Dysphagia Flashcards
Why might some people not listen or accept advice from SLT’s in relation to food and diet?
People have different cultures, traditions and religious rituals with food.
What happens to our bodies without nutrition?
They become slow, fatigued and cannot regulate processes that manage toxins.
What are some physical consequences of dysphagia?
Choking and coughing.
Malnutrition- anaemia, dehydration, general illness.
Weakness, fatigue.
Chest infections. Eg. aspiration pneumonia-> Can lead to death as body is not strong enough to fight infection..
Breathlessness
What is the role of the SLT in managing the physical consequences?
Assess swallowing and make recommendations as to how physical effects can be managed.
What are the practical consequences of dysphagia?
Changes to mealtime preparation, changes to social engagement
What is the role of the SLT in managing the practical consequences?
Problem solve how meals can be prepared to minimise disruption.
Problem solve how they can eat out and socialise without being embarrassed.
What are the emotional consequences of dysphagia?
Fear of choking on food.
Embarrassment about modified diet and needing help.
What is the SLT role for managing emotional consequences?
Provider of support and counselling.
What are the economic consequences of dysphagia?
Medical/hospital costs
Costs of equipment and food preparation.
What is the SLT role in managing economic consequences?
Reduce hospital admissions.
Reduce length of stay.
What are the three phases of swallowing?
Oral, pharyngeal, oesophageal.
Which phase are SLT’s not responsible for?
Oesophageal phase but must have knowledge of presentation of problems.
What occurs in the oral phase of swallowing?
- See the bolus
- Smell the bolus
- Saliva starts flowing
- Vocal cords adduct
- Orbicularis Oris relaxes
- Primary masticatory closers relax
- Jaw openers activate
- Base of tongue approximates palate to contain bolus orally
- Lingual surface grooves with midline drop to collect bolus.
- Midline of tongue elevates to move bolus between teeth.
- Bolus is moved around mouth to breakdown solids and get bolus cohesion.
- Tongue tip followed by blade to palate pushes bolus in to oropharynx (tongue stripping)
What occurs in the pharyngeal phase of swallowing?
These things all happen in rapid succession.
- Hyolaryngeal excursion
- Velopharyngeal closure
- Base of tongue to posterior pharyngeal wall approximation
- Shortening of the pharynx
- Airway protection
- Opening of the upper oesophageal sphicter (UES)
What are the cranial nerves involved in swallowing?
CN5= trigeminal CN7= facial nerve CN9= glossopharyngeal CN10= vagus CN12= hypoglossal
What number is the trigeminal nerve and what does it control (motor, sensory)?
CN5
- Motor: jaw open, bite
- Sensory: sensory to face, hard palate, tongue
What are the problems observed with the trigeminal nerve (see, infer)?
- See: reduced mastication, reduced bolus preparation
- Infer: reduced hyolaryngeal excursion, poor anterior displacement of tongue, hyoid, larynx
What is the number of the facial nerve and what does it control (motor, sensory)?
CN7
- Motor: Close eyes, wrinkle brow.
- Sensory: Taste to anterior 2/3, sensory to soft palate.
What are possible problems with the facial nerve (see, infer)?
CN7
- See: facial control
- Infer: reduced elevation of hyoid. Reduced superiod, posterior placement of tongue, hyoid, larynx (implications for oral containment of bolus or base of tongue to PPW approximation)
What is the number of the glossopharyngeal nerve and what does it control (motor, sensory)?
CN9
- Motor: gag reflex
- Sesory: gag reflex
What are the problems with the glossopharyngeal nerve (see, infer)
- See: gag, swallow, acknowledgement of taste.
- Infer: reduced pharyngeal contraction, post-swallow residue, impaired airway protection (part, supraglottic protection); decreased BoT to posterior pharyngael wall approximation)
What is the vagus nerve number and what does it control (motor, sensory)?
C10
Motor: vocal quality, volitional cough
Sensory: reflexive cough/ inhalation cough challenge
What are problems associated with the vagus nerve (see, infer)?
See: very little but can hear dysphonia.
Infer: reduced capacity for airway protection, potential difficulty for supraglottic airway closure UES impairment.
What is the number for the hypoglossal nerve and what does it control (motor)?
Motor: lingual movement
What problems are associated with the hypoglossal nerve (see, infer)?
See: lingual movement in all planes.
Infer: poor bolus control, premature spillage with pooling, decreased base of tongue posterior pharyngeal wall with vallecular residue.
What are some conditions that impact on normal NEUROLOGICAL functioning in swallowing?
Stroke Parkinson's Disease Motor Neurone Disease Huntington's Disease Dementia Cerebral Palsy
What are some conditions that impact on normal ANATOMICAL functioning in swallowing?
Head and neck cancer (eg. glossectomy)
Cerebral Palsy
Cleft Palate
Who can refer someone to SLT?
The patient themselves
Family member
Paid carer
Another healthcare worker
What would assessment determine?
- If the patient does have dysphagia.
- What further assessment is required to establish a baseline function and decide if the patient is safe to eat and drink.
- What intervention is required to manage dysphagia, while maintaining positive QOL and reducing other medical nursing costs.
- How the dysphagia can be monitored for change.
What medical things would you need to find out from patients?
- Acuity of the condition.
- Diagnosis
- History of respiratory infections.
- Frequency of aspiration
- Length of dysphagia
- Mobility
- Nutritional status
- Odynophagia
- Oromotor control
- Recovery prognosis
- Respiratory status
- Secretion management
- Ventilator dependent
What wider health things must find out about the patient?
- Alertness
- Cognition
- Compliance
- Dental status/ hygiene
- Desire to eat
- Language skills
- Feeding independence
What mental health things must find out about patients?
- Anxiety
- Depression
- Eating disorders
- Schizophrenia
- Treatment (or not)
- Mental wellbeing of caregiver
What personal things must you find out about patients?
- Patient wishes
- Family wishes
- Support network status
- Presence of caregiver
How might you word questions to a client?
- Are you prone to colds/ chest infections?
- Are you often tired/ low on energy?
- Is there a specific type of food that makes you cough?
- Do you find chewing hard or painful?
- Do you have any conditions or diseases?
What kind of assessment might also be done before the SLT sees the patient and why might it be done?
A screening assessment done by another health professional to help SLT make decisions but it is not a full assessment.
What is another screening tool that is carried out by trained nursing or medical staff in Glasgow?
Screening Tool for Oropharyngeal Problems with Swallowing (STOPPS)
- Teaspoons of fluid, then sips of fluid. For recording observations, repeated assessment and clinical decision making.
What assessments could be carried out?
- Oromotor assessment
- Cough reflex testing
- Clinical bedside swallowing assessment
- Pulse Oximetry
- Cervical Auscultation
- Mealtime assessment
- Videofluoroscopy
- Fibreoptic endoscopic examination of swallowing.
What does an oromotor assessment do?
Evaluates cranial nerve function.
What is a cough reflex test?
Assesses how well the patient can protect their airway.
What is the clinical bedside swallowing assessment?
To observe the feeding process and possibly laryngeal palpation to evaluate assessable features of swallowing such as speed and strength of laryngeal movement, number of swallows taken and effort taken.
What can you find out from laryngeal palpation?
You can only infer aspects of swallow as you can’t actually see exactly what is inside the patient.
What are the advantages and disadvantages of a bedside assessment?
Adv= Easily incorporated into a ward/clinic and non-invasive. Also, no toxic substances involved. Dis= Doesn't tell SLT about underlying problem.
What is a pulse oximetry?
Measures oxygen saturation (oxygen reduction reflects reduced airway protection)
What is the conflicting evidence for pulse oximetry?
- Colodny (2000) found no correlation between aspiration and SpO2 decrease.
- Smith et al. (2000) found that there is a good sensitivity but poor predictivity.
- Chan and Lo (2009) had reduced SpO2 for stroke patients but not hospitalised control patients.
What is cervical auscultation?
Use a stethoscope to listen to sounds of swallowing. There were studies for normal swallowing for water, yoghurt and mash and found that the thicker the consistency and bigger the bolus, the longer the sound lasts. Limitations for research meant the computer analysis is not easily transferred to clinical setting.
What is a mealtime assessment?
Provides useful information on how patients cope with a full meal with a variety of textures within one meal. Also, shows how they are fed or feed-themselves.
What is a videofluoroscopy?
Like a video x-ray that captures images of the entire swallow process .
What must you consider for videofluoroscopy?
- Level of consciousness
- Ability and/or willingness to follow instructions.
- Posture, sitting or standing
- Medical fitness for journey, exam and potential waiting time
- Possibility for early spontaneous recovery (eg. in acute stroke impact of information gained.
What are the disadvantages of videofluoroscopy?
- Can be expensive
- Radiation limits the frequency
- Need trained SLT’s
What is a fibreoptic endoscopic evaluation of swallowing?
- Can be used to complement VF.
- Uses a flexible scope through nose to provide data regarding flow of food and fluid pre-swallow and amount of residue post-swallow (aspiration).
- Can be left in place for long periods of time so can be there for whole meal.
- Better for patients who cannot tolerate transfer to radiological suite.
What are some signs of dysphagia?
Coughing, gurgly voice, watering eyes, shortness of breath, change of colour in the patient’s face, evidence of aspiration on videofluoroscopy.
What do the signs indicate?
The signs (along with medical history) can help the SLT make a judgement about the risk of aspiration but this is not fact, it is only an idea.
What is the “description of events” and describe the summary?
Look at page 12 of booklet.
- Material doesn’t enter airway= Safe.
- Material enters airway, remains above vocal folds, is ejected from airway= Lanryngeal penetration with cough.
- Material enters airway, remains above folds, is NOT ejected= L penetration without cough.
- Material enters airway, contacts folds, is ejected= Deeper L penetration with cough.
- Material enters airway, contacts folds, NOT ejected= Deeper L penetration without cough.
- Material enters airway, passes folds, is ejected into larynx or out of airway= aspiration with cough
- Material enters airway, passes folds, not ejected from trachea but with effort= aspiration with ineffective cough.
- Material enters airway, passes folds, no effort to eject= silent aspiration.
Which levels of the swallowing scale are normal, which are concerning due to residue still remaining in the laryngeal vestibule and which levels are of most concern?
Normal= 1,2,4
Concern= 3,5,6
Most concern= 7,8
What are some serious consequences of dysphagia?
Dehydration, malnutrition, chest infections, aspiration and death due to any of these.
What are some feeding considerations/options?
- Oral Feeding vs. NBM
- Normal vs. modified diet
- Normal vs. thickened fluids
- Unlimited oral vs. limited oral
- Postural changes
- Airway protection strategies
- Rehabilitation potential
- Additional precautions
- Liason with other professionals
- Liaison with family members or other carers
When is enteral feeding used and what are the types?
When patients cannot swallow any consistency safely or maintain nutritional needs.
- Nasogastric tube
- PEG tube (percutaneous endoscopic gastronomy)
- RIG tube (radiologically inserted gastronomy)
What is a nasogastric tube?
- A type of enteral feeding
- Tube passed through nose, down oesophagus and into stomach.
- Temorary
- A dietitian calculates nutritional requirements and rate of food flow.
What is a percutaneous endoscopic gastronomy?
- A type of enteral feeding
- More permanent than NG but can be removed.
- An endoscopic procedure that involves a tube being passed through abdominal wall.
What is radiologically inserted gastronomy?
Like a PEG in that it is a small tube inserted into the stomach but x-rays are used to direct tube to right place.
Why are diets and fluids modified?
To make preparation of food, and swallowing process easier.
- What do thickened fluids do?
- What do very thick liquids and solids require?
- What does food require and why might it be difficult?
- Slow the passage of the bolus to allow time for airway closure.
- Need good tongue and pharyngeal muscle strength-> risk of residue if muscle strength compromised.
- Chewing-> difficult for patients with no/few teeth or weakness in masticatory muscles.
What are the different national descriptors for modified diets?
- Normal
- Texture E= fork mashable
- Texture D= pre-mashed diet, requires little chewing.
- Texture C= thick puree, can hold own shape
- Texture B= thick puree, needs spoon
- Texture A= thin puree, needs spoon
What are the different national descriptors for modified fluids?
Stage 3 fluids (equivalent of texture A) Stage 2 fluids= honey Stage 1 fluids= syrup Naturally thick fluids Normal consistency fluids
What else needs to be considered alongside a modified diet?
Size of mouthfuls
Amount of mouthfuls
Intake must be monitored for safety and for nutritional requirements.
What are the new international descriptors for modified foods?
7= Regular 6= Soft and bite size (mashable by fork) 5= Minced and moist (pre-mashed diet, requires little chewing) 4= Pureed (thick puree can hold own shape) 3= Liquidised
What are the new international descriptors for modified liquids?
4= Extremely thick (same as pureed) 3= Moderately thick (same as liquidised) 2= Mildly thick 1= Slightly thick 0= Thin
What are some additional precautions?
- Optimum positioning for eating and drinking is fully upright
- Mealtime strategies (eg. visual, physical or verbal cues)
- Supervision/ assistance
- Monitor chest status
- Encourage coughing
- Good oral hygiene
- Dentures to be worn (if they fit)
- Medications to be given in alternative form if possible.
What must be considered with medication?
- Cannot be given in a different form as it nullifies the license.
- Decisions are not made by SLT. Would liaise with medical staff and pharmacist.
Who would the SLT need to liaise with for adapted cutlery?
OT
What is an example of adaptive cutlery often used?
Cups that control the amount of liquid provided and reduce the effort needed to take a bolus and ensure that head posture (mug with groove so you don’t have to tip your head) is optimised. Visual cue plates also used.
What would the radiologist be involved in?
Videofluoroscopy
What would the GP be involved in?
Prescribing thickening agents and community monitoring.
What would nursing staff be involved in?
feeders, supervisors, monitors
What would a dietitian be involved in?
They would make recommendations for the diet so that the patient receives the required nutritional and energy intake.
What would the occupational therapist be involved in?
Adapted cutlery
What would the physiotherapist be involved with?
Chest status (pre/post assessment), suction
What would paid carers do?
Care for the patient and ensure safety.
What are the key principles of ethical practice?
- Self-determination= respecting the right of the individual
- Beneficence= acting in the good of the patient
- Non-maleficence= avoidance of unnecessary harm
- Justice= acting fairly, distributing resources fairly
Who are the most important people to involve when making decisions?
The patient and their family.
What are the 6 questions you must ask yourself when making decisions in relation to families and ethical practice?
- What does your patient want to do?
- Are they capable of making this decision?
- Are they aware of risks if they go against your advice?
- What awareness, knowledge and skills do family members have of the swallowing difficulty?
- Are family members able to accommodate the recommendations?
- What family history might help or hinder them adhering to the recommendations?
What must patients have in order to give consent and what is it?
The decision making capacity- refers to a persons ability to understand, retain, balance information and communicate a choice.
What 4 things can decision making capacity be affected by?
- Intoxication by alcohol
- An acquired brain injury
- Presence of developmental disability associated with cognitive impairment
- Presence of brain disorder (eg. dementia)
How long does loss of capacity last?
Can be temporary, fluctuating or permanent.
What are the 6 Scottish Government documents which relate to decision making ability and protection of vulnerable groups?
- National Care Standards
- National Guidance for Child Protection in Scotland.
- Getting It Right for Every Child (GIRFEC)
- Adults with Incapacity Act
- Adult Support and Protection (Scotland) Act
- Mental Health Scotland Act
What are the National Care Standards?
Ensures that everyone gets the same high quality care, no matter where they come from.
What is National Guidance for Child Protection in Scotland?
Provides current guidance to anyone who may encounter child protection issues at work.
What is GIRFEC?
Getting it Right for Every Child
- Provides a consistent way for people who work with and support children.
- Child centred
- Governments approach to making a positive difference for all young people and children in Scotland
What is the Adults with Incapacity Act?
Provides a framework for safeguarding the welfare and finances of adults with a lack of capacity.
What is the Adult Support and Protection Act?
Deals with protection of adults who are at risk of harm
What is the Mental Health Scotland Act?
- When and how people can be treated if they have a mental disorder.
- When people can be treated or taken into hospital against their will.
- What people’s rights are, and the safeguards which ensure that these rights are protected.
What are the principles of the mental health act?
- Take past and present wishes into account
- Make sure you get the information and support you need to make decisions
- Take the views of your carer, named person, guardian or welfare attorney into account
- Look at the full range of options for your care
- Give you treatment that provides maximum benefit
- Take account of your background, beliefs and abilities
- Make sure any restrictions on your freedom should be to the minimum necessary
- Make sure you’re not being treated less favourably than others.
- Carers needs are taken into account and they get information and support they need to help them take care of you.
- Take special care of your welfare if you are under 18 years of age.
What s a power of attorney?
A legally appointed person to make decisions on patients behalf. This person is appointed while the patient HAS capacity
What is a welfare guardian?
A person is appointed when patient has LOST capacity and someone needs to be nominated to make decisions on their behalf over the long term.
What is advance directive?
Previously known as Living Wills. Are statements from patients about treatments they do NOT wish to be given in future should they LOST capacity to make decisions. No framework regarding implementation of these but AWI states past and present feelings should be considered.
What is advanced statement?
A statement of wishes of how patient would like to be treated if they LOSE capacity and covers aspects of care. (eg. religious view, food preferences, if you sleep with light on etc)
What are some challenges in perspective for decision making regarding children?
Parental wishes could conflict with SLT or other involved members.
What are some challenges in perspective for decision making regarding clients transitioning from paediatrics to adult caseloads?
Can be difficulties between SLT teams. Must have good communication and be coordinated. Must be proactive, not reactive.
What are some challenges in perspective for decision making regarding learning disability caseload?
High levels of compliance observed at a day centre but external factors (lack of suitable utensils or food) were a problem. Factors not exclusive to LD caseload.
What are some challenges in perspective for decision making regarding paid carers and palliative care?
Paid carers afraid if patient wishes to continue oral intake if it conflicts with SLT advice. Younger adults less likely to comply with advice. End of life situations difficult for patients also.
What data must you take into account if an adult is refusing to take advice?
- Mental State-> re-explain
- Age-> QOL, family opinions
- Offer alternative measures
- Educating them-> might use x-rays so they understand better
- Negotiation-> Try to get them to just taste what you’re giving them.
- Posture-> to make it more manageable
What balance must the SLT find when dealing with patients in palliative care?
Must balance nutrition and the pleasure derived from taste with possible distress and safety.
What is a very important part of palliative care decision making?
Liaison
What is more important than rehabilitation in final stages of life?
information
What are the four clinical recommendations for palliative care?
1) relieving the families sense of helplessness and guilt.
2) providing up-to-date information about hydration and nutrition at the end of life
3) understanding family members’ concerns and providing emotional support
4) relieving the patient’s symptoms
What is risk or comfort feeding?
Hand fed food and/or drink that does not cause distress or excessive coughing, aiming for comfort and satisfaction, not calories.
What should health professionals consider as well as longevity of life?
Quality of life- must consider how swallowing affects an individuals life as a whole
What are the four dysphagia-specific QOL measurements?
- The SWAL-QOL= 44 items divided into 11 domains. Suitable for patients with dyspagia caused by neurological disorders as well as cancer populations (most used)
- The M.D. Anderson Dysphagia Inventory (MDADI)= specific for head and neck cancer (most used)
- The Deglutition Handicap Index (more recent)
- The Dysphagia Handicap Index (more recent)
What is the aim of the QOL measurements?
To capture the consequences of dysphagia as well as the specific difficulties.
What are some social impacts of dysphagia?
Avoidance of eating with others
Social Isolation
Embarrassment
Social stigma associated with a modified diet (e.g. baby food)
What are some psychological impacts of dysphagia?
Reduced mealtime enjoyment Fear of choking Stress Anxiety/ panic Depression
What differs between acute and chronic dysphagia?
Emotional reactions
What are the emotional reactions of those with acute dysphagia?
Fear
Vulnerability
Depression
Frustration
What are the emotional reactions of those with chronic dysphagia?
Depression Frustration Worry Embarrassment Vulnerability
Why do we need to know about the differing psychological impacts of acute and chronic dysphagia?
Because it shows that severity influences reaction to dysphagia and that feelings and QOL concerns can change of the trajectory of the dysphagia.
Who worries more: carers of those with neurological disease with dysphagia or carers of those with neurological disease without dysphagia?
Carergivers of those with neurological disease and dysphagia have greater anxiety.
What is the impact of dysphagia on the caregivers?
Disruption to mealtimes Carer burden Extra food preparation Reduced QOL Guilt Worry
When does swallowing begin to change in life?
45 years
Can healthy people have dysphagia?
Yes
What are some other changes that can affect eating?
Vision= preparing food and self-feeding Hunger= reduced perception of hunger.
What is the normal process of a deteriorating swallow with age?
- Reduced smell and taste.
- Volume per swallow decreases
- Longer oral transmit times
- Time per swallow increases
- Reduced tongue mobility
- Pharyngeal delay
- Penetration occurs
- More pharyngeal residue
What tends to happen after 80 years?
- Reduced vertical movement of hyoid and larynx
- Reduced opening times of cricopharyngeus (upper oesophageal sphincter)
- Reduced opening diameter of cricopharyngeus
What percentage of stroke patients have dysphagia and what percentage aspirate?
64-90% of acute stroke patients have dysphagia with 22-42% aspirate.
What types of lesions have a higher incidence and severity of persisting dysphagia?
Bilateral lesions occur more often, severe dysphagia.
What types of vessels involved in strokes are more associated with aspiration?
Larger vessels
What do brainstem lesions usually result in?
Significant pharyngeal problems
How does hemiplegia affect feeding?
Makes it difficult to feed independantely
What might be recommended for an elderly person with a deteriorating swallow and why?
Enteral feeding when oral intake is unsafe or insufficient.
Can a person recover from a stroke?
Yes. It is not progressive and can improve.
What is Dementia characterised by?
Memory loss Difficulty communicating/ finding words. Difficulties with problem solving/ reasoning. Difficulties with complex tasks. Difficulties organising Behavioural changes Confusion/disorientation Difficulties with motor function
What is dysphagia in dementia characterised by in the pre-oral phase?
- Agnosia for food (difficulty interpreting sensations and recognising what things are)
- Reduced concentration in meals
- Reduced interest in food.
What is dysphagia in dementia characterised by in the oral phase?
Reduced ability to chew
What is dysphagia in dementia characterised by in the pharyngeal phase?
- Delayed triggering
- Reduced laryngeal elevation
- Pharyngeal weakness
- Apraxia (inability) for feeding and swallowing
What strategies can be used for those with dysphagia in dementia?
- Modified diet and fluids
PLUS - Brightly coloured placements= drawing attention to plate.
- Finger foods= do not need a focus on cutting and preparing food.
- Hand over hand feeding= Carer guides patients hand to retain self-feeding which is thought to stimulate swallowing more.
- Enteral Feeding= to maintain adequate intake but consideration needs to be given to value and rational as they are near end of life.
What have studies concluded in terms of the most effective method of supporting oral intake?
There is not strong enough evidence for the variety of interventions. The studies carried out involved small numbers of participants making it hard to come to a conclusion.
What is Parkinson’s disease characterised by?
Tremor Bradykinesia (slow movement) Rigid muscles Impaired posture and balance Loss of automatic movement Speech changes
What percentage of those with Parkinson’s disease develop dysphagia and when?
80% at any stage of the disease
What is Parkinson’s disease caused by?
Dopamine generating nerve cells in the substantia nigra die which causes a fall in dopamine levels. Dopamine is a neurotransmitter that plays a part in many cerebral pathways.
What is the conclusion if dysphagia is the first sign of Parkinson’s disease?
If it is within the first year of onset, it is more likely Multiple System Atrophy (MSA) or Progressive Supranuclear Palsy (PSP)
What would you need to find out from the patient about their PD in relation to dysphagia?
- Impact of tremor on moving food from plate to mouth. OT may be able to give weighted cutlery to reduce impact.
- Timing of your assessment in relation to ON-OFF periods of medication. There are debates to whether dopamine affects swallowing. Levodopa does (positively) affect dysphagia so must know ON-OFF periods.
What is dysphagia in Parkinson’s disease characterised by?
- Reduced spontaneous swallowing of saliva, leads to drooling.
- Difficulty initiating propulsion of the bolus posteriorly with ‘tongue pumping’.
- Piecemeal swallowing
- Delayed triggering of swallowing
- Residue in the vallecular space
- Aspiration
- Somatosensory deficts
What strategies can be used for those with dysphagia in Parkinson’s disease?
Modified diets and fluids
Postural changes= feeding positions may be radically different from ideal depending on the patients posture and rigidity.
What are some strategies for those with dysphagia in Parkinson’s disease that are in early research phases?
Respiratory therapy, video treatment and deep brain stimulation.
What is Motor Neurone Disease characterised by?
- Muscle aches, cramps, twitching
- Clumsiness, stumbling
- Weakness or changes in hands, arms, legs and voice
- Slurred speech and swallowing difficulties
- Cognitive changes
- Fatigue
- Muscle wasting
What is dysphagia in MND characterised by?
- Reduced tongue mobility
- Reduced lip closure
- Impaired velar function
- Reduced tongue base retraction and reduced pharyngeal contraction
- Delayed triggering
- Reduced closure of airway-> aspiration
- Fatigue can impact
What other information would you need to gather from a patient with MND?
Respiratory function= this declines with disease progression, coughing to clear airway may become less effective but might still try which shows sensory input is retained.
What is Motor Neurone Disease caused by?
A progressive neurological disease that attacks neurons within the brain and spinal cord so signals gradually stop reaching the muscles causing muscle weakness and wasting
What is Multiple sclerosis?
An autoimmune condition in which the immune system attacks the myelin sheath around nerve cells in the brain and spinal cord. Signals passing through these nerve cells can then be slowed, disrupted or distorted
What is MS characterised by?
- Sensory and motor impairments
- Reduced range and speed of oropharyngeal structures
- Delays in triggering swallow and reduced pharyngeal wall contraction
- Incomplete opening of upper oesophageal sphincter.
What is the prevalence of dysphagia in MS?
about 40%
What other information would you need to gather about patient with dysphagia in MS?
- Progression of the disease= may be improved swallowing during periods of remission and fluctuating pain may also impact.
- Cognition= reduced deterioration might make it difficult to reason with patient. Potential euphoria can also lead to denial.
What are some management options for dysphagia in MS?
Modify diet and fluids
Effortful swallow
What is some early stage research on treatment for dysphagia in MS?
Botulinum toxin and electrical stimulation
What is Huntington’s disease?
A genetic disorder caused by defective gene on chromosome 4. This produces protein huntingtin which causes neurons to die, especially in parts of the cortex and basal ganglia.
What is dysphagia Huntington’s disease characterised by?
Lingual chorea Mandibular rigidity Incoordination of swallowing Repetitive swallows Prolonged laryngeal elevation Inability to stop respiration Pharyngeal residues
What other information would you need to gather from someone with dysphagia in Huntington’s disease?
- Ability to move food from plate to mouth= due to choreic movements
- Weight loss= choreic movements use so much energy that they lose weight so dietitian must increase calorie intake
What would the management be for dysphagia in Huntington’s disease?
Modified diet and fluids
Weighted cutlery= reduce choreic movements
Liaison with a dietitian= to increase calories
What is Myasthenia Gravis?
A neuromuscular disorder in which a defect of transmission of nerve impulses to muscles causes nerve weakness in skeletal muscles. The transmission is interrupted at the neuromuscular junction (where nerve cells connect with muscles they are innervating)
What is dysphagia in myasthenia gravis characterised by?
Swallowing severity can fluctuate in line with fatigue.
Fatigue can occur within a meal or throughout the day.
Weakness of multiple muscles means there is potential for oral and pharyngeal phases to be affected.
What are the management options for someone with dysphagia in Myasthenia Gravis?
Modified diet and fluids
Planning diet choices around fluctuating fatigue.
What might impact on swallowing in head and neck oncology?
- Tumour may obstruct the passage of bolus before treatment
- Surgical removal will impact swallowing ability
- Swallowing can be affected by pain and discomfort from radiotherapy
What is the SLT role with dysphagia in head and neck oncology?
Informing the patient on possible difficulties
Providing coucilling support.
To liaise with other health professionals.
What can the SLT provide for a patient undertaking radiotherapy for a tumour?
Prehabilitation exercises= aim to preserve strength in swallowing musculature (not proven to work).
What is there a lack of evidence for in head and neck oncology patients?
For the use of thickened fluids but works for other populations so should work with h&n
What is the blue dye test and who would it be tested on?
Tracheostomy patients
- Patient is suctioned
- Blue dyed water is given in teaspoon amounts
- Swallowing is observed
- Patient is suctioned immediately and later
- Blue dye in suctioned secretions is evidence of aspiration
What can be some difficulties with swallowing in mental health?
- Tachyphagia= increased rate of self-feeding-> can lead to choking or asphyxia.
- Taking large mouthfuls-> choking or asphyxia
- Psychotic medication-> choking or asphyxia
- Drug- related parkinsonism (like dysphagia in Parkinson’s disease
What are the intervention options for someone with mental health related dysphagia?
Behavioural strategies and diet modification to improve safety of oral intake
What are some oesophageal difficulties you should be aware of as an SLT?
SLT can offer guidance but must refer to ENT.
- Food sticking below level of pharynx
- Food or fluids backing up into the mouth
- Coughing
When would the SLT suggest tilting the head back?
When bolus transit is a problem
Relies on gravity to clear oral residue but pharyngeal swallow must be intact.
Might use for glossectomy (tongue removal) or oral surgery patients.
When would the SLT recommend chin down position?
To protect airway when there is a delay in triggering pharyngeal swallow. Vallecular space widens so bolus can rest there to stop it entering the airway.
Epiglottis is also pushed posteriorily.
When would you use a head turn?
- Turn to WEAKER side- prevents bolus going down damaged side.
- For patients with unilateral pharyngeal paresis (muscular weakness due to nerve damage).
When would you use a head tilt?
- Tilt to STRONGER side so bolus goes down that side.
- For patients with unilateral oral or pharyngeal weakness
What is an effortful swallow?
Can increase drive of bolus through pharynx and reduce residues in the valleculae.
What is a supraglottic swallow?
Used when reflexive airway protection is impaired.
Fill lungs with air-> close vocal folds-> swallow-> cough (to get rid of any aspirated material.
What is a super- supraglottic swallow?
Same as supraglottic swallow but also must swallow extra hard to compensate for pharyngeal weakness. Throat clearing is encouraged between mouthfuls.
How does an SLT test if positioning is effective?
Videofluoroscopy
What must you consider when giving a patient advice on positioning?
Cognition, comprehension, motivation
What is the shaker exercise?
For poor UES opening and to increase anterior hyolaryngeal excursion.
Must lie on your back and lift head.
What is the manako (tongue hold) manoeuvre?
Hold tongue and try to swallow to improve inadequate base of tongue to posterior pharyngeal wall.
What is the thermo-stim?
A chilled mirror is stroked along pacial pillars to stimulate swallowing reflex but effectiveness is unclear.
