Dysphagia (Week 3 GI)

Question 1

What can cause swallowing impairment?

Answer 1

• anatomical (e.g. head and neck cancer; surgery) + structural abnormalities (e.g cleft palate, cleft lip)
• physiological (may be treatment induced) (e.g. radiation)
• neurological (e.g. stroke, cerebral palsy or muscular dystrophy, Parkinson’s disaase )
• drug induced (e.g. sedation, ataxia, some antidepressants)
• Aging population

Question 2

What age experiences the most dysphagia?

Answer 2

affects > 50% population > 80 yrs

Question 3

How might radiation treatment cause dysphagia?

Answer 3

The radiation sloughs off the cells in the esophagus

Question 4

What is the biggest cause for dysphagia?

Answer 4

stroke

Question 5

Major Warning Signs of Oral Dysphagia

Answer 5

• Drooling, expectoration of food and saliva during/after swallow (often with aging)
• Slow rate of intake/chewing; often associated with SOB
• Altered posturing of head/neck (more common in babies who arch back)
• Food residue in mouth after eating (even something like puree)
• Coughing before swallowing (++liquids), during or after the swallow
• Alterations in voice quality (food spillage into trachea)
• Abnormal/absent laryngeal elevation
• In elderly it can be a simple as unexplained weight loss
• unexplained ammonia
• feeding inefficiency

Question 6

What is feeding inefficiency?

Answer 6

Spending more than 30-40 min when actively trying to eat

Question 7

What voice alterations can occur with dysphagia?

Answer 7

• disphonia: wet voice; crackly
• aphonia: unable to vocalize

Question 8

What are the 2 biggest signs of oral dysphagia?

Answer 8

• food residue in mouth after eating
• alterations in voice quality

Question 9

what are the stages of swallowing?

Answer 9

1. oral phase
2. pharyngeal phase
3. esophageal phase

Question 10

Normal oral phase

Answer 10

voluntary (1 sec)
1. Tongue elevation in anterior to posterior direction to trigger swallow
2. Bolus movement through oral cavity (move food from mouth to back into pharynx)

• UES closed

Question 11

Normal pharyngeal phase

Answer 11

shortest but most complex (1 sec)
1. soft palate elevates (velar elevation) closing off nasopharynx and preventing nasopharyngeal regurgitation & epiglottis blocks the larynx
2. The superior constrictor muscle contracts (pharyngeal peristalsis)
3. tongue base drives the bolus posteriorly

• UES opens

Question 12

Normal esophageal phase

Answer 12

8-20 sec (most people 8 or less depending on product)
1. Upper esophageal sphincter opens and then closes once bolus enters the esophagus
2. bolus is propelled about 25 cm from the cricopharyngeus through the thoracic esophagus via peristaltic contractions.
3. The LES relaxes (opens) and the bolus moves into the stomach.

Question 13

what are the types of dysphagia?

Answer 13

• oral dysphagia (oropharyngeal)
• pharyngeal dysphagia (oropharyngeal)
• Esophageal dysphagia

also esophagogastric, and paraesophageal.

Question 14

describe oral dysphagia

Answer 14

Refers to problems with using the mouth, lips and tongue to control food or liquid.

Question 15

What can oral swallowing stage be affected by?

Answer 15

• surgical defects (tongue weakness)
• neurological disability
• cognitive status/LOA (level of awareness)
• ill-fitting dentures

Question 16

How might alzheimers effect the oral phase?

Answer 16

With Alzheimer’s dementia (declining cognitive and sensory skills) may forget food is in the mouth and may need a reminder
* cold face cloth on side of cheek o stimulate food is there
* reminder to continue to pick up spoon

Question 17

food texture considerations for oral dysphagia

Answer 17

• Mixed textures like a stew or many soups or yogurt with fruit pieces or mashed banana
• can have different textures on a plate but should only have 1 texture entering the mouth
• Things that are too sticky can be a problem such as PB
• Want to avoid things with seeds

Question 18

Describe pharyngeal dysphagea

Answer 18

Refers to problems in the throat during swallowing and is an inability to push food from the mouth into the esophagus.

subtype of oropharyngeal dysphagia.

Question 19

What can affect the pharangeal phase? (pharyngeal dysphagia)

Answer 19

may be due to neurological conditions, such as a stroke, or muscular difficulties, such as cerebral palsy.
* There is a lot of nerves that affect the way these muscles work so a lot of things can go wrong, consistency of contraction is important to prevent a problem. If one thing gets stuck it is right where the larynx is.

Question 20

Describe esophageal dysphagia

Answer 20

occurs when there is difficulty with the passage of solid or liquid material through the esophagus, specifically the region between the upper and lower esophageal sphincter.

Question 21

What can affect the esophageal phase (esophageal dysphagia)?

Answer 21

It results from either abnormal motility of this segment of the esophagus or physical impairment to passage (obstruction)
* inflammatory diseases, autoimmune disorders, collagen disorders

Question 22

What tool is used to monitor swalling ability and dysphagia?

Answer 22

Videofluoroscopic Swallow Study
* An X-ray procedure a speech pathologist completes in order to evaluate the anatomy and physiology of the oral cavity, pharynx, and screening of the esophagus to see how swallowing works
* Uses barium

Question 23

Feeding concerns with dysphagia

Answer 23

• patient safety-modified texture diets (aspiration and regurgitation)
• individual tolerance (hot vs. cold, solid vs. liquid, eating alone, independant eating abilities, cognitive function)
• meeting nutritional (energy and protein) and fluid requirements (less hydration if on thickened fluids)
• odynophagia pain control (swallowing is painful)
• ability to deliver meds (grinding pills)

Question 24

Nutrition management in dysphagia

Answer 24

May differ depending on permanent/ temporary and type of dysphagia
* requires complete nutriton assessment
* consider cognitive status in elderly
* alteration in food texture (pureed, minced, soft)
* alteration in fluid viscosity (hydration a problem)
* incorporation of high protein/ high energy recommendations (often malnourished and anticipate decrease in volume consumed.
* Use of alternate feeding routes ( if gut not working properly - Enteral vs. TPN)
* consider positional and assistive feeding devices
* compliance to prescribed diet alterations (taste fatigue)

Question 25

Nutrition assessment considerations in dysphagia

Answer 25

* time lapse between onset of symptoms and diagnosis will affect assessment * Malnutrition and dehydration are common. * Response to diet therapy in terms of compliance. * Many nutritional deficiencies can occur due to suboptimal intake/hydration

Question 26

What are common texture-modified diet orders?

Answer 26

* pureed * minced * dysphagia soft * easy to chew

Question 27

Pureed * indications for use * description

Answer 27

**Indications for use:** Patients who are unable to chew or swallow food in solid state due to: * chewing and/or swallowing difficulties (dysphagia) * sore or dry mouth * strictures * mucositis * esophagitis * poor or absent dentition. **Description**: Provides a diet of pureed foods that will meet the following characteristics: * pureed to the texture of a pudding or mousse * moist, smooth, and cohesive with small consistent sized particles the same size or smaller than cooked cream of wheat or applesauce * thick enough to spoon up a minimum of 7.5 mL onto a teaspoon (liquid may be thinner) * no water separation. **Includes Pureed Bread Products and No Mixed Consistencies modifications**

Question 28

Minced * indications for use * description

Answer 28

**Indications for use:** Patients who are unable to chew or swallow food in a solid state due to: * chewing and/ or swallowing difficulties (dysphagia) * sore or dry mouth * limited dentition. **Description:** Provides a diet of minced foods that will meet all of the following characteristics: * require little chewing, and are moist and cohesive (e.g., yogurt, minced beef with gravy, pancakes moistened with syrup) * Minced, grated, or finely mashed foods with no water separation * Regular bread products are allowed (e.g., soft, moist cookies, soft buns) excluding breads that are dry or chewy (English muffins, bagels, etc.). **Does not include No Mixed Consistencies modification**

Question 29

Dysphagia Soft * indications for use * description

Answer 29

**Indications for use:** Patients who are unable to chew or swallow food in a solid state due to * chewing or swallowing difficulties (dysphagia) * limited dentition. **Description:** Provides a diet of soft moist foods served with a sauce or gravy that will meet all of the following characteristics: * Firm foods are diced to 1 cm cubed or less on the longest side (e.g. meat, poultry, firm entrees/casseroles or entrees/casseroles with pieces larger than 1 cm cubed) * Foods that can be mashed by a patient using a fork in one hand * Salad type, minced or cheese sandwich fillings * Soft grain products. * Foods excluded are very dry or crumbly; very sticky or gummy; hard such as raw vegetables, whole or chopped nuts, hard large seeds, and whole dried fruit; chewy such as some breads (e.g., English muffins, bagels). **Does not include No Mixed Consistencies modification**

Question 30

Easy to chew * indications for use * description

Answer 30

**Indications for use:** For patients with chewing difficulties, limited dentition, or to facilitate independent eating. **Description:** Provides a diet with foods of a softer texture that are easy to chew. * Foods excluded are dry, crispy, or hard foods; foods with long or stringy pieces; foods with tough skins; nuts, salads and hard raw vegetables and fresh fruit. **Not for dysphagia management**

Question 31

What diets are commonly use for the different types of dysphagia?

Answer 31

* pharyngeal dysphagia - usually pureed but some can handle minced * oral dysphagia - usually minced

Question 32

Types of modifications within the diet order

Answer 32

* mixed consistency * pureed bread products * cut/diced * thickened fluids

Question 33

pureed bread products? Indications for use description

Answer 33

**Indications for use:** Patients who are unable to chew or swallow bread products in a solid state due to * chewing and/ or swallowing difficulties * sore or dry mouth * strictures * esophagitis * mucositis * poor or absent dentition. **Description:** A modification added to a primary diet or diet texture order. Bread products are pureed to the consistency of a pudding or mousse (See pureed definition) as follows: * pureed breads, bread stuffing, muffins, sandwiches, pancakes, crackers, cookies, bread pudding and cake * pasta, rice, couscous, and barley are the consistency of the primary diet or diet texture order.

Question 34

no mixed consistencies * indications for use * description

Answer 34

**Indications for use:** For patients with dysphagia who are not able to control two consistencies (thin fluid and solids) being in their mouth at the same time. **Description:** A modification added to a primary diet or diet texture order, (e.g. Easy to Chew, Dysphagia Soft, and Minced). Foods avoided are those with 2 consistencies or 2 phases. These includes * foods with a thin liquid and solid pieces in the same mouthful (e.g., soup with vegetable or meat pieces, cold cereal with milk) * foods that release thin liquid when chewed (e.g., watermelon, cherry tomatoes). **This modification is included for Puréed Diet and Thick Fluids.**

Question 35

Thickened Fluids * indications for use * description

Answer 35

**Indications for use:** Patients with chewing and/or swallowing difficulties; unable to safely manage thin fluids. **Description:** A modification added to the primary diet or diet texture order for patients with dysphagia. All fluids are thick to improve the patient’s control for drinking and to reduce risk of aspiration. Three levels of thickness are available * Mildly Thick (Nectar) - runs freely * Moderately Thick (Honey) - slowly drips * Extremely Thick (Pudding) - sits on spoon ## Footnote Also thin and slightly thick fluids

Question 36

benefit of thickened fluids

Answer 36

Allow patients more time to control the movement of the fluid in the mouth before initiating a swallow. * Thickened fluids can help reduce the risk of fluids going down toward the airway “going the wrong way”.

Question 37

What are considered thin fluids?

Answer 37

water but also Fluids that melt in the mouth or at body temperature are considered thin fluids – ice cream, Jello, smoothies, Popsicles – these fluids can not be thickened

Question 38

Considerations with thickened fluids

Answer 38

Hydration * adding in extra fluids on meal trays and at snack times to ensure adequate hydration * Patients may or may not be allowed to have regular water or ice chips between meals * free water protocol (Frazier free water protocol) Bowel Medication PEG 3350 no mixed consistency

Question 39

problem with Bowel medication PEG 3350 for patients on thikc fluids diet

Answer 39

Bowel medication PEG 3350 can’t be given orally with patients on thickened fluids – thins out fluids and solids– need to consider alternative

Question 40

what is the free water protocol

Answer 40

Free water is permitted before and between meals. * Free water is not permitted with meals or other oral intake. * Medications are not to be taken with water, as pills may be washed into the lungs.

Question 41

Cut/ diced * indications for use * description

Answer 41

**Indication for use:** To facilitate independent eating for patients who have difficulty cutting their own food * e.g. tremors, fractures, hemiplegia/ hemiparesis, etc. **Description:** A modification added to a primary diet order or diet texture order (e.g., Regular, Easy to Chew). To facilitate eating, food is cut-up into bite- sized pieces or pieces that are manageable to pick up. **Not for dysphagia management**

Question 42

What is IDDSI?

Answer 42

The International Dysphagia Diet Standardized Initiative * A global standard with terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and for all cultures.

Question 43

What are therapeutic feeds?

Answer 43

“Therapy” or exercise for the swallow * Small amounts of food and or fluid given 1 to 3 times a day to help with strengthening the swallow – swallow exercises usually done under supervision with SLP * SLP determines the safest consistency and fluid level * Communication with RD to have the required items put into CBORD

Question 44

comfort vs. pleasure feeds

Answer 44

When no safe consistency is recommended however the patient is willing to take some risk to have desired foods and or fluids as their goals of care is comfort care or palliative care * The swallow is not expected to improve * Quality of life * Celebrate special occasions: birthday cake, ice cream or a milkshake

Question 45

Eating at risk

Answer 45

The patient does not want to follow the recommendations of the feed swallow team. * A managed agreement with the patient who has informed consent (given all the risks associated with choosing to eat orally despite no safe consistency or fluid observed on VFSS) * The physician will discuss the risks associated with eating orally with the patient, patient’s family, caregiver and or decision maker * Sample order may read: “patient has decided to eat at risk and accept the risk of dehydration, malnutrition, choking episodes, aspiration, pneumonia, sepsis and death”

Question 46

Dietitian’s Clinical assessment for feed/ swallow patients

Answer 46

* Assessing anthropometrics – weight loss * Reviewing medications * Appetite - Changes in intake * Hydration concerns * Limiting food repertoire avoiding certain foods * Incorporate a 3 day food record – understand what the patient is currently eating and may be avoiding * Independent or dependent for feeding

Question 47

What do recommendations for feed/ swallow patients include?

Answer 47

* Mode of intake: oral vs. non-oral * Diet consistency: * Therapeutic diet: * Medications * Positioning * Strategies * Oral hygiene: * Consultation * Other * Review