Class 6 Flashcards
Like many other bodily functions _____ changes as we age, sometimes as early as _____.
Swallowing.
45.
These normal aging processes may not be noticeable until…
Safe swallowing is required to maintain good, nutritional intake.
Between 8-16% of __ _______ ________in the community may be affected by dysphagia.
Healthy Elderly People.
Why does vision decline affect feeding?
It makes food preparation more difficult.
It makes self-feeding difficult.
What do older people often have a reduced perception of?
They often have a reduced perception of hunger and decreased appetite.
What can reduced perception of hunger and decreased appetite slowly lead to?
Malnutrition.
Name Normal Changes in swallowing as a result of age.
- reduced smell and taste
- volume per swallow decreases with age
- longer oral transit times
- time per swallow increases with age.
- reduced tongue mobility and force
- pharyngeal delay
- penetration occurs more frequently (but not aspiration)
- a little more pharyngeal residue.
Name 3 greater changes with swallowing that occur at 80+.
- Reduced vertical movement of hyoid and larynx.
- Reduced opening times of cricopharyngeus
- Reduced opening diameter of cricopharyngeus.
What are sometimes are recommended to elderly patients with dysphagia (not from stroke)?
NG or PEG tubes.
No evidence to confirm if this is beneficial though.
Dysphagia can be as a result of an _______ disorder.
Acquired.
Name the serious consequences of dysphagia.
- Malnutrition
- Dehydration
- Reduced quality of life
- Possible death from aspiration pneumonia
Stroke is an acquired disorder that can result in ________.
Dysphagia.
Lesions in_________ vessels and ______ lesions result in more severe dysphagia than lesions in _______ vessels or ______ lesions.
Larger.
Bilateral.
Smaller.
Unilateral.
_____-__% of acute stroke patients have dysphagia.
64-90.
What do brainstem lesions usually result in?
Significant pharyngeal problems- absent or very delayed swallow :(
Any ______ may make feeding difficult.
Hemiplegia.
Large vessels like ______ are more associated with aspiration than small vessels.
MCA
Bilateral lesions have higher ___ and ___________ or persisting dysphagia, than unilateral lesions.
Incidence and severity.
Where do SLTS have a role in stroke patients with dysphagia?
- MDT in stroke unit
- Rehabilitation units.
Why is stroke kinda good?
It isn’t progressive, so swallowing doesn’t worsen over time. There is recovery expected with stroke.
List the Pre-oral difficulties with dysphagia in dementia.
- Agnosia for food (not knowing what food is)
- Reduced concentration at mealtimes
- Reduced interest in food.
What is an oral difficulty with dysphagia in dementia?
Reduced ability to chew.
List pharyngeal difficulties with dysphagia in dementia.
- Delayed triggering
- Reduced Laryngeal elevation
- Pharyngeal weakness
- Apraxia for feeding and swallowing
Name ways to manage dysphagia in dementia.
- Modify diet and fluids.
- Brightly coloured placemats to draw the patient’s attention to the plate.
- Ambient lighting and music that encourages intake.
- Finger foods, reduced need for cutting food
- Hand over hand feeding
- Enteral feeding.
What is hand over hand feeding?
Carer’s hand is placed over the patient’s hand to help guide it to their mouth. This retains self-feeding and stimulates swallowing more than if they were just fed by carer.
What is enteral feeding used to maintain?
Adequate nutritional intake.
What needs to be considered with enteral feeding in dementia?
The value and rationale, as many will be near end-of-life.
What is characterised by a tremor and in terms of dysphagia has particular difficulty initiating a swallow?
Parkinson’s Disease.
The majority of PD patients will develop _____ as their disease ________.
Dysphagia. progresses.
In parkinson’s disease, when can dysphagia occur?
At any stage of the disease, including early stages.
Rarely is dysphagia the _________ of Parkinson’s Disease.
first stage.
If dysphagia occurs within the first year of onset, what is this more likely to represent?
Multiple System Atrophy (MSA)
or
Progressive Supranuclear Palsy (PSP)
These are less typical variants of PD.
Why is it imporatnat to ask about swallowing problems in PD?
As they don’t consistently report it in the early stages of the disease.
In patients with PD, as well as gathering comprehensive data regarding dysphagia, what else should we find out?
- impact of tremor on moving food from plate to mouth.
- On and Off periods of medication- begins to wear off making it harder for them to swallow.
If someone with PD is having difficulty using cutlery because of their tremor, what can be done?
An OT can provide weighted cutlery that reduces the magnitude of the tremor.
What is dysphagia in Parkinson’s Disease characterised by?
- Reduced spontaneous swallowing of saliva which leads to drooling.
- Difficulties initiating propulsion pf the bolus posterior;y with tongue pumping
- Piecemeal swallowing (can only swallow a little at a time)
- Delayed triggering of swallowing
- Residue in vallecular space
- Aspiration
- Somatosesnory deficits
As well as modifying diet and fluids, how else is dysphagia in PD managed?
Postural Changes- feeding positions may be different from ideal position depending on their posture and rigidity, but this can often help.
Deep brain stimulation helps people with _______.
Parkinson’s Disease.
What does swallowing with bulbar type of motor neuron disease present with?
The rapid loss of swallowing abilities which continues to progress swiftly.
What is dysphagia in motor neurone disease characterised by?
- Reduced Tongue Mobility
- Reduced Lip Closure
- Impaired velar function (nasal emission)
- Reduced tongue based retraction and reduced pharyngeal contraction.
- Delayed triggering
- Reduced closure of airway= aspiration
- Fatigue can impact
As well as gathering comprehensive data regarding dysphagia, what else would we want to know about? (MND)
Respiratory function- As this declines with disease progression, coughing to clear the airway becomes less effective.
Though patients may still attempt to cough which suggests sensory input is retained.
In Multiple Sclerosis, the more impaired a patient is, the more frequent the incidence of __________. Name the 2 areas that deteriorate.
Dysphagia.
Not just Physical changes, but cognitive changes too.
Subclinical dysphagia can only be detected on ____.
EMG.
As well as gathering comprehensive data regarding dysphagia, what else would we want to know about? (MS)
- The progression of the disease- there may be improved swallowing during periods of remission (still not back to normal).
- Fluctuating pain may have impact
- Cognition reduced- this may make it difficult to reason with them so they follow advice
- Potential euphoria can lead to feelings of denial
What is dysphagia in multiple sclerosis characterised by?
- Combination of sensory and motor impairments
- Reduced control of the bolus
- Reduced range and speed of oropharyngeal structures
- Delays in triggering swallowing and reduced pharyngeal wall contraction
- Incomplete opening of the UES.
As well as options to modify diets and fluids, what strategy may be used to manage dysphagia in MS?
An effortful swallow.
What disease is characterised by choreic movements and fatigue?
Huntington’s Disease.
What is dysphagia in Huntington’s Disease characterised by?
- Lingual Chorea
- Mandibular rigidity
- Incooridnation of swallowing
- Repetitive Swallows
- Prolonged laryngeal elevation
- Inability to stop respiration
- Pharyngeal residues
What do choreic movements impact?
They impact on the ability to move food from the plate to the mouth and the energy spent constantly repeating theses movements can contribute to significant weight loss.
In Huntington’s disease, why is a dietitian required?
To advise on calorific intake increase to compensate for the progressively worsening , high energy using movements.
Name the strategies used in Huntington’s Disease dysphagia.
- Modify Diet and Fluids
- Weighted Cutlery to reduce choreic movements when moving food from plate to mouth.
- Liaison with Dietitian as clients need to consume a highly inflated number of calories due to their choreic movements.
What is myasthenia gravis characterised by?
Fatigue.
______ is a dominant feature of both Myasthenia gravis and dysphagia with myasthenia gravis.
Fatigue.
When may fatigue occur?
- Fatigue may occur across the day (evening meals harder than breakfast time).
- Fatigue may occur within a single meal (start of meal v.s. end of meal).
In myasthenia gravis all _____ _____ involved in swallowing have the potential to be affected. What does this mean will be affected?
Muscle Groups
Both Oral and Pharyngeal phase will be affected.
What do management recommendations in myasthenia gravis need to take into account?
They need to take into account of how variable swallowing can be e.g. have normal diet in morning but only smooth foods later on.
What may obstruct the easy passage of the bolus pre-treatment?
The location of a head & neck tumour.
Conversely, surgical removal of structures involved in swallowing will undoubtedly impact on _______ ______ ____.
Functional swallowing skills.
In cancer, what else can additionally comprise swallowing?
The side effects of pain and discomfort from radiotherapy.
What is our SLT role in head and neck cancer?
- Inform patient of likely swallowing difficulties before/after treatment
- Counselling/support
- Good liason with medical professionals.
- Prerehabilitation exercises.
What is the aim of prerehabilitation exercises?
To preserve strength in swallowing musculatire during radiotherapy treatment. May not work but some research showed minor improvement in oral intake and significant improvement in efficiency of swallowing in early stages of using the exercises.
What are used even though there is no concrete evidence that they reduce aspiration in head and neck cancer patients?
Thickened Fluids.
Not all _________ patients will be dysphasic as the swallowing mechanism may will be intact.
Tracheostomised.
What is the usual way of assessing dysphagia in tracheostomised patients?
the Modified Evan’s Blue Dye Test (MEDBT).
Name the steps of the Modified Evan’s Blue Dye Test (MEBDT)
- Patient is suctioned via the tracheostomy tube.
- Blue dyed water is given in teaspoon amounts
- Swallowing is observed
- Patient is suctioned immediately and later
- If there’s blue dye in the suctioned secretions, this is evidence of aspiration.
The dye test is better at identifying what?
It’s better at identifying those who don’t have dysphagia than those who do.
What may difficulties with swallowing in mental health disorders be caused by?
Changes to eating such as increased rate of self-feeding (tachyphagia) or taking large mouthfuls. Both lead to choking or asphyxia.
How can mental health disorder drugs cause dysphagia?
- psychotropic medication can cause dysphagia
- some medications can induce drug related parkinsonism, bringing with it a swallowing pattern typical of that seen in parkinson’s disease.
As with dementia, what does mental health related dysphagia intervention include?
Behavioural strategies.
How is mental health related dysphagia managed?
- behavioural strategies
- suggestions around diet modification
Why is working with dementia and mental health hard?
They may not carry over or recall strategies if we rely on the client themselves to manage their dysphagia.
Patients with oesophageal difficulties may be referred to SLTs. Although we can’t offer guidance, we can make an onward referral to gastroenterology or ENT. Typical symptoms include…
Fluid sticking below level of the pharynx
Food or fluids backing up in to the mouth
Coughing
In addition to modifying diet and fluids, some patients benefit from strategies designed to assist in _____ _____. What do these include?
Bolus Transit.
These include- Postural Changes and Behavioural Strategies.
Before suggesting a strategy, what must we do?
We need to identify the nature of dysphagia and match the strategy to that difficulty.
Name the different postural strategies.
Head Back
Head Down
Head Turn
Head Tilt.
Name the different behavioural strategies.
Effortful Swallow
Supraglottic Swallow
Super supraglottic swallow.
What is the head back postural strategy?
Used when bolus transit is a problem but there is a safe swallow mechansim.
Who would the head back posture be relevant for?
Glossectomy patients.
What is the chin down position used for?
It is used to protect the airway when there’s a delay in triggering the pharyngeal swallow.
The vallecular space widens allowing the bolus to rest there rather than entering the airway.
In head turn, the head should be turned to the _____ side.
Weaker.
In head tilt, the head should be tilted to the _____ side.
Stronger.
Head tilt and head turn strategies are good for ____.
Stroke Patients with dysphagia.
What does effortful swallow do?
It increases drive of the bolus through the pharynx and reduces residues in the valleculae.
Name this-
This is used when reflexive airway protection is impaired.
Fill lungs with air, consciously close vocal cords, swallow, then cough to eliminate any aspirated material.
Supraglottic Swallow.
What is the difference between a supraglottic swallow and a super supraglottic swallow?
Super supralottic swallow is exactly the same, apart from the patient is also asked to “swallow hard”.
The effectiveness for these postures for any particular patient is best confirmed by _______________.
Videofluoroscopy.
What must be considered when recommending any compensatory strategies or therapy?
The patient’s cognition, comprehension and motivation.
What are the school of thoughts when it comes to these exercises for dysphagia?
- If it does no harm, why not do them!
- Use it or Lose it- disuse of swallowing mechanisms may diminish if not used for long time.
What is used for patients with poor UES opening and to increase anterior hyolaryngeal excursion?
Shaker Exercise.
What does the shaker exercise involve?
Lying on your back and lifting your head.
The manako manouvre is also known as …
The tongue hold manouvre.
What is the manako manouvre and what does it aim to improve?
Hold your tongue and try to swallow.
This aims to improve inadequate base of tongue-to-posterior pharyngeal wall approximation.
Name this:
A chilled mirror is stroked along the faucial pillars to stimulate the swallowing reflex, but the effectiveness remains under question.
Thermo-stim.
Name 2 developing interventions.
E stim.
Transcranial magnetic stimulation (TMS).
In addition to making recommendations about oral diet and fluids, what else can we recoomend?
- How much to take at one time
- Utensils used
- speed of mouthfuls taken/given
- presentation of meals/spoonfuls
- Modification of the environment (reduce distraction for someone with dementia/ more social environments for others).
In clinical goal setting, a management plan should be…
- client centred
- understood by all
- Take account of the patient’s wider health, including cognition and motivation.
- Consider readiness for therapy (acute/chronic)
- Consider the setting (hospital vs. home vs. care home)
- Understand how the family/carers may influence safety by following recommendations or not.
- Includes a review mechanism appropriate to the patient’s difficulties and can measure outcomes.
