DYSPHAGIA AND THE ELDERLY

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DYSPHAGIA AND THE ELDERLY Powered By Docstoc
					    SWALLOW AWARENESS TRAINING



             ‘Hard to Swallow’

      SPEECH & LANGUAGE THERAPY
         Sally Bradford, June 2006.




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    SESSION PLAN

       THE NORMAL SWALLOW
       WHAT CAN GO WRONG?
       THICKENER
       FOOD TEXTURES
       FEEDING SESSION
       HOW TO HELP


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    SWALLOWING A SIMPLE TASK?

       We all swallow about 1000 times a day
        clearing over a litre of saliva.
       Complex process involving multiple cerebral
        regions.
       It involves 5 cranial nerves and 31 pairs of
        muscles of the mouth and throat.



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    FOUR STAGES OF THE NORMAL
    SWALLOW

       Pre-oral , preparatory stage.
       Oral stage.
       Pharyngeal stage.
       Oesophageal stage.




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    PRE-ORAL STAGE

       Transfer of food or fluid from the plate/cup into the
        mouth.
       Saliva begins to flow, sight and smell of food is
        important.
       Chewing the food and mixing with saliva to form a
        bolus.
       Tongue very mobile, tip, sides & middle collects all
        bits.
       Holding the bolus in the centre of the tongue
        awaiting oral stage to begin.

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    ORAL STAGE


       Voluntary action. Breathing can continue.
       The tongue moves back transferring the
        bolus towards the pharynx.
       The lips and jaw close to form a partial
        vacuum which helps to move the food up and
        back towards the pharynx.
       The soft palate raises.

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     PRE-and ORAL SWALLOW
     DISTURBANCE

        Diffculty getting food/ drink to mouth,e.g. visual difficuties, head not in
         mid-line,or using weak or non-dominant hand.

        Decreased lip closuredrooling, spillage, pooling or residue, change
         in oral pressure.

        Facial weaknessresidue in cheek, biting cheek wall.

        Reduced sensation residue „pocketing‟ difficulty forming bolus,
         premature spillage of material into pharynx, biting tongue.



        Reduced tongue functionimpaired movement of bolus, residue on
         tongue, lateral sulci or palate.
10      Poor soft palate closure food/ drink back down nose.
     PHARYNGEAL STAGE

        Food/ liquid is forced over the back of tongue
         into pharynx.
        Larynx moves up and forward and the airway
         closes off.
        Cricopharyngeal sphincter opens so food/
         drink passes into oesophagus.
        Larynx opens, breathing re-starts.

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     PHARYNGEAL STAGE DISTURBANCE

        Delayed/ absent triggering of pharyngeal swallowpooling in
         pharynx and possible aspiration.

        Reduced tongue base retractionresidue in valleculae.

        Reduced contraction of wall of pharynxresidue.

        Larynx may not rise or close eficiently airway not protected,
         aspiration.

        Cricopharyngeus may not openoverspill when breathing re-
         starts.


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     OESOPHAGEAL STAGE

        Duration approximately 5 seconds.
        Reflex (involuntary) action.
        The bolus is transferred down the
         oesophagus to the stomach.
        Reflux can occur and can be aspirated.




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     WHAT IS DYSPHAGIA?

        Dysphagia is a breakdown in swallowing at any of the 4 stages.

        Occurrence in acute stroke = 50-60%.

        Associated with aspiration, asphyxiation, chest infections
         (pneumonia), weight loss, malnutrition, dehydration,
         depression, poor wound healing, increased length of hospital
         stay.

        High incidence of dysphagia and pneumonia for stroke-
         prominent in brain stem stroke. (Martino, Foley et.al. 2005)


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     WHAT IS ASPIRATION?

        Aspiration is when all or part of the bolus goes down the wrong
         way ie: towards the lungs where it can cause chest infections
         such as aspiration pneumonia.

        Among the elderly caseload ,weakened by their condition and
         stroke, aspiration can be fatal.

        About 52% of stroke patients are aspirators.

        Most stroke patients recover swallow by 3 weeks.



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     SIGNS OF DYSPHAGIA TO WATCH
     FOR!

        Coughing while / shortly after eating or drinking

        „Wet‟, gurgly voice or change in voice

        Shortness of breath whilst eating / drinking

        Difficulty initiating the swallow

        Food sticking in the throat

        Frequent repetitive swallows

        Effortful swallowing
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     More signs of dysphagia

        Recurrent chest infections
        Weight loss, malnourishment
        Loss of appetite, meals/drinks not finished
        Food left in the mouth
        Fear of eating or drinking.
        Drooling or dribbling.
        Difficulty swallowing tablets.
        Patients complaining of difficulty.
        N.B. „silent aspiration‟

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     Dysphagia and oral health

     Saliva normally lubricates, glues, digests, buffers, dilutes, protects.
        Human mouth has over 700 types of bacteria.

     Dry mouth affects chewing, swallow , speech, increase in bacteria -
        mucositis, glossitis, halitosis, caries, denture tolerance, gum disease.

     Lack of oromuscular movement or NBM encourages build up of debris,
        increase in bacteria e.g staphylococcus, pseudomonas, or yeasts in
        plaque and mucosa.
     Candida can build up – hidden in pharynx/ oesophagus-dry, coated
        tongue, painful.
     Excessive salivation causes skin irritation, infection risk.
     N.B.
     POOR ORAL HEALTH = INCREASED RISK OF PNEUMONIA


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     ORAL HYGIENE

        Assessment of the mouth.

        Suctioning secretions.

        Regular mouth care (hourly).

        Water and soft toothbrush, lubricant for lips.

        Treat disorders.

        Royal college of Nursing , or Royal Marsden advice.

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     WHAT MIGHT BE RECOMMEDED?

        Exercises for the tongue, lips, palate, pharynx or larynx

        Postural changes „SIT STROKE UP‟, chin tuck, head turn.

        Manoeuvres

        Use of equipment
          –   Valved straws, valved cups, Cups with cut away, large handled
              utensils, rimmed plates, Anti-slip mats, Aprons (to protect clothing)
          –   N.B. NO SPOUTED FEEDER BEAKERS!

        Modified diet and fluids


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     THICKEN UP!

        Thickener makes fluids more cohesive and slows
         them down thus making them a safer consistency for
         many dysphagic people.
        There are three groups of thickened fluid:

         –   Syrup consistency. 1scoop per 100 mls. fluid
         –   Custard consistency.11/2 scoops per 100mls.
         –   Pudding consistency.2 scoops per 100 mls.
         –   N.B. Whisk with fork. Leave for 1 minute.


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     MODIFIED DIETS

        There are five types of diet that may be
         recommended
         –   Stage 1 = Nil by Mouth
         –   Stage 2 = thick smooth diet
         –   Stage 3 = mashed diet
         –   Stage 4 = soft diet
         –   Stage 5 = normal diet
         –   All modified diets facilitate the oral stage and are less prone
             to block the airway if aspirated.



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     STAGE 1……..NIL BY MOUTH




     NG TUBE                      IV OR SUB CUT      REGULAR
               PEG TUBE           FLUIDS             ORAL CARE


                   •      no food or fluid orally
                   •      regular mouthcare needed




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     STAGE 2……..THICK SMOOTH DIET




     PUREED        BISCUITS SOAKED   ROAST DINNER   FRUIT SMOOTHIE
     PORRIDGE     IN SOLUTION                       OR MILKSHAKE

          •  No chewing required
          • Thick, smooth with no lumps. A uniform consistency
          • Food has been pureed and sieved to remove particles
          • A thickener may be added to maintain stability
          • Can be eaten with a fork or spoon
          • Will hold its own shape on a plate and can be moulded, layerd
24        or piped
     STAGE 3……..MASHED DIET




     PORRIDGE       SPONGE PUDDING   SHEPHERD‟S PIE   VEG CURRY
                    AND CUSTARD

        •   Only requires very little chewing.
        •   Foods can be easily mashed with a fork
        •   Food is moist, with some variation in texture
        •   Has not been pureed or sieved
        •   Tough meat should be pureed.
        •   May be served or coated in a thick sauce/gravy
25      •   Mashed with fork by nurse / carer
     STAGE 4……..SOFT DIET




     COOKED      APPLE PIE AND   MEAT PIE AND     MEAT CURRY WITH
     BREAKFAST   CUSTARD         VEG WITH GRAVY   ROTI


           •   Dishes consisting of soft, moist food.
           • Foods can be broken into pieces with a fork.
           • Avoid foods which cause a choking hazard
              (see list of high risk foods).
           • Dishes can be made up of solids and thick sauces
           or gravies
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     STAGE 5……..NORMAL DIET



     PEAS            CORNFLAKES WITH   CRUSTY BREAD    SALAD
                     COLD MILK
        •   Requires unimpaired ability to bite and chew.
        •   Includes all foods from “high risk foods” list.
        •   Stringy, fibrous, textures.
        •   Vegetable and fruit skins including beans
        •   Mixed consistency foods
        •   Crunchy foods
        •   Crumbly items
        •   Hard foods
27      •   Husks
     HOW TO HELP

        Be aware of those patients at risk of aspiration. Follow
         recommendations that are documented, read before each time pt.
         has food/drink.

        Make sure patient is staying alert for all feeding session.

        Get best seating and positioning of patient.

        Sit yourself in front of patient, below eyeline.

        Monitor closely for signs of difficulty. Watch for worsening
         symptoms.

        If difficulties are noted document this and get advice as soon as
         possible.
28      Ensure good mouth care, dentures fit.
     SITTING POSITION




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     HOW YOU CAN HELP-cont.
        Atmosphere -calm, reduce distractions.


        Ensure mealtime is appropriate- ‘little, often’.

        Encourage and support -give plenty of time.

        Psychological aspects. Be aware patient may be embarrassed
         anxious or depressed. Being fed by someone can cause lack of
         self-respect. Be positive.

        Make sure medication is modified.

        REMEMBER anticipation, vigilance and prevention are more
         effective than post-aspiration therapy.
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     How to refer to Speech and
     Language Therapy

            At present we need a written referral from the
         doctor to see patients with dysphagia.
         Sip Test trained nurses can screen for dysphagia.
         All acute stroke patients should be screened within
         24hrs.

         St. Lukes Hospital Tel. ext.5220 Fax 5443.
         Bradford Royal Inf. Tel. ext 6517 Fax 6946.




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