Swallowing .....on a Plate

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                                       .....on a Plate

                             A Training Package for nursing home staff
                           caring for residents with swallowing problems

                                               Grainne O'Loughlin
                                                 Chris Shanley

                               With written contributions by Sue Radovanovic,
                                       Merryn Kent and Celia Coelli

                                                   CENTRE FOR EDUCATION
                                                   & RESEARCH ON AGEING

                                The Centre for Education and Research on Ageing
                             and the Inner West Geriatrics and Rehabilitation Service

                                                                                            Swallowing....on a Plate
      CONTENTS                                                        Page

      Foreword                                                                 5
      Acknowledgments                                                          6
      Background to the TECH Approach to dementia care                         7
      How to use this Resource Kit                                             8
      A word about definitions                                               10

      MODULE 1         Understanding the Swallowing Process

1.1   The normal wallow                                                      12
1.2   Medical conditions which may cause swallowing problems                 16
1.3   Oropharyngeal dysfunction - causes and consequences                    18
1.4   All you need to know about aspiration                                  21
1.5   The impact of ageing on swallowing                                     23
1.6   Swallowing problems in dementia                                        25

      MODULE 2         Assessment and Management of
                       Swallowing Problems

2.1   Warning signs of swallowing problems                                   28
2.2   Goals for managing swallowing problems                                 29
2.3   Core strategies for managing swallowing problems                       30
2.4   Swallowing ... on a Plate (SOAP) Program                               31
         Prefeeding Assessment Checklist                                     35
         Swallowing Assessment Checklist                                     36
         Swallowing Management Index                                         37
         Swallowing Care Plan                                                47
2.5   Case studies - use of the SOAP Program forms                           48
2.6   Activities and exercises                                               56
2.7   Ethical considerations in the management of
      swallowing problems                                                    59

                                                               Swallowing....on a Plate
       MODULE 3          Implementation of the SOAP Program
                        in your Nursing Home

3.1    Steps in implementing the SOAP Program                                62
3.2    Inservice session lesson plans                                        71
3.3    Promoting and maintaining ongoing change                              79

       MODULE 4          Supplementary Information

4.1    Medications and their effects on swallowing                           84
4.2    Promoting independence in residents                                   88
4.3    Correct positioning for mealtimes                                     89
4.4    Using adapted equipment at mealtimes                                  92
4.5    Managing common nutritional problems                                  95
46.    How to monitor nutritional status in the nursing home                 99
4.7    Modifying food consistency                                          101
4.8    Modifying fluid consistency                                         112
4.9    Dietary supplements                                                 119
4.10   Enteral (tube) feeding                                              120
4.11   Transitional feeding - from tube to oral nutrition                  124

       MODULE 5          Resources

5.1    Books and videos                                                    127
5.2    Organisations                                                       128
5.3    Equipment suppliers                                                 129
5.4    Answers to quiz and b!ank answer sheet                              130
5.5    Answers to case study                                               136

       Package of Handouts/Overheads, SOAP Awards and
       Originals of all SOAP Program Forms

                                                               Swallowing....on a Plate
                             Module 1

                       Swallowing Process

         Module Sections
1.1      The normal wallow                                                                  12
1.2      Medical conditions which may cause swallowing problems                             16
1.3      Oropharyngeal dysfunction - causes and consequences                                18
1.4      All you need to know about aspiration                                              21
1.5      The impact of ageing on swallowing                                                 23
1.6      Swallowing problems in dementia                                                    25

  Learning outcomes
  .   At completion of this module, learners will be able to:
  .   explain in detail what happens in the different stages of swallowing
  .   explain in detail how dysfunction of specific structures can impact on swallowing
  .   explain the risk factors, causes and complications of aspiration
  .   explain the difference between audible and silent: aspiration
  .   explain the possible impact of ageing on swallowing
  .   explain the possible impact of dementia on swallowing.

                                                                              Swallowing....on a Plate
1.1 The normal swallow

Swallowing is complex process that we are usually not conscious of. There are a number of steps
and structures involved in the swallowing process - some of which are voluntary and some
involuntary. A number of cranial nerves and muscles in the mouth and throat are involved in the
swallowing process.
The swallowing process is usually broken dawn into three stages:
.   the oral stage (in the mouth)
.   the pharyngeal stage (in the throat)
.   the oesophageal stage (in the oesophagus).

To examine these stages in more detail, we will look at some of the specific structures involved in
the swallowing process and the functions they fulfil. Refer m Figure 1 : The Anatomy of
Swallowing on page 15 as you go through the stages.

The oral stage
The oral stage begins when food is brought to the mouth. It involves taking hod or fluid from a
utensil using the lips, moving and controlling food in the mouth, using the tongue and cheeks and
chewing the food to fam a bolus in readiness for the next stage of swallowing.
The oral stage is under voluntary control, which means we can decide on such factors as the
length of time we are going to chew our food or on what side of the mouth we will chew.
Important oral structures and their function during swallowing are outlined below.
.   Open and dose, retract and protrude.
.   Stay dosed to prevent food or fluid or saliva from falling from the mouth.
.   Maintain oral pressure when dosed to aid the swallowing process.

.   Opens and closes.
.   Moves from side to side, up and down and in a rotary action when chewing.
.   Strength is important for chewing tougher food consistencies,

.   Moves up and down and from side to side.
.   I Mwes hod towards the teeth for chewing.
.   Mixes food with saliva.
.   Collects food into a ball (bolus) in the middle of the tongue.
.     Presses against the roof of the mouth to push food backwards towards the throat.

                                                                                         Swallowing....on a Plate
.   Clears away food residue from gums and cheeks.
.   Controls and holds food or fluid in preparation for swallowing.

.   Maintain the correct degree of tension to prevent food failing to the sides of the mouth, or in front of
    the teeth or gums.

The pharyngeal stage
The pharyngeal stage of the swa1low begins once the food or fluid passes the faucial pillars at the
back of the mouth. Swallowing at this stage becomes involuntary, which means we no longer
have control over the muscles or structures propelling the food. The swallow reflex is triggered
automatically as material passes the faucial pillars and a series of important mechanisms occur
simultaneously to ensure efficient transit of the bolus to the oesophagus. Important pharyngeal
structures and their function during swallowing are outlined below.

Soft plate
. Lifts upwards and backwards to seal off the nasal cavity.
.   Prevents nasal regurgitation of food or f fluid.

Pharyngeal (throat) muscles
. Constrict and assist with pushing food down towards the oesophagus.

Larynx (voice box)
.   The larynx is designed as a three level valve to protect the airway from food and f bid; these three
    levels are the epiglottis, false cords and vocal cords.
.   When the swallow reflex is triggered, the epiglottis inverts to seal off the entrance to the trachea, and
    the false and vocal cords dose momentarily to provide extra protection to the airway.
.   During this action, the larynx momentarily rises and tilts forward.
.   Breathing momentarily stops as the larynx closes off, until. food is cleared from the throat into the
    oesophagus. This means that we cannot breathe and swallow at the same time.
.   The larynx returns to its resting position once the food has passed through the cricopharynx and
    breathing resumes,
.   Airway protection lasts for less than one second from when the bolus of food or fluid is passing over
    the base of the tongue.

.   This muscle relaxes to allow f o a l or fluid to pass from the back of the throat into the oesophagus.
.   It contracts once food has entered the oesophagus and stays contracted to prevent reflux of a the food
    bolus and stomach contents back into the throat.

                                                                                         Swallowing....on a Plate
The oesophageal stage
The oesophageal phase of the swallow begins once the food or fluid bolus has passed through the
cricopharynx. It is an involuntary action which propels the food down to the stomach.
.   After food enters the oesophagus, automatic wavelike movements in the oesophageal muscles
    direct the material down to the stomach.
.   The cricopharyngeal muscle closes to prevent food being regurgitated into the throat.
Problems with this stage of the swallow such as ref lux and oesophageal strictures are usually
assessed by a gastroenterologist and will not be covered as part of this Training Package.

            Summary of key points
            .    Swallowing has three stages - oral, pharyngeal and oesophageal.
            .    Swallowing is a neurologically controlled response, dependant on the function of a
                 number of cranial nerves and other anatomical structures in the mouth and throat,
            .    While the oral stage of swallowing is under voluntary control, later stages are not.
            .    The involuntary processes are mostly designed to prevent food and fluid entering
                 the trachea and the nasal cavity.
            .    The swallow reflex must be triggered before any of the laryngeal valving actions
                 will occur.
            .    The momentary closure of the airway - by inversion of the epiglottis and closure of
                 the false cords and vocal cords - prevents food, fluid and saliva entering the airway
                 when swallowing.

            Ham your index finger at the top of your neck and your middle finger on your Adam's
            Apple. Now swallow your saliva. You should be able to feel your larynx - moving
            upwards and tilting forward during the swallowing action. You can also feel for the
            movement when having a mouthful of water.

            There is a blank answer sheet in Module 5 for you to photocopy and use. The answers
            to the quiz can also be found in Module 5.
            1.   Which structure seals off the nasal cavity to prevent nasal regurgitation when
            2.   Describe briefly the actions of the larynx during swallowing.
            3.   Name three important roles of the tongue in swallowing.
            4.   Why must the lips be dosed when swallowing?
            5.   What is the role of the epiglottis during swallowing?

                                                                                        Swallowing....on a Plate
Figure 1: The Anatomy of Swallowing

                                  Swallowing....on a Plate
1.2       Medical conditions which may cause
          swallowing problems

Many medical conditions affect the swallowing process and residents in nursing homes often
have multiple medical problems. This makes them more prone to a wide range of acute and
chronic swallowing problems. The most common illnesses contributing to swallowing problems
are listed below.

A stroke (CVN) may cause muscular weakness, loss of coordination, paralysis or lack of
sensation in the muscles of the mouth or throat.

Altered mental state
Dementia, confusion, or alcohol related brain damage may cause swallowing problems due to
memory loss, lack of awareness, loss of initiation or inappropriate behaviours such as eating too
quickly, spitting out food or repetitive chewing. Issues related. to dementia are discussed more
fully in Section 6 of this Module.

Progressive neurological disorders
Parkinson's disease, Huntington's disease, multiple sclerosis, muscular dystrophy, and motor
neurone disease are some of the progressive neurological conditions which often cause associated
wallowing disorders. These disorders commonly give rise to muscle weakness, incoordination or
paralysis, which may effect the muscles used in swallowing.

Developmental disabilities
Cerebral p l s y is one of the most common neurodeveloprnental disorders which may cause
weakness and incoordination in the muscles involved in the swallowing process.

Head injuries, other brain or neck injuries, or removal of tumours may cause neurological damage
and/or damage to the structures involved in the swallowing process.

Cancer of the mouth, throat or oesophagus may be treated with surgery and/or radiotherapy.
Surgery may involve the removal of the affected tissue e.g. cancer of the tongue may require
partial glossectomy, thereby affecting swallowing. Treatment with radiotherapy may cause tissue
scarring, reduction in saliva production or soreness and is likely to affect the motility of the
structures involved in rhe swallowing process.

Connective tissue disorders
Scleroderma is an example of a connective tissue disorder which may cause immotility of the
smooth muscles in the oesophagus and rigidity of the larynx. It frequently causes ref lux and
can also cause difficulty with the motility of the pharyngeal rnusdes and the action of the
larynx during swallowing.

                                                                                Swallowing....on a Plate
Seizure disorders
Scarring of the brain may occur as a result of seizure disorders, thereby causing neurological
damage which may result in swallowing problems. Postictal states may also cause swallowing
problems which can be temporary.

Many medications can adversely affect the swallowing process either by causing drowsiness or
because of neurological side effects. The effects of various medications and how best to
administer medications to those with swallowing disorders can be found in Module 4 of this
Training Package.

Drowsiness, although not strictly a medical condition per se, is sufficient to increase a person's
likelihood of aspiration or choking during a meal.

                                                                                   Swallowing....on a Plate

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