Caregiver: Why Is This Person Coughing Whenever I Feed Them?

 Caregiver: "Why Is This Person Coughing Whenever I Feed Them?"

Souce: Daily Caring

What a serious question! It is a common question all caregivers ask themselves if they are directly feeding a loved one or a resident at their facility. 

Imagine this, you are sitting with your mother with Dementia, a son with a developmental disability, or a resident with dysphagia after a stroke. Just getting them to the table where you have their food set up was a tiring chore. Then, you dip your spoon into their appropriate food texture and give them a bite. 

All of the sudden, they cough once. Then twice. You wait until they say something again, like, "What is this?" You say it's peas and carrots. "No, I don't like peas and carrots". "Well, do you want your mashed potatoes instead?" They agree and you give them a bite of that. A few minutes later, they began coughing again, but this time they cough so much their face turns red. Your heart sank and you begin thinking about your setup.

"Did I give them too big of a bite?"

"Crap, if they cannot handle this, then what? Should they just not eat and have a G-Tube?"

"I was watching them, why is this happening??"

"I saw them swallow! I'm doing everything the therapist told me to do. Why are they coughing???"

It is tough watching someone you care for suffer with something as basic as swallowing. Eating is considered a basic activity of daily living, so when that ability becomes impaired, it can be devastating. 

Source: verywellhealth

When someone has trouble swallowing their food, it is called dysphagia (definition: the impaired transfer of nutrition/hydration from the lips to the stomach)1. One of the most common signs of dysphagia is coughing, but other signs are associated with it too:

• Loss or change in appetite
• Coughing during or after eating/drinking
• Face reddens or blanches during or after eating
• Gasping for breath
• Producing a gargly or raspy voice, like they need to clear their throat
• Reflux or vomiting

Scary signs to see while feeding someone. So what is the problem?

Source: Anatomy Drawing Diagram

A swallowing problem can happen at any of the four phases of swallowing. If they have trouble chewing their food at the oral preparatory phase, then the food pieces may be too big for them to safely swallow. If the hypoglossal nerve is impaired, then the tongue may have difficulty moving the food bolus to the back of the mouth during the oral transport phase. Food may accidentally enter through the vocal cords in the pharyngeal phase. This is a common problem that increases the risk of food entering their trachea and go down to their lungs (aspiration). Once that happens, then they are at a higher risk of aspiration pneumonia, which can cause serious complications to their health. If the problem lies at the esophageal phase, it could lead to gastroesophageal reflux disease (GERD). Impairments are typically determined by a certified physician, nurse, speech therapist, or occupational therapist, depending on where the problem lies.

Knowing the problem is half the battle. Now what can we do to prevent them from aspirating? What can we do to help them stop coughing?

Source: Pocket Dentistry

First, look at their posture; the way they sit is important. Normal alignment makes it easier for food to go down the esophagus and into the stomach 2. If they lean to much on one side or another, then it may change the pressure inside that person's gastrointestinal system (GI system) and make it easier for the stomach contents to move back up the esophagus and now towards the small intestines. Normal alignment typically means sitting upright, with knees bent, and chin is perpendicular to the floor (down when eating/drinking). Sometimes, adding postural straps, harnesses, or a different seat makes a huge difference on someone's posture and improves their ability to swallow.

Second, we must look at how we are giving the food. The standard compensatory feeding methods therapists teach caregivers are:

• Giving smaller bites of food
• Alternate bites of food with sips of liquids, especially if the food texture is dry
• Asking the person to do two swallows for every bite of food/sip of liquid (i.e. double swallow)
• Slower pace of feeding (sometimes as slow as one bite ever 10-15 sec)
• Checking the food texture or liquid consistency
• Reduce the amount of socializing so the person eating are less likely to talk and swallow at the same time.
• Modifying the environment to be quieter with less distractions

If you are a caregiver, you probably know that these simple measures can be extremely hard if not impossible to always achieve. Your father is a chatter box and wants to talk constantly. Sometimes the food texture doesn't look right, but to re-make it would take longer than you would like to spend on feeding someone. At a facility, the dining room can be full of residents and staff talking over each other. If you have a list of people to feed within a couple hours, it is tempting to just shovel as much food as you can into someone's mouth.

All these challenges make it harder to safely feed our loved ones. It can be the reason why we dread going into work on top of the other demands we have to care for others. Yet, we cannot constantly put our loved ones or residents at risks. It is what I continually educate the staff at my facility to remember. Below are a few of my suggestions if you are having trouble following the feeding guidelines given to you:

• Plan ahead. Be realistic about how much time someone needs to eat. If they take an hour to eat, then plan your day to allow them to have an hour to eat. If you have multiple people to feed, consider saving the longest feed for last.
• Use different adaptive dining equipment (if you work at a facility, ask the therapist about different equipment). Use a teaspoon instead of a regular spoon. If they always spill their drink, consider a cup with a small cut-out so the cup can tilt up more without pressing against the nose, or a smaller cup.
• Make sure to look at the resident while they eat. Do you still see food particles inside their mouth after they swallow? Ask them to swallow again before you give them another bite of food. Did they swallow but they Adam apple didn't moved? Food may still be at the back of their throat, so ask them to swallow again. 
• Talk to others about your problem. If you are at home with your loved one, seek out a speech or occupational therapist to help work out specific problems, or see if they qualify for additional speech or occupational therapy to improve their swallowing abilities. If you are at a facility, speak up about the difficulties with feeding the residents and ask the team to work together on how to address larger problems. Can more time be allotted for feeding? Can more help be provided? If someone needs a quiet area to focus on eating, can they eat in the room instead?

Source: Diversified Health Partners, LLC

Feeding someone can be a very intimate and bonding experience for a caregiver and their loved one. It can lead to wonderful memories that last forever for both the feeder and the one eating. Although seeing someone struggle through a meal can be painful for everyone, it does not have to be if we remember to do what is safest and best for our loved one. Safely feeding someone may take time and more effort, but it is worth it if it reduces the risk of aspiration and improves their ability to gain nutrition and hydration. Above all else, we do our best caring for others when we care together.

Sincerely,

Your Humble OT

References:

1. Kendall R. L. A. K. Dysphagia Assessment and Treatment Planning: A Team Approach, 2nd Edition. Plural Publishing Inc.

2. Beckman Oral Motor Protocol. I highly recommend this course to those who want to learn more!

What's the difference between OT and PT or SLP?

 Reader: What's the difference between OT, PT, and SLP?

Short Answer: OT, PT, and SLP provide rehab interventions and treatments to improve physical functioning and overall quality of life, but they approach improvement in different aspects. PT's primary focus is on a person's physical functioning, SLP's focus is on language production, comprehension, and ability to safely consume their nutrition, and OT's focus is on a person's ability to engage in activities most valuable to them.

Physical Therapy (PT) focuses primarily on improving physical function and the body. For example, they use strengthening and stretching exercises to improve range of motion (ROM), activity tolerance, and balance so someone can walk again after injuring their leg. Their perspective on recovery is using a biomechanical approach.

Occupational Therapy (OT) focuses on a person's ability to successfully complete important activities in their life. They are trained to not only provide rehab for physical dysfunction, but also for cognitive impairments and mental health conditions. For example, they may use strengthening and stretching exercises to improve hand and oral muscles, so a person can eat again after a stroke. If that person also has dementia and have trouble remembering how to do self-care tasks (like dressing themselves), the OT will work on cognitive strategies to improve their ability to complete those tasks.

Speech Language Pathology (SLP) focuses on improving a person's ability to produce language/speech, as well as eat and swallow. They are also trained in improving cognition, important for language comprehension and production.

There are many overlaps within all three disciplines, mostly between OT and the others. However, all three disciplines work together to rehabilitate a person with an injury or debilitating condition. In practice, one therapist typically cannot address every single problem area alone. Thus, it is essential for the disciplines to split the work to improve a person's quality of life together.

Source: Mine Sweeper

Case Example:

Carol (70 years old) lives in a nursing home. She has cerebral palsy and diplegia, rendering her unable to walk well. She uses a wheelchair whenever a caregiver cannot assist her to walk. Both arms also do not fully move well and she has trouble dressing herself, especially with small buttons and fasteners. She also has dysphagia (a swallowing disorder) that causes her to cough while she eats, sometimes she even begins choking. She has periodic pneumonia. Carol wants to be as independent as possible and eat desserts. Her problem areas have been identified as impaired balance and endurance, fine motor movements in both hands, and an increased aspiration risk due to impaired oral motor and swallowing muscles.

Carol's PT would most likely work with Carol on her ability to walk and transfer herself between surfaces, such as from her wheelchair to the toilet or shower bench. If Carol is unable to do it safely, the PT would educate the caregiver on the best way to perform the transfer. For walking, they may provide strengthening or balance exercises, as well as recommend what mobility devices would best support Carol to walk (such as a gait trainer or walker).

Her OT would most likely work on improving Carol's ability to dress herself, doing fine motor exercises with Carol until she gains the dexterity to fasten clothing fasteners. They may also work on arm exercises to improve her ability feed herself, since she has trouble moving her arms and hands. If Carol is unable to improve her fine motor skills well enough to do these tasks, then the OT may recommend Carol to use assistive devices (such as a button hook or a spoon with a built-up handle).

Her SLP would most likely be responsible to address her ability to eat safely. They may provide facial exercises to help Carol better chew and swallow her food. If Carol continues to have difficulties, they may recommend Carol to change her food consistency so she can still safely receive proper nutrition (such as chopping cookies or cake into smaller or smoother pieces). 

Want to learn more?

OT vs PT vs SLP: Your Rehab Therapy Team Explained (OT Potential)

Sincerely,

Your Humble OT

The OT Elevator Speech

Reader: What is occupational therapy?

Dear Reader,

The short answer: Occupational therapy (OT) is the profession devoted to improving a person's quality of life by improving their engagement in their most valued and meaningful activities using evidence-based practice, holistic approaches, and person-centered self-efficacy.

Photo Credit: Know Your Meme

    The long answer is not as simple. OT is a medical profession that is often overlooked, underestimated, and underappreciated even within the medical community. When I was first became an OT student, I heard students, physicians, and even teachers say, "Occupational therapy, so you help people find jobs?", "So you can give a good massage", and "Isn't that the same thing as physical therapy (PT)?". Even the profession itself has trouble agreeing on a single definition and one of the first lessons you learn as an OT student is how to explain what you do.

    One reason for the confusion is that OT has one of the broadest scopes of practice. Their scope of practice includes treating physical dysfunction, mental health conditions, sensory processing dysfunction, vision deficits, home or work modifications, wheelchair or other durable medical equipment fitting and modifications . . . The list can go on. Our practice overlaps with other types of therapies, such as PT and speech language pathologists (SLP). This makes it difficult in practice to figure out the role for the OT. In a way, it seems like it is the jack-of-all-trades of therapies.

    OTs also have a broad range of practice settings. They can be found traditionally in hospitals, skilled rehab centers, nursing homes, mental health institutions, schools, and will even visit your home to provide home health therapy. More recently, emerging practice settings include adult day centers, primary care offices, emergency departments in hospitals, and even prison institutions.

Photo credit: Occupational therapy: "Skills for the Living"

    However, their is one simple keyword that is most important to the OT practice: occupation. Occupation, defined as "an activity in which one engages" (Merriam-Webster, 2021). Occupation can be anything, from basic activities of daily living such as bathing or eating to leisure hobbies such as being able to play video games, attending classes, or reading books. OTs skill sets are grounded in task analysis, understanding what it takes to do particular activities and what prevents a specific person from completing them successfully. Achieving the ability to do what is most important in their client's life is the bottom-line goal for all occupational therapists and what drives the profession.

    So, there you have it. A humble take on what occupational therapy is. I hope this explanation is informative enough, but if not, please feel free to reach out to me if you would like to learn more. The door is always open.

Sincerely,

Your Humble OT

Looking for more resources?

• American Occupational Therapy Association's definition for OT