When you can’t swallow.

Dysphagia Facts
 Approximately 300,000 to 600,000 people with

neurogenic disorders are diagnosed with dysphagia.  Swallowing involves the use of 6 cranial nerves.  Approximately 40% of patients with dysphagia silently aspirate.  Swallowing is one of the most complex body reflexes, yet in the normal adult, this process is automatic, effortless and efficiently performed an average of 600 times a day.

Dysphagia Facts
 Evidence of dysphagia in 51% of patients with acute

stroke.  Parkinson’s dysphagia develops in approximately 50% of patients.  With patients with multiple sclerosis, 34% with dysphagia.

Phases of the Swallow
 Oral Phase  Involves the lips, tongue, teeth and cheeks.  The swallow begins when food is presented at the level of the lips.

Patients must have good labial seal to hold the bolus within the oral cavity and to create appropriate pressures to propel the bolus and initiate the swallow. Patients with stroke may have labial weakness which allows the food to spill out of the mouth.

Tongue
 The tongue contains the taste buds allowing us to taste

foods.  The tongue is made up of muscles.  The tongue is used to

 Move the bolus within the oral cavity for proper

mastication of the bolus  Propel the bolus posteriorly to initiate the pharyngeal stage of the swallow

Teeth
 Dentition is important for swallowing and it is

important to assess dentition for appropriate diet recommendations.
 The SLP will need to know if the patient wears dentures,

is missing teeth, etc.  Teeth are important for appropriate mastication of foods.

Cheeks
 Buccal tension:  Assists in creating appropriate pressures for initiating the pharyngeal swallow  Assists in maintaining the bolus  Helps to prevent lateral pocketing of the bolus.

Pharyngeal Phase
 Once the food is masticated and reaches the anterior

faucial arches, the pharyngeal stage of the swallow is initiated.  Within 1-3 seconds the following occurs:
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Tongue Base Retraction Velopharyngeal closure Pharyngeal constriction Pharyngeal contraction Hyoid Elevation Hyoid Protraction Hyothyroid approximation Vocal fold closure Upper esophageal sphincter opening.

Oral Care
 Microorganisms found in the lungs of elderly patients with

pneumonia originate in the mouth and gingival, making a link between poor oral hygiene and aspiration pneumonia.
 Three categories that add to the risk factors that lead to

aspiration pneumonia: o Any factor that increases the bacterial load or colonization in the oral-pharyngeal cavity (lack of tooth brushing, xerostomia).  Any factor that decreases the patient’s resistance to the inoculums (i.e. malnutrition or ventilator dependency).  Any factor that increases the risk of aspiration (i.e. paralysis from stroke or chronic neurological disease affecting the muscles and nerves involved in swallowing.

Oral Care

Those at risk: Patients who are dependent for oral care. Have large numbers of missing teeth. Dentures Have limited hand dexterity Decreased mental capacity Multiple medical co-morbidities Immunosuppressed Ventilator dependent Receive non-prandial feedings Have had a stroke Neurologically impaired Have xerostomia Known Dysphagia Poor access to professional dental care. Dependence on caregivers for oral care. Active smoking Depression. Use of sedative medication Use of gastric acid-reducing medication. Use of ACE inhibitor Poor feeding position.

Frazier Water Protocol
 Patients who are on thickened liquids are often placed

on a Frazier Water Protocol to increase hydration.
 Thickened liquids are given with meals and

medications.  Wait for 30 minutes after meal, complete thorough oral care, then patient can have all the water they want until their next meal.

Thickened Liquids
 There are four consistencies of liquids  Thin or regular

Normal drinks with no thickening agents added.

 Nectar thick liquids  Should be the consistency of maple syrup and run off the spoon like syrup does.  Honey thick liquids  Consistency of honey and should run off the spoon as honey does.  Pudding thick liquids  Should be the consistency of pudding and “plops” off the spoon.

Medications
 When patients have dysphagia, they are often ordered

to have their pills crushed or given in applesauce/pudding.  When passing pills, remember people that have difficulty swallowing and try to give them one pill at a time.  Check at the end of the med pass to make sure all pills were swallowed and were not pocketed.

Food Consistencies
 Pureed  Baby food consistency, should have no lumps and be easy to swallow.  Mechanical Soft/Ground Meat  Should only require minimal chewing, no hard/crunchy foods  Regular  No restricitions

Assessment Techniques by SLP
 Bedside assessment  Cervical Auscultation  Laryngeal elevation  Monitor s/s aspiration  Trial consistencies  Pulse Oximetry  Heart Rate  Blue Dye Assessment  3 Ounce water test  Bolus Manipulation Task  Instrumental Assessment  MBSS  FEES  Manometry  Ultrasound

Treatment Techniques by the SLP
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VitalStim-NMES for dysphagia DPNS/FMEP Thermal/tactile stimulation Myofascial release and manual techniques Oral/Pharyngeal Exercises Exercises with resistance TheraSip Swallowing Trainer IOPI OraLight Ice Finger Laryngeal Mirrors/ThermoStim Probe

Things to Remember
 Patients that self-feed have a lower incidence of aspiration.  Feed patients as you would like to be fed, don’t shovel food into     

their mouth or stick the food into their mouth before they’re ready. Aspiration pneumonia in nursing home residents occurs 10 times more frequently than in elderly community dwellers. Pneumonia is the most common cause of death from nosocomial infections in the elderly. Pneumonia results in functional declines and increased health care expenditures. One study suggests that 70% of patients with a history of pneumonia aspirated during their sleep. One study suggests that effective oral care can decrase mortality due to pneumonia by half.

Bolus Propulsion

Select Medications that Affect Swallowing
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Oropharyngeal function Sedation, pharyngeal weakness, dystonia Benzodiazepines Neuroleptics Anticonvulsants* Myopathy Corticosteroids Lipid-lowering drugs Xerostomia Anticholinergics Antihypertensives* Antihistamines* Antipsychotics Narcotics Anticonvulsants* Antiparkinsonian agents* Antineoplastics* Antidepressants* Anxiolytics* Muscle relaxants* Diuretics Inflammation/swelling Antibiotics*

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Esophageal function Inflammation (resulting from irritation by pill) Tetracycline Doxycycline (Vibramycin) Iron preparations Quinidine Nonsteroidal anti-inflammatory drugs Potassium Impaired motility or exacerbated gastroesophageal reflux Anticholinergics Calcium channel blockers Theophylline Esophagitis (related to immunosuppression) Corticosteroids *--Various agents in the class.

Sources
 American Speech-Language Hearing Association Division 

  

13 (2006). Perspectives on Swallowing and Swallowing Disorders, 15(3), 1-28. American Speech-Language-Hearing Association (1990). Skills needed by speech-language pathologists providing services to dysphagic patients/clients, ASHA, 32 (suppl 5), 7. DPNS Manual. Available through the Speech Team Inc. Author: Karlene Stefanokos. The Source for Dysphagia. LinguiSystems. Author: Nancy Swigert. Logemann, J. A. (1998). Evaluation and treatment of swallowing disorders. Austin, TX: Pro-Ed.

Sources
 Carl, L., & Johnson, P. (2005). Drugs and dysphagia:

How medications can affect eating and swallowing. Austin, TX: Pro-Ed.  Palmer, J.B., Drennan, J.C., and Baba, M. (2000). Evaluation and Treatment of Swallowing Impairments. www.aafp.org/afp/20000415/2453.html