NHS Greater Glasgow & Clyde Advancing Skills in Stroke Care Swallowing problems after stroke

Stroke and dysphagia Dysphagia is the term used for swallowing difficulties Approx 60% of stroke patients will have some degree of dysphagia at the acute phase. Approx. 20% of stroke patients with dysphagia develop aspiration pneumonia. More frequent in patients with haemorrhagic stroke. The majority of people will improve within 6-7 weeks post stroke.

Normal Swallow 1. Oral stage 2. Pharyngeal stage 3. Oesophageal stage

Factors which can influence the oral stage: Consistency Hunger/Thirst Taste Texture Visual Smell

Oral Stage Voluntary control Bolus is propelled backwards along tongue Bolus passes faucial arches and swallow is triggered.

Pharyngeal Stage Involuntary stage Soft palate elevates Pharyngeal muscles contract, pulling the food through the pharynx Breathing is halted

The larynx rises and tips to protect the airway from food/fluids passing through the pharynx The sphincter at the top of the oesophagus opens to allow the food and drink to enter it

Pharynx Trachea Oesophagus

Oesophageal stage This stage is also under involuntary control This stage involves the passage of food/fluids from the oesophagus to the stomach.

Oral stage problems Drooling/Loss of food or fluids from lips Residue of foodstuffs in the mouth Loss of taste or smell Incomplete soft palate seal Loss of food/fluids into the pharynx before the swallow is triggered

Pharyngeal stage problems Unable to trigger swallow Delayed swallow trigger Reduced protection of the airway - leading to penetration/aspiration No cough reflex Pharyngeal muscles are weak Upper oesophageal sphincter dysfunction

Penetration of airway

Oesophageal stage problems The speech and language therapist is not really involved in problems at this stage as they are unable to assist with problems of oesophageal function Medical team investigation and management

Aetiologies of Dysphagia NEUROLOGICAL CVA Motor Neurone Disease Parkinson’s Disease Multiple Sclerosis Myasthenia Gravis Guillain-Barre Disease Cerebral Palsy Dementia (also behavioural) Brain Tumour Head Injury

SLT assessment (Bedside Assessment) Observational assessment Oral examination Food /fluid trials Recommendations/Documentation Videofluorscopy

Food Consistencies Texture A - a smooth, pouring consistency that cannot be eaten with a fork eg tinned tomato soup. Texture B – smooth consistency, drops rather than pours from spoon eg thick custard. Texture C – a thick, smooth consistency. Can be eaten with a fork and can be moulded layered and piped eg mousse

Texture D – food that is moist with some variation in texture. Easily mashed with fork and little chewing required eg flaked fish in sauce / macaroni cheese Texture E – Soft moist food that can be broken into pieces with a fork eg sponge and custard, tender meat casserole

Thickened Fluids Stage 1 (syrup) can be drunk through a straw and from a cup. Leaves a thin layer on the back of the spoon. Stage 2 (custard) Cannot be drunk through a straw, can be drunk from a cup. Leaves a thick coat on back of the spoon. Stage 3 (pudding) cannot be drunk from a straw or cup. Needs to be spooned. A bit like thick custard

Short-term signs of dysphagia Choking or coughing when eating/drinking Change of colour during or eating/drinking Wet, gurgly voice Shortness of breath Loss of food or drink from the mouth Pocketing of food or drink in the mouth Nasal regurgitation

Long-term signs of dysphagia Loss of weight with anorexia and dehydration Recurrent chest infections Frequent episodes of high temperatures

Points to Consider when Feeding Is the person alert? Is the person positioned upright with their body in mid-line? Is the person’s mouth clean? Discourage conversation when eating Use small spoonfuls Check the person has swallowed before giving the next spoonful

Tell the patient what food or drink you are giving them Sit in front of the person or on their ‘good’ side if they have a neglect Check in the mouth at the end of meal for pocketing in the cheeks Keep the person upright for 30 minutes after a meal

Watch out with ice -cream as it starts off as a puree but melts in the throat to a normal fluid.

Dysphagia and Quality of Life Ekberg et al (2002) article on effects of dysphagia on quality of life. Only 45% of the 360 patients in the study enjoyed mealtimes. 41% felt anxious or panicky when eating. 36% avoided eating in public 1/3 of those on modified consistencies still felt hungry/thirsty after a meal. Affects, self-esteem, socialization and dignity.

How to refer to SLT ?

Swallowing Video Endoscope Views of Normal Swallow PLAY