“It Doesn’t Taste Good”: A Practical Approach to Eating and Nutrition in the Elderly

Wednesday, April 1, 2009

Heidi Wierman, MD

Kimberly Bassett, MS, CCC/SLP

Outline Review Normal Aging changes, Disease

effect, Medication Effects Nutritional Needs Swallowing Changes Food Preparation/Texture Environmental Considerations Quality of Life Considerations

Appetite/desire, smell

Access to (appropriate, tasty) food

Ability to feed self or be fed

Mouth function: chew, taste

Swallowing

Absorption

Transport of food/waste through body

Normal Nutrition

Nutritional Requirements Individual variation…watch the weight and adjust. Guideline for calories:

Harris-Benedict Equation WHO Estimated Energy Requirement

Guideline for fluid 30 ml/kg/day

Guideline for protein: 1g/kg/day

Varied diet, consider MVI, Calcium/vit D.

Risk Factors for Undernutrition Alcohol or substance abuse Cognitive Dysfunction Decreased activity, functional limitations Depression Low income, limited education Lack of Transportation Medical Problems/Chronic Diseases, Medications Teeth Problems Restricted diet, poor eating habits Social Isolation

Normal Aging Changes Alteration in body composition Thinning of tooth enamel Change in fit of dentures Decrease in saliva production Decrease in gastrointestinal motility Diminished thirst

Normal Changes in Swallow with Age “Presbyphagia”

Oral phase changes are related to changes in muscle strength of face, tongue Decreased lip seal for cup drinking Reduced masticatory strength Piecemeal swallow

Feeding performance does not seem to be significantly affected by these oromotor changes as older adults effectively compensate by changing diet consistency and meal duration

Normal Changes in Swallow with Age Pharyngeal phase changes can be of greater

clinical significance for the oldest old (80+) and include:

Delay in pharyngeal swallow

Reduced pharyngolaryngeal sensory discrimination

Normal Changes in Swallow with Age Esophageal Phase

Studies of age related changes to UES function have been inconclusive

Primary esophageal peristalsis is preserved in the elderly, however, secondary peristalsis is less frequent or absent

Normal Changes in Swallow with Age: 60-80 Years Old Swallow Timing

Longer oral transit times Elderly are more often “dippers” Reduced tongue pressure Longer pharyngeal delay times Inconsistent findings of slower pharyngeal

wall contraction

Normal Changes in Swallow with Age: 60-80 Years Old Safety and Efficiency of Swallow

Penetration occurs more frequently Aspiration occurs no more frequently in

healthy elders Pharyngeal residue is slightly greater in

elderly compared to young adults

Normal Changes in Swallow with Age: 80+ Year Olds Reduced reserve, especially in men

Hyoid and laryngeal maximum vertical movement significantly reduced in oldest old (80+)

Reduced Flexibility Cricopharyngeal opening durations across

volumes reduced in oldest old Cricopharyngeal opening diameter across

volumes reduced in oldest old

Normal Changes in Swallow with Age: 80+ Year Olds

Other Findings in Healthy Dentate Elderly Piecemeal swallowing Premature loss of liquid Oral and pharyngeal residues Penetration

Normal Changes in Swallow with Age:Research Conclusions An older adult’s swallow is not necessarily an

impaired swallow

Healthy older adults exhibit a highly safe and efficient swallow

Older adults are more vulnerable to the effects of acute illnesses and medications and can cross the line from having a normal older swallow to being dysphagic

Effect of Disease on Swallow

It is the increased incidence of cerebrovascular disease and degenerative neurologic disease with aging that is strongly associated with dysphagia in the elderly

Effect of Disease on Swallow Stroke

Type and severity of dysphagia depends on size and location of lesion

Parkinson’s Disease Dysphagia develops in approximately 50% of

patients Alzheimer’s Disease

Primary issue is eating / food management secondary to cognitive decline

Effect of Disease on Swallow ALS

Swallowing deficits emerge when the disease enters the bulbar phase

Muscular Dystrophy Myotonic Occulopharyngeal

Myasthenia Gravis Characterized by global fluctuating muscle fatigue

Multiple Sclerosis Factors most closely related to dysphagia are bulbar

involvement and severity of illness

Effect of Disease on Swallow Head and Neck Cancer

Swallow dysfunction is related to surgical and radiation treatment

Prolonged Mechanical Ventilation Etiology of swallowing dysfunction is

multifactorial

Medication Effects

Diseases/Medication Effects Dryness Decrease in acid production Taste Changes Nausea/Anorexia Speed of eating Ability to feed self Chewing ability Dysphagia

Associated with Dry Mouth (also Constipation)

Drugs used to treat: Depression, Diarrhea/nausea, Hypertension

(diuretics) Anxiety, Asthma (certain bronchodilators), Allergies

and colds (antihistamines and decongestants) Pain, Psychotic disorders, Parkinson's disease Epilepsy Urinary incontinence

Diseases: Sjogren’s Syndrome, Xerostomia, Parkinson’s Disease

Treatment of Dry Mouth Limiting medications that cause, decreasing doses Sucking on sugar-free candy or chewing sugar-free

gum Drinking plenty of water to help keep mouth moist Protecting teeth by brushing with a fluoride

toothpaste, using a fluoride rinse, and visiting your dentist regularly

Breathing through nose, not mouth Using a room vaporizer to add moisture to the air Using an over-the-counter artificial saliva

substitute.

Impairment of Taste Dryness Destruction of taste buds (burn, radiation) Bell’s palsy or surgical destruction of CN VII Sinusitus, Upper Respiratory Tract Infection Head injury Gingivitis Smoking

Medications that alter smell and taste Antibiotics

Ampicillin, Azithromycin, Ciprofloxacin, Clarithromycin, Griseofulvin, Metronidazole, Ofloxacin, Tetracycline

AnticonvulsantsCarbamazepine, Phenytoin

Antidepressants/Mood StabilizerAmitriptyline, Clomipramine, Desipramine, Doxepin, Imipramine, Nortriptyline

Antihistamines and decongestantsChlorpheniramine, Loratadine, Pseudoephedrine

Antihypertensives/CardiacAcetazolamide, Amiloride, Betaxolol, Captopril, Diltiazem, Enalapril, Hydrochlorothiazide, Nifedipine, Nitroglycerin, Propranolol, Spironolactone

Anti-inflammatory agentsColchicine, Dexamethasone, Gold, Hydrocortisone, Penicillamine

AntineoplasticsCisplatin, Doxorubicin, Methotrexate, Vincristine

Antiparkinsonian agentsLevodopa, Sinemet

AntipsychoticsClozapine , Trifluoperazine

Antithyroid agentsMethimazole, Propylthiouracil

Lipid-lowering agentsFluvastatin, Lovastatin, Pravastatin

Muscle relaxantsBaclofen, Dantrolene

ACE inhibitors one of the most common offenders

How to address alterations in taste Re-evaluate medications Treat diseases of the mouth Stop smoking Use spices…salt, herbs, pepper Extra attention to texture, color,

temperature of food.

Individuals with impaired taste, should avoid cooking by taste

Food Preparation and Texture Meals that Appeal

Vary color, texture, temperature Consider offering meals in “courses”, so food

temperatures are maintained for slower eaters Use moulds to improve presentation of blended foods

Small meals The elderly may benefit from being offered frequent

small servings of foods that they like throughout the day Garnish

Add parsley, lemon slices – provides visual appeal

Food Preparation and Texture Food that is easy to eat

Finger foods allow those with cognitive impairments to be more independent

When needed, cut food up into bite sized portions prior to serving

Add flavor enhancers that amplify the intensity of food odor Appealing odors can help to enhance appetite These may be useful for elderly adults with decreased

smell / taste

Environmental Considerations Make Eating a Social Event

For seniors who live alone: Encourage family to bring food to or invite elderly

family member over or out for dinner Take advantage of local “bean suppers”

Set a nice table Establish good lighting Limit distractions

Environmental Considerations For Seniors Who Live in Assisted Living/Nursing

Home Dining room and ambiance Attend to proper seat positioning, access to adaptive

equipment Have a positive attitude toward those with feeding and

swallowing difficulties Take it slow…

Encourage Family members to assist Time of day

Environmental Considerations Attend to Cultural Concerns / Needs

Observe Rituals

Handwashing Saying a blessing

How to improve Appetite Treat depression, constipation, other

issues Encourage physical activity & fluids Consider medications to stimulate

appetite: Remeron Megace (800 mg/day) Dronabinol

Quality of Life Considerations Restrictions: salt, caloric, textures Feeding Tubes Desires versus nutritional needs

Case discussion 82 year old retired physician diagnosed with

Parkinson’s disease in 1989, hospitalized in 1999 for pneumonia: required intubation

MBS 2/19/99 revealed severe oropharyngeal dysphagia characterized by significant pharyngeal pooling and frank aspiration

Underwent PEG placement and was transferred to a SNF for rehabilitation

Received intensive speech therapy and taught to use chin tuck

Case discussion, continued Follow-up MBS 3/26/99 revealed improved

swallow function and started on a blended diet with thin liquids

Transferred to an assisted living facility from SNF

Eventually returned to a regular diet and PEG tube was removed

Ate 2 meals/day in dining room of assisted living facility – enjoyed the social contact

Case discussion, continued Stable for 3 years - returned for an MBS on

4/30/02 due to increased concerns and episodes of choking

Showed a moderate decline in swallowing function with an episode of silent aspiration on thin liquids

Started intensive outpatient speech therapy addressing both swallowing and voice

CASE STUDY, continued Diet consistency modified to soft, moist

consistencies Advised to drink nectar liquids Advised to make sure her sinemet dose

corresponded well with meals and that she try smaller, more frequent meals / day

Continued to go to the dining room – intake and ability to tolerate diet highly variable

Began to lose weight

CASE STUDY, continued Underwent surgery in 2003 and was put on clear

liquids post-operatively Developed an aspiration pneumonia and required

intubation Discharged back to assisted living; suffered

significant weight loss and worsening of dysphagia PEG replaced and received intensive speech therapy

to try to improve swallowing function Transferred to adjacent nursing home

References Bromley, Steven. Smell and Taste Disorders: A Primary Care Approach American Family Physician, Jan 15, 2000 Simmons, Sandra et al. Prevention of Unintentional Weight Loss in Nursing Home Residents: A Controlled Trial of

Feeding Assistance Journal of the American Geriatric Society 56:1466-1473, 2008 www.healthinaging.org/aginingintheknow AGS Foundation for Health in Aging, Chapters on Nutrition, Disorders of the

Mouth, Disorders of the Digestive System. American Geriatric Society Clinical Guideline: Feeding Tube Placement in Elderly Patients with Advanced Dementia Fucile, Sandra et al. Functional Oral-Motor Skills: Do They Change With Age? Dysphagia 13: 195-201 (1998) Youmans, Scott et al. Differences in Tongue Strength Across Age and Gender: Is There a Diminished Strength Reserve?

Dysphagia 24: 57-65 (2009) Leslie, Paula et al. Swallow Respiratory Patterns and Aging: Presbyphagia or Dysphagia? Journal of Gerontology Vol.

60A, No. 3, 391-395 (2005) Yoshikawa, Mineka et al. Aspects of Swallowing in Healthy Dentate Elderly Persons Older Than 80 Years Journal of

Gerontology Vol 60A, No4, 506-509 (2005) Logemann, Jeri et al. Temporal and Biomechanical Characteristics of Oropharyngeal Swallow in Younger and Older Men

Journal of Speech, Language and Hearing Research Vol. 43, 1264-1274 (October 2000) Logemann, Jeri et al. Oropharyngeal Swallow in Younger and Older Women: Videofluoroscopic Journal of Speech,

Language and Hearing Research Vol. 45, 434-445 (June 2002) Achem, Sami et al. Dysphagia in Aging Journal of Clinical Gastroenterology Vol. 39, No 5 (May/June 2005) Schindler, Joshua et al. Swallowing Disorders in the Elderly Laryngoscope 112: April 2002 Wright, l et al. eating Together is Important; Using a Dining Room in and Acute Elderly Medical Ward Increases Energy

Intake Journal of Human Nutrition Dietetics 19: 23-26 (2006)