Annals of Long-Term Care: Clinical Care and Aging. 2014;22(10):42-48.
1Department of Geriatric Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA
2Department of Family and Community Medicine, Jefferson Medical College,Philadelphia, PA
Abstract: Aspiration, which is a common problem among long-term care (LTC) residents, occurs upon inhalation of oropharyngeal or gastric contents into the lower respiratory tract. This can lead to aspiration pneumonia, and, subsequently, an increased risk of hospital transfers, morbidity, and mortality. Although various treatment guidelines for adults with lower respiratory tract infections exist, a greater emphasis on prevention of aspiration should be considered for older adults, as the mortality associated with this disease process can be staggering in this vulnerable population. This article provides an overview of three key risk factors all healthcare providers need to carefully consider when developing aspiration prevention strategies for their at-risk LTC residents: dysphagia, poor oral hygiene, and the use of certain medications.
Key words: Aspiration, aspiration pneumonia, aspiration prevention, dysphagia, lower respiratory tract infections, medication use, oral hygiene.
Aspiration can be defined as the inhalation of oropharyngeal or gastric contents into the lower respiratory tract. Patients residing in long-term care (LTC) facilities have been shown to have a threefold increased risk of aspiration compared with their community-dwelling counterparts.1 This is likely attributed, at least in part, to the high prevalence of major risk factors for aspiration pneumonia in this population, including dysphagia, poor oral hygiene, and use of certain medications. Many subsequent syndromes can occur following aspiration, including pneumonitis, abscess, obstruction, and pneumonia. Pneumonia typically arises when the aspirated material contains bacteria and other microorganisms, precipitating an inflammatory reaction.
In the LTC setting, aspiration pneumonia is the second most common cause of infection, hospital transfer, and mortality.2 It is also one of the most common causes of nursing home–acquired pneumonia (NHAP), with one study finding that 18% of patients with NHAP had aspiration pneumonia versus 5% of community-dwelling patients with community-acquired pneumonia (CAP; P<.001).3 In another study, the odds ratio (OR) of witnessed aspiration developing into pneumonia among nursing home residents was 13.9 (95% confidence interval [CI], 1.7-111.0; P=.01).4
Reducing Aspiration Pneumonia Risk
Pneumonia Predictive Formula Determines High-Risk Older Adults
Mortality associated with pneumonia in the LTC population has been studied with discouraging results. A prospective study of 108 consecutive patients who acquired pneumonia in an LTC facility over the course of 1 year found mortality to be 19% at 14 days, 59% at 1 year, and 75% at 2 years.5 Another study that included 104 case-control residents of a Veterans Affairs LTC facility showed similar results.4 In this study, mortality due to pneumonia was 23% at 14 days, and patients with pneumonia had a significantly higher mortality at 1 year than controls (75% vs 40%; P<.001), with survival curves only converging at 2 years.4 As these data show, reducing the risks associated with aspiration is clearly an opportunity for healthcare providers to reduce pneumonia-associated mortality.
Although treatment guidelines for adults with lower respiratory tract infections have been previously outlined by expert committees in both infectious diseases and critical care medicine,6 a greater emphasis on prevention of aspiration should be considered in the older adult population, as the mortality associated with this disease process is staggering. In this article, we review three common risk factors associated with aspiration pneumonia: dysphagia, poor oral hygiene, and the use of certain medications. Recognizing and promptly addressing these risk factors is essential to protecting the health and wellbeing of our most vulnerable residents.
Dysphagia is defined as a subjective sensation of difficulty or abnormality of swallowing. It is a common problem in the older adult population and a known cause of aspiration.7 Approximately 15% of older adults are affected by dysphagia,8 with an estimated 70% of referrals to otolaryngologists for dysphagia being for persons older than 60 years.9 The rate of referral for dysphagia increases twofold for patients aged 80 to 89 years and threefold for those older than 90 years.9
Advancing age represents an independent risk factor for dysphagia, as even with healthy aging there is physical toll on head and neck anatomy and changes to the physiologic and neural mechanisms that support swallowing.10 One study that surveyed elderly patients in the community found the prevalence of dysphagia to be 13.8%.11 This percentage is considerably higher in nursing homes. A 2013 South Korean study reported a prevalence of 52.7% among 395 older adults residing in two urban nursing homes.12 This finding is in keeping with the general medical literature, which suggests a prevalence rate between 40% and 60%.13
In addition to older age, a variety of other health conditions can contribute to the development of dysphagia, with the most common being neurologic diseases, stroke, dementia, cerebral palsy, traumatic brain injury, Parkinson’s disease, tumors arising from the nasopharyngeal tract, and achalasia.7,14-17 For example, as many as 50% of patients have swallowing abnormalities following a stroke.7 An increased risk of pneumonia in poststroke patients with dysphagia was documented in a retrospective analysis of database records from 1966 to 2005, which found a relative risk (RR) of 3.17 (95% CI, 2.07-4.87).14 This same study also found that RR increased to 11.56 (95% CI, 3.36-39.77) for patients who aspirated.
Dysphagia is also common in persons with dementia. Oropharyngeal swallowing abnormalities, including aspiration, have been reported to be as high as 45% among institutionalized persons with dementia.18 In patients with Alzheimer’s disease, there is gradual regression in appetite, food intake, and feeding and alimentation skills in addition to cognitive and physical decline, placing these individuals at increased risk for aspiration.15,16
Management of Dysphagia
Dysphagia in the elderly is most successfully managed via an interdisciplinary approach that involves nursing staff and assistants, speech-language pathologists, dieticians, and physicians working in tandem. The goal of most interventions is to maximize the safety of oral feeding when it has been compromised.10 Several interventions that have been used to manage dysphagia include posture changes and swallowing therapy, dietary modification, and tube feeding.
Posture changes and swallowing therapy. Changes in the posture of patients and speech/language pathology–led swallowing maneuvers performed in swallowing rehabilitation have been shown in small studies to help improve swallowing function.19,20 In one study, behavioral interventions (ie, standard swallowing compensation strategies and diet prescription three times weekly for up to 1 month) resulted in a 41% increase in the proportion of patients with dysphagia who regained swallowing function by 6 months.19 Another study reported a 67% improvement in swallowing function following 15 weeks of swallowing therapy after removal of a feeding tube.20
Dietary modification. Dietary modification to facilitate swallowing is another major management strategy for dysphagia. A 2008 videofluorographic swallowing study that assessed the effects of the chin-down posturing approach with thin liquids, nectar-thickened liquids, and honey-thickened liquids on the rates of aspiration in patients with Parkinson’s disease and dementia found that honey-thick liquids were less likely to be aspirated than nectar-thick or thin liquids (53% vs 63% vs 68%, respectively).21 To achieve a honey-like viscosity, starch- and gum-based commercial thickening agents are often added to fluids to prevent aspiration in patients with dysphagia; however, a recent study showed that the fluid these thickeners are added to can affect viscosity.22 The study assessed apple, orange, grape, peach-grape, and pineapple juices; black and chamomile teas; whole, skim, and a vegetable (tigernut) milk; and instant coffee. All of these fluids were separately thickened using a starch- and a gum-based thickening agent and compared with thickened water and assessed against the National Dysphagia Diet (NDD) reference limits. Compared with thickened water, the investigators observed significant changes in viscosity for all beverages except apple juice when using starch- and gum-based thickeners, and orange juice, pineapple juice, and chamomile tea when using the gum-based thickener. However, changes in viscosity per the NDD reference limits were only significant for peach-grape juice and pineapple juice with the starch-based thickener.22 This study indicates that healthcare providers need to be mindful that thickening agents will not provide the same viscosity for all fluids and that some adjustments may be needed to ensure the proper viscosity is achieved.
Tube feeding. Enteral tube feeding is often used to prevent aspiration,23 but it is not without significant risk and should generally be used as a last resort. While trying to prevent anterograde aspiration (normal swallowing process), tube feeding can lead to retrograde aspiration due to loss of upper esophageal sphincter and lower esophageal sphincter (LES) integrity, transient LES relaxation, and loss of swallowing reflex over time.24 A difference in aspiration risk dependent on the location of the feeding tube has been reported, with one study finding a reduction in pneumonia with postpyloric feeding as compared with gastric feeding (RR, 0.63; 95% CI, 0.48-0.83; P=.001).25
Despite the risks associated with tube feeding, this intervention may be needed for certain elderly persons with dysphagia. A healthcare provider tip sheet from The Hartford Institute for Geriatric Nursing notes that short-term tube feeding may be beneficial for managing severe dysphagia and aspiration in elderly patients who are expected to recover their swallowing function.26 It also notes that tube feeding may be an appropriate early intervention for patients with dysphagia following a stroke, with a goal of transitioning these patients to oral feeding as their dysphagia resolves. Finally, it suggests that patients with persistent dysphagia may warrant placement of a percutaneous gastrostomy tube.26
Many persons with dementia will require assistance with oral feeding as their cognitive impairment progresses. In such cases, placement of feeding tubes is often considered, particularly when dysphagia is present; however, the literature has not shown tube feeding to improve quality of life or to reduce mortality rates in persons with dementia, and continued assistance with oral feedings is often recommended.27 Yet assisted oral feedings are not without risk. In a prospective outcomes study of 189 elderly patients recruited from outpatient clinics, inpatient acute care wards, and a nursing home care center, Langmore and colleagues28 identified dependency upon others for feeding, and not necessarily dysphagia alone, as the dominant risk factor for aspiration pneumonia, with an OR of 19.98 in a logistic regression model that excluded tube-fed patients. As these findings indicate, healthcare providers need to carefully assess the risks and benefits of both tube feedings and assisted oral feedings for their patients. In either case, the risks of aspiration can be reduced by employing various safety strategies (Table 1).26
Poor Oral Hygiene
Dental care is often neglected in LTC residents. In one cross-sectional study of 260 LTC patients aged 60 years and older (mean age, 83 years), 70% had not seen a dentist in more than 5 years.29 Of those wearing dentures, 82% were unable to clean their dentures themselves. Only 19% of patients who wore dentures were described as having good denture hygiene, while 37% were described as having poor denture hygiene. Of dentate patients, 75% were reported to be unable to clean their own teeth, but none received regular assistance.29 Yet poor dental hygiene has a significant impact on overall health, including risk for aspiration and associated pneumonia. Poorly fitting dentures and edentulism can lead to chewing and swallowing difficulties, increasing the risk of aspiration, and poor oral hygiene and periodontal disease may enable respiratory pathogens to proliferate in the oropharyngeal region, which, if aspirated, can lead to pneumonia.30
One study randomly assigned 417 elderly patients across 11 nursing homes in Japan to receive standard oral care versus no oral care.31 The standard oral care group was provided daily toothbrushing after meals by trained nurses and also saw dentists/hygienists every week for the duration of the study. Patients randomly assigned to standard oral care showed significant reduction in pneumonia, febrile days, and death compared with the no oral care group. In contrast, in the no-care group the RR was 2.45 for fever and 1.67 for pneumonia.31
Evidence of an association between poor dental hygiene and aspiration pneumonia was also demonstrated in a systematic review of studies including patients with pneumonia or chronic obstructive pulmonary disease and periodontal disease, as measured by assessing level of gingival inflammation, probing depth, clinical attachment, and/or radiographic bone loss or oral hygiene indices.30 The study authors found the OR for pneumonia to be 1.2 for tooth decay, 2.8 for dependency on others for oral care, and 4.2 for the presence of dental plaque.30 There was an overall RR of 9.6 for pneumonia if dental plaques were found to be colonized.
Another study of 697 adults older than 80 years found that those with 10 or more teeth containing a periodontal pocket had 3.9-times the adjusted mortality risk due to pneumonia than those without pocketing.32 Periodontal pockets are associated with severe gum disease and are thought to be a potent source of infection.32 As these data collectively show, a comprehensive oral hygiene program is crucial in preventing pneumonia in nursing home residents. Successful implementation of such programs requires addressing barriers to oral care.
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Addressing Barriers to Oral Care
Several key barriers that prevent oral care from being provided to residents include mouth care–resistant behaviors by residents, lack of staff education on providing oral care to LTC residents, and lack of accountability for providing oral care to LTC residents.33 To overcome these barriers, a multidisciplinary approach that includes dentists, hygienists, and certified nursing assistants (CNAs) is essential.
Managing mouth care–resistant behaviors. Residents may display a variety of mouth care–resistant behaviors, including refusing to open their mouths, biting toothbrushes or fingers inserted in or near the oral cavity, and kicking or hitting the oral care provider. These behaviors are more common among residents with dementia and other cognitive impairments, with one study reporting an eightfold increase in mouth care–resistant behaviors when dementia has become severe.34 Yet even when dementia is present, a key strategy that has been proposed to reduce the risk of precipitating these behaviors is to properly communicate with residents before attempting oral care.35 When communicating with residents, elderspeak should be avoided. Elderspeak is a speech style that resembles “baby talk,” often using fragmented sentences, simple vocabulary, repetition, and a higher pitch tone. It is perceived as patronizing and underestimates the abilities of the older person.35
Other strategies that can prevent or reduce mouth care–resistant behaviors include positioning oneself at or below eye level with the resident; maintaining a friendly disposition; using gestures and pantomime, as needed; ensuring the resident is as upright as possible to prevent aspiration and discomfort; and encouraging the resident to perform his or her own oral care as much as possible.35 A resident with dementia, for instance, might instinctively start brushing his or her own teeth if handed a prepared toothbrush, despite not being able to name what a toothbrush is, or may be successfully guided through the task, with the care provider gently placing his or her hands over the resident’s hands and guiding them along.35
Educating LTC staff about oral care and addressing accountability. Nursing home staff often receive little education on how to provide oral care to their residents or on the importance of providing such care. A questionnaire distributed to 169 caregivers in 13 nursing homes revealed that the majority had received no education on how to provide oral care to their residents, and these individuals did not accept responsibility for oral care, deferring the responsibility to the residents’ regular dentist.36 Furthermore, only 33% of the surveyed physicians indicated that they carried out a systematic examination of their residents’ oral cavities.36
Studies have shown that education of nursing home staff can significantly improve oral care among nursing home residents.37,38 One study reported a reduction in gingival bleeding scores (P<.001) and in plaque scores (P<.001) following a repeated education program for nursing home staff.37 In another study, the residents who received oral care from caregivers who had received 6 weeks of oral care education had a lower plaque index (P=.004) and less halitosis (P=.002) than residents who received usual oral care from a control group of caregivers who had not been educated.38 In addition, scores on caregivers’ knowledge (P<.001), behavior (P<.001), and attitudes (P<.001) for oral care were higher in the educated group than the control group, and the investigators concluded that “oral care education programs for caregivers are effective in improving the oral hygiene of elderly residents in nursing homes through enhancement of caregivers’ knowledge, attitude, and behavioral change.”38
When implementing an oral care program and educating staff on the importance of oral care, it is essential for healthcare providers to understand that all LTC residents require regular oral care, including those on feeding tubes. In fact, tube feeding in elderly persons has been associated with significant pathogenic colonization of the mouth, with these individuals having even more colonization than those receiving oral feedings, placing them at particularly high risk of aspiration pneumonia.26
Numerous strategies have been used to train nursing home staff on oral care. One model specifically trained one CNA to be the facility’s oral health specialist, with this individual becoming responsible for the daily oral hygiene of the residents and having minimal other care responsibilities.33 This specialist then carried out a standardized care plan, which was developed by a dental team and informed by a literature review of best practices in oral hygiene, taking into account barriers such as mouth care–resistant behaviors. The toolkit for this model is available at www.uky.edu/NursingHomeOralHealth.
AMDA – The Society for Post-Acute and Long-Term Care Medicine (formerly the American Medical Directors Association) also offers a variety of oral health resources to healthcare providers in LTC settings via its Oral Health in the Long Term Care Information Series Tool Kit. These resources, which can be customized and used to train staff, are available at www.amda.com/tools/clinical/oralhealth.cfm.
Medication and Polypharmacy
Approximately 95% of older persons take at least one medication.39 In contrast, an estimated 46% of LTC residents take more than nine medications,40 significantly increasing their risk of a variety of complications. Therefore, it is important for healthcare providers to consider the side effects of some of the commonly prescribed medications in this population and their potential to contribute to aspiration pneumonia. At the same time, several medications may protect against aspiration pneumonia, which is another important consideration. Medications that increase and reduce risk are reviewed in the sections that follow.
Medications That Increase Risk
Medications may increase the risk of aspiration pneumonia through numerous mechanisms. For example, some may increase the risk of bacterial overgrowth (eg, proton pump inhibitors [PPIs], H2 blockers), others may impair the ability to swallow (eg, neuroleptics, sedatives, hypnotics, antiepileptics, skeletal muscle relaxants), and yet others may lead to dry mouth and make swallowing more difficult (eg, diuretics, antiemetics). Outlining every medication that has the propensity to affect swallowing and aspiration is well beyond the scope of this article, but what follows are the findings associated with a few of the aforementioned medications. A more comprehensive list of medication classes that can contribute to dysphagia are listed in Table 2.41
Proton pump inhibitors and H2 blockers. A Norwegian retrospective study linked recent treatment with a PPI (<30 days) with an increased risk of developing CAP (OR, 3.1; 95% CI, 1.4-7.1).42 Laheij and associates43 conducted a retrospective study of development of CAP and use of either a PPI or an H2 blocker. The RR of CAP in patients using a PPI was 1.89 versus nonusers, while H2 blockers carried an RR of 1.63 versus nonusers (95% CI, 1.36-2.62). The incidence rate of developing pneumonia while on either medication was four times that of nonusers.43
Neuroleptics, sedatives, and hypnotics. Neuroleptic medications are often prescribed to patients with dementia. Although dementia alone is a known risk factor for aspiration, with one study citing an OR of 6.75 for aspiration among patients with dementia,44 adding a neuroleptic to manage behavior and mood disorders is not without risks. Use of neuroleptics and benzodiazepines, the latter of which has sedative and hypnotic properties, in a subset of patients with Alzheimer’s disease was associated with an OR of 3.1 for development of aspiration pneumonia.44 Even in patients without dementia, neuroleptics can increase the risk of aspiration pneumonia, as these medications may cause extrapyramidal symptoms that can affect swallowing.
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Potentially Protective Medications
Some medications may be protective for certain patients. Dopamine levels and swallowing function share a direct relationship, as low dopamine levels can lead to motor impairments of the muscles in the throat, leading to swallowing difficulties and an increased risk for aspiration pneumonia. Patients who have had basal ganglia infarctions often have delayed triggering of the swallowing reflex, which has been associated with an impairment of dopamine metabolism in their basal ganglia. One study investigating whether the dopamine-inducing drug levodopa, which is typically used to treat Parkinson’s disease, improved the swallowing reflex in patients with basal ganglia infarctions and a history of aspiration pneumonia found that an infusion of levodopa in these patients led to a statistically significant improvement in swallowing reflex time.45 This finding implies that use of levodopa in this population may reduce aspiration risk, but further studies are needed.
Although angiotensin-converting enzyme (ACE) inhibitors can contribute to dysphagia by causing dry mouth (Table 2), they have also emerged as possibly playing a role in reducing the incidence of aspiration pneumonia. In a large retrospective study of patients poststroke who were subsequently hospitalized for pneumonia, use of an ACE inhibitor reduced pneumonia risk by 30% (OR, 0.70; 95% CI, 0.68-0.87), and there was a significant dose-response relationship (P < .01).46 This study considered both the enhancement of the cough reflex and a reduction in proinflammatory cytokine activity to contribute to reduced aspiration rates.46 Similarly, a meta-analysis of several studies showed an overall RR of 0.61 (95% CI, 0.51-0.75; P<.001) for pneumonia in patients prescribed ACE inhibitors versus those not receiving these agents.47 The findings were greater in the Asian population with an RR of 0.42 (95% CI, 0.32-0.56; P<.001), implying that perhaps there is a greater effect seen in this demographic.47
Aspiration pneumonia is a major concern in the elderly population, especially those living in LTC settings, as it is associated with a high risk of morbidity and mortality, even following successful treatment. Therefore, prevention of aspiration is essential in this population. Although aspiration pneumonia has a multifactorial etiology, there are three major risk factors that can significantly lower risk when properly addressed: dysphagia, dental hygiene, and concomitant medication use. Comprehensive interventions for these risk factors is best achieved using a multidisciplinary approach that incorporates the efforts of healthcare professionals within nursing, nutrition, speech-language pathology, dentistry, pharmacy, and medical concentrations.
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Disclosures: The authors report no relevant financial relationships.
Address correspondence to: John Liantonio, MD, 1015 Walnut Street, Suite 401, Philadelphia, PA 19107; firstname.lastname@example.org