Swallowing Problems in Long Term Care...Swallowing Problems in Long Term Care 7th Care By Design Long Term Care Conference IL Epstein, MD, FRCPC Assistant Professor Department of Medicine,

Swallowing Problems in

Long Term Care

7th Care By Design Long Term Care Conference

IL Epstein, MD, FRCPC

Assistant Professor

Department of Medicine, Dalhousie University

Friday Nov 24, 2017

Disclosures

2017 Ad Board Attendee:

Takeda

Abbvie

No conflicts with any products discussed in

this presentation

Thanks

Dr. Melissa Andrew

Dr. Alison Rodger

Dr. Erin Awalt

Objectives

1. Distinguish between common causes of

swallowing problems in LTC

2. Develop a practical approach for

assessment and interventions in dysphagia in

the elderly

3. Evaluate the use of G tubes in LTC

1. DISTINGUISH BETWEEN

COMMON CAUSES OF

SWALLOWING PROBLEMS IN

LTC

Swallowing

Complex voluntary & involuntary process

25 muscles, 5 cranial nerves

People swallow at least 600 times daily

Consequences of dysfunction include:

Malnutrition, dehydration

Airway obstruction, aspiration,

pneumonia/pneumonitis

Reduced rehab potential & QOL, social isolation

Oral phase: voluntary; chewing, bolus delivered

by tongue to posterior pharynx

Pharyngeal phase: involuntary; constrictor

muscles contract, bolus propelled towards UES;

soft palate closes nasopharynx & epiglottis

protects trachea

Esophageal phase: involuntary; UES relaxes,

peristalsis propels bolus down esophagus

dysphagiaonline.com, http://www.med.nyu.edu/voicecenter/patient/speech/howswallow.html

Dysphagia

Subjective sensation of difficulty or

abnormality of swallowing

Oropharyngeal:

Difficulty initiating a swallow

Nasopharyngeal regurgitation, aspiration

Sensation of residual food remaining in pharynx

Esophageal:

Difficulty swallowing seconds after initiating

Sensation of food getting stuck

https://www.uptodate.com/contents/approach-to-the-evaluation-of-dysphagia-in-adults?source=see_link

Oral: jaw weakness/dysfunction, decreased saliva →

poor bolus formation, spillage into trachea, poor setup of

pharyngeal phase

Pharyngeal: delayed swallowing onset → poor

initiation of this phase; reduced throat sensation

→ tracheal spillage; weak/uncoordinated throat

muscles → aspiration

Esophageal: Zenker’s diverticulum, stricture,

regurgitation, cancer

http://www.med.nyu.edu/voicecenter/patient/speech/howswallow.html

Dysphagia: 3 types

Dysphagia: differential

diagnosis

In older adults

dysphagia should not

be attributed to

normal aging

aging alone causes

mild esophageal

motility abnormalities,

rarely symptomatic

Differential dx esophageal

dysphagia: symptom-based

Solids, gradually progressive:

Esophageal stricture (GERD, radiation, post-

surgical)

Solids, rapidly progressive:

Cancer of esophagus or gastric cardia

Progresses to include liquids

Anorexia, anemia, weight loss




Solids, intermittent:

Eosinophilic esophagitis, esophageal web/ring,

vascular anomaly (double aortic arch..)

Liquids +/- solids:

Achalasia

Hypertensive/spastic esophagus (DES,

hypercontractile esophagus, scleroderma)

Absent / ineffective esophageal motility

(scleroderma, Sjogren’s, mixed CT disorder)

Functional dysphagia




Dysphagia + odynophagia:

Infectious (HSV, CMV, candida)

Medication-induced:

Swallowing pill without water, *bedtime

Tetracyclines, potassium supplements, NSAIDs,

alendronate, quinidine1


1. Aslam et al. Gastroenterology & Hepatology 2013;9(12):784.

Candida Esophagitis Takeshi Kondo, M.D., and Kazuhiko Terada, M.D. N Engl J Med 2017; 376:1574April 20,

2017DOI: 10.1056/NEJMicm1614893


Medications causing dysphagia

Chemotherapy immunosuppression, long-

term antibiotics

Via strictures, opportunistic esophageal infections

Pill esophagitis as mentioned

Sedating medications

Elderly especially at risk

2. DEVELOP A PRACTICAL

APPROACH FOR

ASSESSMENT AND

INTERVENTIONS IN

DYSPHAGIA IN THE ELDERLY

Special considerations:

Older, frail, end-of-life

Liquid & solid dysphagia is frequent in the

general debility near end-of-life

Especially prominent in neurologic disorders

Stroke (45% initially), ALS, PD, MS, dementia

Major social importance of food

Inability to eat is socially isolating

Families associate nurturing & well-being with food

Caregivers with good intentions may shift focus from

patient’s experience to the importance of food

https://www.uptodate.com/contents/swallowing-disorders-and-aspiration-in-palliative-care-definition-consequences-pathophysiology-and-

etiology?source=search_result&search=dysphagia%20neurologic&selectedTitle=3~150

Bedside swallowing assessment

Assess LOC, posture, ability to cooperate, gross

oromotor function, gag (poor correlation),

voluntary cough

If it seems safe:

Sips of water (start 1 tsp), monitor for cough, resp

distress, wet voice, laryngeal movement

If ok:

Progress to larger volumes, then yogurt, then food

Moderate sensitivity/specificity

May miss silent aspiration but significance of this is

uncertain1

1. Ramsey et al. Early Assessments of Dysphagia and Aspiration Risk in Acute Stroke Patients. Stroke 2003

Trapl et al Dysphagia Bedside Screening for Acute-Stroke Patients:

The Gugging Swallowing Screen Stroke 2007; 38(11), pp 2948-2952

Invasive swallowing assessment

Videofluoroscopic swallowing study

VFSS or MBS

Foods & fluids prepped with radio-opaque contrast

Imaging of bolus flow from mouth to esophagus

Can assess effects of

positioning,

compensatory

maneuvers, bolus size,

sensory enhancement

techniques

VFSS: Problems

Must be able to maintain upright posture

Radiation exposure - repeated study

inappropriate; risk of aspiration

Unrealistic conditions

Test-retest variability, complex interpretation

Further investigation must align with patient’s

goals & preferences

Invasive Swallowing Assessment

Fiberoptic Endoscopic Evaluation of

Swallowing

FEES

Done via nasoendoscope

Provides direct view of the larynx and pharynx

Functional evaluation of the oropharyngeal phase

specifically

Invasive Swallowing Assessment

Esophago-Gastro-Duodenoscopy or

“Gastroscopy”

Essential in esophageal dysphagia

May be therapeutic and provide tissue diagnosis

Study of choice if odynophagia is present

May be complemented by barium swallow especially if

prior head/neck surgery, or suspected radiation /

caustic injury or motility disorder

Aslam et al. Gastroenterology & Hepatology 2013;9(12):784.

Interventions

Goal is to maintain safe & effective oral

feeding for as long as possible

Postural:

Chin tuck, head rotation

Thickened liquids: patients dislike them

Assoc with more dehydration, UTI, & fevers1

Slows flow, less likely to misdirect into airway in

oral/pharyngeal dysfunction

One approach – water between meals, thickened

liquids with meals2

1. Robbins et al. Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a RCT. Ann Intern Med 2008;148:509-518

2. Karagiannis et al. Effects of oral intake of water in patients with oropharyngeal dysphagia. BMC geriatr 2011;11:9.

Alternatives to tube feeds in

dementia

Position: reduce time supine

Finger foods & preferred

foods

Strong flavours, real

temperatures (not tepid)

gravy, juices, cream…

Reminders to swallow

multiple times/bolus

Gentle coughs after each

swallow

Small bolus size (<1 tsp

Liquid supplements

Brushing, vibration, icing cheeks

and neck

Help with feeding

r/o other illnesses especially

depression

Place food well into mouth

Optimize the environment:

reduce noise, distractions

Finucane et al JAMA review, 1999

3. EVALUATE THE USE OF G

TUBES IN LTC

G Tubes: Common Indications

Neurological diseases and

psychomotor retardation

Cerebrovascular disease

Motor neuron disease

(amyotrophic lateral

sclerosis)

Multiple sclerosis

Parkinson’s disease

Cerebral palsy

Dementia

Cerebral tumor

Psychomotor retardation

Impaired LOC

Head injury

Prolonged coma

Cancer

HEENT

Esophageal

Palliative gastric venting for

abdominal malignancies

Gastroparesis

Interventions: Tube feeds in

elderly patients

Prevention of aspiration with tube feeding is

unproven

Tubes may increase reflux

6-58% risk of aspiration with tube feeding in

12 studies of mixed dysphagia, mean age 70

Risk factors: history of pneumonia, esophagitis,

advanced age, stroke

Patel & Thomas J Clin Gastroenterology 1990

Interventions: Tube feeds in

advanced dementia

US survey of 186,835 NH patients with

advanced cognitive impairment

34% tube fed

No RCTs, no evidence of survival or

nutritional benefit

Conclusions: “Insufficient evidence to

suggest that enteral tube feeding is beneficial

in people with advanced dementia”

Cochrane systematic review 2009; Goldberg et al. Clinical interventions in aging Oct 2014.

Interventions: Perceived benefits

of PEG feeding in dementia

Preventing weight loss /

malnutrition

Healing pressure ulcers

Reducing aspiration

pneumonia

Preventing suffering from

hunger or thirst

Palecek et al. J Am Geriatr Soc March 2011.

Evidence does not suggest

PEG feeding confers

benefit in these ways

Terminally ill patients may

not suffer from hunger or

thirst, and when present,

such symptoms may be

alleviated with minimal oral

intake

Disadvantages of tube feeds

NG tubes:

Nasal wing

Chronic sinusitis

Worsening of GERD

Aspiration pneumonia not prevented

PEG tubes:

Aspiration & mortality not prevented

No survival benefit in nursing home residents

High rates of complications (up to 10.3%)*

The role of endoscopy in enteral feeding. Gastrointest Endosc 2011:74:7-12 Reviewed and reapproved May 2016 / DOI:

http://dx.doi.org/10.1016/j.gie.2010.10.021

Complications

Minor:

Wound infection

Tube leakage to abdominal

cavity (peritonitis)

Stoma leakage

Inadvertent PEG removal

Tube blockage

Pneumoperitoneum

Gastric outlet obstruction

Peritonitis

Major:

Aspiration pneumonia

Hemorrhage

Buried bumper syndrome

Perforation of bowel

Necrotizing fasciitis

Metastatic seeding

Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: Indications, technique,

complications and management. World Journal of Gastroenterology : WJG. 2014;20(24):7739-7751. doi:10.3748/wjg.v20.i24.7739.

Cardin F. Special considerations for endoscopists on PEG indications in older patients. ISRN Gastroenterology 2012.

Tube Placement

Tube Blockage

If the feeding tube becomes clogged or

resistance is felt:

A. First, try to flush tube with 10-30 mL of warm

water. Clamp tube and wait 15 minutes.

B. If not successful, mix a 500 mg tablet of

Sodium bicarbonate with the contents of 1

capsule of Cotazym and 5 mL of warm water. The

Cotazym must be activated, by mixing it with

water and the sodium bicarbonate, prior to

insertion. Clamp the tube for 2-3 hours and then

re-try

Tube Changes

When?

Leaking

Cracking

Blocked

Pain

Redness

Infections

Buried bumper

Fell out (< 24 hrs)

How?

Resite

Rescope with pull

through

Foley

Percutaneous balloon

tube

Buttons

Cages, Bumpers,

Balloons

Buttons

Removal

Recommended when tube is no longer

needed or if complications (eg buried

bumper)

Can not be performed with new tube (< 6 - 8

weeks)

Techniques

Endoscopic retrieval of internal bumper

“Cut and Push”

Traction removal

Take Home Points

1. Swallowing problems are common in LTC.

2. Differential diagnosis is similar to all

causes of dysphagia, but likely higher rates of

oropharyngeal due to neurologic conditions,

and medication induced.

3. Consider bedside assessment, address

patient goals, before invasive testing.

4. G Tubes do not help long term outcomes.

Careful selection required.

Questions & Discussion

Documents

Swallowing Problems in Long Term Care...Swallowing Problems in Long Term Care 7th Care By Design Long Term Care Conference IL Epstein, MD, FRCPC Assistant Professor Department of Medicine,