Overview and Introduction to Swallowing and Feeding

Question 1

Swallowing/Deglutition

Answer 1

All processes, functions and acts associated with introduction of food/material to be swallowed, including preparing, transferring, and transporting to stomach

Question 2

Bolus (masticated food)

Answer 2

Food, liquid, or material placed in mouth for ingestion

Question 3

Dysphagia

Answer 3

The result of a physiologic change in the muscles needed for swallowing
Delay in the propulsion of a bolus as it transits from the mouth to the stomach
¥ Misdirection of a bolus
Ð A swallowing disorder that may involve signs and symptoms of mouth, pharynx, larynx, or/and esophagus

Question 4

Feeding disorder

Answer 4

Impairment in the process of food transport outside the alimentary pathway
Difficulty manipulating food prior to swallow

Disordered placement of food in mouth
Children: Weakness or incoordination in hands/arms
– Adults (feeding difficulty)
Infants/Children: failing to develop or demonstrate developmentally appropriate eating/drinking behaviors

In US & UK, a feeding disorder mostly refers to infants/ toddlers/children.

Question 5

How common are swallowing problems?

Answer 5

¥ 87% of SLPs working in hospitals and residential health care settings report regular service to dysphagic patients (ASHA Technical Report)
Ð “87%” this number continues to increase every year
Ð 16% services to infants and/or children

¥ 3.8% of SLPs practicing in the schools now treat children with dysphagia (ASHA Technical Report)

Question 6

What populations are affected?

PT1

Answer 6

Adults
Ð Stroke, head injury, progressive neurological diseases (e.g., ALS, Parkinson’s), Alzheimer’s, head and neck cancers, tracheostomy, vocal fold dysfunction (paralysis/paresis)
Ð Aging: Individuals 85 and older were 18 times more likely to have a diagnosis of dysphagia compared to those under age 25

Question 7

What populations are affected?

PT2

Answer 7

Children
Ð Prematurity/low birth weight, cerebral palsy, craniofacial anomalies, failure to thrive/pediatric undernutrition, developmental disability
¥ Estimated that 85-­‐90% of children with CP have swallowing disorder at some point (Arvedson & Brodsky, 2002).

Question 8

Why do We Care? Health Risk

Answer 8

Ð Aspiration
Ð Dehydration
Ð Malnutrition

Question 9

Why do we care? Quality of life

Answer 9

Ð Normal adults: 580 swallows per day

Ð Social

Question 10

Priorities & Concerns of SLPs

Answer 10

¥ Adequate nutrition and hydration
Ð Resume prior diet level
¥ Safety of patient during oral feeding (adults)
Ð Oral feeding not appropriate goal for some patients
¥ Patients aspirating 10% or more of bolus despite all possible adjustments should be NPO (Logemann, 1998)
Ð Levels of severity of dysphagia
Ð Medical complications
Enteral or tube feeding = lower quality of life

Question 11

SLP’s Role in Swallowing and Feeding Disorders

Answer 11

¥ Clinical swallowing and feeding assessment
Ð Oral mechanism exam
Ð “Bedside” examination of swallowing/feeding
¥ Perform instrumental assessments as appropriate
Ð (Videofluoroscopy) MBSS/VFSS/VFS
Ð (Endoscopy) FEES
¥ Identify normal and abnormal swallowing anatomy and physiology
¥ Identify signs of possible/potential disorders in oral and pharyngeal stages of swallowing

Question 12

SLP’s Role in Swallowing and Feeding Disorders (cont’d)

Answer 12

¥ Make decisions about management
¥ Develop treatment plan
¥ Provide treatment, document progress, and determine appropriate dismissal criteria
¥ Teach/counsel patients and family
¥ Educate other professionals
¥ Serve as part of a team
¥ Advance the knowledge based through research activities (EBP)

Question 13

The Dysphagia Team?

Answer 13

¥	SLP
The Dysphagia Team
¥	Parents/caregivers/family
¥	Physicians/medical specialists
Ð	Neurologist, pulmonologist, ENT, radiologist, pediatrician, gastroenterologist, maxillofacial prosthodontist
¥	Nursing
¥	OT/PT, or Respiratory therapist
¥	Nutritionist/Dietitian
¥	Other consultant specialties
Ð	Social work, psychiatry

Question 14

Levels of Care

Answer 14

¥ Level of care may differ depending upon the setting where the pt is seen
¥ The role of each professional may be different
Ð Acute (“hospital”)
Ð Subacute
¥ Short-­‐term care
Ð Subacute rehabilitation (inpatient rehab)
Ð Out-­‐patient rehabilitation
¥ Long-­‐term care
Ð Skilled nursing
Ð Home health

Question 15

Acute Care Setting?

Answer 15

(omen “hospital”)
¥ The prevalence of swallowing-­‐related disorders to be 13% (higher!!) (Groher & Bukatman, 1986)
Ð Omen in neurology and neurosurgery units
¥ Due to short stay, swallowing issue must be addressed rapidly
Ð Frequently there is not sufficient time or pt cooperation because of mental/physical status
Ð If pt is able to tolerate testing, future care may be facilitated with the results of swallowing testing using from instrumental assessments.

Question 16

Subacute Care Setting

Answer 16

¥ They may require additional medical monitoring
Ð Pts may stay in the subacute unit from 5 to 28 days.
Ð If a swallowing tx goal was formulated in the hospital, the action plan to achieve that goal is implemented in the subacute unit.

¥ If pts are not ready for a strenuous rehabilitation program
Ð 1~2 hour therapy per day

¥ When pts have the physical stamina for a full day of tasks oriented toward restoring lost function.
Ð Receive PT, OT, SLP as needed
Ð Min 3 hrs per day/disciplines up to 6 days/week

¥ Amer this admission, they may be discharged home, to an outpatient rehabilitation facility, or to a skilled nursing facility

Question 17

(Outpatient) Rehabilitation Setting

Answer 17

¥ Not common setting for dysphagia therapy
¥ Pts may be living at home and visit the clinic for therapy
¥ The rehab team develops individual plans to maximize safety, to improve communication skills, and to assist with self-­‐care independence
Ð Receive therapy for 2~3 days a week
Ð No nursing services
Ð Own transportation is required

Question 18

Long-­‐term Care

Answer 18

¥ Omen “Skilled nursing facility”
¥ Pts are not responded to attempts at rehab, not candidates for rehab, too ill to be at home, or have chronic medical conditions that require monitoring in a structured environment.

¥ The prevalence of swallowing disorders in this setting has been reported to be as high as 60% (higher!!)
Ð Complicate medical complication
Ð Aging

** Some facilities provide subacute care (inpatient rehab) and long-­‐term care

Question 19

Long-­‐term Care (cont’d)

Answer 19

¥ Evaluation may rely on a combination of the medical history and detailed observations of each meal to establish the treatment plan.
¥ SLP works closely with the physician, nursing, dietician, and other rehab disciplines.
¥ Initiating an advance directive is usually required
Ð Stating the ways to sustain nutrition
Ð Some pts may elect to not be fed by a feeding tube despite the risk of aspiration and life-­‐threatening pneumonia.
Ð SLP: recommend the safest mode of ingestion, making sure that the patient and family understand the potential risks.

Question 20

Home Health

Answer 20

¥ Pts who have lem the hospital or the rehab setting for home may require additional monitoring or direct treatment from therapists
¥ Pts who are unable to swallow should receive regular
reevaluations for attempts at oral feeding
¥ SLP is responsible for managing the swallowing disorder in the home environment
Ð ensuring that pt follows the swallowing strategies or has improved to a point at which consideration should be given to changing the dietary level.

¥ Consultation with the pt and family is important

Question 21

What is the Ultimate Goal for Dysphagia Therapy?

Answer 21

¥ SLP: to maintain their skills, improve swallowing function/safety, re-­‐eval for resume oral intake or previous dietary
Ð For some, returning to oral intake will not be possible

¥ No matter what therapeutic/medical approaches and compensatory strategies we use, our ultimate goal is…

¥ Patient will tolerate the least restrictive diet to maintain the maximum/adequate nutrition and hydration without overt s/s of aspiration.