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Swallowing Disorders and Older Adults
Kristine E. Galek, Ph.D. CCC-SLP University of Nevada, Reno School of Medicine Speech Language Pathologist Assistant Professor
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Normal Swallowing
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Includes an Interact with cranial Governed by neural When there are no integrated, nerves regulatory mechanisms issues…an individual will in the medulla, perform sequential interdependent sensory and motor group of complex sensorimotor, and limbic cortical systems patterns of mastication feeding behaviors and swallowing with little effort or conscious awareness
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Dysphagia
The term dysphagia It is NOT a primary should refer to oral, We describe Is a disorder of or difficulty medical diagnosis but pharyngeal, oro- dysphagia by “clinical swallowing a SYMPTOM of an pharyngeal or signs” underlying disease esophageal dysphagia
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Clinical Characteristics (SIGNS) of Oropharyngeal dysphagia
• Coughing • Odynophagia or “painful • Choking during or after a meal swallowing” • Food sticking • Drooling • Regurgitation • Unexplained weight loss • Nutritional deficiencies
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Conditions that contribute to dysphagia
• Neurologic diseases • Progressive diseases • Stroke • TBI • Parkinsonism's • Dementia Huntington’s disease • Motor neuron disease • • Myasthenia Gravis • progressive nuclear palsy • Cerebral Palsy • Guillain-Barre Syndrome • Wilson’s disease • Poliomyelitis • Age related changes • Infectious Disease • Myopathy
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Conditions that contribute to dysphagia
• Connective Tissue disorders • Structural diagnosis • Any tumor involving the alimentary tract Poly and dermatomyositis • • Iatrogenic diagnosis • Progressive systemic sclerosis • Radiation • Sjogren’s disease • Chemo • Intubation or tracheostomy • Scleroderma • Cervical spine fusion • Bypass surgery • Respiratory compromise and psychogenic disorders
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Physiological Changes in swallowing
Only when medical complications or eating Not all patients with habits result in Delay in propulsion of Misdirection of bolus physiological perceptible changes like the bolus from mouth (larynx, trachea, lungs) abnormalities have malnutrition or to stomach dysphagia aspiration pneumonia the patient is truly dysphagic
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Dysphagia is NOT….
Anorexia or Bulimia An impairment in nervosa (eating Weakness or the process of food a FEEDING or disorder) typically incoordination of transport (plate to EATING disorder no complaints of hands or arms mouth) swallowing difficulty
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Incidence and Prevalence
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Incidence is Prevalence is ASHA 300,000-600,000 Most common- difficult to more important estimates 6-10 persons in U.S. stroke determine due million each year affected to different Americans with by dysphagia from Neuro disorders settings (acute, some degree of alone rehab, chronic) dysphagia
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Prevalence by setting
• Community-aging population • Acute Rehabilitation • 16-22% • 102/307 • Acute and chronic geriatric care • 51 patients as a result of stroke 60% in U.S. • TBI (20%) Most Severe • Mortality incidence 45% after one • Spinal cord injury or brain tumor year stay (7%) Least Severe • Acute general hospitals 13% • Progressive neurologic disease (5%)
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Prevalence by Dx STROKE
• 6 months 3% • Acute (less than 5 days) more than 50% of patients • Early detection important
• 2 weeks post onset approx. 28% • Some patients will spontaneously recover
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Prevalence by Dx Head and Neck CA
• Tissue loss
• Radiation therapy • 59% present with dysphagia
• Chemotherapy
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Prevalence by DX TBI
• Common after TBI • More severe the injury, higher the incidence
• Incidence 27-30% • If patient goes to rehab, chances of oral feeding are good
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Prevalence by DX Progressive Neurological disease
• Parkinson’s: common • Multiple Sclerosis: 33% chewing or swallowing
• Dementia: 13%-57% • Myasthenia Gravis: 1/3 of diagnosed patients • ALS: bulbar, first symptom • 1/3 of ALS patients will present with • Muscular Dystrophy: 2 muscle dysphagia weakness ⁰
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Prevalence by Dx Connective Tissue
• Polymyositis and Dematomyositis Erosive esophagitis unknown • 60% • Rheumatoid Arthritis 27% • Sjogren’s Syndrome • Scleroderma 75% 90%
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Prevalence by Dx miscellaneous
• Developmental disability or delays: • Mental Illness: 9%-42% • 36% in the community • 73% of inpatients • Premature Infants: < 26 weeks gestation: 90% prone to disorders • Concomitant mental and physical of swallowing and feeding disability: 8.1% • Adults with Down’s syndrome: 56.5% • Spinal cord injury: 38%
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Consequences of dysphagia
Quality of life Morbidity and mortality Aspiration pneumonia Dehydration Poor nutritional status Decreased energy levels Compromised immune system Delays in healing psychosocial
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Clinical Management
Instrumental examinations…FEES (x-ray) , MBSS, (direct Clinical examination visualization), (medical, psychosocial Manometry (pressure) hx, physical exam, screen mental status, • Appropriateness of these Screenings (Pass/Fail) procedures should NOT be evaluated musculature driven by administrator, of head and neck, trial payor source…if clinician is swallows…if patient asking for orders to treat physiological change they fails… need IMAGING first!
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Behavioral
Treatment Dietary (intervention) Options Medical
surgical
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Behavioral Interventions compensatory techniques
Temporary measures (should not leave Change of posture Change eating rate patient using these techniques)
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Rehabilitative strategies First line of defense!
Strengthening Implementation New way to muscles Exercised based of Neuroplastic swallow (isometric and intervention Principles isotonic holds)
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Dietary Interventions last resort
Modification Taste Volume Viscosity of texture
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Medical Interventions
Medicinal Mental status changes
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Pharmacologic management
• Anti-reflux medication • Salivary management: many (GERD/LPR) medical conditions can alter saliva (reduce watery saliva needed for swallowing) • Prokinetic agents (gastric motility, • Mucolytic can be used to thin increase LES pressure, promote secretions gastric emptying
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What do labs have to do with dysphagia?
• WBC (white blood count) • BMI (body mass index) • RBC (red blood count) • Albumin and pre-albumin • ABGs (blood gases) • Peripheral Oxygen Sat (SpO2) • Hydration & electrolytes • Respiratory rate (RR)
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Labs and dysphagia
• Elevated WBC = infection of immune • Times of stress, injury, illness, neutrophils system are depressed…protective chemistry of oral cavity is altered (over colonized with • Possible new infiltrates pathogenic bacteria • Dysphagia clinician should pay • If aspirated could turn into infection attention to neutrophils on the • Triple threat of aspiration pneumonia (CBC)… (stress of critical illness, temporary neutropenia, and aspiration of colonized • Neutrophils are first responders to oral pharyngeal bacteria microbial infection (present in oral • Elevated ANC (absolute neutrophil count) cavity…destroys pathogens) is elevated too = bacterial infection
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Labs and Dysphagia?
RBC Low values = anemia, blood loss, protein-energy Symptoms = fatigue, loss malnutrition, nutrition of energy, shortness of deficiencies, chronic disease, breath, difficulty B12 and Folate deficiencies concentrating, dizziness…. (Mills and Ashford, 2008)
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Labs and Dysphagia?
• ABGS (arterial blood gases) = ex. • Hypoventilation, abnormal CO2 Ventilator patient making good progress. retention and acidosis Progresses to Passy Muir Valve two hours a • Decrease in pH (acid) day, team draws for ABG…what should we • Increase in PaCO2 (carbon dioxide) be checking for? • More accurate measure of SaO2 % (Oxy. Sat) than peripheral oxygen saturation
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Labs and Dysphagia
• Hydration and electrolytes • Significant mental status change: check (blood/urea, Nitrogen (BUN), creatine changes in ammonia (liver issues) (creat), and sodium (Na) • Low potassium (hypokalemia) = weakness and fatigue • Dehydration is the MOST common • Low calcium (hypocalcemia) mental status dysphagia-associated major disease change, depression, extrapyramidal comorbidity (Altman et al., 2010) symptoms, neuromuscular irritability (numbness around mouth, twitching, • Dehydration can artificially increase spasms, muscle cramps) rad and chemo albumin, RBC, potassium, and chloride patients are at risk!
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Labs and Dysphagia
• BMI (Body Mass Index) • Rule of thumb: loss of 10 # or more • Worried about your patient’s baseline in 30 days or less should be automatic frailty? Refer to Nutritionist/Dietician referral to speech pathology for CSE
• Cachexia (wasting), poor intake, weight loss, ability to meet caloric and hydration needs
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Labs and Dysphagia
• Albumin and pre-albumin • If patient is aspirating, but normally hydrated, albumin of 2.0 (normal 3.5- • Not always a good marker; most 5.0 g/dL)…may indicate weak immune flawed marker (Bahn, 2006) response (hypothesis could be flawed…so check other labs to help) • Nutrition is tied to strength of immune system (Mills & Ashford, • Increase in Al or PAB maybe a result 2008) of improvement in overall clinical • Artificially elevated in dehydrated status, not necessarily improved patients nutritional status (Lebanh, 2006)
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Labs and Dysphagia
• SpO2 (Peripheral O2 saturation) • Colodny (2000) showed no relationship between aspiration on a FEES exam and • Used to assume: aspiration = drop in peripheral O2 saturation rate SpO2 levels • Aspirators tend to have lower levels in general, indicating patients with Leder (2000) concluded that oxygen • dysphagia may have compromised saturation does not correlate with aspiration… “O2 dos not appear to be respiratory systems a clinically relevant indirect marker of aspiration status (p204)
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Labs and Dysphagia
• Respiratory Rates • RR higher than 25 breaths/minute • Leder (2000), HR increased for have been found to be associated aspirators and non-dysphagia patients with aspiration in patients with = should not be used as a marker of COPD (Cvejic et al., 2011). distress either • Drop in O2 during swallowing evaluation could be due to physical exertion, feeding themselves, positioning, underlying disease process
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Labs and Dysphagia
• Respiratory Rate “I think of the ICU patient puffing • Steele & Cichero (2014) it is away at 30-40 breaths per minute and worthwhile to measure resting RR requiring a face mask. I say to during swallowing evaluation (p. myself…if I can’t even get to the 301) mouth and if there is no break between breaths, than we should not be feeding the patient.
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What do I know about Pharmacology? (corbin-Lewis & Liss, 2015) Medication category Side effects affecting swallow Medication names (Generic) Alzheimer’s/Dementia Nausea, anorexia, vomiting Aricept (donepezil); Exelon (rivastigmine) Angiotensin converting enzyme (ACE) Cough, chronic throat clearing, Vasotec (enalapril); Zestril (Lisinopril); inhibitors nausea/vomiting; abdominal pain Lotensin (benazepril) Antibiotics Oral myositis; yeast infection Amoxil; Augmentin (Penicillin); tetracycline Anticholinergic; dyspnea Dyspnea, cough, nausea, xerostomia, Atrovent HFA (ipratropium bromide throat irritation, dyspepsia inhaled); Proventil HFA (albuterol inhaled); Advair HFA (fluticasone/salmeterol inhaled) Antidepressants (benzodiazepines) Appetite change, dysarthria, ataxia, Xanax (alprazolam); Ativan xerostomia (lorazepam) Antihistamines (second generation) Abdominal pain, dry mucous Alavert (loratadine); Allegra membranes; xerostomia, diarrhea, (fexofenadine); Claritin (loratadine); pharyngitis Zyrtec (cetirizine)
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What do I know about pharmacology? (corbin- Lewis & Liss, 2015)
Medication category Side Effects affecting swallow Medication Names (Generic) Antiparkinsonian Dyskinesia, nausea, vomiting, Sinemet (carbidopa/levodopa) xerostomia Antipsychotics (second generation) Xerostomia, dyskinesia, cough, Abilify; Risperdal; Seroquel, Haldol, dysphagia Zyprexa, Olanzapine Antispasmodics Xerostomia Levbid/Levsin (hyoscyamine) Antiulcer-proton pump inhibitors Nausea, abdominal pain, vomiting, Nexium (esomeprazole); Aciphex (PPI) diarrhea (rabeprazole); Prevacid (lansoprazole) Diuretics Nausea, vomiting, anorexia, Lasix (furosemide) abdominal cramps, diarrhea Antiemetic Xerostomia Transderm-scop (scopolamine)
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Surgical Interventions
Mobilization of Placement of vocal cord G-tube or J-tube
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Supplemental Tests
• Current dietary level test • Document current dietary level • Functional Oral Intake Scale (FOIS) • Mini Nutritional Assessment (MNA) • Reflux Disease Questionnaire (RDQ)-food sticking • Nutritional status • Gastrointestinal Symptoms Rating Scale (GSRS) • Reflux Questionnaire (ReQuest) • Reflux Symptom Index (RSI) – Easiest LPR screen
• Suspicion for GERD or LPR • The dysphagia Handicap Index (Silbergleit et al., 2012) Complaints of Globus sensation, hoarseness, chronic cough, dysphagia, odynophagia, chronic throat clearing should be screened for LPR
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Swallow Quality of Life-SWAL-QOL (McHorney et al., 2002)
SWAL-CARE Quality of (McHorney et al., life scales 2002)
MD Anderson For head and Neck Dysphagia Inventory (Chen, 2001)
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Dysphagia Management Team
• Speech Language Pathologist • Dentist • Nurse • Otolaryngologist • Dietician • Gastroenterologist • OT • Radiologist • PAT • Neurologist • Pulmonologist • Neurodevelopmental specialist (Pediatrics)
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