Dysphagia in the Elderly Implications in Long-Term Care Annette T. Carron, DO Director Geriatrics & Palliative Care Botsford Hospital

OBJECTIVES Know and understand: Swallow mechanism and changes with aging Causes of dysphagia Proper assessment and diagnosis of dysphagia Treatment of dysphagia Options if dysphagia treatment unsuccessful Survey implications of dysphagia Topic

Normal Swallow Mechanism Oral preparatory phase Chewed food mixes with saliva to make bolus Bolus sitting between the tongue and the hard palate in a groove formed by the tongue Tongue begins an anterior to posterior pumping motion that moves bolus posteriorly Bolus passes anterior tonsillar pillars Disease in this phase can result with tongue dysfunction, inadequate dentition (impairs bolus formation) Topic

Normal Swallow Mechanism Pharyngeal phase Larynx rises, vocal folds close to protect airway, epiglottis closes entrance to airway, soft palate separates nasal cavity from pharynx Bolus passes through pharyngoesophageal sphincter (UES-upper esophogeal sphincter) into the esophagus Velopharyngeal sphincter closure prevents bolus regurgitation into nose Tongue and pharyngeal muscles propel bolus Larynx is closed off to the bolus Disease here caused by palatal dysfunction, pharyngeal constriction, laryngeal or epiglottic dysfunction (aspiration) Topic

Normal Swallow Mechanism Esophageal phase Food travels to stomach Pharyngoesophageal (PES) sphincter opens to allow bolus into esophagus Disease here may be motility disorder or mass/ anatomical lesion Slide 5 Topic Slide 5

Swallow changes with aging Thickening of the muscular coat Occurs more slowly Initiation of laryngeal and pharyngeal events take longer Bolus may pool or pocket in the pharyngeal recess longer Presbyphagia – changes in the mechanism of swallowing of otherwise healthy older adults Not clear aging itself causes increased risk of aspiration, but with increased co-morbidities, increased risk Normal saliva – 10,000 gallons in a lifetime, meds can reduce salivary gland production (higher risk in elderly) Topic

Swallow changes with aging, cont. In oral phase, food bolus inadequately prepared due to poor or absent dentition, periodontal disease, ill-fitting dentures, inappropriate salivation Taste, temperature and tactile sensation with aging changes Intake may be too rapid with neurological diseases Fatigue or change in endurance as a possible factor in aspiration in the elderly Muscle atrophy in facial muscles with aging may slow swallow Topic

Dysphagia Definition – difficulty in swallowing that may include oropharyngeal or esophageal problems Eating is one of the most basic human needs/pleasure – difficulty is swallowing can cause social/emotional isolation May or may not be inherent in aging, but common in the elderly Incidence 15 % in community-dwelling elderly 50-75% in nursing home population Topic

Barium swallow in achalasia: DYSPHAGIA Oropharyngeal dysphagia—Patients complain of foods getting “stuck,” inability to initiate a swallow, impaired ability to transfer food from mouth to esophagus, nasal regurgitation, coughing Esophageal dysphagia—Patients usually point to the sternum when asked to localize the site Dysphagia in a patient with dyspepsia requires immediate evaluation and therapy Dysphagia implies either the inability to initiate a swallow or a sensation that solids or liquids do not pass easily from the mouth into the stomach; it is a common problem among older adults. Cerebrovascular accidents, Parkinson’s disease and other neuromuscular disorders, Zenker’s diverticulum, oropharyngeal tumors, and prominent cervical osteophytes are the most common causes of oropharyngeal dysphagia in elderly persons. Dysphagia for both solids and liquids from the onset usually implies a motility disorder of the esophagus. In contrast, dysphagia for solids which progresses later to involve liquids suggests mechanical obstruction. Progressive dysphagia results from either cancer or peptic stricture, whereas intermittent dysphagia is most often related to a lower esophageal ring or esophageal dysmotility, such as achalasia or diffuse esophageal spasm. Slurred speech may indicate weakness or incoordination of muscles involved in articulation and swallowing. Dysarthria and nasal regurgitation of food suggest weakness of the soft palate or pharyngeal constrictors. Food regurgitation, halitosis, a sensation of fullness in the neck, or a history of pneumonia accompanying dysphagia may be the result of a pharyngoesophageal (or Zenker’s) diverticulum, which may be associated with a poorly relaxing or hypertensive upper esophageal sphincter. Painful swallowing (odynophagia) typically results from infection or malignancy. Barium swallow in achalasia: Bird beak sign Topic

Dysphagia Risk Factors in the elderly Stroke Silent cerebral infarction fivefold greater risk Neurodegenerative Diseases Alzheimer's, ALS, Parkinson's, MS, Myopathies Iatrogenic conditions Medication side effects/xerostomia Post surgical Irradiation of head and neck Cognitive impairment DM/Thyroid/osteophytes Topic

Dysphagia Risk Factors in the elderly Medications and dysphagia Xerostomia Anticholinergic drugs (tricyclic, antipsychotics, antihistamines, antispasmodics, antiemetic, antihypertensives) Esophageal/Laryngeal peristalsis Antihypertensives, antianginal Delayed neuromuscular responses Delirium causing, extrapyramidal side effects Esophageal injury/inflammation CCB, Nitrates relax lower esophageal sphincture Large pills Topic

Dysphagia Symptoms Most common – choking (bolus entering airway or bolus lodged in the pharynx/ esophagus (ask pt to describe – aspiration symptoms in airway more serious) Pocketing food/pills (food left in mouth after swallowing) Excessive throat phlegm with frequent throat clearing or spitting (wet voice) Delay in triggering swallow Topic

Dysphagia Symptoms Neck pain, chest pain, heartburn Solid food dysphagia (mechanical obstruction) Weight loss without other explanation Increased time to consume meals Drooling Spitting food at meals Rocking tongue back and forth while chewing Topic

Dysphagia Symptoms Prolonged oral preparation Increased time to consume meal Unusual head or neck posturing with swallow Pain with swallow Decreased oral/pharyngeal sensation Slide 14 Topic Slide 14

Dysphagia Symptoms Coughing and choking with swallow Reduced or absent thyroid/laryngeal elevation during swallow Multiple swallows per mouthful Food or liquid leaking from nose Lasting low-grade fever Pneumonia Malnutrition/Dehydration Slide 15 Topic Slide 15

Dysphagia Assessment and Diagnosis Do you have any pain on swallowing? Are there food or liquid consistencies that you have to forgo because they are likely to be difficult to swallow? Have you lost weight because of swallowing difficulties? Topic

Dysphagia Assessment and Diagnosis Speech Language Pathologists (non-instrumental evaluation) History taking Oral motor assessment Voice evaluation Trial swallows Topic

Dysphagia Assessment and Diagnosis Primary care screening for the elderly Example tool – Dysphagia screening form- University of Wisconsin and Madison GRECC One question test – “Do you have difficulty swallowing food?” Correlate symptoms of weight loss, cough and SOB Bedside clinician evaluation 3 oz water swallow test, auscultate over trachea before and after water swallowed; eval for cough, choking change in breath sounds Topic

Dysphagia Assessment and Diagnosis Physical Exam Subtle voice changes (hoarseness, wet, hypernasal, dysarthria) Absent or poor dentition Tongue strength/oral control Palate exam – symmetry, mass Head and neck Gag reflex poor indicator of dysphagia Topic

Dysphagia Assessment and Diagnosis Testing Modified Barium Swallow – can tell which phase is dysfunctional, check for aspiration and compensatory mechanisms Can guide swallow therapy Standard Barium Swallow Testing esophageal structural or functional abnormalities Fiberoptic endoscopy Topic

DYSPHAGIA Endoscopy is the best first test Allows biopsies and therapeutic interventions Lower esophageal rings or extrinsic esophageal compression can be overlooked Radiologic evaluation may identify the level and nature of obstruction If these tests are normal, an esophageal motility study should be performed Anticholinergics, antihistamines, and certain antihypertensive agents can reduce salivary flow. Radiologic evaluation is typically performed with a 13-mm barium tablet or a solid bolus with barium, such as a marshmallow or bread. Naso-pharyngo-laryngoscopy is a bedside procedure that evaluates the oropharynx, vallecula, and piriform sinuses, as well as the larynx and perilaryngeal regions, for pooled secretions or retained food; its utility is uncertain. Peptic stricture Topic

DYSPHAGIA For patients with oropharyngeal dysphagia, videofluoroscopy: Allows detailed analysis of swallowing mechanics Identifies whether aspiration is present Evaluates the effects of different barium consistencies Treatment of dysphagia depends on the underlying cause Esophageal cancer requires resection, chemotherapy, or radiation therapy. For patients who are poor surgical candidates, palliative endoscopic techniques may be considered, such as endoscopic mucosal resection for early esophageal cancer, photodynamic therapy for high-grade dysplasia in Barrett’s esophagus, and stent placement in obstructing esophageal cancer. Following stroke or head or neck surgery, or in degenerative neurologic diseases, swallowing rehabilitation and dietary modifications to facilitate oral intake are required. In some cases, feeding with a cup, straw, or spoon may improve swallowing. Endoscopic dilation is performed in patients with esophageal webs or strictures. Cricopharyngeal myotomy may benefit patients who have inadequate pharyngeal contraction, pharyngoesophageal diverticulum, or lack coordination between the pharynx and the upper esophageal sphincter. Endoscopic incision of the septum between the pharyngoesophageal (Zenker's) diverticulum and the esophagus with a flexible endoscope and needle-knife may also be performed. Botulinum toxin injection to the cricopharyngeus muscle (off-label) is an alternative to surgery for patients with cricopharyngeal achalasia. Topic

Dysphagia Assessment and Diagnosis Consultants Otolaryngologist Gastroenterologist Neurologist Speech therapist Radiologist Topic

Disorders Associated with Dysphagia Neuromuscular – affect the central control over muscles and nerves involved in swallowing (i.e. Parkinsons, CVA, ALS, Myasthenia gravis, MS) Rheumatologic – (i.e. Polymyositis, Dermatomyositis, Inclusion body myositis) Head and neck oncologic – Oropharyngeal cancer Pharyngeal structural – Zenkers Gastrointestinal – tumors, GERD, Schatzki ring (primarily esophageal but cause symptoms radiating to pharynx) Diminished cough Topic

Dysphagia Treatment Goal – optimize safety of swallow, maintain adequate nutrition and hydration, improve oral hygiene Swallow therapy Postural adjustments Food and liquid rate and amounts (time to eat, small amounts, concentrate, alternate food and liquid, stronger side of mouth, sauces) Adaptive Equipment Diet modification Topic

Dysphagia Treatment Swallow therapy – plan set by Speech Pathologist Oral stimulation Pharyngeal and laryngeal stimulation Position/Posture Direct Swallow exercises Compensatory Strategy Education On-going restorative interventions Slide 26 Topic Slide 26

Dysphagia Treatment Dietary modifications (watch for dehydration) Aggressive oral care Modify eating environment Oral Hygiene Also reduce risk of aspiration Interdisciplinary Speech pathologist, dietician, OT, PT, nurse, oral hygienist, dentist, PCP, Caregivers, SW, family Topic

Dysphagia Treatment ACEI – prevent breakdown of substance P Avoid sedatives, antihistamines, anticholinergics (complete med review) Evaluate Quality of Life SWAL-QOL – dysphagia specific patient-centered QOL instrument (document effectiveness of treatment for both function and quality of life) – monitor longitudinal course of treatment Topic

Dysphagia The non-fixable dysphagia Goal is enhanced quality of life Tube Feeding Not essential in all patients who aspirate No data to suggest TF in pts with advanced dementia prevented aspiration pneumonia, prolonged survival or improved function (aspiration pneumonia is the most common cause of death in PEG tube patients) Short term TF indicated if improvement in swallow likely to improve Pt autonomy, self-respect, dignity and QOL Slide 29 Topic Slide 29

Dysphagia Complications Pneumonia Aspiration –misdirection of oropharyngeal or gastric contents into the airway below the true vocal cords Leading cause of death of residents of nursing homes Dysphagia, sedating meds most important risk factor in long-term care residents for pneumonia Increased disease in the elderly, increased risk of oropharyngeal dysphagia and pneumonia Aggressive oral care lowered risk of pneumonia in nursing home residents Topic

Dysphagia Consequences Social isolation (embarrassment) Physical discomfort Dehydration Malnutrition Overt aspiration Silent Aspiration – a bolus comprising saliva, food, liquid, meds or any foreign material enters the airway below the vocal cords without triggering overt symptoms Pneumonia, death Topic

Dysphagia in Long-Term Care Skilled nursing facilities required to provide nursing services and specialized rehab services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident Survey guidelines mandate that the facility must maintain acceptable parameters of nutritional status, such as body weight and protein levels unless the resident’s clinical condition demonstrates this is not possible, and receives a therapeutic diet when there is a nutritional problem Slide 32 Topic Slide 32

Dysphagia in Long-Term Care Common 50-75% Aspiration leading cause of death in nursing home patients Can stress nursing assistants with difficult feeding patients Place food in non-impaired side of mouth Limit use of straws Adaptive feeding equipment Restrictive diets Failure to comply – (citations, inadequate nutrition and hydration, unsafe feeding) Topic

Dysphagia in Long-Term Care Training nursing assistants Mealtime atmosphere Help residents maintain independence Therapeutic diets How to feed residents Identify a choking victim Importance of adequate hydration and nutrition May help to have basic knowledge of swallowing mechanism, signs of dysphagia Slide 34 Topic Slide 34

Dysphagia Training nursing assistants In-service after have worked with feeding residents Meal Time Matters – IDEAS Institute Interactive Institute http://www.ideasinstitute.org Slide 35 Topic Slide 35

Dysphagia in Long-Term Care Goals for treatment in long-term care Interdisciplinary team ID residents with dysphagia Referral to and evaluation by team Objective measurement of resident progress Communication within team Increase resident independence and safety Carryover of treatment goals in facility and at discharge Slide 36 Topic Slide 36

Dysphagia in Long-Term Care Goals for treatment in long-term care Interdisciplinary team –ID Residents Why is resident being fed by staff? Has the resident been able to self-feed in past? Are there residents who experience excessive coughing during or after meals? Are there residents who have excessive burping or hiccups during meals? Are there residents who frequently vomit after meals? Are there residents who refuse to eat? Slide 37 Topic Slide 37

Dysphagia in Long-Term Care Goals for treatment in long-term care Interdisciplinary team –Questions for staff Residents needing assist to eat Recent decline in ability to feed self Recent significant weight loss or gain Tube feedings Recurrent aspiration pneumonia Adaptive feeding equipment Dysphagia Embarrassment or anxiety at mealtimes Poor dentition Slide 38 Topic Slide 38

Dysphagia in Long-Term Care Goals for treatment in long-term care After evaluation establish: Self-feeding goals Swallowing goals Comfortable environment Discuss dysphagia as part of weight loss committee Slide 39 Topic Slide 39

Dysphagia in Long-Term Care F309 – Each resident must receive and the facility must provide the necessary care and services to attain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care Very encompassing Highest possible functioning and well-being, limited by individual recognized pathology and normal aging process Unavoidable or avoidable decline, lack of improvement Slide 40 Topic Slide 40

Dysphagia in Long-Term Care F325 – Based on comprehensive assessment of resident, the facility must ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident’s clinical condition demonstrates that this is not possible, and receives a therapeutic diet when there is a nutritional problem Address risk factors for malnutrition Care plan Meet resident’s ordinary and special dietary needs Treatable causes Monitor progress Slide 41 Topic Slide 41

Dysphagia in Long-Term Care Survey overall importance Care plan Assessment Document interventions Evaluate results of interventions Physician involvement Nursing assistant education as awareness of plan Family involvement Prognostication (avoidable or unavoidable) Slide 42 Topic Slide 42

Summary Oropharyngeal dysphagia may be life-threatening All team members important Pt/Family important Don’t have to put in a tube feeding QOL Topic

CASE 1 A 89-year-old man has difficulty swallowing solids and liquids. His dysphagia has progressed slowly over 8 months and he has lost 20 pounds. Is long-term care resident for 2 years History of dementia, COPD, CHF, DM Physician documentation states – Elderly pt with weight loss, add med pass supplement, monitor weights Dietary states, continued weight loss, add pudding, consider appetite stimulant Speech therapy involved, Care plan in place for weight loss and dysphagia, diet reduced to pureed with nectar-thick liquids Patient aspirates and sent to hospital for pneumonia Topic

CASE 1 Treated for aspiration pneumonia, returns with order for pureed with honey-thick liquids ST works with pt, care plan in place for weight loss and dysphagia Physician H&P done Pt becomes dehydrated 10 days later and sent to hospital Returns, same plan of care, treatment except Lasix reduced to 20mg day from 40 mg/day Slide 45 Topic Slide 45

CASE 1 Physician H&P done ST continues working with pt Care plan for weight loss, dehydration and dysphagia in place Additional 15 pound weight loss in a month. Pt returns to hospital with Aspiration one week later and dies Family complains about care and complaint survey done Slide 46 Topic Slide 46

CASE 1 What should surveyor expect to be on chart when arrives? What is reasonable to expect that all staff knew about resident’s care? Is anything reasonable to expect from doctor in terms of resident’s care If cited what would you include in IDR? Slide 47 Topic Slide 47