ACQ Vol 11 No 1 2009

MULTICULTURALISM AND DYSPHAGIA

(1998) found that aspiration of secretions and excess secretions in the mouth were both significantly associated with pneumonia in dentate subjects. However, normal healthy adults commonly aspirate saliva/secretions while sleeping, without any obvious health effects (Cassiere, 1998; Gleeson &Maxwell, 1997). Any condition that increases the volume or bacterial burden of oropharyngeal secretions in a person with impaired defence mechanisms may lead to aspiration pneumonia (Marik, 2001). While normal saliva has 10 8 organisms/mL, periodontal disease or poor oral hygiene may result in a higher concentration of oral pathogens in the saliva, with saliva from a patient with gingivitis (inflammation of the gums around the roots of the teeth) containing up to 10 11 organisms/mL (Mojon, 2002). In the elderly debilitated patient, both salivary flow and swallowing are frequently abnormal (Palmer et al., 2001). Langmore et al. (1998) conducted a cohort study of male veterans and reported a significant increase in the number of

decayed teeth in subjects with aspiration pneumonia, with significantly more patients who reported they occasionally or never brushed their teeth proceeding to develop aspiration pneumonia. In a study that looked at 50 subjects who developed aspiration pneumonia from a population of 358 veterans, Terpenning et al. (2001) found the presence of Porphyromonus gingivalis, Streptococcus sobrinus and Staphylococcus aureus in saliva was significantly higher in subjects who developed aspiration pneumonia, regardless of presence or absence of dentition. Professional oral care has been associated with a reduction in aspiration pneumonia in nursing home patients (Abe, Ishihara, & Okuda, 2001; Adachi, Ishihara, Abe, Okuda, & Ishikawa, 2002). Elderly patients in residential care have high oral yeast counts and oral candidiasis which are associated with poor oral hygiene and neglect of care of dentures (Budtz- Jorgensen, 1996). These factors are easily modifiable, and may

Table 1. The Frazier Free Water Protocol After several years of a conventional dysphagia program, Frazier’s swallowing management protocol changed dramatically. Concern over patient and family non-compliance with thin liquid restrictions both within the facility and after discharge led us to alter our protocol in 1984. Previously prohibited, oral intake of water became a major feature in both treatment and day-to-day hydration. Features of Frazier’s program include the points listed below. Safety of water n The human body is about 60% water. Small amounts of water taken into the lung are quickly absorbed into the body pool. n Unlike other liquids, water has a neutral pH. Water is free of bacteria and other contaminants and does not contain the chemical compounds found in beverages. Aspiration of other liquids can lead to respiratory infections and pneumonia. n Water provides a safe means of assessing patients with thin liquids. All patients (of any diagnosis) referred to speech pathology are screened for dysphagia with water sips. n Water is safely utilised in daily treatment of thin liquid restricted patients. Water therapy permits better recognition of patient readiness for repeated videofluoroscopy and diet advancement. Hydration n Free water consumption is encouraged for all patients and makes a significant contribution in hydration for many. n The risk and cost of IV fluids should be decreased. n Post-discharge surveys of Frazier dysphagic patients indicate water often is the primary means of hydration. n All patients are screened with water. Patients exhibiting impulsivity or excessive coughing and discomfort will be restricted to water taken under supervision. Patients with extreme choking may not be permitted oral intake of water due to the physical stress of coughing. n For patients on oral diets, water is permitted between meals. Water intake is unrestricted prior to a meal and allowed 30 minutes after a meal. The period of time following the meal allows spontaneous swallows to clear pooled residues. n After the screening described above, NPO patients are often permitted water. n Patients who are thin liquid restricted wear blue bands to communicate the liquid restriction to all staff. Typically, the band reads “No thin liquids except water between meals.” All staff are oriented to blue bands and check for bands before offering liquids to patients. n Water is freely offered to patients throughout the therapy day. n Medications are never given with water. Pills are given in a spoonful of applesauce, pudding, yogurt, or thickened liquid. n Family education includes emphasis on the rationale for allowing water intake. The guidelines for water intake are repeated by the speech pathologist, dietitian, and nurse during the education process. Compliance n Complaints of thirst were frequently voiced prior to 1984. Patients reported thickened liquids did not quench thirst. n Water eliminates thirst and patient complaints are now much less frequent. n Many patients and families object to thickened liquids. Since water is an option, patients appear more likely to comply with the thin liquid restriction. n Once home, preparation of thickened liquids often becomes burdensome. After days or weeks at home the family may tire of patient complaints and abandon thickened liquids. n Availability and cost of thickening agents and/or prepackaged thick liquids may preclude patient compliance. n Thick liquid preparation in addition to other time and energy consuming patient care tasks can overwhelm families. Source: http://www.kysha.org/06%20Handouts/MS%203F%20Panther%20Handout2.pdf Frazier Rehab Center’s water protocol – water between meals n By policy, any patient NPO or on a dysphagic diet may have water.

ACQ uiring knowledge in sp eech , language and hearing , Volume 11, Number 1 2009

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