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NUTR 468 Clinical > Dysphagia (Week 3 GI) > Flashcards

Dysphagia (Week 3 GI) Flashcards

1
Q

What can cause swallowing impairment?

A
  • anatomical (e.g. head and neck cancer; surgery) + structural abnormalities (e.g cleft palate, cleft lip)
  • physiological (may be treatment induced) (e.g. radiation)
  • neurological (e.g. stroke, cerebral palsy or muscular dystrophy, Parkinson’s disaase )
  • drug induced (e.g. sedation, ataxia, some antidepressants)
  • Aging population
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2
Q

What age experiences the most dysphagia?

A

affects > 50% population > 80 yrs

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3
Q

How might radiation treatment cause dysphagia?

A

The radiation sloughs off the cells in the esophagus

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4
Q

What is the biggest cause for dysphagia?

A

stroke

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5
Q

Major Warning Signs of Oral Dysphagia

A
  • Drooling, expectoration of food and saliva during/after swallow (often with aging)
  • Slow rate of intake/chewing; often associated with SOB
  • Altered posturing of head/neck (more common in babies who arch back)
  • Food residue in mouth after eating (even something like puree)
  • Coughing before swallowing (++liquids), during or after the swallow
  • Alterations in voice quality (food spillage into trachea)
  • Abnormal/absent laryngeal elevation
  • In elderly it can be a simple as unexplained weight loss
  • unexplained ammonia
  • feeding inefficiency
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6
Q

What is feeding inefficiency?

A

Spending more than 30-40 min when actively trying to eat

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7
Q

What voice alterations can occur with dysphagia?

A
  • disphonia: wet voice; crackly
  • aphonia: unable to vocalize
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8
Q

What are the 2 biggest signs of oral dysphagia?

A
  • food residue in mouth after eating
  • alterations in voice quality
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9
Q

what are the stages of swallowing?

A
  1. oral phase
  2. pharyngeal phase
  3. esophageal phase
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10
Q

Normal oral phase

A

voluntary (1 sec)
1. Tongue elevation in anterior to posterior direction to trigger swallow
2. Bolus movement through oral cavity (move food from mouth to back into pharynx)

  • UES closed
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11
Q

Normal pharyngeal phase

A

shortest but most complex (1 sec)
1. soft palate elevates (velar elevation) closing off nasopharynx and preventing nasopharyngeal regurgitation & epiglottis blocks the larynx
2. The superior constrictor muscle contracts (pharyngeal peristalsis)
3. tongue base drives the bolus posteriorly

  • UES opens
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12
Q

Normal esophageal phase

A

8-20 sec (most people 8 or less depending on product)
1. Upper esophageal sphincter opens and then closes once bolus enters the esophagus
2. bolus is propelled about 25 cm from the cricopharyngeus through the thoracic esophagus via peristaltic contractions.
3. The LES relaxes (opens) and the bolus moves into the stomach.

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13
Q

what are the types of dysphagia?

A
  • oral dysphagia (oropharyngeal)
  • pharyngeal dysphagia (oropharyngeal)
  • Esophageal dysphagia

also esophagogastric, and paraesophageal.

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14
Q

describe oral dysphagia

A

Refers to problems with using the mouth, lips and tongue to control food or liquid.

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15
Q

What can oral swallowing stage be affected by?

A
  • surgical defects (tongue weakness)
  • neurological disability
  • cognitive status/LOA (level of awareness)
  • ill-fitting dentures
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16
Q

How might alzheimers effect the oral phase?

A

With Alzheimer’s dementia (declining cognitive and sensory skills) may forget food is in the mouth and may need a reminder
* cold face cloth on side of cheek o stimulate food is there
* reminder to continue to pick up spoon

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17
Q

food texture considerations for oral dysphagia

A
  • Mixed textures like a stew or many soups or yogurt with fruit pieces or mashed banana
  • can have different textures on a plate but should only have 1 texture entering the mouth
  • Things that are too sticky can be a problem such as PB
  • Want to avoid things with seeds
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18
Q

Describe pharyngeal dysphagea

A

Refers to problems in the throat during swallowing and is an inability to push food from the mouth into the esophagus.

subtype of oropharyngeal dysphagia.

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19
Q

What can affect the pharangeal phase? (pharyngeal dysphagia)

A

may be due to neurological conditions, such as a stroke, or muscular difficulties, such as cerebral palsy.
* There is a lot of nerves that affect the way these muscles work so a lot of things can go wrong, consistency of contraction is important to prevent a problem. If one thing gets stuck it is right where the larynx is.

20
Q

Describe esophageal dysphagia

A

occurs when there is difficulty with the passage of solid or liquid material through the esophagus, specifically the region between the upper and lower esophageal sphincter.

21
Q

What can affect the esophageal phase (esophageal dysphagia)?

A

It results from either abnormal motility of this segment of the esophagus or physical impairment to passage (obstruction)
* inflammatory diseases, autoimmune disorders, collagen disorders

22
Q

What tool is used to monitor swalling ability and dysphagia?

A

Videofluoroscopic Swallow Study
* An X-ray procedure a speech pathologist completes in order to evaluate the anatomy and physiology of the oral cavity, pharynx, and screening of the esophagus to see how swallowing works
* Uses barium

23
Q

Feeding concerns with dysphagia

A
  • patient safety-modified texture diets (aspiration and regurgitation)
  • individual tolerance (hot vs. cold, solid vs. liquid, eating alone, independant eating abilities, cognitive function)
  • meeting nutritional (energy and protein) and fluid requirements (less hydration if on thickened fluids)
  • odynophagia pain control (swallowing is painful)
  • ability to deliver meds (grinding pills)
24
Q

Nutrition management in dysphagia

A

May differ depending on permanent/ temporary and type of dysphagia
* requires complete nutriton assessment
* consider cognitive status in elderly
* alteration in food texture (pureed, minced, soft)
* alteration in fluid viscosity (hydration a problem)
* incorporation of high protein/ high energy recommendations (often malnourished and anticipate decrease in volume consumed.
* Use of alternate feeding routes ( if gut not working properly - Enteral vs. TPN)
* consider positional and assistive feeding devices
* compliance to prescribed diet alterations (taste fatigue)

25
Q

Nutrition assessment considerations in dysphagia

A
  • time lapse between onset of symptoms and diagnosis will affect assessment
  • Malnutrition and dehydration are common.
  • Response to diet therapy in terms of compliance.
  • Many nutritional deficiencies can occur due to suboptimal intake/hydration
26
Q

What are common texture-modified diet orders?

A
  • pureed
  • minced
  • dysphagia soft
  • easy to chew
27
Q

Pureed
* indications for use
* description

A

Indications for use: Patients who are unable to chew or swallow food in solid state due to:
* chewing and/or swallowing difficulties (dysphagia)
* sore or dry mouth
* strictures
* mucositis
* esophagitis
* poor or absent dentition.

Description: Provides a diet of pureed foods that will meet the following characteristics:
* pureed to the texture of a pudding or mousse
* moist, smooth, and cohesive with small consistent sized particles the same size or smaller than cooked cream of wheat or applesauce
* thick enough to spoon up a minimum of 7.5 mL onto a teaspoon (liquid may be thinner)
* no water separation.

Includes Pureed Bread Products and No Mixed Consistencies modifications

28
Q

Minced
* indications for use
* description

A

Indications for use: Patients who are unable to chew or swallow food in a solid state due to:
* chewing and/ or swallowing difficulties (dysphagia)
* sore or dry mouth
* limited dentition.

Description: Provides a diet of minced foods that will meet all of the following characteristics:
* require little chewing, and are moist and cohesive (e.g., yogurt, minced beef with gravy, pancakes moistened with syrup)
* Minced, grated, or finely mashed foods with no water separation
* Regular bread products are allowed (e.g., soft, moist cookies, soft buns) excluding breads that are dry or chewy (English muffins, bagels, etc.).

Does not include No Mixed Consistencies modification

29
Q

Dysphagia Soft
* indications for use
* description

A

Indications for use: Patients who are unable to chew or swallow food in a solid state due to
* chewing or swallowing difficulties (dysphagia)
* limited dentition.

Description: Provides a diet of soft moist foods served with a sauce or gravy that will meet all of the following characteristics:
* Firm foods are diced to 1 cm cubed or less on the longest side (e.g. meat, poultry, firm entrees/casseroles or entrees/casseroles with pieces larger than 1 cm cubed)
* Foods that can be mashed by a patient using a fork in one hand
* Salad type, minced or cheese sandwich fillings
* Soft grain products.
* Foods excluded are very dry or crumbly; very sticky or gummy; hard such as raw vegetables, whole or chopped nuts, hard large seeds, and whole dried fruit; chewy such as some breads (e.g., English muffins, bagels).

Does not include No Mixed Consistencies modification

30
Q

Easy to chew
* indications for use
* description

A

Indications for use: For patients with chewing difficulties, limited dentition, or to facilitate independent eating.

Description: Provides a diet with foods of a softer texture that are easy to chew.
* Foods excluded are dry, crispy, or hard foods; foods with long or stringy pieces; foods with tough skins; nuts, salads and hard raw vegetables and fresh fruit.

Not for dysphagia management

31
Q

What diets are commonly use for the different types of dysphagia?

A
  • pharyngeal dysphagia - usually pureed but some can handle minced
  • oral dysphagia - usually minced
32
Q

Types of modifications within the diet order

A
  • mixed consistency
  • pureed bread products
  • cut/diced
  • thickened fluids
33
Q

pureed bread products?
Indications for use
description

A

Indications for use: Patients who are unable to chew or swallow bread products in a solid state due to
* chewing and/ or swallowing difficulties
* sore or dry mouth
* strictures
* esophagitis
* mucositis
* poor or absent dentition.

Description: A modification added to a primary diet or diet texture order. Bread products are pureed to the consistency of a pudding or mousse (See pureed definition) as follows:
* pureed breads, bread stuffing, muffins, sandwiches, pancakes, crackers, cookies, bread pudding and cake
* pasta, rice, couscous, and barley are the consistency of the primary diet or diet texture order.

34
Q

no mixed consistencies
* indications for use
* description

A

Indications for use: For patients with dysphagia who are not able to control two consistencies (thin fluid and solids) being in their mouth at the same time.

Description: A modification added to a primary diet or diet texture order, (e.g. Easy to Chew, Dysphagia Soft, and Minced). Foods avoided are those with 2 consistencies or 2 phases. These includes
* foods with a thin liquid and solid pieces in the same mouthful (e.g., soup with vegetable or meat pieces, cold cereal with milk)
* foods that release thin liquid when chewed (e.g., watermelon, cherry tomatoes).

This modification is included for Puréed Diet and Thick Fluids.

35
Q

Thickened Fluids
* indications for use
* description

A

Indications for use: Patients with chewing and/or swallowing difficulties; unable to safely manage thin fluids.

Description: A modification added to the primary diet or diet texture order for patients with dysphagia. All fluids are thick to improve the patient’s control for drinking and to reduce risk of aspiration. Three levels of thickness are available
* Mildly Thick (Nectar) - runs freely
* Moderately Thick (Honey) - slowly drips
* Extremely Thick (Pudding) - sits on spoon

Also thin and slightly thick fluids

36
Q

benefit of thickened fluids

A

Allow patients more time to control the movement of the fluid in the mouth before initiating a swallow.
* Thickened fluids can help reduce the risk of fluids going down toward the airway “going the wrong way”.

37
Q

What are considered thin fluids?

A

water but also Fluids that melt in the mouth or at body temperature are considered thin fluids – ice cream, Jello, smoothies, Popsicles – these fluids can not be thickened

38
Q

Considerations with thickened fluids

A

Hydration
* adding in extra fluids on meal trays and at snack times to ensure adequate hydration
* Patients may or may not be allowed to have regular water or ice chips between meals
* free water protocol (Frazier free water protocol)

Bowel Medication PEG 3350

no mixed consistency

39
Q

problem with Bowel medication PEG 3350 for patients on thikc fluids diet

A

Bowel medication PEG 3350 can’t be given orally with patients on thickened fluids – thins out fluids and solids– need to consider alternative

40
Q

what is the free water protocol

A

Free water is permitted before and between meals.
* Free water is not permitted with meals or other oral intake.
* Medications are not to be taken with water, as pills may be washed into the lungs.

41
Q

Cut/ diced
* indications for use
* description

A

Indication for use: To facilitate
independent eating for patients who have difficulty cutting their own food
* e.g. tremors, fractures, hemiplegia/ hemiparesis, etc.

Description: A modification added to a primary diet order or diet texture order (e.g., Regular, Easy to Chew). To facilitate eating, food is cut-up into bite- sized pieces or pieces that are manageable to pick up.

Not for dysphagia management

42
Q

What is IDDSI?

A

The International Dysphagia Diet Standardized Initiative
* A global standard with terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and for all cultures.

43
Q

What are therapeutic feeds?

A

“Therapy” or exercise for the swallow
* Small amounts of food and or fluid given 1 to 3 times a day to help with strengthening the swallow – swallow exercises usually done under supervision with SLP
* SLP determines the safest consistency and fluid level
* Communication with RD to have the required items put into CBORD

44
Q

comfort vs. pleasure feeds

A

When no safe consistency is recommended however the patient is willing to take some risk to have desired foods and or fluids as their goals of care is comfort care or palliative care
* The swallow is not expected to improve
* Quality of life
* Celebrate special occasions: birthday cake, ice cream or a milkshake

45
Q

Eating at risk

A

The patient does not want to follow the recommendations of the feed swallow team.
* A managed agreement with the patient who has informed consent (given all the risks associated with choosing to eat orally despite no safe consistency or fluid observed on VFSS)
* The physician will discuss the risks associated with eating orally with the patient, patient’s family, caregiver and or decision maker
* Sample order may read: “patient has decided to eat at risk and accept the risk of dehydration, malnutrition, choking episodes, aspiration, pneumonia, sepsis and death”

46
Q

Dietitian’s Clinical assessment for feed/ swallow patients

A
  • Assessing anthropometrics – weight loss
  • Reviewing medications
  • Appetite - Changes in intake
  • Hydration concerns
  • Limiting food repertoire avoiding certain foods
  • Incorporate a 3 day food record – understand what the patient is currently eating and may be avoiding
  • Independent or dependent for feeding
47
Q

What do recommendations for feed/ swallow patients include?

A
  • Mode of intake: oral vs. non-oral
  • Diet consistency:
  • Therapeutic diet:
  • Medications
  • Positioning
  • Strategies
  • Oral hygiene:
  • Consultation
  • Other
  • Review

NUTR 468 Clinical (34 decks)

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