Dysphagia in the Elderly Implications in Long-Term Care

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Dysphagia in the ElderlyImplications in
Long-Term Care

• Annette T. Carron, DO
• Director Geriatrics Palliative Care
• Botsford Hospital

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OBJECTIVES

• Know and understand
• Swallow mechanism and changes with aging
• Causes of dysphagia
• Proper assessment and diagnosis of dysphagia
• Treatment of dysphagia
• Options if dysphagia treatment unsuccessful
• Survey implications of dysphagia

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Normal Swallow Mechanism

• Oral preparatory phase
• Chewed food mixes with saliva to make bolus
• Bolus sitting between the tongue and the hard
  palate in a groove formed by the tongue
• Tongue begins an anterior to posterior pumping
  motion that moves bolus posteriorly
• Bolus passes anterior tonsillar pillars
• Disease in this phase can result with tongue
  dysfunction, inadequate dentition (impairs bolus
  formation)

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Normal Swallow Mechanism

• Pharyngeal phase
• Larynx rises, vocal folds close to protect
  airway, epiglottis closes entrance to airway,
  soft palate separates nasal cavity from pharynx
• Bolus passes through pharyngoesophageal sphincter
  (UES-upper esophogeal sphincter) into the
  esophagus
• Velopharyngeal sphincter closure prevents bolus
  regurgitation into nose
• Tongue and pharyngeal muscles propel bolus
• Larynx is closed off to the bolus
• Disease here caused by palatal dysfunction,
  pharyngeal constriction, laryngeal or epiglottic
  dysfunction (aspiration)

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Normal Swallow Mechanism

• Esophageal phase
• Food travels to stomach
• Pharyngoesophageal (PES) sphincter opens to
  allow bolus into esophagus
• Disease here may be motility disorder or mass/
  anatomical lesion

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Swallow changes with aging

• Thickening of the muscular coat
• Occurs more slowly
• Initiation of laryngeal and pharyngeal events
  take longer
• Bolus may pool or pocket in the pharyngeal recess
  longer
• Presbyphagia changes in the mechanism of
  swallowing of otherwise healthy older adults
• Not clear aging itself causes increased risk of
  aspiration, but with increased co-morbidities,
  increased risk
• Normal saliva 10,000 gallons in a lifetime,
  meds can reduce salivary gland production (higher
  risk in elderly)

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Swallow changes with aging, cont.

• In oral phase, food bolus inadequately prepared
  due to poor or absent dentition, periodontal
  disease, ill-fitting dentures, inappropriate
  salivation
• Taste, temperature and tactile sensation with
  aging changes
• Intake may be too rapid with neurological
  diseases
• Fatigue or change in endurance as a possible
  factor in aspiration in the elderly
• Muscle atrophy in facial muscles with aging may
  slow swallow

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Dysphagia

• Definition difficulty in swallowing that may
  include oropharyngeal or esophageal problems
• Eating is one of the most basic human
  needs/pleasure difficulty is swallowing can
  cause social/emotional isolation
• May or may not be inherent in aging, but common
  in the elderly
• Incidence
• 15 in community-dwelling elderly
• 50-75 in nursing home population

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DYSPHAGIA

• Oropharyngeal dysphagiaPatients complain of
  foods getting stuck, inability to initiate a
  swallow, impaired ability to transfer food from
  mouth to esophagus, nasal regurgitation, coughing
• Esophageal dysphagiaPatients usually point to
  the sternum when asked to localize the site
• Dysphagia in a patient with dyspepsia requires
  immediate evaluation and therapy

Barium swallow in achalasia Bird beak sign
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Dysphagia

• Risk Factors in the elderly
• Stroke
• Silent cerebral infarction fivefold greater risk
• Neurodegenerative Diseases
• Alzheimer's, ALS, Parkinson's, MS, Myopathies
• Iatrogenic conditions
• Medication side effects/xerostomia
• Post surgical
• Irradiation of head and neck
• Cognitive impairment
• DM/Thyroid/osteophytes

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Dysphagia

• Risk Factors in the elderly
• Medications and dysphagia
• Xerostomia
• Anticholinergic drugs (tricyclic, antipsychotics,
  antihistamines, antispasmodics, antiemetic,
  antihypertensives)
• Esophageal/Laryngeal peristalsis
• Antihypertensives, antianginal
• Delayed neuromuscular responses
• Delirium causing, extrapyramidal side effects
• Esophageal injury/inflammation
• CCB, Nitrates relax lower esophageal sphincture
• Large pills

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Dysphagia

• Symptoms
• Most common choking (bolus entering airway or
  bolus lodged in the pharynx/ esophagus (ask pt to
  describe aspiration symptoms in airway more
  serious)
• Pocketing food/pills (food left in mouth after
  swallowing)
• Excessive throat phlegm with frequent throat
  clearing or spitting (wet voice)
• Delay in triggering swallow

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Dysphagia

• Symptoms
• Neck pain, chest pain, heartburn
• Solid food dysphagia (mechanical obstruction)
• Weight loss without other explanation
• Increased time to consume meals
• Drooling
• Spitting food at meals
• Rocking tongue back and forth while chewing

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Dysphagia

• Symptoms
• Prolonged oral preparation
• Increased time to consume meal
• Unusual head or neck posturing with swallow
• Pain with swallow
• Decreased oral/pharyngeal sensation

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Dysphagia

• Symptoms
• Coughing and choking with swallow
• Reduced or absent thyroid/laryngeal elevation
  during swallow
• Multiple swallows per mouthful
• Food or liquid leaking from nose
• Lasting low-grade fever
• Pneumonia
• Malnutrition/Dehydration

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Dysphagia

• Assessment and Diagnosis
• Do you have any pain on swallowing?
• Are there food or liquid consistencies that you
  have to forgo because they are likely to be
  difficult to swallow?
• Have you lost weight because of swallowing
  difficulties?

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Dysphagia

• Assessment and Diagnosis
• Speech Language Pathologists (non-instrumental
  evaluation)
• History taking
• Oral motor assessment
• Voice evaluation
• Trial swallows

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Dysphagia

• Assessment and Diagnosis
• Primary care screening for the elderly
• Example tool Dysphagia screening form-
  University of Wisconsin and Madison GRECC
• One question test Do you have difficulty
  swallowing food?
• Correlate symptoms of weight loss, cough and SOB
• Bedside clinician evaluation
• 3 oz water swallow test, auscultate over trachea
  before and after water swallowed eval for cough,
  choking change in breath sounds

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Dysphagia

• Assessment and Diagnosis
• Physical Exam
• Subtle voice changes (hoarseness, wet,
  hypernasal, dysarthria)
• Absent or poor dentition
• Tongue strength/oral control
• Palate exam symmetry, mass
• Head and neck
• Gag reflex poor indicator of dysphagia

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Dysphagia

• Assessment and Diagnosis
• Testing
• Modified Barium Swallow
• can tell which phase is dysfunctional, check for
  aspiration and compensatory mechanisms
• Can guide swallow therapy
• Standard Barium Swallow
• Testing esophageal structural or functional
  abnormalities
• Fiberoptic endoscopy

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DYSPHAGIA

• Endoscopy is the best first test
• Allows biopsies and therapeutic interventions
• Lower esophageal rings or extrinsic esophageal
  compression can be overlooked
• Radiologic evaluation may identify the level and
  nature of obstruction
• If these tests are normal, an esophageal motility
  study should be performed

Peptic stricture
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DYSPHAGIA

• For patients with oropharyngeal dysphagia,
  videofluoroscopy
• Allows detailed analysis of swallowing mechanics
• Identifies whether aspiration is present
• Evaluates the effects of different barium
  consistencies
• Treatment of dysphagia depends on the underlying
  cause

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Dysphagia

• Assessment and Diagnosis
• Consultants
• Otolaryngologist
• Gastroenterologist
• Neurologist
• Speech therapist
• Radiologist

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Disorders Associated with Dysphagia

• Neuromuscular affect the central control over
  muscles and nerves involved in swallowing (i.e.
  Parkinsons, CVA, ALS, Myasthenia gravis, MS)
• Rheumatologic (i.e. Polymyositis,
  Dermatomyositis, Inclusion body myositis)
• Head and neck oncologic Oropharyngeal cancer
• Pharyngeal structural Zenkers
• Gastrointestinal tumors, GERD, Schatzki ring
  (primarily esophageal but cause symptoms
  radiating to pharynx)
• Diminished cough

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Dysphagia

• Treatment
• Goal optimize safety of swallow, maintain
  adequate nutrition and hydration, improve oral
  hygiene
• Swallow therapy
• Postural adjustments
• Food and liquid rate and amounts (time to eat,
  small amounts, concentrate, alternate food and
  liquid, stronger side of mouth, sauces)
• Adaptive Equipment
• Diet modification

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Dysphagia

• Treatment
• Swallow therapy plan set by Speech Pathologist
• Oral stimulation
• Pharyngeal and laryngeal stimulation
• Position/Posture
• Direct Swallow exercises
• Compensatory Strategy Education
• On-going restorative interventions

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Dysphagia

• Treatment
• Dietary modifications (watch for dehydration)
• Aggressive oral care
• Modify eating environment
• Oral Hygiene
• Also reduce risk of aspiration
• Interdisciplinary
• Speech pathologist, dietician, OT, PT, nurse,
  oral hygienist, dentist, PCP, Caregivers, SW,
  family

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Dysphagia

• Treatment
• ACEI prevent breakdown of substance P
• Avoid sedatives, antihistamines, anticholinergics
  (complete med review)
• Evaluate Quality of Life
• SWAL-QOL dysphagia specific patient-centered
  QOL instrument (document effectiveness of
  treatment for both function and quality of life)
  monitor longitudinal course of treatment

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Dysphagia

• The non-fixable dysphagia
• Goal is enhanced quality of life
• Tube Feeding
• Not essential in all patients who aspirate
• No data to suggest TF in pts with advanced
  dementia prevented aspiration pneumonia,
  prolonged survival or improved function
  (aspiration pneumonia is the most common cause of
  death in PEG tube patients)
• Short term TF indicated if improvement in swallow
  likely to improve
• Pt autonomy, self-respect, dignity and QOL

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Dysphagia

• Complications
• Pneumonia
• Aspiration misdirection of oropharyngeal or
  gastric contents into the airway below the true
  vocal cords
• Leading cause of death of residents of nursing
  homes
• Dysphagia, sedating meds most important risk
  factor in long-term care residents for pneumonia
• Increased disease in the elderly, increased risk
  of oropharyngeal dysphagia and pneumonia
• Aggressive oral care lowered risk of pneumonia in
  nursing home residents

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Dysphagia

• Consequences
• Social isolation (embarrassment)
• Physical discomfort
• Dehydration
• Malnutrition
• Overt aspiration
• Silent Aspiration a bolus comprising saliva,
  food, liquid, meds or any foreign material enters
  the airway below the vocal cords without
  triggering overt symptoms
• Pneumonia, death

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Dysphagia in Long-Term Care

• Skilled nursing facilities required to provide
  nursing services and specialized rehab services
  to attain or maintain the highest practicable
  physical, mental and psychosocial well-being of
  each resident
• Survey guidelines mandate that the facility must
  maintain acceptable parameters of nutritional
  status, such as body weight and protein levels
  unless the residents clinical condition
  demonstrates this is not possible, and receives a
  therapeutic diet when there is a nutritional
  problem

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Dysphagia in Long-Term Care

• Common 50-75
• Aspiration leading cause of death in nursing home
  patients
• Can stress nursing assistants with difficult
  feeding patients
• Place food in non-impaired side of mouth
• Limit use of straws
• Adaptive feeding equipment
• Restrictive diets
• Failure to comply (citations, inadequate
  nutrition and hydration, unsafe feeding)

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Dysphagia in Long-Term Care

• Training nursing assistants
• Mealtime atmosphere
• Help residents maintain independence
• Therapeutic diets
• How to feed residents
• Identify a choking victim
• Importance of adequate hydration and nutrition
• May help to have basic knowledge of swallowing
  mechanism, signs of dysphagia

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Dysphagia

• Training nursing assistants
• In-service after have worked with feeding
  residents
• Meal Time Matters IDEAS Institute
• Interactive Institute
• http//www.ideasinstitute.org

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Dysphagia in Long-Term Care

• Goals for treatment in long-term care
• Interdisciplinary team
• ID residents with dysphagia
• Referral to and evaluation by team
• Objective measurement of resident progress
• Communication within team
• Increase resident independence and safety
• Carryover of treatment goals in facility and at
  discharge

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Dysphagia in Long-Term Care

• Goals for treatment in long-term care
• Interdisciplinary team ID Residents
• Why is resident being fed by staff?
• Has the resident been able to self-feed in past?
• Are there residents who experience excessive
  coughing during or after meals?
• Are there residents who have excessive burping or
  hiccups during meals?
• Are there residents who frequently vomit after
  meals?
• Are there residents who refuse to eat?

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Dysphagia in Long-Term Care

• Goals for treatment in long-term care
• Interdisciplinary team Questions for staff
• Residents needing assist to eat
• Recent decline in ability to feed self
• Recent significant weight loss or gain
• Tube feedings
• Recurrent aspiration pneumonia
• Adaptive feeding equipment
• Dysphagia
• Embarrassment or anxiety at mealtimes
• Poor dentition

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Dysphagia in Long-Term Care

• Goals for treatment in long-term care
• After evaluation establish
• Self-feeding goals
• Swallowing goals
• Comfortable environment
• Discuss dysphagia as part of weight loss
  committee

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Dysphagia in Long-Term Care

• F309 Each resident must receive and the
  facility must provide the necessary care and
  services to attain the highest practicable
  physical, mental and psychosocial well-being, in
  accordance with the comprehensive assessment and
  plan of care
• Very encompassing
• Highest possible functioning and well-being,
  limited by individual recognized pathology and
  normal aging process
• Unavoidable or avoidable decline, lack of
  improvement

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Dysphagia in Long-Term Care

• F325 Based on comprehensive assessment of
  resident, the facility must ensure that a
  resident maintains acceptable parameters of
  nutritional status, such as body weight and
  protein levels, unless the residents clinical
  condition demonstrates that this is not possible,
  and receives a therapeutic diet when there is a
  nutritional problem
• Address risk factors for malnutrition
• Care plan
• Meet residents ordinary and special dietary
  needs
• Treatable causes
• Monitor progress

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Dysphagia in Long-Term Care

• Survey overall importance
• Care plan
• Assessment
• Document interventions
• Evaluate results of interventions
• Physician involvement
• Nursing assistant education as awareness of plan
• Family involvement
• Prognostication (avoidable or unavoidable)

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Summary

• Oropharyngeal dysphagia may be life-threatening
• All team members important
• Pt/Family important
• Dont have to put in a tube feeding
• QOL

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CASE 1

• A 89-year-old man has difficulty swallowing
  solids and liquids. His dysphagia has progressed
  slowly over 8 months and he has lost 20 pounds.
  Is long-term care resident for 2 years
• History of dementia, COPD, CHF, DM
• Physician documentation states Elderly pt with
  weight loss, add med pass supplement, monitor
  weights
• Dietary states, continued weight loss, add
  pudding, consider appetite stimulant
• Speech therapy involved, Care plan in place for
  weight loss and dysphagia, diet reduced to pureed
  with nectar-thick liquids
• Patient aspirates and sent to hospital for
  pneumonia

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CASE 1

• Treated for aspiration pneumonia, returns with
  order for pureed with honey-thick liquids
• ST works with pt, care plan in place for weight
  loss and dysphagia
• Physician HP done
• Pt becomes dehydrated 10 days later and sent to
  hospital
• Returns, same plan of care, treatment except
  Lasix reduced to 20mg day from 40 mg/day

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CASE 1

• Physician HP done
• ST continues working with pt
• Care plan for weight loss, dehydration and
  dysphagia in place
• Additional 15 pound weight loss in a month.
• Pt returns to hospital with Aspiration one week
  later and dies
• Family complains about care and complaint survey
  done

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CASE 1

• What should surveyor expect to be on chart when
  arrives?
• What is reasonable to expect that all staff knew
  about residents care?
• Is anything reasonable to expect from doctor in
  terms of residents care
• If cited what would you include in IDR?

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