Introduction: Independent eating is something that most cultures consider an important activity of daily living. It is not always fully understood that people who are unable to feed themselves can benefit greatly if they can gain control over eating. The activity of eating influences many of the known psychological benefits associated with greater independence, such as improved dignity and self-esteem and reduced feelings of being a burden to their caregiver (Gustafsson)1. Hermann, et al.2, supports a similar view stating that “eating activity influences many aspects of our overall medical, physical, and social well being”. The ability of food self-selection and the capacity to set ones own pace in eating can potentially ameliorate some of the undernourishment and/or gastric problems, as well as some of the risks of being fed, that often occur for people who are fed.
We all start out our lives being fed. During the first year or two of life most people develop the skills necessary to feed themselves. Eating becomes an automatic activity that is given little or no conscious thought. However, some people are unable to develop the skills needed to self-feed due to a variety of causes and being fed is continued out of necessity. This group will potentially be dependent upon another person for all of their nutritional needs, and in many cases for hydration, for their entire life.
An additional group of people, who have been independent eaters, lose the ability to self-feed due to illness or injury and become dependent upon another person to feed them and, often, to also provide them with a drink. To facilitate mealtime independence it must be understood that for those who have never experienced independence in eating, the perception of self-feeding is different from those people who have had self-feeding experience. Therefore, teaching someone, who lacks familiarity with self-feeding, to feed them self must be approached with that understanding. If food has always been placed in their mouth without them being required to participate in removing the food from the utensil, they will not understand the concept and will have to learn it before they will be able to gain any degree of independence.
Potentially, many individuals from both groups of people can gain the ability to eat and drink independently through the use of assistive technology (AT). However, it is common to find that many caregivers including family members (especially older members), paid caregivers, and healthcare insurance company reviewers do not see a need for, and are resistant to, making this change. Yet, eating independently can be justified as being medically necessary for many physical and psychological reasons. (Medical necessity will be discussed in detail in a future Newsletter. If you need assistance with this subject, please contact us.)
Assistive Technology (AT) can range from a simple non-slip mat placed under a plate, to a custom built splint, all the way to sophisticated powered dining equipment like the Mealtime Partner Dining Device. (The various AT’s for eating will be discussed in detail in another Newsletter.) Unfortunately, there is a common misconception that empowering someone with mealtime independence is simply a convenience to the caregiver and provides no significant benefit to the consumer and, therefore, is unessential. Because this is such a predominant misconception, the benefits of independent eating will be discussed in detail in our first and second Newsletters starting with safety and health issues. Next months Newsletter will continue the discussion with issues of socialization and independence.
Safety
Issues. The
greatest safety benefit of eating and drinking independently is that it
reduces the chance of choking and/or aspiration. There are approximately
40,000 deaths in the
Proper positioning for the task of eating can reduce this risk. (We will include more information on this topic in the July 2009 Newsletter.) Also, simply controlling when food and/or liquid is placed in the mouth, enables a person to be more prepared to receive the food or liquid. Their sequence for breathing will better coordinate with the placement of food in their mouth, and, consequentially, reduce the risk of aspiration.
When one is being fed it is not always easy to know exactly when food is going to be placed in your mouth. Those providing food can change their mind and pause, or alternatively, speed up the food presentation depending upon what is occurring at the time. Also, they might change the angle at which the utensil is presented. Furthermore, if the person providing the food is in a hurry they might feel compelled to rush the meal. This is an especially common occurrence in facilities like nursing homes. Presenting food hurriedly, typically results in the person being fed taking the food from the utensil, regardless of whether or not they are ready for it. They will continually take the food when it is offered, even if they have not swallowed the previous bite. This pattern increases the likelihood of choking and/or aspiration.
Health Issues. Hurrying food consumption impacts most people’s digestive system and results in heartburn, indigestion or acid stomach (most of us have, at one time or another, experienced having a hurried meal and then feeling the need for an antacid). Gastroesophageal reflux disease or GERD, commonly referred to as acid reflux, is a condition in which stomach liquids regurgitate into the esophagus and, over time cause damage to it. Many people, who are constantly hurried during eating, develop GERD.
It is common for older people to require a protracted time to eat even a small meal. However, in many institutional settings they are required to eat quickly (generally due to staff shortages at mealtimes), and the result is indigestion following a meal, and over time, the development of GERD. The long term consequence is that the person is reluctant to eat because their stomach is upset and they are in pain. This can cause a downward health spiral with weight loss and undernutrition as the result.
Undernutrition and malnutrition exist at epidemic
proportions in nursing homes in the
Conclusion. The benefits of independent eating are considerable and diverse. This article has only touched on a few points. Next month the discussion will continue. Should you have questions or comments please let us know so that they can be included in the concluding article or one that will be published later.
The Mealtime Partner Dining Device was designed with safety as the highest priority and using it complies with all of the safety and health issues described above. With the Mealtime Partner, the user controls when the food is taken from the spoon so the eating process is fully coordinated. This reduces the risk of choking or aspiration. Also, the Mealtime Partner is infinitely patient and will never hurry the user. The user has adequate time to enjoy the meal and the risk of undernutrition and acid reflux, which can both lead to other health problems, are greatly reduced.
A MtP Tip: When using a Straw to drink, using lip balm can aid in sealing around the straw, making suction easier and requiring less effort. (Vaseline Petroleum Jelly works slightly better than Chap Stick, but both help.)
As mentioned in another article, there are approximately 40,000 deaths in the U.S. each year due to aspiration pneumonia and people who require feeding are more vulnerable to aspiration (which can lead to aspiration pneumonia) than people who self-feed. Ensuring a good chin tuck while eating or drinking can reduce the risk of aspiration and is high on the Mealtime Partners (MtP) list of good practices whether being fed by another person or being aided by an assistive device.
Even though there is no precise anatomical definition of “chin-tuck”, in general, a chin tuck is a head position that places the chin slightly downward towards the individual’s chest. Regardless of the exact execution of the chin tuck, it is a position that can improve the probability of taking a bite of food, chewing it, and swallowing it safely. When the head is slightly forward and down, the windpipe is in a protective position; food or liquid is less likely to enter the airway than if the head is upright. When food enters the airway, the result is choking, or, if the individual does not have an adequate gag reflex or cough, aspiration. (Aspiration occurs when food or liquid is drawn into the lungs instead of going down the esophagus into the stomach. Aspiration frequently results in an infection in the lungs known as aspiration pneumonia.)
The greatest difference in interpretation of how to implement a chin tuck appears to lie in the alignment of the head over the spine and the level of the chin relative to the chest. In a practical sense, having the head aligned over the spine with the chin tilted downward allows the muscles to work at their best to chew and swallow. A simple experiment to understand this phenomenon can be conducted by taking a drink with your head in a chin tuck, and repeating the process with your head fully extended upward. Note how the muscles of the mouth and throat feel in the different positions. Also, note how the muscles are elongated and feel tighter when the head is raised. Basically, more demand is placed on the muscles when the head is raised and controlling swallowing is more difficult. This is particularly significant if the person already has swallowing difficulties.
Some people lack sensation on one side of their throat. This lack of sensation is caused by a variety of reasons ranging from diseases and illness, to scarring due to a previous intubation. For people with numbness in the throat, not only is a chin tuck important, but turning their head to the side that lacks sensation in the throat, will help produce a safer swallow. With the head in this position, the side of the throat that is insensitive is narrowed so food and liquids are directed to the side of the throat that has greater sensation.
For people who sit in a chair that has a chest strap or chest harness, it is important that the straps are not so tight that they prevent a good chin tuck. If the person is normally in a reclining position, the chair should be put in an upright position and the straps checked to verify that they do not restrict the individual from adequately lowering their head for safe eating and drinking.
Most wheelchair seating positions can be adjusted, but the standard wheelchair seating position is designed for transporting someone safely because that is a requirement of the Food and Drug Administration (FDA) who provides the guidelines for all medical device safety. For the same reason, the second most important position for seating is for the user to be able to drive (i.e., control) the wheelchair. Acquiring the appropriate wheelchair position for eating or accomplishing other tasks (like eating) will probably require further seating position adjustment as the safe transport and driving positions are usually inappropriate for performing other tasks.
The normal feeding position for an infant is reclining. However, as the infant grows, and their diet expands from milk to mixed foods, their position should become upright. It is easy to continue feeding children in a reclined position if they have oral motor difficulties and are eating a soft textured diet. However, it is advisable to transition from this position as rapidly as possible as it does not allow the child to experience eating and drinking in an upright position and prohibits the appropriate muscles from developing.
Some people are easier to feed in a reclined position because of their poor oral motor control. When reclined, the food stays in their mouth and, therefore, it is easier and cleaner for the person providing the food, to feed them in this position. But, just because it is easier, doesn't make it appropriate, or safe. (More information on seating and positioning for safe eating will be provided in a future Newsletter.)
Fifty years ago it was common to find people in institutions being fed lying in bed. However, with the availability of technology that allows visualization of a swallow, we are now able to see the negative impact of eating in a reclined position. Safe feeding practices have evolved significantly in the past half-century. We have moved from “bird feeding” (feeding someone with their head tilted back) to understanding that good positioning for eating significantly reduces the risks associated with eating and drinking. Through the use of videofloroscopy6, safe eating practices can now be defined.
Regardless of whether someone has difficulty eating or not, if they are fed by another person, good positioning is not only wise but can make the meal more enjoyable. Remember, whether being fed by another person or using assistive technology – a chin tuck is a wonderful thing.
June 2009 Newsletter References
1. Gustafsson B. The Experiential Meaning of Eating, Handicap, Adaptedness, and Confirmation in Living With Esophageal Dysphagia. Dysphagia, Spring, 1995, 10(2):68-85.
2. Hermann, R. P., Phalangas, A. C., Mahoney, R. M. Powered feeding devices: an evaluation of three models. Arch Phys Med Rehabil, 1999, 80: 1237-1242.
3. Calhoun, K. H., Wax, M., Eibling, D.
E., Expert Guide to Otolaryngology.
4. DeLegge, M. H., Aspiration pneumonia: Incidence, mortality, and at-risk populations. Journal of Parenteral and Enteral Nutrition, Nov/Dec, 2002.
5. Greene Burger, S., Kayser-Jones, J., Prince Bell, J. Malnutrition and Dehydration in Nursing Homes: Key Issues in Prevention and Treatment. Published by: National Citizens’ Coalition for Nursing Home Reform, June 2000.
6. A videofluoroscopic swallow study (VFSS) is a procedure performed using medical imaging technology. During the test, the patient sits next to x-ray equipment and is fed a variety of foods and liquid mixed with barium. The barium makes the food or drink visible during x-ray. The x-ray equipment records a video of the movement of the barium.
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