Clinical Skills Workshop: Dysphagia Evaluation & Treatment Kathryn Denson, MD Jacqueline Hind MS/CCC-SLP, BCS-S Jennifer Carnahan, MD Jessica Kuester, MD Medical College of Wisconsin University of Wisconsin – Madison University of Indiana DONALD W. REYNOLDS FOUNDATION

Objectives Review background information on swallowing o Anatomy o Phases of swallowing Improve identification of dysphagia List treatment options for aspiration o Changes to patient / to positioning / to intake

Dysphagia Difficulty moving food from the mouth to the stomach (Logemann, 1998)

Health Consequences If untreated, dysphagia can lead to pulmonary complications, poor rehabilitation potential, airway obstruction and even death. Fifth leading cause of infectious death in persons age 65 and over. Third leading cause of infectious death for persons over age 85. (LaCroix, 1989)

Phases of Swallowing While swallowing is a series of continuous events— It may be described in 3 phases Oral Phase Pharyngeal Phase Esophageal Phase

Voluntary initiation of the swallow by tongue

Triggering of the pharyngeal swallow

Arrival of the bolus at the vallecula

Tongue base retraction to pharyngeal wall

Bolus in cervical esophagus

Small Group Brainstorm What conditions / diseases may lead to dysphagia and aspiration? With your group, list them under 3 headings: Oral Pharyngeal Esophageal

Identification History taking HPI, PMH, talk to family Physical Exam Cognition Speech/Voice Head/Neck and Oral Exam Bedside Swallow – Our Demo

A Better Evaluation of Dysphagia FEES -Fiberoptic Endoscopic Evaluation of Swallowing Eat real food No radiation Doesn’t visualize oropharyngeal dynamics VFG-Videofluorographic Eval Most comprehensive & common eval Multiple view (lateral and AP) Can assess treatment options

Normal Swallow - Young

Normal Swallow - Old

Aspiration

Dysphagia Treatment Rehabilitation o Intrinsic o Strengthening of oropharyngeal musculature o Older adults can improve Decreased aspiration Increased food variety

Dysphagia Treatment Compensatory strategies o Extrinsic o Postures/ Positioning o Maneuvers o Dietary Modifications

Thin Liquid

Thick Liquid

Small Group – Try it out! Try liquids: o “Nectar Thick” o “Honey Thick” liquids Try Compensatory Strategies: o Postures: for a (hopefully) safer swallow o Maneuvers: Supraglottic swallow o Feeding to increase sensory awareness

To contact us: Kathryn Denson, MD Associate Professor of Medicine (Geriatrics/Gerontology) Medical College of Wisconsin