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Dysphagia: address promptly to avoid serious complications.

Eating a good meal or drinking a glass of water, seemingly two of the most basic human activities, cannot always be taken for granted, especially among the elderly who often suffer from swallowing problems or dysphagia.

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A person who has dysphagia may experience pain when trying to swallow. Others may have difficulty swallowing food, liquid, or saliva, and some people may be unable to swallow at all. Because dysphagia makes it difficult to take in proper amounts of fluids and calories to nourish the body, the condition can lead to malnutrition, dehydration, decreased alertness, pneumonia, and even death.

Complex process

Swallowing is a complex process that moves food from the mouth to the stomach. Swallowing involves the use of many nerves and muscles in the lips, tongue, mouth, throat, and esophagus. Swallowing occurs in four stages: (1) oral preparatory stage--the food is chewed and prepared for swallowing, (2) oral stage--the tongue pushes the food or liquid to the back of the mouth, (3) pharyngeal stage--the swallow is triggered and the food or liquid is moved into the pharynx, and (4) esophageal stage--food or liquid enters the esophagus and is carried into the stomach.

Dysphagia has been found to occur in approximately 40% to 50% of all patients in nursing homes and approximately 33% of the patients in rehabilitation centers. This relatively large number of patients with dysphagia reflects the large number of medical problems which can cause abnormalities in the swallow mechanism.

Any condition that damages or weakens the nerves or muscles involved in swallowing can cause a swallowing problem. These could include having a stroke, head and neck tumors, nerve diseases such as Parkinson's disease, and Alzheimer's disease.

People often ask how they know if they or someone they know or care for has a swallowing problem. Some symptoms of dysphagia could include choking on food or liquids, coughing during or after eating, difficulty getting the food down into the throat, a wet or gurgly type of voice during or after eating, drooling, having food remain in the mouth, and extra effort needed to swallow.

Case study

Mr. G, a 90-year-old male attorney, was admitted to a long-term/subacute facility, two months post-surgical intervention of cervical fracture at C1, dislocation of C2, T1-T2 fracture, and trauma to the left eye following a motor vehicle accident. In addition, during his course of medical treatment, a tracheotomy tube was placed, and then later removed prior to discharge. Mr. G remained at a New Jersey medical center for five weeks following which he received rehab at a New York rehabilitation facility for an additional four weeks. It was at the New York rehab facility, where swallowing therapy was initiated, but unsuccessful.

He arrived at the Jewish Home Lifecare in New York for swallowing therapy due to a diagnosis of severe dysphagia and placement of gastric feeding tube. Mr. G says, "My prime concern was my swallowing." A clinical bedside evaluation was conducted which also determined cognitive, linguistic, behavioral, and medical readiness to eat. Pharyngeal physiology cannot be determined at the bedside. Patients with suspected pharyngeal swallow problems need an instrumental assessment of the oropharyngeal swallow. At the bedside, Mr. G was observed wiping saliva with a towel and continuously spitting because he was unable to swallow his own saliva. We initially performed a fiberoptic endoscopic swallow study, which involves passing an endoscope through the nose and down into the pharynx. We determined, as a result of this procedure, that Mr. G was not a candidate for oral intake at that time. There was an extremely delayed, weak, and incomplete swallow, which resulted in an ice chip falling into the airway. Mr. G was seen two times a day with treatment designed to improve swallow efficiency for increased nutrition and to increase swallow safety by eliminating aspiration. Treatment was directed at his specific physiologic and anatomic abnormalities. Therapy included thermal tactile stimulation, which increases sensory awareness in the oral cavity and decreases the delay between oral stage of the swallow and the onset of the trigger of the pharyngeal swallow.

Electromyography, a form of biofeedback, was used to facilitate Mr. G's visualization of the movements of the swallowing muscles. This was used in conjunction with teaching Mr. G compensatory swallowing strategies such as a "Mendolsohn Maneuver," which involved retraining the muscles in the larynx.

Following initial weeks of intervention, we then further assessed the physiologic components of the oropharyngeal swallow with a videofluoroscopic swallow study that enables radiographic visualization of the oral and pharyngeal components of the swallow and determines the course of therapy. Following this assessment, Mr. G was provided with trials of oral intake during therapeutic sessions using the compensatory swallowing strategies. In less than three months of therapeutic intervention, Mr. G is receiving three meals of regular consistency and thin liquids each day.

If the swallowing problem is in the oral and pharyngeal phase of swallowing, the resident may be referred to a speech-language pathologist. If the problem is in the esophageal phase, the resident may be treated medically. It is important to treat dysphagia since it can lead to further health complications, such as poor nutrition and dehydration, loss of appetite and discomfort, less enjoyment of eating, embarrassment or isolation in social situations involving eating, choking on food or liquids, and risk of aspiration, which can lead to lung infections and possibly pneumonia.

Faerella Boczko, MS, CCC-SLP, BRS-S, a board-recognized specialist in swallowing and swallowing disorders, is chief of the department of Speech-Language and Swallowing Disorders at Jewish Home Lifecare, New York. She has served as principal investigator to two research grants: "Creation of a Model Geriatric Swallowing Center" and "Enhancing the Communication Ability of Alzheimer's Patients." Ms. Boczko has authored book chapters and published research articles. She has presented at numerous professional society meetings, including the Gerontologic Society of America, American Geriatric Society, Dysphagia Research Society, and the American Speech Language Hearing Association. She has more than 30 years of experience working with the adult and geriatric population. She can be reached at fboczko@jewishhome.org.

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by Faerella Boczko, MS, CCC-SLP, BRS-S
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Title Annotation:Clinical Care
Author:Boczko, Faerella
Publication:Long-Term Living
Date:Oct 1, 2010
Words:1018
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