Eating, Drinking and Swallowing skills Fiona Tanner Specialist Speech and Language Therapist NHS Greater Glasgow and Clyde – South CHP 29th April 2013

Overview My perspective as a community SLT Older client group Clinical signs of difficulty that I would look for? Care Pathway: overview of Assessment and Intervention.

Normal swallow ??? I-pad (app) video of normal and disordered swallow.

Clinical signs of difficulty What? Signs: Coughing, gagging, eyes watering, cheeks flushing, choking, lengthened meal times, oral loss. Why? Oral phase - biting and chewing, forming a bolus and ability to hold and control food in their mouth prior to swallow – all can extend mealtime length therefore increasing tiredness and expending energy. Pharyngeal phase - pre-swallow leakage into pharynx, delayed swallow due to reduced muscle strength, insufficient laryngeal elevation to protect airway, incomplete swallows, aspiration. The main point is that the whole management of the bolus depends on muscle strength and  co-ordination so if co-ordination goes then the bolus wont move so efficiently  Might need smaller pieces or easier texture.

Assessment Patient history / story Cervical auscultation – using stethoscope to listen to the swallow sounds i.e. of bolus transfer, the sounds heard are pressure changes. This can tell you about the timing if the swallow and allow hypothesis to be made re: effectiveness and timing of swallow. ****Not a stand alone Ax. Videofluoroscopy - involve client in the process / feedback of assessment. Risk factors – respiration, effectiveness of cough reflex, tiredness, level of alertness, environmental factors. Impact

Intervention Eating and Drinking Plan Positioning Equipment Modified diet Modified fluids Method Risk Alerts Training needs (family / education establishments)

Positioning Link with Physio re: breath support / assisted coughing. Safe - Midline, chin tuck & upright ? tilt Choking – risk / management How long to remain in position after a meal? Reduce impact of reflux, risk of aspiration on any residue. Chin tuck Chin tuck Hips and Knees at 90 degrees

Positions in Tilt-in-space 900 900 900 upright 200 tilt back There has been recent research by the Royal Hospital for Neuro-disability regarding effect of tilt on pharyngeal stage of swallow for people being fed in tilt-in-space wheelchairs.   The study was presented by Sarah Haynes, Head of Speech and Language Therapy at the RHND.    Results indicate improved pharyngeal swallow efficiency, reduced swallow delay and decrease in residue for people fed in 20% tilt. 

Equipment Bottles, spoons and cups - avoid a valve where the client has to put in extra effort. Hot plates (if mealtime length was extended) Link with OT re: specific equipment if assist feeding.

Modified diet This relates to the consistency or texture that is recommended – across environments! 5 standardised texture descriptors A to E + High risk food list: A – Liquid diet (soft pouring, uniform consistency, pureed and sieved) B – Thin Puree (Puree consistency which is thicker) C – Thick Puree (smooth uniform consistency, pureed and sieved, thickener maybe added to maintain stability) D – Finely mashed (moist with some variation in texture, easily mashed with fork) E – Soft and Easily chewed (soft moist food, broken into pieces using fork, solids and gravies)

Modifying fluids Thickness of fluids – by doing this standardised descriptors – this slows down the flow or rate of the fluid and is easier to control in their mouth. Thickeners can be prescribed after they have been assessed - thickener should not be prescribed without prior assessment. Clear thickeners – look less different, social acceptance in a cognitively able group. Pacing / rate of drinking either by carer or client. Equipment in relation to skills of child i.e. free flowing, bottle, self feeder, straw.

Method Pacing, rate of eating or drinking. Verbal or physical prompt to swallow e.g. reduced sensitivity, pooling in larynx, reduced awareness. Level of support required or assist fed (involve OT).

Timing for treatment Multi Disciplinary Team role in relation to clients overall care plan and health status. NB degenerative conditions / profile unstable. Dietician and paediatrician / neurologist in order to discuss timing for alternative feeding and maintaining weight. Client preference and priorities e.g. lifestyle choice. Consent from client where capacity can be given.

Impact Health consequences around aspiration. Differential diagnosis i.e. when chest infections are present - essential to link with acute team. Lifestyle choice Quality of life – MDT and client centred decision. Stress of carer / client around mealtime situation – impact then of tube feeding either partial or incomplete.

Planned intervention Assessment Risk factors Intervention Readiness for change Services involved – can these benefit from SLT involvement. Continually review intervention

Thank you Any questions?