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Malnutrition & Dysphagia Workshop: An Introduction to Dysphagia
Holly Froud & Tracy Broadley-Jackson Speech & Language Therapists
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What is a swallowing problem?
A swallowing problem can occur at any point from the sight of food to the point it enters the stomach and at any point along the way. People may not be able to feed themselves, they may not be able to taste the food, they may not be aware that there is any food in their mouths at all. There is not any one simple answer to a swallowing problem. A swallowing impairment can range from discomfort, mild weakness to absence of swallow.
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“When a person is unable to swallow,
the ability to enjoy almost all other aspects of life is affected… Episodes of choking can lead to a fear of eating that can lead to malnutrition and social withdrawal” McCulloch et al 1997
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Swallowing facts We swallow approximately 580 times a day and 50 times at night Swallowing involves 26 muscles and 6 cranial nerves We swallow up to 1 litre of saliva a day and 20mls at night, that’s without eating or drinking anything! Dysphagia/swallowing problems may occur at any age It may occur suddenly or progressively It may be transient and resolve or it may be permanent Eating & drinking are essential human functions which keep us alive but they are also important for social and emotional wellbeing We associate food with pleasure and caring
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Activity Try the 2 types of food.
What are your tongue, lips, jaw and teeth doing? Think about which ones take more/ less time Think about the number of swallows needed to clear each item
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Swallowing: What do we need?
Brain Lips Tongue Teeth Jaw Cheek muscles Soft palate Hard palate Nerves Good head & body position Saliva Appetite, taste, smell
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The normal swallow There are 4 stages to the normal swallow;
Pre oral phase Oral stage Pharyngeal stage Oesophageal stage
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2.Oral preparatory stage
Function: Preparation Food placed in mouth and lips closed Food mixed with saliva and chewed Breathing continues through nose Back of tongue elevated Food formed into a bolus on centre and front of tongue Time taken: variable Voluntary control
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2.Oral stage Function: propulsion Lip closure
Tongue elevates from front to back to squeeze the bolus against the hard palate & move it backwards Bolus arrives at the back of the tongue and triggers pharyngeal stage Time taken: 1 sec Voluntary control
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3.Pharyngeal stage Function: Propulsion/Protection
Soft palate moves up and back to seal off the nasal passage The bolus then passes through pharynx or throat (peristalsis) Airway is protected/sealed off to prevent food or drink entering the airway or lungs Cricopharyngeus relaxes and opens Time taken: 1 sec for liquids Involuntary control
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4.Oesophageal stage Function: Propulsion
Bolus moves towards the stomach by peristalsis Time taken: 8-10 seconds Involuntary control NB. Most affected by ageing
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When it goes wrong! Dysphagia is the word used to describe any difficulty with eating or drinking or swallowing. It is a symptom rather than a disease itself It is very common It is extremely complex (eating is easy, dysphagia is not!) Can be confusing Needs expert assessment & management Everybody’s business!
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What can go wrong at the Oral stage?
Poor tongue movements Difficulties chewing or prolonged chewing Poor bolus formation Food being lost around the mouth Poor swallow initiation as the tongue is needed to push the food to the back of the mouth in order to trigger a swallow Difficulty controlling the bolus if it falls off the tongue and the tongue cant reach it, it could fall into the airway Poor lip seal This can result in fluid/food falling out of the mouth which means… Less is swallowed Embarrassment can increase for a person There is less oral pressure in the mouth in order to push the food to the back of the mouth Jaw If there is reduced jaw movement this will result in… Abnormal chewing therefore insufficient bolus formation as the food may only be partly chewed Difficulty taking food into the mouth if there is restricted jaw opening Cheeks A decrease in the tone of the cheeks can result in… Pocketing of food Less oral pressure in the mouth Palate If the soft palate is not working then food/ drink may come down the person’s nose
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What can go wrong at the pharyngeal stage?
Aspiration ‘Entry of material into the airway below the level of the vocal folds’ i.e. goes down the wrong way and cannot be removed by coughing
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Aspiration : Immediate signs
Frequent coughing / choking during or after eating/drinking Gurgly/wet/abnormal voice quality Increased respiratory rate/ chestiness Change of colour/ eyes watering/ sneezing Discomfort on swallowing Coughing up sputum of unexpected colour Repeated throat clearing Increased temperature (of unknown origin)
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Aspiration: Long term signs
Recurrent chest infections/ pneumonia Abnormal voice, stridor, loss of voice – gasping/ wheezing/ shortness of breath Weight loss Fear of eating and drinking Reduced intake or number of meals Chronic respiratory distress
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Complications of dysphagia
Malnutrition Dehydration Reduced healing Chest infections Aspiration Pneumonia DEATH Loss of independence Isolation Anxiety & frustration Misery, embarrassment, fear Depression
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Recognise anyone? Chew all day Refusal Pain or food left Pebble dasher
Hamster Plate Decorator
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Signs of swallowing difficulties
Spitting food out Refusal to eat Recent difficulty with tablets Eating very fast or very slowly Pocketing of food in one or both cheeks Food remaining in the mouth after swallowing Difficulty in initiating a swallow Excessive drooling, especially after eating Unintentional weight loss Sneezing/watery eyes during mealtimes Poor oral hygiene
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Other factors affecting eating & drinking
Problems recognising food as edible. Distractibility; may get up from the table Inability to use utensils Problems recognising food as something to swallow in the mouth Change in appetite e.g. always hungry or always feeling full Change in taste e.g. used to like savoury food but now prefers puddings Forgetting to eat and drink or finish meals Eating unusual combinations of food Eating very fast or very slowly Be suspicious about food ( food is poisoned) Medication Altered sleep patterns Want to pay for food Loose dentures/sore mouth
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Management of dysphagia what helps?
Texture modification/thickening fluids Being able to recognise eating/drinking problems & signs of aspiration Only offer food & drink textures advised by SLT Correct positioning & strategies e.g. chin tuck Appropriate amount of food & correct utensils Provide help and support at mealtimes Regular oral care Good communication & documentation Team working
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Why do we modify food? Easier to eat Minimise risk
Decrease time & effort & hence fatigue Optimise swallow safety & efficient movement of food through mouth & throat to compensate for deficits Different textures & consistencies are needed for different problems Some eating/swallowing problems may be made worse by giving the wrong texture of food. Diet modification only works if it happens together with staff & carer training
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Mealtime Management Person Environment Utensils Prompts Food You!
Awake & alert Upright midline position Encourage self feeding if possible Good oral care Environment Quiet & calm Well lit Food within reach Utensils Get advice from OT if necessary Colour contrasts Prompts Talk in a positive way about the food Visual cues such as setting table Smell of food Food Follow SLT guidelines for consistency Personal preferences Likes & dislikes ask the family You! Sit at eye level Avoid talking to other staff when feeding Look interested Be aware of changes
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Thank you, any questions?
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