Force-feeding, Dysphagia, Swallowing

[caregiver222]

Comments on providing nutrition and hydrationto those with difficulties swallowing. Comments welcome.

[caregiver222]

My little 103 year old has complex swallowing difficulties. The difference between life and death is feeding technique. I have fired 33 aides who have not followed instruictions in this regard. In the case of my 103 year old we have a number of co-factors, ranging from stroke to hypothyroidism to muscular atrophy. One of her chief problems stems from a failure of her lower esophageal sphincter to relax. A patient with this syndrome will typically swallow two ounces of fluid (or two teaspoons of food) normally. At that point they "wave off further food." Many aides and nursing staff will have a limited amount of time to assist in feeding. This is the cue for them to "force-feed". Some facilities teach the aides to force-feed. I worked in such a facility. Force-feeding is always wrong. Always. Force-feeding can cause death. Death can occure in two ways. The passageway to the stomach is interupted by the lower esophageal sphincter (LES). For many reasons in the elderly this mucular ring will contact, but not always relax. Since it will not relax the food/liquid blocks up. A co-factor in the elderly is a poor gag" reflex. Thus force-feeding causes fluid/food to enter the trachea. If food/fluid enters the trachea aspiration pneumonia can result, precipitating a lengthy expensive hospital stay. However there is a greater danger. That danger is larangospasm. Many drowning victims are found to have no water in the lung when autopsied. This is due to larangospasm when water enters the trachea. These spasms can completely block the airway. An aide fed my sweety-pie some liquid. She then waved off further liquid. The aide insisted on encouaging her to open her mouth and gave her more liquid. This fluid entered the trachea which went into spasm, she turned blue, and to maintain an airway I had to administer mouth-to-mouth resuscitation. These spasms will release themselves in a short period of time. If you have sublingual nitroglycerine on hand this will also release the spasm. As a caregiver, from time to time you may have an aide to assist, or be involved in a nursing home situation with a loved-one. There is a tendency to submit to "authority", especially when the aide/nurse/caregiver/physician has a "credential" and assurs you :they have years of experience". I have never encountered a situation where force-feeding is indicated. In the case of little sweet-heart feeding sometimes takes two hours. Feeding cannot be hurried. There are treartments for this disorder which are beyond the scope of this post. They include muscle relaxants, particuliarly calcium-channel blockers, emergency nitrates, botux injections and various surgical procedures. Be aware these swallowing difficulties can develop slowly over a period of time. Rejection of nutrient or liquid does not necessarily mean the patient "does not want to eat". They may be protecting themselves from asphyxia due to larangospasm.

[Chelstar]

Thanks for that information.  There is a resident at the facility that I work with who will take two small bites and wave off the rest like you say.  I thought she just wasn't hungry, which seems silly because that is a ridiculously small amount of food to eat.  From now on I will take more time feeding her.

[caregiver222]

One of the big problems with larayngospasm in the elderly is that the muscles don't readily release. In a young person who while swimming inhales a splash of water in the trachea there may be a momentary spasm. In the elderly (particularly the stroke patient), for a number of reasons, the muscles contract but to NOT readily release.  They can take a LONG time to release. There are complex reasons for this, some known and some unknown. Hypothyroidism can cause this condition, for example. If there is choking you should remain with the patient holding them and providing reassurance.  The airway must be kept clear. I recommend keeping the patient in the upright position to prevent the fluid/food from backing up. These episodes can be very scarey. The swallowing is often circardian in nature. That is to say normal swallowing can take place late at night while be non-existant in the morning. Often I can get eight ounces of fluid into my 103 year old after 11 P.M. In any event, a bit of food/water/fluid in the trachea can cause a spasm, changing a swallowing problem into an airway oclusion problem. Generally this situation will resolve itself in time, but it can take a while. The drill is to immediately stop feeding and place your hand on the back and attempt to have the patient spit out food. A finger may be inserted into the mouth, but NOT TOO DEEPLY to sweep food out. You do not want to cause a "gag" reflex. You have to be prepared to provide mouth to mouth rescuscitation or have an AMBU bag handy. This not a cardiac arrest situation, so chest compressions will not be neccesary. You may have to provide assisted breathing to the patient for three to fifteen minutes. If the spasm does not relax, the drill is sublingual nitroglycerine, which will relax the spasm. Of course nitroglycerine will also lower the blood pressure. If nitroglycerine is used do not lie the patient flat, but if you want to lie them down the back should be up at a thirty degree angle. The reason is that the nirtoglycerine will also relax the lower esophageal sphincter and if you lie them FLAT, there may be an upward flow of acid from the stomach, which will precipitate another spasm.  The effects of the nitroglycerine will wear off after from 15 minutes to a hour. You generally won't need endotracheal intubation. Unfortunately this is often the first protocol used by hospital personnel. Probably you won't need transport to a hospital. There is a window of opportunity that must be utilized on-the-spot. The "two-small-bites-and-then-refuses-food" syndrome is definitive for a dysfunctional lower esophageal sphincter (LES). The muscles of the sphincter are not relaxing. Unfortunately, most physicians do not pay attention to this. There are surgical and non-surgical treatments. Muscle-relaxants, particuliar particuliar calcium channel blockers, can sometimes solve the problem. Botox injections have also proved helpful. The problem is compounded because in many elderly patients the conventional diagnospital procedures cannot be used (i.e. - a barium swallow). Liquids seem to pass more easily without precipitating contraction. With my 103 year old, I keep her on an all liquid diet until her daily caloric and hydration needs are satisfied. Only then do I take a chance with a more substantial food, such as yogurt or applesauce. This degradation in her swallowing has been of recent onset. Four months ago she was eating regular meals of very soft foods. I have the aides perform a "swallow evaluation" before any feeding. Most importantly when she is too sleepy feeding is probibited. She will often open her mouth, if encouraged, but that is not enough. She must hold the spoon or cup and feed herself. She will never do this if it will compromise her airway. Force feeding can be life-threatening. The general non-surgical, non-medicinal approach to this problem is simply to take your time with the feeding, and recognize that in the dehydrated/malnourished patient, a "wave-off" and refusal to swallow, does not mean "Don't give me food". It means "Wait a while and give me food later". In the case of my aides I require a meticulous log of feeding times. If you see the feeding takes only fifteen minutes you know it has been an inadequate feeding session. One of the changes I would make if I were running a nursing home is to "split" the feeding sessions, pairing patients with similar problems. Thus an aide/nurse could spent ten minutes feeding one patient, permit the LES to real while feeding a second patient, and then return to the first patient. Going back and forth several times between patients will optimize use of time while decreasing the probability of a fatal complication.