identify it, and don’t rush them. Give them a verbal cue as you approach them with it so they know the goal and can start forming a motor plan to manage the bolus, then verbally reinforce their acceptance. One thing I’ve learned in dementia unit dining rooms is that many of these folks don’t like surprises, so show them and tell them.
The Hide and Seek method is based on the concern that patients who see a bite of food coming toward them may become more agitated and vehemently resist because of their decreased ability to correctly interpret what the clinician is doing. This approach involves sitting quietly next to patients with a bite of food ready where they can’t see it. When their mouth opens, as frequently happens with an agitated patient, plug ’em!
Touch and Go is a helpful technique for patients who either don’t open their eyes or don’t open their mouths to accept the bite of food they see. Simply touching their lips with a utensil, cup or straw can work as a tactile cue for them to open up. If they have a prolonged oral phase or persistent chew, just presenting the next bite sometimes can facilitate the completion of the previous one.
Finally, de-stimulation is a method that can be tried with patients who don’t initiate the eating task and respond poorly to verbal entreaties. Dining rooms in large nursing homes can be busy, noisy places. Patients are often over-stimulated before they’re even served their meal. The last thing they need is more stimulation. You should clear the table in front of them, hold the dish in your hand, and quietly feed them. Admittedly, this is nothing new in the approach to feeding patients with dementia, but it’s surprising how little it’s actually practiced unless we’re vigilant in our training of nursing assistants. Because meals may take a bit longer using these methods, start with the highest-calorie items first. If necessary, consult with the facility dietitian about increasing the caloric density of what the patient can get down successfully. As clinicians, we must train staff members to utilize the most effective methods of presentation, approach and delivery to facilitate maximum PO intake with these patients. Any strategy we use depends on the patient’s level of dementia and presenting behaviors. We also have to be able to adjust our method to the patient’s response, from meal to meal or during a meal. Working with patients who have dementia requires patience and the ability and willingness to connect with them to help maintain their quality of life by enjoying one of the last pleasures they may have — eating a good meal.  Dan Sherwood Jewish Home and Care Ctr, WI
Alzhiemer’s/Dementia and Tongue Strength
When evaluating and treating a special population is necessary that we determine how stable a patient is and we can begin by considering their location in a facility: ICU, floor of acute care hospital, skilled unit, rehab, or home.
Alzhiemers/Dementia –   Alzhiemers/Dementia patients often times can not follow directions, but neither can NICU infants. To find some new treatment approaches consider infant oral motor treatment and learned techniques from occupational and physical therapists, especially in the treatment of muscle tone.  Tongue strength is one of the most common underlying problems in dysphagia in the dementia population.  Since SLP’s are not trained to work with muscle tone, the standard oral motor exercises do not always target the right areas.  Tongue strength is important because the ability of the tongue to tolerate weight of a bolus is important to the swallow process.
TX Consideration: To build tongue strength the therapist must provide resistance to the tongue/muscle.  One method is to use a tongue blade or spoon to push down on the tongue while trying to have the person protrude or lift the tongue, often this might be reflexive.
Guideline for Feeding Assistants in LTC   In March 2002, CMS proposed a rule to allow Medicare and Medicaid program to use paid feeding assistants.  The federal guidelines dictate a minimum of 8 hours of training in eight specific areas: feeding techniques, assistance with feeding and hydration, communication and interpersonal skills, appropriate responses to resident behavior, safety, and emergency procedures, infection control, resident rights, recognition of changes in residents that are inconsistent with their normal behavior, ands the importance of reporting those changes to the supervisory nurse. Janet Brown M.S. CCC-SLP, director of Health Care Services in Speech Language Pathology says that ASHA has recommended that Speech Pathologists be identified as a resource to the supervisors of the feeding assistants and to participate is designing state approved training courses.  The national no profit consumer advocacy organization for nursing home resident favors more extensive training for certified nursing assistant and registered nurses.  ASHA does not plan to take further action on the rule unless members express concern about how it is being implemented.  ASHA urges clinicians to find out if feeding assistants are being used in their buildings and offer to consult on their training, and also monitor whether their referrals for dysphagia change as a result of having feeding assistants.  Keep ASHA informed.
Banotai, A., New Guidelines for Feeding Assistance in Long-Term Care, Speech-language pathologists have a role in training, ADVANCE, March 8, 2004.