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 An Interdisciplinary Approach To Dysphagia

Four distinct phases—oral prep, oral, pharyngeal, and esophageal—factor into the not-so-simple act of swallowing.

 

 
Panic erupts in the dining room at a noon meal. Mr. Smith breaks into a coughing episode while eating fruit salad. His face turns red, his voice is wet and gurgly, and he does not seem to be able to clear his throat. The nurse assistant at his table helps him to sit up straight in his chair, tells him, “cough hard,” and calls for a nurse.
 
Following the meal his primary doctor is contacted and his diet is changed to puree with recommendations for a dysphagia evaluation. Mr. Smith has been previously diagnosed with Parkinson’s disease, which could contribute to fatigue at meals and a reduced visual field.
 
The next morning a speech-language pathologist comes to see him. Mr. Smith  is upset because his morning meal consists of oats, pureed sausage, and no toast. “I am not going to eat this, I have been eating toast and eggs for the last 40 years, and I intend to continue eating toast and eggs every morning,” he says. Breakfast consumption is 10 percent.

Dysphagia Care A Balancing Act

Determining the safest and least restrictive diet for individuals with difficulty swallowing, or dysphagia, can be a very arduous process to navigate. Considerations include the need to maintain adequate oral intake for nutrition and hydration while keeping individuals safe from the risks of aspiration and honoring individuals’ wishes—a tall and complicated order.

Input is needed from multiple members of the interdisciplinary team, such as the patient, family, doctor, nursing teams, social services, and rehab professionals, including  physical, occupational, and speech therapists.

Medicare defines dysphagia in Chapter 15 of the “Benefit Policy Manual” as “difficulty in swallowing, which can cause food to enter the airway, resulting in coughing, choking, pulmonary problems, aspiration, or inadequate nutrition and hydration with resultant weight loss, failure to thrive, pneumonia, and death. Most often due to complex neurological and/or structural impairments, including head and neck trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, dementias, and encephalopathies.”

For these reasons, Medicare says that it is important that only qualified professionals with specific training and experience in this disorder provide evaluation and treatment.

Dysphagia 101

Swallowing is a complex process involving four specific phases: oral preparatory, oral, pharyngeal, and esophageal.
In the oral preparatory phase, food enters the oral cavity requiring adequate labial (lip) strength to hold the food bolus in the mouth. Then lingual (tongue) strength, in conjunction with rotary movements of the jaw (mastication/chewing), hold the bolus in place until an adequate solid and cohesive form is made.

In the oral phase of swallowing, the tongue begins anterior to posterior movements while holding the food bolus (like a cup) to the back of the tongue, then the base (back) of the tongue rises and the bolus begins its decent into the pharynx (throat).

During the pharyngeal phase, the soft palate elevates to contact the posterior pharyngeal wall and the larynx (voice box) elevates toward the base of tongue, bringing a passive flipping over of the epiglottis to cover the opening to the larynx and trachea. Next, the muscles in the pharynx contract, moving the bolus downward toward the opening of cricopharyngeal sphincter (muscle at the top of the food tube) to allow passage of the bolus into the esophagus.

During the esophageal phase, which is the final phase of the swallow, the cricopharyngeus muscle relaxes and the bolus passes into the esophagus. A rapid peristaltic (wavelike) contraction travels behind the bolus to clear it into the stomach.

As the process of swallowing is complex in nature, caregivers often question, “What is the best approach to providing the safest and least restrictive diet for someone with swallowing difficulty?” Impairments specific to each phase of swallowing may be present at meals.

Oral Preparatory Impairment Signs

  • Anterior loss (spillage of food or liquid bolus) from the lips;
  • Food particles on the lips during intake;
  • Decreased ability to clear food from a spoon due to weak lips;
  • Food and liquid remaining in the anterior and lateral sulci (the pocket in front teeth and behind lips and between teeth and cheeks);
  • Limited tongue movement side to side;
  • Munching chewing pattern (up and down) versus rotary chewing pattern (circular movements); and
  • Documented impairment in MDS (Minimum Data Set) Section K0100A: loss of liquids/solids from mouth when eating or drinking.

Oral Impairment Signs

  • Decreased lingual (tongue) movements front to back;
  • Decreased rise of back of the tongue to begin the next phase of swallow (pharyngeal phase), resulting in food remaining on the back of the tongue; and
  • Documented impairment in MDS Section K0100B: holding food in mouth/cheeks or residual food in mouth after meals.

Pharyngeal Impairment Signs

  • Delayed swallow start. Look for the back of the tongue “pumping” up and down (however, it takes multiple pumps to swallow);
  • Non-overt signs and symptoms, including watery eyes, runny nose, or shortness of breath with meals. Non-overt signs should not be overlooked as the geriatric population presents with decreased sensory awareness; therefore, cough reflex and the natural reflex to clear throat when food is hanging in pharynx (throat) may be reduced);
  • Overt signs and symptoms including throat clearing with intake—before, during, or after the swallow—and coughing with intake—before, during, or after the swallow; and
  • Documented impairment in MDS Section K0100C: coughing or choking during meals or when swallowing medications.

 Esophageal Impairment Signs

  • Patient complains of a “lump in the throat;”
  • Odynophagia, or painful swallowing;
  • Increased difficulty with swallowing around 30 minutes into a meal;
  • Oral and/or nasal regurgitation;
  • Signs following periods of decreased head elevation, including increased need to clear throat or increased phlegm in the morning;
  • Complaints of heart burn or reflux; and
  • Documented impairment in MDS Section K0100D: complaints of difficulty or pain with swallowing.

Swallowing Changes With Age

Changes that occur with aging include reduced propulsive forces for the series of valves involved during swallowing (pharynx and esophagus); a later onset of pharyngeal activity (that is, swallow start delayed), which affects airway closure; cricopharyngeal (muscle at the top of esophagus) noncompliance; and decreased sensory function (visual, taste, and touch).

In addition, patients over 75 have double the risk of dysphagia associated with hospitalization, and patients with dysphagia have as great as a 40 percent longer length of stay than patients without dysphagia, according to an analysis of a national hospital database reported in the August 2010 issue of the Journal of the American Medical Association Otolarynglogy—Head and Neck Surgery. The analysis also found that patients with dysphagia undergoing rehabilitation have a 13-fold increase in mortality over those without dysphagia, and the presence of chronic obstructive pulmonary disease has been shown to be the most significant risk factor for aspiration pneumonia in nursing care center patients.

Why Is A Team Approach Needed?

Dining is an activity of daily living that all residents participate in multiple times a day. Even individuals who primarily receive external nutrition may receive therapeutic feedings if outlined within the care plan to include choice, discussion of options to include both positive and negative outcomes, and a determination of best practice to honor choice.

Additionally, successful mealtime experiences require adequate functioning of multiple areas that go beyond the swallow itself, such as: adequate visual field; adequate positioning; adequate fine-motor skills for self-feeding; functional sitting balance with sustained abilities to complete meals; demonstrated cognitive and language function to attend to task and follow directions; and functional oral, pharyngeal, and esophageal function for safe and adequate intake.

Options To Treat Mr. Smith

Consider the benefit of a team approach to managing Mr. Smith’s dysphagia while honoring his wish to continue receiving a regular diet and thin liquids: physical therapy to address sitting balance and sustained positioning during meals, occupational therapy to improve fine motor skills associated with Parkinsonian tremors for enhanced accuracy of bolus size with meals, nurse assistants to provide verbal cues with tray set-up as a compensation for reduced visual field, and speech therapy to develop a maintenance-based plan of care for implementation of safe swallow strategies aimed at increasing oral processing and reducing risks for aspiration.

See Clinical Considerations.
 
Renee Kinder

Renee Kinder, MS, CCC-SLP, RAC-CT, is a clinical specialist at Evergreen Rehabilitation in Louisville, Ky. She also serves as editor for Perspectives on Gerontology, a publication of the American Speech Language Hearing Association. She can be reached at renee@evergreenrehab.com or (502) 544-4648.
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