Introduction

Question 1

What is the difference between dysphagia and a feeding disorder?

Answer 1

A feeding disorder is an impairment in the transport of food to the mouth, exhibited by weak utensil grip, use of arm or lack of awareness. This is regularly treated by OTs rather than SPs. Whereas dysphagia is a disorder in the oral, pharyngeal or oesophageal stages of the swallow, treated by SPs or gastros.

Question 2

True or false:

Dysphagia is considered a risk factor for aspiration pneumonia but not sufficient to cause it without other risk factors present

Answer 2

TRUE

Question 3

List some of the health related impacts of dysphagia

Answer 3

• aspiration/penetration –> potentially leading to aspiration pneumonia - oral intake –> leading to weight loss, malnutrition, energy levels, mental confusion, delay healing (surgery) - issues with safely taking oral medications

Question 4

What is this?

Answer 4

Langmore et al. 1998’s Model for predicting aspiration pneumonia

Question 5

What are some of the factors that influence consequences of aspiration pneumonia?

Answer 5

• nature of aspirate (chemical, physical, bacteriologic (gastric contents = worse)
• amount & frequency
• pre-morbid health –> immune system better equipped

Question 6

How might we detect the presence of aspiration?

Answer 6

• best method: VFSS, FEES ax –> cons: not feasible for bedside, may miss it if happens on other swallows, small amounts difficult to see
• chest x-rays: chest infection –> cons: due to other conditions - respiratory signs –> cons: may be due to bronchitis or congestive heart failure
• spike in temp –> cons: due to other infections
• location of chest infection –> right lower lobe more prone to aspirates due to angle

Question 7

What are some factors that influence possibility of aspiration?

Answer 7

• premorbid health = better ability to cope
• ambulant (can move around)
• dependence for feeding
• dependence for oral care
• no. of decayed teeth
• tube feeding
• more than one diagnosis
• no. of medications

Question 8

True or False?

As SLPs, we are able to diagnose aspiration/penetration at the bedside.

Answer 8

FALSE - we can suspect aspiration based on what we can see with the patient e.g. coughing, residue in mouth, oxygen drop, etc. BUT this would be documented as such: “possible aspiration requires further assessment to confirm. We need to see the physiology to confirm aspiration which requires VFSS/FEES

Question 9

What causes dysphagia?

Answer 9

Dysphagia is a symptom of something else. This can include:

• acute/degenerative neurological injury (physical and cognitive) e.g. stroke, TBI, MS, Parkinson’s, dementia
• mechanical/structural alterations
• pulmonary disorder/disease e.g. COPD
• latrogenic cause (surgery, medications, treatment e.g. radiation)
• age
• general health (infection, #NOF - hip bone connected to swallow bone)

Question 10

What are the psychosocial impacts of dysphagia?

Answer 10

• Reduced quality of life overall
• eating and drinking is a source of human pleasure
• impacts social life enormously
• burden around eveeryday activities - have to plan ahead, forgetting lunch big deal, restaurants might not have
• emotionally - might feel isolated, not enjoying eating anymore, depressed, etc.

Question 11

What is the difference between aspiration and penetration?

Answer 11

Aspiration is where the bolus enters below the level of the vocal folds

Penetration is where the bolus enters the laryngeal vestibute but doesn’t pass the level of the vocal folds

Question 12

Which of the following are true in regards to scope of practice?

A) SLPs are able to assess all phases of the swallow

B) SLPs can insert the endoscope during a FEES assessment

C) SLPs are the leaders in conducting a VFSS assessment

D) SLPs take on the role of evaluating nutritional intake of a patient

Answer 12

The correct answer is C

This assessment does require additional training and is done in collaboration with a radiologist.

Notes for other answers: dieticians evaluate nutritional intake, we don’t insert endoscope that is done by ENT (but we can do this in other countries, + research being done), we do not assess the oesophageal phase (that is done by a gastro)

Question 13

True or False?

Nurses are able to screen for dysphagia

Answer 13

True - nurses are usually trained in this by a SLP

Question 14

When is swallowing frequency the highest?

Answer 14

When we are eating and drinking. It is the lowest when we are sleeping (can take 20 min before we swallow)

Question 15

What is the mean swallow frequency per day?

A) 690

B) 580

C) 740

D) 320

Answer 15

580

Question 16

List potential members of a typical swallowing team

Answer 16

• SLP
• Dietician
• Nurse
• AHA
• Dentist - referral, dentures
• Medical - gastro, neurology, GP, paeds, radiology, ENT, etc.
• Physio
• OT
• Social work
• Family

Question 17

If you were doing a clinical swallowing assessment, and you were concerned about the positioning of a patient due to their medical conditions - who would you ask for assistance?

A) Nurse

B) AHA

C) OT

D) Physio

Answer 17

Correct answer is D - physiotherapist

Question 18

List the ways to ensure you conduct legal & ethical dysphagia practice

Answer 18

• Follow SPA code of ethics
• Follow SPA Clinical guideline
• keep patients informed
• EBP
• Refer to more experienced staff in doubt
• Keep accurate records and documentation
• Work in safe clinical environment

Question 19

What is a globus sensation?

Answer 19

Refers the feeling of something (read: lump) being stuck in throat. This requires further investigation as it may be the result of many different things.

Important to note: It can be the result of something in the upper pharynx or oesophagus – vagus nerve has poor location differentiation.

Question 20

Describe some of the differences in patient management in the acute care and rehabilitation settings.

Answer 20

Patient considerations: in acute care patients may have multiple medical complications and have frequent changes in their medical stability. They are usually very new post stroke/medical issue so they are fatigued, not often super alert and still quite unwell thus their role at this stage is passive. In rehab they are medically stable, ambulant, alert and cognitively well enough to commence more intensive therapy.

Aims: in acute care, their stay may be short (2 to 5 days) so their swallowing needs must be addressed quickly. Will generally try to reduce aspiration through compensatory strategies. It needs to b determined when oral intake is safe. Therapy aim is to rehabilitate the swallow, which requires intensive (Mutliple times a day) therapy with it being a combo of active and compensatory methods.

Assessment: in acute care it may be difficult to do instrumental assessment (VFSS) thus it must be carried out at the bedside.Whereas in rehabilitation, they require a more comprehensive assessment so that the full physiology can be understood.

Question 21

Describe the differences in long term care vs palliative care management.

Answer 21

Aim: in long term it is about quality of life and optimising oral intake to achieve that. In palliative it is also about quality of life and ensuring safe oral/non oral intake.

Family: need counselling to patient and carers. In palliative, it is about support and in long term it is about education.

Asssessment: in long term it is clinical re-assessment/review - through instrumental ax sometimes. In palliative it is slow stream monitoring and implementing appropriate response as change of status reported.

Therapy: In long term, there shoud be ongoing rehab and maintanence of function. In palliative it will be compensatory only.