1. 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

2. 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

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

4. 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)

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

6. Voluntary initiation of the swallow by tongue

7. Triggering of the pharyngeal swallow

8. Arrival of the bolus at the vallecula

9. Tongue base retraction to pharyngeal wall

10. Bolus in cervical esophagus

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

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

13. 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

14. Normal Swallow - Young

15. Normal Swallow - Old

16. Aspiration

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

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

19. Thin Liquid

20. Thick Liquid

21. 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

22. To contact us: Kathryn Denson, MD Associate Professor of Medicine (Geriatrics/Gerontology) Medical College of Wisconsin kdenson@mcw.edu