When you can’t swallow.
Dysphagia Facts
Approximately 300,000 to 600,000 people with
neurogenic disorders are diagnosed with dysphagia.
Swallowing involves the use of 6 cranial nerves.
Approximately 40% of patients with dysphagia silently
aspirate.
Swallowing is one of the most complex body reflexes,
yet in the normal adult, this process is automatic,
effortless and efficiently performed an average of 600
times a day.
Dysphagia Facts
Evidence of dysphagia in 51% of patients with acute
stroke.
Parkinson’s dysphagia develops in approximately 50%
of patients.
With patients with multiple sclerosis, 34% with
dysphagia.
Phases of the Swallow
Oral Phase
Involves the lips, tongue, teeth and cheeks.
The swallow begins when food is presented at the level
of the lips.
Patients must have good labial seal to hold the bolus within
the oral cavity and to create appropriate pressures to propel
the bolus and initiate the swallow.
Patients with stroke may have labial weakness which allows
the food to spill out of the mouth.
Tongue
The tongue contains the taste buds allowing us to taste
foods.
The tongue is made up of muscles.
The tongue is used to
Move the bolus within the oral cavity for proper
mastication of the bolus
Propel the bolus posteriorly to initiate the pharyngeal
stage of the swallow
Teeth
Dentition is important for swallowing and it is
important to assess dentition for appropriate diet
recommendations.
The SLP will need to know if the patient wears dentures,
is missing teeth, etc.
Teeth are important for appropriate mastication of
foods.
Cheeks
Buccal tension:
Assists in creating appropriate pressures for initiating
the pharyngeal swallow
Assists in maintaining the bolus
Helps to prevent lateral pocketing of the bolus.
Pharyngeal Phase
Once the food is masticated and reaches the anterior
faucial arches, the pharyngeal stage of the swallow is
initiated.
Within 1-3 seconds the following occurs:
Tongue Base Retraction
Velopharyngeal closure
Pharyngeal constriction
Pharyngeal contraction
Hyoid Elevation
Hyoid Protraction
Hyothyroid approximation
Vocal fold closure
Upper esophageal sphincter opening.
Oral Care
Microorganisms found in the lungs of elderly patients with
pneumonia originate in the mouth and gingival, making a
link between poor oral hygiene and aspiration pneumonia.
Three categories that add to the risk factors that lead to
aspiration pneumonia: o Any factor that increases the
bacterial load or colonization in the oral-pharyngeal cavity
(lack of tooth brushing, xerostomia).
Any factor that decreases the patient’s resistance to the
inoculums (i.e. malnutrition or ventilator dependency).
Any factor that increases the risk of aspiration (i.e. paralysis
from stroke or chronic neurological disease affecting the
muscles and nerves involved in swallowing.
Oral Care
Those at risk:
Patients who are dependent for oral care.
Have large numbers of missing teeth.
Dentures
Have limited hand dexterity
Decreased mental capacity
Multiple medical co-morbidities
Immunosuppressed
Ventilator dependent
Receive non-prandial feedings
Have had a stroke
Neurologically impaired
Have xerostomia
Known Dysphagia
Poor access to professional dental care.
Dependence on caregivers for oral care.
Active smoking
Depression.
Use of sedative medication
Use of gastric acid-reducing medication.
Use of ACE inhibitor
Poor feeding position.
Frazier Water Protocol
Patients who are on thickened liquids are often placed
on a Frazier Water Protocol to increase hydration.
Thickened liquids are given with meals and
medications.
Wait for 30 minutes after meal, complete thorough oral
care, then patient can have all the water they want until
their next meal.
Thickened Liquids
There are four consistencies of liquids
Thin or regular
Normal drinks with no thickening agents added.
Nectar thick liquids
Should be the consistency of maple syrup and run off the
spoon like syrup does.
Honey thick liquids
Consistency of honey and should run off the spoon as honey
does.
Pudding thick liquids
Should be the consistency of pudding and “plops” off the
spoon.
Medications
When patients have dysphagia, they are often ordered
to have their pills crushed or given in
applesauce/pudding.
When passing pills, remember people that have
difficulty swallowing and try to give them one pill at a
time.
Check at the end of the med pass to make sure all pills
were swallowed and were not pocketed.
Food Consistencies
Pureed
Baby food consistency, should have no lumps and be
easy to swallow.
Mechanical Soft/Ground Meat
Should only require minimal chewing, no hard/crunchy
foods
Regular
No restricitions
Assessment Techniques by SLP
Bedside assessment
Cervical Auscultation
Laryngeal elevation
Monitor s/s aspiration
Trial consistencies
Pulse Oximetry
Heart Rate
Blue Dye Assessment
3 Ounce water test
Bolus Manipulation Task
Instrumental Assessment
MBSS
FEES
Manometry
Ultrasound
Treatment Techniques by the SLP
VitalStim-NMES for dysphagia
DPNS/FMEP
Thermal/tactile stimulation
Myofascial release and manual techniques
Oral/Pharyngeal Exercises
Exercises with resistance
TheraSip Swallowing Trainer
IOPI
OraLight
Ice Finger
Laryngeal Mirrors/ThermoStim Probe
Things to Remember
Patients that self-feed have a lower incidence of aspiration.
Feed patients as you would like to be fed, don’t shovel food into
their mouth or stick the food into their mouth before they’re
ready.
Aspiration pneumonia in nursing home residents occurs 10 times
more frequently than in elderly community dwellers.
Pneumonia is the most common cause of death from
nosocomial infections in the elderly.
Pneumonia results in functional declines and increased health
care expenditures.
One study suggests that 70% of patients with a history of
pneumonia aspirated during their sleep.
One study suggests that effective oral care can decrase mortality
due to pneumonia by half.
Bolus Propulsion
Select Medications that Affect
Swallowing
Oropharyngeal function Esophageal function
Sedation, pharyngeal weakness, dystonia Inflammation (resulting from irritation by
Benzodiazepines pill)
Neuroleptics Tetracycline
Anticonvulsants* Doxycycline (Vibramycin)
Myopathy Iron preparations
Corticosteroids Quinidine
Lipid-lowering drugs Nonsteroidal anti-inflammatory drugs
Potassium
Xerostomia Impaired motility or exacerbated
Anticholinergics gastroesophageal reflux
Antihypertensives* Anticholinergics
Antihistamines* Calcium channel blockers
Antipsychotics Theophylline
Narcotics
Anticonvulsants* Esophagitis (related to immunosuppression)
Antiparkinsonian agents* Corticosteroids
Antineoplastics* *--Various agents in the class.
Antidepressants*
Anxiolytics*
Muscle relaxants*
Diuretics
Inflammation/swelling
Antibiotics*
Sources
American Speech-Language Hearing Association Division
13 (2006). Perspectives on Swallowing and Swallowing
Disorders, 15(3), 1-28.
American Speech-Language-Hearing Association (1990).
Skills needed by speech-language pathologists providing
services to dysphagic patients/clients, ASHA, 32 (suppl 5),
7.
DPNS Manual. Available through the Speech Team Inc.
Author: Karlene Stefanokos.
The Source for Dysphagia. LinguiSystems. Author: Nancy
Swigert.
Logemann, J. A. (1998). Evaluation and treatment of
swallowing disorders. Austin, TX: Pro-Ed.
Sources
Carl, L., & Johnson, P. (2005). Drugs and dysphagia:
How medications can affect eating and swallowing.
Austin, TX: Pro-Ed.
Palmer, J.B., Drennan, J.C., and Baba, M. (2000).
Evaluation and Treatment of Swallowing Impairments.
[Link]/afp/20000415/[Link]
