Dysphagia in the Elderly by mikesanye

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									 Dysphagia in the Elderly
Implications in Long-Term

       Annette T. Carron, DO
 Director Geriatrics & Palliative Care
          Botsford Hospital
• Know and understand:

• Swallow mechanism and changes with aging

• Causes of dysphagia

• Proper assessment and diagnosis of

• Treatment of dysphagia

• Options if dysphagia treatment unsuccessful

• Survey implications of dysphagia        Slide 2
 Normal Swallow Mechanism
1. Oral preparatory phase
  1. Chewed food mixes with saliva to make
  2. Bolus sitting between the tongue and the
     hard palate in a groove formed by the tongue
  3. Tongue begins an anterior to posterior
     pumping motion that moves bolus posteriorly
  4. Bolus passes anterior tonsillar pillars
  5. Disease in this phase can result with tongue
     dysfunction, inadequate dentition (impairs
     bolus formation)                         Slide 3
 Normal Swallow Mechanism
2. Pharyngeal phase
  1. Larynx rises, vocal folds close to protect airway,
     epiglottis closes entrance to airway, soft palate
     separates nasal cavity from pharynx
  2. Bolus passes through pharyngoesophageal
     sphincter (UES-upper esophogeal sphincter) into the
  3. Velopharyngeal sphincter closure prevents bolus
     regurgitation into nose
  4. Tongue and pharyngeal muscles propel bolus
  5. Larynx is closed off to the bolus
  6. Disease here caused by palatal dysfunction,
     pharyngeal constriction, laryngeal or epiglottic
                                                      Slide 4
     dysfunction (aspiration)
Normal Swallow Mechanism
2. Esophageal phase
 1. Food travels to stomach
 2. Pharyngoesophageal (PES) sphincter
    opens to allow bolus into esophagus
 3. Disease here may be motility disorder or
    mass/ anatomical lesion

                                           Slide 5
    Swallow changes with aging
•   Thickening of the muscular coat
•   Occurs more slowly
    – Initiation of laryngeal and pharyngeal events take
    – Bolus may pool or pocket in the pharyngeal recess
•   Presbyphagia – changes in the mechanism of
    swallowing of otherwise healthy older adults
•   Not clear aging itself causes increased risk of
    aspiration, but with increased co-morbidities, increased
•   Normal saliva – 10,000 gallons in a lifetime, meds can
    reduce salivary gland production (higher risk in elderly)
                                                       Slide 6
 Swallow changes with aging, cont.
• In oral phase, food bolus inadequately
  prepared due to poor or absent dentition,
  periodontal disease, ill-fitting dentures,
  inappropriate salivation
• Taste, temperature and tactile sensation with
  aging changes
• Intake may be too rapid with neurological
• Fatigue or change in endurance as a possible
  factor in aspiration in the elderly
• Muscle atrophy in facial muscles with aging
  may slow swallow                          Slide 7
• Definition – difficulty in swallowing that may
  include oropharyngeal or esophageal problems
• Eating is one of the most basic human
  needs/pleasure – difficulty is swallowing can
  cause social/emotional isolation
• May or may not be inherent in aging, but
  common in the elderly
• Incidence
  – 15 % in community-dwelling elderly
  – 50-75%   in nursing home population
                                             Slide 8
• Oropharyngeal dysphagia—Patients
  complain of foods getting ―stuck,‖
  inability to initiate a swallow,
  impaired ability to transfer food from
  mouth to esophagus, nasal
  regurgitation, coughing
• Esophageal dysphagia—Patients
  usually point to the sternum when
  asked to localize the site
• Dysphagia in a patient with
                                           Barium swallow in achalasia:
  dyspepsia requires immediate                   Bird beak sign
  evaluation and therapy

                                                             Slide 9
• Risk Factors in the elderly
• Stroke
  – Silent cerebral infarction fivefold greater risk
• Neurodegenerative Diseases
  Alzheimer's, ALS, Parkinson's, MS, Myopathies
  – Iatrogenic conditions
  – Medication side effects/xerostomia
  – Post surgical
  – Irradiation of head and neck
  – Cognitive impairment
  – DM/Thyroid/osteophytes                      Slide 10
• Risk Factors in the elderly
• Medications and dysphagia
   – Xerostomia
      • Anticholinergic drugs (tricyclic, antipsychotics,
        antihistamines, antispasmodics, antiemetic,
   – Esophageal/Laryngeal peristalsis
      • Antihypertensives, antianginal
   – Delayed neuromuscular responses
      • Delirium causing, extrapyramidal side effects
   – Esophageal injury/inflammation
      • CCB, Nitrates relax lower esophageal sphincture
      • Large pills                                         Slide 11
• Symptoms
• Most common – choking (bolus entering
  airway or bolus lodged in the pharynx/
  esophagus (ask pt to describe –
  aspiration symptoms in airway more
• Pocketing food/pills (food left in mouth
  after swallowing)
• Excessive throat phlegm with frequent
  throat clearing or spitting (wet voice)
• Delay in triggering swallow             Slide 12
• Symptoms
• Neck pain, chest pain, heartburn
• Solid food dysphagia (mechanical
• Weight loss without other explanation
• Increased time to consume meals
• Drooling
• Spitting food at meals
• Rocking tongue back and forth while
  chewing                               Slide 13

• Symptoms
• Prolonged oral preparation
• Increased time to consume meal
• Unusual head or neck posturing with
• Pain with swallow
• Decreased oral/pharyngeal sensation

                                   Slide 14
• Symptoms
• Coughing and choking with swallow
• Reduced or absent thyroid/laryngeal
  elevation during swallow
• Multiple swallows per mouthful
• Food or liquid leaking from nose
• Lasting low-grade fever
• Pneumonia
• Malnutrition/Dehydration            Slide 15
• Assessment and Diagnosis
• Do you have any pain on swallowing?
• Are there food or liquid consistencies that
  you have to forgo because they are likely
  to be difficult to swallow?
• Have you lost weight because of
  swallowing difficulties?

                                         Slide 16
• Assessment and Diagnosis
• Speech Language Pathologists (non-
  instrumental evaluation)
   – History taking
   – Oral motor assessment
   – Voice evaluation
   – Trial swallows

                                       Slide 17
• Assessment and Diagnosis
• Primary care screening for the elderly
  – Example tool – Dysphagia screening form- University
    of Wisconsin and Madison GRECC
  – One question test – ―Do you have difficulty swallowing
  – Correlate symptoms of weight loss, cough and SOB
• Bedside clinician evaluation
  – 3 oz water swallow test, auscultate over
    trachea before and after water swallowed;
    eval for cough, choking change in breath
                                                   Slide 18
• Assessment and Diagnosis
• Physical Exam
  – Subtle voice changes (hoarseness, wet,
    hypernasal, dysarthria)
  – Absent or poor dentition
  – Tongue strength/oral control
  – Palate exam – symmetry, mass
  – Head and neck
  – Gag reflex poor indicator of dysphagia
                                             Slide 19
• Assessment and Diagnosis
• Testing
  – Modified Barium Swallow –
    • can tell which phase is dysfunctional, check for
      aspiration and compensatory mechanisms
    • Can guide swallow therapy
  – Standard Barium Swallow
    • Testing esophageal structural or functional
  – Fiberoptic endoscopy
                                                    Slide 20

• Endoscopy is the best first test
    Allows biopsies and therapeutic
    Lower esophageal rings or extrinsic
     esophageal compression can be

• Radiologic evaluation may identify the
  level and nature of obstruction

• If these tests are normal, an            Peptic stricture

  esophageal motility study should be

                                                   Slide 21
• For patients with oropharyngeal dysphagia,
   Allows detailed analysis of swallowing
   Identifies whether aspiration is present
   Evaluates the effects of different barium

• Treatment of dysphagia depends on the
  underlying cause
                                                Slide 22
• Assessment and Diagnosis
• Consultants
  – Otolaryngologist
  – Gastroenterologist
  – Neurologist
  – Speech therapist
  – Radiologist

                             Slide 23
     Disorders Associated with
• Neuromuscular – affect the central control over
  muscles and nerves involved in swallowing (i.e.
  Parkinsons, CVA, ALS, Myasthenia gravis, MS)
• Rheumatologic – (i.e. Polymyositis,
  Dermatomyositis, Inclusion body myositis)
• Head and neck oncologic – Oropharyngeal
• Pharyngeal structural – Zenkers
• Gastrointestinal – tumors, GERD, Schatzki ring
  (primarily esophageal but cause symptoms
  radiating to pharynx)
• Diminished cough                           Slide 24
• Treatment
• Goal – optimize safety of swallow, maintain
  adequate nutrition and hydration, improve oral
• Swallow therapy
   – Postural adjustments
   – Food and liquid rate and amounts (time to eat,
     small amounts, concentrate, alternate food
     and liquid, stronger side of mouth, sauces)
   – Adaptive Equipment
   – Diet modification
                                             Slide 25
• Treatment
• Swallow therapy – plan set by Speech
   – Oral stimulation
   – Pharyngeal and laryngeal stimulation
   – Position/Posture
   – Direct Swallow exercises
   – Compensatory Strategy Education
   – On-going restorative interventions
                                            Slide 26
• Treatment
• Dietary modifications (watch for dehydration)
• Aggressive oral care
• Modify eating environment
• Oral Hygiene
   – Also reduce risk of aspiration
• Interdisciplinary
• Speech pathologist, dietician, OT, PT, nurse,
  oral hygienist, dentist, PCP, Caregivers, SW,
  family                                     Slide 27
• Treatment
• ACEI – prevent breakdown of substance P
• Avoid sedatives, antihistamines, anticholinergics
  (complete med review)
• Evaluate Quality of Life
• SWAL-QOL – dysphagia specific patient-
  centered QOL instrument (document
  effectiveness of treatment for both function and
  quality of life) – monitor longitudinal course of
                                             Slide 28
• The non-fixable dysphagia
• Goal is enhanced quality of life
• Tube Feeding
  – Not essential in all patients who aspirate
  – No data to suggest TF in pts with advanced dementia
    prevented aspiration pneumonia, prolonged survival
    or improved function (aspiration pneumonia is the
    most common cause of death in PEG tube patients)
  – Short term TF indicated if improvement in swallow
    likely to improve
  – Pt autonomy, self-respect, dignity and QOL
                                                 Slide 29
• Complications
• Pneumonia
   – Aspiration –misdirection of oropharyngeal or gastric
     contents into the airway below the true vocal cords
   – Leading cause of death of residents of nursing homes
   – Dysphagia, sedating meds most important risk factor
     in long-term care residents for pneumonia
   – Increased disease in the elderly, increased risk of
     oropharyngeal dysphagia and pneumonia
   – Aggressive oral care lowered risk of pneumonia in
     nursing home residents
                                                  Slide 30
• Consequences
• Social isolation (embarrassment)
• Physical discomfort
• Dehydration
• Malnutrition
• Overt aspiration
• Silent Aspiration – a bolus comprising saliva,
  food, liquid, meds or any foreign material enters
  the airway below the vocal cords without
  triggering overt symptoms
• Pneumonia, death
                                              Slide 31
  Dysphagia in Long-Term Care

• Skilled nursing facilities required to provide
  nursing services and specialized rehab services
  to attain or maintain the highest practicable
  physical, mental and psychosocial well-being of
  each resident
• Survey guidelines mandate that the facility must
  maintain acceptable parameters of nutritional
  status, such as body weight and protein levels
  unless the resident’s clinical condition
  demonstrates this is not possible, and receives a
  therapeutic diet when there is a nutritional
  problem                                        Slide 32
 Dysphagia in Long-Term Care

• Common 50-75%
 – Aspiration leading cause of death in nursing
   home patients
 – Can stress nursing assistants with difficult
   feeding patients
    •   Place food in non-impaired side of mouth
    •   Limit use of straws
    •   Adaptive feeding equipment
    •   Restrictive diets
 – Failure to comply – (citations, inadequate
   nutrition and hydration, unsafe feeding) Slide 33
  Dysphagia in Long-Term Care
• Training nursing assistants
  – Mealtime atmosphere
  – Help residents maintain independence
  – Therapeutic diets
  – How to feed residents
  – Identify a choking victim
  – Importance of adequate hydration and
• May help to have basic knowledge of
  swallowing mechanism, signs of
  dysphagia                           Slide 34
• Training nursing assistants
  – In-service after have worked with feeding
  – Meal Time Matters – IDEAS Institute
     • Interactive Institute
     • http://www.ideasinstitute.org

                                            Slide 35
  Dysphagia in Long-Term Care

• Goals for treatment in long-term care
  – Interdisciplinary team
  – ID residents with dysphagia
  – Referral to and evaluation by team
  – Objective measurement of resident progress
  – Communication within team
  – Increase resident independence and safety
  – Carryover of treatment goals in facility and at
                                              Slide 36
  Dysphagia in Long-Term Care

• Goals for treatment in long-term care
  – Interdisciplinary team –ID Residents
     • Why is resident being fed by staff?
     • Has the resident been able to self-feed in past?
     • Are there residents who experience excessive
       coughing during or after meals?
     • Are there residents who have excessive burping or
       hiccups during meals?
     • Are there residents who frequently vomit after
     • Are there residents who refuse to eat?
                                                 Slide 37
  Dysphagia in Long-Term Care

• Goals for treatment in long-term care
  – Interdisciplinary team –Questions for staff
     •   Residents needing assist to eat
     •   Recent decline in ability to feed self
     •   Recent significant weight loss or gain
     •   Tube feedings
     •   Recurrent aspiration pneumonia
     •   Adaptive feeding equipment
     •   Dysphagia
     •   Embarrassment or anxiety at mealtimes
     •   Poor dentition                           Slide 38
  Dysphagia in Long-Term Care

• Goals for treatment in long-term care
  – After evaluation establish:
     • Self-feeding goals
     • Swallowing goals
     • Comfortable environment
  – Discuss dysphagia as part of weight loss

                                           Slide 39
  Dysphagia in Long-Term Care
• F309 – Each resident must receive and the facility must
  provide the necessary care and services to attain the
  highest practicable physical, mental and psychosocial
  well-being, in accordance with the comprehensive
  assessment and plan of care
   – Very encompassing
   – Highest possible functioning and well-being, limited
     by individual recognized pathology and normal aging
   – Unavoidable or avoidable decline, lack of

                                                  Slide 40
   Dysphagia in Long-Term Care
• F325 – Based on comprehensive assessment of
  resident, the facility must ensure that a resident
  maintains acceptable parameters of nutritional status,
  such as body weight and protein levels, unless the
  resident’s clinical condition demonstrates that this is not
  possible, and receives a therapeutic diet when there is a
  nutritional problem
   – Address risk factors for malnutrition
   – Care plan
   – Meet resident’s ordinary and special dietary needs
   – Treatable causes
   – Monitor progress
                                                      Slide 41
  Dysphagia in Long-Term Care
• Survey overall importance
  –   Care plan
  –   Assessment
  –   Document interventions
  –   Evaluate results of interventions
  –   Physician involvement
  –   Nursing assistant education as awareness of plan
  –   Family involvement
  –   Prognostication (avoidable or unavoidable)

                                                   Slide 42

• Oropharyngeal dysphagia may be life-
• All team members important
• Pt/Family important
• Don’t have to put in a tube feeding

                                         Slide 43
                     CASE 1
• A 89-year-old man has difficulty swallowing solids and
  liquids. His dysphagia has progressed slowly over 8
  months and he has lost 20 pounds. Is long-term care
  resident for 2 years
• History of dementia, COPD, CHF, DM
• Physician documentation states – Elderly pt with weight
  loss, add med pass supplement, monitor weights
• Dietary states, continued weight loss, add pudding,
  consider appetite stimulant
• Speech therapy involved, Care plan in place for weight
  loss and dysphagia, diet reduced to pureed with nectar-
  thick liquids
• Patient aspirates and sent to hospital for pneumonia
                                                 Slide 44
                      CASE 1
• Treated for aspiration pneumonia, returns with order for
  pureed with honey-thick liquids
• ST works with pt, care plan in place for weight loss and
• Physician H&P done
• Pt becomes dehydrated 10 days later and sent to
• Returns, same plan of care, treatment except Lasix
  reduced to 20mg day from 40 mg/day

                                                  Slide 45
                      CASE 1
• Physician H&P done
• ST continues working with pt
• Care plan for weight loss, dehydration and dysphagia in
• Additional 15 pound weight loss in a month.
• Pt returns to hospital with Aspiration one week later and
• Family complains about care and complaint survey

                                                  Slide 46
                      CASE 1
• What should surveyor expect to be on chart when
• What is reasonable to expect that all staff knew about
  resident’s care?
• Is anything reasonable to expect from doctor in terms of
  resident’s care
• If cited what would you include in IDR?

                                                  Slide 47

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