ࡱ>  4bjbj 0ȋȋ,,,,,,@@@8xdL@C(((PPP‘đđđđđđ$z,,,PP4DDD,P,P‘D‘DD`P!"N0C^@``,BlD|C : Checklist for carers to manage eating, drinking & swallowing problems in people with dementia ProblemHow to help1. Sensory impairment1a Altered sensation  Taste & smell:- Find out individual likes and dislikes, both past and current Enhance or sweeten flavour of food & drinks Pain:- Check temperature is safe 1b Visual difficulties  Glasses:- Find out when they are needed Ensure they are the correct pair (label them) Ensure they fit Clean regularly Ensure everyone knows Consider cataracts Hemianopia or visual neglect:- Draw attention to items on table (explain, touch, use coloured plates) Put utensils directly in hands Describe food / drink being given Place food slightly off-centre, so it is nearer good visual side Turn plate during meal so food on good side1c Hearing difficulties Hearing aid:- Find out if and when needed Check turned on mid volume Check battery Check in correct ear (label left & right) Ensure ear mould clear of wax Check batteries Ensure everyone knows Consider impacted ear wax1d Dentition Teeth & Dentures:- Are there adequate teeth or dentures to bite and chew food? Check whether dentures are being used Check dentures fit well consider replacement or fixative if loose Change food consistency to soft, or fork mashable (texture E), or pre-mashed (texture D), or puree (texture C), if inadequate teeth to bite & chew Infected teeth, mouth or gums:- Remember pain may not be recognised Check for pocketing of food in cheek Use a torch!!! Give regular mouth care to help prevent mouth and chest infections 2. Cognitive State and Behaviour2a Drowsy / reduced consciousness Check investigated for physical illness causing drowsiness or acute confused state (e.g. UTI, chest infection, stroke) Look for pattern to drowsiness that may indicate it is related to medications Feed only when alert enough to swallow safely Ensure food is high in calories if only taking small volume meals Give mouth care after each meal 2b Walking around (wandering) Bring to table only when meal ready Give extra helpings when more settled Give finger foods that can be eaten on the move Consider cause of agitated wandering (medication?) Comprehension problems in people who are walking around / wandering:- Use simple verbal prompts or show them the food is ready to help them understand 2c Forgetful / distracted Check they have been to the toilet before meals Use verbal prompts to keep them on track Use gentle physical or non-verbal prompts to keep them on track (e.g. put the cup back in their hand, or guide them back to the table) Reduce environmental distractions Create a calm environment (soft calm music)2d Passive Need prompting to start:- Give verbal or physical prompts (e.g. put utensil in their hand, and guide their hand) Give first mouthful or feed for first part of meal Need someone to copy:- Sit them next to a more able patient / resident Family, or staff in community settings, could consider eating their own meals with them Prompt when changing courses Check depression is not the cause of being passive. Unable to recognise own hunger:- Increase anticipation of food or drink by giving mealtime cues (talk about food, get people to help set the table, put on the same calming music before every meal)2e Refusing food / drink or spitting food out Refusing:- Check for a mis-match between what they say (no) and what their behaviour indicates (yes they do want food) Try giving the first mouthful so meal is tasted Gently put spoon or food on lips Try triggering eating with a drink first, or triggering drinking with food first Try guided feeding (utensil or cup in their hands and helper guides it to their mouth) Try adding sweetness to savoury food Chart refusal patterns Check underlying thoughts and beliefs (not having enough money to pay for meals substitute by giving meal tokens) Check for depression Spitting out:- Try avoiding types of food that are spat out (e.g. those with skin or bits) Consider swallowing difficulty and need for referral to SLT if they consistently appear to either have weak or uncoordinated mouth muscles movement2f Inappropriate speed or size of mouthful Too fast / cramming:- Cut food up into smaller pieces Supervise or assist to avoid cramming and choking Verbal prompts to slow down and swallow each mouthful Physical prompt (hold hand to stop next mouthful occurring too soon) Try serving each course as a number of smaller portions Try a softer moist diet Too large:- Try a smaller utensil (teaspoon) Too slow:- Use a heat retaining plate Give higher calories and nutritious snacks if reduced volume due to slowness Record intake & weight2g Eating non-food items Uncooked or harmful non-foods:- Check all are aware Change environment Ensure substances hazardous to health cannot be ingested (including thickener powder straight from the tin) Remove non-food items at mealtimes (e.g. tissues) 3. Feeding Situation & Skills3a General environment Seating in small tables Increase opportunity for self service and being involved in tasks Calm and relaxed - soothing music Soft touch and verbal encouragement Drinks and food within reach 3b Low level of staff supervision Group patients / residents carefully (so the more able help the less able) Group so only one helper for several needing only verbal prompts Give supervision and prompts in the following order to encourage independence unassisted and independent (i.e. self feeding) supervised with verbal prompts (e.g. have a drink or that looks delicious) supervised with non-verbal prompts (e.g. demonstration, or someone to copy) assisted with physical guidance (e.g. hand on hand guided feeding) fully assisted and fed for all drinks, food and snacks3c Position Check sitting upright, with head in upright and midline position, for swallowing Check head and trunk supported Check table at right height Check close enough to table3d Difficulty self feeding Use less cutlery, put directly into hand Cut food up Give one course at a time Use plate guard Use non-slip mat under plate Consider large handled cutlery Give verbal and physical prompts Consider a finger food diet3e Eating off other peoples plates Avoid crowded or busy tables Check adequate supervision Give different people their own colour plates, bowls and cups3f Distracted by other items on the table Simplify the meal table (remove clutter), and mealtimes (serve one course at a time) 3g Messy eating Simplify meal table Check good positioning (sitting close to table) Provide supervision (see 3b) Plate guard and napkins / apron If due to difficult behaviour, see section 23h Mixing different courses together Serve courses separately Ignore!3i Concerns about helpers approach Poor approach by helper:- Helper should sit facing the person, making eye contact ( feeding someone from standing encourages poor head position as patient looks up at them - extending neck which opens airway to risk of choking) Use calm and firm tone of voice Consistency of staff as same helper is more likely to tune into non-verbal signals Encourage independence, following hierarchy of supervision and assistance (see 3b) Well paced, not rushed feeding Communication impairment:- Helper to encourage with clear verbal and non-verbal prompts 4. Eating, Drinking & Swallowing4a Significant drooling (saliva or drinks) Check whether excessive saliva is due to medication Consider altering posture Consider altering feeding technique May need reminding to swallow saliva (e.g. Parkinsons Disease) Consider referral to SLT if consistently unable to swallow saliva and drinks4b Difficulty chewing (tongue weakness or dysfunction) Carefully experiment with different tastes, temperatures and textures under supervision (try soft; fork mashable (E); pre-mashed (D); or puree (C) food textures) Ensure good posture and position Consider referral to SLT if consistently unable to control drink and chew food If inappropriate bite reflex:- Use metal cutlery or hard plastic cutlery that will not break if bitten on 4c Difficulty with particular textures  Problems with solids Avoid difficult textures (i.e too hard, crunchy, crumbly, raw, stringy or with skins) Consider altered textures such as: soft; fork mashable (E); pre-mashed (D); puree (C) Remind the person to chew and swallow Assist with guided feeding as hand movement may help trigger swallow Experiment with tastes, textures and temperatures to see if improves recognition of food and thus a better swallow Supervise, giving verbal or non-verbal prompts and reminders to stop cramming Consider referring to SLT if consistent problems swallowing food Problems with bits / lumpy food Change so lumps are a softer texture that can be mashed easily with a fork Avoid liquidising food too soon, to maintain chewing movement if possible. Problems with drinks and fluids Try cup with one side cut away (Nosey Cups) to prevent head tipping back when drinking Encourage self or guided drinking Help trigger the swallow in the following ways:- Giving verbal prompts Prompting with the action of moving hand to mouth Ice cold drinks Sour tastes (e.g. lemon) For people on thickened drinks, make them more appealing and normal-looking by making smoothies, milkshakes, or by pouring pre-thickened drinks from a jug. Consider referring to SLT if consistent problems swallowing drinks 4d Problems with particular foods Avoid specific foods known to be difficult or disliked Replace with something else that is specially for you to encourage compliance Avoid meals with lumps & thin liquid in the same mouthful (e.g. muesli & milk, soup) 4e Difficulty swallowing tablets Try swallowing tablets with yoghurt or custard or jam, or a smoothie drink, rather than with water (e.g. tablet on top of teaspoon of yoghurt) Ask Pharmacy or GP if medication can be prescribed in syrup form Ask Pharmacy or GP if medication can be crushed (this is not for tablets that are specially coated or with a slow release system) NB if concerns about patient being able to consent to having tablets in food ask the prescriber to consider covert administration of medication4f Delay in triggering the swallow Go slow, pause between each mouthful to allow time for the swallow to occur. Watch or feel for each swallow before giving / allowing next mouthful Help trigger the swallow by:- Giving verbal prompts Guiding the hand to the mouth Ice cold drinks Sour tastes (lemon) Consider referral to SLT if consistent long delay triggering swallow with all textures4g Multiple swallows per mouthful Ensure small sips / mouthfuls Supervise / assist so food & drink is given at a slower rate to allow time for extra swallows4h Food left in mouth or cheeks at end of meal Mouth care at end of meal Massage cheek to encourage a swallow4i Repeated coughing throat clearing, choking, or a wet gurgly voice quality after swallowing  Ensure best upright posture Prompt patient to cough and swallow to clear and protect their airway Consider referral to SLT if consistently coughing / throat clearing / wet gurgly voice after swallowing  Reference: Feeding and Swallowing Disorders in Dementia. J Kindell. 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