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SPH528 Intervention for Sensory-Motor Impairments > SPH528 - Dysphagia Treatment > Flashcards

SPH528 - Dysphagia Treatment Flashcards

1
Q

When choosing a specific treatment technique for dysphagia here are some things to consider:

A
  • What are the treatment options?
  • What are the clinical indicators, why do they point to a particular option(s)
  • Anticipated risks and benefit (immediate)
  • Expected functional outcome (long term -> does it fit with Pt goals?)
  • Patient empowerment (choice, partners in treatment -> compliance)
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2
Q

What are medical options for dysphagia treatment?

A
  • Dietary Modifications (ie diet to manage medical condition ie diabetes, specific calorie intake – will interact with planning dysphagia intervention)
  • Pharmacological Management
  • Surgical options
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3
Q

What surgical options for management of dysphagia may be considered?

A
  • Improve glottal closure – who would benefit?
  • Protect the airway: Stent. Laryngotracheal separation, laryngectomy, tracheostomy tube, feeding tube
  • Improve opening of the pharyngoesophageal segment (PES): Dilation, myotomy, Botox
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4
Q

5 very broad categories of Behavioural Options for the management of dysphagia:

A
  1. Food Modifications: texture modification (IDDSI), bolus size, temperature, taste, smell etc…
  2. Modify Feeding Activity: change meal schedule, oropharyngeal cleansing/hydration, Use of feeding aids
  3. Patient Modifications: Head, neck or whole-body positioning strategies.
  4. Mechanism Modifications: motor exercises (strength, range tone etc), sensory stimulation, oral hygiene, Prosthetic managments
  5. Swallow Modifications: to alter the physiology of the attempted swallow, require active participation and intensive practice.
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5
Q

3 Independence issues that impact on treatment-planning:

A
  1. Supervision: direct supervision at mealtimes to monitor food intake, use of compensatory strategies, other reasons…
  2. Assistance: Does the patient require direct physical assistance during mealtimes (ie dementia patients)
  3. Compliance: Patient’s adherence to an intervention plan.
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6
Q

2 safety issues that impact on treatment planning:

A
  1. Airway Protection

2. Nutrition and Hydration

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7
Q

The Action Plan (Activities in which the patient and clinician engage; procedures and progress monitors to be used in therapy are specified) should include:

A
  1. Instructions to the patient regarding technique
  2. Frequency of practice
  3. Amount to be swallowed
  4. Other overt aspects of the therapy program
  5. Outcome measures or techniques to monitor immediate effects of treatment technique(s).
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8
Q

Activities in which the patient and clinician engage; procedures and progress monitors to be used in therapy are specified.

A

Action Plan -> used to work on short-term goals, which work towards the ultimate, long-term goal (ie eat turkey at Christmas)

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9
Q

When considering treatment for a neuro-patient, what needs to be considered?

A
  • Speech: dysarthria, verbal dyspraxia
  • Swallowing: Dysphagia
  • Anatomy and physiology: what is going on?
  • ICF: wholistic treatment
  • Motor learning, exercise physiology and neural plasticity: best, evidence-based way to make positive changes
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10
Q

Always the MAIN GOAL of a management plan for dysphagia:

A

To obtain adequate nutrition and hydration without developing complications from dysphagia, while maximising QoL.

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11
Q

Always the MAIN GOAL of a management plan for speech.

A

To successfully get message across 95% of the time, while maximising QoL.

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12
Q

What is the context for intervention in acute stage in hospital? (non-progressive condition)

A
  • Priority is on medical status
  • Focus is on impairment
  • Co-morbidities may limit Ax/Tx
  • Possible rapid changes
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13
Q

What is the context for intervention in inpatient rehabilitation stage in hospital? (non-progressive condition)

A
  • Medically stable
  • Focus on impairment/activity
  • Intensive Tx
  • Restoration and Compensation
  • Short term goals (and session goals)
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14
Q

What is the context for intervention in outpatient rehabilitation stage in hospital? (non-progressive condition)

A
  • Focus on participation
  • Less intensive Tx
  • Client driven
  • Compensation > Restoration
  • long-term goals
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15
Q

What is the context for intervention over the long-term in community? (non-progressive condition)

A
  • Self-management of “chronic condition”
  • Monitoring
  • Wellbeing
  • Adjustments to “new life”
  • Long-term goals
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16
Q

3 foundations of intervention (Rx) for people who have had changes to their swallowing:

A
  1. Restore: aim to improve acquired impairment(s), back to the pre-morbid status if possible.
  2. Compensate: Aim to maximise function of an impaired system.
  3. Substitute: Reduce need. Aim to replace impaired/lost function with another
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17
Q

A dysphagia intervention that aims to compensate, aims to…

A

…maximise the function of an impaired system.

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18
Q

A dysphagia intervention that aims to restore, aims to…

A

…improve acquired impairment(s) (back to the pre-morbid state if possible)

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19
Q

A dysphagia intervention that aims to substitute, aims to…

A

…replace impaired/lost function with another. [non-oral nutrition/hydration]

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20
Q

What is the context for intervention in acute stage in hospital? (Progressive condition)

A
  • Exacerbations
  • Complications
  • Caregiver burden
  • Consideration of future wishes
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21
Q

What is the context for intervention in inpatient rehabilitation stage in hospital? (Progressive condition)

A
  • Focus on impairment/activity
  • Extensive Tx
  • Compensation
  • Discharge planning
  • Short-term goals
  • Consideration of future wishes
22
Q

What is the context for intervention in outpatient rehabilitation stage in hospital? (Progressive condition)

A
  • Focus on participation
  • Less intensive Tx
  • Client driven
  • Compensation
  • Prevention of acute admissions
  • Consideration of future wishes
23
Q

What is the context for intervention over the long-term in community? (Progressive condition)

A
  • Monitoring
  • Wellbeing
  • Adjustment
  • Goals of care (for the person/family – what can you do for them at that time at that stage of their condition).
24
Q

Targets for intervention for dysphagia: Restore

A
  • Oral-motor exercises (OME) – tongue strengthening etc
  • Rehab. exercises: shaker, chin tuck against resistance…
  • Therapeutic feeding
25
Q

Targets for intervention for dysphagia: Compensate

A
  • Posture
  • Manoeuvres
  • Texture modification (IDDSI)
  • Bolus delivery modification: amount, size, type, flavour, acidity…
  • Environment/assistance: adaptive cutlery, already-cut food…

Volitional airway protection???

26
Q

Targets for intervention for dysphagia: Substitute (reduce needs)

A

*Non-oral feeding

27
Q

How hospitals work for suspected stroke patient on admission:

A

Go to ED, evaluated by registrar. They’d call neurology. Do CT scan, get bloodwork, Oxygen saturation, pulse, Thrombolysis if ischaemic ASAP (if not too late), -> initial priority is to keep this person alive, get them medically stable.

28
Q

How hospitals work for stroke patient after admission, CT, relatively stable:

A

Get allied health staff in to do the assessments. PT, SLP (initially). Dietician on SLP recommendation. OT later, when they start ADL (activities of daily living). Social work if person may not make it – discus level of care and direction that care takes with family.

29
Q

Anosagnosia

A

Decreased insight into their condition, lack of awareness of their deficits

30
Q

Possible symptoms of R hemisphere stroke:

and why dysphagia may be harder to manage for R hemisphere stroke

A

Anosagnosia. Difficulty interpreting and using prosody, facial expression, non-literal meanings, sarcasm and humour, prosopagnosia, left neglect (particularly with large R hemisphere stroke. Pt may not be aware of the LHS of space)

31
Q

If the patient is not safe for a swallowing assessment, and is to remain NBM, what action should you take?

A

Go back and check their notes every day (update on status). You need to see what your priorities are that day, and see the patient ASAP when they are alert enough and when you can fit them in.

32
Q

Drawbacks to using a NG tube:

A
  • Can be placed incorrectly (trachea, spinal column, brain…)
  • Fine-bore gets blocked easily, but can eat with it in, more comfortable
  • rubs nose and throat – may desensitise these areas, which may impact swallowing
  • DON’T prevent aspiration – can aspirate secretions and reflux.
33
Q

What are appropriate goals for a stroke patient in the acute phase?

A
  • Compensate or replace functions until they are stable.
  • May be NBM – NG tube. Liaise w/ pharmacist re: medication
  • Communication board – not yet up to Ax
  • Oral infection control goals: 2 x per day. Clean tongue, cheeks, teeth/gums – scrub with toothbrush
34
Q

Recommendations to write on board for patient who is note yet safe for a swallow Ax:

A
  • NBM. Daily review. Ax pending: sufficient alertness, can be seated upright, managing secretions
  • Twice daily oral care with suction toothbrush, incl. tongue and cheeks, dry mouth spray
  • Communication board
  • Motor speech Ax
35
Q

Prerequisites for VFSS

A

Patient needs to be able to sit upright and stay alert.

Cognitively and communicatively able??

36
Q

Things to consider when arranging a VFSS:

*does he need to be NBM for upcoming tests?
*Time of day – most alert, not after other therapies
*Cognitive status – alert and able to follow instructions
*Cultural/dietary restrictions
*significant other attending?
*Can he sit upright? (special chair/other supports?)
AND

A
  • Respiratory status – can he hold his breath for 4 seconds. If not, some positions may be contraindicated
  • Does Pt need to travel for VFSS – fatigue
  • How many and which consistencies to be trialled? - SLP sufficient data, without fatiguing patient. Later trials may be fatigued -> poorer swallowing outcome.
  • Which order to trial different consistencies?
  • Emergency response in case of airway compromise?
37
Q

Consistencies to trial during VFSS:

A
  • Begin with water (IDDSI- 0) -> not successful go up
  • Food: what may be safe -> go up or down as needed
  • > later trials = more fatigue = possible decompensation
  • Carbonated, sour, hot, cold…
38
Q

Swallowing modifications that may be trialled with VFSS:

A
  • If Pt can hold breath > 4 sec – Mendelsohn manoeuvre, Effortful swallow, ?supraglottic swallow if not contraindicated -> medical advice
  • Turn head to weaker side
  • Chin-tuck, reducing supraglottic space, improving airway protection
39
Q

Things to consider when looking at tube-feeding:

A
  • Aspiration risk not gone (secretions, reflux)
  • Oral Care – can be even more important in someone not eating/drinking -> very dry mouth.
  • Impact on swallowing function (use it or lose it & “the best therapy for swallowing, is swallowing” -> consider mixed feeding)
  • Team work (dietician, pharmacist – how to take medications…)
  • Quality of life: To take away oral food/drink is a big decision, and may be taking one of their only pleasures… Team must carefully consider in light of Ax and other info, with family and patient. INFORMED CONSENT.
40
Q

When might a feeding tube be considered?

A
  • Patient is unsuitable for oral intake
  • > dysphagia, recent oral/pharyngeal/laryngeal surgery
  • Patient requires additional intake (
  • > can’t meet all of their nutritional /hydration needs via oral intake alone
41
Q

What are the 2 main forms of non-oral feeding?

A
  1. Enteral – delivery of hydration and nutrition into GI tract
  2. Parenteral – Delivery of nutritional requirements through a vein
42
Q

When would you look at putting in a PEG?

A
  1. When it looks like the patient will not be able to take all (or any) nutrition by mouth for more than a month.
  2. When they are not tolerating NG tube.
43
Q

2 types of feeding regime for enteral feeding:

A
  1. Bolus enteral feeding (A “meal”. Normalises body nutrient consumption, allows feelings of hunger)
  2. Continuous enteral feeding
44
Q

Things to consider when looking at progression from non-oral to oral feeding:

A
  • Nutritional status
  • Fluid and caloric intake
  • Overall health
  • Strength
  • Endurance
  • Respiratory condition
45
Q

An example of how to progress from non-oral to oral feeding:

**Discuss with dietician

A
  • Bolus feeding continue for 3-5 days to re-stretch stomach and re-initiate the hunger cycle
  • Introduce one oral meal daily for 1 week, with more meals added as tolerance increases.
  • Tube feeding modified as oral intake increases
  • Need a maintenance phase before tube is removed
46
Q

Transitioning back to oral feeding

A
  • Bolus feeding continue for 3-5 days to re-stretch stomach and re-initiate the hunger cycle
  • Introduce one oral meal daily for 1 week, with more meals added as tolerance increases.
  • Tube feeding modified as oral intake increases
  • Need a maintenance phase before tube is removed
47
Q

Managing the ethics of non-oral nutrition:

A
  • SLP MUST CONSULT with the team before discussing with the patient/family.
  • Very thoroughly explore all other options – permanent enteral feeding has a bit impact of person’s QoL and overall health.o
  • INFORMED consent – Present options to patient and their family in a very clear manner so they can make an informed decision. People can choose to risk-feed.
48
Q

If a patient does want to eat and drink with risk, what can we do?

A

Support them to do it more safely or comfortably

  • Make sure they’ve given documented, INFORMED consent (with lot of counselling)
  • Document everything – cover yourself legally
49
Q 
Management plan (Mr Clancy)
Goals (Mr Clancy)
A

MP: Ensure mouth is kept clean. Trial oral intake when safe to do so.
G: Minimise risks of developing complications from oro-pharyngeal dysphagia.
MP: provide Mr Clancy with a communication board, and some basic training in its use.
G: Communicate basic needs effectively with the team on 90% of attempts.

50
Q

If Mr Clancy’s family asks about non-oral feeding, say:

***NOT the SLP’s decision. Don’t say anything about medical stuff. Have a team meeting and discuss the team key worker talking with the family about these things.

A

“There are different opinions about this. It can be a complicated decision based on lots of factors including Mr C’s medical status, past history, nutritional needs etc. The team will need to talk about what we think is best for Mr C right now. We will let you know, and keep reviewing the situation as things can change quickly”

51
Q

Choosing treatment targets for dysphagia:

Ask “What component(s) of eating and drinking are impacting most on the person’s…..”

A
  • Ability to obtain adequate nutrition and hydration
  • Physical Health
  • Distress and wellbeing/QOL
  • Participation

SPH528 Intervention for Sensory-Motor Impairments (7 decks)

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