How To

try this

Continuing Education

2.5

HOURS

By Janice L. Palmer, MS, RN, and Norma A. Metheny, PhD, RN, FAAN

Preventing Aspiration
with Dysphagia
Aspiration can lead to aspiration pneumonia, a serious health problem for older adults.

in Older Adults

40

Ed Eckstein

AJN M February 2008

Vol. 108, No. 2

http://www.nursingcenter.com

read it watch it try it

Overview: Dysphagia, the impairment of any part of the swallowing process, increases the risk of aspiration. Dysphagia and aspiration are associated with the development of aspiration pneumonia. While some changes in swallowing may be a natural result of aging, dysphagia is especially prevalent among older adults with neurologic impairment or dementia, leading to an increased risk of aspiration and aspiration pneumonia. This article discusses best practices for assessment and prevention of aspiration among older adults who are being hand-fed or fed by tube. To view an accompanying online video, go to http:/ /links. lww.com/A226.

Web Video
Watch a video demonstrating the best practices for preventing aspiration in older adults with dysphagia at http://links.lww.com/A226.

A Closer Look
Get more information on how to recognize aspiration, the pathophysiology of dysphagia, and the prevalence of aspiration and dysphagia.

Try This: Preventing Aspiration in Older Adults with Dysphagia

This shows the best practices in the original form. See page 45.

enjamin Link, age 74, was admitted to the hospital for hip-replacement surgery related to crippling arthritis and chronic pain. (This case is a composite based on our experience.) He has a 12-year history of Parkinsons disease and had been taking carbidopa levodopa (Sinemet and others) 25100 mg four times daily. Upon admission the medication was suspended because of preoperative fasting and then, later, postoperative nausea. This worsened his Parkinsons symptoms, including difficulty in swallowing. Mr. Link is now drowsy as a result of the anesthesia and is receiving morphine by patient-controlled pump, both of which increase the risk of impaired swallowing, which could lead to aspiration. On his second postoperative day, the nurse notices that Mr. Link is coughing while the nursing assistant gives him breakfast. She also hears gurgling sounds, which worsen after he drinks juice. Mr. Link is drooling and speaks in a soft, hoarse voice. He doesnt have fever or chills, but on auscultation the nurse detects faint crackles in the base of Mr. Links left lung. The physician is notified; the nurse suspects that Mr. Link had been aspirating during meals.

Online Only
Unique online material is available for this article. URL citations appear in the text; simply type the URL into any Web browser.

IMPLEMENTING THE TRY THIS APPROACHES Although the evidence available on the effectiveness of many preventive strategies is limited,18, 19 the approaches summarized in Try This: Preventing Aspiration in Older Adults with Dysphagia (page 45) are the ones best known for decreasing the risk of aspiration in this population. (To understand the
ajn@wolterskluwer.com

importance of this assessment, see Why Assess for Aspiration in Patients with Dysphagia? page 42.) Dietary modifications are recommended by a speech pathologist or other clinician trained in the assessment of swallowing. Thickened liquids may be recommended. For example, one study found that patients with neurogenic dysphagia aspirated less often when liquids thickened to the consistency of nectar or pudding were provided than when thin liquids were given.20 But thickened liquids arent recommended in all cases of dysphagia; therefore, working with a speech pathologist to determine the specific needs of the patient is critical. Oral care. Poor oral hygiene and tooth decay have been correlated with the occurrence of aspiration pneumonia,11, 12, 17 and good oral care has been associated with a lower rate of pneumonia.10 Mr. Link receives a bedside dysphagia workup by the speech pathologist. She observes no overt aspiration of liquids during the evaluation but determines that Mr. Link is at risk for dysphagia because of his age, Parkinsons disease status, altered medication regimen, and sedation from the analgesia. Therefore, the nurse implements the Try This approaches to promote swallowing. The nurse asks the physical therapist to complete her work with
AJN M February 2008
M

Vol. 108, No. 2

41

How To

try this
Mr. Link at least 30 minutes before mealtimes, which will allow him time to rest before eating. At mealtimes, the nurse helps Mr. Link to sit upright at a 45 angle, the highest permitted by postoperative orders. The nurse instructs the nursing assistant to feed Mr. Link slowly, giving him small amounts and alternating solids with liquidsall suggested in the Try This approaches. Next, the nurse reviews Mr. Links medication list, looking for drugs that may be causing sedation and thus impairing the coughing or swallowing reflex. She also talks with Mr. Link about his home routine of eating meals and taking medications. She wants to get him back on a medication schedule to decrease the dysphagia and other symptoms of Parkinsons disease. To promote chewing and swallowing, the nurse looks for missing teeth or missing or poorly fitting dentures. She finds that his dentures fit well and that his oral hygiene is adequate. The nurse tells him about the importance of good oral hygiene, including cleaning his dentures and rinsing his mouth with mouthwash. (To watch the segment of the online video on preventing aspiration during hand feeding, go to http://links.lww.com/A227. ) IMPLEMENTING THE TRY THIS APPROACHES FOR TUBE FEEDING Good oral hygiene is also important for patients fed by tube. In a comparison of three groups of institutionalized older adults (those fed orally, those fed by nasogastric tube, and those fed by percutaneous enterogastric tube), tube-fed patients had a higher prevalence of oropharyngeal pathogenic bacteria than those fed orally.21 Oral bacteria levels were highest in those receiving nasogastric tube feedings. This suggests to us that tube-fed patients (especially those receiving nasogastric feedings) are at higher risk for bacterial pneumonia if aspiration occurs than are those who receive oral feedings. (To see the segment of the online video on preventing aspiration during ) tube feeding, go to http://links.lww.com/A228. Tube placement. Correct placement of the feeding tube is also critical to the prevention of aspiration. A tube inadvertently positioned in the trachea or lung causes aspiration by proxy if tube feeding is initiated or medications are administered. In addition, a tube whose ports are situated in the esophagus increases the risk of regurgitation and aspiration.22 For these reasons, radiographic confirmation of placement is strongly recommended before a tube is first used. In adults, an abdominal X-ray is preferred over a chest X-ray; it can determine where the tube ends in the gastrointestinal tract.23 Thereafter, the nurse can use a variety of tests at the bedside to help determine the tubes position: observing the
42
AJN M February 2008
M

Why Assess for Aspiration in Patients with Dysphagia?

Recognizing aspiration. Aspiration may manifest itself as coughing and choking while eating or drinking, as well as by drooling, gurgling sounds when speaking, or hoarseness. Silent aspiration, or aspiration without symptoms, also may occur and is even more difficult to detect.1 Aspiration of a substance such as food, tube-feeding formula, saliva, or vomitus into the respiratory tract can lead to aspiration pneumonia. While there may be challenges in recognizing aspiration in older adults, it may also be difficult to detect aspiration pneumonia before the occurrence of overwhelming illness.2 The typical pneumonia symptoms of cough, increased respiratory rate, fever, and chills may not be seen in older adults; delirium, increased confusion, or a fall may be the only apparent initial change. Several methods can be used to determine whether aspiration is occurring, including bedside swallowing assessment by a specially trained speech pathologist, videofluoroscopy (also known as a modified barium swallow test), bronchoscopy, and fiber endoscopy. Recognizing aspiration in the tube-fed patient. Aspiration can occur for many reasons, including vomiting, severe coughing, slowing of the swallowing process, or weakening of the muscles involved in swallowing. Patients who are tube fed are at risk for aspiration for the same reasons, as well as because of poor tolerance of the tube feeding formula and incorrect tube positioning. When tube feedings are used, clinicians observe for tube feeding formula in sputum or secretions obtained during tracheal suctioning; however, this is difficult to do because enteral formula is tan or milky in color and may be indistinguishable from sputum or tracheal secretions. In the past, clinicians added blue food dye to enteral formula to increase its visibility. But according to a recent consensus statement issued by the North American Summit on Aspiration, which was based on the extensive literature

length of the tube extending from the insertion site and the appearance and volume of fluid withdrawn from the tube, for example.24, 25 Contents withdrawn by a syringe from a gastric tube during feedings usually have the appearance of curdled or unchanged formula. While the pH of gastrointestinal contents is buffered by enteral formula, fluid withdrawn from gastric tubes usually has a lower pH than that of fluid withdrawn from small-bowel feeding tubes.26 The volume of fluid withdrawn from gastric tubes is typically higher than that withdrawn from small-bowel tubes.24 Although there is no agreement on how much gastric residual volume is too much, many do agree that
http://www.nursingcenter.com

Vol. 108, No. 2

review and recommendations of a panel of experts, this method is ineffective, perhaps toxic, and is no longer recommended.3 Further, the same panel of experts found that attempting to identify the presence of glucose-containing enteral formula by testing for glucose in tracheal secretions is ineffective and is also no longer recommended. Pathophysiology. Dysphagia, defined as impairment of any part of the swallowing process, increases the risk of aspiration. Dysphagia and aspiration are associated with the development of aspiration pneumonia.4-6 The ability to swallow solid food and liquids depends on the interplay of as many as 50 pairs of muscles in the head and neck. While some changes in swallowing are a natural result of aging, dysphagia is often associated with or caused by neurologic impairment, which can interfere with the proper function of these muscle groups and in turn interferes with the closure of the larynx when food or liquid reaches the back of the tongue. These substances then can enter the trachea and lungs.7 Older adults, especially those with neurologic conditions such as stroke, Parkinsons disease, dementia, and multiple sclerosis, are at risk for dysphagia and aspiration.8,9 Patients who have decreased alertness because of medications (including anesthesia and sedatives), medical conditions, or a combination of these, may have slowed gag and swallowing reflexes and, therefore, be less able to respond to regurgitation and vomiting. Also, because chewing prepares food for swallowing, the absence of teethor the presence of poorly fitted dentures increases the risk of aspiration, as does decreased saliva production. Poor oral hygiene promotes the growth of pathogenic organisms in the mouth, thereby increasing the risk of aspiration pneumonia.10-12 Prevalence. Reports of the prevalence of dysphagia vary with study population, diagnosis, and treatment. According to a 1999 report from the Agency for Health Care Policy and Research, neurologic disordersstroke, mostlycaused dysphagia in an estimated 300,000 to 600,000 Americans annually.13 Researchers employing a dysphagia-screening questionnaire found that almost 14% of community-residing older adults reported symptoms consistent with dysphagia.14 Regan and colleagues found that 32% of adults seen by an

acute and community health psychiatric service had dysphagia.15 Possible causes considered were adverse effects of psychotropic medications and, perhaps, decreased alertness or a concomitant neurologic disorder. Frail patients, especially those with advanced disease, are also at increased risk for dysphagia. For example, in a study of 82 nursing home residents with eating problems, 55% had symptoms of dysphagia, but fewer than a quarter of those had received a formal swallowing evaluation.16 Aspiration pneumonia represents a significant proportion of all pneumonia cases. In one study, 30% of patients hospitalized with pneumonia from a continuing care facility had aspiration pneumonia.9 In a four-year study of men ages 60 and older, Langmore and colleagues found a 22% incidence of aspiration pneumonia, with the highest rate of 44% in nursing home residents.17 Predictors for aspiration pneumonia included being dependent on others for feeding or oral care, having more decayed teeth, and receiving tube feeding. In a later study, Langmore and colleagues identified 18 variables as significant predictors of aspiration pneumonia in nursing home residents; among these were the need for tracheal suctioning, being bedfast, being tube fed, and the presence of chronic obstructive pulmonary disease or congestive heart failure.5 Patients who are on ventilators and receive tube feedings are also at risk for aspirating.6 One of us (NAM, with colleagues) found that 31% of tracheal secretions collected during suctioning of patients on ventilators were positive for pepsin, a digestive protease produced in the stomach, which is indicative of aspiration of stomach contents.6 There was evidence that 89% of patients on ventilators aspirated at least once in a three-day period. Those with frequent pepsin-positive specimens were at significantly greater risk for pneumonia. Additional risk factors for pneumonia in this study population included having the head of bed elevated less than 30o, having decreased consciousness (as measured by a Glasgow Coma Scale Score of less than 9), being sedated, and receiving opioids and paralytic agents. For more information, see Preventing Aspiration When a Patient Eats or During Hand-Feeding of the Patient, at http://links.lww.com/A362.

its wise to measure gastric residual volume when feeding by tube.27-29 This is a reasonable view; a high gastric residual volume increases the risk of gastroesophageal reflux and subsequent aspiration of gastric contents into the trachea. In one study, investigators reported a high correlation coefficient (0.93) between gastric residual volume and gastroesophageal reflux in 19 critically ill patients.30 The most frequently cited volume of concern is 200 mL or greater.3, 27, 29 Tube site and feeding method may also play roles in preventing aspiration. Compared with gastric tube feeding, duodenojejunal (small intestine) tube feeding may be associated with a lower incidence of aspiration.3 This is especially true if the
ajn@wolterskluwer.com

patient has significantly slowed gastric motility. Also, the risk of aspiration continues after placement of a gastrostomy tube.31, 32 The consensus statement of the North American Summit on Aspiration in the Critically Ill Patient recommends continuous feeding (rather than intermittent feeding) in patients at high risk for aspiration.3 In a comparison of pump-assisted and gravity-controlled drip feeding for patients with percutaneous endoscopic gastrostomy tubes, those receiving pumpassisted feedings had less vomiting, regurgitation, and aspiration.33 Unless contraindicated, the head of the bed for a patient receiving tube feedings should be elevated
AJN M February 2008
M

Vol. 108, No. 2

43

How To

try this
more than 30. There is evidence that a sustained supine position (with the head of the bed flat) increases the probability of aspiration.6, 34 For more information, see Preventing Aspiration During Nasogastric, Nasointestinal, or Gastrostomy Tube Feedings at http://links.lww.com/A363. COMMUNICATING THE STRATEGIES Mr. Links nurse will instruct him, as well as his family caregivers and nursing assistants, in strategies to promote swallowing. The nurse already requested the physical therapist to complete postoperative therapy at least 30 minutes before meals and will coordinate the prescribed bedside dysphagia evaluation with the speech pathologist. While the chin-flexed position may be helpful for Mr. Link, different positions may be better for others.35, 36 For example, a patient recovering from head and neck surgery will need to work with a speech pathologist to determine the best feeding position to minimize the risk of aspiration during feeding.37 The occupational therapist and speech pathologist can be helpful in determining the correct feeding position for patients. The nurse will arrange and coordinate the prescribed dietetic assessment and assure that Mr. Link receives the correct diet. (To view the segment of the online video on assessing and preventing aspiration, go to http:// links.lww.com/A229. )

Watch It!

o to http:/ /links.lww.com/A226 to watch a nurse use the best practice approaches described in Preventing Aspiration in Older Adults with Dysphagia. Then watch the health care team plan preventive strategies. View this video in its entirety and then apply for CE credit at www.nursingcenter. com/AJNolderadults; click on the How to Try This series link. All videos are free and in a downloadable format (not streaming video) that requires Windows Media Player.

As the nurse suspected, Mr. Links modified barium swallow test shows a slowing of swallowing function. Aspiration is not noted. The nurse works with Mr. Link, his wife and daughter, the nursing assistant, and the speech pathologist to continue using the Try This approaches. His lung crackles resolve spontaneously. Mr. Links functional status improves and he is discharged home. The nurse instructs Mr. Links wife and daughter on how to do the Heimlich maneuver. A follow-up evaluation 30 days later shows an improvement in Mr. Links swallowing function. (For the segment of the online video on risk-reduction strategies, go to http://links. lww.com/A230. ) CONSIDER THIS What are the considerations for special populations? The need to promote swallowing and decrease the risk of aspiration in patients may be indicated for a variety of medical conditions. A patient with advanced dementia may forget how to chew or swallow, and it may be helpful for a nurse to demonstrate chewing or to gently stroke the area under the chin with a downward motion while the patient is swallowing. A pureed diet may be indicated to decrease the risk of choking. Patients with advanced dementia or hemiparesis, localized disease or injury affecting the oropharyngeal area, may unknowingly pocket food in their cheeks; its important to visually inspect the oral cavity for food (including under the dentures) during and after meals. These patients are at risk for choking or aspirating if left unobserved with food in their mouths. In addition, in patients with hemiparesis or oropharyngeal disease or injury, the caregiver can place the food on the side of the mouth that doesnt have weakness or paralysis. What are the ethical considerations of using feeding tubes in patients with dementia? A 1999 cross-sectional study by Mitchell and colleagues found that 34% of residents with advanced cognitive impairment in Medicare- or Medicaid-certified nursing homes had feeding tubes.38 However, the wisdom of placing feeding tubes in this population has been questioned. In a review article, Finucane
http://www.nursingcenter.com

Symptoms of Dysphagia and Aspiration

Symptoms of dysphagia and aspiration may include the following: coughing during meals hoarse voice following meals gurgling sounds in the throat drooling upper respiratory infection pneumonia

Symptoms of Aspiration Pneumonia in Older Adults

Any of the following symptoms should alert the practitioner that the patient may have aspiration pneumonia. elevated respiratory rate fever cough chills pleuritic chest pain crackles (rales) delirium, increased confusion, or falls
Marrie TJ. Clin Infect Dis 2000;31(4):1066-78.

44

AJN M February 2008

Vol. 108, No. 2

Issue Number 20, Revised 2007

Series Editor: Marie Boltz, PhD, APRN, BC, GNP Managing Editor: Sherry A. Greenberg, MSN, APRN, BC, GNP New York University College of Nursing

Preventing Aspiration in Older Adults with Dysphagia

By: Norma A. Metheny, RN, PhD, FAAN, Saint Louis University School 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, Parkinsons 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 reex (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-uoroscopy or beroptic 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 signicantly 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 specic strategies to prevent aspiration during the feeding of dysphagic individuals (Loeb, et al, 2003). However, the following actions may be of some benet: Provide a 30-minute rest period prior to feeding time; a rested person will likely have less difculty swallowing. Sit the person upright in a chair; if conned to bed, elevate the backrest to a 90-degree angle. Slightly exing the persons 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 benet from this position. Adjust rate of feeding and size of bites to the persons tolerance; avoid rushed or forced feeding. Alternate solid and liquid boluses. Vary placement of food in the persons mouth according to the type of decit. 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 signicantly lower when nectar or pudding was swallowed (as compared to when liquids were swallowed). Minimize the use of sedatives and hypnotics since these agents may impair the cough reex and swallowing. Evaluate the effectiveness of cueing, redirection, task segmentation and environmental modications (minimizing distractions) as alternatives to hand feeding. (See Try This: Assessing Eating and Feeding Issues in Older Adults with Dementia).
Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-prot educational purposes only, provided that The Hartford Institute for Geriatric Nursing, College of Nursing, New York University is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail notication of usage to: hartford.ign@nyu.edu.

ajn@wolterskluwer.com

AJN M February 2008

Vol. 108, No. 2

45

PREVENTION OF ASPIRATION DURING TUBE FEEDING: Persons who aspirate oral feedings are also likely to aspirate tube feedings, either by nasogastric or gastrostomy tubes (Siddique, et al, 2000). Therefore, there is a growing trend to avoid the use of tube feedings merely as a means to prevent aspiration. Nonetheless, there are instances in which tube feedings are needed, especially during periods of acute illness. When tube feedings are necessary, the following activities may help to minimize aspiration: Keep the beds backrest elevated to at least 30 during continuous feedings. When the tube-fed person is able to communicate, ask if any of the following signs of gastrointestinal intolerance are present: nausea, feeling of fullness, abdominal pain or cramping. These signs are indicative of slowed gastric emptying that may, in turn, increase the probability for regurgitation and aspiration of gastric contents. Measure gastric residual volumes every 4 to 6 hours during continuous feedings and immediately before each intermittent feeding. This assessment is especially important when the tube-fed person is unable to communicate signs of gastrointestinal intolerance. Although there is no convincing research-based information regarding how much gastric residual volume is too much, a persistently elevated amount (such as greater than 200 ml) should raise concern (McClave, et al, 2002). A prokinetic agent (such as metoclopramide or erythromycin) may be prescribed to alleviate persistently slowed gastric emptying (McClave, et al, 2002). Post-pyloric placement of the feeding tube (jejunostomy) may be prescribed if persistently slowed gastric emptying is a problem (McClave, et al, 2002). The efcacy of this action is controversial. Pump assisted feedings may be associated with fewer aspiration events than are gravitycontrolled feedings in bedridden patients with gastrostomy tubes (Shang, et al, 2004). PREVENTION OF ASPIRATION PNEUMONIA BY ORAL CARE: Missing teeth and poorly tted dentures predispose to aspiration by interfering with chewing and swallowing. Infected teeth and poor oral hygiene predispose to pneumonia following the aspiration of contaminated oral secretions (Quagliarello, et al, 2005; Terpenning, 2005). Results from a recent study suggest that tube feeding in elderly persons is associated with signicant pathogenic colonization of the mouth, more so than that observed in those who received oral feedings (Leibovitz, et al, 2003). There is evidence that providing weekly dental care and cleaning the elder persons teeth with a toothbrush after each meal lowers the risk of aspiration pneumonia (Yoneyama, et al, 2002). MORE ON THE TOPIC: Best practice information on care of older adults: www.ConsultGeriRN.org. Clave, P., De Kraa, M., Areola, V., Girvent, M., Farre, R., Palomera, E., Serra-Prat, M. (2006). The effect of bolus viscosity on swallowing function in neurogenic dysphagia. Alimentary Pharmacology & Therapeutics, 24(9), 1385-94. Leibovitz, A., Plotnikov, G., Habot, B., Rosenberg, M., & Segal, R. (2003). Pathogenic colonization of oral ora in frail elderly patients fed by nasogastric tube or percutaneous enterogastric tube. Journal of Gerontology Series A-Biological Sciences & Medical Sciences, 58(1), 52-58. Loeb, M.B., Becker, M., Eady, A., & Walker-Dilks, C. (2003). Interventions to prevent aspiration pneumonia in older adults: A systematic review. JAGS, 51(7), 1018-1022. Marrie, T.J. (2000). Community-acquired pneumonia in the elderly. Clinical Infectious Disease, 31(40), 1066-1078. Marrie, T.J. (2002). Pneumonia in the long-term care facility. Infection Control and Hospital Epidemiology, 23(3), 159-164. McClave, S.A., DeMeo, M.T., DeLegge, M.H., DiSario, J.A., Heyland, D.K., Maloney, J.P., Metheny, N.A., Moore, F.A., Scolapio, J.S., Spain, D.A., & Zaloga, G.P. (2002). North American Summit on Aspiration in the Critically Ill Patient: Consensus statement. Journal of Parenteral & Enteral Nutrition, 26(Suppl. 6), S80-85. Quagliarello, V., Ginter, S., Lan, L., Van Ness, P., Allore, H., Tinetti, M. (2005). Modiable risk factors for nursing home-acquired pneumonia. Clinical Infectious Diseases, 40(1), 1-6. Shanahan, T.S., Logemann, J.A., Rademaker, A.W., Pauloski, B.R., & Kahrilas, P.J. (1993). Chin-down posture effect on aspiration in dysphagic patients. Archives of Physical Rehabilitation, 74, 736-739. Shang, E., Geiger, N., Sturm, J.W., & Post, S. (2004). Pump-assisted enteral nutrition can prevent aspiration in bedridden percutaneous endoscopic gastrostomy patients. Journal of Parenteral and Enteral Nutrition, 28(3), 180-183. Siddique, R., Neslusan, C.A., Crown, W.H., Crystal-Peters, J., Sloan, S., & Farup, C. (2000). A national inpatient cost estimate of percutaneous endoscopic gastrostomy associated aspiration pneumonia. American Journal of Managed Care, 6(4), 490-496. Singh, S., & Hamdy, S. (2006). Dysphagia in stroke patients. Postgraduate Medical Journal. 82(968), 383-391. Terpenning M. (2005). Geriatric oral health and pneumonia risk. Clinical Infectious Diseases, 40(12), 1807-1810. Yoneyama, T., Yoshida, M., Ohrui, T., Mukaiyama, H., Okamoto, H., Hoshiba, K., Ihara, S., Yanagisawa, S., Ariumi, S., Morita, T., Mizuno, Y., Ohsawa, T., Akagawa, Y., Hashimoto, K., & Sasaki, H. (2002). Oral care reduces pneumonia in older patients in nursing homes. JAGS, 50(3), 430-433.

A SERIES PROVIDED BY

The Hartford Institute for Geriatric Nursing

EMAIL : hartford.ign@nyu.edu HARTFORD INSTITUTE WEBSITE : www.hartfordign.org CONSULTGERIRN WEBSITE : www.ConsultGeriRN.org

46

AJN M February 2008

Vol. 108, No. 2

http://www.nursingcenter.com

Online Resources
For more information on Preventing Aspiration in Older Adults with Dysphagia and other geriatric assessment tools and best practices, go to www.hartfordign.org, the Web site of the John A. Hartford Foundationfunded Hartford Institute for Geriatric Nursing at New York University College of Nursing. The institute focuses on improving the quality of care provided to older adults by promoting excellence in geriatric nursing practice, education, research, and policy. For more information on best practices in the care of older adults go to www.ConsultGeriRN. org. The site lists resources and offers continuing education opportunities. For access to all articles and videos in the How to Try This series, go to www.nursingcenter.com/AJNolderadults and click on the How to Try This link.
A. Stotts, EdD, RN, FAAN (nancy.stotts@nursing.ucsf.edu), and Sherry A. Greenberg, MSN, APRN,BC, GNP (sherry@ familygreenberg.com), are coeditors of the print series. The articles and videos are to be used for educational purposes only. Routine use of a Try This tool may require formal review and approval by your employer.

REFERENCES
1. Ramsey D, et al. Silent aspiration: what do we know? Dysphagia 2005;20(3):218-25. 2. Marrie TJ. Community-acquired pneumonia in the elderly. Clin Infect Dis 2000;31(4):1066-78. 3. McClave SA, et al. North American Summit on Aspiration in the Critically Ill Patient: consensus statement. JPEN J Parenter Enteral Nutr 2002;26(6 Suppl):S80-S85. 4. Loeb M, et al. Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities. Arch Intern Med 1999;159(17):2058-64. 5. Langmore SE, et al. Predictors of aspiration pneumonia in nursing home residents. Dysphagia 2002;17(4):298-307. 6. Metheny NA, et al. Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: frequency, outcomes, and risk factors. Crit Care Med 2006;34(4):1007-15. 7. National Institute on Deafness and Other Communication Disorders (NIDCD). Dysphagia. National Institutes of Health. 1998. http://www.nidcd.nih.gov/health/voice/ dysph.asp. 8. National Institute of Neurological Disorders and Stroke (NINDS). NINDS swallowing disorders information page. National Institutes of Health. 2007. http://www.ninds. nih.gov/disorders/swallowing_disorders. 9. Reza Shariatzadeh M, et al. Differences in the features of aspiration pneumonia according to site of acquisition: community or continuing care facility. J Am Geriatr Soc 2006; 54(2):296-302. 10. Yoneyama T, et al. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc 2002;50(3):430-3. 11. Terpenning MS, et al. Aspiration pneumonia: dental and oral risk factors in an older veteran population. J Am Geriatr Soc 2001;49(5):557-63. 12. Abe S, et al. Oral hygiene evaluation for effective oral care in preventing pneumonia in dentate elderly. Arch Gerontol Geriatr 2006;43(1):53-64. 13. Agency for Healthcare Research and Quality. Diagnosis and treatment of swallowing disorders (Dysphagia) in acute-care stroke patients. Rockville, MD; 1999 Mar. AHCPR Publication Number 99-E023. Evidence Report/Technology Assessment: Number 8; http://www.ahrq.gov/clinic/epcsums/ dysphsum.htm. 14. Kawashima K, et al. Prevalence of dysphagia among community-dwelling elderly individuals as estimated using a questionnaire for dysphagia screening. Dysphagia 2004; 19(4):266-71. 15. Regan J, et al. Prevalence of dysphagia in acute and community mental health settings. Dysphagia 2006;21(2):95-101. 16. Kayser-Jones J, Pengilly K. Dysphagia among nursing home residents. Geriatr Nurs 1999;20(2):77-82. 17. Langmore SE, et al. Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia 1998;13(2):69-81. 18. Loeb MB, et al. Interventions to prevent aspiration pneumonia in older adults: a systematic review. J Am Geriatr Soc 2003;51(7):1018-22. 19. Deane KH, et al. Non-pharmacological therapies for dysphagia in Parkinsons disease. Cochrane Database Syst Rev 2001(1):CD002816. 20. Clave P, et al. The effect of bolus viscosity on swallowing function in neurogenic dysphagia. Aliment Pharmacol Ther 2006;24(9):1385-94. 21. Leibovitz A, et al. Pathogenic colonization of oral flora in frail elderly patients fed by nasogastric tube or percutaneous enterogastric tube. J Gerontol A Biol Sci Med Sci 2003; 58(1):52-5.

and colleagues noted a lack of evidence showing that tube feedings result in weight gain or reduced aspiration in those with advanced dementia.39 Also, a 1992 study of 40 neurologically impaired nursing home residents (including seven with dementia) who received tube feedings found that they continued to lose weight and lean body mass.40 There is also no evidence that tube feedings promote survival or decrease aspiration in patients with severe Alzheimers disease.39, 41 Less social interaction during mealtimes is a drawback to tube feedings, as is the loss of pleasure that comes with feeling, tasting, and swallowing food. Further, tube feedings may cause diarrhea and abdominal discomfort.39 For these reasons, the Alzheimers Association discourages the use of feeding tubes in people with advanced Alzheimers disease but respects patient and surrogate preferences.42 Initiating tube feedings in this population is an individual or family decision with possible legal, cultural, and religious implications and remains a highly controversial ethical issue for some.43, 44 M
Janice L. Palmer is a doctoral student and a John A. Hartford Foundation Building Academic Geriatric Nursing Capacity Scholar at the Saint Louis University School of Nursing, in St. Louis, where Norma A. Metheny is a professor and Dorothy A. Votsmier Endowed Chair in Nursing. Contact author: Janice L. Palmer, jan.l.palmer@gmail.com. The authors have no significant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity. Try This: Preventing Aspiration in Older Adults with Dysphagia is reproduced with permission of Norma A. Metheny, PhD, RN, FAAN, Saint Louis School of Nursing. How to Try This is a three-year project funded by a grant from the John A. Hartford Foundation to the Hartford Institute for Geriatric Nursing at New York Universitys College of Nursing in collaboration with AJN. This initiative promotes the Hartford Institutes geriatric assessment tools, Try This: Best Practices in Nursing Care to Older Adults: www.hartfordign.org/trythis. The series will include articles and corresponding videos, all of which will be available for free online at www.nursingcenter.com/AJNolderadults. Nancy
ajn@wolterskluwer.com

AJN M February 2008

Vol. 108, No. 2

47

How To

try this
22. Metheny NA. Preventing respiratory complications of tube feedings: evidence-based practice. Am J Crit Care 2006; 15(4):360-9. 23. Metheny NA, Meert KL. Monitoring feeding tube placement. Nutr Clin Pract 2004;19(5):487-95. 24. Metheny NA, et al. Indicators of tubesite during feedings. J Neurosci Nurs 2005;37(6):320-5. 25. Metheny NA, Stewart BJ. Testing feeding tube placement during continuous tube feedings. Appl Nurs Res 2002; 15(4):254-8. 26. Metheny NA, et al. pH and concentration of bilirubin in feeding tube aspirates as predictors of tube placement. Nurs Res 1999;48(4):189-97. 27. Stroud M, et al. Guidelines for enteral feeding in adult hospital patients. Gut 2003;52 Suppl 7:vii1-vii12. 28. Kreymann KG, et al. ESPEN Guidelines on Enteral Nutrition: Intensive care. Clin Nutr 2006;25(2):210-23. 29. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 2002;26(1 Suppl):1SA-138SA. 30. Xin Y, et al. The effect of famotidine on gastroesophageal and duodeno-gastro-esophageal refluxes in critically ill patients. World J Gastroenterol 2003;9(2):356-8. 31. Siddique R, et al. A national inpatient cost estimate of percutaneous endoscopic gastrostomy (PEG)-associated aspiration pneumonia. Am J Manag Care 2000;6(4):490-6. 32. Hassett JM, et al. No elimination of aspiration pneumonia in neurologically disabled patients with feeding gastrostomy. Surg Gynecol Obstet 1988;167(5):383-8. 33. Shang E, et al. Pump-assisted enteral nutrition can prevent aspiration in bedridden percutaneous endoscopic gastrostomy patients. JPEN J Parenter Enteral Nutr 2004;28(3): 180-3. 34. Torres A, et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med 1992;116(7):540-3. 35. Shanahan TK, et al. Chin-down posture effect on aspiration in dysphagic patients. Arch Phys Med Rehabil 1993;74(7): 736-9. 36. Rasley A, et al. Prevention of barium aspiration during videofluoroscopic swallowing studies: value of change in posture. AJR Am J Roentgenol 1993;160(5):1005-9. 37. Logemann JA, et al. Effects of postural change on aspiration in head and neck surgical patients. Otolaryngol Head Neck Surg 1994;110(2):222-7. 38. Mitchell SL, et al. Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment. JAMA 2003;290(1): 73-80. 39. Finucane TE, et al. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999;282(14): 1365-70. 40. Henderson CT, et al. Prolonged tube feeding in long-term care: nutritional status and clinical outcomes. J Am Coll Nutr 1992;11(3):309-25. 41. Murphy LM, Lipman TO. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia. Arch Intern Med 2003;163(11):1351-3. 42. Alzheimers Association. Ethical issues in Alzheimers disease: assisted oral feeding and tube feeding. Chicago, IL: The Association; 2006. http://www.alz.org/documents/ national/FSOralfeeding.pdf. 43. Korner U, et al. Ethical and legal aspects of enteral nutrition. Clin Nutr 2006;25(2):196-202. 44. Kunin J. Withholding artificial feeding from the severely demented: merciful or immoral? Contrasts between secular and Jewish perspectives. J Med Ethics 2003;29(4):208-12.

2.5

HOURS

Continuing Education
Go to www.nursingcenter.com/CE/ajn and receive a certificate within minutes.

EARN CE CREDIT ONLINE

GENERAL PURPOSE: To present registered professional

nurses with information on best practices for the assessment and prevention of aspiration among older adults who are being hand fed or fed by tube.

LEARNING OBJECTIVES: After reading this article and taking

the test on the next page, you will be able to outline the background information helpful for understanding the problems of dysphagia and aspiration, including risks, manifestations, and incidence. plan the appropriate interventions for patients at risk for aspiration.

TEST INSTRUCTIONS To take the test online, go to our secure Web site at www. nursingcenter.com/CE/ajn. To use the form provided in this issue,
record your answers in the test answer section of the CE enrollment form between pages 48 and 49. Each question has only one correct answer. You may make copies of the form. complete the registration information and course evaluation. Mail the completed enrollment form and registration fee of $24.95 to Lippincott Williams and Wilkins CE Group, 2710 Yorktowne Blvd., Brick, NJ 08723, by February 28, 2010. You will receive your certificate in four to six weeks. For faster service, include a fax number and we will fax your certificate within two business days of receiving your enrollment form. You will receive your CE certificate of earned contact hours and an answer key to review your results. There is no minimum passing grade.

DISCOUNTS and CUSTOMER SERVICE

Send two or more tests in any nursing journal published by Lippincott Williams and Wilkins (LWW) together, and deduct $0.95 from the price of each test. We also offer CE accounts for hospitals and other health care facilities online at www.nursingcenter.com. Call (800) 787-8985 for details.

PROVIDER ACCREDITATION
LWW, publisher of AJN, will award 2.5 contact hours for this continuing nursing education activity. LWW is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. LWW is also an approved provider of continuing nursing education by the American Association of CriticalCare Nurses #00012278 (CERP category A), District of Columbia, Florida #FBN2454, and Iowa #75. LWW home study activities are classified for Texas nursing continuing education requirements as Type 1. This activity is also provider approved by the California Board of Registered Nursing, provider number CEP 11749, for 2.5 contact hours. Your certificate is valid in all states.

TEST CODE: AJNTT09

48

AJN M February 2008

Vol. 108, No. 2

http://www.nursingcenter.com