Increasing dependency and disability, with admission into nursing homes frequently accompanies increasing age.1–7 Swallowing problems are not uncommon in older people. Studies suggest that the prevalence, within Scandinavian communities, is between 16 and 45%.8,9 Between 55–59%10 of nursing home residents within the US report to have swallowing problems and 74% have eating problems.
A postal survey of nursing and residential homes in two London boroughs reported a prevalence of dysphagia in 31% of residents.11 Of those 48% of residents required a modified diet, 28% were coughing or choking at the meal table, 11% were reported as having an absent or slow swallow, 50% were noted to be drooling and 43% were reported to have oral residue after swallowing.10
Eating and swallowing problems (and any resultant complications) are associated with an increased morbidity and mortality, including an increased risk of pressure ulcers, chest infection in part due to impaired immunity secondary to nutritional condition, hospital admission or death. Malnutrition at the time of admission to nursing homes is as high as 40%, and this will only get worse if eating and swallowing problems go unrecognised and a management plan is not instituted.12,13
There has been increasing recognition of the special needs of this age group, their vulnerability to variances in care and inadequacies in providing appropriate care for older people with long term conditions and high care/nursing needs. Recent years have seen many documents published by both the British Geriatrics Society and the Department of Health about the care of people in old age and in care homes,7 with the promotion of dignity champions and tool kits for care and dignity14,15 yet care remains variable, with people frequently suffering delays in care, denied care or are charged for free care.
Given the increased morbidity and mortality associated with dysphagia, especially when associated with increased dependency, it is important to ensure that nursing homes are supported by the NHS in providing integrated holistic care to these older people.
This study has investigated the access that older people resident in nursing homes have to NHS provided medical and therapy support.
Nursing homes (as defined by Social Services) in four strategic health regions (South East Coast, West Midlands, East of England and South West) were identified. A questionnaire (Box 1) was posted to the matron/manager of each nursing home enquiring about the number of residents, reasons for admission to the nursing home, prevalence of eating and swallowing problems and access to medical and therapy support to assist them in developing and instituting a coherent management plan for people with swallowing difficulties.
The questionnaire was based on one previously used in a similar study.10 The questionnaire was accompanied by a prepaid envelope to encourage the return of the questionnaires.
No patient identifiable data was requested and advice was sought from the local ethics committee (South East Coast) as to the requirement for patient consent.
Four hundred and seventy four nursing homes across the four regions were sent the questionnaire, 209 (44.1%) responded (Box 1).
The majority of residents were female (72.5%), general frailty (64.1%) was the most frequent reason for moving into the nursing homes, with dementia care (32.4%) being the next most frequent.
Dementia (24.9%) and stroke (20.7%) were the most frequently reported clinical diagnoses, with mental health (14.3%) and neuro-degenerative disease (8.1%) less frequent primary diagnosis.
Many nursing home residents frequently had more than one problem resulting in difficulty eating solids and liquids. Those most frequently reported were posture and movement, food having to be cut up and the inability to feed themselves.
Swallowing problems were less frequently reported, 36.9% of residents had a modified diet, 10% took a very long time to eat and 200 (3.1%) were fed enterally. 41 out of 207 responses reported no service available or no knowledge of speech and language therapy support. Only two out of 207 responses suggested an immediate response.
Support from hospital medical staff was poor with 56 out of 207 not having the support of hospital specialists and only one receiving immediate support and a further five support in one week (Figure 1).
For non urgent support the response times were varied: access to occupational therapy was 29.2% and medical support was 39.9% within four weeks of referral, contrastingly speech and language therapy was very responsive at 73.8% within four weeks. There was no availability to nutritional support for 33.3%, medical speciality for 23.6% and occupational therapy for 24.9%.
Over the last 20 years the displacement in the long-term care of older people from hospital to the community has resulted in an increase in the level of dependency of nursing home residents. With the changing demographics of the population there is likely to be an increase in the number of older people resident in nursing homes, and increasing numbers of these people will have neurological diagnoses including dementia.
Eating is not only a physiological and social function but frequently brings pleasure to people. The provision of nutrition orally is not only a human right and remains part of basic medical and nursing care but is a source of enjoyment and may be the highlight of the day for some people. Therefore, wherever possible carers need to be able to support the intake of food and drink by mouth even when there is a risk of aspiration, and/or people are coming towards the end of their life.16 The support from dietitians and speech and language therapists is important when people are enterally fed to ensure that this remains the appropriate route for nutrition and to maintain the patency of the gastrostomy.
The results documented here, confirm that a significant proportion of people in nursing homes have been diagnosed with degenerative neurological disease or brain injury. Many of these will have or may develop difficulties with eating and swallowing either as part of the progression of their medical condition (dementia, Parkinson’s disease or multiple sclerosis) or when they become unwell with an intercurrent illness. Those with dysphagia are often very dependent, with complex needs, and they may be unable to clear pharyngeal secretions or to keep the mouth clean resulting in more than doubling of the prevalence of aspiration of gram negative infections,5,6,11,12 which may result in prolonged hospital admission, functional decline and high mortality (41%–50%).17
It has long been recognised by the profession, and increasingly so by the media in recent times, that the care of older people residing in nursing homes is frequently not of an acceptable standard. Residents of nursing homes are some of the most vulnerable and frail in society, but they remain the most neglected with the care being provided of variable quality frequently due to inadequate staff training and staffing levels and high staff turnover. Public services are not without fault, with many documented instances of reluctance by local authorities and the NHS to support nursing home staff and provide a service to the residents.6,13
Staff in nursing homes are not trained in the assessment and management of swallowing disorders. As a consequence there will be times when there are legitimate concerns regarding the safety of a resident’s ability to swallow safely and many nursing home care staff do not feel comfortable with providing food orally when there is a possibility that the swallow is unsafe and the risk of aspiration is present. It is therefore essential that those NHS staff that are experienced in assessing and managing swallowing problems support nursing home staff with training and advice. This will instil confidence in nursing home staff and contribute to keeping people out of hospital and improving end of life care.16
The conclusions that can be drawn from the study are limited as it relies on reported diagnoses and comorbidities of residents in nursing homes, which may have resulted in an under or over reporting of the prevalence of morbidities. The response times of community-based staff has not been correlated with contractual requirements as this was not the basis of the study. The division time of request and time of attendance to assess the resident was arbitrarily split at four weeks.
Comments provided by staff from the NHS that responded to the survey make depressing reading and include “we have to fight for services for our clients” and “no speech and language therapy is available”.
If the care of older people is to be improved, particularly at a time when there is pressure to provide an increasing level of support to people in the community,18 then the NHS has to recognise that it has a responsibility towards all the population and cannot exclude people purely on age or where they reside. Consequently to meet these aspirations, it is incumbent on the NHS to provide the training and support to the staff in the care homes providing care to these patients, access to specialist teams (speech and language therapists, dietitians, physiotherapists and occupational therapists) in a timely manner is essential.
These results and comments support the conclusions of “A Quest for Quality in Care Homes” published in 2011.6
This study was funded by an unrestricted education grant from BUPA.
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