Speech and Language Therapy Rebekah Traynor Inpatient and Community, Rugby St Cross Charlotte Courtney and Emily Davies UHCW 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.
Anatomy of the Swallow Soft palate Hard palate Lips Tongue Teeth Epiglottis Trachea Oesophagus
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 • Gives a moving X-Ray image of the swallow • Anatomical structures and their movement during the swallow can be seen • Able to view of all stages of swallow Allows for differentiation of penetration and aspiration of bolus. • Only able to see a limited number of swallows due to radiation exposure times • 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.
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
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 fluids • Swallowing Therapy/ Manoeuvres /Postural changes • NBM and alternative feeding
Thickened Fluids Stage I Description Forms a thin coat on the back of a spoon Can be drunk from a cup Can be drunk through a straw Stage II Description Forms a thick coat on the back of a spoon Can be drunk from a cup Can not be drunk through a straw
Diet • Puree diet (Texture C) • Soft Moist Diet (texture E) • Normal diet • Can be with or without bread
Signs of aspiration • Acute – as seen previously • Chronic • Weight loss • Refusal of food • Recurrent chest infections • Excess oral secretions • Avoidance 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 • Smoking Langmore 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
Social/Pragmatic • appropriateness of content • staying on topic • taking turns, listening • inferring intended meaning • Non-verbal communication • eye contact • gesture • posture • facial expression • Speech • clarity • rate Reading and writing • Language • understanding • finding words • ordering the sounds, and words in a sentence • Voice • volume • pitch • intonation Back to Basics... Communication
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
If you’ve met one person with aphasia…… You have met one person with Aphasia
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