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Dysphagia Lesson

October 23, 2014

 

Definitions

Dysphagia is the loss or the impaired ability to chew and/or swallow. It is a disorder of swallowing due to obstruction, impaired coordination or muscular weakness that affects the biomechanics of the swallow. This disorder may occur in any of the phases of swallow: oralpharyngeal, laryngeal and or esophageal. It is characterized by a disturbance in the swallowing mechanism such as choking, coughing, excess drooling, and the inability to handle one’s secretions.

Aspiration is the entrance of food, secretions or foreign bodies into the airway below the true vocal folds. Aspiration can occur before, during or following the pharyngeal phase of swallowing. Patients may aspirate contaminated oral fluids, any foods or liquids.

Silent aspiration is aspiration that occurs before, during or after a swallow with the absence of coughing.

Aspiration pneumonia is defined as entrance of swallowed materials into the airway that results in lung infection.

NPO-Nothing by mouth or Nothing per Oral Cavity; This means the client is not eating anything at all, no exceptions.

PO-per oral cavity; This means that the client is able to eat food, however, the texture of the diet may be customized.

MBS (Modified Barium Study)-A test used to evaluate the different phases of swallowing: the oral, pharyngeal, and esophageal. The study involves ingesting a substance mixed with barium sulfate.

 

Pathophysiology/Etiology:

Dysphagia can result from many different neurologic disorders including stroke, head injury, progressive neurological disease or cancers of the head/neck. Typically, impairments of the swallowing mechanism includes oral motor impairment, delayed or absent initiation of swallow, impaired pharyngeal function, impaired pharyngeal sensation, decreased pharyngeal muscle contraction, decreased tongue base movement and increased time of pharyngeal transit. Other problems can include diminished lingual control, delayed swallow, decreased pharyngeal motility and changes in oropharyngeal muscular coordination and strength. Decreased pharyngeal muscle control increases the risk of aspiration.

Un-managed dysphagia can cause aspiration, aspiration pneumonia, airway obstruction, malnutrition, decreased quality of life and even death. And even though coughing is a tell sign that a patient may be aspirating, aspiration, the entry of material into the airway below the level of the true vocal cords, is not always followed by coughing. Aspiration is common with brain stem strokes and can lead to aspiration pneumonia. In Silent aspiration, the Patient demonstrates no clinical signs of difficulty and may have no cough at all. 26% of people who aspirate develop aspiration pneumonia, while 82% of people who developed pneumonia were aspirators.

 

PREVALENCE

Dysphagia affects up to 68% of elderly nursing home residents, up to 30% of elderly admitted to the hospital, up to 64% of patients after stroke, and 13%–38% of elderly who live independently. Dysphagia affects 300,000–600,000 persons yearly and nearly 60,0000 people die each year from swallowing complications. 70% of institutionalized frail elderly have some form of dysphagia while 90% residents requiring major meal time assistance will present with some degree of dysphagia.

Stroke and dementia are the two prevalent diseases of aging that reflect high rates of dysphagia. Dysphagia is present in 40 to 70 percent of ischemic stroke patients within the first three days of onset. All acute ischemic and hemorrhagic stroke patients should be screened for dysphagia prior to oral intake to prevent possible aspiration and pneumonia. Aspiration pneumonia is a leading cause of mortality after stroke, accounting for nearly 35% of post-stroke deaths.  It is important to note that symptoms of dysphagia may occur within 72 hours post stroke (3 days). Most stroke-related pneumonias are believed to result from dysphagia and the subsequent aspiration of oropharyngeal material.

Dysphagia is also a common symptom in dementia. It has been estimated that up to 45% of hospitalized patients with dementia have some degree of swallowing difficulty. The fact is, different clinical presentations of dementia will result in different swallowing or feeding impairment with most patients with dementia demonstrating a slowing of the swallowing process which can lead to aspiration.

Dysphagia is also a common occurrence for those patients with terminal illnesses. Studies have shown that incidence of swallowing dysfunction may be as high as 63 percent for those patients during the final year of life. In addition, healthcare practitioners working in a palliative care environment may not recognize the signs/symptoms of swallowing dysfunction due to the focus on other palliative care issues like pain and comfort. Needs assessment of palliative care patients have shown that as many as 27 percent describe swallowing dysfunction. Unfortunately more than 50 percent of those stated they were not receiving any interventions to assist them in symptom management. Involvement of a speech language pathologist in hospice services can greatly increase the number of identified patients with these problems.

Dysphagia has been associated with increased mortality and morbidity in the elderly. As people grow older, there are subtle physiologic changes in their swallow function, related to reductions in muscle mass and connective tissue elasticity, which can result in loss of strength and range of motion. These age-related changes can negatively impact the effective and efficient flow of swallowed materials through the upper digestive tract. A decrease in oral moisture, taste, and smell acuity that occurs with advancing age may also contribute to reduced swallowing performance in the elderly. Other medical conditions that predispose a patient to dysphagia include; Traumatic Brain Injury (TBI), Parkinson’s disease, Dementia, Multiple Sclerosis, Huntington’s, Brain tumors, Mysathenia Gravis, Alzheimers, Head and neck cancer, Structural problems of intubation and tracheostomy, and Postoperative patients or patients getting  radiation and/or chemotherapy.

 

The Normal Swallow

The normal adult swallows approximately 600 times a day effortlessly and efficiently. Swallowing is a quick but complicated sequence of events involving multiple cranial nerves, muscles, and cartilage. The best way to understand dysphagia is to learn oropharyngeal structures and their function in swallowing.  The lips help keep the food/drinks in the mouth, the tongue helps to move the food/drink around in the mouth and to push it back to the throat, the cheeks help keep food from pocketing between the gums and cheeks, the airway moves up and forward and the esophagus opens.

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LIPS-The lips form a seal around a fork or spoon so that food can be retrieved with minimal loss. They also close to form a barrier so that food can’t fall or spill out from the mouth.

TEETH-Teeth cut up and grind food so that it is easier to swallow and it is better prepared for the digestive process.

TONGUE-The tongue collects the food/fluid from the mouth, shapes it into a single mass and, then, propels it to the back of the mouth where it can be swallowed in a timely and controlled fashion.

CHEEKS-the cheeks help keep food from pocketing between the gums and cheeks

HARD PALATE-The hard palate provides a solid platform upon which the tongue can manipulate food – shaping it and moving it.

SOFT PALATE-The soft palate meets the back of the tongue while food is in the mouth. This forms a barrier which prevents food from slipping into the throat before the swallow. During the swallow the soft palate moves up to shut off the nasal passages and prevents the bolus from ending up in the nose.

EPIGLOTTIS-Once a swallow is triggered, the epiglottis moves to cover the entrance to the larynx, diverting the bolus away from the airway and towards the epiglottis.

PHARYNX-The pharynx forms a passage for the bolus as it travels from the base of the tongue to the esophagus. It also provides a passage for air as it flows from the nasal passage to the trachea.

 

Risk Factors for aspiration pneumonia;

  • Patients who are dependent for feeding
  • Patients  with multiple medical diagnoses
  • Patients who are taking multiple medications
  • Patients  with Enteral feedings (Tube feeding via gastric tube or  Nasal Gastric tube)
  • Patients who are dependent for oral care
  • Patients who have a number of decayed teeth

 

Tell Tale Signs and Symptoms of Patients at Risk for Aspiration or are Aspirating;

  • Inability to recognize food
  • Difficulty placing and keeping food in the mouth
  • Coughing before, during or after a swallow
  • Recurring pneumonia
  • Unexpected Weight loss
  • Patient Complains of Swallowing Difficulties
  • Slurred speech
  • Decreased oral motor strength
  • Drooling and inability to manage own secretions
  • Pocketing of food
  • Impaired mastication
  • Delayed initiation of swallow
  • Delayed oral transit
  • Difficulty controlling food
  • Frequent throat clearing, gurgling, gagging,
  • Diminished or absent swallow reflex

 

Nurse Assistant Interventions to prevent dysphagia

  • Evaluate patient readness to eat. Patient should be awake and alert. Do not force feed a patient or try to feed a patient who is lethargic and not fully awake.
  • If you notice any signs and symptoms of dysphagia, notify the RN immediately so that an appropriate speech referral can be done for swallow screen.
  • Follow the speech therapist or Doctor’s orders and be aware of diet modifications , food texture and liquid consistency for the patient.
  • Ensure use of basic aspiration precautions and keep Head of Bed elevated up 90 degrees for all oral intake
  • Ensure patient is fully alert prior to oral intake and decrease environmental stimulation during oral intake.
  • Discourage talking or laughing during oral intake and provide for slow paced eating with small bites and sips with no straws.
  • Recommend diet supplementation with supplemental nutrition like ensure protein shakes or boost protein shakes if patient is unable to achieve adequate food and liquid intake
  • Promote and assist with comprehensive oral hygiene

 

Why is it important?

Practicing consistent low-risk feeding procedures will result in;

  • Reduction in number of tube feeds
  • Increased oral intake
  • Reduction in aspiration pneumonia,
  • Reduction in deaths due to asphyxiation

 

Complications of Dysphagia

  • Aspiration which can lead to pneumonitis or pneumonia
  •  Malnutrition
  • Dehydration
  • Asphyxia or Choking which can lead to death
  • Poor quality of life
  • Fear of eating
  • Social isolation
  • Depression

 

Low Risk Feeding Strategies for Nurse Assistants;

Feeding is a skill that requires knowledge and experience. The Nurse Assistant should adapt the following low risk feeding strategies to prevent aspiration and promote good and adequate nutrition.

  • Check food to ensure correct diet is provided
  • Ensure the environment is calm and minimize distractions
  • Complete mouth care before the meal
  • Present 1 level tsp per bite
  • Use a slow rate of feeding
  • Use a wide mouth cup to prevent hyper– extension of neck
  • Do not use straws please
  • Ensure patient has swallowed before giving another bite  (e.g. Adam’’s apple will pop up!)
  • Ensure patient remains seated at 90 ° during and 30 minutes after all oral intake
  • Proper positioning is VERY IMPORTANT
  • During all oral intake: The patient should be positioned with the trunk of the body at a 90 % angle to the seating plane and aligned in mid position
  • The head should be positioned so that the neck is slightly flexed FORWARD
  • Ensure patients head remains in midline and is in slight chin tuck position
  • Complete oral after the meal (look for pocketing)
  • Document and report any signs or symptoms of aspiration.

 

How to feed a patient in Bed

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  • First, roll the bed down with patient in supine position
  • Move the patient to the top of the bed
  • Put a pillow under their knees to attain knee flexion and prevent sliding down
  • Bring the head of the bed up to 90 degrees, so that the patient is sitting up in a 90 degree angle
  • The patient should keep their head in a lowered chin position

 

Feeder’s Position

When feeding a patient, the feeder should be seated beside and slightly in front of the patient, at an angle where good eye contact can be made. If the patient is to be fed in bed, the feeder may choose to stand or sit, whatever is more comfortable. If seated, lower the patient’s bed for correct eye level positioning, and raise the bed if standing for correct eye positioning.

 

Tube Feeding

The 45 degree position is the best for all tube feeding (e.g. NG, PEG) as it will not cause increased gastric pressure. If patient is on continuous feeding, the bed should not be lower that 30 during for all non -oral feeding.

 

 

How to Thicken Liquids– Tips

  • Measure the correct amount to use and mix for 3-5 minutes until dissolved to reach the desired consistency
  • Product will not continue to thicken after it has reached desired consistency.
  • You may need to re-stir if the fluids is sitting at bedside, the thickener may settle on the bottom. You then have thin fluid on the top and extra thick fluid on the bottom of the glass.
  • To keep cold place the cup containing the thickened fluid in an ice bath (e.g. rest the cup inside a second cup with ice in it).

 

Summary

  • All Diets for Dysphagia Patients are highly individualized and should be periodically reassessed depending upon fluctuating ability to swallow.
  • An absence of a gag reflex does not predict dysphagia, just as a presence of a gag reflex does not protect against aspiration
  • The cough reflex may be impaired or absent in some patients and silent aspiration may still occur.

 

 

 

 

 

                                                                    References

Cabre M, Serra-Prat M, Palomera E, Almirall J, Pallares R, Clave P. Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing. 2010;39:39–45.

Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest. 2003;124:328–336.[Pubmed]

Sura, L., Madhavan, A., Carnaby, G., & Crary, M. (2012, July 30). Dysphagia in the elderly: Management and nutritional considerations. Retrieved October 23, 2014, from Dysphagia in the elderly: management and nutritional considerations