04/11/2014. Swallowing Disorders in Older Adults. Disclosures. Aging in America Administration on Aging. Outline. Changes with Aging

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1 Disclosures The author has no financial or nonfinancial relationships relevant to the content of this presentation Heather M Clark PhD CCC/SLP Minnesota Speech-Language-Hearing Association April 11, MFMER slide MFMER slide-2 Outline Age-related changes affecting swallowing function Assessment of dysphagia in older adults Management of dysphagia in older adults Aging in America Administration on Aging 41.4 million people over age 65 Over one in every eight, or 13.3%, of the population is an older American 79.7 million people over age 65 in million people over age 85 in 2040 Persons reaching age 65 have an average life expectancy of an additional 19.2 years MFMER slide MFMER slide-4 Changes with Aging Reduced sense of smell and taste Increased risk of xerostomia secondary to medications and illness Increased risk of tooth decay and gum disease Reduced esophageal motility Increased prevalence of GERD Slowed gastric emptying Heightened satiety schmoop.com Changes with Aging Decrease in neurons Reduced production of neurotransmitters Slowed neuronal conduction Slowed response times 2014 MFMER slide MFMER slide-6 1

2 Sarcopenia Reduction in muscle mass, strength, and endurance associated with aging Begins in 30 s, accelerates after age 75 (3-5% per decade) Causes Hormonal changes Changes in protein synthesis Nutrition Inactivity Changes in motor unit configurations iofbonehealth.org Sarcopenia in the Oropharyngeal Musculature Reduced lingual strength apparent by age 60 (Clark and Solomon, 2012; Youmans, Youmans, & Stierwalt 2009) Reduced lingual thickness is associated with poor nutritional status (Tamura et al 2012) Age-related changes in swallowing physiology (see Sarcopenia Resources) Increased oral and pharyngeal transit times More posterior/inferior bolus location at initiation of pharyngeal swallow More frequent pharyngeal residue More frequent laryngeal penetration See Sarcopenia Resources by Specialty Board on Swallowing & Swallowing Disorders 2014 MFMER slide MFMER slide-8 Respiratory Musculature Changes in respiratory system associated with aging (see Kim & Sapienza, 2005) Reduced lung elasticity, increased chest wall stiffness Reduced respiratory muscle strength Resistance exercise Inspiratory muscle training improves ventilatory capacity Expiratory muscle training improves nonventilatory functions (cough, swallow, speech) Laryngeal Musculature Intrinsic: Control vocal cord closure and tension Extrinsic: Contribute to hyolaryngeal elevation, epiglottic inversion, UES dilation Age-related changes Laryngeal cartilages ossify, making them less flexible Muscles atrophy, affecting strength as well as bulk for achieving vocal cord closure 2014 MFMER slide MFMER slide-10 Velopharyngeal Musculature Velar movements Contribute to posterior seal preventing premature spillage Prevent flow of bolus into nasopharynx Facilitate pharyngeal pressure generation to enhance bolus transit Pharyngeal constriction Pharyngeal pressures vary with swallowing condition Weakness presumed to contribute to residue 2014 MFMER slide-11 Lingual Musculature Evidence of lingual sarcopenia Animal models (e.g., Schaser et al 2011) Human studies (Beuhring et al, 2013; Clark and Solomon, 2012; Robbins et al, 1995; Tamura et al, 2012; Youmans, Youmans, & Stierwalt 2009) Contributes to multiple aspects of oropharyngeal swallow Oral containment Bolus manipulation Bolus transit (oral and pharyngeal) Oral phase dysphagia more common in patients with lingual weakness (Clark et al, 2003; Reddy et al, 1990; Robinovitch et al, 1991; Stierwalt & Youmans, 2007; Yoshida et al, 2006) 2014 MFMER slide-12 2

3 Orofacial Musculature Lip and Cheek Presumed association with anterior spillage and/or residue in lateral sulci (No studies were identified that specifically associated objectively measured labiobuccal weakness with oral dysphagia) Jaw Presumed to influence chewing effectiveness and efficiency Video of presbyphagia DVD # MFMER slide MFMER slide-14 Dysphagia-related Conditions in Aging Vascular (e.g., CVA) Neuromuscular (e.g., ALS) Movement (e.g., PD) Neurocognitive (e.g., AD, PPA) Respiratory (e.g., COPD) Gastrointestinal Neoplastic Infectious (community and hospital acquired) Assessment Considerations Older Adults 2014 MFMER slide MFMER slide-16 History Relevant co-morbidities Independence with food preparation Diet restrictions associated with co-morbidities or preference Prosthodontic fit Appetite Oral Structure and Function Dentition and prosthodontics Xerostomia Strength/functional reserve 2014 MFMER slide MFMER slide-18 3

4 Clinical and Instrumental Exam Observe clinical signs and evidence of physiologic impairment Consider variations associated with healthy aging Expands range of WNL/WFL Does not change severity ratings of identified dysphagia Management Considerations Older Adults 2014 MFMER slide MFMER slide-20 Candidacy for therapy Age should not be an independent indicator for candidacy Additional factors (examples) Resources (availability of SLP, transportation, funding, etc) Cognitive resources Physical limitations Sensori-perception Mobility or posture Self-feeding Treatment Targets 2014 MFMER slide MFMER slide-22 A Framework for Managing Dysphagia A Framework for Managing Dysphagia Structural and Functional Impairments Rehabilitative Clinical Signs Adaptive (Compensatory) Structural and Functional Impairments Structural impairments Clefts Resections Trauma Functional impairments Forces and pressures Speed and timing 2014 MFMER slide MFMER slide-24 4

5 A Framework for Managing Dysphagia Bolus containment Bolus manipulation Bolus transit Airway protection Clinical Signs Adaptive 2014 MFMER slide MFMER slide-26 Adaptive strategies Address clinical signs Manipulate the swallowing context to facilitate safety Do not induce permanent physiologic change Are effective only when in use Are effective immediately Effectiveness can be assessed during initial evaluation Adaptive strategies Postural changes Swallowing maneuvers Common sense behavioral modifications Somatosensory stimulation Diet modifications 2014 MFMER slide MFMER slide-28 Adaptive strategies Postural changes use gravity and/or pressure changes to contain or redirect the bolus Swallowing maneuvers alter the intensity or timing of swallowing behaviors augment swallow with volitional airway protection Adaptive strategies Common sense modifying bolus size serial swallows alternating solids and liquids moistening solids 2014 MFMER slide MFMER slide-30 5

6 Adaptive strategies Somatosensory stimulation Visual Taste Temperature Tactile Diet modifications manipulate Viscosity Elasticity Particulateness Adaptive Oral Containment 2014 MFMER slide MFMER slide-32 Oral Containment Adaptive : Oral Containment Lip, tongue, jaw and/or velar weakness or coordination Reduced sensitivity Xerostomia Anterior spillage Premature spillage Lateral sulci residue Anterior Spillage bolus placement on strong side head tilt to strong side Rehabilitative Adaptive (Compensatory) side lying posterior bolus placement assisted labial closure thickened liquids 2014 MFMER slide MFMER slide-34 Adaptive : Oral Containment Adaptive : Oral Containment Premature Posterior Spillage head tilt forward thickened liquids reduced particulateness of solids Lateral sulci residue Bolus placement on strong side Head tilt to strong side Sidelying heighten sensory awareness (temperature, taste) Reduce particulateness Finger sweep 2014 MFMER slide MFMER slide-36 6

7 Bolus preparation/manipulation Adaptive Bolus Preparation Lip, tongue, jaw and/or velar weakness or coordination Inadequate dentition Reduced sensitivity Xerostomia Rehabilitative Failure to respond to food stimuli Ineffective mastication Prolonged preparation Adaptive (Compensatory) 2014 MFMER slide MFMER slide-38 Adaptive : Bolus Preparation Adaptive : Bolus Preparation Agnosia Prolonged or incomplete mastication Modify elasticity of solids Targeted chewing rates Small bites Artificial saliva Additional sauces/gravies 2014 MFMER slide MFMER slide-40 Oral Transit Tongue weakness Reduced sensitivity Xerostomia Bradyphagia Oral residue Vallecular residue Adaptive Oral Transit Rehabilitative Adaptive (Compensatory) 2014 MFMER slide MFMER slide-42 7

8 Adaptive : Oral Transit Adaptive : Oral Transit Bradyphagia Oral residue Bolus placement on strong side Head tilt to strong side Reduce particulateness Thicken liquids Small bites Additional sauces/gravies Alternate solids and liquids Finger sweeps 2014 MFMER slide MFMER slide-44 Adaptive : Oral Transit Vallecular Residue Reduce particulateness Serial swallows Alternate solids and liquids Effortful swallow Head turn to weak* side Head tilt to strong* side Adaptive Bolus Transit 2014 MFMER slide MFMER slide-46 Pharyngeal Transit Adaptive : Bolus Transit Tongue weakness Pharyngeal weakness Impaired hyo-laryngeal excursion Impaired UES dilation Reduced sensitivity Xerostomia Nasopharyngeal Reflux Vallecular residue Pyriform residue Nasopharyngeal Reflux Upright posture Effortful swallow Thickened liquids Prosthetics Rehabilitative Adaptive (Compensatory) 2014 MFMER slide MFMER slide-48 8

9 Adaptive : Bolus Transit Effortful Swallow Vallecular Residue Reduce particulateness Serial swallows Alternate solids and liquids Effortful swallow Head turn to weak* side Head tilt to strong* side Linguapalatal pressure (Hind et al, 2001) Tongue base to pharyngeal wall pressure (Lazarus et al, 2002) Hyolaryngeal excursion (Hind et al, 2001) Pharyngeal pressure (peak & duration; earlier onsets) (Huckabee et al, 2005) Submental muscle activity (Huckabee et al, 2005) Duration of UES opening (Hind et al, 2001; Hiss et al 2005) Esophageal peristaltic amplitudes (Lever et al, 2007) Raises hyolaryngeal complex prior to the swallow (Bulow et al, 1999) Reduced penetration (Bulow et al 2001) 2014 MFMER slide MFMER slide-50 Adaptive : Bolus Transit Surface NMES to Neck Pyriform Residue for vallecular residue Mendelsohn VitalStim Condition Effects Normals: reduced laryngeal and hyoid elevation during stimulation (Humbert et al, 2006) Patients Stimulation on: hyoid lowers at rest, improved swallowing on some measures, not on others (Ludlow et al, 2007) Stimulation over time: greater improvement with VS compared to TDT; improved oral intake and swallowing physiology (not laryngeal elevation) (Shaw et al, 2007) 2014 MFMER slide MFMER slide-52 Airway Protection Adaptive Airway Protection Delayed pharyngeal response Reduced hyo-laryngeal excursion Reduced laryngeal closure Impaired sensitivity Impaired cough Rehabilitative P/A before the swallow P/A during the swallow P/A after the swallow Adaptive (Compensatory) 2014 MFMER slide MFMER slide-54 9

10 Adaptive : Airway Protection Adaptive : Airway Protection Penetration/Aspiration before the swallow Head down (chin tuck) posture Thermotactile stimulation Penetration/Aspiration during the swallow Super supraglottic swallow maneuver Supraglottic swallow maneuver Modified food textures 2014 MFMER slide MFMER slide-56 Adaptive : Airway Protection Penetration/Aspiration after the swallow Any strategies addressing residue Supraglottic swallow maneuver Position changes Semi-reclined Sidelying Evidence Supporting Use of Adaptive Techniques Thermal-tactile Stimulation TTS + oral stim + oral massage + digital manipulation improved swallowing physiology (but not occurrence of pneumonia or LOS) 4 studies with normal subjects during a single session 2 showed no effect 1 showed shorter latency with cold+tactile+sour, 1 showed brisk response 2 studies with patient groups during a single testing session Reduced stage transition time (stroke pts) No effect (neurologic pts with delayed swallow response) 2014 MFMER slide MFMER slide-58 Evidence Supporting Use of Adaptive Techniques Bolus Manipulations (taste, texture, temperature, volume, viscosity) Most studies examine single exposure effects There is a lack of evidence of the importance of texture modified foods and thickened fluids related to the amount of diet intake for adults with acute dysphagia There is some evidence of that thickened fluid cannot increase fluid intake for persons with acute and chronic dysphagia Evidence Supporting Use of Adaptive Techniques Bolus Manipulations (taste, texture, temperature, volume, viscosity) There is some evidence that special made and nutritional enriched texture modified food (pureed and minced) and thickened fluid (nectar, honey and pudding consistency) can increase the nutritional status of elderly persons with chronic dysphagia 2014 MFMER slide MFMER slide-60 10

11 Postural Changes Most studies examine single-exposure effects, but at least one reported positive rehabilitation outcomes Swallowing Maneuvers Most studies examine single exposure effects on swallowing physiology Chin tuck and supraglottic swallow Single session: inconsistent effects Long term: generally beneficial 2014 MFMER slide MFMER slide-62 Rehabilitative strategies Rehabilitative Target underlying physiologic impairment Intend to induce relatively permanent change in physiology Generally require time to become effective (dosage) Targets should reflect impairments identified during assessment should be consistent with current models of neuromuscular rehabilitation and motor learning 2014 MFMER slide MFMER slide-64 Rehabilitative strategies Strength Range Structure Neurophysiology Preventing/Slowing/Reversing Sarcopenia Resistance Exercise (see Vella & Kravitz, 2002; Liu & Latham, 2009) Strength gains with exercise similar to those shown in younger individuals Stimulates release of relevant hormones May enhance the benefit of nutritional and hormonal interventions General Principles (American College of Sports Medicine, do not address swallowing musculature) 2-4 days per week minutes 1-2 exercises per muscle group reps 65-75% of maximum 2014 MFMER slide MFMER slide-66 11

12 Rehabilitative Oral Containment Lip, tongue, jaw and/or velar weakness or coordination Reduced sensitivity Xerostomia Rehabilitative Anterior spillage Premature spillage Prolonged preparation Adaptive (Compensatory) 2014 MFMER slide MFMER slide-68 Rehabilitative : Bolus Containment Lip Screen Lip weakness Strengthening Facercise; mookychick.co.uk Facial-Flex; blaisemedical.com 2014 MFMER slide-69 Retrospective (uncontrolled study) of stroke pts showed improved strength and swallow function 2014 MFMER slide-70 Orofacial Strengthening Outcomes Improved oropharyngeal swallow efficiency following range of motion and/or coordination exercises (Logemann et al,1997) Greater weight gain with standard oral motor exercise plus dietary supplement than supplement alone in healthy elderly (Kikutani et al, 2006) Improved lip strength and swallowing capacity in stroke patients (Haag & Aniko, 2008) No change in lip or cheek strength following 4 weeks of training with high resistance straws (Clark & Shelton, 2011) Rehabilitative : Bolus Containment Reduced Tactile Sensation No evidence showing stimulation has direct effects on sensation 2014 MFMER slide MFMER slide-72 12

13 Rehabilitative : Bolus Containment Rehabilitative : Bolus Containment Reduced Taste or Olfactory Sensation?? Lingual weakness Strengthening 2014 MFMER slide MFMER slide-74 Lingual Strengthening Must involve resistance and overload (traditional OME likely insufficient) Specificity effects Observed for strength/endurance (Clark, 2012) Not observed for direction of movement in the context of maximum contraction (Clark et al., 2009) Observed for functional aspects of lingual movements (Clark & Shelton, 2011) Lingual muscle training can result in non-specific functional outcomes Training of anterior lingual elevation improves swallowing function (Robbins et al, 2005, 2007; Yeates et al, 2008) Lingual Strengthening: IOPI 2014 MFMER slide MFMER slide-76 Lingual Strengthening: IOPI Lingual Strengthening: Ora-Light 2014 MFMER slide MFMER slide-78 13

14 High Resistance Straws 2014 MFMER slide MFMER slide MFMER slide MFMER slide-82 Lingual Strengthening -- Outcomes Increased tongue strength (too many references to list) Increased lingual volume (Robbins et al, 2005) Improved swallowing pressures in healthy aging adults (Robbins et al, 2005) Increased swallowing pressures and reduced airway invasion (Robbins et al, 2007) Improved bolus control on videofluoroscopy (Yeates et al, 2008) Improved functional dietary intake by mouth (Yeates et al, 2008) Rehabilitative : Bolus Containment Buccal weakness Strengthening 2014 MFMER slide MFMER slide-84 14

15 Rehabilitative : Bolus Containment Rehabilitative : Bolus Containment Velar weakness? Exercise for velar depression? Hypophagia LSVT Sharkawi et al demonstrated improved swallowing (did not report effects on drooling) 2014 MFMER slide MFMER slide-86 Bolus preparation/manipulation Rehabilitative Bolus Preparation Lip, tongue, jaw and/or velar weakness or coordination Inadequate dentition Reduced sensitivity Xerostomia Rehabilitative Failure to respond to food stimuli Ineffective mastication Prolonged preparation Adaptive (Compensatory) 2014 MFMER slide MFMER slide-88 Rehabilitative : Bolus Preparation Rehabilitative : Bolus Preparation Lip, tongue, jaw and/or velar weakness or coordination Lip and tongue weakness addressed above Reduced jaw strength or ROM Strengthening Stretching Inadequate dentition Dental consult Reduced sensitivity Addressed above 2014 MFMER slide MFMER slide-90 15

16 Jaw Strengthening High resistance chewing gum Ingervall & Sitsanis (1987) Tzakis et al (1989) Chewy Tubes Jaw Stretching Active & Passive ROM mj-exerciser-and-jaw-exercise-for-tmj 2014 MFMER slide MFMER slide-92 Jaw Strengthening Outcomes Immediate decrease in chewing efficiency following exercise with high resistance chewing gum (Tzakis, M. G., et al. 1989) Rehabilitative : Bolus Preparation Xerostomia Modify medications Parasympathetic stimulating drugs Electrical stimulation 2014 MFMER slide MFMER slide-94 Oral Transit Tongue weakness Reduced sensitivity Xerostomia Oral residue Vallecular residue Oral Transit Rehabilitative Adaptive (Compensatory) 2014 MFMER slide MFMER slide-96 16

17 Rehabilitative : Oral Transit Tongue weakness Reduced sensitivity Xerostomia Addressed above Addressed above Addressed above Pharyngeal Phase 2014 MFMER slide MFMER slide-98 Rehabilitative Bolus Transit Pharyngeal Transit Tongue weakness Velar weakness Pharyngeal weakness Impaired hyo-laryngeal excursion Impaired UES dilation Reduced sensitivity Xerostomia Rehabilitative Nasopharyngeal reflux Vallecular residue Pyriform residue Adaptive (Compensatory) 2014 MFMER slide MFMER slide-100 Rehabilitative : Pharyngeal Transit Velar weakness Traditional OME (blowing, sucking exercises) CPAP Effortful swallow McNeil Dysphagia Therapy Program Masako CPAP Constant Positive Airway Pressure Shown to improve velopharyngeal valving during speech (Kuehn et al, 2002) Swallowing outcomes not yet studied 2014 MFMER slide MFMER slide

18 Rehabilitative : Pharyngeal Transit Pharyngeal weakness Masako Effortful swallow LSVT NMES McNeil Dysphagia Therapy Program Masako (Anterior Tongue Anchor) Original studies focused on pharyngeal effects, potentially affects lingual retraction as well Outcomes (condition effects) Bulging of posterior pharyngeal wall (Fujiu & Logemann, 1996) Increased (Lazarus et al 2002) or decreased (Umeki et al 2009; Doeltgen, 2009) tongue base to pharyngeal wall contact pressures Increased UES relaxation pressures in older adults (Doeltgen, 2011) Training effects unknown 2014 MFMER slide MFMER slide-104 Effortful Swallow Clark & Shelton (submitted) 40 healthy adult participants 35 females / 5 males Mean age 23.7 years (range 18 to 59) Assigned to one of three training conditions Tongue elevation + ES (N=15) Resistance straw training + ES (N=18) ES only (N=7) Daily exercise for 4 weeks 3 sets of 10 repetitions 2014 MFMER slide MFMER slide-106 Outcome Measures Lingual swallowing pressure Submental semg Negative pressure Obtained during Noneffortful dry swallow Effortful dry swallow Tongue strength Lingual Swallowing Pressure Tongue + ES Straw + ES ES Only Training x Effort F(1, 37) = 15.2 p =.000 Noneffortful Training Effects t (39) =.703 p =.486 Effortful Training Effects t (39) = 4.73 p =.000 PreTraining PostTraining PreTraining PostTraining Noneffortful Effortful Training F(1, 37) = 9.66 p =.004 Effort F(1, 37) = p =.000 Group F(2, 37) = 3.33 p = MFMER slide MFMER slide

19 Conclusions Training effortful swallow (in isolation or with preparatory contraction) improves only effortful swallows Training with high resistance straws improves only effortful sips. ES and/or tongue exercise did not improved sipping strength 2014 MFMER slide MFMER slide-110 Effortful Swallow Training Outcomes Increased oral pressures during effortful swallows (Clark & Shelton, 2011) Increased cutaneous neck pressure during effortful swallow (Felix et al, 2008) Increased hyoid elevation (paired with NMES) (Park et al, 2009) NMES Uses electricity to cause muscle contraction Electrode Sites Surface Percutaneous Intramuscular Current parameters Amplitude, duration, & frequency Intensity Waveform (pulsed most common) Bursts Has been applied to limb musculature to increase strength, but is most often used in conjunction with active exercise 2014 MFMER slide MFMER slide-112 Electrical Stimulation Surface NMES to Neck VitalStim No impact on pharyngeal physiology, diet advancement or return to oral feeding (Kiger et al 2006) Overall swallowing severity improved more with VS compared to TTS (Freed et al 2001) or traditional treatment (Blumenfeld et al 2006) 2014 MFMER slide MFMER slide

20 Surface NMES to Neck Rehabilitative : Bolus Transit Carnaby-Mann & Crary (2007) Meta-analysis 7 studies accepted for analysis 255 patients studied 2 controlled trials 5 used before/after (case series) design All studies used Transcutaneous stimulation applied to throat 20% improvement in swallowing function (collapsed across all studies) but actual outcome measures varied across studies Methodological flaws not addressed Reduced hyo-laryngeal excursion (weakness) Shaker head lift Mendelsohn Expiratory muscle strength training Falsetto 2014 MFMER slide MFMER slide-116 Extrinsic Laryngeal Muscle Strengthening Strength (ROM) contributes to Airway protection Epiglottic inversion UES dilation Shaker Head Lifts Head lifts Isometric Isotonic Outcomes Significant change in functional swallowing measure (Shaker et al, 2002 participants aged 62-89) Improved laryngeal elevation and UES dilation (Easterling et al, 2005; Logemann et al, 2009; Shaker et al, 1997) MFMER slide MFMER slide-118 ISO SwallowingExercises.com ISO Swallowing Exercise Device Baseline Medical Services, Inc MFMER slide MFMER slide

21 Mendelsohn Sustained laryngeal elevation during swallow Technically a ROM or endurance exercise (no added resistance) Outcomes Prolonged UES opening in normal participants (Ding et al, 2002) Improved timing of pharyngeal events in a single subject during VFSS (Logemann et al 1990) 87% (39/45) of all patients increased their functional oral intake of food/liquid (Neumann, 1993; Crary et al, 2004) Expiratory Muscle Strength Training (EMST) Pressure threshold trainer Resistance set at 75% maximum expiratory pressure 5-6 sets of 5 breaths 3 or 5 days per week (Anand et al 2012) 4-8 weeks 2014 MFMER slide MFMER slide-122 Expiratory Muscle Strength Training (EMST) Training Outcomes (see Sapienza et al 2011) Increased expiratory pressures Improved cough Increased submental muscle activity, influencing hyolaryngeal elevation Improvements in P-A scale Airway Protection 2014 MFMER slide MFMER slide-124 Airway Protection Delayed pharyngeal response Reduced hyo-laryngeal excursion Reduced laryngeal closure Impaired sensitivity Impaired cough Rehabilitative P/A before the swallow P/A during the swallow P/A after the swallow Adaptive (Compensatory) 2014 MFMER slide-125 Rehabilitative Airway Protection 2014 MFMER slide

22 Rehabilitative : Airway Protection Rehabilitative : Airway Protection Delayed pharyngeal response Impaired hyo-laryngeal elevation Addressed above 2014 MFMER slide MFMER slide-128 Rehabilitative : Airway Protection Reduced laryngeal closure Laryngeal adduction exercises Intrinsic Laryngeal Muscle Strengthening Bearing down (push-pull) Case study reported improved swallowing function pairing laryngeal adduction exercise with semg biofeedback (Crary et al, 2004) LSVT (also targets respiratory musculature) LSVT with 8 patients with Idiopathic Parkinson Disease. 51% decrease in swallowing motility disorders (El Sharkawi et al, 2002) 2014 MFMER slide MFMER slide-130 Rehabilitative : Airway Protection Rehabilitative : Airway Protection Reduced laryngeal sensitivity? PMV in the context of tracheostomy Impaired cough Expiratory muscle training 2014 MFMER slide MFMER slide

23 Exercise-based Dysphagia Intervention Outcomes for Older Adults Many studies examining benefits for individuals with dysphagia have not excluded young adults, but the populations of interest (e.g., stroke patients) tended to be older No studies have demonstrated poorer response to exercisebased treatments by older participants compared to younger participants Medicare Issues 2014 MFMER slide MFMER slide-134 Contract # /0003 DynCorp Therapy PSC Final Therapy Review Protocols 30 November 2001 Dysphagia Protocol Indications for Dysphagia Evaluation Documentation within the medical record must include at least one of the following conditions: History of aspiration or high risk for aspiration; Nasal regurgitation, choking, or frequent coughing during swallowing; Wet gurgling voice quality after swallowing, or delayed or slow swallow reflex; Presence of oral motor disorders such as drooling, oral food retention, or leakage of food or liquids placed into the mouth; Impaired salivary gland performance and/or presence of local structural lesions in the oral cavity or pharynx; Contract # /0003 DynCorp Therapy PSC Final Therapy Review Protocols 30 November 2001 Dysphagia Protocol Indications for Dysphagia Evaluation In-coordination, sensation loss, postural difficulties or other neuromotor disturbances affecting oropharyngeal abilities necessary to close the oral cavity and/or to bite, chew, suck, shape and/or squeeze the food bolus into the upper esophagus while protecting the airway; Post-surgical reaction affecting ability to adequately use oropharyngeal structures for swallowing; Documented weight loss and/or malnutrition of undetermined etiology that would require an evaluation to rule out dysphagia; 2014 MFMER slide MFMER slide-136 Contract # /0003 DynCorp Therapy PSC Final Therapy Review Protocols 30 November 2001 Dysphagia Protocol Indications for Dysphagia Evaluation The presence of a tracheostomy, NG- or G-tube; reduced or inadequate laryngeal elevation, labial closure, airway management problems, velopharyngeal closure, laryngeal closure, or pharyngeal peristalsis; or criocopharyngeal dysfunction. Existence of other conditions affecting the structural or functional integrity of the pharyngeal area. Examples of Information to be Included In Documentation of Skilled Services Use terminology that reflects the clinician's technical knowledge. Indicate the rationale (how the service relates to functional goal), type, and complexity of activity. Because patient has residue in the mouth with solids, putting him at risk to aspirate that material, he performed tongue sweeps of the buccal cavity with minimal cues on 80% of solid boluses MFMER slide Documentation-of-Skilled-and-Unskilled-Care-for-Medicare- Beneficiaries/ 2014 MFMER slide

24 Examples of Information to be Included In Documentation of Skilled Services Report objective data showing progress toward goal, such as accuracy of task performance speed of response/response latency frequency/number of responses or occurrences (e.g., patient swallowed 6/10 PO trials of ½ tsp boluses of puree textures with no delay in swallow initiation); number/type of cues level of independence in task completion (e.g., patient verbally described all compensatory strategies to maximize swallow safety independently, but required minimal verbal cues from SLP/caregiver to safely implement them at mealtimes) 2014 MFMER slide-139 Examples of Information to be Included In Documentation of Skilled Services Specify feedback provided to patient/caregiver about performance Explain decision making that result in modifications to treatment activities or the POC. Explain how modifications resulted in a functional change (e.g., patient's attention is enhanced by environmental cues and restructuring during mealtime, allowing her to consume at least 50% of meal without redirection). Explain advances based on functional change (e.g., coughing has decreased to less than 2x/6 oz. drink; liquids upgraded from nectar to thin). Documentation-of-Skilled-and-Unskilled-Care-for-Medicare- Beneficiaries/ 2014 MFMER slide-140 Examples of Information to be Included In Documentation of Skilled Services Explain decision making that result in modifications to treatment activities or the POC. Indicate additional goals or activities Indicate dropped or reduced activities (e.g., cuing hierarchy was modified to limit tactile cues to enable greater independence in patient's use of compensatory strategies at mealtimes). Elaborate on patient/caregiver education or training Evaluate patient s/caregiver s response to training Documentation Short-term goal Pt will safely consume mechanical soft diet with thin liquids x 3 meals per day with 1 overt s/s of aspiration to meet all nutrition/hydration needs. Documentation-of-Skilled-and-Unskilled-Care-for-Medicare- Beneficiaries/ 2014 MFMER slide Documentation-of-Skilled-and-Unskilled-Care-for-Medicare- Beneficiaries/ 2014 MFMER slide-142 Documentation Unskilled progress note Pt has been tolerating mechanical soft/thin liquid diet well. Comment: This progress note does not reflect change in status as a result of skilled intervention. Skilled progress note Pt has been seen for 8 treatment sessions during this period. Pt's diet was upgraded from puree/nectar thick liquids to mechanical soft/thin liquid diet. Pt safely consumed 3 trial meals at lunch with no overt signs and symptoms of aspiration. Pt requires mod verbal cues to safely implement compensatory strategies. The shortterm goal has been updated to include trials of regular texture foods. Plan of care includes caregiver education prior to discharge MFMER slide-143 Documentation Unskilled discharge note Pt has made progress during treatment. Pt and wife educated on use of swallow strategies for safety. Recommend discharge SLP services at this time. Comment: This note does not detail skilled intervention, patient's functional change in status, or skilled aspects of caregiver training. Documentation-of-Skilled-and-Unskilled-Care-for-Medicare- Beneficiaries/ 2014 MFMER slide

25 Documentation Skilled discharge note Skilled SLP services included caregiver education, dysphagia management, therapeutic diet upgrade trials, compensatory strategies (pacing, full oral clearance, cyclic ingestion, relaxation technique for controlled breathing) and discharge counseling. Pt currently has orders for mechanical soft with thin liquids x 2 meals (breakfast/lunch) but remains on puree at dinner. Significantly reduced swallow safety noted in evening due to increased cognitive-behavioral changes associated with sun-downing. Pt and his wife educated re: compensatory swallow strategies to improve safe and efficient swallowing with 100% return demonstration of strategies by his wife. SLP educated pt and family on the need to implement relaxation strategies while eating due to pt experiencing anxiety during meal times. Recommend pt returns home with home health SLP services to address swallow safety while maximizing efficient PO intake on mechanical soft diet with thin liquids. Concluding Remarks The knowledge and skills relevant for managing dysphagia in older adults have broader application Additional study is needed to demonstrate benefit of adaptive and rehabilitative strategies for older adults with dysphagia 2014 MFMER slide MFMER slide-146 References American College of Sports Medicine (no date) Resistance training and the older adult. Indianapolis IN: ACSM. Anand, S., El-Bashiti, N., & Sapienza, C. (2012). Effect of training frequency on maximum expiratory pressure. [Research Support, Non-U.S. Gov't]. American journal of speech-language pathology / American Speech- Language-Hearing Association, 21(4), doi: / (2012/ ) Questions & Discussion Ashford, J., McCabe, D., Wheeler-Hegland, K., Frymark, T., Mullen, R., Musson, N.,... Hammond, C. S. (2009). 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