May 23, 2006 Feature

Nutritional and Dysphagia Services for Individuals with Alzheimer's Disease

As the number of elderly is increasing, the number of people with Alzheimer's disease (AD) residing in long-term care facilities is increasing. A growing body of evidence demonstrates that speech-language pathologists can have a positive impact on the well-being and the nutritional status of clients with AD by using the environment, caregiver training, and an individual's preserved abilities to help compensate for one's deficits.

On Sept. 25, 2001, the Centers for Medicare and Medicaid Services (CMS) issued a Program Memorandum (Transmittal AB-01-135) to all Intermediaries/Carriers. In this memorandum CMS stated that persons with AD may become eligible for speech-language pathology services if these services were reasonable and necessary.

It's important to remember the phrase "may become eligible" for speech-language pathology services and the words "reasonable and necessary" in the preceding sentence. What CMS really said in this transmittal was that not every patient with AD would be an appropriate candidate for services and that only under certain conditions would Medicare pay for these services. CMS used the words "reasonable and necessary" as criteria for appropriate candidates but offered no specific guidelines to help SLPs determine which patients are and which are not appropriate candidates.

General Medicare guidelines state that all candidates for speech-language pathology services must demonstrate potential for positive change, so this guideline needs to be considered when selecting persons with AD for evaluation and potential treatment. The fact that persons with AD have a progressive neurological disorder with deficiencies in certain memory skills makes the documentation process challenging. How does one document potential for positive change and the ability to learn new skills when there are deficits in memory skills? More specifically, how does one document that a person with AD can learn to communicate new words, to communicate basic and medical needs, to swallow safely, and/or to respond to environmental changes?

Establishing functional goals is another documentation necessity. Medicare reviewers want to see that the accomplishment of the established goals will result in changes that make a significant difference in the life of the person with AD. Helping persons with AD improve their ability to communicate basic and medical needs and to swallow more safely (to reduce risk for aspiration, malnutrition, and dehydration) would all be acceptable goals assuming that the limitations in functional skills were directly related to the progressive nature of the AD.

Keeping in mind that the process of documenting services for persons with AD is no different than the process of documenting services for persons without AD can help the SLP justify and ethically treat persons with AD and make a significant contribution in improving the quality of life for this population.

Memory

Understanding the different memory systems can help the SLP establish potential for positive change. The two major categories of memory are declarative (explicit) and non-declarative (implicit). The types of memory are distinguished by the kind of information processing involved in each.

Declarative memory requires conscious recall of information that is explicitly stored and retrieved. Declarative memory includes episodic memory, which concerns information about a situation, and semantic memory, which concerns abstract knowledge about the world.

In contrast, non-declarative (also called procedural) memory is based on implicit learning of certain patterns. Non-declarative memory is a memory of skills and procedures acquired through a series of trials. Declarative memory depends heavily on the hippocampus (an area of the brain that is damaged in people with AD), whereas procedural memory is managed by other brain mechanisms.

Procedural memory is generally preserved late into the course of AD. By documenting intact procedural memory and using effective techniques such as spaced retrieval to improve function, the SLP can make a strong case for evaluating and treating patients with AD. The traditional practice of including caregivers in the treatment program can also be justified by documenting preserved procedural memory and how caregiver cuing, specifically related to this preserved skill, can improve language and swallow function.

Mealtime Behavior Changes

As AD progresses, changes occur in a person's nutritional status. During the early to middle stages the risk of malnutrition may be related to forgetting steps involved in preparing a meal or shopping for food items. The individual may be unable to safely operate a stove, unable to recognize food when spoiled, and may be unable to hold attention throughout a meal.

It is common during this stage for the person to become distracted by environmental factors, experience a change in food preference, pour liquid into food, or take others' food. Individuals often express concerns about money to pay for food or meals.

During the middle to advanced stage, the individual may become more confused and unaware of the surroundings, place, and time. The person may forget which utensil to use, and may not recognize hunger, thirst, or food temperature. Individuals may be at risk for dehydration as they may not ask for drinks. The person may pace or refuse to sit down for a meal, causing weight loss.

Environment

Research has shown that physical and social environments are important but often untapped resources that can have a significant impact on quality of life. However, assessing such factors as environmental stimuli, lighting, and noise levels are not always part of routine clinical practice for an SLP.

There are many situations in which clients with memory loss do not perform to their maximum potential, and/or exhibit what the staff consider to be "behaviorial problems." For example, a client who is perceived as disruptive may simply be responding to something in his or her environment that is not supportive.

Caregiver Training

In addition to documenting potential for positive change and the ability to learn new skills, SLPs need to document when skilled services will be needed to effect positive change. What this means is that the knowledge and training of a professional is needed to develop and implement an intervention program. If a Medicare reviewer determines that the services provided could have been provided by nursing staff or family members, services are likely to be denied.

Caregivers can maintain a program developed by an SLP, but documentation must show that a professional was needed to assess strengths and weaknesses related to language and swallow abilities so an appropriate program can be developed. Clinicians need to document specific intervention techniques that can only be administered by an SLP. Statements like, "trained in spaced-retrieval technique to improve ability to communicate medical needs," or "trained caregivers to use gravity on the unaffected side to facilitate a safe swallow," or "assessed for appropriate amount and texture of food for safe swallow" would demonstrate that the knowledge and training of a professional were required.

Many clients with AD require a thorough dysphagia evaluation. Preserved abilities should be identified and a treatment plan that builds on preserved abilities and past and current meal preferences should be developed, with an eye to the possible facilitators and barriers in the environment. Interventions should include simple techniques to reduce the demands on impaired memory systems and provide cues that will enable the client to function using preserved abilities.

Jennifer A. Brush, is the director of Healthcare Education for Brush Development Company and the Project Director for I.D.E.A.S., Inc. (Innovative Designs in Environments for an Aging Society). She is located in Cleveland, OH, and can be reached at Jennifer@Brushdevelopment.com.

Thomas Slominski, is the president of Northern Speech Services, Inc., the parent company of National Rehabilitation Services, a provider of continuing education, in Gaylord, MI.  He can be reached at tslominski@nss-nrs.com.

Faerella Boczko, is the director of the speech-language pathology and swallowing center at the Jewish Home and Hospital Life Care System, Bronx, NY. She can be reached at fboczko@jhha.org.

cite as: Brush, J. A. , Slominski, T.  & Boczko, F. (2006, May 23). Nutritional and Dysphagia Services for Individuals with Alzheimer's Disease. The ASHA Leader.

Interventions

Some Useful Mealtime Strategies for Clients With AD:

  • Offer environmental cues to signal the change from a recreational activity to eating
  • Increase lighting and contrast at the table setting
  • Use visual cues and written reminders
  • Control noise, light glare, and odor
  • Serve individuals promptly after they are seated
  • Offer visual cuing for boundaries by using place mats or square tables to reduce interest in another's meal
  • Decorate the dining room in a homelike manner to provide reassurance and environmental cues
  • Supervise the meal, cue and encourage eating, use one-step directives
  • Limit the number of utensils (usually people will choose the utensil closest to their dominant hand)
  • Use cups with handles that are easy to grasp
  • Serving larger portions for breakfast may help to maintain weight
  • Increase the number of finger foods and provide foods “on the go”
  • Clients often can be tempted to eat by adding sweeteners to food
  • Serve one item at a time to decrease distractions and limit choices
  • Provide ethnic or culturally appropriate foods
  • Alternate hot and cold, add sweetener, and alternate with spicy foods, add ketchup, mustard, or salt and pepper (if medically appropriate)
  • Tell concerned individuals that their meals are paid for, provide meal tickets or imitation money, or explain that it is included in a meal club
  • Seat individuals according to compatibility rather than disabilities
  • Offer liquids and water consistently throughout the day and place beverage stations in high traffic areas
  • Repeat redirection to the task of eating meals and snacks
  • Do not use garnishes or decorations that are not easily chewed
  • Make small tables for one or two available for residents who perform better when eating alone or in a small group 


Assessing the Environment

In addition to conducting a clinical evaluation of a person's swallowing abilities, an environmental assessment of the dining room should be conducted to determine if there are aspects of the environment that could be having a negative impact on the ability to consume meals. Begin by sitting at a table in the dining room during a meal and ask the following questions:

1. Who is the person having the eating problem? What history of preferences, dislikes, ethnicity, and habits does the person bring to this environment? Does the person have any visual deficits or changes in the eye as a result of aging?

2. When are the eating difficulties occurring? Are the problems consistent at each meal or just during a certain meal? Do the difficulties occur throughout the meal or at its beginning and end?

3. What is being served? Examine the consistency of the food items as well as the type of food. Consider food preferences and regional differences among meals. Is the food being served family style, is the person given a choice of food items, and does the food arrive on covered trays?

4. Where does the person sit? Is the person seated next to socially compatible persons or near persons with similar abilities? Is the person seated next to a window with sunlight glaring through it, or in a corner where the light may not be adequate?

5. What is happening in the environment? Consider all of the noise, motion, and other stimuli in the environment. Is the person distracted by the environment? Will the person be more successful in a less noisy environment? In addition, observe the lighting at the table level and the degree of contrast at the table setting. For example, is there light directly overhead that may be causing a glare on the table? Is there contrast between the table and the plate or tray? A dark tablecloth or place mat will make a light plate stand out better to aged eyes.



References

Boczko, F., & Santo Pietro, M. J. (1997). The breakfast club. Vero Beach, Florida: The Speech Bin, Inc.

Brush, J. A., & Camp, C. J. (1998). A therapy technique for improving memory: Spaced retrieval. Beachwood, OH : Menorah Park Center for the Aging.

Brush, J. A., Meehan, R. A., & Calkins, M. P. (2002). Using the environment to improve intake in people with dementia. Alzheimer’s Care Quarterly, 3(4), 330–338.

Calkins, M., & Brush, J. (2003). Designing for dining. Alzheimer’s Care Quarterly, 4(1), 73–76.

Chernoff, R.(1999). Geriatric nutrition. Gaithersburg, MD: Aspen Publishers, Inc.

Neidert. K. C. (Ed). (1998). Nutrition care of the older adult. A handbook for dietetic professionals working throughout the continuum of care. Chicago, IL: American Dietetic Association.

Squire, L., & Kandel, E. (1999). Memory: From mind to molecules. Scientific America Library.

Thomas, D. R., Ashman, W., Morley, J. E., Evans, W. J., & the Council for Nutritional Strategies in Long-Term Care. (2000). Nutritional management in long-term care: Development of a clinical guideline. Journal of Gerontology 55A, M725–M734. 



  

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