Swallowing Difficulty In-service Training Guide Most of us effortlessly swallow up to 600 times a day without even thinking. Yet this multi stage process involves the mouth, tongue, jaw muscles, larynx and esophagus. If you have ever swallowed something and felt as if it had gone down the wrong way, you know how it feels to have a swallowing problem. We swallow up to 600 times a day, so multiply that and you can imagine how difficult it would be to deal with a swallowing problem on a daily basis.

Four Phases of Normal Swallow Oral Preparatory Oral / Voluntary Pharyngeal / Involuntary Esophageal / Involuntary Swallowing is a complex process. Some 50 pairs of muscles and many nerves work to move food from the mouth to the stomach.

Oral Preparatory Phase “Anticipatory stage” Occurs prior to the food entering the mouth Your mouth begins watering and your stomach may start to growl Your body’s reaction to the anticipation of eating

Oral Phase / Voluntary The tongue moves the food around in the mouth for chewing. Chewing makes the food the right size to swallow and helps mix the food with saliva. Saliva softens and moistens the food to make swallowing easier. The tongue collects the prepared food or liquid, making it ready for swallowing. Begins with contractions of the tongue and striated muscles. These work in a coordinated fashion to mix the food with the saliva and propel into the oropharynx where the involuntary swallowing reflex is triggered.

Pharyngeal Phase / Involuntary This stage begins when the tongue pushes the food or liquid to the back of the mouth, which triggers a swallowing reflex that passes the food through the pharynx (the canal that connects the mouth with the esophagus). During this stage, the larynx (voice box) closes tightly and breathing stops to prevent food or liquid from entering the lungs. Aspiration is most likely to occur during this phase. This phase is totally involuntary & totally reflexive, so no pharyngeal activity occurs until the swallow reflex is triggered. The swallowing reflex lasts approximately 1 second.

Esophageal Phase / Involuntary The food is propelled downward from the upper esophagus to the stomach by a peristaltic movement. Impaired esophageal functioning can result in retention of food & liquid in esophagus after swallowing An interval of 8-20 seconds may be required to drive food into the stomach. In a normal swallow this takes about nine seconds. As you can see, something that we assume is as simple as a swallow, is actually a complicated process. Problems can occur at any one of the four stages of swallowing.

Abnormal Swallow 53 – 74% of Nursing Home Residents Affected Aspiration Pneumonia 5th Leading Cause of Death = over 60 year of age 3rd Leading Cause of Death = over 80 years of age Someone who cannot swallow well may not to able to eat enough of the right foods to stay healthy or maintain an ideal weight.

Swallowing Difficulties Actually symptoms of other underlying conditions. Because swallowing requires the healthy function of many different oral structures, muscles, and nerves, a wide range of different medical and dental conditions can cause swallowing issues.

Two Broad Types of Swallowing Difficulties -Oropharyngeal Dysphagia Affects the mouth & upper throat -Esophageal Dysphagia Affects the esophagus These two types can be distinguished based on: personal medical history (Specific symptoms) specific signs noted during the physical exam results of diagnostic test Oropharyngeal dysphagia is more common that esophageal dysphagia.

Oropharyngeal Dysphagia Characterized by difficulty moving food or liquid to the back of the throat, and initiating a swallow. Food accumulates in the mouth - spills out the corners or from the back of the mouth into the nasal passages Will actually pass the vocal cords and enter the trachea causing respiratory distress.

Esophageal Dysphagia Characterized by a sensation that swallowed food or liquid is sticking in the esophagus somewhere near the neck or chest.

Causes of Oropharyngeal Dysphagia Stroke Parkinson's Disease Muscular dystrophy Tumors of the mouth Radiation-induced dry mouth Drug-induced dry mouth Chemotherapy-induced inflammation of the mouth Stroke is the most common cause of Oropharyngeal dysphagia. About half of all stroke victims experience some degree of swallowing problems. In most cases, normal or near normal swallowing returns within one week. Drugs that may cause dry mouth are essentially the medications that we give every day in our facilities. Can you name a few? CNS Depressants Antipsychotic Corticosteroids Lipid-lowering drugs Anticonvulsants Certain drugs can actually produce a chemical inflammation if they stay in contact with the esophageal lining for long periods of time. This is called pill esophagitis and it can cause dysphagia.

Causes of Esophageal Dysphagia Inability to produce involuntary, wave-like contractions of the esophagus Esophageal spasms that block food and liquid instead of propelling them downward toward the stomach. Esophageal dysphagia is often due to actual blockages within the esophagus that are referred to as structural disorders. These disorders mechanically block food and liquid from moving towards the stomach. The most common structural problems are esophageal cancer.

Causes of Esophageal Dysphagia (continued) Age related changes of motor function of esophagus Tumors of the esophagus Functional dysphagia with no physical reason - stress Esophagitis induced by reflux disease (GERD)

Symptoms of Dysphagia Difficulty chewing Difficulty initiating swallowing Persistent sensation of a "lump" in the throat Frequent need to clear throat Drooling Pain during swallow Bad breath Change in voice (Nasal voice or hoarseness) Hiccups Weight Loss Heartburn Chest Pain These two types typically produce different types of symptoms. Residents with Oropharyngeal dysphagia often have more difficulty swallowing liquids, while those with esophageal dysphagia often have more difficulty swallowing solids. If the resident's esophagus has difficulty producing the contractions to move the food down to the stomach swallowing either solids or liquids will be a problem.

Warning Signs of Swallowing Difficulty Taking a long time to begin a swallow Needing to swallow 3-4 times for each bite Coughing Frequent throat clearing Difficulty swallowing liquids in mouth Wet / gurgly voice Extremely slow eater - > 45 minutes Rocking tongue back & forth Spitting food out

Swallowing Difficulty Complications Malnutrition Weight Loss Dehydration Choking Aspiration Pneumonia Depression

Swallowing Assessment Watch the resident while he or she drinks a few ounces of water – delayed swallowing initiation, coughing, a wet or hoarse voice quality may indicate a problem. After the swallow, observe resident for 1 minute or more to see if delayed cough response is present. Document observations in medical record.

This tool can be completed and placed in your ADL book for facility CNA's or perhaps even in your MAR for the nurses. We are including it for you to utilize as you wish! The information on this guide is vital for those residents who have a swallowing difficulty.

Signs to Report Oral leaking Choking Pocketing food Taking longer than 2-10 seconds to swallow Choking on pieces of food

Positioning for Swallowing Difficulty 90 degree angle / swallowing is easier & safer If paralyzed on one side, turn head slightly to the weak side & slightly down (may increase ability to swallow – positioning this way may help reduce the passageway on the paralyzed side of the esophagus) If resident is in bed, position as close to a 90 degree angle as possible – support the head, back, neck & sides. Avoid the incidence of the head tipping back at any time, unless recommended by the SLP. The facility must work closely with the SLP on positioning that is appropriate. Straws may be unsafe.

Reducing Swallowing Problems Solutions/Interventions/Techniques Tilt the head down slightly Place food in the back of the mouth If paralyzed on one side, place food on strong side of mouth For tongue thrusting – try placing food on the back of the tongue Small management sips or bites Keep upright for 30 minutes after eating to prevent risk of aspiration

Meal Time Interventions Remove distractions Use special swallowing maneuvers recommended by SLP Eat more slowly Smaller mouthfuls of food Special utensils & prosthetics Adjust temperature, taste & texture of food Choose appetizing foods that are dense in calories. Moderate and severe dysphagia can lead to weight loss and malnutrition. If dry mouth is causing dysphagia, try chewing gum, sucking on lozenges, or using a homemade artificial saliva solution, 1 teaspoon of baking soda ands 1 teaspoon of salt to a quart of water. Avoiding caffeine may be helpful Residents with swallowing problems are often tired at night and may be better having the main meal served at lunch.

Solutions/Interventions/Techniques Avoid dry foods – moisten with gravy, sauce or broth Wait for resident to swallow prior to placing any more food in mouth Check mouth very carefully after meals Clear all food from back of mouth, between cheek & gums & under dentures NEVER RUSH BE VERY ATTENTIVE

Making Swallowing Easier Soft, chopped, ground or pureed foods Thickened liquids Cohesive foods Serve food cold or hot, (not warm). Cold, sour foods or liquids can improve the oral stage of the swallow by the triggering of a swallow.

What if Choking Occurs? Stop feeding immediately Call for assistance Utilize Heimlich maneuver if needed Sit the individual forward (If unable to sit, turn head to side) Do not give water or fluids until symptoms subside Trained personnel may need to use suctioning techniques

Always follow the recommendations of the Speech Language Pathologist (SLP), in addition to your facility’s policy and procedures.

Questions? Thank you for all that you do for our residents!