Month: October 2017

More Isn’t Always Better: The downside of appetite stimulants in the elderly.

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Magic little pills…oh, let me count thy side effects. But when does the benefit outweigh the cost? Are some of these commonly used stimulants better than others? Let me recount a recent case…Mrs. Geri Atric was an independent-living 90-something before a recent hospitalization after a fall and elbow fracture which left her deconditioned and on puree and honey thick liquids. Her medical history is significant for COPD and recurrent UTIs. And not surprisingly, she came to a facility not eating. Geri’s physician and dietician pushed for Remeron. Within 24 hours of starting the lowest dose (7.5 mg) increased somnolence was evident, but despite this report, the physician continued the med for 7 full days and somnolence persisted. GIven Geri’s risk factors to be a silent aspirator (COPD and reduced arousability), a FEES was pursued at day 5 by a very smart SLP to further assess swallow anatomy and physiology. Sure enough, when Geri was barely alert enough to self-feed thin liquid sips, spillage was significant resulting in aspiration during the swallow, no cough. But with a cued throat clear, Geri could effectively clear the material from her trachea. And with solids, Geri was too tired chew more than a couple bites but there was no pharyngeal residue. With her good mouth care and under supervision, she was identified as a candidate for thin water between meals, reducing her risk for dehydration and subsequent UTIs. And 2 days later when the Remeron was stopped and the resident started to wake up, the SLP could confidently push trials of thins at meals and challenging solids, knowing that the throat clear would inevitably protect the airway per the FEES results. And in my experience, I don’t think Geri will continue to be a silent aspirator as the sedating effects of the Remeron wear off.(Author’s note: In talking with the SLP recently, Geri is indeed coughing with thins now that she is fully awake.)
I was inspired to read up a little more on Remeron. Turns out, the side effect of increased appetite the physician was aiming for is only a “greater than 7%” likelihood of occurrence, in contrast to a 54% chance of somnolence. If you aren’t using the Medscape app or online version at Medscape.com, you need to check it out. It’s easy to access dosing and uses, interactions and adverse effects for any meds you might find in a medical chart, generic and brand names.
But what’s the alternative? There are great ideas out there for stimulating appetites for residents living with dementia, to promote the pre-feeding stage of intake. Room sprays in food scents like baking cookies (check out Bath and Body works Room Perfume holiday scents, also demeterfrangrance.com for some truly unique Atmosphere Sprays like brownie, waffle or apple pie) can be effective. So can talk about the upcoming meal, to promote salivation. For residents that need oral warm-up, brushing pre-meal (sans toothpaste so that taste isn’t changed) or stimulation with a toothette-type vibrator (TalkTools, $11 plus shipping) can also be effective. I’ve heard about families who pour their loved one’s favorite flavor (pureed blueberries, chocolate or maple syrup) over the whole meal to successfully improve intake.
Polypharmacy may often be the reason for poor appetite in folks whether or not there is an underlying dementia, since med side effects commonly include dry mouth, taste alterations, nausea, upset stomach and somnolence and the likelihood experiencing these side effects only increases with the number of meds prescribed. So what’s an SLP to do? For starters, click here to read Appetite Stimulants in Long Term Care: A Literature Review. The article puts a strong focus on the lack of research supporting stimulants to prevent unwanted weight loss and shares a thorough reference list. Another good review (click here to access it) on safety and efficacy of stimulants is accessible on the Nutrition411 website (geared toward dieticians and health care professionals). The article asks important questions, like is the resident already taking a med that contributes to anorexia? It also reiterates the importance of a team approach in decision making. I encourage you to share this literature with your facility staff, educating them about the lack of evidence about the efficacy of most appetite stimulants in LTC and about the undesirable side effects of some of these meds. Nursing staff can implement evidenced-based clinical practices, ensuring that residents at risk for weight loss (like those residents that need assist with feeding) receive supplements and snacks. With meds in the elderly, less is more.
Thoughts on #SNFlife from Katrina Woodward, MS, CCC-SLP
Proud Leader of the SDX Scope Squad SDX-FEES.COM &
Certified Dementia Practitioner

Differentiating a Chonic Cough: Case Study of a Patient with COPD

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Mrs. M had been on a modified diet texture at her nursing home since her admission from the acute care hospital last week.  She had eaten regular foods with thin liquids her whole life.  Her primary diagnosis was exacerbation of COPD and a sensation of “globus” or a “lump in her throat.”  She was conservatively downgraded at bedside by the hospital SLP to nectar liquids and moist fork-mashable foods with sides of extra gravies and sauces due.  She was restricted from thin liquids due to a suspicious chronic cough that was “concerning for possible aspiration.”

Her acute stay was too short to complete an instrumental dysphagia exam before hospital discharge.  She was sent to a SNF for rehab on the modified diet recommend by the hospital SLP and sure enough, she started to refuse most meals.  The facility SLP noted that even though she was drinking nectar, she was still coughing intermittently when she ate, and also coughing even when she wasn’t eating.  The facility SLP requested a FEES in order to get to the bottom of the suspicious chronic cough and her physician agreed and ordered the exam.

SDX arrived on-site the next day.  Upon scoping Mrs. M, the FEES exam revealed severe signs and symptoms of laryngopharyngeal reflux (LPR). She scored above an 11 (!!!) on the Reflux Finding Score which is indicative of such significant LPR that an ENT and or GI consult is indicated.  She had severe edema and erythema to her arytenoid/interarytenoid space as well as bilateral vocal fold edema.  She was deemed appropriate for thin liquids and a soft chopped diet texture with sides of gravies and sauces on the side to alleviate the discomfort in the lower pharynx. Her cough was not related to food or liquid aspiration after all.  Mrs.  M was seen for outpatient GI as well as ENT consultations and was placed upon an aggressive short-term PPI (proton pump inhibitor) BID and an anti-reflux regiment.  Pulmonary was also consulted and indicated that there was some suspected backflow of reflux into the upper airway, potentially exacerbating some of her overall lung health issues.

Mrs. M continued to rehabilitate at the SNF prior to being ready to return home with family support. A second FEES prior to her discharge home was ordered and completed.  The results of this repeat FEES only 4 weeks after the initial FEES revealed decreased respiratory incoordination, as the exacerbation of COPD had resolved, plus a decrease in laryngeal edema and erythema at the arytenoid/interarytenoid space.  She reported easier transit of boluses and the chronic cough she had for many years had finally subsided with the LPR treatment. She was ready for diet advancement since she had successfully regained coordination of her swallow-breathe cycle.  

If Mrs. M hadn’t been seen on a FEES, her issues including LPR and chronic cough would have resulted in an unnecessarily restricted diet.  A FEES is your best tool for viewing the glottis and top of the esophagus and airway over longer periods of time, in color and in real-time. It is the ideal instrumental exam for patients with COPD and chronic cough issues of questionable etiology.  Mrs. M returned home on a regular diet texture and will continue to see her specialists to wean reflux medications if/when indicated and to provide ongoing support for her lung health.  See the FEES difference with SDX!

WHY SHOULD YOU HAVE FEES IN YOUR TOOLKIT?

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Let’s ask expert Kathy Fitzgerald, MS, CCC-SLP!  

Kathy, you have owned and operated both a mobile MBS truck and a mobile FEES business.  What do you see as the strengths of each study and when do you choose one over the other?  As the research has shown, there is no one “gold standard” dysphagia instrumental study any more. I was fortunate to have both procedures available to me at all times. Typically my younger pediatric patients, severely anxious/agitated patients, patients with a history of significant epistaxsis (nosebleeds) and patients with more of an esophageal dysphagia presentation participated in an MBS study.

 

Patients who presented with suspected or documented voice/vocal fold issues and dysphagia, globus sensation/suspected LPR (laryngopharyngeal reflux ),  NPO patients who are working on managing secretions safely, head and neck cancer patients, trach/vent, intubated  and ICU patients, bariatric patients, patients who cannot tolerate barium are excellent candidates for the FEES. I also like that I can grossly test and gather some laryngopharyngeal sensation information for patients with a neuro sequelae, something I cannot do with an MBS study. FEES is also excellent for many NICU infants.   No radiation and no time limits allows me the flexibility when scoping to test as long as needed.  For patients with COPD and CHF, I can really tease out fatigue and look at swallowing over the course of an entire meal.  The “breaking point” for aspiration due to fatigue occurs for many of these patients after the 10-minute mark.  Fatigue over a meal is something I can’t capture on an MBS.

A FEES may be minimally invasive but it has no time limits.  How long does your average FEES exam last?  How much more do you see compared to an MBS?  And how do patients react? It’s interesting as I was trained for 10 years as a pediatric and adult dysphagia clinician having access to only MBS studies. When I mastered FEES and began bringing the procedure into my clinic- based and then mobile practice, I found I was using FEES more and more. It is more mobile, easier to do in terms of being able to set up in an office or at a patient’s bedside. Depending upon what type of patient you have and what information you are looking to learn, a FEES can run from 5-20 minutes, averaging 12 minutes of continuous recording.  When you have a COPD patient or a patient with a neurogenerative process, the scope can be held in place for a whole meal which may even last over a half hour.  No time limits!1  When fatigue sets in, you can finally see decompensation of the pharyngeal swallow which often ties to the clinical report of “patient is coughing at the end of the meal.”  I was unable to capture this with my MBS as fluoroscopy time is limited to 3 minutes or so, and the fluoro picture isn’t continuous because the machine is turned on/off intermittently. An MBS is a black and white picture where you are viewing a patient’s swallow usually laterally with perhaps a turn to get an A/P view BUT the FEES picture is continuous as there is no radiation, capturing video throughout the whole exam time. A FEES exam is a bird’s eye view of the pharyngeal swallow, 3-dimensional and in color. Tissue color/abnormalities, vocal fold structure and function, radiation damage, signs of laryngeal reflux are unparalleled.

Patients who are appropriate for the exam do very well with the exam. The patient is educated about the procedure, and are able to talk to me during the entire test to let me know how they are doing. It is no different than an in-office ENT nasendoscopy exam which is routinely preformed daily. In the rare circumstance the patient is uncomfortable/anxious and cannot tolerate the test, it of course can be discontinued at any time. FEES clinicians have training that specifically deals with these challenges and clinicians need to be proficient in dealing with patients as well as performing a competent exam. I teach this procedure to others and have been scoped numerous times. Most often the feedback I get is “there’s a little pressure but it’s not bad.”  Also, clinicians must remember that most often a patient experiencing actual dysphagia has less sensation due to stroke, deconditioning and structural issues or even age related changes.  Our geriatric patients have more open spaces in the nasal passages since the turbinates shrink with age.

What about the “white-out?”  Yes, this is when during a FEES exam there is a quick white out of the glottic picture as the scope light shines on the back of the epiglottis, deflects then recoils during a pharyngeal swallow. Camera shutter speeds have greatly improved. The literature suggests that 90% of aspiration occurs before the swallow or after the swallow. Some clinicians who are newer to FEES often are concerned that “they will miss aspiration during a swallow.” This was my greatest concern when I moved from solely MBS and incorporated FEES into my practice. A skilled clinician moves the scope over the epiglottis as it is recoiling to catch anything leftover that would be in the glottis due to aspiration during the swallow with the green contrast left over. Also within the literature and years of research, there is no suggestion that having a FEES over an MBS study results in missed aspiration. I have now performed FEES for 17 years and my outcomes correlate with this as well.

 

What foods can a FEES test?  How does this measure up to an MBS?  Typically flavorless food coloring (the same as used to color frosting) is used in liquids or complex solids for a FEES exam to differentiate left over residue or aspiration from secretions. We do not use barium as we do not need radiopaque contrast. We can use any consistency of food and liquid, including milk, soda and even “questionable nectars” like health shakes.  The fact that such a variety of REAL food with no barium mixed in is appealing to many therapist and many patients do not like the look/taste or viscosity of the barium mixed in the foods for an MBS study. Sometimes there is even barium paste used for MBS studies which is difficult for the patient to transit as it is very sticky and adheres to food, or even breaks food down if left too long on breads and crackers.

 

Can you share a recent FEES success story? Yes! Just last week a female patient in her 80’s had two previous MBS studies. There was a general concern of general “coughing a lot, but also at meals.”  She was consuming a regular textured diet with thin liquids. The two previous MBS studies were negative for penetration/aspiration, however, the nursing facility downgraded her to nectar liquids and a moist ground diet texture “as a precaution.”  The patient slowly stopped eating. The SLP/ MD ordered a FEES exam for another look to assess if there was anything that was being missed. Sure enough, this patient ended up having significant post nasal drip/sinus issues which hadn’t been addressed. The patient also had significant LPR and was making a lot of mucous. Although the patient was not remotely penetrating or aspirating food or liquid, she was intermittently penetrating post nasal drip and mucous when her airway was open and this was the root of the cough.  Her excessive coughing contributed to a hypersensitive glottis and in combination with the LPR this set her into the chromic cough pattern. Since the FEES saw the secretions and the color of the reddened post-cricoid area, the patient’s physician was able to address both issues with nasal spray and short term reflux medication. She is happily eating a regular diet again and her coughing has significantly diminished!