VOL: 97, ISSUE: 16, PAGE NO: 60
Roger Weetch, RN, DipHS, is staff nurse, Bradford Royal Infirmary
A nutritionally sound diet has been shown to be an important factor in healthy ageing (Evans, 1994).
Up to 40% of acute hospital patients are malnourished (McWhirter and Pennington, 1994). Some of them may be admitted in this condition, others become malnourished while in hospital (Association of Community Health Councils England and Wales, 1997).
While a lower metabolic rate and less exercise reduces the amount of food needed, this reduction should be in fats and carbohydrates. An adequate supply of protein, vitamins, minerals and fluid is still essential.
Malnutrition is a problem among older people, particularly those in nursing homes (Kayser-Jones, 1996) and can lead to slower wound-healing, higher rates of infection and pressure ulcer development. Among the causes of inadequate food intake are ‘feeding problems’, difficulty transferring food from plate to mouth and swallowing it.
In a nursing home or hospital ward several patients may need to be fed individually. Some may also have difficulty swallowing. Often a student nurse or junior care assistant is asked to feed these patients. Seen as a chore to be got through as quickly as possible, even experienced nurses may try to coerce patients into swallowing. Hovering with the next spoonful exacerbates swallowing problems.
The loss of teeth and ill-fitting dentures can make chewing uncomfortable. Reduced smell and taste may tend to render food bland and unappetising. In some people reduced or thicker saliva may make the mouth dry, increasing swallowing difficulty. This can lead to low-fibre foods being selected, resulting in constipation. Incomplete relaxation of the gastro-oesophageal sphincter can make swallowing difficult, while weakening of the sphincter can allow reflux of food and gastric acid.
Patients with swallowing problems can include those with cancer, stroke affecting the motor cortex or the deglutition centre, Parkinson’s disease, arthritis and some muscular disorders. Medications, such as antihypertensives and diuretics, can cause dryness of the mouth. In patients with dementia, feeding difficulties change as the condition progresses. These may range from refusal to eat, turning the head away, keeping the mouth closed, spitting out food to leaving the mouth open and not swallowing. If patients can feed themselves they need encouragement and monitoring. If they are to be fed, it is important this should be done safely.
Nurses need to pay attention to the amount of food being eaten and the timing of people’s hunger. Patients are more likely to eat when with others, and a second course should not be placed on the table while the first is being eaten. Food should be colourful and well-seasoned so that it stimulates the appetite via sight, smell and taste (Tanton et al, 1995). Portion size should be individually adjusted and consideration given to individual hunger and stamina. Some patients may need smaller, more frequent meals. The person’s sensory abilities also need to be assessed.
Hearing and sight deficiencies cause isolation, and glasses and hearing aids need to be checked. Oral hygiene and well-fitting dentures are important considerations. If reduced food intake is likely, a dietitian’s advice regarding a balanced diet is helpful. It is particularly important that adequate fibre is consumed to reduce constipation, the bane of many older people’s lives.
Posture is important when eating. People should be sitting upright, with their heads inclined forwards. They should be encouraged to remain seated for 15 minutes after eating in case of regurgitation. Some people will have difficulty transferring the food to their mouths. Occupational therapists may be able to provide eating utensils that will make this easier. People should be encouraged to do as much as possible themselves or they may learn helplessness.
If it is necessary to feed someone, the helper should sit in the line of sight of the person being fed and talk calmly, providing verbal and non-verbal prompts and encouragement.
Appropriately sized mouthfuls should be given. If chewing is a problem, food can be minced, shredded or liquidised. However, different food items should be dealt with separately, not mixed before liquidising, so that there is a variety of flavours.
Problems with the oral or pharyngeal phases of swallowing (Box 1) can be of neurological or mechanical origin. Assessment is needed from a speech and language therapist (North et al, 1996). Swallowing uses much the same muscles and nerves as speech. A radiologist may be needed for a fluoroscopic analysis of a barium swallow.
If food needs to be adjusted, four main factors need to be considered: flavour, texture, density and temperature. Food should not be bland: salty, sweet and sour tastes all elicit mastication and swallowing. Milk products increase mucous secretions, which, in some circumstances, may increase swallowing difficulty, while oily liquids, such as meat broth, make secretions thinner.
Texture is needed to stimulate oral sensation: liquidising should not be too thorough. The density of the food provides resistance to stimulate the mouth and tongue. Although it must not be too hot, the food temperature needs to be appreciably above or below body temperature, otherwise the person may not be aware of it in the mouth. As feeding may take some time, insulated containers should be used to maintain temperature control.
It is important to avoid aspiration when feeding (Box 2). Tilting the head forwards while swallowing will help protect the airway. Liquids should be thickened as they are difficult for the tongue to control and can easily splash into the trachea.
The swallowing reflex may be encouraged by touching an ice-cold laryngeal mirror four or five times to each side of the faucial arch, the point at which swallowing is normally triggered. One or two mouthfuls of iced water before a meal may help. Standing behind the person, stroking with the thumbs backwards under the chin to the neck, then instructing to swallow at the same time as pressing gently upwards in the angles of the jaw sometimes works.
For some people it may be necessary to hold their lips closed while they eat. People with poor lip and tongue seal may take liquids best through a straw or a feeder mug with a spout. However, most people are better off with a full normal mug so that they do not tilt back their heads.
Some may hold food in their mouths for a long time without initiating swallowing. The food will acquire the same temperature as the mouth and the person may forget that it is there. Ice cream, which can be useful for triggering swallowing in some people, will melt and as a liquid may be aspirated. It is important that people are watched closely and that they are encouraged to deal with each mouthful as quickly as possible. If their airways are secure, some people who have difficulty manipulating food with their tongues can be taught to throw back their heads to move food to the pharynx. Alternatively, a syringe might be used.
Where the pharynx is not being cleared after a swallow, perhaps due to insufficient relaxation of the cricopharyngeal sphincter at the top of the oesophagus, a drink between each mouthful of food may help. A carbonated drink may stimulate sphincter opening.
If a person has a weak side, perhaps following a stroke, then the head should be tilted towards the stronger side to reduce food collecting. The helper will need to feel the cheek on the weaker side to check whether there is any food of which the person is unaware. If there is unilateral weakness in the cricopharyngeal sphincter the head should be turned to the weaker side to open up the stronger side.
Those liable to suffer gastric reflux should remain seated upright for 30 minutes following a meal to avoid aspiration.
Many people assume that anyone can assist another to eat. However, feeding a patient is not a simple procedure that can be assigned to a junior member of staff without experience. Nurses need to be taught how to do it, what the problems are and how they might be overcome. Most importantly, they need to know the danger signs and when help is needed.