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Dysphagia: prevalence, management and the community nurse.

INTRODUCTION

Eating and drinking are an important part of life, both physically and socially. Where swallowing is difficult, people may become isolated, under-nourished and frail.

Dysphagia may be caused by pathology in the mouth, pharynx or oesophagus. The following paragraphs will focus on the mouth and pharynx, and outline the swallowing process, the frequency of swallowing problems, complications and their management.

NEUROLOGY

Swallowing is essentially a reflex involving 55 muscles, five cranial nerves and two cervical nerve roots. The swallowing control centre is situated in the medullary area of the brain stem and receives inputs from the mouth and pharynx regarding the bolus size and consistency, the respiratory centre to coordinated swallowing and breathing and from cortical and subcortical areas of the brain all of which result in the modulation of and duration of different phases of the pharyngeal swallow, but the sequence of events remains consistent (Smithard, 2002; Kendall et al, 2000; Molfenter, 2014).

The pharynx is a common pathway for ingested food/ liquid and inspired air. As they pass through the pharynx, air enters the larynx and food/ liquid passes over/ around the larynx and continues to the oesophagus. When this relationship is disturbed, swallowing problems/ dysphagia occurs (Matsuo, 2008).

DYSPHAGIA

Dysphagia is always abnormal, irrespective of age. The only difference being the timing of the different components is more critical (Lelsie et al, 2005). Dysphagia is a symptom, not a diagnosis, very much like cardiac failure and falls. Once identified the underlying aetiology needs to be sought (Table 1).

EPIDEMIOLOGY OF DYSPHAGIA

Oropharyngeal dysphagia in the general population varies between 2.3% and 16% (Chiocca et al, 2005; Cho et al, 2005; Eslick et al, 2008; Mansson et al, 1991; Watson et al, 2009; Ziolkowski et al, 2013). The data is based on self-reported questionnaires or surveys.

Dysphagia is frequently under recognised and under appreciated. Medical/nursing staff often do not inquire as to whether their patients have difficulty swallowing unless weight loss is evident, yet a proportion of people living in the community, let alone institutions, will have previously unreported swallowing problems. For many this is gastrooesophageal reflux.

Dysphagia is a common problem with increasing age; frequently because of accompanying medical problems. Using the Standardised Swallowing Assessment (Perry and Love, 2001; Yang et al, 2013) describe in a Korean longitudinal study an overall prevalence of dysphagia of 33.7% (95% CI, 29.1-38.4%) for people above 65 years living independently. Barczi and Robbins (2000) found prevalence rates near 15% in community dwelling and more independent individuals, and upward of 40% of people living in institutionalised settings such as assisted living facilities and nursing homes.

This is even more so in those people who are frail. In the presence of frailty, the swallow may be intact on a day-to-day basis, until medication is changed (side effects causing drowsiness, confusion or dry mouth) or illness occurs, then dysphagia will occur. With the multiple possible aetiologies of dysphagia in this age group it is high time that dysphagia was added to the list of Geriatric Syndromes or Giants.

Dysphagia will occur in many disease situations, not just in the presence of neurological disease. Swallowing requires a period of apnoea, and where this is not possible (lung disease, cardiac failure) dysphagia will occur (Table 1).

PRESENTATION AND IDENTIFICATION IN THE COMMUNITY

The presentation of dysphagia will often depend on the context in which it occurs. The most common complaints will be that food/liquid goes down the wrong way, may regurgitate through the nose, may cause coughing or a change of diet. In others where they cannot recognise or communicate their problem, food refusal, regurgitation, and spitting may be the presenting complaint by carers. In those who are frail, swallowing only becomes a problem when another stressor such as infection or prescribed (or non prescribed) medication wipes out their physiological reserve resulting in dysphagia and the risk of aspiration.

Signs of dysphagia will be a changed/ wet voice, recurrent chest infection, hypoxia, a grumbling pyrexia or weight loss. Coughing is frequently a sign of airway penetration (food/ liquid not going below the vocal cords), then the airway is cleared with a cough and aspiration does not occur.

MANAGEMENT

The management of dysphagia is a multidisciplinary problem. First the problem has to be identified by a clinical history and a swallow screen (Hinchey et al, 2005; Donovan et al, 2013) (such as the water based Bedside Swallowing Assessment BSA). Any member of the clinical team can do this. Once the problem has been identified, referral to the local expert should occur, in the United Kingdom this will be the speech and language therapist. The speech and language therapist will then fully assess the patient looking at the anatomy of the swallow as well as the functional aspects (Ramsey et al 2003; SIGN, 2010; Speyer, 2010). Following the clinical assessment, recommendations will be made to ensure that nutrition can be provided safely, and, in some situations, further assessment is required.

Various guidelines suggest that instrumental assessment of the swallow should occur where indicated, different countries have different approaches. In the UK, the speech and language therapist will recommend videofluoroscopy and/ or Flexible Endoscopic Evaluation of Swallowing (FEES), the approach is often dictated by local availability. Other investigations that may be required include manometry and pH monitoring where reflux is considered to be the aetiology of oropharyngeal dysphagia (European Society 2013; Kelly et al, 2007).

The management of swallowing is to encourage a safe swallow and ensure that the patient receives adequate nutrition (Wright et al, 2005) and is able to take their medication. From a nutrition point of view there are two basic approaches, one is to modify the diet (i.e. consistency of food taken (Cichero, 2013) and the other is to modify the swallowing physiology (swallowing manoeuvres) (Ashford et al, 2013).

Where it is not possible to swallow safely or it is not possible to ensure someone's nutritional needs are met, enteral feeding needs to be considered. In the acute phase nasogastric feeding is the route of choice, and where necessary a nasal loop or bridle is used to keep the tube in place (Bevan et al, 2010). Longer term, depending on patient choice and acceptability a gastrostomy may be placed, either endoscopically or radiologically (Gomes et al, 2010). Some, usually younger patients, may prefer to repeatedly pass a nasogastric tube.

There is at the present time a lot of hope and expectation around the management of swallowing disorders, particularly in those due to neurological disease with otherwise no health problems, this is termed presbyphagia.

In the case of brain injury (including stroke), there are opportunities with transcranial stimulation, pharyngeal stimulation and neuromuscular stimulation. Where there is reduced tongue strength, either due to brain injury, post-surgery or sarcopenia, muscle resistance training may be beneficial, not only in strengthening the tongue but also improving the swallow. Where laryngeal elevation is a problem, neuromuscular stimulation or muscle strengthening of the hyoid musculature (Shaker exercise and chin tuck against resistance) offers hope (Shaker et al, 1997; Smithard, 2013; Steele et al, 2012).

LIFESTYLE

Living with dysphagia can prove to be problematic, not only for the person with dysphagia but also family members. Dysphagia can lead to social isolation and embarrassment. Enterostomy feeding may take over one's life as feeding is often done over many hours, usually at night. Nasogastric feeding may affect body image. Enteral tubes are not without their complications.

Even where swallowing problems are not overt, such as in presbyphagia (Lelsie et al, 2005; Reginelli et al, 2008), dietary changes may have taken place subconsciously and people may not wish to attend events that involve eating.

MEDICATION

Medication can pose a particular challenge in people who have an abnormal swallow. The pharmacist is key to assisting the patient and clinical staff to make the right decision. The first question should be, is the medication necessary? Is it making the swallow worse (dry mouth, confusion, reduced alertness). If it is, how can it be administered? Some medications can dissolve (e.g. statins), others may come as liquid/syrup formulations, and some are available as wafers/melts or skin applications.

THE ROLE OF THE COMMUNITY NURSE

It is most likely that district nurses and their teams eg community staff nurses and also practice nurses working with adults with dysphagia. Whatever the context, community nurses have an important role to play in the identification and management of people with dysphagia.

Nurses work in specialty areas, intermediate care teams and as part of the matron teams for long term conditions.

They will need to be aware of the effect that many long term conditions can have on swallowing, and many of these are not neurological (Table 1). Community nurses will need to support families when patients with dementia refuse to eat and drink, which is often part of the terminal phase of dementia.

Dysphagia will be present in many neurodegenerative conditions as the disease progresses, and for many, this will be part of the terminal decline. Being able to recognise this and implementing end of life care is very important (Palecek et al, 2010). This will prevent unnecessary and distressing transfers to hospital.

Community nurses need to be able to spot when people are likely to be having difficulties with swallowing and questions about swallowing should form part of the holistic assessment undertaken in the community.

Screening for swallowing problems can be part of the general assessment. Watch someone eating/drinking. Do they cough or choke? Are they unintentionally losing weight. Is uneaten food left around?

One area that is very neglected is mouth care. Poor oral care (including teeth/ denture care) increases the risk of aspiration pneumonia. Failure to inspect a dental plate may make the treatment of oral thrush pointless, as the mouth will just be re-infected.

Many people are enteral fed in the community, and although they are supported by community nutrition teams, nurses will have occasions to review the position of a nasogastric tube, inspect a PEG tube site or attempt to unblock PEG tubes if trained to do so. Most trusts have guidelines and protocols around blocked tubes.

SUMMARY

Swallowing problems are common and may occur in non neurological conditions. Swallowing problems are often insidious and ignored in older people; dysphagia should be recognized as a geriatric syndrome. It is important to identify this to ensure appropriate intervention and management is put into place. A Community Nurse is ideally placed to do this.

DAVID G SMITHARD MD FRCP Consultant in Elderly and Stroke Medicine Chair of the UK Swallowing Research Group Hon Reader University of Kent Princess Royal University Hospital King's College Hospital Foundation Trust

CORRESPONDENCE: david.smithard@nhs.net

TAKE HOME POINTS

Swallowing problems are common Swallowing problems are under reported and under recognised

Swallowing problems occur in all age groups, but you need to be aware and look for them

Further Information: www.rcslt.org; www.uksrg.org.uk

References

Ashford J, McCAbe D, Wheeler-Hegland K, Frymark T, Mullen R, Musson N, Schooling T, Hammond CS. Evidence based systematic review: Oropharyngeal dysphagia behavioural treatments. Part III--Impact of dysphagia treatments on populations with neurological disorders. JRRD 2009;46:195-204.

Barczi SR, Sullivan PA, Robbins JA. How should dysphagia care of older adults differ? Establishing optimal practice patterns. Semin Speech Lang 2000;21:0347-0364.

Barczi SR, Sullivan PA, Robbins JA. How should dysphagia care of older adults differ? Establishing optimal practice patterns. Semin Speech Lang 2000;21:0347-0364.

Bevan J, Conroy SP, Harwood R, Gladman JRF, Leonardi-Bee J, Sach T, Bowling T, Sunman W, Gaynor C. Does looped nasogastric tube feed improve nutritional delivery for patients with dysphagia after acute stroke? A randomised controlled trial. Age and Ageing 2010;39:624-630.

Chiocca JC, Olmos JA, Salis GB, Soifer LO, Higa R, Marcolongo M, Prevalence, clinical spectrum and atypical symptoms of gastroesophageal reflux in Argentina: a nationwide population based study. Alimentary Pharmacology and Therapeutics 2005;22:331-342.

Cichero JAY. Tickening agents used for dysphagia management: effect of bioavailability of water, medication and feels of satiety. Nutrion J 2013;12:54 http://www. nutritionj.com/content/12/1/54.

Cho YS, Choi MG, Jeong JJ, Chung WC, Lee SI, Kim SW, Han SW, Choi KY, Chung IS Prevalence nad clinical spectrum of gastroesophageal reflux: a population based study in Asan-si, Korea. AJ Gastroenterol 2005;100:747-753.

Donovan NJ, Daniels SK, Edmiaston J, Weinhardt J, Summers D, Mitchell PH. Dysphagia screening: State of the art. Stroke 2013;44:e24-e31.

Donovan NJ, Daniels SK, Edmiaston J, Weinhardt J, Summers D, Mitchell PH. Dysphagia screening: State of the art. Stroke 2013;44:e24-e31.

Eslick GD, Talley NJ. Dysphagia:epidemiology, risk factors and impact of life--a population-based study Alimentary Pharmacology and Therapeutics 2008;27:971-979.

ESSD103. European Society for Swallowing Disorders Position Statement. Dysphagia 2013;28:280-335.

Gomes Jr CAR, Lustosa SAS, Matos D, Andriolo RB, Waisberg DR, Waisberg J. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances (Review). The Cochrane Library 2010;11. http:// www.thecochranelibrary.com.

Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal dysphagia screening protocols prevent pneumonia. Stroke 2005;26:1972-1976.

Kelly AM, Drinan MJ, Lelsie P. Assessing penetration and aspiration: How do videofluoroscopy and fibre optic endoscopic evaluation of swallowing compare? The Laryngoscope 2007;117:1723-1727.

Kendall KA, McKenzie S, Leonard RJ, Goncalves MI, Walker A. Timining of events in normal swallowing: a videofluoroscopic study. Dysphagia 2000;15:74-83.

Lelsie P, Drinnan MJ, Ford GA, Wilson JA. Swallow respiratory patterns and ageing: presbyphagia or dysphagia? J Gerentol Med Sci 2005;60a;3:391-395.

Matsuo K, Hiiemae KM, Gonzalez-Fernandez M, Palmer JB. Respiration during feeding on solid food: alterations in breathing during mastication, pharyngeal bolus aggregation, and swallowing. J Appl Physiol 2008;104:674-681.

Molfenter SM, Leigh C, Steele CM. Event sequence variability in healthy swallowing: building on previous findings. Dysphagia 2014;29:234-242.

Palecek EJ, Teno JM, Casarett DJ, Harrison LC, Rhodes RL, Mitchell SL. Comfort feeding only: a proposal to bring clarity to decision making regarding difficulty with eating for presons with advanced dementia. J Am Ger Soc 2010;580-584.

Perry L, Love C. Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia 2001;16:7-18.

Ramsey DJC, Smithard DG, Kalra L. Early assessments of dysphagia and aspiration risk in acute stroke. Stroke 2003;34:1252-1257.

Reginelli A, Pezzullo MG, Scaglione M, Scialpi M, Brunese L, Grassi R. Gastrointestinal disorders in elderly patients. Radio Clin of NAmerica 2008;46:755-771.

Ruth M, Mansson I, Sandberg N. The prevalence of symptoms suggestive of oesophageal discorders Scand J Gastroenterol 1991;26:73-781.

SIGN: Management of patients with stroke: identification and management of dysphagia. A national clinical guideline 2010.

Shaker R, Kern M, Bardan E, Taylor A, Stewarrt ET, Hoffman RG, Arndorfer RC, Hofmann C, Bonnevier J. Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise. AJP. Gastrointestinal and Liver Pathology 1997;272:G1518-G1522.

Speyer R, Baijens L, Haijen M, Zwijnenberg I. Effects of therapy in oropharyngeal dysphagia by speech and language therapists: A systematic review. Dysphagia 2010;25:40-65.

Steele CM, Bennett JW, Chapman-Jay S, Polacco RC, Molfenter SM, Oshalla M. Electromyography as a biofeedback tool for rehabilitating swallow muscle function. 2012 www.intechopen.com.

Smithard DG Swallowing and Stroke Cerebrovascular Dis. 2002;14:1-8.

Smithard DG Swallowing rehabilitation post stroke. Int J Phys Med Rehabil 2013, 2:191 doi: 10.4172/2329-9096.1000191.

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CPD questions (please visit www.communitypractitioner.com/CPD to submit your answers)

1. The brain stem swallowing centres receives information from?

a) Mouth

b) Pharynx

c) Cortex

d) Respiratory Centre

e) All of the above

2. To be able to swallow safely you must be able to?

a) Stop breathing

b) Stand up

c) Walk

d) Have a gag reflex

e) Talk

3. The most common cause of aspiration pneumonia is?

a. Difficulty swallowing

b. Poor mouth care

c. Nasogastric tubes

d. Percutaneous endoscopic gastrostomy (PEG)

e. Medication

4. How many muscles are involved in swallowing?

a. 10

b. 55

c. 90

d. 40

e. 22

5. Which of the following is not used in the assessment of swallowing?

a. Manometry

b. Drinking a yard of ale

c. Videofluoroscopy

d. Flexible endoscopic evaluation of swallowing

e. pH monitoring

6. Dysphagia may be caused by?

a. Stroke

b. Heart failure

c. Head injury

d. Cancer

e. All of the above

7. Which of the following may not indicate a swallowing problem

a. Spitting food out

b. Food refusal

c. Refusal to eat in company

d. Coughing on swallowing

e. Taking longer than usual to eat

8. Dysphagia is indicative of:

a. Difficulty in eating

b. A sore mouth

c. Difficulty in swallowing

d. Loss of taste

e. Poor appetite

9. Dysphagia is a geriatric syndrome because

a. Has many different aetiologies

b. Is associated with frailty

c. Associated with a poor outcome

d. Occurs with increasing age

e. All of the above

10. Which of following is not a form of enteral feeding

a. Sip feeds

b. Puree diet

c. Nasogastric tubes

d. Subcutaneous fluids

e. Gastrostomy
Table 1: Aetiological factors for dysphagia

Diagnostic Group     Example

Neurological         Stroke
                     Sub Arachnoid Haemorrhage
                     Multiple Sclerosis
                     Motor Neuron Disease
                     Brain tumour
                     Traumatic Brain Injury
                     Encephalitis
                     Post Polio Syndrome
                     Developmental problems (Cleft palate)
Musculoskeletal      Cervical Osteophytes
                     Spondylolisthesis
                     Rheumatoid arthritis
                     Disc Prolapse
Malignancy           Tongue
                     Gum
                     Larynx
                     Pharynx
                     Oesophagus
Infection            Candida
                     Streptococcal
Cardio respiratory   Heart Failure
                     COPD
                     Lung Fibrosis
Iatrogenic           Post intubation
                     Post surgery
Other                Pharyngeal pouch
                     Pharyngeal atresia/stenosis
                     Cricopharyngeal spasm
                     Oesophageal atresia
                     Oesophageal achalasia
                     Frailty
Medication           Anticholinergic medication
                     Antibiotics
                     Opiates
                     Anti psychotics
                     Benzodiazepines
                     Calcium Channel Blockers
Self Harm            Bleach
                     Fire
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Author:Smithard, David G.
Publication:Community Practitioner
Article Type:Report
Geographic Code:4EUUK
Date:Oct 1, 2015
Words:3037
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