Management of Dysphagia in Stroke

An Educational Manual for the Dysphagia Screening Professional in the Long-Term Care Setting

Management of Dysphagia in Stroke: An Educational Manual for the Dysphagia Screening Pro- fessional in the Long-Term Care Setting © 2016, Swallowing Lab, University of Toronto / University Health Network All rights reserved. No portion of this reference manual may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, re- cording, or otherwise without prior written permission from the Swallowing Lab.

Published by: Swallowing Lab, University of Toronto / University Health Network Department of Speech Language Pathology 160—500 University Avenue Toronto, ON M5G 1V7 Tel: 416-946-3826 www.swallowinglab.com

This publication was prepared with input from a number of health professionals who have reviewed the information to ensure its suitability. However, the information contained herein is for reference only, and is intended to supple- ment the learning provided by a recognized educational program and should not be relied upon exclusively. The Swallowing Lab and other contributing organizations and health professionals assume no responsibility or liability arising from the reader’s failure to successfully complete a recognized course, or to become informed about the practice guidelines applicable to their area or profession. In addition, the Swallowing Lab assumes no responsibility or liability arising from any error in or omission from this publication or from the use of any information or advice contained in this publication. No endorsement of any product or service is implied if other agencies or persons distribute this material.

Acknowledgements

The Swallowing Lab is grateful to the following professionals for their work in developing the Management of Dysphagia in Stroke: An Educational Manual for the Dysphagia Screening Professional In the Long-Term Care Setting.

Becky French, MSc Speech Language Pathologist Southlake Regional Health Centre Newmarket, Ontario

Beverley Powell-Vinden, RN, MEd Senior Manager, Knowledge Exchange Heart and Stroke Foundation Toronto, Ontario

Rosemary Martino, MA, MSc, PhD Speech Language Pathologist Associate Professor University of Toronto University Health Network Toronto, Ontario

Forward

The Ontario Stroke System is a comprehensive stroke strategy with the goal of providing the best possible care to all individuals who suffer a stroke anywhere in the province. One important aspect of this strategy is improving the recognition and management of dysphagia, or difficulty swallowing. Dysphagia is one of the most common sequelae following acute stroke, affecting as many as 55% of patients. 1 Dysphagia may resolve within 14 days after stroke or it may persist for longer periods of time. In Canada in 1994, it was estimated that dysphagia was present in 15,000–21,000 new stroke patients older than 65 years of age, and that only half of these individuals would recover within the first week, with the other half living with dysphagia for months after the stroke.2 Also, as the Canadian population ages, the incidence of new stroke with dysphagia is expected to continue increasing over the next few years. The presence of dysphagia in stroke survivors has been associated with increased mortality and morbidi- ties such as malnutrition, dehydration and pulmonary compromise. 3-10 However emerging evidence indicates that early detection of dysphagia in acute stroke survivors improves outcomes such as pneumonia, mortality, length of hospital stay and overall healthcare expenditures. 2

The Heart and Stroke Foundation of Ontario, as part of its commitment to realizing a comprehensive stroke strategy, convened an expert panel to develop a series of educational resources on the management of dysphagia in acute stroke. Management of Dysphagia in Acute Stroke: An Education Manual for the Dysphagia Screening Professional has been previously developed for acute stroke survivors. 11 Subsequently, Management of Dysphagia in Stroke: An Education Manual for the Dysphagia Screening Professional in the Long-Term Care Setting was adapted for registered nurses (RNs), registered practical nurses (RPNs), occupational therapists (OTs), physiotherapists (PTs), and registered dietitians (RDs) caring for stroke survivors in long-term care facilities. These trained screeners work alongside a dysphagia expert in the community such as a speech-language pathologist (SLP).

2 Table of Contents

I . Dysphagia and Stroke Care ..………………………………………………………………………..pg 5 Dysphagia and the Stroke Survivor in the Long-Term Care Setting ……………………pg 5 Vision for Dysphagia Management ………………………………………………………………….pg 5 Best Practice Guidelines for Managing Dysphagia in Long-Term Care ………………..pg 6 Review Questions …………………………………………………………………………………………...pg 8

II. Swallowing: Anatomy, physiology and pathophysiology ………………………………..pg 9 Normal Swallowing ………………………………………………………………………………………...pg 9 Anatomy ……………………………………………………………………………………………….pg 9 Physiology …………………………………………………………………………………………...pg 10 Coordination of Swallowing, Speaking, and Breathing …………………………………pg 12 Swallowing in the Elderly ………………………………………………………………………………pg 13 Impaired Swallowing: Dysphagia ……………………………………………………………………pg 13 Types of Dysphagia …………………………………………………………………………….pg 14 Complications of Dysphagia ……………………………………………………………………pg 16 Dysphagia Risk Factors …………………………………………………………………………..pg 17 Review Questions …………………………………………………………………………………………pg 19

III. Clinical Approach to Dysphagia …………………………………………………………………pg 20 Interprofessional Dysphagia Care Team ………………………………………………………….pg 20 Dysphagia Screening …………………………………………………………………………………….pg 25 Toronto Bedside Swallowing Screening Test (TOR-BSST©) …………………………..pg 26 Dysphagia Assessment ………………………………………………………………………………….pg 27 Clinical Bedside Assessment …...……………………………………………………………….pg 27 Instrumental Assessment ………………………………………………………………………..pg 27 Ongoing Monitoring ……………………………………………………………………………………..pg 28

3 Table of Contents

Clinical Indicators of Possible Dysphagia ………………………………………………………..pg 28 Dysphagia Management ……………………………………………………………………………….pg 30 Oral Hygiene ………………………………………………………………………………………pg 30 Oral and Non-Oral Intake ……………………………………………………………………….pg 33 Safe Feeding Practices ……………………………………………………………………………pg 37 Education and Counselling ……………………………………………………………………..pg 40 The Continuum of Dysphagia Care …………………………………………………………..pg 42 Review Questions …………………………………………………………………………………………pg 42

IV. Dysphagia Case Studies ……………………………………………………………………………pg 43 Case study #1 ……………………………………………………………………………………………….pg 43 Case study #2 ……………………………………………………………………………………………….pg 44 Case Study #3 ………………………………………………………………………………………………pg 44

V. Appendices 1. The Dysphagia Care Team ………………………………………………………………………….pg 45 2. Medications That Should Not be Crushed …………………………………………………..pg 46 3. Communication Strategies for Healthcare Professionals working with Residents with Aphasia ……………………………………………………………………………pg 47

VI. Glossary …………………………………………………………………………………………………..pg 48

VII. References ……………………………………………………………………………………………...pg 52

4 portant that staff who work in the LTC facility are Dysphagia and Stroke trained to identify stroke survivors at risk for dysphagia to allow an appropriate and timely refer- Care ral to the consultant SLP for a full swallowing assessment. Dysphagia and the Stroke Survivor in the Long-Term Care Vision for Dysphagia Manage- Setting ment

Implementation of optimal stroke care includes The Heart and Stroke Foundation has identified identifying and managing dysphagia. Dysphagia a vision for identifying and managing dysphagia may be evident immediately after a stroke, or it in acute stroke survivors in Ontario. 13 This vi- may develop during the first few days after a sion has been maintained in the LTC adaptation. stroke. Studies indicate that almost 50% of acute The vision states that: stroke patients have some degree of dysphagia  All stroke survivors will have access to within the first 72 hours after the stroke. 6 Of rapid and timely [swallowing] screening to those initially affected, approximately 50% con- minimize the development of complica- tinue to have dysphagia one week after the on- tions. Stroke survivors who have a positive set of the stroke. 2 Those who remain affected result from screening will have access to a after the first week experience much slower rapid and timely comprehensive dyspha- swallow recovery. gia assessment by a [dysphagia expert]. Undetected dysphagia may lead to potentially Those stroke survivors found to have dys- serious medical complications, including dehy- phagia will receive appropriate individual- dration, malnutrition and aspiration pneumonia. ized and nutritional management that 3, 4, 6, 7, 10 Risk for pneumonia increases 3-fold for meets the best practice guidelines for 1 stroke survivors with dysphagia. Evidence managing dysphagia. supports the importance of identifying and managing dysphagia in stroke survivors as a strategy The Registered Nurses’ Association of Ontario 2, 12-14 to reduce these complications. Dysphagia (RNAO) has echoed this vision for stroke survi- is also associated with an increased length of vors in their best practice guidelines, Stroke As- hospital stay, institutional care, and increased sessment Across the Continuum of Care, which 8, 9 mortality. As a result, promptly detecting dys- were developed in collaboration with the Heart phagia and instituting appropriate management and Stroke Foundation of Ontario (HSFO). These strategies is expected to shorten length of stay guidelines focus on stroke assessment across the 2 and reduce medical complications. continuum of care. More specifically related to dysphagia these guidelines recommend: 15 Few long-term care (LTC) facilities have a speech -language pathologist (SLP) dysphagia expert on  Nurses in all practice settings, who have staff. Access to this professional is limited to appropriate training, should administer consultation from the community (e.g., Commu- and interpret a dysphagia screen within nity Care Access Centre). As a result, it is im-

5 24 hours of the stroke client becoming dietitian (RD), physiotherapist (PT), personal sup- awake and alert. This screen should also port worker (PSW), health care aide (HCA), reha- be completed with any changes in neuro- bilitation assistant (OTA/PTA), activation, restora- logical or medical condition, or in swal- tive, pastoral care, environmental, housekeeping lowing status….In situations where impair- and food services staff, dietary aid, member of ments are identified, clients should be the management team (i.e., Director of Care, referred to a trained healthcare profes- Administrator, Programs Director) and the off- sional for further assessment and man- site SLP consultant. The team members would agement. be trained to:

 Screen all newly admitted and/or resident stroke survivors (by Screeners). Because Ontario has a shortage of dysphagia experts especially in the LTC setting, for example  Refer residents with a positive screen to SLPs, achieving this vision requires the creation the SLP (by Screeners). of interprofessional dysphagia care teams  Practice safe feeding and swallowing trained to identify dysphagia risk and collaborate care during meal times (by Feeders). with dysphagia experts to manage dysphagia in stroke survivors.  Act as a contact/resource for family and staff. (by Screener and Feeders). A pilot project completed in the Toronto West Stroke Network in 2005/2006 supported the es- tablishment and training of interprofessional Best Practice Guidelines for Manag- dysphagia care teams in LTC facilities. Educa- tional support for the team related to dysphagia ing Dysphagia in Long-Term Care was provided through the SLP working within the Regional Stroke Network. The SLP dyspha- The best practice guidelines for long-term care 13 gia expert in the community provided the swal- were adapted from the acute version. These lowing assessment for stroke survivors identified guidelines provide a benchmark against which at risk for dysphagia. The Dysphagia Care Team facilities with stroke survivors can measure their was made up of two subgroups: screeners and progress in improving the management of dys- feeders. Screeners included regulated phagia post stroke. healthcare professionals (e.g., nurse, dietitian) 1. Screen all stroke survivors for swallowing diffi- who were trained to screen stroke survivors for culties within 24 hours of admission to the long- dysphagia and refer those survivors who fail term care facility. A Screener member of the screening for a full assessment by the SLP dys- Dysphagia Care Team trained to administer the phagia expert. Feeders were unregulated swallowing screening test and interpret the re- healthcare professionals (e.g., personal support sults should perform the screening. If the stroke workers, activation staff) who were trained in survivor is known to have a previously identified safe feeding and swallowing strategies to allow dysphagia, the Screener should abide by recom- successful implementation of the SLP recommendations detailed in the admission notes and mendations post swallowing assessment. arrange follow-up SLP intervention as indicated. The team could include a physician (MD), registered nurse (RN), registered practical nurse (RPN), occupational therapist (OT), registered

6 2. If the stroke survivor has a positive result on complications, including airway ob- the swallowing screening, the Screener will: struction, aspiration of food and liquid and inadequate nutrition and hydra-  Complete a referral for a swallowing tion. assessment by the consultant SLP dysphagia expert.  Identify associated factors that could interfere with adequate oral nutrition  Notify the in-house dietitian of the failed swallowing screening. and hydration or lead to aspiration- related complications, such as impaired  Recommend the stroke survivor contin- motor skills, cognition or perception. ues oral intake (PO – per os), with close monitoring for tolerance, on the diet  Recommend appropriate individualized consistency deemed to be safest until management, which may include the swallowing assessment can be changes in food or fluid consistency, completed. feeding strategies, swallowing therapy, oral care regimens and possibly referral  Notify the Feeder team members to to other healthcare professionals. closely monitor the survivor during eating and drinking since a swallowing assessment is pending. 4. Assess the nutrition and hydration status of all stroke survivors with a positive screening. The  Recommend the survivor be maintained nil per os (NPO) only in situa- stroke survivor’s MD and RN/RPN may monitor tions where continued PO safety is in hydration status and initiate appropriate labora- question. NPO prohibits the admin- tory investigations. An RD, in conjunction with istration of oral medications, water, and other team members, should: ice chips. Intravenous fluids may be re-  Assess energy, protein and fluid needs. quired. As a result, this may necessitate  Recommend alterations in diet to meet transfer to the closest emergency de- energy, protein and fluid needs in ac- partment as a swallowing assessment cordance with allowable food texture by the consultant SLP is unlikely to be and fluid consistency. completed within 24 hours of the referral. 5. The Screener team member should communicate results and recommendations from the 3. Assess the swallowing ability of all stroke survi- swallowing assessment to other team members vors who have a positive result on swallowing (e.g., Food Services, RD, Activation, PSW/HCA screening. The assessment includes a clinical and MD) to ensure continued safety and conti- bedside examination and, if warranted by the nuity of care with respect to oral intake. clinical signs, an instrumental examination. An SLP dysphagia expert, in consultation with other team members, should: 6. Provide feeding assistance or mealtime supervision to all stroke survivors. Feeder team mem-  Assess the stroke survivor’s ability to bers or those trained in low-risk feeding strate- swallow food, liquid, and medications. gies should provide this assistance or supervi-  Determine the level of risk of dysphagic sion. The Screener team member should moni-

7 tor mealtimes and provide assistance and support to the Feeder team members as needed. Review Questions

1. At what point after admission to LTC is it ap- 7. Perform regular mouth-clearing or oral care propriate to screen a newly admitted stroke procedures to prevent colonization of the mouth survivor for dysphagia? and upper aerodigestive tract with pathogenic bacteria. Minimal amounts of water can be used 2. Who can complete the dysphagia screening to wet utensils before inserting them into the for stroke survivors? survivor’s mouth. 3. Who should be referred to an SLP dysphagia expert for a swallowing assessment? 8. Arrange for a reassessment of all stroke survi- 4. When should stroke survivors known to have vors receiving modified texture diets or enteral dysphagia have their swallowing status reas- feeding for alterations in swallowing status regu- sessed? larly. Stroke survivors known to have dysphagia should be re-evaluated by an SLP dysphagia expert at minimum intervals of every two to three months during the first year after the stroke and then every six months thereafter. The severity of swallowing impairment and the rate of improvement may alter the reassessment schedule.

9. Provide the stroke survivor or substitute decision-maker with sufficient information to allow informed decision making about nutritional options. Consider the wishes and values of the stroke survivor and family concerning oral and non-oral nutrition when developing a dysphagia management plan.

10. Act as resource to all stroke survivors, family members and care providers regarding dysphagia and feeding difficulties post stroke. Explain the nature of the dysphagia and recommendations for management, follow-up and reassessment. Consult other team members as necessary.

8 Swallowing: Anatomy, Physiology and Patho- physiology

Normal Swallowing

Efficient swallowing involves the combination of sensory information and motor activity in the Anatomy mouth and surrounding anatomic structures. Swallowing is a complicated process that in- The sensory components include the perception volves the oral cavity, pharynx, larynx and of taste, viscosity, temperature, smell and tactile esophagus (Figure 1). This process is the product input from the teeth, oral mucosa and tongue. 16 of a series of events that require an intact nerv- Eating involves two motor processes: feeding, ous system and adequate musculature for initia- which entails recognizing food and drink and tion, facilitation, and conclusion of a safe swal- transporting it to the mouth; and swallowing, low. 18 which involves moving food from the mouth to the stomach, with no negative impact on breath- 17 ing. Figure 1 Anatomy of swallowing

9 The oral cavity begins at the lips and includes the UES initiates the esophageal phase of swal- the teeth, gums, tongue, hard palate and soft lowing. Esophageal peristalsis helps to push the palate (velum), the uvula, faucial arches and food and drink toward the stomach. Closing of cheek muscles. The oral and nasal cavities are the LES completes the esophageal phase of connected at the back of the throat by a pas- swallowing and prevents regurgitation, or reflux, sage with a valving action that closes during of stomach contents, including acid, into the swallowing. This valving action prevents food esophagus. 20 and liquid from entering the nasal cavity. Also, within the oral cavity are three pairs of salivary Physiology glands. Saliva produced by these glands main- Effective swallowing depends on the coordinated tains oral moisture, reduces tooth decay, assists action of 25 pairs of muscles. These muscles are 19 with digestion, and neutralizes stomach acid. controlled by 5 cranial nerves: the trigeminal (V), The pharynx, or throat, is a muscular tube that is facial (VII), glossopharyngeal (IX), vagus (X) and involved both in ingesting food and breathing. hypoglossal (XII). 21 The base of the tongue forms the front of the pharynx, and the side and back muscular walls enclose the pharynx. The pharyngeal spaces in- Stages of swallowing clude the valleculae and pyriform sinuses. Also, Swallowing physiology can be divided into 4 in the pharynx is a small piece of cartilage known stages: the oral preparatory stage, the oral pro- as the epiglottis. The pharyngeal muscles help pulsive stage, the pharyngeal stage, and the propel food through the throat toward the esophageal stage. The oral stages of swallowing esophagus. 19 involve voluntary actions, and the pharyngeal The larynx or voice box is located at the front of and esophageal stages of swallowing involve in- the neck, directly in front of the junction be- voluntary actions. 21 tween the pharynx and esophagus and just above the trachea (i.e., airway). The larynx acts as a passageway for air to the lungs. Functions Oral preparatory stage of the larynx are varied and include the follow- The oral preparatory stage involves the muscles ing: 19 of the lips, cheeks and mandible; the teeth, and  Passage for inhaled and exhaled air. the tongue. The teeth and muscles of the mouth  Role in voice production. chew the food and form it into a ball known as the bolus. Taste, temperature, and texture infor-  Prevention of foreign objects, including mation stimulate production of saliva, which food, from entering the trachea, and adds moisture to bind the bolus. Papillae on the ejection of any inhaled foreign objects. tongue also provide sensory information that  Pressure-regulating valve allowing safe helps to prepare the bolus to the right size and and efficient swallowing. consistency. The tongue holds the bolus against The esophagus is a collapsed muscular tube with the front of the hard palate, while the lips and sphincters at both ends; the upper esophageal jaw close, sealing the mouth (Figure 2). Liquids sphincter (UES) and the lower esophageal are also formed into a bolus. The length of the sphincter (LES). The esophagus transports food oral preparatory stage varies, depending on the from the pharynx to the stomach. Opening of amount and texture of the food and individual

10 eating habits. During the oral preparatory stage Pharyngeal stage of swallowing, the larynx and pharynx are at rest, When the bolus reaches the area at the level of the airway is open, and normal breathing contin- the tonsils, the pharyngeal stage of swallowing ues. 22 This is the stage of swallowing from begins. This stage of swallowing is reflexive, and which most people derive the greatest pleasure. it occurs quickly, typically in less than two seconds. The soft palate elevates against the back Figure 2 Oral preparatory stage of swallowing of the throat triggering closure and preventing solids and liquids from entering the nasal cavity

(Figure 4a). Within the larynx, the vocal cords

close, preventing food and drink from entering

the trachea or airway. This closure of the vocal

cords results in a momentary pause in breathing.

The airway is further protected by the backward

movement of the epiglottis, which directs food

into the esophagus and away from the larynx.

The larynx elevates, assisting in opening the UES (Figure 4b). The bolus moves quickly and smoothly through the pharynx and its spaces, Oral propulsive stage the valleculae and pyriform sinuses (Figure 4c). At the end of the pharyngeal stage, the bolus The oral propulsive stage of swallowing occurs passes to the esophagus. 19, 23 when the tongue, the primary muscle in the oral stage, begins transporting the bolus from the oral cavity to the pharynx. The tongue elevates Figure 4 a) Soft palate elevates against the back and moves from the front of the mouth to the of the throat triggering closure. b) Vocal cords back, with the surface of the tongue pushing close, epiglottis lowers, and larynx elevates. c) against the hard palate and squeezing the bolus Bolus moves quickly and smoothly through the backwards until it reaches the pharynx (Figure 3). pharynx. 23 This stage of swallowing typically takes 1-1.5 a) b) c) 22 seconds.

Figure 3 Oral propulsive stage of swallowing

Esophageal stage During the esophageal stage of swallowing, the bolus is propelled down the esophagus by waves of peristaltic contractions. It takes 8-20 seconds for the bolus to travel from the UES to the LES, making the esophageal stage consider- ably longer than the pharyngeal stage (Figure 5). After the bolus enters the stomach, the LES

11 closes preventing gastroesophageal reflux. Coordination of swallowing, speaking, and breathing Figure 5 Bolus is propelled down the esophagus

Swallowing, speaking and breathing are three basic human functions that use many of the

same anatomical structures. For example, the lips produce sounds, but they can also prevent food or liquid from leaking from the mouth during chewing. The tongue is involved in speech, and it also propels the bolus back into the pharynx

and esophagus during swallowing. The larynx produces the voice, but it also seals the airway during swallowing, so that food and liquid do not enter the lungs.

An important reciprocal relationship exists between the functions of breathing and swallowing, as they use many of the same muscles. Air flows into and out of the lungs through the nasal pas- sages and the pharyngeal cavity. The pharynx, however, is a shared passage for the movement of air and for the transport of food and liquid into the esophagus. The larynx also plays a dual role: it protects the airway from food and liquid during swallowing, and it maintains an open airway for effortless breathing. Breathing and swallowing cannot occur at the same time. During swallowing, the larynx closes the airway through a series of valving actions. The epiglottis deflects downward to direct food and liquid into the esophagus, and the vocal cords contract to close off the trachea. Breathing therefore stops for a fraction of a sec- ond during the transition from the pharyngeal to the esophageal stage of swallowing. 24 This pause in breathing, known as swallowing apnea, ensures airway protection. Swallowing apnea begins with airway closure when the bolus reaches the lower pharynx and finishes when the last of the bolus enters the esophagus. 25 The length of the apneic period increases with bolus size. 26 The timing of swallowing and breathing must be

12 coordinated to prevent inhalation of food or liq- 16%19, and yet it is estimated to occur in more uid. Changes in muscle strength and timing can than 50% of acute stroke survivors. 3, 6, 30 affect this coordination.

Swallowing in the elderly: Presby- Did you know? The gag reflex does phagia not help with the process of swallowing. The purpose of swallowing is to ingest food and drink while the gag reflex functions to eject for-

Aging is a systemic process that affects physio- eign objects. The absence of a gag reflex does logic functions to varying degrees. Age-related not indicate that a resident will have dysphagia changes that can affect swallowing result from nor does the presence of a gag reflex exclude loss of muscle tone, loss of elasticity of connec- the possibility that the resident may have dys- tive tissue, decreased saliva production, changes phagia. 13 in sensory function, and decreased sensitivity of 27 the mucosa. In healthy individuals, age-related changes in swallowing are known as primary presbyphagia. 18 Impaired Swallowing: Dysphagia

Changes in muscle and nerve function begin around 50 to 60 years of age, but the most sig- Dysphagia is defined as difficulty or discomfort in nificant loss of muscle strength, approximately swallowing, and the term describes a set of 30%, occurs between 50 and 80 years of age as symptoms or signs related to changes in swal- muscle mass diminishes. 19 These age-related lowing. Any motor, sensory or structural changes changes reduce motility of the pharyngeal and to the swallowing mechanism can result in im- esophageal muscles, changing the movements paired swallowing. Dysphagia is one of the most of the epiglottis, reducing closure of the vocal common sequelae of acute stroke, affecting as 1, 6, 31, 32 cords, and altering UES function. In addition to many as 55% of acute stroke survivors. these physiologic changes, older adults have a Individuals with stroke may have reduced cogni- higher rate of structural abnormalities that can tive abilities, advanced dementia, reduced ability also affect the pharyngeal and esophageal stag- to sequence swallowing patterns, or may not es of swallowing, such as pharyngeal webs and recognize the purpose of food. Stroke can affect diverticula; osteophytes; cervicothoracic ky- any or all of the stages of swallowing, thus af- phoscoliosis; and rheumatoid arthritis. 22 In addi- fecting an individual’s ability to eat and drink tion, poor dentition or poorly fitting dentures safely. 28 can impair the oral stages of swallowing.

Healthy elderly individuals can compensate for 29 presbyphagia. However, dysphagia can result when presbyphagia is compounded by changes resulting from fatigue or weakness or from a concomitant disease process, such as stroke. 22 The prevalence of dysphagia in healthy individuals 60 to 95 years of age is estimated to be 8 to

13 Types of Dysphagia  Changes in chewing due to loose or poorly fitting dentures or missing teeth.

Oral Dysphagia Oral Propulsive Dysphagia Oral dysphagia refers to dysphagia affecting the During the oral propulsive (or transit) stage, the voluntary, or volitional, stages of swallowing, tongue transfers the bolus of food or liquid from during which movement of the bolus can be the oral cavity to the pharynx, triggering the controlled. Stroke can cause oral dysphagia pharyngeal stage of swallowing (See Fig 3 page through a variety of mechanisms. Post stroke 11). Dysphagia in the oral propulsive stage af- changes to facial muscle strength and/or move- fects the effectiveness of this movement of the ment as well as oral motor movement and plan- bolus. Dysphagia is present if the oral propulsive ning difficulties can affect this volitional control. stage is prolonged; taking more than 2 seconds Stroke can also affect underlying oral processes to complete. 22 and sensations involved in swallowing, such as salivary flow and taste and temperature sensitivi- If a stroke survivor is experiencing oral propulsive ty. 22 dysphagia you may notice the following:  Pocketing of food in spaces between the Oral Preparatory Dysphagia gums and cheeks. A stroke may reduce the strength, coordination  Food, liquid or saliva pooling at the front and control of oral muscles involved in swallow- of the mouth. ing, decreasing the stroke survivor’s ability to manipulate food and form a bolus (See Fig 2  Food or drink running from the nose. page 11). As a result, dysphagia in this stage of swallowing affects preparation of the bolus.  Holding food in the mouth. Dysphagia is also present if the oral preparatory  Unusual tongue movements to start the stage is prolonged. swallow or attempt to move the bolus. If a stroke survivor is experiencing oral preparatory dysphagia you may notice the following:  Drooling Pharyngeal Dysphagia  Spillage of food or liquid from the During the pharyngeal stage of swallowing, the mouth. bolus moves from the back of the mouth to the  Difficulty drinking from a straw or taking esophagus. Pharyngeal dysphagia can be harder food from a cup or spoon without spill- to identify because the affected anatomical age. structures and processes are not easily seen. During the pharyngeal stage, a coordinated se-  Slow eating ries of events, involving complex movements of  Dry mouth the tongue and pharyngeal structures, propels  Food residue remaining in the mouth the bolus into the esophagus while protecting after swallowing. the airway (See Fig 4 page 11). Stroke can affect the timing of the swallow, clearance of residue,  Food refusal or complaints of poor taste.

14 adequacy of airway protection and the flow of a mechanical obstruction, motility disorder, or the bolus through the pharynx resulting in phar- impaired LES function. yngeal stage dysphagia. The pharyngeal stage of If a stroke survivor is experiencing esophageal swallowing can be delayed if the bolus does not dysphagia you may notice the following: trigger a pharyngeal swallow. Because the signs can be subtle, caregivers may not suspect phar-  Reflux of food into the throat or mouth. yngeal dysphagia, especially if the oral stages of  Report of food sticking in the throat or swallowing are unaffected. chest.

If a stroke survivor is experiencing pharyngeal  Heartburn dysphagia you may notice the following:  Vomiting of undigested food.  Throat clearing, coughing, choking when  Report of sour taste in mouth, especially eating or drinking. in morning.  Difficulty swallowing — gulping. Dysphagia can affect all four stages of swallow-  A wet or gurgly sounding voice when ing. Your observations will vary depending on eating or drinking. which stage(s) of swallowing is/are affected. If  Breathing difficulties — shortness of you observe difficulty, this suggests the presence breath during meals. of a swallowing problem and further investigation is required. As a result, the resident should  Late or no movement of the Adam’s ap- be referred to an SLP dysphagia expert for a ple with swallowing. swallowing assessment.  Report of food sticking in their throat.  A history of recurrent pneumonias.

Esophageal Dysphagia Esophageal peristalsis propels the bolus from the UES, through the esophagus, and past the LES toward the stomach (See Fig 5 page 12). The LES relaxes, allowing the bolus to pass, but contracts again immediately after the entire bolus enters the stomach to prevent gastroesophageal reflux. Similar to the pharyngeal stage, the signs of esophageal stage dysphagia are more difficult to identify because the anatomical structures and processes are not easily seen. Stroke can affect the timing, effectiveness and clearance of residue in the esophageal stage. This stage of swallowing may be prolonged if the bolus takes longer than normal to travel to the stomach. Esophageal dysphagia can also be characterized by retention of food in the esophagus caused by

15 Complications of Dysphagia ness.  Poor baseline chest status.

 Inability to cough and clear secretions. Aspiration  Inability to sit upright. Aspiration occurs when food or liquid enters the  Inability to walk. trachea. 33 Signs of aspiration include coughing, shortness of breath, difficulty breathing, and res-  Dependency on others for care (i.e., feeding). 34-36 piratory complications. The occurrence of The risk of developing aspiration pneumonia is aspiration with no observable signs (i.e., no also affected by what is aspirated, how much is coughing or throat clearing) is known as silent aspirated, how far it travels into the respiratory 37, 38 aspiration. Stroke can cause reduced lar- system and the person’s ability to clear the aspi- yngeal sensation, increasing the resident’s risk rate from their lungs. 44, 47 For example, a bolus for silent aspiration. Silent aspiration can be un- that is acidic (e.g., orange juice) when aspirated detected until a complete swallowing assessment in large quantities is at greater risk of causing 39 is administered. pneumonia.

Malnourished individuals have a higher risk of aspiration, because muscles are weakened, reducing breathing strength, throat clearing, and Did you know? The cough reflex coughing. 37 Aging affects both breathing and can be impaired or absent in residents with dys- swallowing, increasing the risk of aspiration. 40 phagia, so silent aspiration may occur. These normal changes are compounded by stroke, chronic obstructive pulmonary disease 41-43 (COPD), and other medical conditions. Malnutrition Malnutrition is the result of an imbalance be- Aspiration Complications tween a person’s caloric need and a person’s actual intake.48 Malnutrition is common among Dysphagia is strongly associated with aspiration the elderly. Sixteen percent of individuals with pneumonia, a chest infection caused by the en- acute stroke are malnourished on admission to try of foreign substances and/or bacteria into the hospital. 49 Over time, malnutrition can develop lungs. This common respiratory complication or worsen in stroke survivors. Up to 50% of following stroke is associated with repeated en- stroke survivors admitted to rehabilitation from try of food or liquid into the lungs due to abnor- acute care may be malnourished. 4, 50 Signs of 36, 44, 45 mal swallowing physiology. Not everyone malnutrition include48: who aspirates develops aspiration pneumonia. The likelihood that someone will develop aspira-  Weight loss tion pneumonia is based on the following risk  Confusion factors: 39, 46, 47  Fatigue  Difficulty with oral hygiene – including dental  Dizziness caries.  Skin breakdown  Decreased cognitive status and level of alert-

16  Decreased resistance to infection. the hydration status cannot be improved by oral means the resident may require transfer to hos- If you notice these signs and suspect that the pital for temporary intravenous fluids support. resident may be suffering from malnutrition it is important to notify the registered dietitian (RD). The RD can assess the clinical indicators of mal- Dysphagia Risk Factors nutrition, such as weight loss, decreased body mass index (BMI) and evaluation of biochemical 4 indices. Stroke Location Cerebral hemisphere stroke can affect motor Dehydration and sensory responses of the swallowing mechanism. A left hemisphere stroke may also affect Dehydration is a water and electrolyte disturb- the stroke survivor’s ability to understand or use ance resulting from either water loss or deple- language, produce clear speech or effectively tion of sodium with accompanying water loss. communicate information. It may affect the right Dehydration can develop when metabolic water side of the face, lips and tongue, resulting in needs and losses exceed intake, for example, asymmetry, weakness, and slow uncoordinated 51, 52 with vomiting and diarrhea. As elderly indi- movement. A right hemisphere stroke may affect viduals may have a decreased sense of thirst, the left side of the face and reduce the ability to dehydration becomes more common with age. recognize and appreciate the extent of swallow- Almost 25% of individuals over 70 years of age ing impairment. are dehydrated on admission to hospital, and more than 33% of long-term care residents ad- The brainstem, the origin of most cranial nerves, mitted to hospital are dehydrated. 50 is the main control especially for the pharyngeal stage of swallowing. Survivors of a brainstem Dysphagia is a risk factor for dehydration be- stroke may or may not have any apparent cause it is associated with an inability to manage weakness on either side of the face, mouth or liquids safely. In older adults the risk for dehy- throat, but they may have significant difficulties dration increases because of impaired cognition, beginning or executing the pharyngeal stage of reduced mobility and need for feeding assis- swallowing. 53, 54 tance. Dehydration is an important predis- posing factor in stroke reoccurrence.50, 55 Signs of dehydration include the following48: Comorbid Conditions Comorbid conditions are physical or mental  Confusion conditions that an individual developed before,  Dry mouth and tongue. during or after a stroke. Comorbidities may be present at birth or acquired during the course of  Sunken eyes maturation. Numerous conditions increase the  Dry loose skin (decreased skin turgor). risk of dysphagia, but not all individuals with  Decreased urine output. these conditions have swallowing difficulties. When an individual with one or more relevant If you notice these signs of dehydration it is im- comorbid conditions experiences a stroke, the portant to request that the physician (MD) and risk for dysphagia increases significantly.39, 46 It is the RD assess the resident’s hydration level. If therefore important to obtain a full medical his-

17 tory to identify comorbid conditions, the date of  Zenker’s diverticulum onset, and relation to swallowing history. 22, 56  Achalasia The following comorbid conditions increase the  Degeneration of cervical spine risk of dysphagia:

Progressive neurologic conditions 29 Medications  Parkinson’s disease Medications can contribute to or cause dyspha-  Multiple sclerosis gia by affecting fine motor function or by alter-  Huntington’s chorea ing alertness or cognition. 29, 61-63 Individuals  Amyotrophic lateral sclerosis (ALS) weakened by stroke, dehydration, malnutrition, or comorbid conditions may be more suscepti-  Advanced dementia ble to the side effects of medications, such as: Neuromuscular disorders 29  Psychotropic agents (e.g., Fluoxetine,  Myasthenia gravis Risperidone), which can result in tardive  Polio and post-polio syndrome dyskinesia.  Neuropharmacology agent.  Brian injury (e.g.,Clonazepam), whose actions mimic Respiratory disorders 39, 44 neurotransmitters involved in swallowing muscle function.  Asthma  Anticholinergic agents that decrease sali-  COPD vation (e.g., antihistamines, antidepres- 39, 44 Systemic diseases sants, antihypertensives), causing xero-  Arthritis stomia (i.e., dry mouth), or those that increase salivation (e.g., Haloperidol,  Diabetes mellitus Clonazepam), affecting the resident’s  Epilepsy management of their saliva.  Gastrointestinal reflux disease (GERD) Some required medications may be in a format that is difficult for those with dysphagia. For ex-  Thyroid conditions ample, medications that cannot be crushed, sus- 57 Connective tissue diseases tained-release or liquid formulations. As a result,  Rheumatoid Arthritis the format of the medication may need to be altered and/or a change in medications may be  Systemic lupus erythematosus (SLE) necessary. Consultation with the pharmacist and  Scleroderma physician will be necessary if medication changes 56, 64 Cancer and its treatment 58 are required.

 Ablation of oral, pharyngeal or esophageal structures.  Radiotherapy to oral, pharyngeal or esophageal areas. Structural deficits 59, 60

18 Review Questions

1. How many stages does the normal swallow have? Give one anatomic and one physiologic landmark for each stage. 2. Name 3 changes that occur to the swallowing mechanism due to normal aging. 3. How is the gag reflex associated with swallowing? 4. Define dysphagia. 5. Provide 3 complications of dysphagia. 6. List the 3 most accurate clinical signs of aspiration. 7. Define silent aspiration. Why is it a concern for caregivers of stroke survivors? 8. What risk factors increase the likelihood of developing aspiration pneumonia? 9. Name 3 comorbid or pre-existing medical conditions with an increased risk of dysphagia. 10. Describe how medications can contribute to dysphagia.

19 Clinical Approach to Interprofessional Dysphagia Care Te a m Dysphagia The interprofessional dysphagia care team in- The clinical approach to dysphagia in stroke sur- cludes dysphagia experts (an SLP), dysphagia vivors involves initial screening, assessment, on- screeners (typically RD, RN, RPN), and dysphagia going monitoring and management (Figure 6). feeders (typically PSW, HCA, activation and re- Screening identifies the likelihood of dysphagia, storative staff, food services staff) (see Appendix but does not indicate the severity. Assessment 1). All other professionals can, with proper train- identifies specific structural and physiological ing, participate in various roles with the support deficits and determines their severity. Ongoing of the SLP dysphagia expert. And of course, the monitoring involves regular observation of integral member is the stroke survivor him/ stroke survivors for clinical indicators that may herself and their family. Each trained member of be a sign of the development of dysphagia or the team plays an essential role in identifying the changes in its severity. Management includes risk of dysphagia, preventing complications, and implementation of all strategies required to pre- rehabilitating the stroke survivor with dysphagia. vent complications of dysphagia, including oral hygiene, appropriate dietary modifications, and Speech-Language Pathologist safe feeding strategies. An interprofessional dysphagia care team implements this approach ac- The Speech-Language Pathologist (SLP) plays a cording to the specific needs of an individual central role in screening, assessing, treating and stroke survivor as determined by a complete as- managing the stroke survivor with dysphagia. sessment administered by an SLP dysphagia ex- The College of Audiologists and Speech- pert. Language Pathologists of Ontario (CASLPO) and the Speech-Language & Audiology Canada (SAC) have identified assessment and treatment of dysphagia as within the scope of practice of the SLP.65, 66 The SLP is also a resource to the dysphagia care team, stroke survivors, and the community. In the long-term care setting the SLP is typically involved in establishing and maintaining a system by which health care professionals can accurately and efficiently identify stroke survivors with an increased risk for dysphagia. ”A screening serves to identify patients at risk for dysphagia and initiate early referral for assessment, management or treatment for the purpose of preventing dis- tressful dysphagia symptoms and minimizing risks to health.” 66

20 The SLP is further responsible for assessing and high risk for dysphagia. The SLP then completes developing a treatment and/or management the swallowing assessment and provides recom- plan for each stroke survivor presenting with mendations for management through visits to dysphagia. The intervention must be customized the stroke survivor at the LTC site. The on-site to the specific swallowing impairment of each dysphagia care team members play a large role individual. in implementation of the SLP recommendations and observation for tolerance of the recom- “The scope of practice includes screen- mended diet textures and strategies. Clear coming, identification, assessment, interpreta- munication (i.e., written or verbal reports) be- tion, diagnosis, management and reha- tween the SLP and the other team members is bilitation of disorders of the upper aero- 65 essential in providing the best possible care for digestive tract, including swallowing.” the stroke survivor with dysphagia.

Specifically, the SLP has the following role in ad- Registered Dietitian dressing dysphagia among stroke survivors: 66 The Registered Dietitian (RD) plays a key role in  Develop, educate and mentor dysphagia assessing and monitoring clinical indicators of care teams. nutritional status. This may include evaluation of  Conduct a clinical assessment in all biochemical indices, body weight, fluid and solid stroke survivors with a positive dyspha- intake and route of nutrition administration (i.e., gia screen. oral, enteral or parenteral). The RD also recom-  Recommend and administer an instru- mends types and route of administration of en- mental assessment of dysphagia when teral feeding and dietary components. The RD is necessary. responsible for ensuring that the stroke survivor receives sufficient intake to maintain or achieve  Generate a report interpreting clinical adequate caloric (micro and macro nutrients) and/or instrumental assessments. and fluid balance. This is done working with the  Recommend remedial programming to textures prescribed by the SLP dysphagia expert the physician and dysphagia care team. to achieve safe swallowing. Most often, the RD and SLP work collaboratively to monitor the  Provide swallowing treatment and/or management to stroke survivors, care stroke survivor and allow modification of the providers and the dysphagia care team. dysphagia treatment and management strategies as appropriate. 22, 56  Recommend an appropriate diet texture progression in consultation with other Both the roles of the SLP dysphagia expert and team members, i.e., RD. the RD are critical to proper management of the stroke survivor with dysphagia. They each pro-  Provide recommendations, information, vide separate but complementary approaches to and education for families, care provid- dysphagia management. ers, LTC staff and stroke survivors. It is rare for an SLP to be on staff in the long- term care setting. As a result, the SLP is often an external consultant that can be brought in as needed when a stroke survivor is identified as

21 Table 1. SLP and RD Roles in Dysphagia Man- agement

SLP RD

Complete initial swallowing assessment and fol- Assess and monitor nutritional adequacy low-up assessments as indicated Recommend supplements, dietary treatment Recommend safest diet consistency, feeding and (e.g., no added salt) and/or tube feeding if swallowing strategies needed Educate stroke survivor, family and Dysphagia Educate stroke survivor, family and Dysphagia Care Team Care Team Work closely with the RD to monitor and modify Work closely with the SLP to monitor and modify dysphagia management as needed dysphagia management as needed

Registered Nurse or Registered Practical Nurse The Registered Nurse (RN) and Registered Prac- assessment and/or recommendations following tical Nurse (RPN) are key members of the dys- the assessment. phagia care team based on their essential role in resident care. The nurse is the central communi- cator on the team, relaying information regarding the resident stroke survivor to all other team members. As well, the nurse is responsible for the monitoring of stroke survivors at all times. 67

As a result, the RN or RPN is usually the individual providing screening when an institution implements universal dysphagia screening for stroke survivors. 68, 69 Optimally, to reduce acci- dental aspiration, screening should be performed immediately upon admission, or as soon as the resident is alert, and before any oral intake is administered. The use of a systematic screening approach or a standardized protocol is ideal, as this increases the accurate detection of dysphagia and provides better protection for the stroke survivor. 68 In the LTC setting the trained RN/RPN is responsible for dysphagia screening, making the referral for an SLP swallowing assessment and informing other team members of the stroke survivor’s need for an

22 Table 2. Collaborative Approach to Dysphagia ture. and Nutrition Management Post Stroke Personal Support Worker or Health Care SLP RD RN/ Other Aide RPN Team Mem- The Personal Support Worker (PSW) or Health bers Care Aid (HCA) assists the stroke survivor with   Screens for Dysphagia    completion of regular oral hygiene care and Screens Nutritional Sta-    feeding during meal times. The PSW/HCA also tus plays an important role in monitoring for signs of dysphagia, ensuring that the survivor receives Completes Swallowing  Assessment the appropriate diet texture and encouraging use of safe swallowing strategies. In keeping  Completes Nutritional with stroke best practice guidelines the PSW/ Assessment HCA should be educated in the use of safe feed- Recommends Swallow-  ing and swallowing strategies. Those trained being Treatment come feeder members of the dysphagia care (i.e., diet texture chang- team. PSWs/HCAs should be familiar with the es, feeding and swal- stroke survivor’s SLP recommendations post lowing strategies, etc.) swallowing assessment and with the signs of Recommends Dietary  dysphagia. They are responsible for reporting Treatment any difficulties noted to the resident’s RN/RPN. (i.e., need for nutritional supplements, need for low salt, diabetic, etc.) Restorative Care and Activation Staff Monitors Dysphagia     Staff members working in restorative care or ac- Management tivation assist the stroke survivor in maximizing independence with eating and drinking. Similar if trained to the PSW, these professionals are trained to Physician provide assistance during meal times and monitor for signs of dysphagia and, when trained, The doctor (MD) supervises the medical man- also become feeder members of the dysphagia agement of the stroke survivor, monitoring and care team. managing pulmonary status and hydration, or- dering appropriate investigations, consulting with the RD and SLP about the need for enteral or parenteral feeding, and reviewing dysphagia Food Services Staff care team recommendations with the family as Individuals working in food services are respon- 22, 56 required. Policies vary between facilities, sible for preparation and supplying of food, however, frequently the MD needs to approve drinks and mealtime equipment (i.e., plate, cups, the referral to the SLP for a swallowing assess- spoons, etc.) to the residents. Together with the ment (i.e., telephone order) and the MD needs RD, the food services manager establishes the to be aware of recommendations after the as- meal options, ensures the correct diet texture is sessment to approve any changes to diet tex-

23 recorded and monitors for nutritional adequacy. Physiotherapist These professionals ensure that the appropriate The Physiotherapist (PT) can assist with optimal diet textures are properly prepared and served positioning, such as bed and wheelchair posi- to the stroke survivor. tioning for safe feeding, and with implementing swallowing strategies that direct the bolus away from the airway and facilitate safer swallowing. 23 Administration When a PT is not on staff at a LTC site, access to The Administrative Team includes any managers this consultant can occur through a community on-site. These professionals assist the dysphagia agency. care team in implementation of new polices and procedures related to dysphagia care for stroke survivors. As well, they provide support in com- Other Dysphagia Care Team Members pletion of training and problem solving around Other individuals working in the LTC facility can challenging clinical issues (i.e., resident choosing also be members of the dysphagia care team. to take an unsafe diet consistency). These individuals can play an important role in balancing the resident care workload for other staff during mealtimes. It is important for safety Pharmacist reasons that these team members also receive The Pharmacist is responsible for medication training in safe feeding and swallowing strategies management for the stroke survivor. They can and that their assistance be limited to those assist the RN/RPN in determining safest mode of individuals who have been identified as low risk medication administration when an individual for dysphagia. has dysphagia and can outline which medications cannot be given in crushed format (see Ap- Stroke Survivor and Family pendix 2). The stroke survivor and their family are integral to the dysphagia care team. These individuals Occupational Therapist require support and education about dysphagia and its safe management as they move across The Occupational Therapist (OT) is traditionally the care continuum. Family members interested responsible for activities of daily living. The OT in assisting their loved one with feeding during determines the types of adaptive equipment meal times will benefit from dysphagia care needed and ways to improve meal set-up and team member guidance around use of safe food transport to the mouth. Expertise of this feeding and swallowing practices. discipline includes teaching stroke survivors with motor deficits to adapt to new feeding tech- Dysphagia education is best provided through- niques and recommending adaptive feeding out the continuum of care. It is critical that the equipment and upper extremity positioning to stroke survivor and family receive sufficient infor- assist with feeding. 22, 56 When an OT is not on mation about appropriate management and the staff at a LTC site, access to this consultant can potential negative outcomes to help them make occur through a community agency. informed decisions, especially about diet and nutritional issues. It is important to remember

24 that stroke survivors and their families may  Fast and easy to understand and use. choose to follow personal dietary choices rather  Acceptable to the stroke survivor. than team recommendations. Stroke survivors have the right to decline intervention, but they  Sensitive enough to provide a positive or must be informed of the possible consequences negative result. of their decisions, and both the education and  Specific enough to rule out individuals 13, 66, 70 refusal should be well documented. without risk of swallowing difficulty. All stroke survivors should be screened for dysphagia as soon as they are admitted, provided Dysphagia Screening they are awake and alert. Screening should also The trained screener member of the dysphagia occur before any oral intake is administered, in- 13 care team is responsible for screening the stroke cluding oral medications. survivor for signs and symptoms that may sug- Stroke survivors with a negative screen result gest an increased risk of dysphagia. Regulated (pass) are unlikely to have difficulties with oral health professionals, such as RNs, RPNs, RDs, intake and may receive meals and medications. OTs, or PTs, can be trained to screen for dyspha- These individuals should be monitored during gia. However, the SLP dysphagia expert remains their first few meals to ensure safe and efficient responsible for program development, referral swallowing. criteria, and professional education. 66 Stroke survivors with a positive screen result (fail) Screening helps to identify the presence or ab- are referred to the SLP for a full assessment. The sence of dysphagia and the risk of pulmonary, individual should continue on the oral diet hydration, or nutrition complications that may deemed to be safest for them until a full clinical exist with the individual’s current diet. However, bedside assessment has been completed by the screening does not provide information about SLP dysphagia expert. In situations where safety pathophysiologic changes to the swallowing of any oral intake is in question, the individual mechanism, which is determined by the SLP dys- should be kept NPO pending the swallowing as- phagia expert during assessment. Screening may sessment. This may necessitate transfer to the include an interview with the stroke survivor and closest emergency room for supplemental hy- family members about swallowing difficulties; a dration. Any time a resident is made NPO good review of relevant medical history; direct obser- oral hygiene practices are to be continued at the vation of signs and symptoms of swallowing dif- bedside to prevent colonization of the oral cavity ficulties during routine or planned oral feeding, by pathogenic bacteria. 13 including a water swallowing test; and education These individuals should be monitored during and counselling about the need for further eval- their first few meals to ensure safe and efficient uation. swallowing. Screening should include a fast, safe and efficient test for identifying individuals who are at high risk for dysphagia. In addition, screening should determine the stroke survivor’s tolerance for evaluation and indicate changes in swallowing status during rehabilitation. A good screening test has the following attributes:

25 Figure 7 Actions to Take Following Dysphagia

Toronto Bedside Swallowing Screen- ing Test (TOR-BSST©)

initial test that can accurately and reliably detect Several screening tools for swallowing difficulties the presence of dysphagia, defined as the pres- have been evaluated. Most screening tools share ence of aspiration or any physiological abnor- common features, but some screening proce- mality, in stroke survivors, regardless of time dures are better predictors of dysphagia than post stroke. Any regulated healthcare profes- others. The Toronto Bedside Swallowing Screen- © © sional trained to administer the TOR-BSST to ing Test (TOR-BSST ) is the only screening tool individuals with a stroke diagnosis and interpret that has been developed from a systematic re- 2 © the results can use this dysphagia screening tool. view of the literature. The TOR-BSST offers The TOR-BSST© comprises 4 clinical tests (50-ml the greatest value as it is based on the best water test, impaired tongue movements, dys- 71 The TOR-BSST© is a brief available evidence. phonia and general muscle weakness), which together have the highest likelihood of predict- © ing dysphagia. Evaluation of the TOR-BSST tool is now completed. 72

26 Dysphagia Assessment formed only after a clinical assessment, may include videofluoroscopy and endoscopy. 66 Assessment extends beyond the basic risk identified in the screen to determine the exact site of structural or physical involvement and the de- Videofluoroscopy gree of impairment. The SLP dysphagia expert Videofluoroscopy, also known as a modified bar- may use a variety of clinical and instrumental ium swallow, is the most common instrumental methods to assess the swallowing mechanism. procedure administered to individuals with dysphagia . 73 It is the SLP dysphagia expert who conducts this assessment. Videofluoroscopy is a Clinical Bedside Assessment radiologic procedure to study the anatomy and A clinical bedside assessment is completed by physiology of swallowing and define manage- the SLP dysphagia expert and includes a com- ment and treatment strategies to improve swal- plete medical, developmental and swallowing lowing safety or efficiency. The resident stroke history along with evaluation of the current survivor will need to be temporarily transferred medical, swallowing, and communication status. out to a hospital or other medical facility to have This portion of a swallowing assessment can be the videofluoroscopic procedure completed, as it conducted in the LTC facility during routine or requires a radiology suite, SLP, medical radiation planned eating and drinking. Clinical assessment technologist and possibly a radiologist. evaluates swallowing structure and function to Videofluoroscopy is also a valuable educational determine the overall nature and cause of im- resource to demonstrate to the stroke survivor paired oral swallowing physiology; it determines and caregivers the importance of compensatory the severity of oral dysphagia and provides de- strategies in improving swallowing safety. tails about oral swallowing pathophysiology, while also predicting potential impairment of pharyngeal and esophageal swallowing physiol- Endoscopy ogy. Potential risks of medical complications and Fiberoptic endoscopic evaluation of swallowing the impact of the dysphagia on functional and (FEES) uses a small fiberoptic camera placed in psychosocial aspects of daily living, such as feed- the nasopharynx or oral cavity to assess vocal ing safety and mode, are also identified. A clini- fold function, especially closure, which protects cal assessment includes follow-up recommenda- the lungs from aspiration. tions for further assessment and for treatment and discharge. If warranted, the SLP dysphagia expert recommends an instrumental assessment. 66

Instrumental Assessment

Instrumental assessment determines impairment in the structure and function of swallowing and identifies compensatory and/or treatment strategies to enhance the efficacy and safety of swallowing. Instrumental assessment, which is per-

27 Ongoing Monitoring months after that time. 13 Regular and careful monitoring of stroke survivors for dysphagia is critical. A stroke survivor’s physical status can fluctuate, directly affecting Clinical Indicators of Possible Dysphagia the ability to manage food and drink safely. The Numerous clinical indicators can alert health dysphagia care team must be observant enough care professionals to potential dysphagia. Some to identify subtle changes and the potential im- clinical indicators are readily apparent, whereas pact of these changes on the safety of oral in- others can only be identified through careful take. observation or screening. Finally, some indica- The dysphagia care team must monitor the tors can only be determined through a clinical stroke survivor’s level of consciousness and or instrumental dysphagia assessment by an SLP alertness, especially since the oral stage of swal- dysphagia expert. The likelihood of dysphagia lowing involves voluntary and planned move- increases with the presence of multiple indica- ment. Swallowing frequency is greatly reduced tors. Table 3 outlines some of the common clini- during sleep, and swallowing does not occur cal indicators of dysphagia. during unconsciousness. As a result, the stroke survivor with a reduced level of consciousness or alertness has an increased risk of aspiration from saliva or food residue moving into the pharynx where it cannot be controlled voluntari- ly. The team also monitors stroke survivors without initial signs or symptoms of dysphagia for the clinical indicators of potential dysphagia. Dys- phagia may develop with changes in physical status, and swallowing abilities may deteriorate in stroke survivors already diagnosed with dysphagia. All changes in an individual’s status should be discussed with the dysphagia care team and, if necessary, the SLP dysphagia expert should reassess the individual.

Feeding strategies should be reviewed regularly for stroke survivors receiving modified diets or enteral feeding, as swallowing function often changes. Best practice guidelines recommend that stroke survivors identified as having dysphagia receive regular reassessment to capture changes that may occur over time. Stroke survivors with dysphagia who are receiving modified diets or enteral feeding should be reassessed at minimum intervals of two to three months during the first year after the stroke, and every six

28 Table 3 Dysphagia Red Flags: Clinical Indicators That Can Signify Dysphagia

Stage of Swallowing Clinical Indicators

Oral Preparatory & Propulsive Drooling Dry mouth Poor oral hygiene Facial droop and lip weakness Missing or no teeth, or loose and poorly fitting dentures Difficulty with or excessive chewing Dysarthria — slurred speech Difficulty moving the tongue Pocketing of food in mouth Difficulty initiating a swallow, slow or delayed swallow

Pharyngeal Food or liquid coming from nose Difficulty initiating a swallow, slow or delayed swallow Audible or effortful swallowing — gulping with swallow Multiple swallows to clear a single bite of food Coughing or choking during or after eating Shortness of breath and/or breathing difficulties that increase during the meal Reports of food sticking in throat or chest Changes in voice

Esophageal Reports of food sticking in throat or chest Vomiting of undigested food

All Unexplained weight loss Change in dietary habits Recurrent respiratory infections, specifically pneumonia Report or history of dysphagia signs and symptoms

29  Feeding and swallowing strategies to in- Did you know? Silent aspiration is crease safety at mealtimes. common in individuals with dysphagia. The  Therapy or exercises to increase strength cough reflex may be absent when food or fluid and coordination of swallowing muscles. enters the airway, so it is important to know the others signs and symptoms of dysphagia.  Consultation with physician and RD about alternative feeding options if oral

intake is unsafe. Dysphagia Management

Oral Hygiene

Individualized dysphagia management is based on history, findings of the clinical and instrumen- Oral Health tal assessment, and prognosis. The objectives of A healthy mouth enables an individual to speak managing dysphagia are to protect the airway and socialize comfortably and contributes to from obstruction, reduce the chance of food or general well-being. The healthy mouth is colo- drink entering the lungs, ensure adequate nutri- nized by a variety of nonpathogenic bacteria tion and hydration, and maintain quality of life. bathed in saliva. Saliva production, which is stim- The primary areas of intervention in managing ulated by chewing, maintains a neutral oral pH, dysphagia in the LTC setting are the following: prevents dental caries, and flushes bacteria out  Oral hygiene. of the mouth, thereby suppressing oral colonization by pathogenic bacteria and fungi. 75 Oral  Restriction of diet textures. health depends on adequate fluid intake, nutri-  Feeding strategies. tion, saliva production, oral hygiene, and chewing ability. 76 The objectives of maintaining a  Ongoing education and counselling. healthy mouth are the following: 77 Dysphagia must be managed effectively, as the negative impact of dysphagia on nutrition and  Clean, debris-free teeth and/or dentures. hydration can negate the benefit of other inter-  Well-fitting dentures. ventions. A compromised physical status resulting from malnutrition and dehydration can lead  Healthy pink and moist oral tissues and to a suboptimal rehabilitation process, affecting tongue. both the duration and completeness of recovery.  Moist smooth lips. Timely and coordinated care for the individual  Adequate salivary production. with dysphagia is best provided by a interprofessional dysphagia care team. 74 The SLP dyspha-  Reduced difficulties with swallowing or gia expert develops an appropriate and compre- eating. hensive individual plan for each stroke survivor in Oral health can change with age and illness. With whom dysphagia has been identified, incorporat- age, teeth lose soft tissue attachments, and bone 66 ing interventions such as the following: loss occurs, resulting in loose and brittle teeth. 76  Modified diet texture. Changes to a softer diet consistency can cause disuse atrophy of the chewing muscles, and de-  Compensatory swallowing strategies. creased chewing increases dental caries. Poorly

30 fitting dentures make chewing difficult, negative- also affect the way the dentures fit reducing ly affecting oral intake. Ill-fitting dentures may chewing effectiveness. In addition, any loss of also cause mouth ulcers and sores and could be fine motor skills in the arms and hands, due to accidentally swallowed. Poor dental hygiene paresis, makes it more difficult for an individual and continuous wear of dentures can cause oral to maintain good dental hygiene independently. infection (e.g., thrush) and changes to the oral Poor oral hygiene can create a variety of prob- tissues and/or structures (i.e., spongy gum) lems. Xerostomia makes speaking difficult and which are associated with complaints of pain, painful and can make dentures difficult to wear. difficulties chewing and changes to denture fit. Decreased saliva production can cause swallow- Several medical problems that can be seen in ing difficulties, which can lead to reduced oral stroke survivors can also affect oral health. 78 intake, adversely affecting health. 81 Halitosis, Uremia associated with chronic renal failure can bad breath, may lead to social isolation. Oral in- cause bleeding of the gums; a red, dry, ulcer- fections can result from a variety of causes and ated oral mucosa; complaints of a salty, metallic lead to potentially serious systemic infections. taste; and a urine-like or ‘fishy’ breath odour. Oral plaque that is undisturbed for as little as Diabetes can decrease mucosal circulation, re- three days provides an ideal environment for sulting in poor healing of oral ulcers. bacterial growth and can result in mucositis, xe- Dependence on others for feeding and oral care rostomia, and gingivitis. Because the oral cavity as well as the presence of dental caries are pre- is highly vascular, oral hygiene problems must dictors of aspiration pneumonia, because of in- be addressed promptly. Delays in treating oral creased oral colonization by pathogenic bacteria infection can lead to tissue destruction at the and pulmonary microaspiration of these organ- gum line or at the tooth base, allowing bacteria isms. 46, 79 to enter the bloodstream and resulting in a potentially serious systemic infection. 78

Impact of Stroke on Oral Health The nurse and personal support worker are the primary caregivers for stroke survivors living in Stroke survivors experience numerous sources of long-term care. Several oral hygiene assess- stress that can adversely affect oral health and ment tools for nursing are available and can be oral hygiene. These stressors include medica- used to determine whether assistance is required tions that cause dry mouth; decreased alertness and what strategies are appropriate in an indi- and cognitive changes; depression; paresis or vidual situation. Appropriate oral hygiene as- paralysis resulting in immobility; reduced fluid sessment is an important component of care, as intake; mouth breathing; and poor oral hygiene. incomplete assessment may lead to inadequate 80 Poor oral hygiene negatively affects an indi- oral care, negatively affecting health status. 77 vidual’s ability to chew, swallow and digest food, possibly leading to malnutrition and weight loss. Stroke survivors, who are dependent on others Oral Hygiene Approaches for oral hygiene, have an increased risk of oral The objective of oral hygiene is to maintain the health problems. Depression, which is common mouth in a comfortable, clean, moist and infec- after stroke, may result in lack of attention to tion-free state. Effective oral care requires clean- personal care, negatively affecting dental health. ing the entire oral mucosa, the tongue, the After stroke, tongue and cheek weakness can teeth, and the sulci (spaces between the cheeks and gums) (Figure 8). Stroke survivors who have

31 impaired oral sensation, and those who are re- stimulates saliva production initially, but ceiving enteral feeds , or eating and drinking this effect rapidly disappears, resulting in minimally, require thorough and effective oral xerostomia. In addition, the acidity of the care to maintain a healthy oral environment. 78 lemon can cause breakdown of the teeth At minimum, oral care should be provided twice and oral irritation. 81 daily; however, individuals with dysphagia may  Sodium bicarbonate and hydrogen perox- require more frequent oral care as part of their 82 ide: These agents are effective in removing safe dysphagia management approach. debris, but they have an unpleasant taste and have been associated with fungal Figure 8 Anterior and lateral lower sulci, or spac- overgrowth and inflammation. 75 In addi- es between cheeks and gums tion, concentrated solutions can burn the mucosa. 81

 Toothpaste: Toothpaste loosens debris, and fluoride prevents dental caries. How- ever, incomplete rinsing can increase xerostomia. 77

 Mouthwash: Most mouthwashes contain alcohol, which can dry and irritate the mouth. 81

 Floss: Flossing should be done at least once per day. If flossing is difficult a rubber tipped stimulator, special toothpicks or small pointed toothbrush could be tried Numerous oral hygiene approaches have been instead. Flossing reaches between the evaluated, with the following results: teeth where a toothbrush cannot. It is effective in removing food and plaque from  Foam swab or toothette: Foam swabs are 82 between the teeth. ineffective in removing plaque, which accu- mulates in sheltered areas, such as be-  Denture brush: Dentures should be re- tween teeth. 83 moved at night, cleaned and placed in a cup of warm water overnight. Use of a  Toothbrush: Soft or baby toothbrushes denture brush to clean dentures daily will used appropriately are effective in remov- help to remove plaque that forms on the ing dental plaque and minimizing mucosal dentures which is a source of bacteria and injury. 83 Hard adult toothbrushes cause can increase the risk of developing pneu- mucosal damage and gingival bleed- monia. Oral structures (i.e., cheeks, tongue 75,77 ing. and palate) should also be cleaned daily  Gauze: Gauze, used with forceps, a tongue with a soft toothbrush. 82 depressor or a finger is ineffective in clean-  Water: Water is the best oral moistening ing teeth but beneficial in cleaning the oral agent. 81 cavity. 81

 Lemon and glycerine: Lemon and glycerine

32 The following are the key implications for prac- affect the stroke survivor’s oral feeding safety. tice of these findings: 77 The number of different diet textures offered by facilities varies. Some facilities may offer three  Oral care approaches should be evi- different textures (i.e., pureed, minced, regular) denced based. while others may offer four (i.e., pureed, minced,  Nurses or personal support workers soft, regular). Still others may include bread should assist stroke survivors to maintain products with the different diet textures while good oral care. other facilities may exclude them. The availabil-  The equipment of choice should be a ity of a variety of thickened fluids across different soft toothbrush. facilities may also vary. It is important that the dysphagia care team be alert to the various diet  Drug therapy can negatively affect oral texture labels that exist. Collaboration with the health. SLP dysphagia expert should occur when there is  Baseline assessment of oral status can uncertainty about the safest food or liquid con- identify problems early. sistency in an effort to avoid negative complications for the stroke survivor. Oral and Non-Oral Intake The following are the typical diet textures given to stroke survivors with dysphagia:

 Mechanically chopped or minced semi- After completing a swallowing assessment, the solids that require little chewing. SLP dysphagia expert works with the dysphagia care team to develop a comprehensive strategy  Pureed solids with homogeneous, very to ensure that the stroke survivor can manage cohesive, pudding-like consistencies that oral intake (i.e., food, drinks and medications) as require bolus control but no chewing. safely as possible. When oral intake is deemed to  Thickened, slower-moving liquids that be unsafe the SLP dysphagia expert works with compensate for slower-moving swallow- the dysphagia care team, including the MD and ing muscles. the RD, to determine an appropriate alternate A complete dysphagia assessment most often route for nutrition and medications. determines the appropriate dietary texture modifications. 13 These modifications, however, can Diet Consistencies reduce an individual’s enjoyment of food, decreasing oral intake, which can lead rapidly to Diet texture modification is one of the most fre- dehydration and eventually to malnutrition. Also, quently used interventions to compensate for starch-based fluid thickeners increase carbohy- dysphagia in hospitals and long-term care facili- drate intake, which may produce a nutritional ties. Efforts have been made to attempt to imbalance if the diet is not carefully monitored. standardize the labels for diet textures across all Controlling dietary carbohydrates is especially healthcare facilities but at this time universal la- important in individuals with diabetes. bels have not been approved by national professional associations. As a result, diet consistency label variations exist across different clinical settings and it is important for the dysphagia care team to be aware of how these variations may

33 A consultation with an RD is critical to ensure nuts, and steak. that the modified diet texture is nutritionally adequate and appropriate. Consultation with the Examples of common liquid texture labels are stroke survivor or substitute decision-maker en- the following: sures that the modified diet texture is as appeal-  Thickened fluids: The purpose of thickening as possible. It may be possible to manipulate ing liquids is to slow the time it takes for the texture of some favourite foods to make the fluid to move through the mouth and them safe for individuals with dysphagia. esophagus. This allows better control of Examples of common food diet texture labels the swallow, and decreases the risk of as- are the following: piration pneumonia. The recommended  Pureed foods: Pureed foods are smooth thickness of thickened fluids varies. Thick- and homogenous, with a spoon-thick ened fluids can be nectar, honey or pud- consistency. This food texture includes ding consistency. The level of thickness mashed or blenderized foods with a required is determined individually. Is it dense, smooth consistency, such as pud- important to note that when a stroke sur- ding, applesauce or mashed potatoes. vivor requires thickened fluids this affects Pureed foods should never be lumpy or all liquids that they eat or drink (i.e., soup, runny. nutritional supplements, juice, etc.). Thick- ened fluids reduce the risk of aspiration, but stroke survivors often find them unap-  Minced or ground foods: This refers to pealing, increasing the risk of malnutrition foods that have been chopped to pea- and dehydration. 53 sized particles and are moist enough to form a cohesive and easy-to-chew bolus. A ground/minced diet consistency allows  Thin or regular fluids: This refers to all liq- the individual to eat with minimal chew- uids in their regular or unmodified format. ing. Typical foods in this category in- Thin fluids include water, juice, milk, tea, clude shepherd’s pie and cottage coffee, broth, creamed or strained soups, cheese. soft drinks, commercial supplements and cold or frozen food items that liquefy at  Soft foods: This refers to foods that are body temperature, such as ice cream, ice soft and easier to chew. Often these are cubes and gelatin. Thin fluids can be diffi- the softer choices found in ‘regular’ cult for the stroke survivor to swallow be- foods. Examples of foods in this catego- cause they move very quickly through the ry include pasta, tuna sandwiches, and swallowing mechanism and require good well-cooked vegetables. bolus control. Thin fluids may enter the pharynx prematurely and leak into the  Regular or hard foods: This diet texture open airway resulting in aspiration. refers to foods found in their regular or ordinary format. The ability to chew is required. There are no foods excluded from this category. Examples of regular or hard foods include raw vegetables,

34 Certain food textures may be difficult for stroke viduals with dysphagia to control in the survivors with dysphagia to manage. As a result, mouth. Mixed textures require the stroke recommendations from the SLP dysphagia ex- survivor to first separate the different pert may note the importance of excluding the consistencies and then manage them following: separately. Foods with mixed consistency include fresh fruits like watermelon  Dry particulates: Dry particulates can be and pineapple, canned fruit in syrup, ce- difficult for individuals with dysphagia to real with milk, soups like vegetable or form into a bolus and control in the minestrone, and pills given with water. mouth. Dry particulates include dry, However, fresh and canned fruits and crumbly cheeses; raw fruit and vegeta- soups can be pureed for the individual bles; cooked vegetables, such as corn with dysphagia. and peas; rice and noodles; cookies, crackers, pastries and dry cakes; dry ce-  Reflux-promoting foods: Some food and real and snacks; dried foods, such as rai- liquids cause gastroesophageal reflux sins; hard candies; and peanut butter. which can produce respiratory complica- Some of these dry particulates, such as tions in some individuals with dysphagia. rice and corn, could be included in the This category includes highly spicy and diet texture if the preparation method acidic foods, peppermint, spearmint, moistens them and binds them together, fried foods, coffee, tea, chocolate and for example, by incorporating them in cola. puddings or casseroles.

 Bread products: Gummy bread products Did you know? If thickened fluids and foods made from these products are recommended it is extremely important that can stick in the throat. This category in- the stroke survivor with dysphagia receives the cludes fresh bread and rolls, muffins, correct liquid thickness. If the liquid is thicker cookies, cakes, pastries, toast, French than necessary it can affect the stroke survivor’s toast, sandwiches and pancakes. In hydration status and make drinks unappealing. some situations, bread products can be If the liquid is runnier than necessary it can make moistened with sauces, butter, oil or swallowing unsafe and increase the risk of aspi- cream, so that they form a relatively safe ration. Liquids can be purchased pre-thickened (i.e., in bolus. For example, adding liberal amounts of butter or margarine prevents boxes) or they can be thickened by adding a fresh bread from sticking in the throat, thickening agent (i.e., thickening power or gel). and removing dry crusts facilitates swal- All of the following variables affect ‘desired thick- lowing. In this way, individuals with dys- ness’ when preparing thickened fluids: phagia can enjoy well-buttered crustless  Amount of liquid – a smaller amount of liq- sandwiches with soft moist fillings, such uid will need less thickening agent as egg salad.  Liquid properties – is the liquid hot or cold? Is it a milk product, juice or water? Each liq-  Mixed textures: Foods that combine liquid mixes with the thickening agent uids and solids can be difficult for indi- differently.

35  Time – thickening agents need time to using specific parameters). work.  Pills should be placed in a spoon of puree,  Amount of thickening agent used – use such as applesauce or pudding. a measuring spoon and follow the direc-  Pills should not be taken with water. tions on the container. Each thickening agent has different instructions.

 Utensil used to make the thickened liq- Non-Oral Feeding uid – spoons often leave the drinks If the stroke survivor’s dysphagia is more severe, lumpy while a fork or whisk allows the the SLP dysphagia expert may recommend that thickener to blend better with the liquid. the individual remain NPO for safety reasons. Using input about the swallowing prognosis from the SLP, the physician and the RD deter- Medication Administration mine the most appropriate enteral nutrition Most individuals with dysphagia must change route. Typically, either a percutaneous endo- the way they take their medications for safety scopic gastrostomy (PEG) tube or a jejunostomy reasons. 77 An SLP dysphagia expert recom- tube (J tube) is selected. Tube feeding ensures mends the safest way to administer medications proper nourishment and hydration, but tubes based on the stroke survivor’s swallowing ability. that are improperly cared for or managed can Consultation with the pharmacist to ensure that increase the risk of aspiration pneumonia. Spe- the medication form can be changed is very im- cifically, tube displacement, improper tube re- portant. (see Appendix 2) Stroke survivors with moval, or gastroesophageal reflux in stroke sur- dysphagia who have a recommendation for vivors who are improperly positioned during and thickened fluids should never be given their pills after feeding may lead to pulmonary complica- 84 with water. Recommendations might include the tions. following:  Pills should be taken with water, one at a time. Did you know? Potential risks asso-  Pills should be taken with thickened fluid, ciated with gastrostomy tubes (i.e., PEG tube) one at a time. include aspiration due to delayed gastric empty- ing and gastroesophageal reflux, tube displace-  Pills should be crushed (verify with phar- ment and tube removal. Potential risks associat- macist that the pill is crushable). ed with jejunostomy tubes (i.e., J tube) include  Pills should be cut in half (verify with phar- clogging of small-bore tubes and infections due macist that the pill can be cut). to poor stoma care. Mouth care is critical in individuals receiving tube feeding, because sub-  Medication should be given as a liquid stantial volumes of secretions can accumulate, (verify with the pharmacist that the medi- harbouring considerable numbers of pneumonia cation can be dispensed in liquid form). causing bacteria.  Medication should be changed to liquid

format and thickened (verify with pharmacist that medication can be dispensed in liquid form and that it can be thickened

36 Safe Feeding Practices tions so that food brought in for the stroke survivor is in keeping with the safest diet consistency. Good communication between dysphagia care team members is essential for providing effective Swallowing Recommendations and efficient care for the stroke survivor. Swallowing recommendations are designed to In the long-term care setting it is often the nurse increase safety; reduce fatigue; maintain ade- who functions as the team’s central communica- quate nutrition and hydration; and improve the tor because all team members interact with and stroke survivor’s quality of life during the feeding report to the nurse. It is critical that the nurse process. These recommendations address all as- relay the swallowing recommendations to the pects of therapeutic meal plans and safe swal- other team members to ensure uniform imple- lowing strategies and have the following objec- mentation of these suggestions. Studies indicate tives: that nurses who are not knowledgeable about  Reduce risk of aspiration, airway obstruc- an individual’s feeding and regard it as a nui- tion and pneumonia in stroke survivors. sance or outside their role description may not  Assist staff on all shifts in caring for implement swallowing recommendations. Lack stroke survivors. of compliance may contribute to increased swallowing and feeding problems, thereby increasing  Increase feeding safety and efficiency by the risk of aspiration pneumonia and other ad- posting information at bedside. verse sequelae.46, 68, 85-87 The SLP dysphagia expert develops the swallow- The swallowing recommendations should be in- ing recommendations in collaboration with other corporated into the stroke survivor’s care plan team members to meet the needs of the individ- and provided to the food services department. ual stroke survivor and modifies it as physical This will make it easier for all persons who assist status changes. These recommendations incor- with preparation and serving of meals and with porate as many pictures or graphic instructions feeding to refer to individual needs wherever as possible to make it easy to interpret and im- necessary. plement. Swallowing recommendations can include the Uniform implementation of the swallowing rec- following specific information about the individu- ommendations by everyone providing feeding al stroke survivor and environment: assistance to the stroke survivor is a critical aspect of managing dysphagia. Therefore, it is im- Stroke survivor portant that the swallowing recommendations  Physical status: reduced tolerance for are communicated to all staff, family members eating, as a result of weakness, nausea, or other caregivers that may be involved in feed- or loss of appetite. ing or providing food and drink to the stroke survivor. For example, it is important that the  Cognitive status: reduced alertness, ori- activity staff are aware of the swallowing recom- entation, cooperation. mendations so that a resident attending a pro-  Sensory deficits: deficits in vision, hear- gram or special event receives the appropriate ing, touch, taste or smell. food and drink texture and the necessary level of feeding assistance. Likewise, it is important that  Assistance levels: level of feeding assis- family members are aware of the recommenda-

37 tance or meal supervision required. fective eating.

 Performance of repetitive feeding move- Environment ments, such as stabbing but not securing  Distractions and deficits: High noise or food, or stopping with utensil in midair, activity levels, inadequate lighting, diffi- that prevent food/liquid intake and culty reaching food/liquid. cause fatigue.

 Environmental structures and re-  Serving very hot food/liquids that cause strictions. oral burns in individuals with loss of sen- Swallowing recommendations should also in- sation. clude the following types of information  Visual field neglect, which results in un-  Positioning during and after mealtime. touched food on one side of plate.

 Safest diet textures.

 Assistive or adaptive equipment require- Strategies to improve oral intake include the fol- ments. lowing:

 Need for special feeding techniques or  Time medications so that the stroke sur- swallowing strategies. vivor is pain-free at meal times.

 Communication strategies.  Present high-protein, high-energy foods first if oral intake is low.  Recommendations for managing behav- iours.  Socialize during the meal to make eating more enjoyable.  After-meal care.  Ensure food/liquid is warm, and reheat it

if necessary, as warm food/liquid is more Safe Feeding Strategies palatable and increases sensory input and intake. Family and other caregivers can assist with feeding to help to maintain the stroke survivor’s enjoyment of eating and quality of life. It is im- Effective feeding techniques include the follow- portant that dysphagia care team members ed- ing: ucate family members or others wanting to as-  Feed slowly. sist with feeding regarding safe feeding strategies. Good feeding practices include observing  Identify food and drink items by name the stroke survivor during feeding; encouraging especially when the stroke survivor takes strategies to improve oral intake, effective feed- a modified diet texture. ing techniques and maximizing the stroke survi-  Allow adequate time between bites of vor’s independence with eating and drinking. food.

Dysphagia care team members, including family  Limit the amount of food presented to 1 and the stroke survivor, must address behav- teaspoon per bite. ioural problems or sensory issues, such as the  Place food on the strong side of mouth. following, that can interfere with effective eating:  Encourage the stroke survivor to take 2  Use of incorrect utensils preventing ef-

38 or more swallows per bite, to clear resi- mealtimes. Turn off radios, televisions and limit due and aid esophageal transit. the conversation between staff during mealtimes to only that necessary for serving the meal. Fa-  Alternate liquids and solids, but never tigue may result from the stroke, medications, combine them in the same bite. stress, or completion of daily activities. Reducing  Talk conversationally with the stroke sur- fatigue is important to safety and health, as fa- vivor during mealtimes, but time re- tigue is associated with an increased risk of aspi- sponses so that the stroke survivor does ration and a decreased ability to eat sufficient not reply with food/liquid in mouth. food/liquid to maintain nutritional requirements. 88  Identify the food/drink being presented.

 Offer choice in terms of sequencing of Sensory input food and drink items during the meal. The senses — sight, hearing, smell, taste and  Provide visual or verbal cues for opening touch — provide important information about mouth, chewing, and swallowing. the environment and increase eating safety and enjoyment. Therefore, adaptive devices that en-  Check for pocketing and residue after hance sensory information should be in place feeding and clear as needed. before eating and drinking. Dentures should be clean and conveniently lo- Environment cated for the stroke survivor to insert before oral intake. Dentures and partial plates should fit The dining atmosphere and its set-up is very improperly. Denture adhesives can anchor den- portant for the individual with dysphagia. Con- tures that have loosened because of oral chang- sideration of the resident’s physical status and es related to the stroke. Dentures that do not fit environment, sensory needs, social interaction properly can be a safety hazard for the resident and independence are all important for imple- trying to chew their food and choking may re- mentation of safe feeding practices. sult.

Eyeglasses should be worn if needed to improve Physical status and environment vision and depth perception and provide addi- Safety and quality of life of the stroke survivor tional sensory input about food/liquid textures. are primary considerations in managing the Visual field deficits and neglect can create prob- physical environment, especially adjusting light- lems with eating, such as an inability to see food ing, temperature and noise. The stroke survivor on part of the plate. In this situation, the SLP should be placed near a window or light source should work with the OT to ensure that appro- that provides adequate light to see the colour, priate instructions for managing visual problems texture and type of food/liquid. Lighting should are included in the swallowing recommenda- be assessed at different times of day to minimize tions. The person providing feeding assistance shadow, glare, and inadequate lighting. Shades should move the plate or the food to ensure that and blinds can reduce light and glare. Tempera- the stroke survivor can see and eat the entire ture extremes, such as drafts and hot spots, can meal. cause discomfort or increase fatigue and should Hearing aids should be clean and properly be avoided. Unnecessary noise should be limited placed in the stroke survivor’s ears, and batteries to allow the stroke survivor to focus on should be checked regularly.

39 Social aspect of meals Special cups, plates, weighted or shaped uten- People generally associate eating and drinking sils, and materials such as dicem, that prevent with health and wellbeing. In addition, in most dishes from sliding, are some of the devices cultures, meals are important social events, and which can be useful for stroke survivors. The sharing meals with loved ones increases feelings SLP dysphagia expert or the OT may introduce of wellbeing. The decreased ability to eat and the use of one of these devices to the stroke drink in social situations without coughing, chok- survivor during their assessment. Stroke survi- ing or embarrassment contributes to depression vors and their family members or caregivers re- in stroke survivors with dysphagia. 89 Therefore, quire education in how to use these devices and it is important to reduce feelings of isolation dur- their potential usefulness. Once use of these ing eating without introducing distractions or devices is established, consistency is essential as creating sensory overload. Talking during eating the stroke survivor will become dependent on and drinking and distractions, such as radio and their use to solve problems with food/liquid ac- television, place the stroke survivor with dyspha- cess and spillage, and will become accustomed gia at increased risk of aspiration and choking. to restored eating independence. Encourage the stroke survivor to talk between The RD can recommend alterations in food/ bites or between courses. liquid preparation and presentation to increase safety and meal independence. Finger foods, sandwiches and firm foods, which can easily be Meal independence managed with one hand or one utensil, increase Meal independence is a primary objective for meal independence for individuals with hemi- stroke survivors, as an increased dependency on paresis. others to provide feeding assistance is associated with an increased risk of aspiration, dehydration, and malnutrition. 46 Many stroke survivors Education and Counselling can feed themselves if the environment is adjust- The need for better information about stroke ed to accommodate their physical impairments. and its impact on stroke survivors and families The dysphagia care team can maximize meal has been identified, and many Heart and Stroke independence by ensuring appropriate position- Foundation of Ontario initiatives have ing, equipment, and food/liquid preparation and addressed this need. However, stroke survivors presentation. and caregivers still report that they have not re- The PT can assess trunk control. The safest pos- ceived any information about their illness, de- ture for eating is sitting upright at 90°, with the spite discussions with health care professionals body at midline and the head and trunk aligned. and the provision of written information. 90 Up to Paresis, spasticity and impaired cervical stability 89% of stroke survivors are satisfied with their can reduce the ability of the stroke survivor to overall care, but only 50% are satisfied with the maintain this posture. Cushions, bolsters, and information received in hospital. neck supports can stabilize the head and help Information needs vary over time and circum- the stroke survivor maintain an upright position. stances, and may continue for several years after The OT can suggest assistive or adaptive devices stroke. 91 Too much information too early may that can assist the stroke survivor with maximiz- be detrimental to recovery. 90 Surveys conducted ing their independence with eating and drinking. among individuals with a variety of conditions

40 show that education can influence behavioural changes that lead to better health outcomes and Did you know? The following prac- reduce stress in decision making. 92 Stroke survi- tices may have significant clinical consequences, vors and caregivers found that the most benefi- including aspiration or dehydration, for individu- cial education met the following criteria: 90, 91 als with dysphagia:

 Individualized and personalized.  Feeding someone who is not fully alert  Delivered at appropriate times during  Syringe feeding the recovery process; for example, providing information about feeding op-  Feeding in a fully or partially recumbent posi- tions to a stroke survivor who is NPO. tion

 Provided in written form.  Giving pills with water to individuals on a ‘no thin fluids’ diet consistency  Supported by functional examples and implementation.  Unnecessarily restricting a diet consistency to thickened fluids and pureed solids Education about dysphagia can take place at the bedside by example or demonstration. Infor-  Feeding with a tablespoon rather than a tea- mation can be given verbally, but it is more ef- spoon fective when provided in written form as often as  Giving anything not approved in the diet: tell possible. Processing auditory information is re- the family, other staff members and visitors to duced when people are under stress, distracted check if specific food items are safe before or dealing with unfamiliar information. For the giving them to the resident. stroke survivor and caregivers, terms and con- cepts important for understanding dysphagia may be unfamiliar and overwhelming when first presented. Stroke survivors and caregivers may benefit from being made aware of the educational materials and approaches that are available to them, including the following:

 Brochures providing overviews of dysphagia information developed on site or obtained from standard sources.

 Booklets providing stroke- and dysphagia-specific information available through support groups.

 Support groups, through organizations such as the Heart and Stroke Foundation of Ontario and Stroke Recovery Network.

 Internet chat lines, special-interest Web pages, and general topic information.

 Local Libraries.

The Continuum of Dysphagia Care Review questions

This manual has been developed for the dys- 1. List 3 different diet consistencies an SLP phagia care team screener working with stroke might prescribe for a stroke survivor with survivors in the long-term care setting. Most of dysphagia. this information also applies to individuals in re- 2. Residents unable to eat by mouth are in- habilitation and complex continuing care settings stead fed via a tube. Name one risk and with persistent dysphagia. one benefit of tube feeding. When a stroke survivor is admitted to long-term 3. Describe 3 purposes for a program of oral care, it may already be known if they have dys- hygiene for residents with dysphagia. phagia and swallowing recommendations from the SLP dysphagia expert that have been previ- 4. Discuss 1 risk and 1 benefit for giving a ously implemented. To ensure a smooth transi- stroke survivor only thickened fluids. tion into the long-term care setting it is critical 5. What is the role of the SLP in the care of that all information about the individual’s swal- the stroke survivor with dysphagia? lowing status and their swallowing recommendations accompany them and get communicated 6. What is the role of the RD in the care of to the dysphagia care team. 66 If there are ques- the stroke survivor with dysphagia? tions regarding the previously implemented SLP 7. What is the difference in purpose between recommendations it would be appropriate to a screening tool and an assessment tool? contact the SLP where possible. Occasionally, a 8. Name 4 members of the interprofessional stroke survivor may be admitted without any in- dysphagia care team and identify their formation pertaining to their swallowing or the roles. information provided may be incomplete or unclear. It is vital that the transferring facility be 9. What is the most common instrumental contacted to request the dysphagia information test for dysphagia and who typically ad- and/or clarify any incomplete or unclear infor- ministers it? mation. Likewise, if a resident with dysphagia is transferred to hospital, another care facility or a day program, sending comprehensive information related to their dysphagia and swallowing recommendations will be important in preventing negative complications. Effective transitions between the various levels of care ensures continued successful management of the dysphagia and prevents consequences of unmanaged dysphagia, such as pulmonary, nutrition or hydration complications.

42 Dysphagia case studies Case Study # 1

RS is a 71-year-old male who was admitted to hospital with right-sided weakness and garbled speech. RS was accompanied to hospital by his wife of 50 years, and she provided medical and social histories. His medical history includes Park- inson’s disease (1998), transurethral radical pros- tatectomy (1996), and appendectomy (remote). His wife, children and grandchildren are all ac- tively involved in his care. RS worked as an elec- trician for 40 years and recently worked as a clerk in the local farmers’ supply store for 3 years until his Parkinson symptoms became pro- nounced. A CT scan done while in hospital showed a left sided lacunar infarct. RS is admitted to the long-term care facility where you work 6 weeks after his stroke. Trans- fer notes indicate the following symptoms: right visual field neglect, right facial asymmetry, dense right-sided weakness in the arm and leg, unintel- ligible speech and drooling.

Speaking with Mrs. S. you learn that RS wears

glasses, has one hearing aid and wears dentures.

Further discussion with her indicates that she is

eager to have RS resume oral feeding.

You are the nurse on shift when this resident is admitted to your facility. For discussion

1. Based on best practice guidelines for dysphagia, how will the dysphagia screening process take place for this resident? That is:  Who will start the process?

 What will or will not be done?  When will it occur?

2. Briefly describe how you should respond to

the swallowing needs of this individual.

3. How will you address the wife’s concerns?

43 Case Study #2 Case Study #3 DL is a 66-year-old male who presented in the HN is an 85-year-old Cantonese speaking wom- emergency department after collapsing at home an living in the long-term care facility where you while digging in the garden. His wife found him work. She had a right brain stroke nine months unable to move his right arm or leg and unable ago and had been living with her daughter until to speak. A CT scan performed in the emergen- her long-term care admission two months ago. cy department detected an early left middle cer- Her medical history includes steroid-dependent ebral artery (MCA) infarct. rheumatoid arthritis, atrial fibrillation and type 2 Previously, DL had been independent and in diabetes mellitus. Her residual deficits on admis- good health, with no history of hypertension, sion included: left sided weakness, decreased diabetes, hypercholesterolemia or hospitaliza- pain and temperature sensation, facial droop, tion. He did not take any medications and had slurred speech, dry mucous membranes and an stopped smoking 18 years ago. DL lived with his absent gag reflex. wife and 3 children. On admission you screened HN for dysphagia. You come in as the evening shift nurse. In re- She failed the screen and was seen by the SLP port you learn that DL was admitted today at dysphagia expert for a swallowing assessment. 2pm from the nearby rehabilitation facility. You Recommendations after the swallowing assess- learn that his stroke was 4 months ago. ment resulted in a change of diet texture from regular to minced. HN’s liquids remained nectar Transfer notes indicate that DL has no gag re- thick. There are no planned follow-up visits by flex, left deviation of the eyes, and aphasia. the SLP. Notes from the rehab SLP indicate that DL should have a dysphagia minced with honey Yesterday HN’s daughter came to you con- thick fluids diet consistency, no thin fluids and cerned about the food that her mother has been oral medications with applesauce. The notes fur- receiving and indicated that she feels that it is ther indicate that he should use a chin tuck the cause of her mother’s recent weight loss. when drinking and that he pockets food in his She continued by telling you that she gave her right cheek. mother some tea and she swallowed it just fine. His family members accompanied him to your For discussion facility. They are very anxious. They come to 1. What are your most immediate concerns you asking for pain medications and a snack for after this conversation with HN’s daughter? DL because he is hungry. 2. How will you address the daughter’s con- For discussion cerns? 1. What are your most immediate concerns 3. As a member of the dysphagia care team for this resident? what is your role with this resident? 2. As a member of the dysphagia care team, briefly describe your role with this resident? 3. How will you best address the family’s concerns?

44 Appendix 1

45 Appendix 2: Medications that should not be crushed

The following medications should not be 93 crushed:  Adalat CC, XL, PA (nifedipine CC, XL, PA)  Wellbutrin SR (bupropion)  Arthrotec (diclofenac/misoprostol)  Voltaren SR (diclofenac SR)  Asacol (5-aminosalicylic acid)  Zyban (bupropion).  Bayer Aspirin (ASA enteric coated)  Cardizem CD, SR (diltiazem CD, SR)  Cipro (ciprofloxacin)  Cronovera (verapamil)  Depakene (valproic acid)  Enteric Coated Naproxen  Effexor XR (venlafaxine XR)  Flomax (tamsulosin)  Imdur (isosorbide-5-mononitrate)  Isoptin SR (verapamil)  Isosorbide dinitrate SR  Losec (omeprazole)  MS Contin (morphine slow release)  OxyContin (oxycodone slow release)  Pantoloc (pantoprazole)  Prevacid (lansoprazole)  Proscar (finasteride)  Prozac (fluoxetine)  Sinemet CR (levodopa/carbidopa SR)  Tegretol CR (carbamazepine)  Theo-Dur (theophylline SR)  Trental (pentoxifylline)  Uni-Dur (theophylline SR)  Uniphyl (theophylline SR)

46 Appendix 3: Communication Strate- gies for Healthcare Professionals working with Residents with Aphasia

Residents who have aphasia after their stroke Tips to Help the Resident with know more than they are able to say. Every person with aphasia is different. As their caregiver, Aphasia Get their Message Across it is important that you have patience and continue to try different strategies to make commu-  Communicate in a quiet, distraction- nication with the resident with aphasia as easy as free environment. possible. You will find that some strategies are  Encourage the resident to write key effective with some residents while others are words or draw. not. The following are some tools to assist your  Ask yes/no questions. communicative interactions with the resident  Be patient. If you do not have time with aphasia. then explain this and return when you have time to finish the conversation.  Help to clarify the topic when you Tips to Increase the Resident’s Un- aren’t sure. derstanding of Your Message  E.g., “Are you talking about dinner?” “Do you wonder what is on  Communicate face to face. Facial ex- the menu for dinner?” pressions help to clarify the message.  Encourage the resident to use gestures.  Speak clearly in an appropriate tone for Pay attention to facial expression. communicating with an adult.  Communicate one idea at a time.  E.g., It is dinner time. (pause) First you will have soup. (pause) Next you can have macaroni and cheese or Sheppard’s pie. (Show examples, pause and wait for the resident’s choice.) I will help you to eat.  Print key words on paper for the resident to see.  Use gestures to clarify your message.  Use yes/no questions.  E.g., “Would you like milk?” rather than “Would you like milk or water?”

47 Glossary

Achalasia: Failure of a ring of muscle, such as a and then propelled posteriorly into the pharynx. sphincter, to relax. Achalasia occurring in the 94 UES or LES can contribute to pharyngeal and/or Clinical bedside swallowing assessment: A bed- esophageal dysphagia. The most common side assessment is carried out by an SLP during symptoms of achalasia are dysphagia, regurgi- evaluation of an individual’s oral swallowing tation, and chest pain. Although initially dyspha- mechanism, vocal quality, productivity of cough, gia may be for solids only, as many as 70-97% language and cognitive skills, self-feeding skills, of patients with esophageal achalasia have dys- and level of endurance. The findings determine phagia for both solids and liquids at presenta- recommendations for further investigation, in- tion. 20 cluding instrumental assessment; management; Apraxia: Motor programming deficit that can and education. 66 involve speech and the oral preparatory stage Comorbid conditions: Comorbid conditions are of swallowing but does not affect involuntary or any congenital or acquired, physical or mental automatic tasks. conditions, present independently of the onset Aspiration: Entry of food or liquid into the air- of another medical condition, determined by way below the muscles that produce sound, taking a history. that is, the vocal cords. 33 Dehydration: A water and electrolyte disturb- Aspiration pneumonia: Respiratory tract infec- ance resulting from either water loss or deple- tion resulting from inhalation of oropharyngeal tion of sodium with accompanying water loss, secretions, food or drink. 66 which develops when metabolic water needs 53 Assessment: Evaluation of the structural and and losses exceed intake. physiologic details of a disorder and determina- Discharge planning: Process that directs inter- tion of the best intervention. Assessment of ventions toward an ultimate goal of appropriate swallowing determines the overall nature and and timely discharge from current services or causal factors of impairment of oral swallowing transfer to another setting. 66 stages and predicts impairment of pharyngeal, Dysarthria: A group of speech disorders result- laryngeal and esophageal swallowing physiolo- ing from disturbances of muscular control due gy. This is in contrast to screening (see defini- to damage to the peripheral or central nervous tion below). 94 system, or both. Dysarthria is characterized by Brainstem stroke: The brainstem controls basic weakness, slowness, or lack of coordination of physiologic functions. Signs of brainstem stroke the speech mechanism. 96 include ataxia, impaired swallowing, coma or Dysphagia: A swallowing disorder associated low-level consciousness, loss of balance, unsta- with difficulty moving food/liquid from the ble blood pressure, double vision, bilateral pa- 22, 56 mouth to the stomach. ralysis, difficulty breathing, nausea and vomiting. 95 Dysphagia diets: Diets modified in physical properties, such as texture or viscosity, to meet Bolus: Accumulation of liquid or masticated sol- the needs of an individual with dysphagia. Opti- ids held between the tongue and hard palate

48 mally, dysphagia diets are prescribed based on and vitamin deficiencies. 96 the results of a clinical and, possibly, an instru- Instrumental assessment: Various investigations, mental assessment to compensate for identified such as videofluoroscopy and FEES, which are physiologic and/or structural swallowing abnor- adjunctive to clinical assessment. Instrumental malities malities. Dysphagia diets are often pre- assessment helps to determine impairment in scribed in stages designed to gradually facilitate the structure and function of oral, pharyngeal, 94 safe return to a regular diet. laryngeal and upper esophageal swallowing Dysphagia management: Intervention prescribed physiology and identifies treatment or compen- by an SLP to compensate for impaired swallow- satory strategies that enhance the efficiency and ing structure and neurophysiology to optimize safety of the swallow. 66 safety, efficiency, and effectiveness of the oro- Interdisciplinary dysphagia team: A team of pharyngeal swallow and maintain nutrition and health care professionals who work together col- 94 hydration. laboratively to screen, assess, and manage dys- Dysphagia team: A team with representation phagia. 13 from different disciplines and/or specialties that Lower esophageal sphincter (LES): A muscular acts together to screen and manage stroke sur- sphincter at the distal end of the esophagus that vivors with swallowing and feeding disorders un- 13 relaxes to open and constricts to close. The LES der the direction of an SLP. keeps food/liquid and digestive juices in the Enteral feeding: Administration of nutritional stomach and prevents reflux, or regurgitation, of preparations into the digestive tract orally or food/liquid into the esophagus. 20 through a tube, using gravity, pump-controlled 97 Malnutrition: Unintentional loss of usual body infusion, or a bolus with a syringe. weight, during a period of less than 6 months. 4 Esophagus: A collapsed muscular tube, approxi- Mucositis: Inflammation of the mucous mem- mately 23 to 25 cm in length, with a sphincter or branes of the oral cavity that can cause pain, valve at each end: the UES at the top and the edema, ulceration and erythema. 96 LES at the bottom. Proximally, the esophagus is directly below the pharynx and distally it attaches Nasal regurgitation: Leakage of food or drink to the stomach. 20 into the nasopharynx before swallowing due to reduced contraction of the posterior tongue Faucial arches: Located bilaterally inside the oral and/or the reduced elevation of the soft palate 23 cavity at the level of the tonsils along the sides of to appose the posterior nasopharyngeal wall. the throat. Nasogastric (NG) tube: The NG tube passes Feeding: The act of transporting food/liquid to- through the nose, pharynx and esophagus into ward the mouth in preparation for swallowing. 22 the stomach. Liquid feed is passed through the NG tube for hydration and nutrition. The volume Fiberoptic Endoscopic Evaluation of Swallowing and number of feedings per day varies depend- (FEES): FEES is performed using a flexible scope ing on the individual being fed and the setting. inserted through the nose to the level of the soft Having the person remain upright for 1 hour af- palate or below to evaluate swallowing. 66 ter feeding can minimize gastroesophageal re- Gingivitis: Inflammation of the gums with red- flux. A narrow tube reduces pharyngeal irritation. ness, swelling and bleeding; often associated 98 with mouth breathing, poorly fitting dentures

49 Oral cavity: The oral cavity includes the lips ante- Postural change: Adaptive swallowing technique riorly, 24 deciduous and 32 permanent teeth, incorporating changes in a client’s body posi- hard palate, soft palate (velum), uvula, lower jaw tioning to alter bolus flow through the orophar- (mandible), tongue, floor of the mouth, and the ynx to increase swallowing safety and/or effi- faucial arches. 23 ciency. Turning the head to the weaker side to Oral intake: This term refers to food/liquid enter- redirect the bolus flow through the stronger side of the pharynx is an example of postural change. ing the mouth in preparation for swallowing. It 56 includes meals, snacks, intake of medications, etc. Presbyphagia: Changes to the swallowing mechanism due to the normal aging process. 27 Oral transit time: The time for a bolus to travel through the oral cavity, beginning when the Risk indicators: Measurable characteristics or cir- tongue starts to propel the bolus posteriorly and cumstances associated with increased likelihood finishing when the bolus reaches the base of the of a poor status or outcome, such as impaired tongue. 23 swallowing, malnutrition, poor health, or death. Osteophytes: Bony outgrowths that can arise on Screening: Procedure to identify individuals at the cervical vertebra and displace the posterior risk of dysphagia and initiate earlier referral for pharyngeal wall anteriorly. Surgical intervention assessment, management or treatment to pre- may be considered if severe pharyngeal narrow- vent dysphagia complications and minimize ing is present. 23 health risks. This is in contrast to assessment, Palate: Roof of the mouth, including the bony which evaluates the swallow in detail and pro- hard palate (the anterior two-thirds of the pal- vides information about severity and adequate 66 ate) and the muscular soft palate (the posterior intervention (see above). one-third of the palate). 96 Silent aspiration: Passage of material below the Percutaneous endoscopic gastrostomy (PEG) level of the true vocal cords in the absence of 33 tube: The PEG tube is a long-term method of cough or alteration in vocal quality. feeding using liquid feed delivered through a Swallowing apnea: Apnea, or cessation of tube inserted through the abdomen into the breathing, occurring with airway closure during stomach. Insertion of a PEG tube is a reversible the pharyngeal stage of swallowing; duration of surgical procedure performed under local anes- airway closure increases with bolus size. 100 99 thesia. Swallowing strategy: Adaptive swallowing tech- Pharyngeal transit time: The time for a bolus to nique incorporating changes to a client’s swal- travel through the pharynx, from the base of the lowing physiology, thus increasing swallowing tongue to the top of the esophagus. 23 safety and efficiency. The super-supraglottic swallow, a voluntary airway protection manoeu- Pharyngeal webs: Webs that occur in the esoph- 66 agus or the pharynx and are usually composed vre, is an example of a swallowing strategy. of normal mucosal folds. Swallowing treatment: Intervention intended to Pneumonia: see Aspiration pneumonia change swallowing physiology or the developmental swallowing pattern to improve the safety, Pocketing: Food residue in the upper or lower efficiency, and effectiveness of the oropharynge- sulci, between the gums and cheeks, or under al swallow and maintain nutrition and hydration. 23 the tongue after swallowing. Procedures to improve laryngeal functioning

50 and airway protection may also be involved. 66 py, oxygen therapy, certain medications, and 56 100 salivary gland diseases.

Tracheotomy: A surgical procedure by which an Zenker diverticulum: A pocket resulting from opening is made in the wall of the trachea into herniation of muscle in the area joining the lower 56 which a tube is inserted to facilitate breathing. pharynx and upper esophagus. Upper esophageal sphincter (UES): The UES is located at the proximal end of the esophagus. The UES opens to allow the bolus to pass into the esophagus and closes to prevent food and drink from refluxing from the esophagus into the pharynx. 20 Velum: The posterior one-third of the palate, also called the soft palate, terminating at the finger-like uvula in the midline. 96 Ventilator: A machine that provides mechanical support for breathing and an appropriate mix- ture of gases for life support. Mechanical ventila- tion is used when spontaneous inhalation and exhalation are inadequate for effective respiration. 100 Videofluoroscopic swallowing study: A videotaped or digitized fluoroscopic evaluation of oral, pharyngeal, laryngeal and upper esophageal swallowing physiology that incorpo- rates compensatory or treatment strategies. 66 Viscosity: A measure of the intrinsic ability of a fluid to resist shear force. Viscosity is quantified as the ratio of shear stress to shear rate or the rate of fluid deformation and is commonly referred to as texture. 97 Vocal cords: Two muscles within the larynx and positioned behind the thyroid laminia, primarily responsible for producing sound. During the swallow, they adduct to close off the airway and thereby help prevent aspiration of food or liquid. This is referred to as the period of swallow apnea. Xerostomia: Oral dryness due to reduced salivary flow, which can occur due to dysphagia, mouth breathing, oral infection, radiation thera-

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