Thursday, November 22, 2012

Issues With Swallowing Difficulties - Dysphagia

The Regional Geriatric Program in Hamilton, Ontario, published an e-zine called BP Blogger, now defunct. Here is some good info from them.

Many residents in LTC have swallowing problems
Swallowing difficulties, also known as dysphagia, occur as a result of direct and indirect damage by numerous diseases to the swallowing muscles. These may be neurological or neuromuscular (28- 64% of persons with stroke, up to 81% with Parkinson’s disease, and 24-34% with MS), structural (tumours, salivary), immunological, environmental, psychological, or social. The severity can vary from mild to severe with any of these causes. Swallowing is complex and involves 26 muscles.

Dysphagia is an uncomfortable, frightening and potentially lifethreatening condition because it interferes with the oral intake of food and liquids; and can lead to aspiration, choking, suffocation, dehydration, malnutrition, decreased quality of life; and frustration for residents, family and staff. Swallowing, eating and chewing problems are common among LTC residents. Up to 70% of residents will have signs of swallowing problems. Signs of swallowing difficulties are usually obvious during meals.

Signs of Swallowing Difficulties
Coughing when eating or drinking
Food or liquid spilling from the lips when eating or drinking
Trouble moving food or liquid around in the mouth
Prolonged chewing
Trouble starting to swallow once food or liquid is in the mouth
Clearing throat when eating or drinking
Coughing or clearing throat shortly after a meal
Has a wet or gurgly sounding voice
Complains feeling that something is “stuck” after swallowing
Shortness of breath during or right after mealtime
Has frequent heartburn or bitter taste in the mouth
Unexplained weight loss
Recurrent chest infections
Refusal to eat or reluctance to have food in the mouth
Pocketing food or liquid in the cheeks or holding food in mouth

Thickened liquids
Some dysphagic residents may have difficulty swallowing thin liquids such as water, coffee , tea and juices. They may have difficulty controlling the liquid in their mouth before swallowing or clearing it during the swallow. Thin liquids may spill into the upper airway before they are ready to swallow, increasing the risk of “aspirating” fluids into the lungs. A cough usually clears the airway but for dysphagic residents their cough may be weak or absent. Aspiration of food may cause blockage in the lungs and could lead to an infection called “aspiration pneumonia”. Even non-dysphagic residents may aspirate when fed if they are tired, lethargic, inattentive or sedated. Thickened liquids often help prevent aspiration pneumonia because they flow slower and allow for the swallowing reflex to be triggered. Pre-thickened products are offered in nectar, syrup or thick texture consistencies. Thickened liquids take longer to digest and they don’t feel as thirst quenching but they do provide hydration as the body digests the product and absorbs almost all the water from it.

Food Aspiration =  Aspiration Pneumonia
 Aspiration of food or liquid means that residents are at greater risk of developing pneumonia. Aspiration pneumonia rates are highest in LTC homes, up to 44%. Residents dependent for feeding are 20 times more likely to develop aspiration pneumonia. Pneumonia is the second most common infection after urinary tract infection, most common reason for transfer to hospital and a leading cause of death from infection in LTC. Because dysphagic residents have problems starting to swallow or a weakened swallow causing spillage or incomplete clearing of food in the throat, food can then fall into the airway (aspirate) when they start breathing. These large-volume aspirations are of great concern, because chunks of food can block airways and if not cleared, can lead to infection. Pneumonia can also result from aspiration of saliva loaded with oral bacteria (100 million bacteria per 1ml); reflux; weakened immune system; dependency on staff for feeding; and reduced mobility. With recent information on oral hygiene and lower incidence of pneumonia in those receiving regular oral care, providing oral care to residents who are dependent on feeding or on tube feeds could significantly lower the incidence of aspiration pneumonia in LTC.
Other causes of aspiration pneumonia stems from tooth plaque, in those who cannot effectively brush their teeth. Bacteria grows in the plaque, and is inhaled into the bronchial tubes.

Tube feeds do not necessarily prolong life

Tube feedings are sometimes implemented for those who are severely dysphagic or malnourished. For residents with reversible conditions, tube feeding may be viewed as a temporary intervention and the goal might be to retrain to eat again. One reason why many families opt for tube feeding in LTC homes is the belief that tube feeding will prolong life. Many studies have concluded that using tube feedings does not prolong life nor improve quality of life especially for those with severe cognitive impairment. Placement of the feeding tube may result in a weaker esophageal sphincter, increasing the risk of stomach contents regurgitating into the esophagus and the lungs. Residents on tube feeds often don’t eat any food by mouth and this can result in poorer mouth care. Tube feeding can increase the risk of aspiration pneumonia from both stomach contents and oral secretions. In fact, severely dysphagic residents who are orally fed have much fewer episodes of aspiration pneumonia.
For many without an appetite, tube feed may prolong a quality of life they may not want to experience. For these reasons, family members must the knowlege of what a loved one would want, expecially those with diseases that have predictable trajectories such as MS, dementia, or bone or stomach cancers.

1 comment:

SARA said...

"I think your blog is brilliant"