Malnutrition & Dysphagia Workshop:An Introduction to Dysphagia

Holly Froud & Tracy Broadley-Jackson

Speech & Language Therapists

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.

“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

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

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

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

The normal swallow

There are 4 stages to the normal swallow;

1.Pre oral phase

2.Oral stage

3.Pharyngeal stage

4.Oesophageal stage

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

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

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

4.Oesophageal stage

• Function: Propulsion

• Bolus moves towards the stomach by peristalsis

• Time taken: 8-10 seconds

• Involuntary control

• NB. Most affected by ageing

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!

What can go wrong at the Oral stage?

Poor lip sealThis 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

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

CheeksA decrease in the tone of the cheeks can result in…

•Pocketing of food

•Less oral pressure in the mouth

PalateIf the soft palate is not working then food/ drink may

come down the person’s nose

JawIf 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

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

What can go wrong at the pharyngeal stage?

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)

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

Complications of dysphagia

MalnutritionDehydration

Reduced healingChest infections

Aspiration PneumoniaDEATH

Loss of independenceIsolation

Anxiety & frustrationMisery, embarrassment, fear

Depression

Recognise anyone?

Pain or food left

Chew all day

Refusal

Pebble dasher

Plate DecoratorHamster

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

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

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

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

Mealtime Management

Utensils•Get advice from OT

if necessary•Colour contrasts

Environment•Quiet & calm

•Well lit•Food within reach

Prompts•Talk in a positive way

about the food•Visual cues such

as setting table•Smell of food

Person•Awake & alert

•Upright midline position•Encourage self feeding

if possible•Good oral care

Food•Follow SLT guidelines

for consistency•Personal preferences

•Likes & dislikesask the family

You!•Sit at eye level

•Avoid talking to other staff when feeding

•Look interested•Be aware of changes

Thank you, any questions?