Geriatric patients with damage to the mouth, cranial nerves, or brain stem as a result of disease or traumatic injury often experience difficulty swallowing.1,2 With dysphagic disorders, the danger of choking on solids or liquids always is present. The potential development of complications such as aspiration pneumonia is also considered. Responsibility for the effective feeding of total care geriatric patients with dysphagic disorders rests upon nursing personnel, and the responsibility dictates that knowledge of effective procedures in this important area of patient care be available.
Normal swallowing is a complex, coordinated activity which can be divided into three successive parts. In the bucco-pharyngeal stage, food which enters the mouth is organized into a bolus upon the tongue and forced to the rear of the mouth into the pharynx. Since the trachea and esophagus share this common entry tube, the pharyngeal stage involves closure of the vocal folds over the trachea and closure of nasopharynx to maintain proper pressure on the bolus as it passes into the circopharyngeal sphincter.3,4 The third part of swallowing consists of the passage of the bolus through the esophagus to the stomach upon closure of the circopharyngeal sphincter.2,3,5
The deglutition sequence, as described above, is coordinated into a single physiological process by the action of the nervous system.6 Cranial nerve V transfers information from the gums and palate about the chewing and temperature (heat, cold, and pain) to the brain stem, while other cranial nerves (VII, IX, X) provide data about taste to the medulla oblongata. The unitary aspects of this control system are evident from observations that normal swallowing is performed in an all-ornone fashion.7
Deviant deglutition activities occur when the characteristic coordinated movements described above are disturbed as a result of either the disruption of the nervous system control or the anatomical impairment, such as a cleft palate. Disease and/or traumatic injury to the cranial nerves mentioned above are common causes of dysphagia.
Review of the literature reveals a paucity of information related to the treatment of dysphagic disorders in geriatric populations. Techniques usually derived from nursing or rehabilitative journals emphasize mechanical process aids such as positioning patients upright, giving them pureed foodstuffs, using specialized silverware, etc. In addition, two other procedures - sensory stimulation8 and intellectualization2,5 - have been recommended for treatment of swallowing difficulty. Management of swallowing techniques via intellectualization encourages subjects to control the swallowing response volitionally rather than letting swallowing occur on a reflexive basis.2,5 This type of intellectual control is difficult, if not impossible, with some geriatric patients who are unable to follow instructions but most sensory stimulation techniques can be used irrespective of patient condition and with minimal risk or patient discomfort.
Sensory stimulation techniques can "lessen resistance" along neural pathways generally not involved in evoking responses, such as swallowing.8 These techniques seek to facilitate the usage of various muscles by stimulation of reflexes associated with the desired response.8 Sensory stimulation techniques for dysphagia are accomplished by procedures such as icing or brushing of facial areas innervated by the cranial nerves associated with deglutition or heel tapping to increase general arousal.
This is a pilot study designed to assess the effectiveness of three sensory stimulation techniques, at a behavioral level that could be used by nurses for dealing with dysphagia among longterm geriatric patients. Utilizing such measures as the amount of coughing during a feeding session and length of time a session lasted as behavioral indices of feeding ease, it was hypothesized that sensory stimulation techniques would reduce the difficulty of feeding. In addition, the distribution of coughing during an average feeding session was described.
Four subjects were drawn from the total care unit of a midwestern neuropsychiatrie Veterans Administration Hospital. All subjects were over 60 years old with a history of stroke or disease-impaired systems. Initially, three subjects chosen from the patient pool were selected to represent each degree of coughing incidents (i.e., high, middle, and low frequency per session). A fourth subject was added when two of the orginal subjects became ill and were temporarily discontinued from the study. However, when their health permitted, these two subjects were reinstated in the experiment.
Two variables were examined in this study. One variable consisted of the type of sensory stimulation a subject received (icing, brushing, heel tapping and baseline). The second variable was successive five minute feeding intervals within a twenty minute total feeding session.
The dependent variables used to evaluate the effects of stimulation techniques and feeding intervals in relation to feeding of dysphagic patients were: 1) frequency of coughing and 2) total time spent feeding. Coughing was defined as a sudden noisy expulsion of air followed by a pause of inhalation, while total feeding times was defined as the time between the start of feeding and when all food had been given or when twenty minutes had elapsed.
Each of the four subjects served as their own control. Every week subjects alternated a baseline (no treatment) condition with one of the sensory stimulation techniques. At the end of a six week period, each subject had received all treatments. Each subject, therefore, participated in all conditions of a 6 (treatment weeks) x 4 (feeding interval) randomized block factorial design.
Presentation of Treatment
One of the treatment conditions was administered to subjects approximately one-half hour before a noon feeding session in the following manner:
Icing - The patient was allowed to suck briefly on the ice, after which it was run around his mouth three times. Next, three sets of strokes were applied from the earlobe to the outer corner of the mouth and from the front of the ear along the edge of the jawbone to the center of the chin to each side of the face. Finally, the ice was held for three seconds on the sternal notch. The total time of application was usually thirty seconds.
Brushing - The brush was run around the lips three times, each revolution taking about three seconds.
Following this, five sets of strokes were applied along the cheek and jaw in a manner similar to icing procedures. Each stroke lasted approximately three seconds. Finally, the brush was held at the sternal notch for about three seconds.
Heel Pounding - A nurse used the palm (heel portion) of her hand to lightly tap the heel of the patient's foot for approximately thirty seconds at a rate of three taps per second.
Baseline - No treatment was administered prior to the subject's feeding sessions.
During feeding sessions, patients were seated upright in chairs behind a small movable table. Food was delivered to the patient in the following sequence: (a) main course, (b) desserts, (c) liquids, and (d) soup. No foods were mixed together, i.e., none of the main course was put in the soup or no "washing down" of a part of the main course with a liquid was permitted. Adherence to this policy assures that each subject was fed in a consistent manner, and minimized effects other than those accompanying the stimulation techniques. A variety of staff personnel fed patients to minimize any idiosyncratic effects associated with just one feeder. In general, personnel who did the feeding were not aware of what treatment a subject had received previously.
During each feeding session , another staff member recorded the amount of coughing for each five minute interval of a feeding session on a pocket counter and the total amount of time each feeding session lasted. This information was recorded on a standardized data sheet for later analysis.
MEAN AMOUNT OF TIME SPENT FEEDING SUBJECT DURING EACH SESSION
The average number of coughing incidents per session for a subject during each successive week is shown in the Figure. With the exception of subject number four, no patients showed a decrease in coughing. The coughing incidents per session were further broken down into the amount of coughing occurring during successive five minute intervals and subjected to an analysis of variance (ANOVA). No significant effect was found which could be attributed to a particular type of sensory stimulation or to the interaction between stimulation and interval effects.
Interestingly, an increasing number of coughing incidents occurred through the third five-minute interval, but during the last five minutes of the feeding session, there was a decrease in coughing.
A summary of the amount of time each subject took to eat his food is presented in the Table. Examination revealed individual differences in average time spent feeding, especially for subject two in relation to other subjects.
For this variable, day of the week was used to distinguish any cumulative effect of treatment during an experimental week. Again we found that sensory stimulation techniques were not effective in reducing the total amount of time spent feeding dysphagic geriatric patients.
This pilot study was a beginning effort to evaluate the effectiveness of sensory stimulation techniques in facilitating deglutition among total care dysphagic geriatric patients. In addition, information about the distribution of coughing during feeding sessions was obtained.
The findings of this study suggested that stimulation techniques were not helpful in feeding dysphagic geriatric patients, as indicated by the sustained amount of coughing during a feeding session and the lack of reduction in the total time required to feed a patient. Further evidence for lack of treatment effects was gained by re-examination of individual experimental records. For three of the four subjects studied, the least amount of coughing was recorded during baseline weeks.
Interestingly, rate of coughing appears to be related to temporal aspects of a feeding session. More coughing occurred during the second and third five minute segments when compared to the first five minutes of a session; thus, as one proceeds with feeding, there is a greater likelihood of coughing incidents. Subjective observations of the investigators suggest that the first two or three minutes of the session were relatively free of coughing. Once coughing started, however, it tended to increase dramatically. Two possible explanations for this phenomena are offered. In normal people, swallowing is a relatively easy activity, requiring little effort and accomplished in a reflexive manner. This is not the case for dysphagic geriatric patients, where swallowing takes place with effort. One possible interpretation of the coughing effect is that patient fatigue may be a critical factor. As the feeding sessions progress, dysphagic geriatric patients may find the effort to coordinate swallowing to be too demanding. Maintaining such a concentrated effort for that period of time may be extremely fatiguing for the elderly. Therefore, one might expect such patients to do considerably worse in terms of increased coughing toward the end of the session as opposed to the beginning of the session.
Another interpretation of our findings concerns the type of food administered to patients during feeding. The order of delivering foods to the patient was standardized with the main course given first, desserts second, liquids third, and finally soups. These food stuffs were presented in successive intervals, although no attempt was made to control for this. Thus, it is possible that increases in coughing observed during the meal were due, in part, to the change in food material given to the subject. Specifically, the changes from semi-solid foods in the beginning to the liquids at the end of the session could be interpreted as influencing the rate of coughing.
The latter explanation lends itself to a facet of the model for swallowing,2,3,5 namely the action of the neural system. In dysphagic geriatric patients, it is possible that neural transmission is incomplete. That is, some receptors still may be active in transporting information, while others are active partially and perhaps some are totally inactive. Information with regard to the consistency of food suggests that stimuli from chewing foods are not interpreted while proceeding to the "swallow center," while other sensory stimuli (i.e., temperature, pressure, and taste) may encounter variable amounts of interference.5 Therefore, in the present study, little coughing was recorded with foods which required some chewing in addition to swallowing. Concomitantly, when food stuffs were presented which did not need to be chewed or which relied on temperature, pressure, or taste stimuli, an increase in coughing was noted.
The strong temporal coughing effect in this study was not an expected finding and both of the above explanations of this effect are only hypotheses. Further nursing research in this area, involving the manipulation of food, is needed to determine which of the interpretations are viable.
While differences of opinion exist regarding effective methods of dealing with dysphagic problems, the implications of our findings for feeding dysphagic total care geriatric patients are clear. Sensory stimulation of the face, neck, and heel (as described in the procedures section of this report) does not provide consistently positive outcomes for dysphagic geriatric patients in terms of reducing coughing or lessening the total amount of time spent for a feeding session. Rather, results suggest that nurses in charge of feeding dysphagic patients should observe the patients for signs of fatigue and manipulate the presentation of food carefully. In a recent review, Buckley, Addicks, and Maniglia recommended ". . . small feedings at frequent intervals. . ." and a ". . . diet intended to employ foods that will stimulate the patient's swallowing reflex. . ."9 It is hoped that further guidelines for dealing with dysphagia will be developed and tested empirically by nurses in the field and that these guidelines eventually will serve to replace the confusion that presently exists in this area.
Heel pounding and icing are two techniques used.
Several factors may have affected the results obtained. Since all subjects had a history of severe neural impairment, this may have interfered or disrupted the effects of stimulation techniques. Future research should seek to compare sensory stimulations utilized with dysphagic geriatric patients where impairment is primarily mechanical or damage to neural pathways is not as severe as those used here. Future research also should employ a larger sample size and a greater number of patient trials. In this pilot study, only four subjects were used, making it impossible to generalize the findings. It is also recommended that nurses who undertake research in this area evaluate the quantity of food consumed, in addition to simply measuring the coughing frequency. The training effect of the procedures on patients should be taken into consideration in future research as well.
Figure 1. Average frequency of coughing per feeding session for each patient.
Our findings also suggest that future dysphagic research evaluate factors such as "sensitizing" the mouth, and coordinating activities related to the ingestion of food in this geriatric population.
This article has examined feeding techniques that may be helpful for use with dysphagic geriatric patients in preventing adverse effects of inefficient swallowing. Although the stimulation techniques tested in this pilot study were not found to be particularly helpful in feeding dysphagic geriatric patients, the study should be replicated with a greater number of subjects. We believe it is both appropriate and essential for nurses who work with geriatric patients to be an integral part of the research team that develops and evaluates innovative approaches to solutions for common clinical problems.
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- This research was supported partially by Veterans Administration Research Funds. Project No. 592-9421.
- The authors wish to acknowledge James Whitehouse and Emmett B. Swim and ihank ihem for their invaluable contributions to this manuscript.
MEAN AMOUNT OF TIME SPENT FEEDING SUBJECT DURING EACH SESSION