Considering Nutrition
Clients with dementia have a tendency to loose weight (Finucane, Christmas & Travis, 1999). This weight loss can lead to malnutrition. When modifying diets, the nutritional needs of the client must be considered. Wright et al, (2005) found that clients on modified diets in nursing facilities were not receiving the nutrition they needed. Another study Suominen et al (2005) which looked at a particular rest home in Sweden found that 29% of residents suffered from malnutrition (p 580). One of the things this was highly related to this was the existence of dementia and swallowing difficulties. The clients with dementia can be unable to regulate their own dietary needs and can have behaviour issues such as food refusal (Finucane, Christmas & Travis, 1999). This can contrbute to the issue of malnutrition. The decrease in the desire for food and the decrease in taste sensation mentioned above, can also contribute to the problem. It is essential therefore to ensure that clients are receiving adequate nutrition and collaboration with dietician will most likely be needed. Consideration for this is needed when planning interventions.




Modification of Diet

Dietary modifications are cited as been overused (Huckabee and Pellitier, 1999). However with this client group many of the compensatory and rehabilitation techniques cannot be carried due to the cognitive impairment. Hence this maybe the only appropriate approach.

Solid food
Modification of the consistency, temperature, flavour and amount presented are some of the ways of managing the consumption of solid foods in clients with dysphagia. Certain foods will be more problematic for certain clients and therefore may need to be eliminated from their diet. The assessment of the client should reveal this.
Modification of consistency
NZAT standards for descriptors and standards of modified food consistencies
A thorough assessment of the client should reveal the consistencies that the clients tend to aspirate on more or less. Consistencies that induce more aspiration should be eliminated from the client’s diet. Some clients who don't ave dementia may eliminate consistencies that induce more aspiration themselves (Rosenvinge and Starked, 2005). However clients with dementia do not have the insight to moderate these themselves especially at the severe stages The responsibility is therefore on speech language therapists, other medical professionals and caregiving staff in the nursing facilities to monitor and review the client’s dietary and swallowing needs.
Modification of Bolus Size, Temperature and Flavour
Another way to manage dysphagia through dietary modification is modifying the size, temperature and flavour of the bolus presented to the client. Modifying the size of the bolus presented, modifying the temperature and flavour of the bolus are common interventions used with clients with dementia. Temperature and flavour are often used to stimulate the activation of a swallow (Easterling and Robbins, 2008). The use of a sour bolus has been cited as been particularly effective in the literature. It is thought to stimulate a stronger swallow, to increase strength of muscle contraction and reduce aspiration (Logemann et al, 1995). Due to the anosmia (loss of sense of smell resulting in loss of taste) experienced by clients with dementia they often prefer highly seasoned, flavoured or sweet foods (Easterling and Robbins, 2008). This can help to stimulate their swallow.
Liquids
Thickening of liquids is a common practice in the treatment of dysphagia. Thicker liquids are considered to induce less aspiration and be easier to control during the swallow (Groher and Crary, 2010).
NZSTA link for descriptors and standards of modified liquids.
Research has shown that thickening liquids can be effective in decreasing aspiration in clients with dementia. Logemann, et al (2008) studied the short term effectiveness of three treatments – chin-tuck, nectar thickened liquids and honey thickened liquids. They found that significantly more people aspirated with the chin-tuck movement and thin liquids than the nectar thickened or honey thickened liquids. The honey-thickened liquids were the most effective strategy for decreasing aspiration.



Maintaining Nutrition and Preventing Malnutrition
As previosuly discussed dementia client are at an increased risk for malnutrition. Lack of apetite and food refusal increases the risk of malnutrition. The risk for malnutrition is also increased in clients with dementia because they are often unable to feed themselves (Easterling and Robbins, 2008). They therefore rely on others to supply their nutritional needs. There are a few strategies that can help to increase a clients nutritional intake. One thing that can be done is through supporting a person diet with numerous high calorie snacks throughout the day. A study by Boczko (2005) showed that patients who were given timed snacks two hours after each meal improved their nutrition and hydration over four weeks. The study by Boczko found that it is most successful if the snacks are tailored to the clients personal preference. Another way to increase a patient nutrition is to support their diet with nutritional supplements that come in the form of drinks. This is not to replace eating but to add to client diet

The Actual Meal
Decreasing the Risk of Aspiration

Aspiration is common cause of pneumonia in clients with dementia (Gradon, 2006). Aspiration pneumonia has been linked to the presence of oropharyngeal and esophopharyngeal dysphagia. Oropharyngeal dysphagia is common with dementia (Eisenstadt, 2008, see the Dysphagia coupled with Dementia page for further details on this). However Langmore, et al (1998) found that aspiration pneumonia was highly associated with lack of oral care. The amount of bacteria in the oral cavity and the presence of tooth decay were associated with the presence of aspiration pneumonia. Another interesting finding they found was that aspiration pneumonia in clients was significantly related to been dependent on others for their oral care. Hence it is important for caregiver staff to ensure that clients have good oral care. In clients with dementia it is likely that they will be unable to maintain adequate oral care so it will fall to the care-giver staff to carry this out to an appropriate standard.

Working with clients with dementia and in the Residential Care Environment
Meal time environment
The page a Introduction to Clients with Dementia discusses the residential care environment. The meal time environment within these facilities tends to be a communal eating environment with everyone eating in a dining room. These environments tend to be busy with many patients and staff members moving around. This can increase distractions for clients with dementia and therefore increase the chance of food refusal. This will make the intervention strategies discussed above less effective and increase the chance of malnutrition.
Several things can help to promote greater compliance and food intake in clients with dementia.
Having the same seat and table in the dining room as well as the same caregiver assisting with feeding can help to establish a regular meal time routine for the person with dementia (Easterling and Robbins (2008). It also helps to eliminate distractions from tables and trays also by removing non-food items such as salt shakers and vases. Making sure that the person feeding the client is attending to the client for the entire meal is also important. This is especially important if the client needs cues to maintain attention on the meal and swallowing. Dinning with Dementia (p18-19) provides some safe swallowing guidelines that describe how to modifiy the environment to promote safe swallow. Their guidelines are photocopyable and therefore can be place around the meal time areas to remind carers and nursing staff of the safety protocol to take with these clients. Working with other professional
In residential and nursing facilities there are often many different staff members working to help manage client’s dysphagia. The link below provide more information on the team that a speech and language therapist may work with when providing intervention for a client with dementia.The TeamWith this client group speech language therapist do not tend to work with the actual clients. Instead speech therapists tend to work under a consultative model. They determine the appropriate intervention for each client and provide the knowledge and tools to the nursing staff and caregiver within the residential home. Working closely with nursin gstaff is important as these are the people who have the most contact with the clients with dementia. It is especially important that nursing and caregiver staff are educated as to the importance of complying with speech language therapist recommendations. A study by Rosenvinge and Starke (2005) in a hospital in London showed that 73% of non-compliance with speech language therapists recommendations, for safe swallowing and food and drink volume, by clients was due to lack of recommended supervision. It also showed that 54% of inappropriate food consumption was due to the wrong foods been served to the patients by the staff (p591-592). However with education of the nursing, and food preparation staff, the amount of compliance with speech language therapist recommendations increased dramatically. Due to clients with dementia been unable to regulate their own food consumption and lack of insight into swallowing problems the responsibility is on the staff to know how to monitor their meal times adequately


Tube feeding in patients with late stage dementia and dysphagia

Reasons for tube feedingWhen it becomes very difficult to feed patients with advanced dementia often tube feeding is implemented to provide the individual with adequate nutrition (McNamara & Kennedy, 2001).
There is much debate surrounding the initiation of tube feeding and there are pros and cons that accompany both options.
Risks and benefitsGroher and Crary (2010) note the risks and benefits of gastrostomy feeding. Risks include surgery, as this is required for placement. Site care is needed to prevent infection. There is a risk of the tube falling out and the individual can experience reflux if the food/food substitute is given too quickly and the stomach subsequently fills too quickly. The benefits of a gastrostomy according to Groher and Crary (2010) are that it can be used long term and the tube can be removed or replaced fairly easily.
It is anticipated that providing nutrition via tube feeding, not only prevents malnutrition and subsequent weight loss but reduces the incidence of skin breakdown and development of pressure sores and reduces the risk of aspiration (McNamara & Kennedy, 2001). However, it has been found, that there is no data to suggest this is the case (McNamara & Kennedy, 2001). In addition to this, patients generally continue to lose weight despite receiving adequate calories through their tube feeds (Huffman,2000).
There is no literature that indicates prolonged survival in patients with advanced dementia (Huffman, 2000). In fact a large study that was carried out showed no difference in survival rates between individual who ate orally and those who were tube-fed (Huffman, 2000).
With regard to quality of life, which tube-feeding should ideally improve, due to adequate nutrition and the subsequent benefits of this. It may not be the case. Restraints are commonly used on tube-fed patients with advanced dementia, (Huffman, 2000) which is counter intuitive to the goal of increasing quality of life. In addition to this, data shows that tube-feeding does not improve patient comfort levels and reduces the amount of human contact the patient has (Huffman, 2000). The benefits of tube feeding are uncertain. Finucane, Christmas & Travis (1999) searched through research performed in this area to see whether tube-feeding can prevent aspiration pneumonia, reduce the risk of pressure sores, improve function, prolong survival or improve comfort levels. There were no published, randomised trials that compared oral feeding with tube feeding to prove or disprove these benefits.
Curran and Wattis (2004) believe there is adequate evidence illustrating that artificial feeding is associated with an increased incidence of aspiration.

Patient PreferenceThis is unable to be obtained as the stage where it is suggested the patient is unable express their wishes (McNamara & Kennedy, 2001).



Advance Directives

An advance directive can be put in place while an individual is still competent to make decisions, so they can make their wishes known, should they be incapable in the future to make decisions due to mental incapacity or being in an unconscious state (Groher & Crary, 2010). There are two parts to the advance directive. One is a ‘living will’ which is a written document, instructing health professionals to forego some type of treatment and giving them consent to do this. The other part is the ‘durable power of attorney for health care’, where the individual appoints a person to act on their behalf should they be in a state in future where they are unable to make decisions about their medical treatment (Groher & Crary, 2010). This would enable them to say whether or not they would want nutrition provided for them via a feeding tube to sustain life (Groher & Crary, 2010).

Ethics


Ethical decision making surrounding such treatments as tube feeding when the individual concerned is unable to make the decision for themselves involves balancing all factors (Groher & Crary, 2010). Morals and values of society and individuals are considered as well as evidence based medical facts and legal precedence (Groher & Crary, 2010).

Below are the links for ethics policies from the NZSTA and Auckland DHB


http://www.adhb.govt.nz/CETU/IMGs/Legislation&Ethics.htm
http://www.speechtherapy.org.nz/about-nzsta/ethics