Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

Dangers of Chronic Dysphagia and Malnutrition

Deanna Elizabeth Cheathem

Dietetic Intern & Graduate Student

NFS 780 - Fall 2019

The University of Southern Mississippi

Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

Abstract

This case study integrates evidence-based literature and the nutrition care process for a 92

year old male patient struggling with severe malnutrition secondary to prolonged inadequate oral

intake related to silent aspiration dysphagia. Patient G.W. has an extensively complex medical

history involving a stroke, stage III of chronic kidney disease (CKD), congestive heart failure

(CHF), kidney and prostate cancer, silent aspiration related dysphagia, and subsequently

aspiration pneumonia. The patient currently resides at the Armed Forces Retirement Home

(AFRH) and has been hospitalized on two separate occasions between March to September of

2019 for aspiration pneumonia. In late July, the patient had a percutaneous endoscopic

gastrotomy (PEG) tube placement and initiated enteral nutrition of Jevity 1.2. The patient was

not able to tolerate the volume of the formula prescribed to meet his nutritional needs. The

initial assessment was completed on October 10th, 2019 and identified the nutrition diagnoses of

inadequate enteral nutrition infusion, unintended weight loss, and malnutrition. Evidenced-based

literature was used for the rationale and development of the nutritional intervention plan. The

intervention consisted of modifying the enteral nutrition formula, fiber supplementation, and

collaboration with other health care professionals, specifically the facility’s social worker. The

follow-up assessment was completed approximately one month later with generally positive

outcomes. Patient G.W. tolerated the modified enteral formula, met nutritional needs by at least

100%, and stabilized his weight. It can be predicted that if the patient continues to implement

the prescribed nutrition intervention, G.W.’s nutritional status and general well-being will

continue to improve.
Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

PART I: LITERATURE REVIEW

Primary Disease Description

Silent aspiration related dysphagia is one of the most common complications associated

with swallowing difficulties, specifically for the aging population. Potential diagnoses of acute

and chronic neurological diseases, muscle disorders, gastrointestinal disorders, and various

malignancies are associated with the development of symptoms of dysphagia (Hand et al., 2016

& Nelms, 2016). Unfortunately, the elderly population is most affected by swallowing

difficulties as older individuals face age-related ailments such as strokes, dementia, tumors,

cancers, etc. In the United States, approximately 27% of individuals who are 76 years of age or

older have a form of dysphagia (Nelms, 2016 & Shaw et al., 2015). Stroke patients have an

increased risk of 30%-65% for the development of swallowing difficulties, contributing to

further complications such as aspiration pneumonia, malnutrition, increased length of hospital

stay, and increased mortality rates.

Collectively, dysphagia can be defined as any disruption of the four swallowing phases:

oral preparatory, oral, pharyngeal, and/or esophageal. When any of these stages of ingestion are

disrupted, the risk of inhaling oropharyngeal contents increases and often causes various forms

of aspiration. The fundamental process of swallowing is multifaceted and involves intuitive

motor function synchronization of cranial nerves, skeletal muscles, and spinal cord segments

(Jalil, Katzka, & Castell, 2015 & Nelms, 2016). The functional action of swallowing involves a

concise pause of breathing, or deglutition apnea. This hiatus requires crucial involvement of

adequate closure of the tracheal airway per coordination of the epiglottis function. Disruptions

of swallowing patterns are most often associated with neurologic conditions of dementia and

stroke activity. Associated neurological disorders and the high rate of dysphagia symptoms can
Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

be assumed to be related to the large role that the nervous system plays in the function of

swallowing (Shaw et al., 2015). The pathophysiology of acute and chronic neurological

syndromes can lead to interference with the basic functions of neural pathways and motor

function, consequently disrupting the delicate and compound coordination needed for safe

swallowing patterns.

Various forms of aspiration can occur as a result of dysphagia as the inability to swallow

food and beverages appropriately may allow foreign materials to be inhaled into the airway and

lungs. Clinical signs of aspiration typically include coughing and choking as the body tries to

remove the materials from the respiratory system (Jalil, Katzka, & Castell, 2015). Silent

aspiration, however, lacks obvious clinical signs and symptoms as there is an absence of

neurological response to remove the inhaled material with coughing. Due to the lack of outward

signs and symptoms, silent aspiration is often missed or misdiagnosed. Barium swallow studies

are a more conclusive diagnostic tool for identifying silent aspiration as the functionality of the

swallowing phases are observed via imaging testing with x-ray screenings (Jalil, Katzka, &

Castell, 2015 & Nelms, 2016). Healthcare physicians may try to treat dysphagia by addressing

the original cause of the symptoms with certain medications and sometimes surgical procedures.

Associated silent aspiration and dysphagia symptoms require management by a team of health

professionals involving attending physicians, speech therapists, and registered dietitians to help

oversee adequate care and prevent further complications associated with swallowing difficulties.

Secondary Disease Description

Subsequent complications often develop into secondary diseases for individuals

struggling with silent aspiration related dysphagia. Malnutrition and aspiration pneumonia are

some of the most prevalent correlated complications that can develop from the implications of
Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

swallowing difficulties. Prolonged inadequate oral intake is often a result of dysphagia as the

altered swallowing mechanisms drastically reduce the amount of nutrition that can be safely

consumed. These permutations can essentially lead the affected elderly population down a road

of chronic poor nutrition status and consequently, malnutrition. Shaw et al. (2015), exhibited

data that reported a prevalence of 22%-26% of nutrition deficits for acute care stroke inpatients

struggling with dysphagia. The concurrent poor nutritional intake contributes to unintended

weight loss, dehydration, fat wasting, and muscle wasting, collectively leading to the

development of malnutrition.

Aspiration pneumonia is a complication that originates from bacteria that is introduced

into the respiratory system as a result of aspiration related dysphagia and the incidental

inhalation of food material. Adequate treatment for aspiration pneumonia may require

hospitalization depending on the severity as well as the level of antibiotics that will be needed.

Jalil, Katzka, & Castell (2015) discuss the benefits of supportive care in addition to antibiotic

treatments including breathing treatments with oxygen and steroids that can help with providing

adequate oxygenation to the body’s tissues and generalized recovery. The nutritional

implications of aspiration pneumonia indicate increased nutrient needs for the promotion of

healing and recovery. Meeting these increased nutrient needs, however, is proven to be difficult

as silent aspiration related dysphagia is still a present issue for these individuals (Hede, Faxén-

Irving, Olin, Ebbeskog, & Crisby, 2016 & Jordan, Mastnak, Palamar, & Kozjek, 2018). Studies

suggest that the placement of a feeding tube and initiating enteral nutrition therapy is beneficial

for improving the patient’s overall nutritional status and meeting the increased nutrient needs

required for adequate recovery and healing (Dalton et al., 2017 & Shaw et al., 2015). Nutrition
Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

support will not only help with recovery of aspiration pneumonia, but it can also reduce the risk

of reoccurrence by helping to remove the barrier of dysphagia with enteral nutrition delivery.

Evidenced-Based Nutrition Recommendations

Nutrition recommendations for silent aspiration related dysphagia varies according to

current nutritional status as well as other concurrent diagnosed ailments. Due to the high

prevalence of malnutrition, stroke activity, and cancer in elderly individuals diagnosed with

silent aspiration related dysphagia, collective evidence-based nutrition recommendations are

required in order to create an individualized and tailored nutrition plan of care. The Evidence

Analysis Library recommends an energy intake of 30-40 calories per kilogram of body weight

each day for severely ill and malnourished oncology patients ("UWL: Executive summary of

recommendations "). Correspondingly, daily protein intake recommendations are suggested to

be of at least 1.2-1.5 grams of protein per kilogram of bodyweight. Specifically meeting

increased energy and protein needs is essential for elderly malnourished patients diagnosed with

cancer and silent aspiration related dysphagia.

Meeting nutrient needs for individuals with swallowing difficulties can be accomplished

by circumventing nutrition delivery though the initiation of enteral nutrition per feeding tube

placement. Enteral nutrition interventions are recommended over parenteral nutrition as the

Evidence Analysis Library’s executive summary, “Enteral nutrition care pathway for critically-ill

adult patients” identifies higher risk of infections and mortalities with the delivery of parenteral

nutrition. Dietary fiber needs increase for enteral nutrition therapy due to the common side

effect of diarrhea and loose stools. Nelms (2016) recommends a dietary intake goal of 30-40

grams of fiber daily to help relieve associated gastrointestinal symptoms. Currently, there are no

specific evidenced-based recommendations indicating increased carbohydrate needs for elderly

Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

malnourished patients. An appropriate intake goal for carbohydrate is 50%-60% of the total

estimated energy needs (Dalton et al., 2017). Nutrition recommendations for fluid intake mirrors

energy intake as the Academy of Nutrition and Dietetics (2018) suggest 1mL/kcal per day.

Collectively, enteral nutrition utilizing a high caloric and protein dense formula would be most

appropriate via feeding tube delivery to help provide adequate nutrition and achieve improved

nutrition status.

PART II: NUTRITION CARE PROCESS

Patient Information

Patient G.W. is a 92 year old Caucasian male who is a retired United States veteran

whom resides in the AFRH. Patient G.W. has a complex medical history that has led to his most

recent diagnosis of malnutrition related to silent aspiration dysphagia. G.W. speaks English and

requires staff assistance, wheelchairs, and a rollator for mobility and transportation. Per chart

review, patient G.W. has a history of silent aspiration dysphagia, chronic heart failure, stroke,

coronary artery disease, hypertension, chronic kidney disease (Stage III), kidney and prostate

cancer, falls with a corresponding fracture of the left clavicle, and aspiration pneumonia. The

patient’s father was reported to also have a past medical history of recurrent strokes.

In April of 2016, G.W. was admitted into the hospital and diagnosed with aspiration

pneumonia. During this hospitalization, a speech pathologist completed a modified barium study

and the results yielded indications of silent aspiration related dysphagia. Recommendations for a

mechanical soft diet with honey thickened liquids was suggested and compliance was not

reported. In March of 2019, the patient was re-admitted into the hospital and diagnosed with a

reoccurrence of aspiration pneumonia and exacerbation of chronic heart failure. Speech

pathology reassessed the patient and concluded the same results of silent aspiration and
Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

recommended soft solids, cut up meats, and liquids as tolerated. The diet order that was

prescribed, however, was a cardiac diet without any modified textures to accommodate for his

previous and current dysphagia diagnosis. Patient G.W. returned to the AFRH on April 19th,

2019 and was placed on a regular diet order without any texture modifications and fortified

orange juice provided daily. Recommendations for protein supplements were suggested, but

never ordered. Poor intake was reported and was reinforced through observation of continued

decline of weight and overall health. On June 27th, 2019, the patient was re-admitted into the

hospital with another reoccurrence of aspiration pneumonia and provided a more appropriate diet

order of a dysphagia textured diet with encouraged oral intake using chin tuck strategies.

The patient’s daughter, who acts as his family support and healthcare advocate,

suggested the placement of a PEG tube placement to G.W. and his healthcare providers. The

patient agreed with this idea and a PEG tube was placed without any complications on July 31st,

2019. Per coordination of his healthcare team, an enteral nutrition regimen of Jevity 1.2 of 1,995

mL or 7 cartons per day was prescribed and the patient verbalized understanding and idealistic

compliance. Unfortunately, G.W. continued to lose weight and had a total of 12% severe weight

loss over a six month time period. At the time of the initial nutrition assessment for this case

study on October 10th, 2019, the patient was only tolerating about 4.5 cartons of Jevity 1.2 per

day. Physical assessment and review of G.W.’s past and current health concerns classified G.W.

as malnourished as his health and well-being continued to drastically decline. A tailored

nutrition intervention was clearly warranted to achieve the initial goal of weight preservation and

subsequent safe weight gain as appropriate.

 Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

Nutrition Care Process: Assessment

Food/Nutrition-Related History (FH)

Nutrition Assessment List Specific Nutrition Describe the actual information gathered from the
Terms Assessment Term patient/patient’s family/medical record
Total Energy Intake -Ordered: Jevity 1.2 – 7 cartons ~ 1,995 kcals/d
Energy Intake (1.1) (FH-1.1.1.1) -Tolerating: 4.5 cartons ~ 1,282 kcals/d
Enteral Nutrition - Ordered: Jevity 1.2 – 7 cartons or 1,662.5 mL/d
Formula - Tolerating: Jevity 1.2 – 4.5 cartons or 1,069 mL/d
(FH-1.3.1.1)
Enteral nutrition intake (1.3)
Feeding Tube Flush - Ordered: 1,937 mL flushes of free water/day
(FH-1.31.2) - Tolerating: ~ 1,240 mL flushes of free water/day
Total Protein from - Ordered: 92 gm/day of Protein
Protein intake (1.5.3) Enteral Nutrition
(FH-1.5.3.8)
- Tolerating: 59 gm/day of Protein
Total carbohydrate from - Ordered: 282 gm/day of Carbohydrates
Carbohydrate intake (1.5.5) enteral nutrition
(FH-1.5.5.10)
- Tolerating: 181 gm/day of Carbohydrates

Diet Order (2.1.1) Enteral Nutrition Order -Jevity 1.2 – 7 cartons or 1,662.5 mL per day
(FH-2.1.13)

-Recommendation: 4/20/16 - Mechanical Soft;

Honey Thick Liquids (Speech Pathologist)
-Diet Order: 3/5/19 - Cardiac Diet: Memorial
Hospital for Aspiration Pneumonia
-Recommendation: 3/13/19 - Soft Solids – Meat cut
into bite-size pieces as needed; Thin Liquids as
tolerated. (Speech Pathologist)
-Diet Order: 4/19/19 - Regular Diet – Fortified
Orange Juice Supplement Daily (AFRH RD)
-Diet Order: 6/27/19 - Dysphagia Modified Diet –
Previously Prescribed Encourage Chin Tuck with Meals (Memorial
Diet Experience (2.1.2) Diets
(FH-2.1.2.1)
Hospital for Aspiration Pneumonia)
7/31/19 PEG TUBE PLACEMENT
-Diet Order: 8/12/19 Jevity 1.2 – 6 Cartons/Day
(Pt only tolerating 5 cartons/day) – AFRH RD)
-Diet Order: 9/25/19 Jevity 1.2 – 7 Cartons/Day
(Pt only tolerating 4.5 cartons/day – AFRH RD)
-Diet Order: 10/10/19 - TwoCal HN–4 Cartons/Day
-Diet Order: 10/14/19 - Full Liquid Diet
(Hospitalization – TF was not running)
-Diet Order: 10/17/19 - TwoCal HN – 4
Cartons/Day (Pt tolerating diet well – AFRH)
Enteral and parenteral
Enteral Access PEG Tube
administration (FH-2.1.4.1)
(2.1.4)
 Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

-Cetirizine: Allergies – Crush, Per PEG Tube

-Atorvastatin: Cholesterol - Crush, Per PEG Tube
-Lisinopril: Blood Pressure - Crush, Per PEG Tube
-Ferrous Sulfate: Supplement – Liquid, Per PEG
Prescription Medication -Loperamide: Loose Stools - Liquid, Per PEG
Medications (3.1) Use -Clopidogrel: Heart Med - Crush, Per PEG Tube
(FH-3.1.1) -Levothyroxine: Thyroid - Crush, Per PEG Tube
-Zantac: GERD Pressure – Liquid, Per PEG Tube
-Atenolol: Blood Pressure - Crush, Per PEG Tube
-Furosemide: Fluid Overload – Liquid, Per PEG
-Vitamin D: Supplement – Liquid, Per PEG Tube
Self-Management as Pt verbalizes that he is comfortable with self-care
Adherence (5.1)
Agreed Upon (FH-5.1.5) and self-administration of tube feeding regimen.
Anthropometric Measurements (AD)
Describe the information Provide calculations
Nutrition Assessment List Specific Nutrition gathered from the and interpretation of
Terms Assessment Term patient’s family/medical anthropometrics
record
-Height (AD-1.1.1) -182.8 cm or 6’ -Measured
3/13/19: 72.5 kg or 160 lbs -Recorded in kg & lb
4/19/19: 70.5 kg or 155 lbs
6/27/19: 67.0 kg or 147 lbs -Measured Monthly
7/09/19: 66.0 kg or 146 lbs
-Weight 8/06/19: 63.0 kg or 139 lbs
(AD-1.12)
9/23/19: 62.0 kg or 137 lbs -Wt pre-intervention
10/10/19: 60.0 kg or 133 lbs
Body 10/28/19: 60.0 kg or 133 lbs
composition/growth/weight 11/13/19: 61.0 kg or 136 lbs -Wt Follow-up Assess.
history (1.1) -Frame (AD-1.1.3) -Small Frame Size -Observation
-Calculation:
-Weight Change -10.5 kg or 22.5 lbs wt
72.5 kg (3/19) – 62 kg
(AD-1.1.4) loss
= 10.5 kg or 22.5 lbs
-Weight Change % -14% Weight Loss -Calculation:
(AD-1.1.4.3) Severe 62/72.5 x 100 = %
-Body Mass Index -18.3 Underweight -Calculation: kg/m2
(AD-1.1.5.1)

Biochemical Data, Medical Tests, and Procedures (BD)

Describe the Describe the cause of the
List Specific
Nutrition Assessment information gathered abnormal lab values, specifically
Nutrition
Terms from the patient’s as it relates to the patient’s
Assessment Term
family/medical record medical condition(s)
Mar 2019: 21 mg/dL­ Decreased renal function
Electrolyte and renal BUN Apr 2019: 21 mg/dL­
elevates BUN lab values; Most
profile (1.2) (BD-1.2.1) Aug 2019: 46 mg/dL­
Oct 2019: 48 mg/dL­ likely related to CKD diagnosis.
 Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION
Gastrointestinal profile (1.4)
Glucose/endocrine profile
(1.5)
Nutritional Anemia profile
(1.10)
Protein profile (1.11)
Nutrition-Focus Physical Findings (PD)
Nutrition Assessment
Terms
Nutrition-focused physical
findings (1.1)
Mar 2019: 1.80 mg/dL­ Decreased renal function
Creatinine (Cr) Apr 2019: 1.52 mg/dL­
elevates Cr lab values; Most
(BD-1.2.2) Aug 2019: 1.59 mg/dL­
Oct 2019: 1.70 mg/dL­ likely related to CKD diagnosis.
Mar 2019: 36mL/min/1.73m2 ¯ Decreased renal function reduces
GFR Apr 2019: 39 mL/min/1.73m2¯
(BD-1.2.4) Aug 2019: 37mL/min/1.73m2¯
GFR lab values; Most likely
Oct 2019: 33 mL/min/1.73m2¯ related to CKD diagnosis.
Mar 2019: 142 mEq/L ✓
Sodium Apr 2019: 145 mEq/L ✓
Within Normal Limits
(BD-1.2.5) Aug 2019: 141 mEq/L ✓
Oct 2019: 136 mEq/L ✓
Mar 2019: 3.6 mEq/L ✓
Potassium Apr 2019: 3.8 mEq/L ✓
Within Normal Limits
(BD-1.2.7) Aug 2019: 4.0 mEq/L ✓
Oct 2019: 4.9 mEq/L ✓
Modified Barium April 2016 Final Impression: Silent
Swallow Aspiration Dysphagia with Thin
(BD-1.4.36) March 2019 Liquids
Esophagogastro- Final Impression: Normal
duodenoscopy July 2019 esophagus, stomach, and
(BD-1.4.38) duodenum
Mar 2019: 97 mg/dL ✓
Glucose, casual Apr 2019: 121 mg/dL­
Within Normal Limits
(BD-1.5.2) Aug 2019: 101 mg/dL ✓
Oct 2019: 92 mg/dL ✓
Mar 2019: 13.3 gm/dL ¯ Decreased hemoglobin and
Hemoglobin Apr 2019: 11.6 gm/dL ¯ hematocrit lab values indicate
(BD-1.10.1) Aug 2019: 10.9 gm/dL ¯
the state of anemia in a patient.
Oct 2019: 11.4 gm/dL ¯
For this case, it is most likely
Mar 2019: 40.0% ¯
Apr 2019: 36.2% ¯ caused by the destruction of red
Hematocrit
(BD-1.10.2) Aug 2019: 35.3% ¯ blood cells from past diagnoses
Oct 2019: 35.9% ¯ pneumonia and cancer.
Mar 2019: 3.3 g/dL ¯ Low albumin lab values may
Albumin Apr 2019: 3.2 g/dL ¯ indicate malnutrition and one of
Aug 2019: 3.3 g/dL ¯
(BD-1.11.1) the contributing factors is
Oct 2019: 3.6 g/dL ✓ inadequate oral intake of protein.
Describe the Provide a narrative that explains
List Specific
information gathered your findings from a NFPE that
Nutrition
from the patient’s you conducted on your
Assessment Term
family/medical record patient/client
-Severe weight loss
Cachexia NFPE
-Loss of fat/muscle
(PD-1.1.1.3)
-Anemia/Fatigue
 Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

Loss of -Notable loss of fat A nutrition focused physical

subcutaneous fat around temples, exam was conducted on the
(PD-1.1.2.3) clavicle, and scapula patient including close
Loss of -Notable loss of fat observations and palpations for a
subcutaneous around the tactile examination.
triceps fat (PD-1.1.2.5) triceps/arms
Loss of -Notable loss of fat First impressions of the patient
subcutaneous around the biceps/arm include generalized cachexia and
biceps fat (PD-1.1.2.6) circumference muscle atrophy as his overall
Loss of -Notable loss of stature was very slender and frail
subcutaneous fat subcutaneous fat in the in appearance.
overlying the ribs abdominal area;
(PD-1.1.2.7) prominence of ribs Assessment of the upper body
Clavicle abnormal -Notable prominence included palpation of temples,
prominence of the clavicle bone triceps, biceps, clavicle, scapula,
(PD-1.1.3.9) due to fat loss and ribs. This exhibited
Scapula abnormal -Notable prominence significant signs of both loss of
prominence of the scapula bone subcutaneous fat tissue as well as
(PD-1.1.3.11) due to fat loss muscle tissue.
Heartburn -Pt verbalizes
(PD-1.1.5.18) discomfort in gut The patient had notable loss of
-Pt verbalizes grip strength with normal skin
Liquid Stool
(PD-1.1.5.22) continued diarrhea turgor response.
Muscle Atrophy -Visual weakness and
(PD-1.1.14.1) dysfunction observed Nutrition Screening Tools:
Dysphagia -Dx: Silent Aspiration SGA Score: 1 – Severely
(PD-1.1.19.3) Malnourished
-Per pt verbalization
and observation, the pt Nestle MNA: 5 – Malnourished
Hoarse Voice
(PD-1.1.19.7) experience persistent ADA/ASPEN: Severe
coarseness Malnutrition
Client History (CH)
Nutrition Assessment List Specific Nutrition Describe the information gathered from the
Terms Assessment Term patient’s family/medical record
Age 92 years of age
Gender Male
Personal data (1.1) Race Caucasian
Language English
Mobility Wheelchair, Rollator, Staff Assistance
Patient: Chief Nutrition Dysphagia: Silent Aspiration
Patient/client OR family Complaint (CH-2.1.1) Malnutrition
nutrition-oriented medical Patient: Cardiovascular Hx of CHF, Stroke, CAD, HTN, TIA
(CH-2.1.2)
history (2.1)
Family: Cardiovascular Pt’s father had a history of stroke(s).
(CH-2.1.2)
 Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

Patient: Excretory Hx of CKD Stage III

(CH-2.1.4)
Patient: Gastrointestinal Hx of Oro-pharyngeal Dysphagia & C-Diff Colitis
(CH-2.1.5)
Patient: Oncology Hx of Kidney & Prostate Cancer
(CH-2.1.7)
Patient: Musculoskeletal Hx of Left Clavicle Fx, OA of Left Knee, Arthritis
(CH-2.1.10)
Patient: Respiratory Hx of Pneumonia
(CH-2.1.13)
Treatments/therapy (2.2) Medical Treatment Hx of Colonoscopy Polypectomy, EGD with Bx,
(CH-2.2.1)
Cardiac Catherization, Cholecystectomy, Insertion
Surgical Treatment
(CH-2.2.2) of Cardiac Pacemaker, Stent Placement
Social history (3.1) Living/Housing Resides in Assisted Living at Armed Forces
Situation Retirement Home in Gulfport, Mississippi
(CH-3.1.2)
Social and Medical Pt’s daughter plays a large role in supporting the pt
Support emotionally and also with making appropriate
(CH-3.1.2) medical decisions by working with AFRH.
Occupation Retired United States Veteran
(CH-3.1.6)
Comparative Standards (CS)
Provide a referenced
Nutrition Assessment Indicate the Comparative rationale for the
Calculate, as needed
Terms Standard Used Comparative Standard
Used
Nelms, M. N.
(2016). Nutrition therapy and
Estimated energy needs 1,860 kcals/day 30 kcal/kg pathophysiology. Australia:
Cengage Learning.
Nelms, M. N.
(2016). Nutrition therapy and
Estimated protein needs 80 gm/day 1.3 gm/kg pathophysiology. Australia:
Cengage Learning.
Nelms, M. N.
Estimated carbohydrate 50% of estimated energy (2016). Nutrition therapy and
233 gm/day pathophysiology. Australia:
needs needs
Cengage Learning.
Nelms, M. N.
(2016). Nutrition therapy and
Estimated fiber needs 30-40 gm/day Recommended Value pathophysiology. Australia:
Cengage Learning.
Nelms, M. N.
(2016). Nutrition therapy and
Estimated fluid needs 1,860 mL/day 1 mL/kcal pathophysiology. Australia:
Cengage Learning.
Recommended body IBW: 81 kg or 178 lbs 106 lbs + 72 lbs (12 x 6) Nelms, M. N.
(2016). Nutrition therapy and
weight/body mass pathophysiology. Australia:
index/growth 1-2 lb increase/week Safe Weight Gain Cengage Learning.
Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

Malnutrition. Initial assessment of G.W. included a comprehensive observation of

weight trends, lab values, and nutrition focused physical exam. Collected evidence

suggested that the patient was severely malnourished with a body mass index (BMI) of

18.3, below range albumin lab values, severe 12% weight loss over a six month time

period, and collected physical attributions observed per NFPE. According to the

ADA/ASPEN Consensus Statement, G.W. is severely malnourished in the context of

chronic illness. Additional malnutrition screening tools were used to assess the patient’s

nutritional status. Similar results were yielded as the Subjective Global Assessment and

Nestle Mini Nutrition Assessment tools classified G.W. as severely malnourished.

Medical Nutrition Therapy & Diet Orders. Patient G.W. has a history of inconsistent

and inadequate diet orders prior to, during, and after hospitalizations. A regular diet with

a daily fortified orange juice was ordered on April 19th, 2019 at the AFRH. The patient’s

chart indicated an average intake of < of 25% of provided meals. This rate of food intake

was only meeting about 28% of his energy needs. Recurrent hospitalizations and

diagnoses of aspiration pneumonia led to the placement of a PEG tube on July 31, 2019.

Six cartons of Jevity 1.2 was ordered for the patient and then was increased to seven

cartons per day on September 25, 2019 to provide 1,991 kcals/day. Unfortunately, the

patient was not able to tolerate the rate and volume of the formula and was only meeting

about 69% of his energy needs. The highlighted section of Table 1 indicates the date of

this case study’s assessment and intervention. Recommendations to change enteral

formula to TwoCal HN were completed with the patient tolerating it well and meeting

107% of his needs.

Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

The patient was readmitted into the hospital on October 14th, 2019 due to

exacerbation of CHF. During this hospitalization, his tube feeding was discontinued and

he was ordered a full liquid diet. Though the intake was not reported, it can be predicted

to be inadequate per observation of the continued weight decline during that time frame.

The patient verbalized confusion about his most recent hospitalization and stated that a

speech pathologist conducted a bedside swallow study and inappropriately cleared him

for an oral diet. Upon return to the AFRH, the patient’s tube feeding regimen was

reinitiated and tolerated well, meeting 107% of his nutrient needs. Patient G.W.

administers his own tube feeding formula correctly with adequate water flushes.

Table 1.

Patient Orders and Comparison to Reported Dietary Recall

Date: Diet Order: Estimated Intake

3/5/2019 Cardiac Diet (Hospital)
4/19/2019 Regular Diet – 2,050 kcal
Fortified OJ QD (AFRH)
6/27/2019 Dysphagia Diet (Hospital)
8/12/2019 Jevity 1.2 – 6 Cartons/Day
(Provides 1,706 kcal/day)
Not Reported
< 25% Provides ~ 513 kcal/d
(Meets 28% kcal needs)
Not Reported
Pt only tolerating 5 Cartons
(Meets 76% kcal needs)

9/25/2019 Jevity 1.2 – 7 Cartons/Day Pt only tolerating 4.5 Cartons

(Provides 1,991 kcal/day)
10/2/2019 TwoCal HN – 4 Cartons/D
(Provides 1,896 kcal/day)
10/14/2019 Full Liquid Diet (Hospital)
Tube Feeding Not Running
10/17/2019 TwoCal HN – 4 Cartons/D
(Provides 1,896 kcal/day)
(Meets 69% kcal needs)
Pt tolerating rate/formula
(Meets 107% kcal needs)
Not Reported
Pt Verbalized Confusion
Pt tolerating rate/formula
(Meets 107% kcal needs)
Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

Anthropometric and Biological Trends.

Figure 1. G.W. Renal Profile Lab Trends from March 2019 to Present

The above graph displays the trend of G.W.’s renal profile over the most recent

eight months. Patient G.W. has a history of stage III chronic kidney disease (CKD) and

has routine lab work completed to check the status of renal function. Renal function is

measured and categorized based on the glomerular filtration rate or GFR. Over the past

eight months, the patient has had an GFR average of 36.25 mL/min/1.73m2, indicating

that he remains to be in stage III of CKD. Once an individual is diagnosed with CKD,

the main goal is to preserve the remaining function of the kidneys in hopes to delay the

progression of renal failure. Preservation can be attained though routine monitoring of

lab values, medications, and appropriate nutrition interventions. Moderate protein intake

is usually recommended for patents in stage III of CKD, but in this case, the status of

malnutrition takes precedent, justifying the increase of protein and energy needs.
Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

Figure 2. G.W. Anemia and Protein Lab Trends from March 2019 to Present

The above chart displays G.W.’s anemia and protein profile lab trends over the

past eight months. Protein status is used as one of the many indicators of malnutrition

and G.W.’s poor nutritional status is supported by his assessed low albumin and

hemoglobin lab values from March to October of 2019. The vertical green line seen in the

above figure indicates the intervention of this case study that encompasses a more

appropriate tube feeding formula at a more tolerable rate for the patient. At this point, the

patient was able to completely meet his nutritional needs (107% of energy needs and

100% of protein needs) as compared to his reported prolonged inadequate intake over the

past eight months. The observed slight increase of albumin and hemoglobin post-

intervention supports the impression of the beginning of improved nutritional status

related to the intervention of this case study.

Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

Figure 3. G.W. Weight Trends from March 2019 to Present

The above chart exhibits patient G.W.’s weight trend over the past eight months

in kilograms. G.W.’s verbalizes that his usual body weight is between 73-77 kg or 160-

170 lbs. Per chart review, G.W. has experienced at least 14% of severe unplanned weight

loss over the past eight months and at least 12% over the past six months. The continual

unplanned weight loss can be assumed to be related to the patient not meeting his

nutritional needs through both oral and enteral diet orders. The vertical green line

represents the implications of this case study’s interventions. After this point, G.W.’s

weight was able to stabilize and then begin to slightly increase. There was a slight

continuation of weight loss following the intervention as the patient was readmitted to the

hospital for exacerbation of chronic failure and was not prescribed the appropriate diet

order. The slight weight increase in the observed trend can be used to predict the current

and future success of the proposed nutrition interventions of this case study.
Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

Nutrition Care Process: Diagnosis

1. Inadequate enteral nutrition infusion related to intolerance of EN/PN as evidenced by

patient’s self-report of only tolerating four cartons (948 mL) of Jevity 1.2 per day with

the diet order for seven (1,659 mL) cartons per day.

2. Unintended weight loss related to decreased ability to consume sufficient

energy/nutrients as evidenced by patient’s original diagnosis of silent aspiration

dysphagia in 2016, average recorded oral intake of <25% of meals, and 12% severe

weight loss over the past six months.

3. Malnutrition (undernutrition) related to inadequate energy intake as evidenced by BMI of

18.3, physical findings of nutrition focused physical exam (NFPE), and subjective global

assessment (SGA) score of 1, indicating severely malnourished nutrition status.

Nutrition Care Process: Intervention(s)

Medical interventions for G.W. have been identified through his intricate past of health

complications of silent aspiration dysphagia and aspiration pneumonia. During his multiple

hospitalizations in the past eight months, the patient underwent multiple swallow studies and

antibiotic treatments for his associated pneumonia. Unfortunately, the patient continues to suffer

from silent aspiration dysphagia, despite efforts of speech therapy and modified textured diets.

The patient’s current medication regimen involves various prescriptions for allergies, cholesterol,

blood pressure, fluid overload, and hypertension. A liquid form of Zantac and Loperamide is

administered per the PEG tube by the patient to help alleviate heart burn associated pressure as

well as to help with loose stools. The initial assessment of the patient indicated inadequate

enteral nutrition infusion as the patient was not able to tolerate the volume of the prescribed

formula.
 Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

Discuss the
List Specific Describe if this was the
Nutrition Describe the actual rationale/justification
Nutrition most appropriate
Intervention intervention that was for recommendations,
Intervention intervention based on
Terminology completed including references,
Term(s) the literature
as appropriate
Rationale for
Modification of
Modify Recommend Composition and Rate Based on the literature
Composition Modification to: of Enteral Formula and the change in
of Enteral ASPEN’s Journal of weight, lab values, and
Formula TwoCal HN Parenteral and Enteral patient compliance, this
(ND-2.1.1) 4 - 8oz Cartons/Day Nutrition (2015) and intervention was most
Or 948 mL/Day Nelms (2018) express appropriate for G.W.
Modify Rate & evidence that supports
of Enteral Water Flushes modifying the enteral The patient’s weight
Formula 10 Flushes - 120 mL formula to TwoCal HN stabilized and started to
Enteral (ND-2.1.3) to will help meet the increase while his
Nutrition increased nutrient protein lab profile was
Modify This will provide: needs for healthy observed to slightly
Volume of 948 mL of Formula weight gain while also improve as well.
Enteral 1,896 kcals/day assisting the patient
Formula 80 gm/day of PRO with tolerating the Continuation of this
(ND-2.1.4) (100% of PRO Needs) volume and rate. intervention may help
~5 gm/day Fiber Nelms (2018) to continue to improve
Feeding Tube 208 gm/day CHO recommendations for G.W’s overall
Flush 1,864 mL of Water malnourished patients nutritional status and
(ND-2.1.9) (102% of Fluid Needs) were referenced when well-being.
selecting the formula to
meet G.W.’s needs.
Benefiber Rationale for Fiber Based on the literature,
Supplement Supplementation the incorporation of a
12 tsp/day ASPEN’s Journal of fiber supplement was
Per PEG Tube Parenteral and Enteral an appropriate choice as
(3gm of Fiber/Tsp) Nutrition (2015) this intervention allows
(15 kcal/2Tsp) explains that loose the patient to meet his
stools are a common fiber intake goal by
Medical Food Commercial
issue for individuals 110%. Per patient
Supplement Food This will provide: utilizing nutrition discussion, his loose
Therapy (ND-3.1.2) 90 kcals/day support. Increasing stools have slightly
27 gm/day of Fiber fiber has been shown to improved. He states
Total Energy Intake: help create bulkier that he has decreased
1,986 kcals/day stools and from 3-4 bowel
(107% of Energy Needs) improve/reduce loose movements/day to 2-3
Total Fiber Intake: stool bowel bulkier bowel
33 gm/day of Fiber movements. movements/day.
(110% of Fiber Needs)
 Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

Social Work Rationale for Based on the literature

Counseling Collaboration and discussion with the
The AFRH includes The Academy of patient, this
an interdisciplinary Nutrition and Dietetics intervention of
health team, (2018) supports that the collaboration of other
including social use of n healthcare health care
Team Meeting workers and the team in care of older professionals was
Collaboration
(RC-1.1) registered dietitian. adults can lead to better beneficial. Losing the
Quarterly meetings quality and continuity ability to eat orally and
and Referral
Collaborations with the patient and of care as well as learning to self-
of Nutrition
with Other the team occur every improved health administer tube feeding
Care
Providers three months. A outcomes. Referral and regimens can be
(RC-1.4) referral for G.W. to collaboration with the mentally taxing.
see the social worker social worker for Chronic poor health has
will be recommended AFRH coincides these the ability to manifest
to meet twice a recommendations and into associated anxiety
month to assess the will promote and and depression if not
mental and emotional encourage continued monitored and
status of the patient. improvement of health. addressed prematurely.

Nutrition Care Process: Monitoring and Evaluation

Monitoring and evaluation will be completed through previously established AFRH

protocols of monthly weight checks. G.W.’s weight will be recorded and compared to previous

weights with the goal of being > 61kg of 136 lbs for weight preservation and continued safe

weight gain. Appropriate weight gain for G.W. is approximately 1-2 lbs per week as to return to

the goal weight of 160-170lbs slowly and safely. In addition to the standard monthly weight

collection by the facility, patient G.W. will visit with the registered dietitian once a month to

discuss the toleration of his enteral formula with an intake of 100%, compliance and intake of

Benefiber supplement of 100% with the goal of bulkier and less frequent stools. Physical signs

of malnutrition will have not progressed any further or improved, and albumin lab values will be

within normal range. Monitoring and evaluation of the patient’s compliance with attendance

counseling sessions with the social worker will be 100%. The mental and emotional status of the
Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

patient will be evaluated through collaboration with the social worker to ensure the patient is

handling his new lifestyle change well and is adjusting appropriately.

Initial assessment of the nutritional status of G.W. and implementation of proposed

interventions occurred on October 10nd, 2019. Follow-up monitoring for the patient post-

intervention was evaluated about one month later on November 13th, 2019. The patient’s weight

met the goal by measuring to be 61 kg or 136 lbs, indicating weight stabilization. The patient’s

physical attributes did not exhibit further muscle and fat wasting. The patient reported to meet

his intake goal of 100% for his enteral nutrition regimen and Benefiber supplementation. The

increased fiber intake helped to improve bowel movements by decreasing frequency from 4-5 to

2-3 bulkier movements per day. Additionally, the patient’s albumin lab value for October 23rd,

2019 had improved and increased to 3.6 g/dL, meeting the goal of being within normal limits.

Conclusion

Patient G.W. is a 92 year old male who retired from the United States Army and Air

Force and currently resides at the AFRH facility in Gulfport, Mississippi. G.W. has been

struggling with the grim and relentless conditions of silent aspiration dysphagia that was most

likely onset by his history of a stroke. Recurrent hospitalizations for aspiration pneumonia and

chronic disease related malnutrition has led to the patient initiating enteral nutrition per PEG tube

placement in order to allow the patient to safely meet his nutrient needs without the risk of

aspiration and consequential aspiration pneumonia while also improving his overall nutritional

status long term. Based on the collected evidenced-based literature and practice experience,

initiating a nutrient dense enteral formula with fiber supplementation is an appropriate nutrition

intervention for malnourished elderly patients struggling with disabling silent aspiration related

dysphagia.
Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

References

Academy of Nutrition and Dietetics, A.N.D. (2018). Standards of Practice and Standards of

Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient,

and Expert) in Post-Acute and Long-Term Care Nutrition.

ASPEN's journal of parenteral and enteral nutrition. (2015). Select Appropriate EN Formula .

Dalton, B. G. A., Friedant, A. J., Su, S., Schatz, T. A. P., Ruth, K. J., & Scott, W. J. (2017).

Benefits of supplemental jejunostomy tube feeding during neoadjuvant therapy in

patients with locally advanced, potentially resectable esophageal cancer. Journal of

Laparoendoscopic & Advanced Surgical Techniques, 27(12), 1279–1283.

https://doi.org/10.1089/lap.2017.0320

Academy of Nutrition and Dietetics Evidence Analysis Library. "CI: Enteral vs. parenteral

nutrition” Accessed 14 November 2019:

https://www.andeal.org/template.cfm?template=guide_summary&key=3222&highlight=

CI%3A%20enteral%20vs&home=1.

Academy of Nutrition and Dietetics Evidence Analysis Library. "UWL: Executive summary of

recommendations" Accessed 14 November 2019:

https://www.andeal.org/topic.cfm?cat=3652&highlight=UWL: Executive Summary of

Recommendations (2009)&home=1.

Hand, R. K., Murphy, W. J., Field, L. B., Lee, J. A., Parrott, J. S., Ferguson, M., … Steiber, A. L.

(2016). Validation of the academy/A.S.P.E.N. Malnutrition clinical characteristics.

Journal of the Academy of Nutrition and Dietetics, 116(5), 856–864.

https://doi.org/10.1016/j.jand.2016.01.018
Running Head: DANGERS OF CHRONIC DYSPHAGIA AND MALNUTRITION

Hede, G. W., Faxén-Irving, G., Olin, A. Ö., Ebbeskog, B., & Crisby, M. (2016). Nutritional

assessment and post-procedural complications in older stroke patients after insertion of

percutaneous endoscopic gastrostomy – a retrospective study. Food & Nutrition

Research, 60(1), 30456. https://doi.org/10.3402/fnr.v60.30456

Jalil, A. A. A., Katzka, D. A., & Castell, D. O. (2015). Approach to the patient with

dysphagia. The American Journal of Medicine, 128(10). doi:

10.1016/j.amjmed.2015.04.026

Nelms, M. N. (2016). Nutrition therapy and pathophysiology. Australia: Cengage Learning.

Jordan, T., Mastnak, D. M., Palamar, N., & Kozjek, N. R. (2018). Nutritional therapy for patients

with esophageal cancer. Nutrition and Cancer, 70(1), 23–29.

https://doi.org/10.1080/01635581.2017.1374417

Shaw, S. M., Flowers, H., O’Sullivan, B., Hope, A., Liu, L. W. C., & Martino, R. (2015). The

effect of prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement on

swallowing and swallow-related outcomes in patients undergoing radiotherapy for head

and neck cancer: A Systematic Review. Dysphagia, 30(2), 152–175.

https://doi.org/10.1007/s00455-014-9592-z