What Can Go Wrong ? Difficulty chewing/moving keeping food in the mouth Excess/reduced saliva Muscle weakness/stiffness in face and neck Changes in sensation Changes to the Swallow reflex
Gastro oesophageal reflux disease (GORD) Acid from the stomach leaks into the oesophagus Common terms Reflux Heartburn –burning pain -upper chest Indigestion - discomfort -lower abdomen Laryngo-pharyngeal reflux –where stomach acid travels into the throat
Reflux and people with learning disability Prevalence higher in people with a learning disability(LD) –with severe and profound LD. Poly pharmacy, scoliosis/Kyphosis, obesity,poor diet. Helicobacter pylori, a class 1 carcinogen linked to stomach cancer, gastric ulcer High prevalence of oesophageal stage cancers in LD 48%-59% vs 25% of general population cancer deaths.
Causes of Reflux Band of muscle/sphincter at bottom of oesophagus does not work well Pressure in stomach increases to more than sphincter can withstand. Side effect of medications. Anti-inflamatories and painkillers, Anticonvulsants, psychotropics, muscle relaxants E.g. diazepam, Baclofen, Taking tablets with water -getting stuck (Oesophagitis) Other medical conditions eg Hiatius hernia/helicobacter pylori
Symptoms of reflux Feelings of reflux -Heartburn burning pain/feeling rises from lower chest up towards the neck. -Sore throat -Pain after meals and after hot drinks. A feeling of a lump in the throat.(globus) Feeling sick, an acid taste in the mouth, bloating, Post nasal drip –normal mucus drips down back of the throat -irritated mucosa and tissue.(Hypersensitive) Silent reflux –maybe no symptoms
Signs/Observations of Reflux Irritable “barking” Cough worse at night Throat clearing Breathing difficulties – newly diagnosed with asthma –Chronic obstructive pulmonary disease (COPD). Noisy breathing Belching, Excess saliva Gum/teeth problems Bad breath Hoarse voice/wet voice -mucus in the throat Trouble swallowing/choking -sensation or event
Investigations Treatment on reported signs and symptoms Barium swallow –check motility and ? anatomical problems Oesophago-gastro duodenoscopy (OGD) –gastroscopy or endoscopy/flexible endoscopy by ENT -check vocal cords and anatomy Hiatius hernia. helicobacter pylori – 24 hour PH monitoring
Patients` story Referral – Lady 60 years, coughs when eating and drinking. Diagnosis -Cerebral palsy, learning disability, Hypertension, Hypothyroid. Reported -Just want the cough to stop unable to sleep, “Little accidents” - “No ones listening” “will have a heart attack”, “am scared of choking” Observed breathless and wheezy. Verbal communication –? Limited comprehension. Difficulty communicating health needs.
Behaviour and lifestyle Obese BMI 33kg 2 (31-40) healthy range = overweight = Wanted “to diet “ - chose a poor diet and food choices. Lack of exercise -uses electric wheelchair.
Interventions Frequent course of antibiotics A number of chest X-Rays Rx asthma inhalers Referral to respiratory nurse Referred to Dysphagia team for adults with a learning disability (DTALD) Food choices/changes made, Easy Read Information/training sessions VF/barium meal
1 year on Fed up is just getting worse “is really bad now” Pain, discomfort, feeling full, hoarse voice Non compliance with medications Deteriorating relationships with carers –screaming arguments. Antidepressants Rx Endoscopy
Stage 4 Oesophagitis with Hiatius Hernia
Treatment Lansoprazole 30mg twice daily -Inhibitor Administered 30 minutes prior to eating. Gaviscon advance –raft after meals Motility medications after meals No food and limited sips of drink 2 hours before lying down at night. To lay in a semi upright position at night –.
How is Reflux Treated ? Changing habits/lifestyle choices Medications Surgery
Habits/Lifestyle choices Stopping smoking Avoid fried foods and high fat foods Avoid Citrus, acidic fizzy drinks and alcohol Avoid peppermint, tomatoes, chocolate, spicy foods, hot drinks, caffeine. - Exacerbates reflux Avoid large-meals Weight loss. Not wearing tight clothing/belts/lapstraps slipping Not eating for approx 2-3 hours before bed. Remain upright for a time after eating Raise head of bed. Avoid bending over
Medical Treatment Antacids -neutralise acid/coats eg Gaviscon Reflux suppressant eg Gaviscon Advance/Peptac builds the raft. Proton pump inhibitor Acid blocking/ stops production - eg lansoprazole/omeprazole/Ranitidine. Pro Kinetic medications -Motility medications – metoclopramide/Domperidone Surgery
Surgical intervention Stricture - Dilation Fundoplication -Wrap and sew top of the stomach around the lower part of the oesophagus. Lynx band a ring of placed around the outside of the lower oesophagus. strengthens the valve.
Complications of reflux Change in quality of life, Mood/ behaviour changes. Choking, aspiration, chest infections, food/drink medication refusal Scarring and narrowing (stricture). long-standing inflammation can cause a stricture of the oesophagus. Barrets oesophagus -Cells lining the oesophagus become changed by acid. Cancer. The changed cells may become cancerous
Contact details Dysphagia team for adults with a learning disability Team members Speech and Language Therapist Dietitian Specialist Dysphagia Nurse ALD Maureen Hounslow