Swallowing difficulties: a prognostic signpost.

Yolanda, an 88-year-old woman, is transferred from her residential care home to acute care for management of confusion and a reduced level of consciousness. She has a history of dementia, non–insulin-dependent diabetes, osteoporosis with compression fractures, mild chronic renal failure, and hypertension. On admission she is diagnosed with aspiration pneumonia in the right lower lobe and is treated with intravenous then oral antibiotics. Yolanda's family is told that the cause of the pneumonia is aspiration secondary to swallowing problems. The family reports that the amount of food eaten by their mother has steadily declined and they are concerned about the staff in her residence not having the time to feed her. In residential care facilities the estimated prevalence of dysphagia is 50% to 75%, with half of those patients aspirating their food and one-third developing pneumonia as a complication. 1 In patients with advanced dementia who develop pneumonia the 6-month mortality rate is 46.7%. 2 The same study showed that those families who had an understanding of the prognosis and the expected course of the illness were less likely to agree to burdensome interventions in the last 3 months of life. Dysphagia contributes to reduced intake of food, but there is also a known reduction in the appetite of patients with dementia, likely owing to reduced caloric needs secondary to inactivity and lower basal metabolic rate. 3 The swallowing difficulties and lower appetite are natural indicators of the progression of the disease. Families will experience less distress and have a greater understanding of the progression of the disease if they are prepared for these events in advance. Six months before admission to acute care, Yolanda had a swallowing assessment done by the occupational therapist at her facility, which showed decreased awareness of food in her mouth and a delay in initiating swallowing. The instructions for helping Yolanda with her eating had been adjusted, and the family was informed that Yolanda must be sitting up, awake, and swallowing 1 mouthful of food before another was offered. Several days after her admission to acute care, Yolanda has improved with fluid and antibiotics. Her acute delirium secondary to the infection is improving and she is more awake and aware. Her estimated glomerular filtration rate has stabilized at 45 mL/min, and her electrolyte levels show that she is now hydrated adequately. The occupational therapist in acute care uses a bedside water test in which …