Module One: Dementia – Overview and Impact...dementia may change the manner by which your resident...

Hand-Feeding Techniques for Nursing Facility Residents

Module One: Dementia – Overview and Impact

Resource Manual for CNA’s

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Hand-feeding Techniques for Nursing Facility Residents March 2018

HAND-FEEDING TECHNIQUES FOR NURSING FACILITY RESIDENTS WITH

DEMENTIA

Module One: Dementia – Overview and Impact

WHAT this Module will teach me:

In the first module, we will take a look at the ways that a resident with dementia may see and

interpret the world around them. We will examine cognition and how cognitive skills help us to

process all that we see and hear while storing information for later application and use. We will

also explore how cognition may be impaired in the resident with dementia. We will look at why

dementia causes the behaviors that you may often see exhibited by your residents and how

dementia may change the manner by which your resident communicates with you. Dementia

may also change how the resident sees, hears, tastes, and smells, and even how your resident

eats. An overview of the common responses, including fight, flight and fright will be provided

because these responses may explain many of the behaviors demonstrated by your residents. .

At the end of this module, we will look at a new way to approach how you care for your

residents and how you can use the C3P problem solving framework to address behaviors that are

challenging.

Objectives: At the end of the module, the CNA will be able to:

1. Discuss how dementia causes brain changes that impact the resident’s ability to think,

reason, and remember.

2. Discuss the term dementia and the term Alzheimer’s and why they are sometimes used

interchangeably.

3. Identifies ways in which the sensory processes (sight, hearing, smell, taste and touch) are

affected by dementia.

4. Define how a resident with dementia may respond when a fight, flight or fright response

is stimulated.

5. Give an example of how the C3P problem solving method can be used when caring for a

resident with dementia.

Every day at home, work, and in life, we come into contact with many sources of information.

This information is provided to us through our senses…….what we see, hear, taste, and smell.

Our senses do not work alone. Once the “sense” picks up a signal (stimuli), it has to send it to

the brain. The brain then has many jobs to do. The brain will receive the information, break it

down and make sense of it, store it into our memory banks, and give it back to us when we need

it. If our brain is able to handle all of this in a useful way, we have the tools we need to do a

good job at home, work, school and in life. This ability comes from the brain’s “cognitive

skills”.

The brain’s cognitive skills include long- and short-term memory. This is what we learned or

experienced either a long time ago……..or what we learned just recently. Cognitive skills also

include auditory processing and visual processing……..what we hear and what we see.

Importantly, our brain controls logic & reasoning. These help us to make sense of the world we

live in. Working together, all of these cognitive skills play important roles in processing new

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information. That means if even one of these skills is weak, no matter what kind of information

is coming your way, being able to hold on to the information, process the information or

understand the information will be damaged.

Dementia

Dementia is an umbrella term for many types of memory loss diseases. The most common is

Alzheimer’s disease and is the cause of 60% of the dementias. The two terms, Alzheimer’s and

dementia, are often used interchangeably. Dementia causes a deterioration of the resident’s

abilities, beyond the scope of “normal”. A resident will have problem with memory and with

judgement. The resident will not be able to remember simple directions for even a few minutes

and cannot make good decisions or know what is safe and what is dangerous. The resident’s

ability to communicate with you suffers. Because of this, the resident cannot tell you, with

words, what he/she needs or wants nor can they understand the words you use when you talk

with them. Because of lost communication skills, the resident has problems talking with you,

their family or with other people and becomes more and more isolated to their world.

Remember…….these declines may be gradual but they are progressive and do not get better. As

the disease gets worse, the resident will become unable to communicate because they can’t use

words anymore. Can you imagine how this must feel to the resident? Sometimes the resident

will become frightened because they don’t understand what you are trying to do. Some may be

combative due to high levels of frustration (fight). Some may try to get away from you (flight).

The short term memory loss means they become repetitive and repeat the same things over and

over even if you have just given them an answer. As the disease progresses, the declines in the

brain become more severe.

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Late Stages of Dementia:

The brain loses the ability to recognize. This is why residents with dementia often do not

recognize people, places, objects, and even their own bodily sensations.

The brain loses the ability to perform an action that should have been familiar. For example, the

resident would not know how to ride a bicycle any longer (nor would they recognize the object

as a bicycle).

This lost ability generally impacts more complex actions first but as the disease progresses,

residents with dementia begin to lose the ability to perform even the most simple task…….this

includes eating! The resident will not understand the need to eat, what to eat, or even how to

eat. They cannot remember how to use a fork, or spoon, or glass, etc.

This is how the brain with Alzheimer’s (a type of Dementia) looks as compared to

a normal brain:

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Sensory Changes in the Resident with Dementia

Much of life’s pleasures come from our ability to excite our five senses……..sight, hearing,

taste, touch and smell. Individuals with dementia, however, frequently experience damage to the

senses and often have problems understanding what is going on around them.

Communication is the way that we send messages to each other. Messages can be either

conscious or subconscious, and we do not always know we are communicating. We

communicate by talking with each other (verbally), texting each other, sending letters or emails

(visually, requiring the ability to interpret letters to read words), and facial expression, body

positioning and other forms. As the disease progresses and memory declines, individuals may

forget even the last sentence spoken. This impairs the individual’s ability to maintain a

conversation. The individual has difficulty staying on topic, remembering details, and handling

information received. In time, the individual uses language skills less and less to express

themselves.1

1 American Speech-Language-Hearing Association. Dementia: An Overview. Retrieved from: https://www.asha.org

https://www.asha.org/

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Nonverbal communication is especially important when communicating with a resident with

dementia. Here are some key points to remember when using a nonverbal approach to

communicate with your resident with dementia:2

Facial expressions

The human face is extremely expressive, able to express countless emotions without saying a

word. And unlike some forms of nonverbal communication, facial expressions are universal. The

facial expressions for happiness, sadness, anger, surprise, fear, and disgust are the same across

cultures.

Body movements and posture

Consider how your perceptions of people are affected by the way they sit, walk, stand up, or hold

their head. This type of nonverbal communication includes your posture, bearing, stance, and

subtle movements.

Gestures

Gestures are used frequently throughout our day. We wave, point, beckon, and use our hands

when we’re arguing or speaking animatedly—expressing ourselves with gestures often without

thinking. However, the meaning of gestures can be very different across cultures and regions, so

it’s important to be careful to avoid misinterpretation. When working with residents with

dementia, gestures can often be used with a cue to help convey a message. Gestures can also

communicate affection. Keep in mind, however, that gestures can also be seen as threatening

and should be selected with care.

Eye contact

Eye contact is an especially important type of nonverbal communication. The way you look at

someone can communicate many things, including interest, affection, hostility, or attraction. Eye

contact is also important in maintaining the flow of conversation and for gauging the other

person’s response.

Touch

2 Dementia Today. Improving your nonverbal communication skills. Retrieved from: http://www.dementiatoday.com/improving-your-nonverbal-communication-skills-and-reading-body-language/?doing_wp_cron=1519631717.4653770923614501953125

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We communicate a great deal through touch. Touch is often used with one of the other forms of

non-verbal communication and should express concern and affection for the resident with

dementia.

Voice

It’s not just what you say, it’s how you say it. When we speak, other people “read” our voices in

addition to listening to our words. Things they pay attention to include your timing and pace,

how loud you speak, your tone and inflection, and sounds that convey understanding, such as

“ahh” and “uh-huh.” Think about how someone’s tone of voice, for example, can indicate

sarcasm, anger, affection, or confidence. Residents with dementia may not understand what you

are saying but they can “feel” how your voice is saying it.

Smell is created from specialized sensory cells (olfactory sensory neurons). These cells are

located in a small area high inside the nose. When microscopic molecules, produced by

substances around us (the smell of pumpkin bread cooking or coffee brewing), are released, these

receptors are excited and send messages to the brain. The brain then identifies the smell.

Dementia causes residents to not be able to smell very well. This is why they may not be aware

of their own body odors or when they have had an elimination accident. The loss of smell may

also be a factor in the loss of appetite in residents with dementia.

Taste is closely connected to the sense of smell. When an individual chews, drinks, or digests,

molecules are released that excite sensory cells located in the mouth and throat (gustatory cells).

When the gustatory cells are excited, messages are sent to the brain and the brain identifies the

taste qualities (sweet, sour, bitter, salty, and umami, or savory). In addition to taste, the taste

sensors help us to detect other qualities such as heat, cold, and texture. If a resident spits food

out, it may be because they don’t like the texture, temperature, or taste of food. The taste for

sweets lasts longer than the other taste qualities which is why many of your residents prefer to

eat sweets.

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Vision is affected in people with several different forms of dementia including those individuals

with Alzheimer’s. These vision abnormalities occur because of the significant changes in how

the brain receives and understands the information that it sees. Vision may be impacted in

several different ways:

The person has no depth perception. This makes it hard for them to step off the curb, for

example. They cannot tell how much space exists between the curb and the pavement.

Steps or stairs would be equally difficult to manage.

Peripheral vision is reduced. Peripheral vision is side vision; what is seen on the side by

the eye when looking straight ahead. This causes the person to have “tunnel vision”. The

person can only see what is in front of them at eye level. That is why it is important for

you to talk with them at eye level but standing off to the side so that you don’t block

all of their vision.

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What you see with Tunnel Vision

The eye loses the ability to contrast between colors. If the colors are nearly the same, the

person cannot see them separately. If a brown blanket is on a brown chair, the person

will not see the blanket. If mashed potatoes are on a white plate on a white tablecloth, the

plate and/or the mashed potato cannot be seen.

People with dementia require good lighting in order to see. Aging eyes already have

difficulty seeing in poor lighting. Dementia makes it worse.

Glare and shadows can be confusing to the person with dementia.

People with dementia have trouble understanding and seeing correctly an environment

that is cluttered or “busy”. Too much “stuff” is distracting to the resident. This is why

keeping their eating area simple and tidy is helpful. Contrasting colors, such as a dark

placement with a white plate, is best for eating/feeding.

Hearing loss can impair an individual’s ability to communicate. This makes it hard for the

person with dementia to have social interactions with others and may cause the person to isolate

themselves.

Touch can be affected by dementia as the resident will not be able to localize pain. This means

that if their knees hurts, they will hurt all over, not just in their knee. The resident may have

either an increase or a decrease in the way in which they respond to pain and may not be able to

tell you what the problem is due to the loss of their ability to use and understand words. They

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will communicate they are in pain with behaviors such as facial grimacing, or not moving if the

pain is caused with movement.

Resident Responses: Fight, Flight, Fright

Whenever we are faced with danger, we will respond with fight, flight or fright. You will either

be scared (fright), or take flight and run away from the danger, or you will stay to defend

yourself (fight). Think about a situation in your own experience where you were frightened.

What did you do? When we respond to a stimulus by fight, flight or fright, a hormone called

Adrenaline is released to help us overcome the danger. Why is this important to you?

Understanding the response of fight, flight, fright is in the part of the brain that is preserved in

dementia so a residents emotions stay the same even when they have a progressive loss of

abilities. This means they can still fell anxious or feel agitated which can lead to acting out

behaviors. If this response is expressed as “fight”, the resident may begin yelling, resisting care,

and/or attempting to hit others/caregivers. If the response is “flight”, the resident may try to get

away from you or the situation. If they feel “fright”, the behaviors displayed include withdrawal,

apathy or refusals. Their brain is telling them to respond because it senses a threat! This

response is expressed as a behavior with fight being the most common behavior expressed.

Unpredictability is also a major cause of stress in the person with dementia. Remember, the

resident with dementia cannot always view their environment in a logical way. A change, even a

very small one, can be very stressful and can stimulate a response for fight, flight or fright. This

results in the resident acting out.

TO REVIEW: Dementia is a progressive disorder so the symptoms get worse over time. The

person’s abilities to function…..to even perform simple tasks like brushing their hair or feeding

themselves, is lost. This may cause the person to feel frustrated, anxious and even agitated. The

person can no longer tell if something is really threatening them or not. Small and unimportant

things can cause stress and stress will release ADRENALINE that causes the person to react.

This can lead to behaviors that are hard to understand and hard to control.

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C3P Model: Problem Solving

Amella and Batchelor-Aselage (2014), emphasized the importance of recognizing that behavior,

in the resident with dementia, is a form of communication and/or a form of control and is derived

from an unmet need. To address this, a framework was developed to promote an approach that

can be used by all members of the care team when providing care for the Resident with

dementia. This means that all of the care team is working off the same page.

The framework is called C3P: change the person, change the people, and/or change the

place. As outlined by the authors, Amella and Batchelor-Aselage, C3P includes:3

Change the Person:

The nurse will need to do an assessment on the Resident to see if there are other problems that

may be causing the Resident to have abnormal behaviors. The nurse will look at weight records

to see if the Resident has lost weight. Lab values will be reviewed to determine if the Resident is

receiving the right nutrition. The nurse will also need to gather information about the Resident’s

eating patterns……how much do they eat, how much help do they require, how does the

Resident behave during meals. You will be asked to provide much of the Resident information

since you provide so much of the care. Even small details can be important. You can help by

giving the nurse important details about a resident’s ability to self-feed and about any problems

the resident has with eating and/or swallowing.

Change the People:

Addressing feeding difficulties requires a person-centered care approach. Batchelor-Murphy and

Crowgey note that successful completion of a meal depends on the caregiver who is assisting or

feeding the resident and the interpersonal process that is used to interact with the resident.4

Individualizing the resident’s meal time to meet his own unique needs also increases the chances

the meal will be successful. You will be the person who knows most about how to best feed a

particular resident. Share that information! If everyone on the care team is helping the Resident

in the same way, the Resident is more likely to be able to maintain his/her nutrition needs.5

Change the Place:

An environment that supports eating is critical to the success of resident feeding. The authors,

Amella and Batchelor-Aselage, suggest that even small changes to the eating environment can be

conducive to an improved intake of food. It is also suggested that contrasting colors be used for

tableware and tablecloth and that eating items be placed in the same place on a daily basis.

Being sure the resident is in a proper position for eating will also enhance the process as will

ensuring the resident is in a small group rather than a large setting. Smaller environments often

3 Amella, E. & Batchelor-Aselage (2014). Facilitating ADLs by caregivers of persons with dementia: The C3P Model. Occupational Therapy

Health Care. 28(1), 51-61. 4 Batchelor-Murphy, M. & Crowgey, S. (2016). Mealtime difficulties in dementia. In Boltz, M., Capezuti, E., Fulmer, T., and Zwicker, D. (Eds)

(2016). Evidence-based geriatric nursing protocols for best practice, 5th ed. New York: Springer. 5 Amella, E. & Batchelor-Aselage (2014). Facilitating ADLs by caregivers of persons with dementia: The C3P Model. Occupational Therapy

Health Care. 28(1), 51-61.

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work better for the resident with dementia as distractions can be better controlled. Music has

also been found to be conducive to the promotion of a successful eating/feeding session6

Mechanical Processes of Swallowing

There are 6 things that happen when we swallow during eating: These are mechanical

processes.7

1. Food Transport – food is carried into the mouth. The tongue moves the food toward the

back lower teeth for chewing (food processing).

6 Batchelor-Murphy, M. & Crowgey, S. (2016). Mealtime difficulties in dementia. In Boltz, M., Capezuti, E., Fulmer, T., and Zwicker, D. (Eds)

(2016). Evidence-based geriatric nursing protocols for best practice, 5th ed. New York: Springer 7 Matsuo, K., & Palmer, J. (2008). Anatomy and physiology of feeding and swallowing – Normal and abnormal. Physical Medicine

Rehabilitation Clinics of North America, 19(4), 691-707.

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2. Food Processing – Food is reduced in size by chewing and softened by salivation.

Chewing occurs until the food reaches a consistency that is ready to be swallowed.

Chewing requires movement of the tongue, cheek, soft palate and hyoid bone.

3. For Liquid Processing: liquid taken into mouth. The tongue and soft palate are used to

help seal the oral cavity and prevent the liquid from escaping into the oropharynx before

the swallow occurs. An inadequate seal can cause liquid to enter the pharynx. This

potential increases with aging.

4. Transport: Once the food is chewed to the appropriate consistency, it is moved back onto

the tongue. The back of the tongue drops down to open the back of the oral cavity. As

this process occurs, the liquid is squeezed into the pharynx. The same process occurs

with liquids. This process is primarily driven by the tongue, not gravity.

5. Pharyngeal: The pharyngeal swallow is a rapid action and only takes about one second.

During this phase, the food bolus is propelled through the pharynx and the upper

esophageal sphincter into the esophagus. Several airway protective mechanisms take

place during this phase to prevent aspiration from occurring.

6. Esophageal: The lower esophageal sphincter is normally at tension in order to prevent

food regurgitating into the esophagus from the stomach. The sphincter relaxes during a

swallow and this allows the bolus of food to pass into the stomach. When the good enters

the esophagus through the upper esophageal sphincter, active peristalsis moves the food

bolus forward into the stomach through the lower esophageal sphincter.

Use the diagram above to follow the path of food as it enters

the mouth until it reaches the stomach.

Eating/Feeding Behaviors in Residents with Dementia

Problems with eating are commonly present in residents with dementia. These problems can

include:8

an increase or decrease in the amount of food eaten

a change in how often the resident eats

inability to properly use eating utensils such as the fork and knife

playing with food

a change in the selection of foods with sweet foods being most commonly selected if

given a choice

8 Cipriani, G., Carlesi, C., Lucetti, C., Danti, S. & Nuti, A. (2016). Eating behaviors and dietary changes in patients with dementia. American

Journal of Alzheimer’s Disease and Other Dementias, 31(8), 706-716.

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eating items with no food/nutrition value

inability to recognize food as food

inability to execute the plan to ingest food (what to transport to the mouth, what quantity,

what means, etc.)

Since there are different types of dementia, there are many different symptoms of eating

problems that the person with Dementia may have. For example, weight loss is common in

persons who have Alzheimer’s Dementia.

Other behaviors that you might see include:

refusal to eat

indifference to food

inability to handle the food bolus once it is in the mouth

aspiration during swallowing

overeating

bulimia

cravings for sweets

weight gain

obsession with specific foods

snatching food from other sources,

trying to eat items that are not designed to be eaten (i.e. plastic fruit, flowers, etc.)

difficulty swallowing food or liquid

problems with handling food on the plate (Does not understand how to use fork, spoon,

knife, cannot move food from plate to fork/spoon, etc.)

transporting food to the mouth

difficulty swallowing

Hoarding of food in the mouth is common

turning away of the head when attempts are made to feed

clamping their mouth shut

pushing away assistance.

development of unusual eating behaviors.9

Assessment of the Resident with Dementia

9 Cipriani, G., Carlesi, C., Lucetti, C., Danti, S. & Nuti, A. (2016). Eating behaviors and dietary changes in patients with dementia. American

Journal of Alzheimer’s Disease and Other Dementias, 31(8), 706-716.

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It will be important that the interdisciplinary care team meet to plan how to address the eating

problems for a resident with Dementia. You may be asked to be on the team. Since you work

very closely with the resident it will be important that you

carefully describe the behaviors you are seeing with this resident

describe ways that you have used to try and address these problems. Which of your

actions worked? Which did not work? What other suggestions would you like to try?

does your resident have any special needs? Special preferences? Rituals that need to be

carried out before eating?

Cultural considerations that need to be incorporated into the plan?

In this module we have learned a lot about Dementia and have identified how changes in the

brain can cause many difficulties for the Resident. We have also talked about why the Dementia

Resident may present with different behaviors and have reviewed a framework that we can use

when working with the Resident. We reviewed the 5 senses and the act of swallowing as it is

controlled by the brain. In our next module, we will look specifically at 3 different approaches

we can use to assist the Resident who needs help with eating.

QUESTIONS

Module One: Dementia – Overview and Impact...dementia may change the manner by which your resident...

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