Oral Care, Monitored Meals, and Aspiration Pneumonia: “What We Don’t Know We Don’t Know” in Health Care:
Carson Eldercare Consulting & Management
For more information about the author, click to view their website: Carson Eldercare Management and Consulting
Sep 25, 2024
Pennsylvania - Greater Pittsburgh Area
“What We
Don’t Know We Don’t Know” in Health Care:
September
24, 2024 -
Oral Care,
Monitored Meals, and Aspiration Pneumonia
Proper oral care is crucial for maintaining optimal health.
Keeping the mouth clean not only helps maintain the protective properties of
saliva but also reduces bacteria in the mouth which can be a source of
infection in aspiration pneumonia. In addition, monitoring meals and assisting
with feeding for those at high risk for aspiration is also a necessity. The
process of swallowing involves dozens of muscles that start in the mouth and
include the pharynx, larynx, and esophagus. These muscles can become weakened
with age and from various, often age-related diseases. The aging population is especially at risk
for aspiration pneumonia due to comorbidities, frailty, and conditions that can
impair swallowing. As a result,
aspiration pneumonia is one of the leading causes of death from infection in
individuals over the age of 65. One study shows that 1 in 10 deaths from
pneumonia in elderly nursing home residents may be prevented by improving oral
hygiene (Sjogren et al., 2008).
Unfortunately, proper oral care and monitoring of meals is
often overlooked in the health care setting.
Perhaps the greatest reason for this is the challenge that almost every
health facility faces today: adequate staffing. When I started working in acute
care as an RN over 20 years ago, nursing assistants (these are the staff
generally responsible for proving oral care in an acute care setting) were
typically responsible for 5-7 patients. Nurses had 3-5 patients (this was on a
step down cardiac unit). Between the nurse and the assistant, we were able to
provide oral care at every meal and offer one-on-one assistance to any patient
that was at risk for aspiration. This is no longer the case. RNs oftentimes look after upwards of 8
patients, and there is generally either no nursing assistant on the floor or
only 1 for a patient load that can exceed 20.
Consequently, proper oral care is neglected. I have often seen patients that are aspirating
during meals, but do not have adequate staffing on hand to provide them with
the supervision and monitoring that they need. This presents a hazardous catch-22:
the aging individual needs to eat to maintain nutritional needs yet he/she
needs assistance with eating to prevent aspirating pneumonia.
How can this be remedied? If the family is present, they can
provide oral care and meal monitoring. If meal monitoring is required for an at-risk
individual, it’s recommended to touch base with the health care team to inquire
as to what the specific aspiration precautions are (every individual may have a
different need and/or recommendation). A care companion can also be hired to
provide the needed care. I hired a companion for my father when he was in a
skilled nursing facility. He was not getting his teeth brushed or flossed
regularly, and I was seeing a decline in his dentition. Having this extra
support provided him with much needed assistance and the care companion had the
added benefit of encouraging him to eat more at every meal, something that was
a bonus as he was not meeting his nutrient needs. Touching base with staff to
request that oral care and meal monitoring be done can also be helpful. Having
an advocate to ensure necessary care is getting done can also be very effective
in the health care setting.
What is proper oral care and effective meal monitoring?
Proper oral care includes brushing the teeth for at least 1
minute after every meal. It also includes using a soft bristle brush, fluoride
toothpaste, flossing daily. A final component of oral care that is often not
discussed is denture care. Dentures should be cleaned at least once per day and
removed at bedtime. Removing them prior to sleeping can greatly reduce the risk
of pneumonia (Iinuma
et al. 2014). Effective meal monitoring includes adequate supervision during
mealtime for those at risk of aspiration. Such supervision includes ensuring
the individual is properly positioned for a meal (head of bed as high as can be
tolerated and supine position), takes small bites, eats slowly, swallows a
couple times in between each bite, and intermittently takes a sip of liquid to
clear the mouth of food particles. The use of straws is generally not
recommended for an individual at risk for aspiration as it propels the food to
the back of the throat and hence can increase risk. I recall when I was working
as a Registered Nurse (RN) in acute care that I was constantly removing straws
from the bedside of ‘at risk’ individuals and often reminding them to eat
slowly and swallow at least twice between each bite to ensure food clearance.
Individuals at risk for aspiration often require a modified texture diet as it
can further prevent the aspiration of food and liquids.
This is a brief summary of the attention to detail needed in
addressing oral hygiene and meal monitoring amongst the aging population. Both measures
can play a significant role in reducing aspiration pneumonia. If you would like more information on understanding
proper oral care or any other questions that you may have regarding aging life
care, please feel free to reach out to me.
Sources:
1.
Sjogren P, Nilsson E, Forsell M, Johansson O,
Hoogstraate J. 2008. A systematic review of the preventive effect of oral
hygiene on pneumonia and respiratory tract infection in elderly people in
hospitals and nursing homes: effect estimates and methodological quality of
randomized controlled trials. J Am Geriatr Soc. 56:2124–2130.
2.
Iinuma T, Arai Y, Abe Y, Takayama M, Fukumoto M,
Fukui Y, et al. 2014. Denture wearing during sleep doubles the risk of
pneumonia in the very elderly. J Dent Res. doi:
10.1177/0022034514552493
3.
F Muller, 2015. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4541086/#
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Carson Eldercare Consulting & Management
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