When you can’t swallow.

Dysphagia Facts
 Approximately 300,000 to 600,000 people with
neurogenic disorders are diagnosed with dysphagia.
 Swallowing involves the use of 6 cranial nerves.
 Approximately 40% of patients with dysphagia silently
aspirate.
 Swallowing is one of the most complex body reflexes,
yet in the normal adult, this process is automatic,
effortless and efficiently performed an average of 600
times a day.
Dysphagia Facts
 Evidence of dysphagia in 51% of patients with acute
stroke.
 Parkinson’s dysphagia develops in approximately 50%
of patients.
 With patients with multiple sclerosis, 34% with
dysphagia.
Phases of the Swallow
 Oral Phase
 Involves the lips, tongue, teeth and cheeks.
 The swallow begins when food is presented at the level
of the lips.
 Patients must have good labial seal to hold the bolus within
the oral cavity and to create appropriate pressures to propel
the bolus and initiate the swallow.
 Patients with stroke may have labial weakness which allows
the food to spill out of the mouth.
Tongue
 The tongue contains the taste buds allowing us to taste
foods.
 The tongue is made up of muscles.
 The tongue is used to
 Move the bolus within the oral cavity for proper
mastication of the bolus
 Propel the bolus posteriorly to initiate the pharyngeal
stage of the swallow
Teeth
 Dentition is important for swallowing and it is
important to assess dentition for appropriate diet
recommendations.
 The SLP will need to know if the patient wears dentures,
is missing teeth, etc.
 Teeth are important for appropriate mastication of
foods.
Cheeks
 Buccal tension:
 Assists in creating appropriate pressures for initiating
the pharyngeal swallow
 Assists in maintaining the bolus
 Helps to prevent lateral pocketing of the bolus.
Pharyngeal Phase
 Once the food is masticated and reaches the anterior
faucial arches, the pharyngeal stage of the swallow is
initiated.
 Within 1-3 seconds the following occurs:
 Tongue Base Retraction
 Velopharyngeal closure
 Pharyngeal constriction
 Pharyngeal contraction
 Hyoid Elevation
 Hyoid Protraction
 Hyothyroid approximation
 Vocal fold closure
 Upper esophageal sphincter opening.
Oral Care
 Microorganisms found in the lungs of elderly patients with
pneumonia originate in the mouth and gingival, making a
link between poor oral hygiene and aspiration pneumonia.
 Three categories that add to the risk factors that lead to
aspiration pneumonia: o Any factor that increases the
bacterial load or colonization in the oral-pharyngeal cavity
(lack of tooth brushing, xerostomia).
 Any factor that decreases the patient’s resistance to the
inoculums (i.e. malnutrition or ventilator dependency).
 Any factor that increases the risk of aspiration (i.e. paralysis
from stroke or chronic neurological disease affecting the
muscles and nerves involved in swallowing.
Oral Care
 Those at risk:
Patients who are dependent for oral care.
Have large numbers of missing teeth.
Dentures
Have limited hand dexterity
Decreased mental capacity
Multiple medical co-morbidities
Immunosuppressed
Ventilator dependent
Receive non-prandial feedings
Have had a stroke
Neurologically impaired
Have xerostomia
Known Dysphagia
Poor access to professional dental care.
Dependence on caregivers for oral care.
Active smoking
Depression.
Use of sedative medication
Use of gastric acid-reducing medication.
Use of ACE inhibitor
Poor feeding position.
Frazier Water Protocol
 Patients who are on thickened liquids are often placed
on a Frazier Water Protocol to increase hydration.
 Thickened liquids are given with meals and
medications.
 Wait for 30 minutes after meal, complete thorough oral
care, then patient can have all the water they want until
their next meal.
Thickened Liquids
 There are four consistencies of liquids
 Thin or regular
 Normal drinks with no thickening agents added.
 Nectar thick liquids
 Should be the consistency of maple syrup and run off the
spoon like syrup does.
 Honey thick liquids
 Consistency of honey and should run off the spoon as honey
does.
 Pudding thick liquids
 Should be the consistency of pudding and “plops” off the
spoon.
Medications
 When patients have dysphagia, they are often ordered
to have their pills crushed or given in
applesauce/pudding.
 When passing pills, remember people that have
difficulty swallowing and try to give them one pill at a
time.
 Check at the end of the med pass to make sure all pills
were swallowed and were not pocketed.
Food Consistencies
 Pureed
 Baby food consistency, should have no lumps and be
easy to swallow.
 Mechanical Soft/Ground Meat
 Should only require minimal chewing, no hard/crunchy
foods
 Regular
 No restricitions
Assessment Techniques by SLP
 Bedside assessment
 Cervical Auscultation
 Laryngeal elevation
 Monitor s/s aspiration
 Trial consistencies
 Pulse Oximetry
 Heart Rate
 Blue Dye Assessment
 3 Ounce water test
 Bolus Manipulation Task
 Instrumental Assessment
 MBSS
 FEES
 Manometry
 Ultrasound
Treatment Techniques by the SLP
 VitalStim-NMES for dysphagia
 DPNS/FMEP
 Thermal/tactile stimulation
 Myofascial release and manual techniques
 Oral/Pharyngeal Exercises
 Exercises with resistance
 TheraSip Swallowing Trainer
 IOPI
 OraLight
 Ice Finger
 Laryngeal Mirrors/ThermoStim Probe
Things to Remember

 Patients that self-feed have a lower incidence of aspiration.

 Feed patients as you would like to be fed, don’t shovel food into
their mouth or stick the food into their mouth before they’re
ready.
 Aspiration pneumonia in nursing home residents occurs 10 times
more frequently than in elderly community dwellers.
 Pneumonia is the most common cause of death from
nosocomial infections in the elderly.
 Pneumonia results in functional declines and increased health
care expenditures.
 One study suggests that 70% of patients with a history of
pneumonia aspirated during their sleep.
 One study suggests that effective oral care can decrase mortality
due to pneumonia by half.
Bolus Propulsion
Select Medications that Affect
Swallowing
 Oropharyngeal function  Esophageal function
Sedation, pharyngeal weakness, dystonia Inflammation (resulting from irritation by
 Benzodiazepines pill)
Neuroleptics  Tetracycline
Anticonvulsants* Doxycycline (Vibramycin)
 Myopathy Iron preparations
 Corticosteroids Quinidine
Lipid-lowering drugs Nonsteroidal anti-inflammatory drugs
Potassium
 Xerostomia  Impaired motility or exacerbated
 Anticholinergics gastroesophageal reflux
Antihypertensives*  Anticholinergics
Antihistamines* Calcium channel blockers
Antipsychotics Theophylline
Narcotics
Anticonvulsants*  Esophagitis (related to immunosuppression)
Antiparkinsonian agents*  Corticosteroids
Antineoplastics*  *--Various agents in the class.
Antidepressants*
Anxiolytics*
Muscle relaxants*
Diuretics
 Inflammation/swelling
 Antibiotics*
Sources
 American Speech-Language Hearing Association Division
13 (2006). Perspectives on Swallowing and Swallowing
Disorders, 15(3), 1-28.
 American Speech-Language-Hearing Association (1990).
Skills needed by speech-language pathologists providing
services to dysphagic patients/clients, ASHA, 32 (suppl 5),
7.
 DPNS Manual. Available through the Speech Team Inc.
Author: Karlene Stefanokos.
 The Source for Dysphagia. LinguiSystems. Author: Nancy
Swigert.
 Logemann, J. A. (1998). Evaluation and treatment of
swallowing disorders. Austin, TX: Pro-Ed.
Sources
 Carl, L., & Johnson, P. (2005). Drugs and dysphagia:
How medications can affect eating and swallowing.
Austin, TX: Pro-Ed.
 Palmer, J.B., Drennan, J.C., and Baba, M. (2000).
Evaluation and Treatment of Swallowing Impairments.
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