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CPD 50: DYSPHAGIA Biography - Eamonn Brady MPSI is the owner of Whelehans Pharmacy in Mullingar. He graduated from the Robert Gordon University in Aberdeen in 2000 with a First Class Honours MPharm degree in pharmacy. He worked for Boots in the UK before moving back to Ireland in 2002. He bought Whelehans Pharmacy in Mullingar in 2005. He undertakes clinical training for nurses and other healthcare professional in the midlands and undertakes talks on health and pharmacy related subjects. Contact Eamonn at 04493 34591 if you wish him to undertake training or a health talk.

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TYPES OF DYSPHAGIA Two general classifications of dysphagia are: • Oropharyngeal (also known as high dysphagia). Swallowing problems result from mouth or throat problems. • Oesophageal (also known as low dysphagia). Swallowing problems result from oesophageal problems. Low dysphagia can be due to a blockage in the oesophagus and surgery is often the treatment option. High dysphagia is due to problems with nerves and muscles that control swallowing.

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Identification and Management of Dysphagia Dysphagia is the medical term for swallowing poorly. Dysphagia is usually an additional complication of other conditions including stroke, mouth cancer, throat cancer and gastro-oesophageal reflux disease (GORD). The oesophagus connects the throat and the stomach. For patients presenting with unexplained pneumonia and progressive weight loss, dysphagia needs to be considered.

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High dysphagia is more challenging to treat than low dysphagia. HOW COMMON IS DYSPHAGIA? Dysphagia is commonly associated with other health conditions (eg) stroke, Parkinson’s disease, multiple sclerosis. Studies indicate that 30% to 40% of older nursing homes› residents have some form of dysphagia, with dysphagia being one of the reasons a person first enters a nursing home. It is reckoned that 50% of people develop some form of dysphagia after a stroke. PROGNOSIS Dysphagia can lead to malnutrition, due to the person’s inability to eat properly and this can reduce life expectancy dramatically, especially in older people. The risk from fluid or food particles aspirating into the lungs is another serious complication that can cause serious or even fatal consequences, including lung infection (aspiration pneumonia).

60 Second Summary Dysphagia is a complication of conditions like stroke, mouth and throat cancer, gastro-oesophageal reflux disease and neurological diseases including Parkinson’s Disease, Cerebral palsy, Multiple sclerosis and Motor neuron Disease. Two types of dysphagia are (1) Oropharyngeal dysphagia or high dysphagia (where swallowing problems result from mouth or throat problems) (2) Oesophageal dysphagia or low dysphagia (where swallowing problems result from oesophageal problems). High dysphagia is more challenging to treat than low dysphagia as it generally caused by neurological problems. Common complications of dysphagia include malnutrition and aspiration pneumonia. Diagnostic techniques include a waterswallow test, a barium swallow test and endoscopy Treatment options for oropharyngeal or ‘high’ dysphagia: • Swallowing therapy: where a speech and language therapist teaches the patient different swallowing techniques • Dietary changes (eg) softer foods, thickeners for fluids, reducing mouthful volume, using strong flavours to stimulate swallowing reflex, using foods that do not crumble in the mouth, avoiding foods like milk that may increase mucus production • Feeding tubes provides nutrition short term while the patient is recovering swallowing function or more long if swallowing is no longer possible Treatment options for oesophageal or ‘low’ dysphagia: • Dilation Surgery: a small balloon is placed inside the oesophagus and gradually inflated before being deflated and removed. • Botulinum toxin used in tiny doses to paralyze stiff muscles that prevent food moving down the oesophagus.

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CPD 50: DYSPHAGIA

• Gastro-oesophageal reflux disease (GORD) can lead to stomach acids damaging the oesophageal lining leading to scar tissue • Infections (eg.  tuberculosis, herpes simplex,) may cause inflammation of the oesophagus Muscular conditions Caused by the muscles of the oesophagus not functioning properly. Muscular conditions which cause dysphagia include: • Scleroderma. An autoimmune condition in which the immune system attacks healthy tissue causing throat and oesophageal muscles to become stiff. • Achalasia.  A condition where oesophageal muscles become stiff, thus causing difficulty passing food and drink to stomach

Treatment type for dysphagia depends on the cause(s) and options include: • physiotherapy, • diet modification • surgery • feeding tubes SYMPTOMS OF DYSPHAGIA • difficulty or inability to swallow, • pain when swallowing, • coughing or gagging when swallowing • choking when trying to swallow

Symptoms can occur at any stage during the swallowing process. During the oral preparatory phase, symptoms that tend to occur include drooling, difficulty drinking from cups, difficulty chewing or the inability to manage certain textures. In the oral transit phase, symptoms include pocketing or stasis of food in the oral cavity. In the pharyngeal phase, symptoms include, audible breathing, gagging, coughing, congestion, a gurgle type sound and hoarse voice. In the oesophageal phase, symptoms include reflux, pain or vomiting. CAUSES OF DYSPHAGIA Neurological causes Damage to the brain or the nervous system may interfere with nerves that enable the swallowing reflex, which can lead to dysphagia. Neurological causes of dysphagia can include:

Muscles do tend to weaken with ageing, which is one of the reasons it is more common in the older population. However, dysphagia should not be accepted as a natural part of aging and there are treatment options no-matter what age the person. Dry mouth Dry mouth or eyes may indicate that insufficient saliva is being produced, which can exacerbate swallowing problems. A detailed review of medications is advised if medication is suspected to be causing dry mouth. Medications that can cause dry mouth include anticholinergics, antihistamines and certain antihypertensive medication (diuretics, beta blockers, ace-inhibitors, calcium channel blockers) so a review may be advised. DIAGNOSING DYSPHAGIA 

• Cerebral palsy

If a GP suspects dysphagia, he/she has the option of referring the patient to an ear, nose and throat (ENT) specialist for more tests. Diagnosis of dysphagia means (1) Finding an exact location of the swallowing problem (‘high’ or ‘low’ dysphagia?) (2) Determining how swallowing ability is affected.

• Multiple sclerosis                                                          

Diagnostic techniques include:

• Motor neuron Disease                                                  

Checking recent medical history

Obstruction

How long dysphagia has been occurring, its severity and whether there is weight loss (indicating progression of the condition)

The normal adult swallowing process includes four phases:

Conditions that cause a blockage or narrowing of the throat and oesophagus often affect swallow and examples include:

Water-swallow test

1.    Oral Preparatory Phase

• Oral cancer or lung cancer

2.    Oral Transit Phase

• Cleft palate

3.    Pharyngeal Phase

• Radiotherapy because radiation can lead to scar tissue, which may narrow the throat and oesophagus

• sensation of food being stuck in throat or chest • food coming back up • unexplained weight loss • frequent lung infections (due to aspiration of food and drink into the lungs, which can lead to pneumonia). Many symptoms of dysphagia can be seen (eg gagging, coughing) or heard (eg audible breathing) and often are detected by the patient themselves or by a primary carer.

4.    Oesophageal Phase

• Stroke • Parkinson’s Disease

A water-swallow test can provide an initial assessment of swallowing abilities. For this, the patient must swallow 150ml of water as quickly they can; the length it takes to drink this glass of water and the number of swallows is recorded and helps indicate the extent of the problem.

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CPD 50: DYSPHAGIA

Barium swallow test A barium swallow test is performed by getting the patient to swallow barium and then assessing for swallowing ability and location of the problem (as barium can be seen clearly on X-ray). Video footage of the barium swallow is used to determine the extent of the problem. Endoscopy An endoscopy is where an endoscope (small, flexible camera) is passed down the throat and into the oesophagus. The endoscopy can detect scar tissue or cancerous tumours brought on by gastro-oesophageal reflux disease (GORD). DYSPHAGIA TREATMENT Dysphagia is diagnosed, treated and controlled using a multidisciplinary team and the input of a GP, radiologist, speech and language therapist, dietician, occupational therapist, pharmacist and nurse are all important. Treatment of oropharyngeal or ‘high’ dysphagia There is no complete cure for ‘high’ dysphagia as neurological problems are not easily fixed.  An exception is dysphagia caused by Parkinson’s disease, for which there is no cure currently but it can be controlled with medication. If you exclude dysphagia resulting

from Parkinson’s disease, there are three general treatment types for ‘high’ dysphagia: • Swallowing therapy is where a speech and language therapist (SaLT) teaches the patient different swallowing techniques. • Dietary changes (eg) eating softer foods. • Feeding tubes provide nutrition short term while the patient is trying to recover swallowing function or longer if swallowing is no longer possible Swallowing therapy The SaLT can teach the patient exercises that stimulate nerves that trigger the swallowing reflex and strengthen muscles used while swallowing. Some simple physical techniques, which can help make swallowing easier include:

• Tilting the head back and placing the bolus at the back on the stronger side of the mouth can help make swallow easier.

• Bending the neck forward can offset delayed pharyngeal contraction by helping the larynx rise and close easier.

• Turning the head to the weaker side while

tilting it to the stronger side can help direct and propel the bolus, especially when the swallowing disorder is due to pharyngeal dysfunction.

• Certain mouth and oral exercises can be

learned, which can strengthen the lip and tongue, thus controlling drooling and helping bolus formation and propulsion.

• Deliberate multiple swallows can clear

pooling of excess saliva in the pharynx. Dietary modifications can improve swallowing and reduce the risk of aspiration. Patients may find it easier to swallow solid, soft or liquid consistencies depending on the type and extent of dysphagia. For example, those who have difficulty swallowing liquids may benefit from food additives which thicken liquids. By using thickeners, the increase in bolus viscosity can help swallowing function. (eg) Nutilis®, Think & Easy®. Reducing the volume of mouthfuls can help make swallowing easier in some patients. Not giving food and drink at the same time can also help. For some patients, feeding with a certain implement, such as a certain type of cup or a spoon may help make swallowing easier (avoid straws); an occupational therapist can advise on appropriate utensils and devices to help swallow. For patients where dysphagia is related to neurological problems, administering meals during times of maximal attentiveness can help. Another perhaps obvious procedure is for a person with dental problems (eg. missing teeth) to get dentures fitted.

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CPD 50: DYSPHAGIA

Dietary changes A patient may be referred to a dietician or nutritionist, who can advise on foods that are easier to swallow. For example, mashed potatoes can provide carbohydrates and scrambled eggs and cheese can provide protein and calcium. Two main considerations in the dietary management of patients with dysphagia are to ensure adequate nutrition and safety during feeding. The patient needs to be trained to select and prepare appropriate foods and use the recommended swallowing techniques to help self-sufficiency. Standard hospital diets serve liquids and foods together. Patients with dysphagia require modification of the standard diet. Kitchen, catering and nursing staff should be conscious of foods and liquids that cause swallowing hazards for patients at risk. Different patients and different types and degrees of dysphagia create different problems. Thinner liquids such as water, juices and tea tend to be more difficult to swallow (thickeners may be required). Some patients find it difficult to manipulate, swallow and clear thick liquid textures such as treacle, milk shakes and honey. Others can have issues swallowing foods which are dry, crispy chewy or stringy. Good communication between kitchen, catering and nursing staff is important to provide each individual patient with their specific dietary requirements (eg) regular staff meetings, clear notes, clear signage at the patient bedside, etc. Taste Strong flavours like sweet, sour, spicy or salty tastes will help stimulate saliva production, swallow and chew. Bland flavours are best avoided. Temperature Food is best served at hot or cold temperatures, instead of being tepid or at room temperature, because hot or cold food stimulates the swallowing reflex better. Cold foods known to stimulate sensory input (if tolerated) include ice cubes and ice cream. Exceptions should be made for those with reduced oral sensation (eg due to nerve damage); these patients should be given food that is tepid or at room temperature because more extremes in temperature run the risk of the burning or numbing the oral area. Texture Liquids should be thickened to enable the formation of a bolus in the mouth, allowing easier swallow. Foods that crumble or fall apart in the mouth are more difficult to swallow so are best avoided. Density and shape are also important. Jelly is often used as it slips down easily. Apple-sauce can prove difficult to swallow as it does not maintain a single strong bolus in the mouth. Canned fruit, jelly and ice cubes may be more manageable. However patient preference must be considered based on the patient’s swallowing ability. Consistency Easy chewed does not automatically mean easy

swallowed. Softer foods like porridge (which can be made thicker depending on need), soft peaches and thickened pureed fruits are easier to swallow because they tend to hold shape in the mouth for longer, thus stimulating the swallow reflex. Liquids are the most difficult to swallow for those with dysphagia as, unlike solids they do not form a bolus so do not give a strong swallowing stimulus. Water is the thinnest fluid so is most difficult of all fluids to control because it flows into corners and down the throat. However, liquids such as juices, gravies, milk, etc can be added to some dry foods to moisten them, thus allowing easier swallow and helping provide hydration. Liquids and foods should be presented separately because two differing consistencies can send confusing stimuli if given together. Avoid using fluids to wash a bolus down as, again this causes confusing stimuli and increases aspiration risk.

dysphagia causes the larynx not to close properly during swallowing, which makes the aspiration pneumonia a particularly high risk as the larynx (when working properly) acts as a guard for the lungs during swallowing.

Mucus Production Excess and inadequate saliva production needs to be tackled (eg) Is prescription medication leading to dry mouth? The elderly more often have reduced salivary production. Milk products are known to form excess mucus which is difficult to clear and swallow. Chocolate can stimulate mucus secretions in some patients. Yoghurt, cheese and cottage cheese can be added to the diet instead of milk if milk is increasing mucous production.

• Logemann JA, Kahrilas PJ, Cheng J, Pauloski BR, Gibbons PJ, Rademaker AW. Closure mechanisms of laryngeal vestibule during swallow. Am J Physiol 1992; 262: G338-G344.

Feeding tubes Feeding tubes, either a Nasogastric tube or Percutaneous Endoscopic Gastrostomy (PEG) tube may be needed for severe dysphagia where dehydration and malnutrition is a risk or is evident. Nasogastric tubes are aimed at short-term use of maximum 28 days before they need replacing. PEG tubes (tube passed through abdominal wall to stomach for purpose of feeding) can be used long-term and each tube can last up to six months before needing to be replaced. Treatment oesophageal or ‘low’ dysphagia Surgery Surgery is often successful for treating low dysphagia. Dilation is a common surgical procedure used to treat obstruction and involves small balloon being placed inside the oesophagus. The balloon is then inflated to gradually widen the oesophagus before balloon deflation and removal. Botulinum toxin Botulinum toxin is used for treatment of achalasia (condition where oesophageal muscles become stiff thus causing difficulty passing food and drink to stomach). Botulinum toxin in tiny doses can paralyze stiff muscles that prevent food moving down the oesophagus. DYSPHAGIA COMPLICATIONS  Aspiration pneumonia is a severe lung infection caused by small particles of food or drink entering the lungs. Oropharyngeal or ‘high’

Symptoms of aspiration pneumonia: • fever • chest pain • fatigue • wheezing • shortness of breath • blue skin (cyanosis), due to shortage of oxygen REFERENCES

• Kikuchi R, Watabe N, Konno T, Mistuna N, Sekizawa K, Sasaki H. High incidence of silent aspiration in elderly patients with community-acquired pneumonia. Am J Respir Crit Care Med 1990; 150: 251-253. • Feinberg MJ, Knebl J, Tully J, Segall L. Aspiration and the Elderly. Dysphagia 1990; 5: 61-71. • Groher ME. Dysphagia: Diagnosis and management. 1st Edition. Stoneham MA; Butterworth 1984. • Groher ME. Dysphagia: Diagnosis and management. 2nd Edition. Stoneham MA; Butterworth 1992. • Logemann JA. A manual for videofluoroscopic examination of swallowing. Austin, Texas; Pro-Ed 1986. • Shanahan TK, Logemann JA, Rademaker AW, Pauloski BR, Kahrilas PJ. Chin-down posture effect on aspiration in dysphagic patients. Arch Phys Med Rehabil 1993; 74: 736-739. • Linden P. Videofluoroscopy in the rehabilitation of swallowing dysfunction. Dysphagia 1989; 3: 189-91. • Hargrove R. Feeding the severely dysphagic patient. J Neurosurg Nurs 1980; 12: 102-107. • Loustau A, Lee KA. Dealing with the dangers of dysphagia. Nursing 1985; 15: 47-50. • Power S. A nutritional challenge: the elderly patient with dysphagia. Gerontion 1986; 1: 12-13. • Anthony J Lembo. Diagnosis and treatment of oropharyngeal dysphagia (Case study). Version 16.2: May 2008  • Ronnie Fass. Approach to the patient with dysphagia (Case Study). May 2008

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