Swallowing in the Elderly and The Impact of Stroke

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STROKE Swallowing and the Impact of
StrokeModule V
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OBJECTIVES

• Discuss the clinical signs and symptoms of
  dysphagia
• Review problems that may exist as a result of
  dysphagia
• Identify components included in a screen for
  dysphagia
• Identify resources for management of dysphagia

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DYSPHAGIA

• Becomes an increasingly common problem with age
• 6-10 million Americans currently report some
  degree of swallowing difficulty
• Despite advances in the assessment and treatment
  of dysphagia, it is often underappreciated by the
  general public and by health care providers

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KNOW THE BASICSPHASES OF SWALLOWING

• Oral Phase
• Pharyngeal Phase
• Esophageal Phase
• Important to know this level of detail
• This information is crucial to the development of
  a treatment plan
• Swallowing problems can occur in any or all of
  the phases of the swallowing

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ORAL PHASE (1)

• Two parts to the oral phase
• Oral Preparatory
• Oral Transit
• Oral Prep
• Chewing / mixing food with saliva, forming a
  bolus
• Completely voluntary

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ORAL PHASE (1)

• Oral Transit
• Ready to swallow the bolus
• Stop chewing and gather the bolus along the
  tongue dorsum
• Tongue moves up against the hard palate and
  sequentially moves the bolus posteriorly toward
  the oropharynx

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PHARYNGEAL PHASE (2)

• Once the bolus passes by the faucial arches, the
  swallow reflex is triggered
• The following occurs as part of the reflex
• Velum elevates and occludes nasopharynx
• Larynx elevates
• Pharyngeal constrictor muscles contract

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PHARYNGEAL PHASE (2)

• Closure of the larynx bottom-top (3 level airway
  protection)
• True vocal cords
• False vocal cords
• Epiglottis deflects
• Stop breathing
• Cricopharyngeus (upper esophageal sphincter)
  relaxes

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ESOPHAGEAL PHASE (3)

• Bolus passes through the upper esophageal
  sphincter
• Esophagus contracts, sequentially moving the
  bolus toward the lower esophageal sphincter

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IMPACT OF DYSPHAGIA

• Aspiration pneumonia
• Malnutrition
• Dehydration
• Debilitation, fatigue
• Diminished quality of life
• Increased length of stay

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STROKE The Bad News

• The most common cause of dysphagia in the elderly
• The literature suggests that swallowing
  difficulties can affect 22-64 of the acute
  stroke population
• Nearly half of all stroke patients aspirate early
  after the event
• As many as 35 of the deaths that occur after an
  acute stroke are caused by pneumonia

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STROKE The Good News

• Studies of the natural history of dysphagia in
  the stroke population suggest that nearly half of
  the patients recover to their pre-morbid
  swallowing status within a week of the event
• Up to 87 resume normal oral intake by 6 months
  after the event

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STROKE AND DYSPHAGIA

• Given the high number of cases annually, and
  associated mortality, it is critical to identify
  the stroke patients that are at greatest risk for
  developing pulmonary complications
• Prompt identification and treatment of dysphagia
  can have a positive impact on morbidity and
  mortality in the stroke population
• As a result, it is critical to address dysphagia
  in the acute care setting

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STROKE PATIENTS MOST AT RISK for dysphagia

• Anterior hemispheric lesions (associated with
  decreased tongue control and facial weakness)
• Brainstem lesions
• Cortical lesions (particularly on the right) can
  cause cognitive impairments that compromise
  swallowing function
• Large area strokes and those with other comorbid
  conditions that can effect swallow
• Dysfunction of cranial nerves V, VII, IX, X, or
  XII

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OTHER POPULATIONS COMORBIDITIES that impact
swallow function

• Parkinsons Disease
• Muscular Dystrophy
• Myasthenia Gravis
• Multiple Sclerosis
• Head and Neck Cancer
• Medication effects
• Polypharmacy
• Amyotrophic Lateral Sclerosis

• Chronic Obstructive Pulmonary
• Disease
• Alzheimers disease
• Prolonged mechanical ventilation
• History of previous strokes
• Prior decreased functional status
• Prior malnutrition

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SIGNS AND SYMPTOMS OF DYSPHAGIA Oral Phase (1)

• Drooling
• Facial asymmetry
• Pocketing food in the cheek
• Poor tongue movement
• Inability to close lips tightly, with resulting
  leakage of food or fluid from the mouth

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SIGNS AND SYMPTOMS OF DYSPHAGIA Pharyngeal Phase
(2)

• Nasal regurgitation
• Inability to swallow
• Coughing when eating or drinking
• Wet sounding voice or cough
• Complaints of food catching in the throat

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SIGNS AND SYMPTOMS OF DYSPHAGIA Esophageal Phase
(3)

• Burping or indigestion
• Globus sensation lump in the throat
• Complaints about a bad taste in the mouth on
  awakening

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DYSPHAGIA SCREENING

• Dysphagia screening is one of JCAHOs core
  performance measures for Primary Stroke Centers
• Must show evidence that every stroke and
  transient ischemic attack (TIA) patient is
  screened for dysphagia prior to being given
  anything by mouth (including meds)
• Screening can be done by physician or speech
  pathologist
• There are 6 order sets that address this
  requirement ED Stroke, Stroke Post Thrombolysis,
  Stroke Ischemic Adult, Stroke-Hemorrhagic ICH /
  SAH, Stroke mini Order, and TIA

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SWALLOWING SCREENING

• To date, no swallowing screening tool has been
  universally accepted or recommended
• Most of the swallowing screening tools have been
  developed for the stroke population
• All however evaluate
• Level of alertness
• Presence of a communication deficit
• (dysarthria / aphasia)
• Symmetry of face, tongue and lips
• Presence of voluntary cough
• Ability to swallow own secretions (no
• drooling)

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SWALLOWING SCREENING

• All Include PO trial
• Assessment for
• Presence of a swallow
• Coughing
• Gurgly vocal quality
• Water dribbling out of mouth

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SWALLOWING SCREENINGMaine Medical Center

• Swallowing screening is included in the physician
  admission order sets for ischemic and hemorrhagic
  stroke and TIA
• Stipulates the following for initiation of diet
• Alert
• Cranial nerves VII-XII intact
• Cough present
• Managing oral secretions
• Able to swallow 1 teaspoon of water
• Documentation that the patient has no evidence of
  swallowing difficulties and is cleared to have
  oral intake

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MANAGEMENT OPTIONS

• Diet / liquid consistency modifications
• Environmental modification to reduce noise and
  distractions
• Aspiration precautions
• Oral hygiene
• Positioning / postural strategies
• Chin tuck
• Head turn / head tilt
• Swallowing strategies
• Hard swallow
• Double swallow
• Supraglottic swallow
• Super-Supraglottic swallow
• Mendlesohn maneuver
• Alternative modes of nutrition

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KNOW WHO TO CONSULT

• Speech-Language Pathologist
• Bedside assessment
• Modified Barium Swallow
• Development of a management plan
• Dietician
• Other Physicians for possible surgical or other
  medical management interventions

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KNOW HOW TO ADVOCATE

• Be aware of the dysphagia management plan
  collaborate with the Speech Pathologist and other
  staff
• Monitor for compliance with positional guidelines
  and swallowing strategies at meal time
• Be supportive of the diet consistency
• Involve the patient and family
• Contact the Speech Pathologist with any questions
  or concerns

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Test question(s)

• Behaviors that would indicate a need for
  swallowing evaluation include which of the
  following
• Drooling, coughing, choking, poor tongue movement
  
• Clear voice quality
• Prompt initiation of swallow
• Symmetric palate elevation

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Test question(s)

• Which of the following is not in compliance with
  the JCAHO quality measure for dysphagia
  screening
• Screening should be completed on all stroke and
  TIA patients
• Oral intake of medications is initiated prior to
  screening
• Screening prior to oral intake is documented
• NPO ordered until swallow evaluation is completed
  by physician or speech pathologist

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Test question(s)

• Resources that are available to guide evaluation
  and management of dysphagia include
• Speech language pathology
• Nutrition services
• Adult admission order sets for stroke and TIA
• All of the above

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Test question(s)

• 4. The most serious complication associated
  with a
• swallowing deficit is
• a. Gastric tube infection
• b. Pulmonary complications due to aspiration
• c. Anorexia
• d. Weight loss