Optimizing Eating and Swallowing for People With Dementia Dysphagia expert Jeanette Benigas talked about spaced retrieval, careful hand feeding, restorative dining and other strategies. Overheard
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Overheard  |   August 01, 2017
Optimizing Eating and Swallowing for People With Dementia
Author Notes
  • Jeanette E. Benigas, PhD, CCC-SLP, is a private-practice clinician with extensive experience working with adults in the post-acute, long-term care, and home health settings. Her research has incorporated the use of spaced retrieval to teach swallowing strategies so that people with dementia can avoid unwanted dietary modifications. She is the coauthor of “Spaced Retrieval Step by Step: An Evidence-Based Memory Intervention.” Benigas is an affiliate of ASHA Special Interest Groups 13, Swallowing and Swallowing Disorders (Dysphagia); and 15, Gerontology. jbenigas21@gmail.com
    Jeanette E. Benigas, PhD, CCC-SLP, is a private-practice clinician with extensive experience working with adults in the post-acute, long-term care, and home health settings. Her research has incorporated the use of spaced retrieval to teach swallowing strategies so that people with dementia can avoid unwanted dietary modifications. She is the coauthor of “Spaced Retrieval Step by Step: An Evidence-Based Memory Intervention.” Benigas is an affiliate of ASHA Special Interest Groups 13, Swallowing and Swallowing Disorders (Dysphagia); and 15, Gerontology. jbenigas21@gmail.com×
Article Information
Swallowing, Dysphagia & Feeding Disorders / Special Populations / Older Adults & Aging / Overheard
Overheard   |   August 01, 2017
Optimizing Eating and Swallowing for People With Dementia
The ASHA Leader, August 2017, Vol. 22, online only. doi:10.1044/leader.OV.22082017.np
The ASHA Leader, August 2017, Vol. 22, online only. doi:10.1044/leader.OV.22082017.np
Participant: You mentioned that increased incidence of penetration is normal in aging adults, but how much penetration is normal (frequency and depth/amount)?
Jeanette Benigas: To my knowledge, I don’t know if a study exists that has measured the amount of food or liquid penetrated. That’s not to say the research doesn’t exist, but I think it would be very difficult for a researcher to know how much volume has been penetrated under videofluroscopy since it is only an image.
Participant: When doing spaced retrieval (SR) have you found any specific verbiage to be more effective than others, or has there been a lot of interpatient variability?
Benigas: When using a continuous visual cue (CVC) as part of the SR protocol, it should reflect the response to the lead question that you ask. The lead question should be simple for someone to understand and lead the person to the behavior or change you want to see. For example, if we want to teach a finger sweep you might ask, “What do you do after you swallow?” The response should be simple, direct, to the point, and something the patient understands. In this example it might be, “I clean my mouth out with my finger,” because our technical answer of, “I use a finger sweep,” is too difficult to understand.
The CVC in this example would say, “I clean my mouth out with my finger,” in a large sans serif font. As always, check in with the patient when developing your lead question, response and CVC to make sure all verbiage is understood and is what the patient would naturally use. If you find during practices that the patient is substituting an appropriate word, it is OK to change your expected response and CVC, but be consistent with the new verbiage.
Participant: What would be your recommendations and strategy for a patient who refuses any assistance to eat but does not initiate eating for herself?
Benigas: I would begin by treating these two issues separately. I recommend getting to the bottom of why the person is refusing assistance first. You probably have done this already, but consider if this is a responsive behavior—is the person trying to communicate something that isn’t being addressed? Does she not like the person assisting? Is she embarrassed by the help? Does she even recognize the food coming toward her as food? If you are able to figure that out, it might be an easy fix.
To improve initiation I would first try her favorite food. If it isn’t available, make arrangements to get it from family. Yes, I have gone out and gotten cherry pie, strawberry ice cream and a McDonald’s hamburger for patients before. It would be interesting to see what happens when an enticing treat is right in front of her. If the initiation still isn’t there, you can assume that initiation has been impacted by frontal lobe degeneration caused by dementia. If she can read (do a quick screening—I have some research that says she probably can), make an external memory aid, something like, “I pick up the spoon and take a bite.” To make it even more directive, you might get some bright red plastic spoons to enhance contrast and help direct her right to the spoon. If this doesn’t work, go ahead and try some spaced retrieval. The CVC you have already created, the motor movement of lifting bright red spoon to mouth, the verbalization, and the reward of a treat and independence might do the trick.
Participant: In terms of social experiences with dining for people with dementia and dysphagia in a residential setting, what are your experiences on a restorative dining group versus maintaining the client at a familiar table? I’ve tried both models in several facilities, and I feel that each has strong pros and cons, but we try to “push-in” (maintain the familiar table with others without dysphagia) as much as possible at my current facility.
Benigas: Socialization is so important for optimizing intake for persons with dementia. I love what a restorative table is meant to do, but it can be very disruptive to a person’s dining routine, and consistency is also important. One trick is to try to see if the facility is open to clustering tables. If the tables could be arranged in a way that the restorative aide could have easy access to four-ish people, that might help people stay at their own tables. The aide could sit on a stool or chair with wheels. The tables would need to be close enough that a watchful eye is on the people who need help, so quick assistance can be provided.
Participant: When oral phase of swallow appears largely due to cognitive limitations, how do you suggest entering of diagnostic codes within our EMR documentation?
Benigas: If the person has an oral dysphagia due to cognition, you would document oral dysphagia (R13.11) and cognitive communicative impairment (R41.841) because you would end up treating both.
Presenter: The term “hand-under-hand” has been used several times throughout this conference. Could you comment on your thoughts and how to encourage our patients with dementia and teach caregivers (family and hospital staff) to implement this, so that safe oral intake is achieved?
Benigas: Hand under hand—or careful hand feeding—is such a wonderful thing if done well. I know we often see care partners shoveling food into oral cavities, and we then get a referral because the person is pocketing.
In my humble opinion, careful hand feeding begins before the utensil is even lifted from the plate. This relates directly to ensuring a good dining environment and making sure the food is pleasurable. Then it needs to be confirmed that the person is alert (doesn’t have to be oriented, just awake and aware that something is going to come toward the mouth). If all of these factors have been considered, then the care partner may give total assist by loading the bolus, putting the utensil in the person’s hand, and gently lifting it to the person’s mouth. At other times, perhaps the person just needs the bolus loaded and can get spoon to mouth with little to no assist.
Whatever the case may be, I find sitting with the care partners and giving demonstrations (again… and again… and again…) is most effective. Even writing a little “cheat sheet” of reminders for those who need it most can be helpful. Each case will be different. When teaching, make sure to model a gentle voice, soft touch, and focus on supporting independence as much as possible. We know care partners are always in a hurry, so the conversation of “this person needs a lot of time” might need to be had with administration who can direct if needed.
Participant: What is the baseline for being able to use spaced retrieval?
Benigas: There is an SR screening available (no equipment or paperwork required). If the person is not successful with the screening, it is recommended the screening be re-administered on a different day due to expected waning levels of cognition. On a second try if the person is not successful, SR should not be used. If the person is successful on the first or second screening that’s a green light for go ahead and try. The screening uses very simple novel information, and at times what we want to use SR for is much more complex. For this reason, SR may not be successful with some people. This would prompt us to either simplify the lead question, response, or expected behavior—if those can’t be simplified, SR may not be an appropriate strategy at that time.
Participant: You mentioned a patient where the chin-down posture caused aspiration (after significant strengthening) on the second swallow study. Can you explain why this might have occurred and what we should keep in mind about this? I’m working in several settings where a final study is not always an option.
Benigas: I was using this patient to test out my idea for my dissertation, but I was seeing him in a home health setting and he was not part of official research. For this reason, my objective was to rehabilitate this guy. I threw in the SR with the CVC just to see what happened because at that time there wasn’t any significant research. He was able to participate in restorative treatments very well, so his muscles became stronger.
We know without question that a chin-down posture redirects the flow of the bolus. His muscles were strong enough that they redirected that bolus the wrong way, because the airway is the path of least resistance and it was simple for the bolus to flow there. It was very difficult for me to then unteach the guy with dementia to stop his “sip, tuck, swallow” after the modified barium swallow study (MBSS).
This was a good learning experience for me, and in my research I enrolled people who had been discharged by SLPs because they were judged to have reached “max potential.” None of them were getting restorative treatment. I did this to make sure any strategy that redirected the flow of the bolus would not cause harm because the people in the study were not getting a post-MBSS. In my own practice, I now do not combine a compensatory strategy like chin-down posture with restorative treatment unless I know the person can go back out.
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August 2017
Volume 22, Issue 8