Special Situations

Dehydration

Dehydration occurs when a person is either not getting enough liquids (about six cups) daily or excreting too much urine. The body's ability to detect thirst diminishes with age. Illness and medication can also cause dehydration. A dehydrated person may need help drinking from a cup or glass and have trouble swallowing liquids.

Signs and symptoms of dehydration

• Headache — the most common symptom
• Dry mouth and tongue
• Cracked lips
• Dry skin
• Sunken eyes
• Nausea, vomiting, diarrhea
• Dark, strong smelling urine
• Weight loss
• Fast heart beat
• Low blood pressure
• Confusion, light-headedness
• Disorientation

Use ice chips, popsicles, juice bars, gelatin, ice cream, sherbet, soup, broth, fruit and vegetable juices, lemonade and flavoured water to incorporate liquids into the diet.

Chewing and swallowing problems

Chewing and swallowing problems (also called dysphagia) can be life threatening for elderly people and people with diseases such as stroke, cerebral palsy, Parkinson's disease, muscular dystrophy, multiple sclerosis and dementia. The muscles of the mouth and throat may no longer be working properly, so bits of food and liquid will be aspirated or drawn into the lungs. Other factors contributing to dysphasia could be level of consciousness, medications, distractions and eating patters.

Signs of chewing and swallowing problems

• Extra effort chewing or swallowing
• Eating very slowly
• Packing food into the cheeks
• Swallowing several times for a single mouthful of food
• Shortness of breath during eating
• Coughing or choking while eating or drinking
• Drooling
• Fluid leaking from the nose after swallowing
• A wet-sounding voice after eating
• Increased congestion in the chest after eating
• Repeated bouts of pneumonia

If a parent is coughing or choking too often when eating and you are getting worried, ask the following questions:

• What type of food or fluid was he eating when the choking occurred?
• If the person wears dentures, were they in at the time?
• Was the person walking around with food in his mouth?
• Was he laughing or talking?

Record this information for a visit to the doctor.

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How to assist someone to eat and improve nutritional intake

• Ensure that foods are neither too hot nor too cold
• Feed attractive, tasty, pleasant-smelling foods to enhance appetite
• Use finger foods to encourage independence and safety
• Make sure he is ready to eat i.e. the dentures, eyeglasses and hearing aid are in place
• Try to make the eating environment quiet and inviting with as few distractions as possible. Try playing some quiet music.
• Make sure he is seated correctly i.e. as close to 90 degrees as possible
• Try to tuck the chin under so it points to the chest (if necessary have the person in a chair offering head support)
• Sit at eye level as you assist the person with eating
• Use a teaspoon to avoid putting too much food in the mouth at once
• Remind the person to chew each mouthful thoroughly
• Touch the person's lower lip to stimulate opening the mouth
• Massage the throat to stimulate the swallow reflex
• Take as much time as necessary to help the person enjoy the meal
• Ensure the person remains sitting in an upright position for at least 30 minutes after each meal
• Clean out the mouth after each meal

	Feed small amounts of food first, then gradually increase the amount as the ability to swallow increases.
	If the person is not swallowing between spoonfuls, put an empty spoon into the mouth to trigger the swallowing mechanism.
	Use wide, shallow glasses instead of tall, narrow ones.
	Never feed someone lying down if at all possible and do not tilt the head back. If the person must be fed in bed, prop up with pillows
	Watch for foods that have a double consistency i.e. anything with a skin such as peas, grapes. These may be difficult to manage.
	Do not wash food down with a liquid.
	Do not use straws for chewing and swallowing problems. Straws increase air swallowing and add to the number of steps required for drinking.

Swallowing test

If choking and drooling become excessive, contact a speech pathologist or speech therapist to arrange for a swallowing test through your physician or home care. The test is called a Videofluoroscopic Swallow Study. While the person swallows liquids of varying amounts and consistencies, the therapist watches a screen showing which liquids proceed to the stomach and which are aspirated into the lungs. If the test has to be done at home, a therapist will observe the person eating and drinking without the equipment. The therapist will then recommend appropriate changes, such as changing the size of the spoon, placing food on a specific area of the tongue and positioning the person at a certain angle during or immediately after eating. The therapist may also recommend a special diet.

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Special diets

Special diets may be recommended following a swallowing test.

• Minced diet
  In a minced diet, all food is minced for easier chewing or swallowing.
• Pureed diet
  A pureed diet may be the only alternative for a person with dementia or severe eating and swallowing problems. Use a blender or food processor to puree foods to the consistency of baby food. Soft and smooth foods, such as applesauce, puddings and eggs can be served in their normal form.
• Thickeners
  Thickened fluids may be recommended as a remedy to chewing and swallowing problems. Natural thickeners include tapioca, flour, instant potato flakes, oats and matzo meal. Thickeners can be used in hot or cold fluids. Add the thickener gradually until the fluid reaches the desired consistency.
• Liquid supplements
  Nutrition drinks and liquid supplements, such as Ensure, can be used to supplement the diets of people who are having trouble eating and drinking and not getting enough nutrients.

Fortified nutritional drinks such as Carnation Instant Breakfast are a good source of nutrition and may be cheaper than liquid supplements. Powdered protein can also be used to make a high protein drink.

• Tube feeding
  Tube feeding bypasses a person's swallowing mechanism and delivers food and liquids directly into the stomach. The tube may be inserted into the nose, for short-term use, for instance, after surgery. Or the tube may be inserted into the stomach for long-term or permanent use. In the late stage of dementia, when swallowing difficulties and loss of interest in eating become extreme, caregivers may be asked to make a decision about tube feeding.

  In making the decision to tube feed or not to tube feed, caregivers may want to consider what the sick person would have wanted if he or she were capable of making the decision. Also, ask about the implications of tube feeding: Can the body make use of the nutrition that is being provided through the tube? Will tube feeding prevent aspiration pneumonia? Will it lessen or increase the person's suffering? Will it prolong the person's life? Is there an alternative to tube feeding?

Complications associated with tube feeding

• Nausea, vomiting, diarrhea
• Constipation and cramping
• A swollen stomach
• Coughing, wet breathing, a feeling of having something caught in the throat
• Infection at the site where the feeding tube enters the body
• Clogged tubes
• Tubes pulled out by the person with dementia
• Aspiration pneumonia