#11 Safe Swallowing and Aspiration Pneumonia

Faiman Chow, MS, SLP provides insight into safe swallowing practices, good oral care, the risk factors for aspiration pneumonia, and the use of artificial nutrition in advanced dementia.

Oral/Pharyngeal Phase Anatomy

Nursing Swallow Screen

Used by stroke nurses to identify those who will require a comprehensive assessment of swallow with an SLP.

1. Can they sit up and maintain alertness to participate, are they managing their own secretions, if they answer no to those initial screening questions they fail and if they answer ‘yes”, they can move onto the 3 oz water challenge
2. This is a validated swallow screening tool that is part of the Yale Swallow Protocol
   • Give your patient a cup with 3 oz of water.  
   • Have your patient drink all the water without stopping until it is gone.
   • They pass if:  they are able to drink all the water without stopping with no coughing or signs of swallowing difficulty. Then they can recommend the patient to be placed on a diet.
   • They fail if:  they are unable to drink all the water without stopping or they cough while drinking the water or immediately after. The patient is kept NPO and the SLP will need to follow up. 

Best Practices for Oral Hygiene

Suction swabs are good for removing large amounts of oral debris and dried secretions, but ultimately good old teeth brushing with a toothbrush is the way to go for great oral hygiene and to reduce the risk of aspiration pneumonia. 

• This can be hard with confused, cognitively impaired, or dementia patients
• Try to find the most opportune time when they open their mouth to get in there
• Ideally you would use a suction brush in order to optimize your time in their mouth.

What are some signs that my patient may need a referral for a swallow evaluation?

• Difficulty chewing or pocketing food 
• Coughing with PO intake 
• Decreased PO intake 
• Significant unwanted weight loss (collaborate with registered dietician)
• Trouble taking pills
• Wet/gurgly voice quality with meals 
• Increased confusion 
• Clearing throat after swallow
• Delayed swallow (in the sense of prolonged time to observe pharyngeal movement, based on perceptual observation)
• Reduced vocal quality or vocal loudness 
• Slurred or garbled speech  

Source: https://www.asha.org/slp/clinical/ 

Tips for administering PO Medication

• Most important: ask the patient, patients family, or caregiver how the patient typically takes pills at home. This also should go hand in hand with figuring out their baseline diet at home or the facility they came from before ordering a diet. 
• To assess how well a patient takes pills, start with a bite of puree (applesauce) or sip of thin liquid and see how they coordinate that. If they do pretty well, start with a small pill and follow up with liquid. If that goes well you can give them larger pills, proceeding with one pill at a time. If the patient states that pills seem to get caught or are having difficulty with it going down, place the pill in applesauce to ease pharyngeal transport.
• Of course, always check the patient’s oral cavity at the end of medication administration to ensure it was cleared and that the patient is not pocketing it in their buccal cavity or under their tongue. In the end if there are still concerns you can consult your SLP. 
• Check in with your pharmacist to see if it’s OK to crush a medication. This can sometimes also be indicated on the MAR.
• Shout out to The Swallow Your Pride Podcast that has an entire episode about crushing medications

Aspiration Pneumonia

Aspiration pneumonia occurs when food, saliva, liquids, or vomit enters the lungs instead of being swallowed into the esophagus and stomach.

Aspiration of food and liquid alone does not cause pneumonia. It is the bacteria in the mouth that enters the lungs with the food which causes pneumonia (Ashford, 2012).

Remember not everyone that aspirates will develop pneumonia. You and I sometimes inadvertently aspirate our food, liquid, or even saliva, and we will be fine.

Artificial Nutrition for Dementia Patients

The topic with use of artificial nutrition and hydration in patients in the final stages of dementia is a controversial and emotional issue. Healthcare professionals commonly rely on feeding tubes to supply nutrition to severely demented patients, however various studies have NOT shown use of feeding tubes to be effective in preventing malnutrition. Furthermore, they have not been demonstrated to prevent the occurrence or increase the healing of pressure sores, prevent aspiration pneumonia, provide comfort, improve functional status, or extend life. Rather there are high complication rates, increased use of restraints, and other adverse effects further increase the burden of feeding tubes in severely demented patients. Knowing all this as health professionals we need to educate patients’ families that feeding tubes do not prolong life or improve their quality of life.

At an advanced stage of dementia, the most appropriate way to manage their care may be comfort/palliative- with this we are maintaining their quality of life, dignity, and comfort. Really the preferable alternative to tube feeding is hand feeding which the American Geriatric Society also advocates for older adults with advanced dementia. Though it may not be effective in preventing malnutrition and dehydration, hand feeding allows the maintenance of patient comfort and intimate patient care.

Further reading: Feeding Tubes in Patients with Severe Dementia by Ina Li, M.D.