Nutrition, Dysphagia, and Dementia (Questions & Answers)

Nutrition, Dysphagia, and Dementia

Short answer questions

This assessment task is worth 30% (30 points). Please read these instructions carefully.

There is no specific word length for your answer to each of the 30 questions. You are encouraged to be succinct but thorough.

Please write in complete and grammatical sentences. If you are listing items in a response, you may use dot points and grammatically correct phrases. Do not use quotes unless this is a specific part of the question (i.e., question 8).

You must include each numbered question in full before your answer. Please present the questions and your responses in sequential order. Rather than re-typing the questions, feel free to insert your responses after each question on this document.

You need to support your answer to each question with at least one correctly cited reference from the 16 articles you have read. Do not cite lectures.

A complete reference list at the end of your work is not needed.

Your responses to each question will be graded as follows:

You did not answer the question, or your response was incorrect, or did not contain a supporting reference, or was difficult to understand, or did not relate to a specific question, or you relied on quotes (NN, 0 points)

You answered the question correctly but not completely (PP = 0.5 points; CR = 0.6 points; DN = 0.7 points)

You answered the question correctly and completely (HD = 0.8 to 1.0 point)

1. List the five main groups of nutrients that are important to include in a balanced diet for people with dementia. Why are these nutrients important?

Malnutrition has been found to be a major disease affecting the elderly and is associated with poor nutritional intake regarding not only calories but also nutrients as well as micronutrients. Some of the consequences include muscle wasting as well as impaired immune defense. The man five groups of nutrients include proteins, carbohydrates, vitamins, minerals, and oils. Minerals such as zinc prevents progression of AMD while vitamins such as C and E acts as protective agents against eye disease (Vega, 2015). While proteins are required for bodybuilding, carbohydrates are sources of energy. Oils are essential for overall well-being of the body since some helps enhance immune function, while others such as fish oil reduces the tendency of blood to clot.

2. Valid and reliable screening tools are essential to identify if adults with dementia are at-risk and need further comprehensive evaluation. What is the most frequently recommended screening measure of malnutrition risk? What information does this screening tool provide?

Nutrition assessment has been described as comprehensive evaluation performed on a patient to not only diagnose malnutrition but also associated problems. Additionally, nutrition screening helps in identification of the appropriate intervention measures. Unlike the younger adults, nutrition screening among the older adults has been found to be more difficult.  There are various nutrition screening tools that have been found to be appropriate for the older adults. Although the tools have been found to be appropriate for identifying the existence or the risk of malnutrition, they are not good for the identification of the relevant intervention measures. The nutrition screening tools include Mini Nutritional Assessment (MNA) that combines both screening and assessment, Malnutrition Universal Screening Tool for screening, Nutrition Risk Screening, and Subjective Global Assessment which is mainly an assessment tool. However, in all the screening methods, one of the most superior one for older adults is individualized nutrition assessment. The screening tool is popular since it not only helps in the diagnosis of malnutrition but also identification of appropriate interventions (Mueller, 2015).

3. When an adult with dementia is referred for a comprehensive nutrition assessment, what does this comprehensive assessment need to include?

Some of the nutritional assessment methods include obtaining laboratory, clinical or historical information of a client. However, while several tools can be used to perform nutritional assessment for a client, none of them qualifies as a reliable and valid predictor of nutritional status. According to Mueller (2015), a comprehensive nutritional assessment include several ways of assessing one’s level of malnutrition. This include evaluation of one’s food insecurity, and obtaining and analyzing laboratory, anthropometric, and dietary data. It also include not just determining clinical signs but also performing physical examination on the client. Evaluation of food insecurity as well as measuring the functional status of the client has been suggested as other procedures that comprise a comprehensive screening.

4. The role of dietary flavonoids in preventing or stabilizing cognitive decline is being examined. What are dietary flavonoids? Where can they commonly be found in the diets of older adults?

Cognitive decline has been found to be associated with neurodegeneration that leads to AD. Research has shown that a modification of lifestyle factors that include not only diet but also nutrition are some of the factors that play a significant role during primary prevention (Vega, 2015). Some of the nutrients that have been found to prevent cognitive degeneration include omega-3 fatty acids, vitamins C, D, and E, and B vitamins, and flavonoids (Ragdale, 2014). Flavonoids have been defined hydroxylated polyphenolic compounds that comprise. The compounds comprise a large family that is over 5,000-6,000 types and play critical functions in pants. However, dietary flavonoids are found in not only fruits but also vegetables. Therefore, older adults can obtain their dietary flavonoids from both fruits and vegetables.

5. Adults with dementia who live in residential aged care are vulnerable to being malnourished. In addition to the type of food eaten, the physical and social contexts in which the food is provided are important. Identify four (4) physical or social issues that can hinder food intake; then four (4) evidence-based ways in which these issues can be overcome to facilitate food intake.

While it is known that there is rampant malnutrition in residential aged care, it has been found that the solution lies in not only the type of food provided but also on the social as well as physical contexts in which the diet is provided (Divert et al., 2014). Research has shown that four major factors influence their food intake. According to Divert et al. (2014), the manner of naming the main course on the menu, elemental factors that modify the surroundings of the table, size as well as variety of vegetable portions served, and availability of condiments positioned at the center of the table. Solutions for the issues include appropriate naming of food in the menu, serving small portions of food at a time, enhancing food flavorings, and improvement of the surroundings.

6. Cost-effectiveness data are essential when considering whether to implement changes in residential aged care communities, including for nutrition-related interventions to decrease risk of malnutrition. What is the current thinking on the cost of implementing food-based nutrition interventions?

It has been found that although certain nutritional methods used for managing malnutrition in the residential healthcare may be cost-effective, the available data is not sufficient. Hugo et al. (2018) investigated cost-effective methods that can be employed while addressing the issue of malnutrition in a residential aged care. Their study revealed that supplements, as well as other interventions that are food-based provided in the aged care facility, are not only clinically effective, but their cost of implementation is low. Additionally, the authors further found that the interventions are cost-effective when used to improve clinical outcomes that are associated with malnutrition. However, they contend that more studies need to be done using robust frameworks that help in economic analysis, strong study methods that allow for improved quality, as well as validated measures of nutrition.

7. How can living in a residential aged care community adversely affect residents’ oral health, particularly for residents who are frail?

Older adults tend to be frail. Oral healthcare is important for not only younger adults but also older adults. However, oral health care among older frail adults in a residential care have been found to be compromised. In their work, Niesten et al. (2013) investigated not only how the type but also level of frailty has on the dental service-use as well as the oral self-care behavior among the older adults in a residential care facility. The findings of their study showed that people’s perspective about oral health, as well as associated behaviors, are not only influenced by their level and type of frailty. While older adults link oral health with self-worth, they fail to visit the dentists unless they have a specific oral problem that need to be solved.

8. Niesten and her colleagues (2013) identified important themes affecting oral care. Which theme or sub-theme and supporting quotation resonated with you the most? Why?

A study conducted by Niesten et al. (2018) led to the identification of important themes that has an impact on the healthcare. The researchers identified five sub-themes, and three themes during their analysis of data. The major themes support the view that frail adults have a preference for routines of oral hygiene that are along-established for them to maintain a sense of self-worth. The authors also found out that older adults tend to abandon oral hygiene when they are overwhelmed by severe complaints of health such as low energy, low morale, and chronic pain. Further, older adults experience not only psychological barriers but also social barriers to oral health care when they are institutionalized. The theme that resonates with me is that older adults tend to abandon oral hygiene when they are overwhelmed by severe complaints of health such as low energy, low morale, and chronic pain. This is natural given that the other health complications may be too severe that they compromise r overshadow oral health concerns. Therefore, I feel that adults in such a status deserve more attention on the aspect of oral hygiene.

9. What is “sarcopenia”? How might sarcopenia affect the nutritional status of a person with dementia? What is the relationship between sarcopenia and the tongue?

Sarcopenia has been defined as the decline in not only the muscle mass but also the strength that is related with age. Sarcopenia has an impact on the nutritional status of the affected person since it leads to decreased physical function of the affected person. Loss in muscle mass and physical strength is a characteristic of malnutrition. Sarcopenia is a factor of frailty, and it can be diagnosed by observing common attributes associated with it which include low physical activity due to weakness, self-reported exhaustion, slow walking speed, unintentional loss in weight, and weakness (Mueller, 2015). Sarcopenia is related with the tongue in that physical weakness in the tongue can influence malnutrition since the affected person may have difficulty during eating.

10. Adults with dementia frequently take multiple prescription medications (polypharmacy) and are at-risk for adverse side effects. Identify two side effects that can have a negative impact on swallowing and gastrointestinal function. What could be the nutritional consequences of these side effects?

One of the interventional measures for adults with dementia is prescription of drugs known as polypharmacy. Although the drugs can help in managing the condition, it has side effects which include dry mouth, alteration in taste, and stomatitis (Han et al., 2014).

11. What is aspiration pneumonia? Identify the seven best predictors of aspiration pneumonia:

Aspiration pneumonia is a type of pneumonia associated with aspirating patients. Seven best predictors of aspiration pneumonia include reduced appetite, reduced interest in food, holding food in the mouth, coughing or choking, eating very slowly, playing with food, lack of ability to use utensils, and malnutrition (Ragdale, 2014).

12. Explain why being dependent on others for feeding increases the risk of aspiration pneumonia for adults with dementia

When one depends on others for feeding, it may be difficult for him or her to control many factors including the quantity of food that need to be put in the mouth, the frequency of putting in the mouth, and many other factors. Hence the person may choke while swallowing food resulting in food particles, liquids, saliva, and other matter breathed into the lungs instead of being directed down to the esophagus.

13. Thickening liquids is a common strategy to facilitate a safe swallow for adults with dementia who have difficulty swallowing thin (regular) liquids. However, thickening liquids can increase risk for dehydration. Explain why:

Thin regular liquids contain a large amount of water that can be absorbed into the blood system. However, thick food suggests a reduced water level. Consequently, the amount of water available to be absorbed into the body system is lower in thickening liquids as compared with thin (regular) liquids.

14. What are the two important issues to address in the effective management of dry mouth (xerostomia) for adults with dementia? What are the negative consequences of a dry mouth?

Two critical issues to address in xerostomia are attempts to influence a change in the factors causing it, and prevention of any likely or worsening of existing impacts of dry mouth on the oral health.   Additionally, cost and effectiveness of the intervention measures are also factors that need to be considered. Dry mouth can be effectively managed using various interventions that include direct diagnosis management, topicals, moisteners, modifiable behaviors, medication substitution, toothpaste and fluoride as treatment, prescription medication, and non-pharmacological interventions (Han et al., 2014).  Non-pharmacologic interventions include acupuncture, electrostimulation of the salivary glands, removable intraoral devices, and immunologically active medication such as immunosuppressant.

15. Adults with advanced dementia experience physiological and neurological changes that affect their desire need, and ability to eat. Loss of weight is characteristic of the end-of-life stage. Percutaneous endoscopic gastrostomy (PEG) tube placement is no longer considered an effective treatment strategy. Explain (a) why PEG tube placement is no longer recommended at this end-of-life stage, and (b) what can replace it regarding nutritional care
16. Caring for adults with dementia at the end-of-life, particularly regarding nutritional intake, can involve complex decisions. Qualitative research through interviews with family members and legal guardians has identified four major interconnected themes regarding PEG tube placement. Summarise these themes and state how each can be addressed to help families and guardians understand that PEG tube placement is not a recommended option.
17. Why are quality of life (QOL) measures an essential part of care for adults with dementia?
18. Identify and describe a frequently used and recommended generic/general health QOL measure.

The most frequently used parameter for QOL is dietary intake (Carson et al., 2014). The ability to take appropriate dietary intake suggests one has a high chance of living a high QOL as compared with somebody who do not get appropriate dietary intake. Failure to get appropriate dietary intake may lead to weight loss or malnutrition which are features of a poor QOL.

19. Identify and describe a QOL measure that is specific to swallowing (you do not have to cite a reference in your response).

One of the QOL measures that is specific to swallowing is weight loss. When a person has difficulty in swallowing food, the quantity of diet consumed is compromised. Consequently, the reduction in dietary intake results in weight loss.

20. Abdelhamid and colleagues (2016) report that studies investigating a strong social element around eating/drinking show how this social element can improve the nutritional intake and quality of life for adults with dementia. These investigators report promising evidence for four (4) socially-oriented strategies. What are these four strategies?

Socially-oriented strategies that can be used to improve nutritional intake, as well as quality of life for people with dementia, include family-style meals, sharing meals with them, application of reminiscent treatment, and group treatment of multimodal-modal nature. Family-style meals are important since they not only increase participation but also communication among people with dementia.

21. Continuing to focus on the systematic review by Abdelhamid and colleagues (2016), what aspects of quality of life did the socially-oriented interventions improve?

Socially-oriented type of interventions improve ability of the people with dementia to communicate, quality of interactions, enjoyment of meals, and autonomy. Family-style meals has been shown to increase participation of dementia people during meal times, frequency of praise of the carer, and appropriate communication. Additionally, it helps them to gain weight and become satisfied with the carer. Further, the use of reminiscent cooking therapy helped people with dementia to not only feel happier but also to engage in positive communication.  Investigations also revealed that a facilitated breakfast club has a positive impact on the cognition status, involvement and procedural memory, and interest as compared with discussion with coffee.

22. What is dysphagia? Explain how dysphagia can create a significant social and psychological burden for adults with dysphagia and dementia and their caregivers.
23. Explain the relationship between dysphagia and aspiration pneumonia.
24. Repeated chest infections of no obvious cause can indicate the need to investigate possible dysphagia. What else is it important to screen for when problem-solving why such chest infections are occurring? What does such screening involve?

Besides the need to screen repeated chest infections without any obvious cause, it is important to screen other features that may be associated with dysphagia. The features include frequent temperature spikes, unexplained weight loss, drastic changes in feeding habits, avoidance or intolerance of certain food items, and prolonged swallow. The screening involves swallow tests, instrumental assessments, clinical examination, and oral, physical assessment (Miller and Carding, 2007).

25. When a comprehensive swallowing examination is needed, there are two instrumental assessments that can provide detailed information about the anatomy and physiology of a person’s swallow. Briefly explain these two clinical procedures and explain why one of them is more useful outside of a hospital setting.

Several methods of swallow tests are available. Tow instrumental methods that are often used are the cervical auscultation and assessing oxygen saturation levels. In cervical auscultation, a stethoscope is used to audit the process of swallowing as well as activities taking place in the airway. Individuals are then classified based on their risk or not penetration or aspiration. Pulse oximetry, however, involves prolonged obstruction of the airway during an abnormal swallowing, and it has been predicted to result in depressed oxygen concentration which suggests existence of dysphagia (Miller and Carding, 2007). Since pulse oximetry has been found to be unreliable method, and thus ineffective, cervical auscultation is best used outside a hospital setting.

26. Healthcare professionals and caregivers want to ensure that adults with dementia do not develop the “frailty syndrome.” What are the five (5) essential elements of this frailty syndrome?

Elements of frailty syndrome include:

• Unintentional weight loss
• Self-reported exhaustion
• Weakness
• Slow walking speed
• Low physical activity (Vega, 2015).

27. Consistent and appropriate physical exercise is recognized as important to maintain muscle strength, mobility, flexibility, and balance for adults with dementia. How might such exercise have positive effects on the emotional and cognitive function, nutritional intake and swallowing ability of older adults, including those with dementia? 

Physical exercises in older adults have been found to improve swallowing ability, nutritional intake, and emotional and cognitive function. Physical exercises has been shown to minimize depression among older adults. Depression has a negative impact on the emotional and cognitive functions. Additionally, research has revealed that physical exercise are associated with improved moods and confidence among old age women.  Further investigations have shown that older adults engaged in physical exercise exhibit improve level of cognitive functioning as demonstrated by their fluid intelligence, memory, and reaction time (Vega, 2015). Nutritional intake improve with increased physical exercises since a lot of calories are burned during the exercises. Swallowing ability also improve since physical exercises improve muscular tissues responsible for swallowing.

28. Case presentation #1: CT is a 93-year-old woman who has been living in a residential care facility for three years. Her weight was 51kgs on admission and has been measured regularly approximately every two months. In the eight months following admission, her weight increased by 6.9kgs. However, it then dropped over time to 44.3kgs, 6.7kgs below her weight at admission. A loss of 9.5kgs has occurred in the past 12 months.

CT’s weight was measured regularly. What was not measured or calculated? Why is the sole measurement of weight not the best way to monitor a person’s nutritional status?

While CT’s weight was measured regularly, the increase or decrease in weight is not enough evidence of judging her nutritional status. One critical element that was not measured in this case is her height. BMI captures a person’s height as well as the weight. BMI beyond a certain value suggest overweight or obesity, while a BMI below a certain level may suggest malnutrition or starvation. Since one’s height influence BMI, weight alone is not the best way to monitor an individual’s nutritional status.

29. Case presentation #2: ML stated that she had no energy to “get up and go” anymore and that she is content to fall asleep in front of the television. She reported being constipated and upset that her food does not have much taste. She stated that she eats an egg for breakfast but prefers cooked potatoes and tomato sauce for lunch and dinner when she eats alone. She stated these foods minimize the “thick tongue” feeling she frequently has. She avoids alcohol and tobacco and drinks one cup of coffee and two cups of tea daily. She does not like water.

What general conclusions can you draw regarding the adequacy of ML’s current diet and what would you recommend?

ML not taking a balanced diet. Ml’s diet is lacking in vitamins, minerals, and essential oils that are good for the overall health. Other than egg, potatoes, and tomato sauce, there is a need to expand the variety of Ml’s diet to include other favorite carbohydrates and proteins. To improve Ml’s health status, it is advisable that ML starts physical exercises. ML’s tastes should be improved with appropriate food flavorings. Although ML should continue to keep off alcohol and tobacco, it is highly recommended that there should be regular water intake which can be taken pure or in form of other fluids or beverages with minimum health impacts. It is also recommended that ML should take food in a social setting. Other options that can be explored include appropriate naming of food in the menu, serving small portions of food at a time, enhancing food flavorings, and improvement of the surroundings.

30. Case presentation #3: RE is an 80-year-old woman who will move into residential care in one week. She has been married for almost 60 years and has lived in her current home with her 86 year-old husband for the past 50 years. She has a complicated neurological history. She now has difficulty finding food on her plate and getting it to her mouth and assistive devices and utensils do not seem to help. She gained weight initially as an effect of medications for depression but has now began to lose weight at an alarming rate. She is unable to hold her cup of tea steady and level. She enjoys a glass of wine in the afternoon and at dinner but drinks it quickly rather than sipping. She swallows without coughing but has begun to experience recurring low-grade fevers.

Why can a low-grade fever be a clue for swallowing difficulty?

The recurring low-grade fevers could be an early indication of the swallowing difficulty. Due to her frailty and her habit of swallowing wine faster, there is a likelihood that wine, saliva, and other food particles have found their way to the lungs or the airways. Therefore, the low-grade fevers could be an indication of aspiration pneumonia. However, she should be undergo a clinical assessment.