Chapter 1 Flashcards
What is Dysphagia?
Name comes from greek root pahgein, meaning ingest or engulf, and the prefix “dys” is difficulty with swallowing.
Dictionary Definition of Dysphagia
Book Definition: an impairment of emotional, cognitive, sensory and or motor acts involved with transferring a substance from the mouth to stomach, resulting in failure to maintain hydration and nutrition
Often leads to delay in propulsion a bolus, or misdirection of the bolus from the mouth to the stomach (with these circumstances, classification of dysphasia seems warranted and straightforward).
Sometimes there is not obvious delay or misdirection in bolus in patients
Typically physiologic changes are described in older patients, due to reduction in tongue strength or esophageal motility
Five subcategories of dysphagia
Constricta (narrowing of the pharynx/esophagus),
Lusoria (compression of the esophageal by the right subclavian artery),
Oropharyngeal (difficulty with propulsion from mouth to esophagus, only dysphasia used with any frequency),
Paralytica (paralysis of muscles of mouth, pharynx, and esophagus),
Spastica (spasm of the pharynx or esophagus)
Dysphagia is not a primary medical diagnosis but
rather a symptom of underlying disease*
Swallowing is a dynamic process so there may not be sign and symptoms for every person
Feeding disorder:
impairment in the process of food transport outside the alimentary system. Usually result of weakness or incoordination in the hand or arm used to move the food from plate to the mouth. In the US, a feeding disorder is the same as swallowing disorder in terms of infants and children.
A swallowing disorder should be distinguished from an eating disorder, such as anorexia and bulimia.
Incidence:
the reported frequency of new occurrences of that disorder over a long time (usually at least one year), in relation to the population in which it occurs.
Prevalence:
the number of cases in a population during a shorter, prescribed period, usually in a specific setting.
Hard to measure incidence and prevalence due to differences in accepted definitions of dysphagia
Most demographic data reported of swallowing disorders are prevalence data. Knowledge of prevalence data provides valuable assistance to medical personnel.
ASHA estimates that 6-10 million americans show some degree of dysphagia
Prevalence by setting: Rehab centers
Patients in rehab center may have less accompanying medical problems than those entering nursing homes
Prevalence by setting: premature infants
Premature infants may have medical problems that can secondarily result in dysphagia
Prevalence by setting: Community
Percentage of older dysphagia people: 16-22%
Out of 14-30 years old who had been referred for complaints of dysphagia, 70% had pathologic conditions that accompanied their symptoms
Prevalence by setting: Acute and Chronic Geriatric Care
Out of 211 patients, that were admitted to a acute geriatic unit, there was 29% admission for dysphagia and 28% discharge
60% of residents in a nursing facility in Maryland had swallowing and feeding difficulties
A study found that when there is both feeding and swallowing difficulties, 87% of residents in a home for ages were at risk for inadequate oral intake
Nursing home residents with oropharyngeal dysphagia have a mortality rate of 45% at 1 year.
Stroke:
Acute stroke: the prevalence of dysphagia (5 days after onset) may be as high as 50%. 2 weeks after stroke only 10-28% of patients may be dysphagic
51% of people were believed to be at risk for aspiration immediately after stroke. After 7 days, 27% were at risk. At 6 months, 3% still had difficulties.
Early detection is important, some people will improve without intervention
Events of aspiration can only be detected by videofluoroscopy, not bedside evaluation.
Head and Neck Cancer
Dysphagia can result from the removal of tissue
When patients had laryngectomies that were treated with surgeries, radiation or chemotherapy, 33% had swallowing related difficulties
Parkinson’s Disease (PD)
50% of patients with PD have dysphagia
Prevalence of Dysphagia may be higher in patients with PD who also have significant dementia
Amyotrophic Lateral Sclerosis (ALS)
Affects the bulbar musculature
One of the 1st symptoms of disease is Dysphagia
On 1st diagnosis 23-30% of patients have bulbar symptomatology (drooling, weak tongue, jaw, facial muscles etc)
⅓ of ALS patients will have some difficulty swallowing
Multiple Sclerosis (MS)
Not all MS patients will have dysphagia only the ones with bulbar musculature involvement (as symptoms progress more likely dysphagia will occur)
33% with MS had chewing or swallowing problems (Hertelious study)
34% dysphagia symptoms (Calcagno study)
24% of 309 MS patients confirmed chronic swallowing difficulty (DePauw study); As patient became more diabled the prevalence of dysphagia increase to 65% (used scale of disability measurement)
=
Myasthenia Gravis
⅓ wil have dysphagia (selected populations)
Depends on the extent of muscle fatigue, respiratory impairment and acute exacerbation of muscle weakness
Scleroderma
90% of patients with this disease have swallowing complaints
Dysphagia is always an accompany complaint in this disease
Usually confined to esophagus
Sjogrens Syndrome
75% of patients have dysphagia
Involve all stages of swallowing function
Dementia
In Alagiakrishnah systematic review and dysphagia prevalence was 13-57%
Usually in the later stages of those with frontotemporal dementia
Earlier stages in those with Alzheimer’s disease
Developmental Disability
Importance of documentation of prevalence of dysphagia in those with developmental disorders to highlight the need for appropriate intervention (many don't do it) Only found (bc of not best documentation) 36% in community and 73% inpatient with prevalence of dysphagia Prevalence of dysphagia and concomitant mental or physical disability was 8.1% W/ down syndrome 56.5% were at risk of respiratory infection based on overt signs of cough during the meal
Mental illness
Not a lot of data is recorded between dysphagia and mental illness
According to Aldridge and Taylor study; adults w/ mental illness were 43 times more likely to die from organic mental illness
Prevalence of dysphagia from 9-42%
Phagophobia
Aka fear of swallowing
Associated with psychogenic etiologic factors ( panic disorders, Posttraumatic stress disorder, social phobia etc
Patients descri problem as “sensation they are unable to swallow in the absence of any documented sensory or motor abnormality.
No good research for this
Premature infants
Increase of more than 12% of premature babies born in U.S
18% increase in African american births
90% of low birth weight infants maybe be prone to disorders of feeding
Oropharyngeal dysphagia =
complication of pneumonia associated with: costly, longer hospital stays, greater disabilities @ 3-6 months and poor nutrition during hospital stays
Dehydration is common with patients who suffer
from dysphagia after stroke: which leads to mental confusion, organ system failure which lead to decompensation (failure to work to do its functions) of swallowing
Lead to undernutrition which affects energy levels and could affect immune system which leads to infection, sepsis and death
Psychosocial Consequences
Limit extend to which a person might socialize (dinner parties, weddings breakfast etc)
Fear of choking episodes and discomfort might cause isolation and depression
Family is also involved because if the social limitations dysphagia causes
Small changes in diets can cause discontent to a patient
Special preparation of food might produce stress
Specific diet and food can be expensive
Clinical Management
Examination to identify if dysphagia is present: simple screening (watching patient eat or drink)
Usually done after a neurological event like stroke; sometimes when patient did not have prior swallowing problems they go back to regular eating without testing. Then they noticed their difficulty in swallowing or a doctor might notice which leads to a screening to be requested
Clinical Examination
Medical and psychological history is made
Then clinician gives a screening of mental status, musculature of the head and neck evaluation, trial swallows of liquids, semisolids and solid materials
IF those did not work then they move to a imaging study if necessary
Imaging Examination
Most common x-ray technique that assess the oral, pharyngeal and cervical esophageal phases of swallowing is the Modified barium swallow videofluoroscopy
Endoscopy: done to get direct visualization of the pharyngeal, laryngeal and esopharyngeal
Manometry (pressure measurement during swallowing) are usually done for clinical purposes in the esophagus
Treatment Options
Goal of most treatment plans: ensure that the patient can consume enough food and liquid to remain nourished and hydrated and that the consumption of these materials do not open a threat to airway safety resulting in aspiration pneumonia
In treatment 4 areas are considered: behavior, dietary, medical and surgical
Behavioral: change in posture, eating rate, new way to swallow
Dietary: modification of texture, taste or volume in food
Medical: change in medication who is affecting mental health, placement of nasogastric feeding tube
Surgical: mobilization of a weak vocal fold, placement of gastrostomy tube
Speech Language Pathologist
Management of patients with poor oral and pharyngeal swallowing mechanism
First to perform history and physical examination
ONLY within the last 20 years have SLP managed dysphagia according to practice guidelines in 1940s SLPs treated and evaluated a child with cerebral palsy their decompensation oromotor system both speech and swallowing were affected BUT swallowing was not in their scope of practice.
Dr. Jeri Logemann: discovered that videofluoroscopy could help study speech and swallowing skills; she also used this technique to study effects of cancer in the head and neck on swallowing performance; she presented the 1st paper by an SLP on the diagnosis and treatment of swallowing disorders after surgery of head and neck cancer WHICH was a monumental achievement
Not all treatments are for every patient and some treatments carry accompanying risk
Otolaryngologist
o Is skilled in eval. of upper digestive tract
o Uses endoscopy for visualization of structures of the nasopharynx, oropharynx, pharynx, and larynx
o Adds info. relative to the structural, sensory, and motor aspects of the pharyngeal stage of swallowing
o Are involved with surgical placement and removal of tracheostomy tube (tube interferes with normal swallowing.)
Gastroenterologist
o Focus on the esophagus
o Primary esophageal disorders that precipitate dysphagia can have secondary effects on swallowing (pharyngeal and oral stages)
o A symptom that may be related to dysphagia is heartburn or gastroesophageal reflux disease (GERD)
24-hour pH monitoring: sensors measure amount of acid
Medications can control GERD
o Responsible for nonsurgical placement of feeding tube in stomach: percutaneous endoscopic gastrostomy tube
Radiologist
o Focus on gastrointestinal tract
o Provide imaging of the aerodigestive tract and lungs
o Provide diagnostic info that guides swallowing treatment
o Work in conjunction with SLP for modified barium swallows (MBS)
o not all radiologists are familiar with MBS and rely on SLP for guidance and interpretation of the procedure
Neurologist
o Majority of patients with dysphagia have swallowing impairment due to a neurologic disease
o Crucial for someone with symptoms of dysphagia to see a neurologist
Dentist
o Many symptoms of dysphagia are identified by a dentist
o Dental prosthodontist can make appliances for the mouth to help facilitate swallowing in patients who had oral structures removed due to cancer
o Dental hygienist: limit presence of oral pathogen formation
Nurse
o Monitor patient 24/7
o Monitor intake and record it
o Can identify issues during eating that no one else might notice
o Provide guidance to patient during eating
o Administer tube feedings, maintain oral hygiene, assign volunteers to help patients during feeding
· Dietitian
Assess patient’s nutritional and hydration needs and their response to those needs
o Is crucial to the overall medical stability of patient
o Monitor mealtime activities: may be the ones to detect swallowing disorder
o May make recommendation for tube feeding and adjusts the appropriate levels
Occupational Therapist
o Retrain patient to self-feed
o If the patient is unable to self-feed (due to weakness or incoordination), the OT can use adaptive feeding devices
o OT and SLPs work closely in the NICU
Neurodevelopmental Specialist (NDS)
o NICU affects infant’s brain development/organization as well as the parent-infant relationship
o NDS can be an SLP or OT who is specialized in supportive care
o Neurodevelopmental care is (not limited to): proper infant positioning for brain’s tone and maturation
Limit infant’s auditory, visual, and tactile stimulation
o Feeding is one of the hardest tasks for an infant to succeed in
o Provide continued assessment of oral feedings
Pulmonologist and Respiratory Therapist
o Patients with trachs and ventilatory support often have swallowing difficulties
o Removing patient’s respiratory support is a prerequisite for improving swallowing
Levels of Care
The prevalence, cause, and type of swallowing disorder depends, in part, on the setting the patient is in
Acute Care Setting
o Prevalence of swallowing related disorders are 13%
o Patients have multiple medical complications
o Stay in this hospital is short (2-5 days), swallowing needs must be addressed quickly
o Not enough time or patient cooperation (due to mental state) to order fancy lab tests
o Clinician may have to rely on history and clinical eval. to make diagnosis and establish a Tx
o Important to develop strong relationship with radiology to get fast image results
Neonatal Intensive Care Unit
o To improve the survival rates of low-birth-weight infants, a strong interdisciplinary team is crucial
this care recognizes parent-child separation and the environments effect on the baby’s development
Subacute Care Setting
o These patients aren’t ready for intense rehab program
o Need extra medical monitoring, but not as intense as an acute care setting
o In Tx was developed in acute care, the plan will be implemented in subacute care
o Can stay here for 5-28 days
Can be discharged home, rehab facility or SNF
Rehabilitation Setting
o Learn or solidify the swallowing strategies
o SLP: teach swallowing strategies; maneuvers or postures
o The goal is for patient to return to near normal (and safe) dietary level
o After 1 month (successful) patient can be discharged
Skilled Nursing Facility
o Patients here have not responded to attempts at rehab, not candidates for rehab, to sick to be home, or have chronic medical conditions
Prevalence of swallowing disorders here: 60%
Multiple medical problems expose them to dysphagia
Swallowing disorders are chronic
Patients are usually older: impairments in swallowing due to aging process
o SLPs have large caseloads
SLPs focus on prevention: keeping the patient as safe as possible while they eat
· Direct intervention: behavioral and dietary treatment
· Monitor mealtime activities for risk of aspiration
o Clinicians rely on medical history and observations due to mental or physical state of patient
o Advance Directive
Patient or family’s desires regarding medical care in life-threatening situations
Role of SLP: make sure they understand potential risks
· Home Health
o Therapists perform responsibilities in patient’s home
o Patients unable to swallow need regular reevaluations
o Clinician must make sure the patient is following the swallowing strategies and that they have improved
