NURSING ASSISTANTS IN A NURSING HOME Bianca Havel, M.C.D. DYSPHAGIA NURSING ASSISTANTS IN A NURSING HOME Bianca Havel, M.C.D.

What is Dysphagia? Dys=Difficult Phagein=To Eat Dysphagia literally means: “Difficulty Eating” Dys=Difficult Phagein=To Eat It can mean difficulty or pain when swallowing any of the following: Liquids Various consistencies of food Saliva Oral Medications

How common is dysphagia? Estimates of the prevalence of dysphagia in older people in the community range from 16-22%. (Crary & Groher, 2010, p. 5). In a nursing home, this number will most likely be higher due to the fact that some primary medical diagnoses are more likely to precipitate symptoms of dysphagia, especially for diseases that affect the central and peripheral nervous systems. For example, it is estimated that dysphagia occurs in about: 50% of patients with Parkinson’s disease 30% of patients with Amyotropic Lateral Sclerosis (ALS) – it is also one of the first symptoms of ALS 33% of patients with Multiple Sclerosis (MS)

What are the risks of Dysphagia? Without appropriate diagnosis and management, dysphagia can lead to: Aspiration Pneumonia (food, saliva, vomit, or liquids pass through the vocal folds and into the lungs which causes inflammation of the lungs and bronchial tubes) Silent Aspiration (aspiration occurs but there are no signs) Malnourishment/Dehydration Inability to take oral medications Death

Anatomy of the Swallow Main structures involved: Tongue-moves bolus Muscles of Mastication Pharynx-posterior to oral cavity and superior to larynx and esophagus Pharyngeal constrictors Larynx-contains vocal folds Hyoid bone-attached to epiglottis Thyroid cartilage-anterior attachment of vocal folds Cricoid cartilage-complete ring Arytenoids-attach to posterior vocal folds Epiglottis-projects over larynx to protect trachea Vocal Folds-adduct to protect the airway Upper Esophageal Sphincter-opening to esophagus

3 Phases of the Swallow Can you guess what happens in each phase of the swallow? Please take a bite of the graham cracker in front of you. What do you think happens in: The first phase? A) The bolus is formed OR B) Hyoid Bone and Larynx elevate 2. The second phase? A) Epiglottis folds down and back to protect the airway OR B) The upper esophageal sphincter closes The third phase? A) The upper esophageal sphincter opens OR B) The swallow is initiated

Phase 1: Oral Phase Oral Phase= 1) Oral Preparatory + 2) Oral transport Oral Preparatory Phase: Food is chewed and mixed with saliva to create a bolus. The bolus is positioned at the anterior part of the tongue for transport. Oral Transport Phase: The bolus is transported from the anterior to the posterior oral cavity for passage to the pharynx.

Phase 2: Pharyngeal Phase The bolus enters the pharynx and the swallow is initiated by the following actions: Complete closure of the velopharyngeal opening Hyoid bone and larynx move anteriorly & superiorly Epiglottis folds down and back Tongue base moves to posterior pharyngeal wall to push bolus down Top to bottom contractions of the pharyngeal constrictor muscles (peristalsis) Vocal folds move to the midline Relaxation of the upper esophageal sphincter

Phase 3: Esophageal Phase 1) The upper esophageal sphincter opens 2) Peristalsis (contraction and relaxation of sphincter muscles) carries the bolus through the esophagus 3) The lower esophageal sphincter opens and food passes into the stomach

Signs of Dysphagia in Each Phase of the Swallow ORAL PHASE PHARYNGEAL PHASE ESOPHAGEAL PHASE Premature leakage of bolus into pharynx Pocketing of food in spaces between gums & teeth Abnormal tongue movements-tongue pumping Excessive secretions, drooling Difficulty masticating Poor taste sensation/refusal to eat Extended oral prep time Reports of sticking sensation in throat Throat clearing/coughing/choking Difficulty swallowing:gulping Changes in vocal quality: wet, gurgly, hoarse sounds when eating or drinking Breathing difficulties-shortness of breath during meals Nasal regurgitation Feeling of food getting stuck in throat or chest Reflux of food into throat or mouth Heartburn Sour taste in mouth, especially in the morning

Role of the SLP Perform clinical feeding and swallowing evaluations Perform instrumental assessments with a physician Identify additional disorders in the upper aerodigestive tract and make referrals to other medical professionals Management of swallowing disorders Develop treatment plans for individuals with swallowing and feeding disorders Work together as part of an integral medical team to care for patients

What preliminary tests can be performed by the SLP to detect the presence of Dysphagia? Screening Quick & Noninvasive Based on chart review and brief patient observation Clinical Bedside Evaluation More in-depth than a screening Past medical history/chart review Current medical status Respiratory status Cognitive/communicative history Nutrition/hydration check A complete oral motor exam is performed, including laryngeal function -

Instrumental Assessment If the patient demonstrated trouble with swallowing during the clinical bedside evaluation, an instrumental assessment to help evaluate oral, pharygneal, and upper esophageal function as it applies to normal or abnormal swallowing may be recommended. These assessments are typically carried out by a physician and an SLP: Videofluoroscopic Swallow Study (VFSS) Patients are given liquids/foods of different consistencies mixed with barium so that the bolus can be monitored as it passes through the three phases of the swallow Fiberoptic endoscopic examination of swallowing (FEES) A transnasal laryngoscope is used to assess pharyngeal swallowing

What Are Some Ways We Can Treat Dysphagia? The goal of treatment is to reduce aspiration, improve the patient’s ability to eat/swallow, and/or optimize their nutrition. Treatments can include: Dietary Modification Thickening of food Compensatory Techniques Postural/positioning techniques Indirect therapy Exercises to strengthen respiration and/or swallowing muscles Direct therapy Exercises to perform while swallowing

Dietary Modification Many patients with Dysphagia have trouble eating tough foods such as meat safely. In addition, some patients with poor tongue or laryngeal control experience less aspiration with thick liquids (i.e. nectar) than with thin liquids (i.e. water). However, a patient that is having problems with the upper esophageal sphincter will require thinner liquids. Thus, after an individual is evaluated, he/she is put on the safest and least restrictive diet suitable for them.

Dietary Modification cont. Be sure to verify on the patient’s chart what types of food they are allowed to eat. The National Dysphagia Diet (2002) is as follows: Level I: Dysphagia Pureed: Pudding-like, no chewing required Level II: Dysphagia Mechanically Altered: Moist, semi-solid, requires chewing Level III: Dysphagia Advanced: Soft-solid foods, requires more chewing Level IV: Regular: All foods allowed

Go ahead and THICK-IT!!! If a patient is on a diet that requires thickening of liquids, you will be the one thickening it! Depending on the patient’s diet, we thicken liquids to: Intermediate (nectar): Add 1 1/2 teaspoons of Thick-It to 1/2 cup of thin liquid Thick (honey): Add 1 1/2 tablespoons of Thick-It to 1/2 cup of thin liquid Pureed (pudding): Add 2 tablespoons of Thick-it to 1/2 cup of thin liquid

Compensatory Techniques If a patient has a delayed swallow reflex: Have them put their head down. Also called a chin tuck (allows more time for larynx to elevate and vocal folds to adduct) If a patient has unilateral paralysis of the pharynx: Have them turn their head to the paralyzed side (keeps food on the functioning side of the pharynx) If a patient has unilateral paralysis of the oral cavity: Have them tilt their head to the strong side (helps bolus go down the strong side of the pharynx) These techniques allow the patient to utilize their strengths to compensate for their weaknesses!

Indirect Therapy Strengthening Respiration: Client takes a deep breath and holds it Clinician applies light pressure to abdomen, patient resists Goal is to hold breath for 10 seconds, repeat 5 times Control of Exhalation: Breath out slowly & steady for 10 seconds Take a breath, exhale 5 seconds, hold, exhale another 5 seconds Take a breath, exhale 3 seconds, hold, exhale another 3 seconds Repeat 5 times

Direct Therapy Take a bite of the graham cracker and try each technique below. Do you notice a difference? These techniques protect the airway and strengthen the force of vocal fold adduction In order for them to work, a patient must be cognitively intact! A cognitive screening is vital! Supraglottic Swallow Take a breath and hold it while swallowing Cough after the swallow (voluntary closure of vocal folds before, during, after swallow) Supra Supraglottic Swallow Same procedure as the supraglottic swallow Patient also pushes down on their chair/wheelchair/etc. (pushing down increases the force of vocal fold adduction)

Dining Environment and Duration In a study conducted in a nursing home over a three-month period, there was an average weight gain of 2.06 lbs for individuals fed in the dining room, compared to feeding patients in their rooms (Musson, 1994). Whenever possible, make sure your patient is dining in a social context! Also keep in mind that feeding an eating-dependent patient requires a minimum of 30-45 minutes. Patients with dementia may even require up to 90 minutes per meal!

50% Of Patients are Silent Aspirators! Signs that could indicate silent aspiration: Facial redness Runny nose Tearing Increased heart rate Signs of struggle/discomfort Pharygneal redness/edema(swelling)

Last Thoughts Check your patient’s chart to see the type of diet they are on and be careful to only administer consistencies of the foods/liquids they are allowed to ingest If a patient’s chart states NPO (nothing by mouth) it means that they should not be fed orally Watch for signs of aspiration Watch for signs of silent aspiration Whenever possible, make sure your patient is eating in a social context Be patient and allow for longer feeding times

Questions?

References Crary, M., Groher, M. (2010). Dysphagia: Clinical Management in Adults and Children. Maryland Heights, Missouri: Mosby Elsevier. Musson, N. (1994). Dysphagia Team Management: Continuous Quality Improvement in a Long-Term Care Setting. Quality Improvement Digest. Retrieved July 21, 2014 from http://www.asha.org Thickened Liquids. (2014) Retrieved July 24, 2014, from http://www.upmc.com/