To Tube or Not to Tube: Navigating Aspiration Risk in Dementia
Aspiration pneumonia is a serious concern, especially in patients with dementia. It's a complex issue with no easy answers. I often am asked how I handle this sensitive situation and what options we have. Here's a breakdown of the thought process I go through when considering aspiration risk, particularly in the context of a patient with dementia:
1. The Big Picture:
Underlying Conditions: What are the patient’s host factors? For example, is there an underlying cardiopulmonary disease? This can increase the risk of aspiration and aspiration pneumonia. Further, it can make the diagnosis of aspiration pneumonia even trickier than it already is.
What stage is the dementia? Is the dementia advanced? Remember that feeding tubes are generally not recommended for individuals with late-stage dementia.
More Than Just Aspiration: Aspiration is just one piece of the puzzle. We need to consider the patient's overall quality of life, their preferences, and their goals of care. If they cannot communicate these things, discuss them with the family or responsible party to determine what’s best based on the options and risks/benefits you lay out for them.
Aspiration Doesn't Always Equal Pneumonia: A 2008 study by Robbins et al. showed that only about 10% of individuals with dementia or Parkinson's who aspirated developed pneumonia. 10%! What percentage of people might become dehydrated on thickened liquids? Do you think it’s more or less than 10%? Hint: it’s more. A lot more. 75%! This highlights the importance of not overreacting to aspiration, even if an instrumental swallowing evaluation confirms it. It also tells us that the cure can be worse than the disease. We don’t want to mistakenly overweigh the benefits of minimizing aspiration risk and minimize the potential risks of some of the interventions we use (i.e., modified diets and thickened liquids).
2. Risk Mitigation:
The risk of aspiration isn’t always something we have much control over. For example, we may not be able to employ compensatory strategies in a patient with dementia who is unable to follow directions. But often, we can manage the potential effects of that aspiration without resorting to life-changing dietary changes or feeding tubes. There’s always more than one road to use. Making a patient NPO is never the only option. If you can’t build a bridge, try a tunnel. Here are some strategies we can use to mitigate the overall risk and avoid extreme measures:
Hand-over-hand assistance during meals.
Compensatory strategies to improve swallowing safety with cueing or spaced retrieval training.
Close supervision and support during meals.
Reducing aspiration pneumonia risk by improving self-feeding, mobility, and oral care.
3. The Immediate Situation:
If you're concerned about a patient with dementia and potential aspiration but don't yet have immediate access to an instrumental swallowing evaluation, ask yourself these questions:
Is there recurrent aspiration pneumonia?
Is there an unreasonably high risk of irreversible damage?
Is mealtime uncomfortable, leading to weight loss, dehydration, or a lower quality of life?
Is there a high risk of choking?
If the answer to these questions is "no," there may not be a pressing need for immediate, drastic changes.
4. A Cough is Just a Cough (Without Further Information):
As SLPs who specialize in dysphagia management, we tend to think every cough under the sun is related to dysphagia. It isn’t. The only thing it does confirm is an intact laryngeal and pulmonary reflex. An MBS or FEES is crucial for accurately assessing swallowing function and identifying aspiration. If you can’t get one immediately, don’t assume the worst. Instead, fight for that swallow study and make a clinical judgment based on the objective data you can access. For example, a standardized clinical assessment like the Mann Assessment of Swallowing Ability (MASA) can assess overall function and aspiration risk.
In Conclusion:
Managing mealtime risk in individuals with dementia requires a holistic approach. We need to consider all factors, prioritize patient preferences and quality of life, and explore all available options before making significant changes to their diet. Food and liquid may be one of the few things that bring this patient pleasure. We need to think about ALL options before taking that away.
Written by George Barnes MS, CCC-SLP, BCS-S
What are YOUR go-to strategies for managing aspiration risk in patients with dementia? Share your experiences and tips in the comments below! Let's learn from each other and advocate for the best possible care.
