Kevin Grunden , MS, CCC-SLP Lindsey R. Neal, MD, CMD

1. The #thickenedliquidchallenge and How to Best Work with Your Speech Therapist to Optimize Quality of Life and Quality of Care Kevin Grunden, MS, CCC-SLP Lindsey R. Neal, MD, CMD

2. Speaker Disclosures Mr. Grundenhas disclosed that he has no relevant financial relationship(s). Dr. Neal has disclosed that she has no relevant financial relationship(s).

3. Learning Objectives By the end of the session, participants will: • Experience what our patients experience when we write orders for downgraded diets - #thickenedliquidchallenge. • Understand the swallowing mechanism and differences between imaging options. • Balance quality of life and rights of patients with potential aspiration. • Understand state and federal regulations in regards to swallowing and resident rights

6. #thickenedliquidchallenge

7. #thickenedliquidchallenge • Social media “challenge” • Response to #ALSicebucketchallenge - the viral social media movement for ALS awareness • Started by the Geripal blog (www.geripal.com) • “Putting ourselves in the shoes of our patients who are prescribed thickened liquids”

8. #thickenedliquidchallenge • Rules: • 12 hour challenge (All fluids for 12 hours are honey thick) • Mini challenge (8oz honey thick liquid) • Video yourself and accept the challenge • If you fail- donate $20 to geriatrics or palliative charity of your choice • Nominate others • Post your video on social media with the hashtag #thickenedliquidchallenge

11. #thickenedliquidchallenge • https://www.youtube.com/watch?v=MkZLHMGdT6Y

12. #thickenedliquidchallenge • LET’S TAKE THE CHALLENGE TOGETHER TODAY!!!! • Pick one or 2 liquids of choice • 2 packets of thickener to make honey thick • DRINK

13. #thickenedliquidchallenge • Why is this challenge important? • 8% of our patients in skilled nursing facilities are on thickened liquids!!!!! • That’s 1 in 12 patients • Of these, 30% honey thick

14. Dysphagia is common • Average adult has an experience of “food going the wrong way” ~ 1-2x year • Common in elderly • 9% age 65-74 • 19% age 75-80 • 33% > 80 • EVEN more common in SNF Population (up to 40-80%)

15. Why do we prescribe thickened liquids? • To decrease the chances of aspiration • Life threatening • Any SINGLE episode can lead to aspiration pna

16. Where does the order for thickened liquids come from? • Comes from hospital on them • Speech therapist wrote the order after eval • Choking event - nurse wrote the order • Coughing with meals – CNA reports to nurse • Nursing home culture of fear • Who knows???!!! • Family issues

17. Thickened liquids • People HATE IT. • WHY DO WE DO IT? • There’s got to be tons of evidence to back up years and years of forcing our patients to thicken their liquids, right?

18. Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial Ann Intern Med. 2008 May 6;148(9):715. • RCT with 515 hospital/NH patients with dementia/park dz who aspirated thin liquids on MBSE • Randomized to chin-down swallow, nectar thick liq or honey thick liq • Main outcome: incidence of pneumonia • No diff in rates of pna between groups • Nectar thick lower incidence of pna than honey thick * • Combined outcome of at least 1 dehydration, UTI or fever more common in thick liquids groups • didn’t include the patients who had improved swallow with chin down or thickened liquids during the initial MBSE (those people could have had improvement- but maybe not?)

19. Leads to complicated ethical dilemmas

20. Anatomy of a Swallow • Four phases • Oral Preparation • Oral Transit • Pharyngeal Phase • Esophageal Phase

21. Oral Preparation • Sensory recognition of food approaching the mouth • Food / drink introduced into the oral cavity • Lips / teeth / tongue remove bolus from utensil • Salivation has begun (helps create bolus and break down food) • Labial seal prevents food from spilling out of the oral cavity anteriorly • Nose breathing due to closed mouth

22. Oral Phase with Liquids and Solids • Liquid held in oral cavity prior to oral transfer • Held between tongue and anterior hard palate • Prior to initiating the swallow, material pulled together in a cohesive bolus • If there is no active chewing, soft palate is pulled down and forward sealing off the oral cavity from the pharynx • Oral phase for materials requiring mastication involves rotary lateral movement of the mandible and tongue • Tongue positions material on the teeth • Need sensory feedback for correct positioning of bolus on teeth and to prevent tongue injury during chewing • Buccal tension closes off lateral sulci and prevents food particles from falling between mandible and cheek • During chewing soft palate is not down and premature spillage of food into the pharynx is normal • Airway is open and nasal breathing continues

23. Oral Transit • Oral Transit Phase begins when the tongue begins posterior movement of the bolus • Bolus is moved posteriorly due to the midline of the tongue sequentially squeezing against the hard palate • As food viscosity thickens, greater muscle activity is required to squeeze the bolus back • -If larger volumes of thicker foods are placed in the mouth, tongue subdivides the food after chewing forming only part of it into a bolus at one time, saving the rest on the side of the mouth for later swallows • Oral transit phase typically lasts approximately less than 1 to 1.5 second • As tongue propels bolus back, sensory receptors in the oropharynx and tongue itself are stimulated and pharyngeal swallow is triggered

24. Pharyngeal Swallow Trigger Around the level of the anterior faucial pillars to the valleculae, the pharyngeal swallow is triggered Younger, normal individuals trigger the swallow around the area of the faucial pillars Normal, older individuals may trigger the swallow lower (around middle of base of tongue)

25. Pharyngeal Phase • Complete closure of the velopharyngeal port to prevent material from entering the nasal cavity • Elevation and anterior movement of the hyoid and larynx. • Closure of the Larynx (vocal folds) begins in a bottom - up sequence in order to clear any penetration. -Bottom-up sequence for VF to laryngeal vestibule to clear penetration • True vocal folds contract and respiration ceases-Laryngeal vestibule closes-False folds (Aeryepiglottic folds) contract-Arytenoids move in a downward, forward, and inward direction which narrows the laryngeal opening -At same time, larynx is elevated and pulled forward which thickens the epiglottic base-Laryngeal framework is pulled up, the epiglottis inverts

26. Pharyngeal Phase (cont.) • Epiglottis inverts and comes into contact to further protect the airwayTop to bottom contractions of pharyngeal constrictor muscles • Opening of the cricopharyngeal sphincter to allow material to pass from pharynx to esophagusTension released - Yanked open due to laryngeal elevationTongue base to posterior pharyngeal wall contact delivering bolus to pharynx • Food is directed around the epiglottisRelaxation of cricopharygeus muscle & opening of upper esophageal sphincter region • Pharyngeal phase ends when the esophageal phase begins as the bolus passes through the Upper Esophageal Sphincter (UES) entirely • Breathing is reinitiated - The reported apnea interval duration ranges from 0.5 to 3.5 s. • Average apneic interval is typically between 1.0 to 1.5 s in most healthy adults –

27. Esophageal Phase • Upon entry of the bolus through the cricopharyngeal muscle, the esophageal phase is initiated • Esophageal propulsion begins via muscle contractions occurring initially in response to the arrival of a bolus that stretches the esophageal lumen and then continue as each segment of the esophagus is stretched by the bolus in a feed-forward fashion Here there is no spinal/brainstem mediation. Once the bolus has entered the esophagus, it is carried to the stomach by a mixture of esophageal peristalsis and gravity • Esophageal transit takes approximately 8 to 20 seconds • It normally takes two peristaltic waves to clear the esophagus • The bolus enters the stomach, the swallowing process has finished, and digestion begins.

29. Dysphagia – trouble swallowing • Clinical presentation: • coughing, gurgling during meals • No symptoms (silent aspiration)

30. 2 Categories of Dysphagia Oropharyngeal dysphagia Esophageal dysphagia Achalasia Esophageal Spasm Scleroderma Esophageal Cancer Peptic stricture Rings or webs Vascular compression Med-induced esoph injury • Stroke • Parkinson’s • Dementia • MS • MG • ALS • Zenkers Divertic • Other structural lesions (ENT cancers/surgery)

32. Dysphagia in PA/LTC • Impaired cognitive function • Delirium • Cognitive frailty • Dementia • Other neurologic condition • Physical debility • Muscle weakness • Iatrogenic disabilty • Multi-morbidity

33. Dysphagia • Rarely a primary disorder • Symptom of an underlying condition

34. Medications associated with Dysphagia • Direct esophageal injury • Abx, NSAIDs, bisphosphonates, VitC, K, theophylline, iron • Decreased LES tone / reflux • Theophylline, nitrates, Ca channel blockers, etoh, chocolate • Xerostomia • Anticholinergics, A blockers, ARBs, Antihistamines, atrovent, antiarrythm, Diuretics, opiods, antipsychotics

35. What can go wrong??? • Oral Prep: • Impaired executive function related to dementia • Oral Phase: • Disorders of mastication, bolus formation / pocketing, oral transit • Pharyngeal Phase • Poor pharyngeal constriction = residue • Impaired airway protection • Esophageal Phase • Stricture, Cricopharygeal Dysfunction, Dysmotility

36. Dysphagia • WHEN TO ASSESS • HOW TO ASSESS • WHAT CAN WE DO?

37. Role of the Speech Language Pathologist • Identify risks related to chewing / swallowing / nutrition. • Determine cause of impairment without significantly objective methods (i.e., BSE v MBS) • Determine proper diet consistency, feeding protocols, and liquid consistencies prior to medication administration or meals. • Weekend Dysphagia Protocol • Train staff (usually the weekend staff is not available at time of training)

38. Assessment of Swallow Function • Bedside Swallow Evaluation (BSE) • assessment takes into consideration history regarding the swallowing problem, evaluation of the anatomy and functionality, of sensitivity and the reflexes, of the swallowing apparatus • Cervical Auscultation • Cervical auscultation is the use of a listening device, typically a stethoscope in clinical practice, to assess swallow sounds and by some definitions airway sounds. Judgments are then made on the normality or degree of impairment of the sounds. • Imaging • Modified Barium Swallow Study (MBSS) • FiberopticEndoscopic Evaluation of Swallowing (FEES)

39. Modified Barium Swallow • 1. Videoflouroscopic evaluation of Oral, Pharyngeal and, rudimentarily, Esophageal dysphagia. • 2. Why: • Benefits include objective data regarding aspiration v laryngeal penetration. • Safe diet consistencies • Benefit of postural maneuvers • Ability to clear aspirated material • Conclusive evidence of swallow function

41. MBS Continued • Why Not? • Can the patient tolerate sitting through the procedure • Cognitively, can the patient participate? • How much of a burden is transportation? • Who will accompany them? • Family? SLP? Nursing? At what cost?

42. https://www.youtube.com/v/Ri8bBhw9msQ

43. Fiberoptic Endoscopic Evaluation of Swallowing (FEES) • Pros: • Cost effective • Portability to bedside • No radiation • Uses actual meal tray items • Direct viewing of laryngeal functioning for airway protection • Quick testing and results • Assesses secretions management before risking aspiration of a feeding trial • Better assessment of neurological status (including sensation) • More detailed rendering of the anatomy than other methodologies • Reliable in detecting aspiration • Strong evaluation tool in the establishment of treatment and compensatory strategies

44. Limits of FEES • Cons: • Unable to visualize during pharyngeal constriction / apneic period. Must judge aspiration v. laryngeal penetration based on staining prior to and after swallow.

45. Aspiration or Not???

46. https://www.youtube.com/v/l8eICovpb28

47. How will it change the course of action? • In other words…Why do you want to know the nature of the problem? • Will it change your treatment approach? (diet mod based on info other than overt s/s) • Will it significantly reduce the risk for aspiration? • What impact will the intervention have on Nutrition? Quality of life? • Fact: Food is good • Fact: Eating is a Social activity • Fiction: Permanent diet modification will significantly improve medical condition / safety of swallow function.( i.e., reduce risk for aspiration and aspiration pneumonia) • Do you want closure, reassurance?

48. Limitations of an SLP • Fear of educated guess = possible injury. • Need time to discuss the situation • Help students/new grads learn • So much we don’t know… • Multiple factors effect swallow function including acute and chronic medical conditions, lab work, cognitive function, medications. • Physicians drive the bus • Opportunity for teamwork

49. CULTURE OF FEAR

50. Legal issues • Examples of suits • Failure to provide ordered pureed diet / supervise eating • Resident choked on meatball, staff lacked training for Heimlich maneuver, resident wheeled from dining room before Heimlich and was bagged using BVM before • Delay in treatment of choking resident. Was being fed, began gurgling, then choking. Staff cleaned suction equipment before suctioning patient (while resident was choking). Also falsification of documentation.