The Reality of Dysphagia is a Hard Pill to Swallow

Among elderly persons, dysphagia is a common problem that not only affects quality of life but also increases the risks of morbidity and mortality, especially for frail, vulnerable elders in long-term care settings. In particular, dysphagia is associated with increased risk of aspiration, including aspiration of foreign material—which may increase the risk of airway obstruction—and aspiration of material containing bacteria or other microorganisms—which may precipitate an inflammatory reaction, leading to pneumonia. Aspiration pneumonia remains one of the most common causes of nursing home–acquired pneumonia, the burden of which is significant, with 30-day mortality rates estimated between 10% and 30%.¹ Among community-dwelling older adults, the rate of pneumococcal vaccination uptake is only about 60%. As we approach the peak of flu and pneumonia season in the United States, we wanted to highlight the strategies for preventing pneumonia, and in particular, aspiration pneumonia, with the articles and resources in this month’s issue of Annals of Long-Term Care: Clinical Care and Aging^® (ALTC).

John Liantonio, MD, and colleagues provide a comprehensive discussion of a multidisciplinary approach to preventing aspiration pneumonia by addressing three key risk factors: dysphagia, poor oral hygiene, and medication use. As Liantonio and colleagues note, advancing age and a variety of other conditions can contribute to dysphagia, such as dementia, stroke, and Parkinson’s disease, all of which can create barriers to care. Additionally, as nursing home residents are taking 7 medications, on average, attention must be paid to the medications that increase the risk of dysphagia.

In the center of the journal, you will find the first in our series of Quick Guide handouts, which serve to highlight an important disease state or other news affecting geriatric care providers. This month, we provide an overview of the current pneumococcal vaccination guidelines in light of the new recommendation for the routine use of the 13-valent pneumococcal conjugate vaccine (PCV13) in older adults, in addition to the existing 23-valent pneumococcal polysaccharide vaccine. This Quick Guide features an interview with leading respiratory disease researcher Tamara Pilishvili, MD, of the Centers for Disease Control and Prevention.

A case report by Richard Whalen, MD, CMD, and colleagues, lends another dimension to our focus on pneumonia: the problem of polypharmacy and the importance of frequent medication reviews. The authors describe the case of a 93-year-old cognitively impaired nursing home resident who was experiencing renal failure as a result of the cumulative burden of multiple medications. After a thorough medication review, many of the patient’s medications were decreased or discontinued, which led to marked improvements in her cognitive status, appetite, and renal function. One of the discontinued medications was fluticasone/salmeterol, which may have been contributing to her anxiety and neuropsychiatric symptoms. The drug had been prescribed after an episode of pneumonia to treat dyspnea attributed to a questionable diagnosis of chronic obstructive pulmonary disease (COPD)/asthma. Upon review, the care team identified that kyphosis was likely the cause of her dyspnea—not COPD/asthma—and the team was able to safely discontinue the patient’s fluticasone/salmeterol without worsening of the respiratory symptoms.

In this issue, you will also find an article by Lorraine Ernst, RN, that reviews the numerous benefits of animal-assisted therapy (AAT) in long-term care settings. The author offers her advice on how to start AAT programs within skilled nursing facilities and how to determine what type of AAT will best serve the needs of the residents. Special consideration is given to reducing the risk of zoonotic infection.

For additional articles, news, and resources about pneumonia and infectious disease, we encourage you to visit our Infectious Disease Medical Resource Center at www.annalsoflongtermcare.com/resource/infectious-disease.

As always, we welcome your thoughts on this month’s issue of ALTC. Reach out to our interim managing editor, Allison Musante, at amusante@hmpcommunications.com, with your comments and questions.

Thank you for reading!

Reference

1.  Mills K, Winslow BT, Springer K. Treatment of nursing home–acquired pneumonia. Am Fam Physician. 2009;79(11):976-982.