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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

M

Vol. 108, No. 2

http://www.nursingcenter.com

the nurse notices that Mr. B enjamin Link. hoarse voice.lww. To view an accompanying online video. lww.) Dietary modifications are recommended by a speech pathologist or other clinician trained in the assessment of swallowing. which could lead to aspiration. including difficulty in swallowing. URL citations appear in the text. see Why Assess for Aspiration in Patients with Dysphagia? page 42. Thickened liquids may be recommended.com importance of this assessment. For example. 108. the impairment of any part of the swallowing process. This worsened his Parkinson’s symptoms. dysphagia is especially prevalent among older adults with neurologic impairment or dementia.20 But thickened liquids aren’t recommended in all cases of dysphagia.10 Mr. postoperative nausea.) He has a 12-year history of Parkinson’s disease and had been taking carbidopa– levodopa (Sinemet and others) 25–100 mg four times daily. Online Only Unique online material is available for this article. Oral care. Poor oral hygiene and tooth decay have been correlated with the occurrence of aspiration pneumonia. working with a speech pathologist to determine the specific needs of the patient is critical. See page 45. 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. both of which increase the risk of impaired swallowing. Link had been aspirating during meals. A Closer Look Get more information on how to recognize aspiration. No. The physician is notified.com/A226. He doesn’t have fever or chills. She observes no overt aspiration of liquids during the evaluation but determines that Mr. and the prevalence of aspiration and dysphagia. On his second postoperative day.read it watch it try it Overview: Dysphagia. increases the risk of aspiration. While some changes in swallowing may be a natural result of aging. Dysphagia and aspiration are associated with the development of aspiration pneumonia. Link’s left lung. Therefore. the nurse suspects that Mr. age 74.18. and sedation from the analgesia. Try This: Preventing Aspiration in Older Adults with Dysphagia This shows the best practices in the original form. was admitted to the hospital for hip-replacement surgery related to crippling arthritis and chronic pain. but on auscultation the nurse detects faint crackles in the base of Mr. altered medication regimen. This article discusses best practices for assessment and prevention of aspiration among older adults who are being hand-fed or fed by tube. the pathophysiology of dysphagia. Web Video Watch a video demonstrating the best practices for preventing aspiration in older adults with dysphagia at http://links. Mr. IMPLEMENTING THE TRY THIS APPROACHES Although the evidence available on the effectiveness of many preventive strategies is limited. (This case is a composite based on our experience. Link is at risk for dysphagia because of his age. Link is coughing while the nursing assistant gives him breakfast. which worsen after he drinks juice. Upon admission the medication was suspended because of preoperative fasting and then. She also hears gurgling sounds. the nurse implements the Try This approaches to promote swallowing. Mr. 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. simply type the URL into any Web browser. The nurse asks the physical therapist to complete her work with AJN M February 2008 M Vol. leading to an increased risk of aspiration and aspiration pneumonia. Link receives a bedside dysphagia workup by the speech pathologist.com/A226. later. 17 and good oral care has been associated with a lower rate of pneumonia.11. Link is drooling and speaks in a soft. Parkinson’s disease status. Link is now drowsy as a result of the anesthesia and is receiving morphine by patient-controlled pump. go to http:/ /links. 12. (To understand the ajn@wolterskluwer. therefore. 2 41 .

or weakening of the muscles involved in swallowing. increased confusion.22 For these reasons. Recognizing aspiration in the tube-fed patient. 108. At mealtimes. fluid withdrawn from gastric tubes usually has a lower pH than that of fluid withdrawn from small-bowel feeding tubes. as well as by drooling.24.24 Although there is no agreement on how much gastric residual volume is too much. ) IMPLEMENTING THE TRY THIS APPROACHES FOR TUBE FEEDING Good oral hygiene is also important for patients fed by tube.com Vol. slowing of the swallowing process. it may also be difficult to detect aspiration pneumonia before the occurrence of overwhelming illness. 25 Contents withdrawn by a syringe from a gastric tube during feedings usually have the appearance of curdled or unchanged formula. which will allow him time to rest before eating. Tube placement. giving him small amounts and alternating solids with liquids—all suggested in the Try This approaches.26 The volume of fluid withdrawn from gastric tubes is typically higher than that withdrawn from small-bowel tubes. the nurse looks for missing teeth or missing or poorly fitting dentures. No. Link’s medication list. Correct placement of the feeding tube is also critical to the prevention of aspiration. In addition. a tube whose ports are situated in the esophagus increases the risk of regurgitation and aspiration. She finds that his dentures fit well and that his oral hygiene is adequate. gurgling sounds when speaking. She wants to get him back on a medication schedule to decrease the dysphagia and other symptoms of Parkinson’s disease. 2 . While there may be challenges in recognizing aspiration in older adults. the nurse helps Mr. or a fall may be the only apparent initial change. Link about his home routine of eating meals and taking medications. But according to a recent consensus statement issued by the North American Summit on Aspiration. In a comparison of three groups of institutionalized older adults (those fed orally. tube-feeding formula. videofluoroscopy (also known as a modified barium swallow test). To promote chewing and swallowing. however. many do agree that http://www. it can determine where the tube ends in the gastrointestinal tract. and those fed by percutaneous enterogastric tube). the nurse reviews Mr. also may occur and is even more difficult to detect. go to http://links. and chills may not be seen in older adults.23 Thereafter. 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. Aspiration may manifest itself as coughing and choking while eating or drinking. or aspiration without symptoms.21 Oral bacteria levels were highest in those receiving nasogastric tube feedings. A tube inadvertently positioned in the trachea or lung causes “aspiration by proxy” if tube feeding is initiated or medications are administered.1 Aspiration of a substance such as food. Several methods can be used to determine whether aspiration is occurring. including bedside swallowing assessment by a specially trained speech pathologist. for example. increased respiratory rate. including vomiting.nursingcenter.2 The typical pneumonia symptoms of cough. When tube feedings are used. While the pH of gastrointestinal contents is buffered by enteral formula. this is difficult to do because enteral formula is tan or milky in color and may be indistinguishable from sputum or tracheal secretions. fever.How To try this Mr. Next. She also talks with Mr. clinicians observe for tube feeding formula in sputum or secretions obtained during tracheal suctioning. Link slowly. as well as because of poor tolerance of the tube feeding formula and incorrect tube positioning.com/A228. go to http://links. severe coughing. the nurse can use a variety of tests at the bedside to help determine the tube’s position: observing the 42 AJN M February 2008 M Why Assess for Aspiration in Patients with Dysphagia? Recognizing aspiration. Link at least 30 minutes before mealtimes. looking for drugs that may be causing sedation and thus impairing the coughing or swallowing reflex. The nurse instructs the nursing assistant to feed Mr. clinicians added blue food dye to enteral formula to increase its visibility. the highest permitted by postoperative orders. The nurse tells him about the importance of good oral hygiene. and fiber endoscopy. tube-fed patients had a higher prevalence of oropharyngeal pathogenic bacteria than those fed orally. Silent aspiration.lww. bronchoscopy. In the past. (To see the segment of the online video on preventing aspiration during ) tube feeding. an abdominal X-ray is preferred over a chest X-ray. or hoarseness. or vomitus into the respiratory tract can lead to aspiration pneumonia. Link to sit upright at a 45° angle. Patients who are tube fed are at risk for aspiration for the same reasons. saliva. 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.com/A227. those fed by nasogastric tube. (To watch the segment of the online video on preventing aspiration during hand feeding. including cleaning his dentures and rinsing his mouth with mouthwash.lww. In adults. radiographic confirmation of placement is strongly recommended before a tube is first used. Aspiration can occur for many reasons. delirium.

Dysphagia and aspiration are associated with the development of aspiration pneumonia.15 Possible causes considered were adverse effects of psychotropic medications and. those receiving pumpassisted feedings had less vomiting. at http://links. In a later study. regurgitation. and is no longer recommended. 30% of patients hospitalized with pneumonia from a continuing care facility had aspiration pneumonia. mostly—caused dysphagia in an estimated 300. investigators reported a high correlation coefficient (0. therefore. Dysphagia. which is indicative of aspiration of stomach contents.9 In a four-year study of men ages 60 and older.com patient has significantly slowed gastric motility. having more decayed teeth. dysphagia is often associated with or caused by neurologic impairment. For example. this method is ineffective.16 Aspiration pneumonia represents a significant proportion of all pneumonia cases. Those with frequent pepsin-positive specimens were at significantly greater risk for pneumonia. Also. and receiving tube feeding.000 Americans annually. with the highest rate of 44% in nursing home residents.13 Researchers employing a dysphagia-screening questionnaire found that almost 14% of community-residing older adults reported symptoms consistent with dysphagia.3 In a comparison of pump-assisted and gravity-controlled drip feeding for patients with percutaneous endoscopic gastrostomy tubes. increases the risk of aspiration. For more information.93) between gastric residual volume and gastroesophageal reflux in 19 critically ill patients.3 Further. may have slowed gag and swallowing reflexes and.3 This is especially true if the ajn@wolterskluwer. Langmore and colleagues identified 18 variables as significant predictors of aspiration pneumonia in nursing home residents. having decreased consciousness (as measured by a Glasgow Coma Scale Score of less than 9). 29 Tube site and feeding method may also play roles in preventing aspiration. are also at increased risk for dysphagia. Langmore and colleagues found a 22% incidence of aspiration pneumonia.14 Regan and colleagues found that 32% of adults seen by an acute and community health psychiatric service had dysphagia. Frail patients. being bedfast.6 One of us (NAM. neurologic disorders—stroke.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.com/A362. and the presence of chronic obstructive pulmonary disease or congestive heart failure. According to a 1999 report from the Agency for Health Care Policy and Research.6 There was evidence that 89% of patients on ventilators aspirated at least once in a three-day period. Additional risk factors for pneumonia in this study population included having the head of bed elevated less than 30o. being sedated. perhaps toxic. and multiple sclerosis.17 Predictors for aspiration pneumonia included being dependent on others for feeding or oral care. Parkinson’s disease. with colleagues) found that 31% of tracheal secretions collected during suctioning of patients on ventilators were positive for pepsin. Poor oral hygiene promotes the growth of pathogenic organisms in the mouth. and receiving opioids and paralytic agents. perhaps. 27. especially those with advanced disease. diagnosis. While some changes in swallowing are a natural result of aging. being tube fed. In one study. Reports of the prevalence of dysphagia vary with study population. be less able to respond to regurgitation and vomiting. see Preventing Aspiration When a Patient Eats or During Hand-Feeding of the Patient. Compared with gastric tube feeding. and aspiration. as does decreased saliva production.review and recommendations of a panel of experts.7 Older adults.lww.10-12 Prevalence. are at risk for dysphagia and aspiration. In one study. and treatment. or a combination of these.000 to 600. 108. Pathophysiology. duodenojejunal (small intestine) tube feeding may be associated with a lower incidence of aspiration.30 The most frequently cited volume of concern is 200 mL or greater.9 Patients who have decreased alertness because of medications (including anesthesia and sedatives).3. the absence of teeth—or the presence of poorly fitted dentures— increases the risk of aspiration. medical conditions. thereby increasing the risk of aspiration pneumonia. in a study of 82 nursing home residents with eating problems.33 Unless contraindicated. because chewing prepares food for swallowing.8. These substances then can enter the trachea and lungs. No. the head of the bed for a patient receiving tube feedings should be elevated AJN M February 2008 M Vol. defined as impairment of any part of the swallowing process. decreased alertness or a concomitant neurologic disorder. but fewer than a quarter of those had received a formal swallowing evaluation. the risk of aspiration continues after placement of a gastrostomy tube. 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.31.5 Patients who are on ventilators and receive tube feedings are also at risk for aspirating. among these were the need for tracheal suctioning. especially those with neurologic conditions such as stroke. Also. 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. a high gastric residual volume increases the risk of gastroesophageal reflux and subsequent aspiration of gastric contents into the trachea. 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.27-29 This is a reasonable view. 55% had symptoms of dysphagia. a digestive protease produced in the stomach. it’s wise to measure gastric residual volume when feeding by tube. dementia. 2 43 .

36 For example. Link’s functional status improves and he is discharged home. his wife and daughter. and the speech pathologist to continue using the Try This approaches. see Preventing Aspiration During Nasogastric. 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. A pureed diet may be indicated to decrease the risk of choking. as well as his family caregivers and nursing assistants. All videos are free and in a downloadable format (not streaming video) that requires Windows Media Player. The nurse works with Mr. As the nurse suspected. may unknowingly pocket food in their cheeks. go to http:// links.or Medicaid-certified nursing homes had feeding tubes. 108. His lung crackles resolve spontaneously. These patients are at risk for choking or aspirating if left unobserved with food in their mouths. Link’s wife and daughter on how to do the Heimlich maneuver. Mr. A patient with advanced dementia may forget how to chew or swallow. increased confusion. the nursing assistant. it’s important to visually inspect the oral cavity for food (including under the dentures) during and after meals. Nasointestinal. While the chin-flexed position may be helpful for Mr.How To try this more than 30º. click on the How to Try This series link. 34 For more information.37 The occupational therapist and speech pathologist can be helpful in determining the correct feeding position for patients. Link.com/A226 to watch a nurse use the best practice approaches described in Preventing Aspiration in Older Adults with Dysphagia. in strategies to promote swallowing. There is evidence that a sustained supine position (with the head of the bed flat) increases the probability of aspiration.31(4):1066-78.nursingcenter.38 However. com/AJNolderadults. View this video in its entirety and then apply for CE credit at www. different positions may be better for others. In addition. Link’s swallowing function. lww. In a review article.lww. A follow-up evaluation 30 days later shows an improvement in Mr. in patients with hemiparesis or oropharyngeal disease or injury.nursingcenter.com/A230. (To view the segment of the online video on assessing and preventing aspiration. Finucane http://www. No. The nurse will arrange and coordinate the prescribed dietetic assessment and assure that Mr. 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. 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. Aspiration is not noted. localized disease or injury affecting the oropharyngeal area. ) 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. 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. Patients with advanced dementia or hemiparesis. COMMUNICATING THE STRATEGIES Mr. (For the segment of the online video on risk-reduction strategies. • elevated respiratory rate • fever • cough • chills • pleuritic chest pain • crackles (rales) • delirium. Then watch the health care team plan preventive strategies.6. Link receives the correct diet.lww. or Gastrostomy Tube Feedings at http://links. the wisdom of placing feeding tubes in this population has been questioned. the caregiver can place the food on the side of the mouth that doesn’t have weakness or paralysis. Mr.com/A363. go to http://links. or falls Marrie TJ. Clin Infect Dis 2000. ) Watch It! G o to http:/ /links. 44 AJN M February 2008 M Vol. Link’s nurse will instruct him. Link’s modified barium swallow test shows a slowing of swallowing function. The nurse instructs Mr. Link.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.35.com/A229.lww. 2 .

other symptoms to observe for include fever. • Observation for aspiration pneumonia should be ongoing in high-risk persons. Revised 2007 Series Editor: Marie Boltz. • A voice change (such as hoarseness or a gurgling noise) after swallowing. et al. and/or distribute. avoid rushed or forced feeding. RN. BC. for this reason. 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. 1993). APRN. a rested person will likely have less difficulty swallowing. and dementia. Conditions that suppress the cough reflex (such as sedation) further increase the risk for aspiration. clinical observations are also important. some persons swallow thickened liquids more easily than thin liquids. post. Symptoms to look for include: • Sudden appearance of respiratory symptoms (such as severe coughing and cyanosis) associated with eating. BEST PRACTICES: ASSESSMENT AND PREVENTION ASSESSMENT Aspiration: Although aspiration during swallowing is best detected by procedures such as video-fluoroscopy or fiberoptic endoscopy.com AJN M February 2008 M Vol. chills. GNP Managing Editor: Sherry A. (See Try This: Assessing Eating and Feeding Issues in Older Adults with Dementia). ajn@wolterskluwer. elevate the backrest to a 90-degree angle. Parkinson’s disease. FAAN. 2000). • Adjust rate of feeding and size of bites to the person’s tolerance. drinking. GNP New York University College of Nursing Preventing Aspiration in Older Adults with Dysphagia By: Norma A. • Slightly flexing the person’s head to achieve a ‘chin-down’ position is helpful in reducing aspiration in some types of dysphagia (Shanahan. A recent study showed that increasing food viscosity greatly improved swallowing in neurological patients (Clave. Swallowing studies may be needed to determine which individuals are most likely to benefit from this position.org. APRN. PREVENTION OF ASPIRATION DURING HAND FEEDING: There is little research-based information regarding specific strategies to prevent aspiration during the feeding of dysphagic individuals (Loeb. Permission is hereby granted to reproduce. Available on the internet at www. food may be placed on the right side of the mouth if left facial weakness is present. 2006).edu. E-mail notification of usage to: hartford. aspiration was significantly lower when nectar or pudding was swallowed (as compared to when liquids were swallowed). task segmentation and environmental modifications (minimizing distractions) as alternatives to hand feeding. if confined to bed. This material may be downloaded and/or distributed in electronic format. et al. et al. Aspiration Pneumonia: • Older persons with pneumonia often complain of significantly fewer symptoms than their younger counterparts. That is. TARGET POPULATION: Dysphagia is common in persons with neurologic diseases such as stroke.org and/or www. aspiration pneumonia is under-diagnosed in this group (Marrie. • Vary placement of food in the person’s mouth according to the type of deficit. redirection. • Evaluate the effectiveness of cueing. 108. • Determine the food viscosity that is best tolerated by the individual. • An elevated respiratory rate is often an early clue to pneumonia in older adults. Metheny. 2000). 2003). New York University is cited as the source. For example. • Minimize the use of sedatives and hypnotics since these agents may impair the cough reflex and swallowing. provided that The Hartford Institute for Geriatric Nursing.hartfordign. pleuritic chest pain and crackles (Marrie.ConsultGeriRN.ign@nyu. download. including PDA format. it has been suggested that dysphagia carries a sevenfold increased risk of aspiration pneumonia and is an independent predictor of mortality (Singh & Hamdy. Greenberg. MSN. 2 ¡ 45 . • Small-volume aspirations that produce no overt symptoms are common and are often not discovered until the condition progresses to aspiration pneumonia. 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. • Alternate solid and liquid boluses. or regurgitation of gastric contents.Issue Number 20. College of Nursing. 2002). For example. • Delirium may be the only manifestation of pneumonia in elderly persons (Marrie. the following actions may be of some benefit: • Provide a 30-minute rest period prior to feeding time. No. PhD. • Sit the person upright in a chair. However. PhD. 2006). this material in its entirety only for not-for-profit educational purposes only. In fact. BC.

2 http://www. Becker. (2000). 24(9). Y. J. 180-183. Quagliarello.A. • When the tube-fed person is able to communicate.P. E. Infection Control and Hospital Epidemiology. S. Crown. 51(7). increase the probability for regurgitation and aspiration of gastric contents. E.. A. (2004). & Hamdy. A national inpatient cost estimate of percutaneous endoscopic gastrostomy associated aspiration pneumonia. Clinical Infectious Disease... 50(3). 2005).. Modifiable risk factors for nursing home-acquired pneumonia. S. Ohrui. et al. Loeb. G. M.. 58(1). Ihara. R. 40(12). K. A. J. N. MORE ON THE TOPIC: Best practice information on care of older adults: www. (2005). T. Community-acquired pneumonia in the elderly. 736-739. (1993). et al. Infected teeth and poor oral hygiene predispose to pneumonia following the aspiration of contaminated oral secretions (Quagliarello. abdominal pain or cramping. 6). Nonetheless..A. (2002). Spain. Y. et al. C. C.. M... 1807-1810. & Kahrilas. 40(1). Therefore. Metheny. Hoshiba. S. There is evidence that providing weekly dental care and cleaning the elder person’s teeth with a toothbrush after each meal lowers the risk of aspiration pneumonia (Yoneyama.. et al. A.. W.A. Girvent.. S. 2002). (2006).A. 2000). T.nursingcenter.A. (2005). S. S80-85.org. L.. Farre.. P. S. & Post. (2003). 31(40).P. V. 490-496.A. • A prokinetic agent (such as metoclopramide or erythromycin) may be prescribed to alleviate persistently slowed gastric emptying (McClave. Geiger. Pump-assisted enteral nutrition can prevent aspiration in bedridden percutaneous endoscopic gastrostomy patients. H. Postgraduate Medical Journal. S. more so than that observed in those who received oral feedings (Leibovitz. Leibovitz. & Farup... B... H. Rademaker.hartfordign. Journal of Parenteral & Enteral Nutrition.. McClave. Serra-Prat. Areola... M.K..B. Neslusan. Palomera. • Pump assisted feedings may be associated with fewer aspiration events than are gravity–controlled feedings in bedridden patients with gastrostomy tubes (Shang. Clave. Sloan. J.. 23(3). (2002). American Journal of Managed Care. Ginter. M. & Sasaki. 52-58. Van Ness... Chin-down posture effect on aspiration in dysphagic patients. When tube feedings are necessary.T. 2002). K.. Scolapio. Maloney. 2005.. Yoshida. M. there are instances in which tube feedings are needed.org 46 AJN M February 2008 M Vol. 2004). 2002).. Ariumi.PREVENTION OF ASPIRATION DURING TUBE FEEDING: Persons who aspirate oral feedings are also likely to aspirate tube feedings. & Segal. et al. PREVENTION OF ASPIRATION PNEUMONIA BY ORAL CARE: Missing teeth and poorly fitted dentures predispose to aspiration by interfering with chewing and swallowing. J. Moore. Geriatric oral health and pneumonia risk. Hashimoto.. Shanahan. et al. Dysphagia in stroke patients. the following activities may help to minimize aspiration: • Keep the bed’s backrest elevated to at least 30º during continuous feedings..... Singh. Terpenning. Yanagisawa. R. in turn. Clinical Infectious Diseases. De Kraa. Logemann. C. Sturm.S. Habot. M.. M. Oral care reduces pneumonia in older patients in nursing homes. 2003). The effect of bolus viscosity on swallowing function in neurogenic dysphagia.. 28(3). Mukaiyama.ConsultGeriRN. A SERIES PROVIDED BY The Hartford Institute for Geriatric Nursing EMAIL : hartford. (2000). B. H. Shang.S. Alimentary Pharmacology & Therapeutics.. H.. JAGS. J.. Journal of Gerontology Series A-Biological Sciences & Medical Sciences. This assessment is especially important when the tube-fed person is unable to communicate signs of gastrointestinal intolerance.H. 74. DeLegge.. Clinical Infectious Diseases. 6(4). Although there is no convincing research-based information regarding how much gastric residual volume is ‘too much. 430-433.. 108. S. Ohsawa.. & Zaloga. Crystal-Peters. (2002). Tinetti. JAGS.J.J. 159-164. M. F.ConsultGeriRN. Interventions to prevent aspiration pneumonia in older adults: A systematic review. D. DeMeo.. G. Results from a recent study suggest that tube feeding in elderly persons is associated with significant pathogenic colonization of the mouth. T. 1-6. T. 82(968). Archives of Physical Rehabilitation. (2006). 26(Suppl.J. et al. Rosenberg. Lan.. Akagawa. Pauloski. S. These signs are indicative of slowed gastric emptying that may. especially during periods of acute illness. Heyland.H. T. N.. DiSario.’ a persistently elevated amount (such as greater than 200 ml) should raise concern (McClave. there is a growing trend to avoid the use of tube feedings merely as a means to prevent aspiration.org CONSULTGERIRN WEBSITE : www. North American Summit on Aspiration in the Critically Ill Patient: Consensus statement... 1385-94. M.. T. M.A. Terpenning M. Marrie. 2002). Siddique. P. • Measure gastric residual volumes every 4 to 6 hours during continuous feedings and immediately before each intermittent feeding. Marrie.com Ê . Morita. R.. No. Pneumonia in the long-term care facility. ask if any of the following signs of gastrointestinal intolerance are present: nausea.W. 383-391. et al. Yoneyama. • Post-pyloric placement of the feeding tube (jejunostomy) may be prescribed if persistently slowed gastric emptying is a problem (McClave.. 1018-1022. Journal of Parenteral and Enteral Nutrition. Eady. T.. Okamoto.W. P.. The efficacy of this action is controversial. Allore. & Walker-Dilks. Pathogenic colonization of oral flora in frail elderly patients fed by nasogastric tube or percutaneous enterogastric tube. V. 1066-1078. J.edu HARTFORD INSTITUTE WEBSITE : www.ign@nyu... feeling of fullness.R. either by nasogastric or gastrostomy tubes (Siddique. Plotnikov.. (2003).. Mizuno. D.

20(2):77-82. J Am Geriatr Soc 2002. 2 47 . Loeb MB. et al. Clave P.hartfordign. Pengilly K. Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: frequency.BC. Dysphagia among nursing home residents. 7. National Institutes of Health. nih. J Am Geriatr Soc 2006. For access to all articles and videos in the How to Try This series.13(2):69-81. et al. 58(1):52-5. 41 Less social interaction during mealtimes is a drawback to tube feedings. Differences in the features of aspiration pneumonia according to site of acquisition: community or continuing care facility. Evidence Report/Technology Assessment: Number 8. and religious implications and remains a highly controversial ethical issue for some. J Am Geriatr Soc 2001. Dysphagia 2006. 20.stotts@nursing. North American Summit on Aspiration in the Critically Ill Patient: consensus statement. RN. financial or otherwise. et al. Loeb M. FAAN. and policy. et al. McClave SA.nursingcenter. Leibovitz A.39 Also. Metheny. Agency for Healthcare Research and Quality. RN. Dysphagia 2004.51(7):1018-22. FAAN (nancy. et al. Routine use of a Try This tool may require formal review and approval by your employer. 9. 108. et al. NINDS swallowing disorders information page.43. 12.49(5):557-63. Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia 1998. Votsmier Endowed Chair in Nursing. 19. 15. For more information on best practices in the care of older adults go to www. jan.nidcd.gov/health/voice/ dysph. No. et al. Yoneyama T. as is the loss of pleasure that comes with feeling. Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities. where Norma A. Abe S. Non-pharmacological therapies for dysphagia in Parkinson’s disease. et al. Metheny NA.nursingcenter.com/AJNolderadults.40 There is also no evidence that tube feedings promote survival or decrease aspiration in patients with severe Alzheimer’s disease. Crit Care Med 2006. 14. 11.20(3):218-25.ConsultGeriRN. 1998.Online Resources For more information on Preventing Aspiration in Older Adults with Dysphagia and other geriatric assessment tools and best practices. 10. 54(2):296-302. PhD.26(6 Suppl):S80-S85. Arch Gerontol Geriatr 2006. the Web site of the John A.50(3):430-3. et al. 1999 Mar.com). and swallowing food. go to www.gov/disorders/swallowing_disorders. outcomes. APRN. 21. Prevalence of dysphagia among community-dwelling elderly individuals as estimated using a questionnaire for dysphagia screening. Aliment Pharmacol Ther 2006. JPEN J Parenter Enteral Nutr 2002. Oral hygiene evaluation for effective oral care in preventing pneumonia in dentate elderly. Hartford Foundation–funded Hartford Institute for Geriatric Nursing at New York University College of Nursing.39 For these reasons. Dysphagia 2002. The site lists resources and offers continuing education opportunities.43(1):53-64.com/AJNolderadults and click on the How to Try This link. AHCPR Publication Number 99-E023. How to Try This is a three-year project funded by a grant from the John A.asp. Oral care reduces pneumonia in older patients in nursing homes.hartfordign. J Gerontol A Biol Sci Med Sci 2003.159(17):2058-64. A. and colleagues noted a lack of evidence showing that tube feedings result in weight gain or reduced aspiration in those with advanced dementia. 17. the Alzheimer’s Association discourages the use of feeding tubes in people with advanced Alzheimer’s disease but respects patient and surrogate preferences.org/trythis.21(2):95-101. The articles and videos are to be used for educational purposes only. Langmore SE. The authors have no significant ties.htm. et al. Try This: Best Practices in Nursing Care to Older Adults: www. Try This: Preventing Aspiration in Older Adults with Dysphagia is reproduced with permission of Norma A. http://www. Metheny is a professor and Dorothy A. Prevalence of dysphagia in acute and community mental health settings. et al. et al. tube feedings may cause diarrhea and abdominal discomfort. and risk factors. tasting. 16.39. http://www.palmer@gmail.com. Clin Infect Dis 2000. Reza Shariatzadeh M. to any company that might have an interest in the publication of this educational activity.nih. Louis.gov/clinic/epcsums/ dysphsum. in St.ucsf. National Institute of Neurological Disorders and Stroke (NINDS).ninds. 2007. Community-acquired pneumonia in the elderly. Nancy ajn@wolterskluwer. org. 44 M Janice L. Cochrane Database Syst Rev 2001(1):CD002816. Ramsey D. Kayser-Jones J. Deane KH. Hartford Foundation to the Hartford Institute for Geriatric Nursing at New York University’s College of Nursing in collaboration with AJN. et al.com AJN M February 2008 M Vol. Geriatr Nurs 1999. Aspiration pneumonia: dental and oral risk factors in an older veteran population. The series will include articles and corresponding videos. 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.org. Palmer. EdD. http://www. Arch Intern Med 1999. education. 18. 8. National Institute on Deafness and Other Communication Disorders (NIDCD). National Institutes of Health. 3. 13. Rockville. Palmer is a doctoral student and a John A. Predictors of aspiration pneumonia in nursing home residents. MSN. cultural. and Sherry A. Terpenning MS. GNP (sherry@ familygreenberg. et al. MD. Saint Louis School of Nursing. Marrie TJ. 4. The effect of bolus viscosity on swallowing function in neurogenic dysphagia. Hartford Foundation Building Academic Geriatric Nursing Capacity Scholar at the Saint Louis University School of Nursing. The institute focuses on improving the quality of care provided to older adults by promoting excellence in geriatric nursing practice. J Am Geriatr Soc 2003. Regan J. Langmore SE. Kawashima K. et al. 5. 19(4):266-71.17(4):298-307. Dysphagia. Interventions to prevent aspiration pneumonia in older adults: a systematic review. This initiative promotes the Hartford Institute’s geriatric assessment tools. go to www. Further. Contact author: Janice L. Greenberg.42 Initiating tube feedings in this population is an individual or family decision with possible legal.edu). Diagnosis and treatment of swallowing disorders (Dysphagia) in acute-care stroke patients. Stotts.34(4):1007-15. 2. Silent aspiration: what do we know? Dysphagia 2005. Pathogenic colonization of oral flora in frail elderly patients fed by nasogastric tube or percutaneous enterogastric tube.31(4):1066-78.l. research.24(9):1385-94.ahrq. et al. all of which will be available for free online at www. REFERENCES 1. 6. are coeditors of the print series.

30. Am J Manag Care 2000. Chin-down posture effect on aspiration in dysphagic patients. et al.19(5):487-95. Lipman TO. et al.11(3):309-25. No. Kreymann KG.com/CE/ajn. J Neurosci Nurs 2005. Indicators of tubesite during feedings. 42. 36. 25. Surg Gynecol Obstet 1988. et al. Am J Crit Care 2006. PROVIDER ACCREDITATION LWW. Clin Nutr 2006. Brick.5 HOURS Continuing Education Go to www. Finucane TE. publisher of AJN. LWW is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.29(4):208-12. Nurs Res 1999. • complete the registration information and course evaluation. The effect of famotidine on gastroesophageal and duodeno-gastro-esophageal refluxes in critically ill patients. Stewart BJ. Siddique R. Metheny NA. nursingcenter. DISCOUNTS and CUSTOMER SERVICE • Send two or more tests in any nursing journal published by Lippincott Williams and Wilkins (LWW) together.9(2):356-8.48(4):189-97. • record your answers in the test answer section of the CE enrollment form between pages 48 and 49.pdf. Torres A. JPEN J Parenter Enteral Nutr 2002. Your certificate is valid in all states. by February 28.74(7): 736-9. 40. will award 2. 39. Tube feeding in patients with advanced dementia: a review of the evidence. Chicago. 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. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. 24. Ethical and legal aspects of enteral nutrition. Gut 2003. Mail the completed enrollment form and registration fee of $24. 31.160(5):1005-9.116(7):540-3. 37. Korner U. Meert KL. NJ 08723. A national inpatient cost estimate of percutaneous endoscopic gastrostomy (PEG)-associated aspiration pneumonia.nursingcenter. 41. 15(4):360-9. http://www. Effects of postural change on aspiration in head and neck surgical patients.org/documents/ national/FSOralfeeding.nursingcenter. You will receive your CE certificate of earned contact hours and an answer key to review your results. Metheny NA. provider number CEP 11749. Otolaryngol Head Neck Surg 1994. you will be able to • outline the background information helpful for understanding the problems of dysphagia and aspiration.95 to Lippincott Williams and Wilkins CE Group. 27. • We also offer CE accounts for hospitals and other health care facilities online at www. 2010. • plan the appropriate interventions for patients at risk for aspiration. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. et al.com/CE/ajn and receive a certificate within minutes. Florida #FBN2454. 28. Mitchell SL. AJR Am J Roentgenol 1993. Ann Intern Med 1992. 29. Preventing respiratory complications of tube feedings: evidence-based practice. 43. Logemann JA. et al.. Arch Phys Med Rehabil 1993. go to our secure Web site at www. Alzheimer’s Association. 38. Kunin J. Murphy LM. and Iowa #75. IL: The Association. Pump-assisted enteral nutrition can prevent aspiration in bedridden percutaneous endoscopic gastrostomy patients. for 2. This activity is also provider approved by the California Board of Registered Nursing. Metheny NA. et al. For faster service. JPEN J Parenter Enteral Nutr 2004. Monitoring feeding tube placement.28(3): 180-3. Appl Nurs Res 2002. Henderson CT. et al. 108.com. Guidelines for enteral feeding in adult hospital patients. Clin Nutr 2006. Prevention of barium aspiration during videofluoroscopic swallowing studies: value of change in posture. District of Columbia.290(1): 73-80. No elimination of aspiration pneumonia in neurologically disabled patients with feeding gastrostomy.110(2):222-7. Arch Intern Med 2003. Nutr Clin Pract 2004. 2. Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia. et al. 34. manifestations. Metheny NA. ESPEN Guidelines on Enteral Nutrition: Intensive care.52 Suppl 7:vii1-vii12. Stroud M.37(6):320-5. Rasley A. Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment.nursingcenter.95 from the price of each test. 44. Shang E.25(2):210-23. Withholding artificial feeding from the severely demented: merciful or immoral? Contrasts between secular and Jewish perspectives. World J Gastroenterol 2003. TEST CODE: AJNTT09 48 AJN M February 2008 M Vol.167(5):383-8. et al.alz.com . J Med Ethics 2003. et al. et al. LWW is also an approved provider of continuing nursing education by the American Association of CriticalCare Nurses #00012278 (CERP category A).5 contact hours for this continuing nursing education activity. including risks. LEARNING OBJECTIVES: After reading this article and taking the test on the next page.How To try this 22. There is no minimum passing grade. and incidence. et al. JAMA 1999. et al. Ethical issues in Alzheimer’s disease: assisted oral feeding and tube feeding. JAMA 2003. and deduct $0. You will receive your certificate in four to six weeks.26(1 Suppl):1SA-138SA.163(11):1351-3. 15(4):254-8. 23. TEST INSTRUCTIONS To take the test online. 2710 Yorktowne Blvd.5 contact hours. Shanahan TK. 26. Each question has only one correct answer. 33. 32. 35. include a fax number and we will fax your certificate within two business days of receiving your enrollment form. 2006.6(4):490-6. pH and concentration of bilirubin in feeding tube aspirates as predictors of tube placement. Hassett JM. J Am Coll Nutr 1992. To use the form provided in this issue. et al. Call (800) 787-8985 for details. et al.282(14): 1365-70. et al. LWW home study activities are classified for Texas nursing continuing education requirements as Type 1. You may make copies of the form. Testing feeding tube placement during continuous tube feedings. Prolonged tube feeding in long-term care: nutritional status and clinical outcomes. 2 http://www.25(2):196-202. Metheny NA. Xin Y.