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

2. 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

3. 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)

4. 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

5. 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

6. 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
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

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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 -

13. 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

14. 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

15. 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.

16. 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

17. 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

18. 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!

19. 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

20. 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)

21. 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 minutes.
Patients with dementia may even require up to 90 minutes per meal!

22. 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)

23. 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

24. Questions?

25. 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 Thickened Liquids. (2014) Retrieved July 24, 2014, from