Dysphagia as a Geriatric Syndrome Assessment and Treatment. Ashton Galyen M.A., CCC-SLP St. Vincent Indianapolis Acute Rehabilitation Unit

Transcription

1 Dysphagia as a Geriatric Syndrome Assessment and Treatment Ashton Galyen M.A., CCC-SLP St. Vincent Indianapolis Acute Rehabilitation Unit March 16, 2018

2 Ashton Galyen, M.A., CCC-SLP Master s degree in Speech Language Pathology from Indiana University, class of Speech Language Pathologist (SLP) at St. Vincent Hospital 2012-current Indiana State Certified Nationally certified through American Speech Language Hearing Association. 2

3 Disclosure This speaker has no conflict of interest to disclose. 3

4 Dysphagia Red Flags Clinical signs of dysphagia to monitor for during meals: Coughing/Choking Throat clearing Wet/ gurgly vocal quality Effortful chewing or swallowing Losing food/ liquid/ drool from the mouth Pocketing food/ liquid in the mouth Complaints of things getting stuck Changes in respiration during intake Subtle Signs of Aspiration: watery eyes, runny nose, congestion, increased coughing or shortness of breath after intake, temperature spikes after meals. 4

5 Bedside Swallow Evaluation (BSE) Completed by Speech Language Pathologist Conducts interview with patient and caregivers: Noted coughing/ choking during meals Length of meal times Weight loss Plus red flags Observes the patient swallowing different liquid & food consistencies, looking for red flags and signs/symptoms of aspiration. Bedside assessments cannot detect silent aspiration. 5

6 Videofluoroscopic Evaluation of Swallow The videoflouroscopic swallowing study (VFSS), or the modified barium swallow study (MBSS), is a radiographic procedure that provides a direct, dynamic view of oral, pharyngeal, and upper esophageal function (Logemann, 1986). An SLP completes the VFSS by providing the patient with various consistencies of food and liquid mixed with barium. The VFSS identifies: 1. Aspiration 2. Assesses amount and timing of aspiration 3. Assesses anatomy and pathophysiology of swallow function in the oral and pharyngeal phases. It provides clinically useful information on the influence of compensatory strategies and diet changes (Martin-Harris et al, 2000). 10

7 Normal elderly swallow This is a clip of an 84 year-old woman swallowing from "Videofluoroscopic Review of Swallowing" DVD by Roger D. Newman, BSc (Hons), MSc, MRCSLT Julie M. Nightingale, PhD, MSc, DCR(R). 7

8 PENETRATION food or liquid enters the airway, but does not pass the level of the vocal folds 8

9 ASPIRATION food or liquid enters the airway past the level of the vocal folds Aspiration Video 9

10 SILENT PENETRATION/ ASPIRATION penetration/aspiration occurs & the patient gives no outward signs of difficulty (no coughing or throat clearing) Silent Aspiration Video 10

11 RESIDUE food or liquid material remaining in the aerodigestive tract Residue Penetration Video Residue Aspiration FEES Oral cavity Valleculae Pyriform sinus 11

12 Treatment for Dysphagia Diet/Liquid Modifications SLP may change the texture/ consistency of foods and liquids to allow for safer and more efficient swallowing. Compensatory Strategies SLP may recommend following certain precautions to help compensate for the particular swallowing problems, reducing risk for aspiration Neuromuscular Re-education SLP may lead the patient in exercises to target specific muscles to improve swallow function, usually determined after visualization of deficits and areas of weakness on an instrumental swallow study *Both rehabilitative and compensatory 12

13 Diet/ Liquid modification Current terminology: Liquids: Thin liquid Nectar thick liquid Honey thick liquid Pudding thick liquid Solids: Regular textures Dysphagia Chopped (mechanical soft) Dysphagia ground Puree NPO (c) The International Dysphagia Diet Standardisation Initiative 13

14 Compensatory Strategies General Safety Precautions Sit upright for intake Small bites and sips Pacing strategies (i.e., slow intake; one bite/ sip at a time) Compensations, if warranted by instrumental testing: Dry swallow or multiple swallows (to clear residue) Alternate foods and liquids Avoid mixed consistencies 14

15 Compensatory techniques Head Turn SLP may recommend turning the head to one side to help close off the weaker side of the throat in order to better protect the airway and prevent buildup of residue. Chin Tuck Patient tries to touch chin to chest during intake, keeping their chin down until after they have finished swallowing. Changes position of anatomical structures. Gravity can help prevent premature spillage into the pharynx. Can increase the risk of aspiration for some patients, therefore should NOT be used unless recommended by SLP. 15

16 Effortful swallow Swallow hard! The patient is instructed to swallow and push hard with the tongue against the hard palate. Influences multiple aspects of swallow function: Increases posterior tongue base movement to facilitate bolus clearance (Huckabee & Steele, 2006). Hyolaryngeal excursion (Hind et al, 2001) Reduced penetration (Bulow et al, 2001) Tongue base to pharyngeal wall pressure (Lazarus et al, 2002) 16

17 Neuromuscular Re-education Laryngeal elevation Targets the longitudinal pharyngeal muscle groups (Pearson et al, 2013) Attempts to lift and maintain the larynx in an elevated position by patient gliding up a pitch scale and holding a high note for several seconds. This maintains the larynx in an elevated position. Masako or tongue hold The patient holds the tongue forward between the teeth while swallowing. Improves movement and strength of the posterior pharyngeal wall during the swallow. (Fuji et al, 1996). Shaker exercise, head-lifting exercises While resting in supine position, patient lifts the head to look at the toes which allows an increased opening of the upper esophageal sphincter through increased hyoid and laryngeal anterior and superior excursion. Significant change in functional swallowing measures for participants aged (Shaker et al 2002) Improved laryngeal elevation and UES dilation (Easterling et al, 2005; Logemann et al, 2009; Shaker et al, 1997) 17

18 Masako or tongue hold The patient holds the tongue forward between the teeth while swallowing. Improves movement and strength of the posterior pharyngeal wall during the swallow. (Fuji et al, 1996). Shaker exercise, head-lifting exercises While resting in supine position, patient lifts the head to look at the toes which allows an increased opening of the upper esophageal sphincter through increased hyoid and laryngeal anterior and superior excursion. Significant change in functional swallowing measures for participants aged (Shaker et al 2002) Improved laryngeal elevation and UES dilation (Easterling et al, 2005; Logemann et al, 2009; Shaker et al, 1997) 18

19 Bibliography American Speech-Language-Hearing Association. (2004b). Preferred practice patterns for the profession of speech-language pathology [Preferred Practice Patterns]. Available from American Speech-Language-Hearing Association. (2009).Frequently asked questions (FAQ) on swallowing screening: Special emphasis on patients with acute stroke. Retrieved from Barczi, S. R., Sullivan, P. A., & Robbins, J. (2000). How should dysphagia care of older adults differ? Establishing optimal practice patterns. Seminars in Speech and Language Pathology, 21, Bhattacharyya, N. (2014). The prevalence of dysphagia among adults in the United States. Otolaryngol Head Neck Surg, 151(5) doi: / Bloem, B. R., Lagaay, A. M., van Beek, W., Haan, J., Roos, R. A. C., & Wintzen, A. R. (1990). Prevalence of subjective dysphagia in community residents aged over 87. British Medical Journal, 300, Bulow, M., et al. (2001). Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in patients with pharyngeal dysfunction. Dysphagia. Summer;16(3): Cabré, M., Serra-Prat, M., Force, L., Almirall, J., Palomera, E., & Clavé, P. (2014). Oropharyngeal dysphagia is a risk factor for readmission for pneumonia in the very elderly persons: Observational prospective study. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 69, Crary, M., et al. (2004). Functional benefits of dysphagia therapy using adjunctive semg biofeedback. Dysphagia. Summer;19(3):

20 Donzelli, J., & Brady, S. (2004). The effects of breath-holding on vocal fold adduction: Implications for safe swallowing. Archives of Otolaryngology Head & Neck Surgery, 130, Easterling C, et al (2005). Attaining and maintaining isometric and isokinetic goals of the Shaker exercise. Dysphagia. 20: Fujiu, M., Logemann, J.A. (1996). Effect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. American Journal of Speech-Language Pathology, 5, Hind, J., et al. (2001). Comparison of effortful and noneffortful swallows in healthy middle-aged and older adults. Arch Phys Med Rehabil. Dec;82(12): Huckabee, M. L., & Steele, C. M. (2006). An analysis of lingual contribution to submental surface electromyographic measures and pharyngeal pressure during effortful swallow. Archives of Physical Medicine and Rehabilitation, 87, Kawashima, K., Motohashi, Y., & Fujishima, I. (2004). Prevalence of dysphagia among community-dwelling elderly individuals as estimated using a questionnaire for dysphagia screening. Dysphagia, 19, Langmore, S. E., Kenneth, S. M., & Olsen, N. (1988). Fiberoptic endoscopic examination of swallowing safety: A new procedure. Dysphagia, 2, Layne, K., Losinski, D., Zenner, P., & Ament, J. (1989). Using the Fleming Index of Dysphagia to establish prevalence. Dysphagia, 4,

21 Lazarus, C., et al. (2002). Effects of voluntary maneuvers on tongue base function for swallowing. Folia Phoniatr Logop. Jul-Aug;54(4):171-6 Lindgren, S., & Janzon, L. (1991). Prevalence of swallowing complaints and clinical findings among year-old men and women in an urban population. Dysphagia, 6, Logemann J. (1986). Manual for the videofluorographic study of swallowing. Boston, MA: Little, Brown. Logemann, J., et al (2009) A Randomized Study Comparing the Shaker Exercise with Traditional Therapy: A Preliminary Study. Dysphagia. Dec; 24(4): Published online 2009 May 27. doi: /s Martin-Harris, B., Logemann, J., McMahon, S., Schleicher, M., & Sandidge, J. (2000). Clinical utility of the modified barium swallow. Dysphagia, 15, National Foundation of Swallowing Disorders. (n.d.). Swallowing disorder basics. Retrieved from National Institute on Deafness and Other Communication Disorders. (n.d.). Statistics and epidemiology Statistics on voice, speech, and language. Retrieved from Neumann, S. (1993). Swallowing therapy with neurologic patients: results of direct and indirect therapy methods in 66 patients suffering from neurological disorders. Dysphagia. 8(2):

22 Pearson, W., et al. (2014). Effortful Pitch Glide: A potential new exercise evaluated by dynamic MRI. J Speech Lang Hear Res. Aug; 57(4): Doi: /2014_JSLHR-S Roden, D. F., & Altman, K. W. (2013). Causes of dysphagia among different age groups: A systematic review of the literature. Otolaryngologic Clinics of North America, 46, Shaker R, et al. (1997). Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise. Am J Physiol. 272(6 Pt 1):G1518 G1522. Shaker R, et al. (2002). Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology. 122(5): Steele, C., Greenwood, C., Ens, I., Robertson, C., & Seidman-Carlson, R. (1997). Mealtime difficulties in a home for the aged: Not just dysphagia. Dysphagia, 12, Sura, L., Madhavan, A., Carnaby, G., & Crary, M. A. (2012). Dysphagia in the elderly: Management and nutritional considerations. Clinical Intervention and Aging, 7, Tibbling, L., & Gustafsson, B. (1991). Dysphagia and its consequences in the elderly. Dysphagia, 6, World Health Organization. (2001). International classification of functioning, disability, and health. Geneva, Switzerland: Author 22