NHS%20Greater%20Glasgow%20

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NHS Greater Glasgow ClydeAdvancing Skills in
Stroke Care

• Swallowing problems after stroke

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Stroke and dysphagia

• Dysphagia is the term used for swallowing
  difficulties
• Approx 60 of stroke patients will have some
  degree of dysphagia at the acute phase.
• Approx. 20 of stroke patients with dysphagia
  develop aspiration pneumonia.
• More frequent in patients with haemorrhagic
  stroke.
• The majority of people will improve within 6-7
  weeks post stroke.

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Normal Swallow

• 1. Oral stage
• 2. Pharyngeal stage
• 3. Oesophageal stage

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Factors which can influence the oral stage

• Consistency
• Hunger/Thirst
• Taste
• Texture
• Visual
• Smell

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Oral Stage

• Voluntary control
• Bolus is propelled backwards along tongue
• Bolus passes faucial arches and swallow is
  triggered.

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Pharyngeal Stage

• Involuntary stage
• Soft palate elevates
• Pharyngeal muscles contract, pulling the food
  through the pharynx
• Breathing is halted

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• The larynx rises and tips to protect the airway
  from food/fluids passing through the pharynx
• The sphincter at the top of the oesophagus opens
  to allow the food and drink to enter it

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Pharynx
Trachea
Oesophagus
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Oesophageal stage

• This stage is also under involuntary control
• This stage involves the passage of food/fluids
  from the oesophagus to the stomach.

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Oral stage problems

• Drooling/Loss of food or fluids from lips
• Residue of foodstuffs in the mouth
• Loss of taste or smell

• Incomplete soft palate seal
• Loss of food/fluids into the pharynx before the
  swallow is triggered

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Pharyngeal stage problems

• Unable to trigger swallow
• Delayed swallow trigger
• Reduced protection of the airway - leading to
  penetration/aspiration
• No cough reflex
• Pharyngeal muscles are weak
• Upper oesophageal sphincter dysfunction

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Penetration of airway
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Oesophageal stage problems

• The speech and language therapist is not really
  involved in problems at this stage as they are
  unable to assist with problems of oesophageal
  function
• Medical team investigation and management

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Aetiologies of Dysphagia

• NEUROLOGICAL
• CVA
• Motor Neurone Disease
• Parkinsons Disease
• Multiple Sclerosis
• Myasthenia Gravis
• Guillain-Barre Disease
• Cerebral Palsy
• Dementia (also behavioural)
• Brain Tumour
• Head Injury

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SLT assessment(Bedside Assessment)

• Observational assessment
• Oral examination
• Food /fluid trials
• Recommendations/Documentation
• Videofluorscopy

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Food Consistencies

• Texture A - a smooth, pouring consistency that
  cannot be eaten with a fork eg tinned tomato
  soup.
• Texture B smooth consistency, drops rather than
  pours from spoon eg thick custard.
• Texture C a thick, smooth consistency. Can be
  eaten with a fork and can be moulded layered and
  piped eg mousse

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• Texture D food that is moist with some
  variation in texture. Easily mashed with fork and
  little chewing required eg flaked fish in sauce /
  macaroni cheese
• Texture E Soft moist food that can be broken
  into pieces with a fork eg sponge and custard,
  tender meat casserole

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Thickened Fluids

• Stage 1 (syrup) can be drunk through a straw and
  from a cup. Leaves a thin layer on the back of
  the spoon.
• Stage 2 (custard) Cannot be drunk through a
  straw, can be drunk from a cup. Leaves a thick
  coat on back of the spoon.
• Stage 3 (pudding) cannot be drunk from a straw or
  cup. Needs to be spooned. A bit like thick custard

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Short-term signs of dysphagia

• Choking or coughing when eating/drinking
• Change of colour during or eating/drinking
• Wet, gurgly voice
• Shortness of breath
• Loss of food or drink from the mouth
• Pocketing of food or drink in the mouth
• Nasal regurgitation

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Long-term signs of dysphagia

• Loss of weight with anorexia and dehydration
• Recurrent chest infections
• Frequent episodes of high temperatures

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Points to Consider when Feeding

• Is the person alert?
• Is the person positioned upright with their body
  in mid-line?
• Is the persons mouth clean?
• Discourage conversation when eating
• Use small spoonfuls
• Check the person has swallowed before giving the
  next spoonful

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• Tell the patient what food or drink you are
  giving them
• Sit in front of the person or on their good
  side if they have a neglect
• Check in the mouth at the end of meal for
  pocketing in the cheeks
• Keep the person upright for 30 minutes after a
  meal

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• Watch out with ice -cream as it starts off as a
  puree but melts in the throat to a normal fluid.

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Dysphagia and Quality of Life

• Ekberg et al (2002) article on effects of
  dysphagia on quality of life.
• Only 45 of the 360 patients in the study enjoyed
  mealtimes.
• 41 felt anxious or panicky when eating.

• 36 avoided eating in public
• 1/3 of those on modified consistencies still felt
  hungry/thirsty after a meal.
• Affects, self-esteem, socialization and dignity.

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How to refer to SLT ?
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Swallowing VideoEndoscope Views of Normal
Swallow
PLAY