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Speech and Language Therapy
Rebekah TraynorInpatient and Community, Rugby St Cross
Charlotte Courtney and Emily DaviesUHCW Speech and Language Therapy
A few facts about a normal swallow
swallowing is a sequence not a reflex you swallow your saliva 1000 times a day a gag reflex is not an indicator of dysphagia pooling can be normal up to 2 swallows to clear is normal variable no. of chews depending on consistency
Prevalence of Dysphagia and Communication difficulties Stroke – 30-40% of conscious individuals have
significant dysphagia on day of stroke and 15-20% one week post (RCSLT 2005)
20-30% of stroke survivors experience Aphasia. Dementia – bronchophneumonia was leading
cause of death in Alzheimer's disease; 28.6% in this study were found to be aspirating (Horner et al. 1994)
Definitions – 5 D’s
Dysphagia - Difficulty transporting food/liquid/saliva from mouth to stomach.
Dysphonia – alteration in voice due to abnormal pitch, loudness and/or quality resulting from disordered laryngeal, respiratory or vocal tract functioning.
Dysarthria – neuromuscular speech disorder which result from paralysis, weakness or inco-ordination of speech muscles.
Dyspraxia – impaired ability to carry out volitional movements – disorder of motor programming.
Dysphasia – Disorder of language processing – can affect speech, comprehension of speech, reading and writing.
Dysphagia
Difficulty transporting food/liquid/saliva from mouth to stomach.
Oral preparatory stage: recognition, lip seal, chewing, taste.
Oral stage: initiated when tongue manipulates bolus. Bolus propelled to pharynx (1-11/2 sec)
Pharyngeal – soft palate elevates, tongue base retracts and pharynx wall constricts, Larynx prepares for closure, cricopharyngeal sphincter relaxes. (1 sec)
Oesophageal – food passes into oesophagus and carried by peristalsis into the stomach
Symptoms of Oropharyngeal Dysphagia Aspiration: ‘Entry of material into the airway,
below the true vocal folds’ Penetration: entry of material into the larynx at
some level down to but not below the vocal folds Residue: material left behind in the mouth or
pharynx after the swallow Reflux (backflow): material from the
oesophagus into the pharynx or nasal cavity. Silent aspiration – 40% of patients, who
consistently aspirate on Videofluroscopy, show no signs of doing so at bedside examination (Splaingard 1988)
Our assessment options
Videofluroscopy Fiberoptic Endoscopic evaluation of swallow –
FEEs EMG traces Bedside Swallowing Assessment
Fiberoptic Endoscpoic evaluation of swallowing and Videofluoroscopy
Allows a view of the structures and tissues in the pharynx/ larynx and a moving image of the swallow
Can be carried out at the bedside Can be used for multiple trials of
food and drink, even a whole meal.
Gives a moving X-Ray image of the Gives a moving X-Ray image of the swallowswallowAnatomical structures and their Anatomical structures and their movement during the swallow can be movement during the swallow can be seenseenAble to view of all stages of swallow Able to view of all stages of swallow Allows for differentiation of Allows for differentiation of penetration and aspiration of bolus. penetration and aspiration of bolus. Only able to see a limited number of Only able to see a limited number of swallows due to radiation exposure swallows due to radiation exposure timestimes
Bedside assessment
State Alert levels Positioning Compliance Interaction Fatigue Control of secretions Oral Intake -
Malnourishment
Oro-motor assessment Oral dyspraxia Dysarthria – highest predictor
of oral stage dysphagia compared to facial weakness or reduced oral sensation (Logemann 1999)
Facial weakness Dysphonia – absence of
voice can indicate inability to adduct vocal folds, needed for cough reflex, therefore reducing airway protection (Atkinson & McHanwell 2002)
Bedside assessment
Swallowing assessment Anticipatory behaviour Manipulation of bolus Initiation of swallow Suspension of breathing Cough/throat clearing Number of swallows to clear Cervical auscultation Vocal changes Residue Changes in O2 saturation - >2% below baseline
(Smith 2000)
Aspiration can not be predicted from any one sign or symptom
from clinical examination (ECRI 1999)
It’s not just about coughing/choking
Outcome
Level of risk based on above signs of penetration/aspiration.
Mild Moderate Severe Recommendations:
Texture Modification e.g. thickened fluidsSwallowing Therapy/ Manoeuvres /Postural
changesNBM and alternative feeding
Thickened FluidsStage IDescriptionForms a thin coat on the back of a spoonCan be drunk from a cupCan be drunk through a straw
Stage IIDescriptionForms a thick coat on the back of a spoonCan be drunk from a cupCan not be drunk through a straw
Signs of aspiration
Acute – as seen previously Chronic
Weight lossRefusal of foodRecurrent chest infectionsExcess oral secretionsAvoidance of food textures
Complications of dysphagia
Aspiration Pneumonia Malnutrition Dehydration
All the above are preventable
Predictors of Aspiration PneumoniaCurrently completing research at UHCW
Dependence of feeding – best single predictor of pneumonia
Dependence of oral care Number of decayed teeth Tube feeding More than one medical diagnosis Number of medications SmokingLangmore 1998
Please remember ……
Include the patients recommendations on the discharge letter – stage of fluid and type of diet, there is no such thing as stage 2 diet!!
Put thickener on the TTO’s so the patient can get it on prescription once home
The forgotten Role
On discharge from hospital Mr X can walk to the shop but can’t
ask for the loaf of bread he wants.
What do you need to communicate? You need to understand what is being said
You need to have a means of expressing your thoughts
Opportunities
Back to Basics...
Communication
Social/Pragmatic•appropriateness of content•staying on topic•taking turns, listening•inferring intended meaning
Language•understanding•finding words•ordering the sounds, and words in a sentence
Reading and writing
Non-verbal communication•eye contact•gesture•posture•facial expressionSpeech• clarity• rate
Voice•volume•pitch•intonation
Types of communication difficulties
Aphasia (dysphasia) - breakdown of the language centres in the brain and can cause difficulty speaking, writing, reading and using numbers. Expressive aphasia Receptive aphasia Global aphasia
Dysarthria – muscle weakness causing slurred speech
Dyspraxia – difficulty programming the sounds in a word
How do these difficulties affect communication? No speech Reduced understanding of language Producing the wrong word Difficulty finding the word Incorrectly saying sounds in words Jumbled speech Reduced awareness of speech Reduced clarity
What does this mean for the individual? Social isolation Reduced confidence Limited opportunities to talk to people Depression Strong emotional reactions – anger Increased dependency
Capacity
Dysphasia does not imply mental incapacity. People with aphasia can make informed decisions given the right support to understand and express their opinions.
Ten top tips
Use pen and paper Draw diagrams or pictures Say one thing at a time Don’t rush – slow down and be patient Write key words Always recap to check you both have understood Relax – be natural Ask what helps Reduce background noise Don’t pretend to understand
Your team at UHCW
There are 3.4 wte neuro based speech therapists to cover the whole hospital
There is 1.6 wte head and neck SLTs that cover ward 32 and head and neck out patients
We work from 8am - 4pm
Our guidelines state We see stroke patients in 24 hours of referral We see all other Dysphaiga in 48 hours of referral We see communication patients in 5 working days
References
ECRI Report (1999) Diagnosis and Treatment of Swallowing Disorders (Dysphagia) in Acute-Care Stroke Patients. Evidence Report/Technology Assessment No. 8. (Prepared by ECRI Evidence-based Practice Center under Contract No. 290-97-0020.) AHCPR Publication No. 99-E024. Rockville, MD: Agency for Health Care Policy and Research.
Horner , J., Alberts, MJ, Davison, D., cook, GM. Swallowing in Alzheimer’s disease in Alzheimer’s Disease and associated disorders, 1994.
Langmore, S., Terpenning, M., Schork, A., Chen, Y., Murray, J., Lopatin, D., Loesche, W. (1998) Predictors of aspiration pneumonia: How important is Dysphagia? Dysphagia, 13, 69-81
RCSLT (2005). Clinical Guidelines. Bichester. Speechmark