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Dysphagia power point
1. Clinical Skills Workshop:
Dysphagia Evaluation & Treatment
Kathryn Denson, MD
Jacqueline Hind MS/CCC-SLP, BCS-S
Jennifer Carnahan, MD
Jessica Kuester, MD
Medical College of Wisconsin
University of Wisconsin – Madison
University of Indiana
DONALD W.
REYNOLDS
FOUNDATION
2. Objectives
Review background information on
swallowing
o Anatomy
o Phases of swallowing
Improve identification of dysphagia
List treatment options for aspiration
o Changes to patient / to positioning / to intake
4. Health Consequences
If untreated, dysphagia can lead to
pulmonary complications, poor rehabilitation
potential, airway obstruction and even death.
Fifth leading cause of infectious death in
persons age 65 and over.
Third leading cause of infectious death for
persons over age 85.
(LaCroix, 1989)
5. Phases of Swallowing
While swallowing is a series of
continuous events—
It may be described in 3 phases
Oral Phase
Pharyngeal Phase
Esophageal Phase
11. Small Group Brainstorm
What conditions / diseases may lead to
dysphagia and aspiration?
With your group, list them under 3 headings:
Oral Pharyngeal Esophageal
13. A Better Evaluation of Dysphagia
FEES -Fiberoptic Endoscopic
Evaluation of Swallowing
Eat real food
No radiation
Doesn’t visualize oropharyngeal
dynamics
VFG-Videofluorographic Eval
Most comprehensive & common eval
Multiple view (lateral and AP)
Can assess treatment options
21. Small Group – Try it out!
Try liquids:
o “Nectar Thick”
o “Honey Thick” liquids
Try Compensatory Strategies:
o Postures: for a (hopefully) safer swallow
o Maneuvers: Supraglottic swallow
o Feeding to increase sensory awareness
22. To contact us:
Kathryn Denson, MD
Associate Professor of Medicine (Geriatrics/Gerontology)
Medical College of Wisconsin
kdenson@mcw.edu
Editor's Notes
These are the three primary objectives for the session.
This session is taught with some portions with all learners together and other sections with learners paired off or working with their neighbor.
The goal is to cover the practical assessment and management of dysphagia in older adults. We are not speech therapists, but the materials were created with the collaboration of geriatricians and speech /swallow therapists. We may not be able to answer all your questions (especially very detailed ones!) but we can get you started and point you in the direction for further study.
A practical definition of Dysphagia is “Difficulty moving food from the mouth to the stomach.” This shouldn’t be so hard– as the mouth and stomach are connected directly by the esophagus– it’s just that airway opening in the same space that’s the problem!
Dysphagia is a big deal!
While for most of us, swallowing seems to be a single, continuous process, it is simplest to think about it as three main phases: the Oral Phase, the Pharyngeal Phase and the Esophageal Phase.
The Oral Phase involves the teeth, mouth, oral cavity. Dysphagia in this phase may be seen in patients with dementia who have trouble coordinating their chewing and have difficulty moving the food to the back of the throat. They may “pocket” the food in their cheeks, not swallowing it for extended periods of time. This phase is generally under cognitive control.
The Pharyngeal Phase includes the muscles of the pharynx. This phase has both cognitive and reflexive control and involves a number of muscles and nerves.
The Esophageal Phase is the third phase. This phase is under reflexive/automatic control.
This is a cross sectional view. Note the tongue, and how it reaches quite far back in the pharnyx. Here is the soft palate, the epiglottis (note that it is covering the airway), and the esophagus (posterior to the trachea). Here are the vocal cords and the upper esophageal sphincter.
The first step after mastication is the voluntary initiation of the swallow by the tongue.
Next, when the bolus of food or fluid reaches the back of the pharnyx, the pharyngeal swallow is triggered.
At this point, the bolus of food/fluid arrives at the vallecula. That is the area posterior to the tongue and superior to the epiglottis. A key point to see here is the importance of the tongue pushing the epiglottis downward to protect the trachea.
In this view we see the tongue base retract towards the pharynx. This is a key step in propelling the bolus downward into the esophagus. The tongue muscle needs to press strongly back towards the pharynx at this point.
Now, reflexively, the esophageal musculature propels the bolus downwards towards the stomach.
Now that we’ve reviewed the anatomy and phases of swallowing, we are going to continue with a bit of brainstorming as to causes of dysphagia in older adults. What conditions/diseases may lead to dysphagia and aspiration?
With your neighbor, (groups of 1-3 people), fill out the Dysphagia Etiology table. List the potential causes of dysphagia under the categories of Oral/Pharyngeal/Esophageal. A cause may be under more than one heading (for example, a stroke may cause dysphagia of both the oral and pharyngeal phases).
Work on this as a small group for about 10 minutes and then we’ll discuss your thoughts as a group.
After learners are done with the small group session- the facilitator will ask for their ideas and can review other conditions as found on the Dysphagia Etiology Table (facilitator version).
Identifying dysphagia can only be done if you are thinking about it!
Think about your dysphagia etiologies and tailor your history taking and physical exam to look for causes of dysphagia and for risk factors.
Decreased cognition of dementia puts patients at risk for dysphagia. Also, if you hear that the patient has a “wet” voice, then you KNOW that they are aspirating, because their saliva is currently on their vocal folds, causing that “wet” voice quality.
Bedside evaluation – A bedside evaluation of dysphagia is suboptimal but can give you some information. It can be particularly helpful in situations where you can not easily get a more comprehensive swallow study with a speech therapist.
(Here, the facilitator can demonstrate, if they wish, a bedside swallow exam with another teacher or a willing learner):
Look at the head and neck for any abnormalities/scars/deformities/check for cervical lymphadenopathy
Test muscles of mastication by having the patient puff out the cheeks and keep them puffed while you gently press against them
Have the patient smile and purse their lips.
Look in the oral cavity with a penlight. Look for poor dentition, lesions, masses.
Have the person stick out their tongue and then press their tongue against the tongue depressor (front, and side to side)
Have the person swallow a small amount of water. Listen for cough or throat clearing after the swallow.
Have the person then swallow a normal swallow volume of water and listen for cough or throat clearing after the swallow.
50% of aspiration is silent. So a bedside evaluation is only helpful if the person is coughing after the swallow. If the person does NOT cough after swallowing the liquid/food, you do not know if they are either 1) not aspirating, or 2) silently aspirating (where there is no cough reflex triggered but food/fluid still has entered the airway).
A Bedside swallow evaluation does not identify the anatomy or cause/etiology of dysphagia/aspiration. A better evaluation would include either Fiberoptic Endoscopic Evaluation of Swallowing or a videoflouroscopic swallow evaluation (which is considered the Gold Standard).
This is a video swallow study in a normal young adult. What do you notice about the swallow?
Answer: the bolus of food /liquid moves through the pharynx and esophagus quickly and in one bolus. There is no cough after the swallow is completed. There is no residual liquid in the pharynx/vallecula.
This a swallow of a normal older adult. This is not considered aspiration. What do you notice?
Answer: the fluid moves more slowly, it takes a couple of swallows for all the food to move into the esophagus.
This is a video swallow of aspiration. What do you see here?
Answer: Ouch! Fluid is entering the airway and the patient has a strong reflexive cough.
Dysphagia CAN improve in some cases. As other muscles improve and strengthen with nutrition and physical therapy, so can the muscles of swallowing. Treatment of dysphagia starts with speech therapists working to strengthen those muscles. This is done through some of the exercises you saw earlier (pressing tongue against a tongue depressor, puffing out cheeks, etc).
Besides trying to improve the person themselves, external compensatory strategies may be recommended by the speech therapist. This could include various postures/positions and maneuvers.
Postures include: sit up straight, don’t eat/drink in bed, don’t watch tv (near ceiling) as this neck extension may cause more open airway and further aspiration.
Speech therapists may recommend maneuvers (take swallow, turn head to side, hold breath, swallow twice, cough) to decrease aspiration risk.
Dietary modifications may be recommended by the speech therapist and may include a solids recommendation (regular diet, mechanical, pureed) and a liquid recommendation (nectar thick, honey thick, pudding thick).
Here is an example of a patient swallowing thin liquids. What do you notice?
Answer: the fluid moves quickly through the pharynx and esophagus, it is spread out and some stays in the valleculae, some enters the airway and the patient aspirates with a subsequent cough to try to clear the airway.
This is the same patient with the fluids thickened. What do you notice:
Answer: The fluid bolus goes down the pharynx more slowly. It stays together as more of one confluent bolus. The slower speed gives the tongue/epiglottis time to close off to protect the airway prior to the bolus reaching it.
Now it’s your turn to try it out!
Postures: sit straight up. Not reclining in bed or chair. Neck/head may be neutral, or with some patients, flexed, with chin tucked or turned to side with weaker swallow to close that portion of the airway. Head extension is not good: e.g. looking upward to watch a hospital TV. A video swallow study can help determine what positions may be helpful or if the positions actually make the dysphagia worse.
Maneuvers:
Chin tuck, turn, swallow, cough
Supraglottic swallow: hold breath, take liquid, swallow, cough. Yet, weigh potential benefit of this against the work/energy of eating- time it takes to eat, small sips can be impractical. Must have decent cognition to follow instructions.
Dementia patients with feeding issues/problems: You can try to increase sensory awareness: hand over hand feeding (you have the patient hold the spoon and then you hold their hand and help direct the scooping of the food from plate and to mouth – helps with pattern recognition and habit), socialization (can have others eating nearby to “model” eating, but beware because this can also be a distractor to eating), adding downward spoon pressure on tongue, and a mid-size food bolus to require chewing can be helpful –(if too small, it is not always recognized as in the mouth), the bolus could be larger or of cooler temperature to increase awareness of the food and to facilitate the swallow.
Overall, remember that when assessing and managing older adults with dysphagia and risk of aspiration, you are needing to work with the patient and family to assess their care goals and weigh the risk and benefits of any treatment (e.g. aspiration risk vs. risk of dehydration from not taking in enough thickened liquids)
The Frequently Asked Questions Sheet and a copy of the Dysphagia Etiology Answer Sheet may be provided to the learners.
