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DysphagiaintheOlderAdultSeptember25,2019
AidaWen,MDAssociateProfessor
DepartmentofGeriatricMedicineJohnA.BurnsSchoolofMedicine
ShariGoo-YoshinoMSCCC-SLPInstructor
DepartmentofCommunicationSciencesandDisorders
JohnA.BurnsSchoolofMedicine
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ThispresentationwassupportedinpartbytheGeriatricsWorkforceEnhancementProgram(GWEP)DHS,DHHS,BureauofHealthProfessionsawardedtothePacificIslandsGEC.Thisisalso supportedinpartbygrantNo.90ADPI0011-01-00fromtheU.S.AdministrationforCommunityLiving,DepartmentofHealthandHumanServices,Washington,D.C.20201,awardedtoCatholicCharitiesHawaiifortheAlzheimer’sDiseaseProgramInitiative.Granteesundertakingprojectswithgovernmentsponsorshipareencouragedtoexpressfreelytheirfindingsandconclusions.Therefore,pointsofvieworopinionsdonotnecessarilyrepresentofficialpoliciesfromACL,DHS,DHHS,orBHW.
Sponsoredby
University of HawaiiCenter on Aging
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Thespeakershavenorelevantfinancialrelationshipstodisclose.
LearningObjectives
ThecommonsymptomsandcausesofdysphagiainolderadultsIdentify
TheindicationsandfunctionaloutcomesofswallowevaluationsExplain
ThemanagementandtreatmentoptionsfordysphagiaDescribe
IssuesregardingtubefeedingforadultswithdementiaDiscuss
Person-centeredcaretooptimizesafe,effective,andefficientswallowingforpleasurableparticipationinmealtime
Provide
Dysphagia(difficultyinswallowing)
• Highlyprevalentamongolderadultslivinginassistedornursingfacilities(40-60%),relatedtodementia(13to57%),stroke(37to78%),andParkinson’sdisease(35%-82%)
• Mealtimedifficulties:disinterest,selectiveeating,efforttoswallow,earlysatiety,andfatigue
• Consequences:malnutritionanddehydration,aspirationpneumonia,chroniclungdisease,choking,andmortality
• Compromisedqualityoflife– lifestylechanges• Usuallyasymptomofothermedicalconditions
Alagiakrishnan,Bhanji,&Kurian,2013;Aslam,M.,&Vaezi,M.F.,2013;Kalf,deSwart,Bloem,&Munneke,2011;Martinoetal.,2005.
OralandPharyngealDysphagia
CAUSES• Stroke,Dementia,Parkinson’s,otherneurologicalconditions
• Medications• Drymouth(anticholinergicdrugs)• Sedatingdrugs(psychotropicmeds,opioids,sleepingpills,etc.)
• Anorexia(donepezil,macrolideabx,etc.)
• Weaknessanddeconditioning• Headandneckcancers
EsophagealDysphagia
• ESOPHAGUS- troublewithfoodmovingpastthesphincters(upperandlower),troublewithperistalsisthroughtheesophagus,reflux.
• Symptoms:• Painwithswallowing(odynophagia)• Unabletoswallow• Feelingthatfoodisstuckinyourthroator
chestbehindyourbreastbone• Hoarse• Regurgitation(foodbackingup)• Frequentheartburnorfeelingacidbackingup
intoyourthroat• Havingtocutfoodintosmallerpiecesor
avoidingfoodbecauseoftroubleswallowing• Frequentrespiratoryproblems(asthma),or
infection
EsophagealDysphagia
CAUSES• Achalasia
• esophagealmotilitydisorder• Esophagealspasms
• triggerfoods,stress,GERD• Mechanicalproblems
• cancer,radiationtreatment,stricture,
• Barrett’sesophagus(preventedbyearlytreatmentofGERD)
• Weaknessanddeconditioning
OverviewofNormalSwallowing
1st:Oral:Liquidandfoodenterthemouthandaremanipulated,chewed,mixedwithsaliva,andtransferredintothepharynx
2ndPharyngeal:Foodandliquidentersandpassesthroughthepharynx
3rdEsophageal:Passageofliquidandfoodthroughtheesophagusandloweresophagealsphincter
OverviewofNormalSwallowing
1st:Oral:Liquidandfoodenterthemouthandaremanipulated,chewed,mixedwithsaliva,andtransferredintothepharynx
2ndPharyngeal:Foodandliquidentersandpassesthroughthepharynx-Aspiration
3dEsophageal:Passageofliquidandfoodthroughtheesophagusandloweresophagealsphincter
OverviewofNormalSwallowing
1st:Oral:Liquidandfoodenterthemouthandaremanipulated,chewed,mixedwithsaliva,andtransferredintothepharynx
2ndPharyngeal:Foodandliquidentersandpassesthroughthepharynx-Aspiration
3rdEsophageal:Passageofliquidandfoodthroughtheesophagusandloweresophagealsphincter
GeneralSymptomsAndSignsOfDysphagiaCoughingChoking
HoarsevoiceGlobussensation
InvoluntaryweightlossanddifficultygainingweightRecurringpneumonia,respiratoryinfection,orfever
SymptomsandSignsofOropharyngealDysphagiaCoughingduringorshortlyaftereatinganddrinkingComplaintsoffood"sticking"inthethroatHoldingfoodorliquidinmouthProlongedchewingSpilloffoodorliquidfromthelipsornasalcavityFoodorliquidremaininginthemouthDroolingDysarthriaWetvoiceduringorafterswallow
SymptomsandSignsofEsophageal DysphagiaChroniccoughingComplaintsoffood“sticking”inthethroatorchestPressureorburninginchestProgressivedifficultyinswallowingsolidstoliquidsVomiting
AdaptedfromBell,C.&Goo-Yoshino,S.(2018)
NonInstrumental- ClinicalSwallowEvaluation
• Reviewofhistoryandperceptionoftheproblem
• Examinationoforalstructuresandfunction
• Assessmentofswallowing
• Trialsofcompensatoryorrehabilitativetechniques
NonInstrumentalorClinicalSwallowEvaluationOutcomes
• Diagnosisoforalprepororalphasedysphagia• Optimumfoodandliquidtexturesbymouth/ConsiderNPO• Strategiestofacilitatesafeandefficientswallowing• Counseling,education,andtraining• Personalizedtreatmentplan• Referralforotherservicese.g.,dietician,gastroenterologist• DoesNOTdeterminepresenceorabsenceofaspirationorpharyngealphasedysphagia->Indicationsforinstrumentalswallowevaluation
IndicationsforInstrumentalSwallowEvaluation
• Symptomsorsignsofpharyngealphasedysphagia
• Uncertaintyinsafetyandefficiencyofswallowingfornutrition,pulmonaryhealth,andairwaysafety(aspiration,choking)
• Historyofmedicalconditionsassociatedwithhighriskfordysphagiaandaspiration
• Previouslyidentifieddysphagiawithasuspectedchangeinswallowfunctionthatmaychangerecommendations
Informationguidesmanagementandtreatment
InstrumentalSwallowEvaluations- VideofluoroscopicSwallowStudy/ModifiedBariumSwallowStudy
• Providesdirectvisualizationoforal,pharyngeal,andupperesophagealstructuresandfunction
• Assessswallowoffoodandliquidwithbarium
• Observeflowandclearanceofmaterialsfrommouthtoentranceintoesophagus
• Determineinfluenceofdietchangesandcompensatorystrategiesonswallowefficiencyandsafety
InstrumentalSwallowEvaluations- Fiberoptic EndoscopicEvaluationofSwallow
• Providesdirectvisualizationofpharyngealstructuresandfunction
• Assessswallowoffoodandliquid
• Observeflowandclearanceofmaterialsthroughpharynx
• Determineinfluenceofdietchangesandcompensatorystrategiesonswallowefficiencyandsafety
InstrumentalSwallowEvaluationOutcomes
• Diagnosisoforalandpharyngeal phasedysphagia• Detectionofaspiration• Optimumfoodandliquidtexturesbymouth/ConsiderNPO• Strategiestofacilitatesafeandefficientswallowing• Counseling,education,andtraining(withbiofeedback)• Referralforotherservicese.g.,dietician,gastroenterologist• Personalizedtreatmentplan
ManagementandTreatmentOptions– Person-CenteredCare
RestorativeExercises
Oralmotorswallowingexercises
Expiratorymusclestrengthtraining
Feeding/BehavioralStrategies
OptimalalertnessHeadandbodypositioning
Rateoffeeding- Bolussizeandplacement
Swallowmaneuvers
DietaryConsiderations
Appropriatetexture
Preferredfoodsanddrinks
Attractive- Propertemperature
Smaller,morefrequentmeals
Accessiblesnacks
EnvironmentalModifications
Maintainmealroutines
Seatingtoimproveposture
Calmenvironment- Reducedistractions
Supportself-feeding– Consistentprompts
Pleasantexchanges– Optimizecommunication
CounselingEducationTraining
GastricFeedingTubes
RISKSBENEFITS
• Prolonglife,gainweight• Preventaspiration• HealingofPressuresores• Improvefunctionalstatus
• DecreasedQOL(isolation,decreasedhumancontact,deniedgratificationoffood,restraints)
• Nausea,Vomiting,Diarrhea• Complications:Bleeding,Infection,
Skinirritation,Leaking,Blocked,Fallingout,Pulledout
• IncreasedriskforPressureUlcers• Morelikelytogetaspiration
pneumonia• Morelikelytogetfluidoverload
DOESNOT HELPINEND-STAGEDISEASE(Alzheimer’s,Parkinson’s,Terminalcancer,CVAwithoutimprovement,PVS,poorprognosis)
• Easier,lesstime,ensurecaloricintake
• OnlybenefitsthoseNOTinthelaststageofillness,suchas:
• acutestroke,• headtrauma• criticallyillwithgood
chanceofrecovery,• HeadandneckCA• ALS• youngpatients,• morefunctionalpatients.
NOBENEFIT
Decisionmakingprocess
• Considerboththemedicalfacts,andpersonalsubjectiveelements
• Atime-limitedtrialisalwaysanoption.• Thedecisiontoeitherinstituteartificialfeedingsortowithholdthemrarelyneedstobemadeemergently.
SlideCredit:ChristinaBell,MD
“Ican’tjustletherstarve!”
• Iftheexplanation,theclinician’sstory,ofwhyitisbelievedthatANHwouldnotbebeneficialisunderstoodsimplyasaninvalidationofthefamily’sstories,itwill,quitereasonably,berejected.
• Validateintent• Trytoreframe• Suggestalternativeinterpretationsintermsoftheirstoryline.
SlideCredit:ChristinaBell,MD
Reframing examples…
“He is dying because he is not able to eat or drink.”
Empathic validation of concern
“I understand how worrisome that must be.”
“Of course, it must seem that getting food and water into him would be important.”
Validation that their explanation, if true, would suggest the appropriateness of ANH.
“We have noticed that he only wants small amounts of food and water.”
Drawing attention to information available to suggest an alternative explanation.
“People with this illness who are dying tend not to be hungry or thirsty.”
Sharing alternative explanation that validates linkage between nutrition and dying, but in a different way, thereby reframing the issue.SlideCredit:ChristinaBell,MD
While it may seem like starvation, what
is going on is somewhat different…
Suggest possible alternative interpretation.
It would be great if tube feeding worked that way. However, in other patients with this illness we have found that tube feeding does not make
people live longer or feel better.
Share more info that suggests that ANH will not accomplish their goals, which are reasonable in and of themselves.
We can’t let him starve to death, which can be prevented
by artificial feeding.
You are right, if he were starving or thirsty and we could prolong his life through such
feeding, that would make
sense.
Validation of internal consistency of their story.
SlideCredit:ChristinaBell,MD
He may not be able to eat or drink
much, but is there some special food
he really liked?
Involve family (facilitating nurturing) concretely in a new way – feeding for pleasure vs. calories.
At this stage dry mouth is a big
problem. You could really help us care
for him by giving…
Identify how family can be of help in paying special attention, thereby forming an alliance
“So we’re just going to do nothing.”
Not at all! This is a time to pay special
attention…
Acknowledge “need to nurture” and reframe current situation in terms of this.
SlideCredit:ChristinaBell,MD
Alternatives&
Suggestions
Treatconditionsthatcausepoorappetite:constipation,depression,infection
Stopmedicinesthatmakeeatingproblemsworse
Antipsychotics/Antianxiety
Sleepingpills
BladderControlmedsAlendronate
Donepezil
DentalCare
CarefulHandfeeding,favoritefoodsforQOLfeeding
Hospicereferral
Otherwaystoshowlove(massage,read,music)
FeedingTubes
CaregiverVideo
ReferencesAlagiakrishnan,K.,Bhanji,R.A.,&Kurian,M.(2013).Evaluationandmanagementoforopharyngealdysphagiaindifferenttypesofdementia:Asystematicreview. ArchivesofGerontologyandGeriatrics, 56(1), 1–9.
AmericanSpeechLanguageHearingAssociationAdultDysphagiahttps://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942550§ion=Assessment
AmericanSpeechLanguageHearingAssociationDementiahttps://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935289§ion=Treatment
Aslam,M.,&Vaezi,M.F.(2013).Dysphagiaintheelderly. Gastroenterology&Hepatology, 9(12),784–795.
Baijens,L.W.,Clave,P.,Cras,P.etal(2016).Europeansocietyforswallowingdisorders—EuropeanUniongeriatricmedicinesocietywhitepaper:Oropharyngealdysphagiaasageriatricsyndrome.Clin Interv Aging,11,1403–1428.
Bath,P.M.,Lee,H.S.,&Everton,L.F.(2018).Swallowingtherapyfordysphagiainacuteandsubacutestroke.CochraneDataBaseofSystematicReviews,10.
Bell,C.,&Goo-Yoshino,S.(2018).Chapter10:NutritionalIssuesandSwallowingintheGeriatricPopulation.InCifu,D.X.,Lew,H.,&Oh-Park,M.(Eds.)GeriatricRehabilitation.St.Louis,MO:Elsevier.
Goyal&ShakerGIMotilityOn-Linehttp://www.nature.com/gimo/contents/synopsis.html
Kalf,J.G.,deSwart,B.J.M.,Bloem B.R.,&Munneke,M.(2011).PrevalenceoforopharyngealdysphagiainParkinson'sdisease:Ameta-analysis. ParkinsonismRelatedDisorders,18(4), 311–315.
Martino,R.,Foley,N.,Bhogal,S.,Diamant,N.,Speechley,M.,&Teasell,R.(2005).Dysphagiaafterstroke:Incidence,diagnosis,andpulmonarycomplications. Stroke, 36(12), 2756–2763.
vanHooren,M.R.,Baijens,L.W.,Voskuilen,S.,Oosterloo,M.,&Kremer,B.(2014).TreatmenteffectsfordysphagiainParkinson’sdisease:Asystematicreview.ParkinsonismRelat Disord,20(8),800–807.
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