An Introduction to Dysphagia Housekeeping – Fire - Register - Toilets Introduce training team Ask attendees to introduce themselves This training course DOES NOT qualify you to screen or assess individuals for dysphagia. Nicola Davidson, Dysphagia Training Education Lead Community Speech and Language Therapy (Adults) 1

What is dysphagia? Dysphagia means difficulty swallowing. An introduction to dysphagia What is dysphagia? Dysphagia means difficulty swallowing. Any disruption in the swallowing process may be defined as dysphagia 1

How common is dysphagia? An introduction to dysphagia How common is dysphagia? Studies show 40-60% of residents in elderly care settings have some degree of dysphagia. Dysphagia occurs in 25-45% of all patients in acute care settings and up to 60% of residents in institutionalised elderly settings. Paterson 1996. 40% of nursing home residents have some degree of dysphagia. Shanley Loughlin 2000. Only 4 out of 25 people with Alzheimer’s have a normal swallow. Horner 1994. 1

An introduction to dysphagia What is aspiration? Food, fluid, or saliva goes down the wrong tube and enters the lungs rather than the stomach. ……increasing the risk of developing pneumonia 1

Why does it matter? “Tragic death could have been avoided” An introduction to dysphagia Why does it matter? “Tragic death could have been avoided” ‘‘Care home death was preventable’’ “Choked to death on "high risk” food” “Pensioner died of 'natural causes by neglect' after she ate sandwich, coroner rules” Rita Smith “UK’s biggest care home provider fined over fish & chip death” 1

An introduction to dysphagia How do we swallow? Normal swallowing involves taking food and drink into the mouth… keeping it in the mouth and using the tongue, teeth and cheeks to chew if necessary, and forming the food or drink together in a bolus… moving the bolus backwards towards the throat by using the tongue. 1

But before then…. What happens when you Think about food? See food? An introduction to dysphagia But before then…. What happens when you Think about food? See food? Smell food? Talk about food? 1

Soft palate Tongue Pharynx (throat) Epiglottis Larynx (voice box) An introduction to dysphagia Soft palate Tongue Pharynx (throat) Epiglottis Larynx (voice box) Labels for Oro-Facial Anatomy Lips – Maintains food in mouth, pressure on bolus to move food back in mouth. Teeth – Chewing food to consistency suitable to swallow. Habitual use of gums ok if consistency appropriate. Dental carries, missing teeth can lead to pain.  Jaw – Mouth opening to get food in. Chewing to mix food with saliva and break the food down. Cheeks – Moves food bolus. Keeps food in midline. Holds false teeth in! (often a problem after stroke due to muscle weakness).  Tongue – Moves food to mix with saliva. Moves food to teeth for chewing. Movement triggers swallow. Clears mouth e.g. teeth, sulci.  Soft palate – Keeps food in mouth during chewing. Closes nasal passage. Pharynx - Throat. Epiglottis – Protects airway by tipping over. Voice box – Entrance to windpipe. (Larynx) Cords close to prevent aspiration. Moves up and forwards during swallow. Windpipe – Airway into lungs. (trachea) Oesophagus – Food from throat to stomach. (gullet) Oesophagus (for food) Trachea (for air) 1

What can go wrong in swallowing? An introduction to dysphagia What can go wrong in swallowing? Your residents might have difficulty with: chewing (for reasons other than poor dentition) transporting food/fluids to the back of the mouth initiating a swallow transporting food or fluids through the throat towards the stomach 1

What causes swallowing problems? An introduction to dysphagia What causes swallowing problems? There are many different causes affecting all age groups including: Stroke Neurological diseases such as MS, Parkinson’s Disease, etc – people may be very slow eating & swallowing as their muscles aren’t working properly Brain injury 1

What causes swallowing problems? An introduction to dysphagia What causes swallowing problems? Dementia – people may be very confused because of an infection or have “forgotten” how to chew & swallow and can’t concentrate on what they are doing Severe breathing problems that affect the windpipe closing off during swallowing. 1

What are the risks to your residents? An introduction to dysphagia What are the risks to your residents? A person who has dysphagia may be at risk of choking and/or aspiration of food/fluid into the lungs. They may also be at risk of being unable to eat sufficient food to maintain their weight and unable to drink sufficient fluid to maintain hydration. 1

The good news is there is a lot we can do to reduce these risks…... An introduction to dysphagia The good news is there is a lot we can do to reduce these risks…... Early swallow screening and dysphagia management in patients with acute stroke reduces risk of aspiration pneumonia, is cost effective and assures quality of care with optimal outcome. Odderson et al 1995 1

Start by getting educated about dysphagia An introduction to dysphagia Start by getting educated about dysphagia If you are caring for someone with dysphagia, you need training in how to safely manage their care. 1

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General safe swallow guidelines An introduction to dysphagia General safe swallow guidelines Smaller, more frequent meals may be less tiring Snacking between meals may help maintain a good functioning swallow Avoid large mouthfuls Sip drinks Softer foods are easier to manage than dry, flaky textures Only suitable food and drink within easy reach Always refer to and follow the Safe Swallow Plan Reduce distractions - including chatty neighbours at the table and tv/radio. - be aware of over stimulation. Do not encourage someone to talk – direct communication to the patient e.g. make them aware of each mouthful of food, but do not encourage conversation. Be aware of communication difficulties and the impact upon the ability to choose from a menu. Use visual prompts if patient has receptive difficulties. Prompt and cue the patient to feed themselves, encourage patients to choose their own meal. Consider likes and dislikes The importance of appearance (colour), texture, smell, temperature and quantity of food. 1

Helpful positioning Sitting in a chair in a dining room at a table An introduction to dysphagia Helpful positioning Sitting in a chair in a dining room at a table Sat upright to 90 degrees Head in a good upright mid-line position Reposition during meals if necessary All food and drink within reach Correct height to table and chair Comfortable distance between plate and mouth WHY IS POSITIONING SO IMPORTANT? Poor sitting balance and trunk control affect the swallow Leaning towards the dense side/weak side will mean the food goes down the weak side. Check with carers and SLT before altering positions for people with learning disabilites 1

A note on utensils Why is this? An introduction to dysphagia A note on utensils People with swallowing difficulties should not be given spouted cups or straws unless advised to do so by a Speech and Language Therapist Why is this? Drinks are placed directly at the back of the mouth and may go down the wrong way before the person is ready to swallow Sensation and taste are reduced because the drinks are not touching the lips and tongue, so the person is less likely to swallow When using spouted cups, people need to tip their head back to get the drink in their mouth, resulting in more effort to close off the airway when swallowing, putting them at a greater risk of things going down the wrong way People with facial weakness will have difficulty sucking, and this will tire them out However, people with learning disabilities may have used spouted cups throughout their lives and sudden change could be inappropriate or difficult to achieve. Learning Disabilities - increased support or supervision may be necessary - Consult OT for appropriate utensils. Discuss the need to use appropriate utensils ie spoons to feed patients with. Maybe modified cutlery, non slip mats. This applies to both patients who can and cannot feed themselves. Mention the need to avoid syringes for medication. Be aware of visual neglect and where you place the food. Show a variety of cups 1

Oral hygiene and aspiration pneumonia An introduction to dysphagia Oral hygiene and aspiration pneumonia There is a strong link between poor oral hygiene and aspiration pneumonia. Why is this? 1

Summary Always follow Safe Swallow Plan guidelines An introduction to dysphagia Summary Always follow Safe Swallow Plan guidelines Consider the individual’s preferences, habits, cultural and religious needs to help maintain dignity as well as safety at mealtimes Use and encourage safe feeding practices An upright position reduces the risk of aspiration and choking The right utensils can help; the wrong ones can increase the risks Good oral hygiene reduces the risk of developing aspiration pneumonia Monitor, record, and report any changes that you observe Don’t be afraid to ask for advice. 1

Dysphagia Training Education Lead An introduction to dysphagia Any questions? Nicola Davidson, Dysphagia Training Education Lead 01305 213065 Nicola.davidson@dhuft.nhs.uk 1