Even in ordinary times, managing swallowing disorders can require complex coordination and care in senior living communities—and these are not ordinary times.
With the limitations and precautions the COVID-19 pandemic has imposed, senior living operators have had to make adjustments to ensure residents who suffer from swallowing disorders continue to receive the close attention that they require to eat safely and receive sufficient nutrition to stay healthy.
“COVID has presented a whole new set of circumstances that require us to double down on our efforts to focus on our high priority residents,” says Margaret Roche, founder of Roche Dietitians.
Roche says focusing on top priorities is key to navigating the COVID era, and “residents with chewing and swallowing problems are certainly near the top of the list.”
Katie Holterman, senior director of clinical programming, Legacy Healthcare Services, says there is a great deal of coordination involved in managing patients and residents with swallowing problems, and “making sure that coordination is still taking place is at the forefront of everybody’s mind.”
Risks can increase
“A speech-language pathologist’s role in combatting swallowing difficulties and disorders is vast,” says Jonross Neptune, MS, CCC-SLP, director of speech-language pathology (SLP) clinical services at FOX Rehabilitation.
“At the core, SLPs assist in identifying abnormal structures and functioning as well as treating those living with swallowing difficulties, that if left unchecked can place the senior living population at a high risk of hospitalization and worse.”
Individuals with chewing and swallowing disorders are at risk for choking and aspiration pneumonia, which occurs when particles of food or liquid do not travel down the esophagus into the stomach but rather into the lungs, Roche says. Another risk is malnutrition, because those with chewing and swallowing problems tend to be reluctant to eat and drink as much as they need because they find the process difficult.
“Dietitians and dining leaders work together to make sure that foods and liquids are modified to the appropriate consistency and then monitor the resident’s eating and weight,” Roche says.
“Weight change is an important indicator of how well the resident is doing nutritionally. So you can see why in senior living, those with chewing and swallowing problems have always been one of our top priorities.”
Marta Kazandjian, director of speech pathology and resident centered care for Silvercrest Center for Nursing and Rehabilitation in New York, and Faerella Boczko, director of speech-language and swallowing disorders at The New Jewish Home in New York, are National Foundation of Swallowing Disorder members and speech-language pathologists board-certified in the treatment of swallowing and swallowing disorders.
A major challenge for residents with the COVID-19 virus, they point out, is the potential impact of the loss of taste and smell. This loss of sensory function can influence some residents’ acceptance and intake of food, exacerbating problems those with swallowing disorders may already have.
“COVID-19 has positioned a spotlight on the benefits gained by having a strong rehabilitation partner,” says Neptune.
“Residents being socially isolated, meals taken in rooms, and the lack of access to extremely important instrumental swallowing assessments are only a few of the roadblocks created by this pandemic that can create unsafe situations for the residents. With this, SLP’s have been forced to rely even more on their own clinical skills to create and implement a plan of care that addresses the needs of the residents.”
Coordinate with your dietitian to keep monitoring
your residents with chewing and swallowing
problems even after the dining rooms are open.
It will take some time and focus to gain back
losses in nutritional status,” says Margaret Roche,
founder of Roche Dietitians.
In a more stable environment, Adrienne Ellison, regional director of operations, Legacy Healthcare Services, says the industry has excelled at supporting residents with swallowing disorders, both in a therapeutic environment and through compensatory strategies and skills or adaptive equipment.
A restorative dining program, which allows residents to eat independently with supervision and assistance as needed, is a great step for residents after therapy or to be used concurrently with it, she says.
“Now, we’re adapting to the challenges that COVID presents, because restorative dining might not be an option in some of these communities – communal dining might not be an option,” Ellison says.
“So, we’re trying to find ways to meet the needs of these individuals with the staffing ratio that we’ve been operating with.”
Effects of isolation
Based on polling she has done during webinars in recent months, Roche believes that residents in senior living communities are seeing an increase in unintentional weight loss. She says the culprit is social isolation.
“The challenge that caught us all off guard has been the social isolation,” Roche says.
“Up until COVID, our communities have been the antidote to social isolation. We have been learning that even though we are providing enough nutrition, many have been eating less because the dining experience has changed so drastically.”
Ellison says communal dining plays an important role in inspiring general motivation to eat. She noted that residents eating isolated in their rooms also don’t have someone there to notice if they’re not eating and to encourage them.
“So, what some of the clinicians are describing is that these patients are in their rooms and they’ve been so isolated that the depression rates are going up and the intake is going down,” Ellison says.
“The challenges for meal delivery from room to room is far harder than delivering meals in a dining experience, so maybe the food isn’t in its optimal state by the time it’s delivered to a resident. It just seems like a perfect storm.”
One of the other risks of isolation is that residents with swallowing disorders may not eat sitting at a table.
“Proper positioning from a swallowing dynamics perspective is really important,” Holterman says.
“If somebody is lying in their bed eating most of their meals, they’re not in a good position to support the function of swallowing. Then if you have somebody with active COVID or even recently recovered, they may have a compromised respiratory function.
“Breathing and swallowing is this very intricate balance and lying down, or even slumping, can place pressure on the diaphragm. So, you have this lack of socialization, this lack of kind of sensory input, and now you also are possibly putting difficulty on the mechanics of swallowing.”
Holterman says it’s essential to work as a team to identify the needs of residents and to track the fluctuating patterns of how they’re functioning day to day, including for identifying the early onset of COVID through symptoms such as loss of appetite, loss of taste, and loss of smell.
With staffing limitations, Ellison says, increasing training to make sure direct care staff understand the importance of monitoring intake and weight can be crucial, so that “we can start to identify an issue sooner rather than later if someone should begin to lose too much weight or not have adequate hydration.”
Roche agreed that socialization is a key element to increasing motivation to eat, and communities should take any opportunity they can to “increase the coordination of dining services and resident engagement programs to take full advantage of any opportunities to provide extra calories and hydration to residents.”
Some with swallowing disorders depend on texture-modified foods and thickened liquids, and Roche, who has consulted for Kent Precision Foods Group, Inc., producers of the Thick-It brand family of products, says ensuring there are appropriate options in those categories for residents is important.
Many recipes can be adjusted for texture-modified diets, she says, and she suggests building themes around food and socialization, selecting foods that offer nutritious calories and hydration.
“Coordinate with your dietitian to keep monitoring your residents with chewing and swallowing problems even after the dining rooms are open,” Roche says. “It will take some time and focus to gain back losses in nutritional status.”
A lasting impact?
According to Kazandjian and Boczko, “it is unclear what lasting impact the virus has on managing swallowing disorders.”
“We know that endurance and fatigue contribute to recovery of function,” Kazandjian and Boczko note.
“We also know that breathing and swallowing coordination can be disrupted for patients with respiratory compromise. An individualized treatment program created to maximize swallowing safety and oral intake of food and liquid is necessary.”
Ellison, Kazandjian, and Boczko each noted that adjusting for those with swallowing disorders who are in recovery from COVID could include a shift to smaller, more frequent meals that are less tiring to complete.
In addition, a meal plan with calorie-dense portions could reduce the effort required to breathe during meals, and Holterman says senior living communities may need to extend dining hours to ensure residents are not rushed to eat.
“We’ll adapt and we’ll learn from this,” Ellison says. “We’ll come up with some great, new strategies and solutions to support those residents and keep them as healthy as possible.”