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DYSPHAGIA IN THE GERIATRIC POPULATION AND THE ROLE OF THE SLP IN PALLIATIVE MEDICINE

Sarah Novak, M.A., CCC-SLP, CBIS

October 2023

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WHY SHOULD WE KNOW ABOUT GERIATRIC POPULATION?

“Swallow evaluation referral rates increased by 64% for 60-90+ year-old acute care geriatric-hospitalized participants despite only a 23% increase in inpatient discharges for the years 2007 v. 2014.”

More screeners and trained allied health professionals

Leder et al., 2016

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NORMAL AGING & CHANGES IN SWALLOWING

(Thiyagalingam et al., 2021)

Changes in anatomy and pathophysiology

Changes in function

[Gradual changes in swallow mechanism related to aging]

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(Thiyagalingam et al., 2021)

What are some other risk factors you can think for a geriatric patient in addition to cognition, normal aging changes to swallow mechanism and behavior?

Co-morbidities

Reduced mobility/activity

Multiple medications

Nutrition deficits

Wounds

Requires assistance

Dentition

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SLP ROLE: PALLIATIVE CARE

SLPs play an integral role in facilitating discussions surrounding patient care and goals when one or more of the following:

Dysphagia and/or swallow dysfunction is present
Known aspiration risk
Concerns for overall nutrition/hydration

Often play a role in palliative care meetings in this capacity as they can comment on normal and dysfunctional swallowing, provide suggestions to maximize comfort and quality of life.

(Hawksley et al., 2017)

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RISK FEEDING/FEED AT RISK/COMFORT FEEDING

Is appropriate when:

Medical condition is not curable
When preferred diet takes priority over swallow safety
Severe swallow dysfunction with poor prognosis (not reversible or rehab-able)
Swallow therapy has been unsuccessful in changing function
Tube feeding is declined or deemed inappropriate

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CONSIDERATIONS

These are often complex issues:

Swallow prognosis

Degenerative conditions, chronic illness, advanced age, hx

Risk/benefit discussions

Overall health/safety, quality of life/enjoyment, oral nutrition and hydration

Patient wishes

Advanced directive, quality of life, comfortability

Capacity

Own decisions v. designated decision-maker

Best interest

Taking into consideration all of the above and advocating for the best interest of the patient. Help paint an outcome picture.

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PATIENT CENTERED/INDIVIDUALIZED

Focusing on the person, not just their disease
Defining realistic goals and objectives given patient’s overall medical condition
Clearly explain expected risks and benefits
Incorporate POLST and advanced directives
Be cognizant of difficulty of decision making on families

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SLP ROLE AT END-OF-LIFE

SLPs provide patients, families, and the medical team with an increased understanding of the normal and dysfunctional swallowing processes, and suggests methods for maximizing comfort and quality of life in the face of the progressive symptoms of dysphagia.

EDUCATION with focus on:

Prioritizing quality of life
Living life enjoyably
Sometimes can incorporate care needs and discharge location into discussion (home with hospice)

Also: It is common near end-of-life (any etiology) to have associated dysphagia

(Hawksley, et al., 2017 & Pollens, 2012)

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WHAT DIAGNOSES CAN YOU THINK OF?

Dementia
Parkinson’s
ALS
Huntington’s
MS
Cancer-late stages, not just specifically head and neck
End stage kidney, lung, heart disease

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Smith et al., 2009

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SLP ROLE AT EOL: ADDITIONAL INFO.

https://www.asha.org/slp/clinical/endoflife/

Question-Answer format regarding role of SLP

https://www.asha.org/SLP/End-of-Life-Resources/

Provides list and links to websites for education/resources

https://leader.pubs.asha.org/doi/10.1044/leader.ftr1.09132004.1

Walks through SLP role at End-of-Life (EOL)

I like how it explains how medical team determines who qualifies as EOL

Many times the SLP has to spend additional time explaining rehab prognosis/lack thereof to team in order to provide prognosis overall
This determination helps team be on the same page when discussing plan of care with pt/family

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REFERENCES

Brady Wagner, L.C. (2008). Dysphagia: Legal and ethical issues in caring for persons at the end of life. Perspectives on Swallowing and Swallowing Disorders, 1, 27-32.

Cappa, J., Donague, J. & Epstein, M. (2018). Dysphagia at End of Life.[Powerpoint slides]. Advocate Health Care.

Goldsmith, T. & Kurash Cohen, A. (2022, March 2). Swallowing disorders and aspiration in palliative care: Assessment and strategies for management. UpToDate. https://www.uptodate.com/contents/swallowing-disorders-and-aspiration-in-palliative-care-assessment-and-strategies-for-management/print

Leder, S.B., Suiter, D.M., Agogo, G.O. & L.M. Cooney Jr. (2016). An epidemiologic study on ageing and dysphagia in the acute care geriatric-hospitalized population: A replication and continuation study. Dysphagia, 31(619-625).

Novak S.J.(2020). Feed at Risk and Related Discussions. [Powerpoint slides]. CHOMP.

Hawksley, R., Ludlow, F., Buttimer, H. & Bloch, S. (2017). Communication disorders in palliative care: Investigating the views, attitudes and beliefs of speech and language therapists. International Journal of Palliative Nursing, 23(11)543.

Smith, H.A., Kindell, J., Baldwin, R.C., Waterman, D. & Makin, A.J. (2009). Swallowing problems and dementia in acute hospital setting: Practical guidance for the management of dysphagia. Clinical Medicine, 9(6) 544-548.

Stead, A. & McDonnell, C. (2015). Discussing end of life care: An opportunity. Perspectives on Gerontology, 20, 12-15.

Thiyagalingam, S., Kulinski, A.E., Thorsteindottir, B., Shindelar, K.L. & Takahashi, P.Y. (2021). Dysphagia in older adults. Mayo Clinic Proceedings 96(2) 488-497.

Wirth, R., Dziewas, R., Beck, A.M., Clave, P., Hamdy, S., Langmore, S., Leischker, A.H., Martino, R., Pluschinski, P., Rosler, A., Shaker, R., Warnacke, T., Sieber, C.C. & Volkert, D. (2016). Oropharyngeal dysphagia in order persons-from pathophysiology to adequate intervention: A review and summary of an international expert meeting. Clinical Interventions in Aging, 11, 189-208.

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INTRODUCTION TO PALLIATIVE CARE

Jamie Reeder and Jessica Amarante

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HOSPICE VS. PALLIATIVE CARE

Any time during illness
Symptom management can be combined with curative care
Covered by Medicare and most other health plans

Prognosis of 6 months or less
Focus on comfort care and symptom management
Medicare hospice benefit

Hospice

Palliative

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GOALS OF CARE

Goals of care refer to the general aims of healthcare and the preferred location of that care.
Patients engage in meaningful goals-of-care conversations as it is a way to providing patient-centered, individualized care.
The best practices for a goals-of-care conversation include sharing prognostic information, eliciting decision-making preferences, understanding fears and goals, exploring views on quality of life and impaired function, and wishes for family involvement.
High-quality care can only be achieved when a patient’s care is aligned with their goals, preferences, and values. The treating team works with the patient and family to identify goals of care.
Goals of care inform medical decision-making and limitations of medical treatment (resuscitation plan). Medical management aligns with the patient’s values and preferences from the point of admission.

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ADVANCED CARE PLANNING

Advance directives are legal documents where a patient can name a Durable Power of Attorney for Health Care (DPOAHC) and provide guidelines about their healthcare wishes.
Can be legally transferred in any of the 51 states and US territories.
Anyone over the age of 18 and has legal capacity can complete this document.
It is notarized or witnessed and is a legal document.
The only way this document can be changed is to complete a new advance directive.
An online version of the California directive can be completed at:

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CODE STATUS

Full resuscitation – all resuscitative and aggressive curative treatment are provided.
Do Not Attempt Resuscitation (DNAR) or Do Not Resuscitate (DNR) – order designating that in the event of a cardiac or respiratory ARREST, resuscitation will not be attempted. All other aggressive treatment desired will be provided as appropriate.
Comfort Measure Only - In the event of a cardiac or respiratory ARREST, ALLOW NATURAL DEATH. Do NOT attempt resuscitation (CPR, Cardiac Arrest Medications, Defibrillation, Intubation). AGGRESSIVE TREATMENT WILL BE DISCONTINUED OR NOT BE PROVIDED and only treatment to promote comfort will be provided.
Approximately 11% of individuals survive resuscitation.

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POLST: PHYSICIAN’S ORDER FOR LIFE SUSTAINING TREATMENT

POLST are a quick way for medical teams to understand a patient’s healthcare wishes.
This form is to prevent EMS from going against a patient’s wishes regarding code status.
There is not a state or national database so a physical POLST must be provided to EMS or the ED.
Can be a way to support a patient’s wishes but they do not transfer to different states as each state’s legislator must pass legislation to authorize EMS to accept these orders.
Physicians or Nurse Practitioners can sign these orders.

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END OF LIFE CARE

End of Life Care aims to help individuals with life limiting or life threatening illnesses.
The focus of this type of care is managing symptoms and providing comfort and assistance.
It also includes help with emotional and mental health, spiritual and social needs.
End of life care is an important part of palliative care and involves bringing together a range of health professionals to help people live out their life as comfortably as possible.

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PALLIATIVE CARE DEFINITION

Specialized medical care for people with serious illnesses.
Focus on relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis.
Improve quality of life for both the patient and the family.
Provided by a team of doctors, nurses, and other specialists.
Provides extra layer of support
Appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.

CAPC 2023

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SERIOUS ILLNESS

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THE PALLIATIVE TEAM PROVIDES:

Time to devote to intensive family meetings and patient/family counseling
Skilled communication about what to expect in the future in order to ensure that care is matched to the goals and priorities of the patient and the family
Expert management of complex physical and emotional symptoms, including complex pain, depression, anxiety, fatigue, shortness of breath, constipation, nausea, loss of appetite, and difficulty sleeping
Coordination and communication of care plans among all providers and across all settings
Code status conversations and completion of POLST/DNR forms and Advanced Directives
Assistance with feed at risk discussions along with SLP and physician