Comprehensive Dysphagia Management: Assessment, Nutrition, & Medication Challenges

for the Speech Language Pathologist

Stephen C. Enwefa, Ph.D., CCC-SLP, ND Department of Speech Language Pathology

Southern University, Baton Rouge, LA

Regina L. Enwefa, Ph.D., CCC-SLP, ND Department of Speech Language Pathology

Southern University, Baton Rouge, LA

MSHA 2013 Annual Continuing Education Conference Jackson, MS

Dysphagia dys·∙pha·∙gia  \dis-­‐ -­‐ -­‐) \    

O Disorders O Dysphagia risk? O Which ones travel

together? O Phase of swallow

affected: O oral O pharyngeal O esophageal

O Medications O One pill may not be

the problem-what is taken together is

O Drug Interactions O Bedside Evaluation O Standardized O Personal evaluation

Statistics for Dysphagia O An estimated 15 million people in the United States

have the current diagnosis of dysphagia. Approximately one million people annually receive a new diagnosis of dysphagia. Nearly 60,000 people die each year from complications associated with swallowing disorders.

O 25% of the elderly are malnourished

Dysphagia

O Caregiver Compliance

O Misjudge the assistance needed

O Too busy O

knowledge either disinterested vs. lack of training

O CNAs disagree with recommendations

(Colodny, 2001)

O One pill may not be the problem- what is taken together with the pill is!

O Drug-Drug Interaction

O Drug-Food Interaction O Drug-Herb Interaction

Coughing? Why? What Reason? Cannot be established at bedside O Medication side effect O Post nasal drip O Penetration/aspiration from initial swallow

or residue O 30% of unexplained cough have reflux O 38.1% with unexplained cough have

esophageal cancer O Will dysphagia therapy change this? NO

Increase risk for esophageal cancer

O Look for COPD O Boniva drug O Reflux O Bone Density O Psy. Meds

Dysphagia O Behavioral, sensory & preliminary motor

preparation for swallow: O Swallow starts with smelling food!

O We call it Dysphagia Aromatherapy! O Cognitive awareness of eating situation O Sensory input to the patient O Self feed as long as possible but make it

enjoyable O Remember: all physiologic responses to

smell/presence of food: INCREASES SALIVATION

Statistics O Every $1 spent on nutritional services saves

at LEAST $3.25 in medical costs Mealtimepartners.com February Newsletter

O Pre-thickened liquids 44%-59% LESS EXPENSIVE than mixing at bedside

(Nursing Economics. April/May 2010)

O US Census Bureau: O 21% nursing home pts MUST BE FED O 26% nursing home pts NEED HELP AT MEALS O 40% nursing home pts UNDERNOURISHED

Dysphagia Patient Screening O If we ask specific

questions, not general, such as do you have trouble swallowing? Patient usually responds NO

O We must look at diet changes reported if any

O Check if they refuse certain foods

O Make excuse for diet changes

O Make a refusal to eat with the family

O Weight loss

O Poor awareness or have difficulty controlling secretions

O Constant chest secretions

O Gurgly voice O Cough before, during,

and after swallow

Observe Patient at MEALTIME

O Breathing difficulty O Voice changes O Multiple swallows per

bolus O Throat clearing O Coughing O Increased secretions O Pocketing O Significant fatigue at

meal O Holding food O Decreased chewing O Prolonged mealtime

O Requires extra time O Assess environment and

behavioral variables O Identify positive and

negative variables: O Lighting O Atmosphere O Table mates O Time needed for meal

completion O Consumption O Amount of assistance

required O Response to food (Mills, 2000)

Chart Review and Medical HX O Medical/Health Status O Function Status O Oral/dental status O GE Reflux status O (All are predictors of aspiration

pneumonia) O At risk if you have dentures and teeth

and you do not clean them) O Mouth sores from meds

MOUTH CARE for the SLP O IMPORTANT AND A NECESSITY!!! O

student nurses O Mouth care is a 24/7service before and

after a meal O Should play a major role for the SLP

now

VERY IMPORTANT ALWAYS!!!

MOUTH CARE O 4 common etiologies that contribute to

oral mucosa breakdown: O Motor/cognitive deficits O Oropharyngeal

musculature/swallowing dysfunction O Specific medications O Oxygen or suctioning therapies

MOUTH CARE O 44% - 65% of patients dependent on

caregivers receive INADEQUATE ORAL CARE!!!

(Nursing staff perspectives on oral care for neuroscience patients. Journal of Neuroscience Nursing. (Cohn, Fulton, 2006)

O What does that mean for the SLP? O This is an area we can improve better

conditions of our patients through education and training. O

MOUTH CARE GUIDELINES FOR THE SLP

O Regular tooth brushing for alert patients O Alcohol free mouthwash for alert patients O Hard candies, ice chips, sips of water or water

sprays-only when upright and if tolerated patient specific

O Biotene, Oasis, Sage Products O Swab less alert patients with cholorhexidine

0.12% alcohol free mouthwash or water O Remove/clean dentures regularly O Treat cracked lips with lip balm ointment

preferably Burt Bees and not petroleum jelly because of interactions

Why should hospitals care so much about the oral cavity ?

Most bacterial nosocomial pneumonia are caused by aspiration of bacteria colonizing the oropharynx or upper GI tract of the patient. Center for Disease Control (1997) Nosocomial pneumonia accounts for 10-15% of all hospital acquired infections. 20-50% of all infected patients will die as a result of the infection J.Can.Dent.Assoc.(2002)

     

Why is Speech-Language Pathology Addressing the

issue of Oral Care?    

Current Oral Care Practices                    

Foam swabs are commonly used to provide mouth care to patients who cannot provide their own care. SWABS ARE NOT EFFECTIVE FOR PLAQUE REMOVAL

AND ONLY PROVIDE MOISTURE REFIEF.

Journal of Advanced Nursing (1996) Nursing Times (1996)

Two Models of Implementation (see Winter 2007 Communique Article)

    ICU

O Standard Already Created. Told to

change anything but the key points (Win Win Situation) O Worked with Nurse Manager and Nurse Educator O Multiple in-services O Chose objective research measure

Acute Care (Including Stroke Unit) O Standard Already Created. Told to

change anything but the key points (Win Win Situation) O Worked with nurse educator O Single in-service O Chose subjective measurement

http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm

How  They  Form  

http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Structure-Function/default.htm

Oral Hygiene Planning Checklist

Oral Care

SAGE Products

Article  

Good Oral Hygiene O An oral hygiene program must begin

with a good assessment tool.

O Some are available commercially, and others can be found on the Internet.

O Any protocol should first identify the usual care practices of patients and then identify those most at risk and those that will need assistance.

Tips for Oral Care Management An examination should be performed upon admission and at least once a day. Using a flashlight and tongue depressor, examine the oral mucosa, the lips and corners of the mouth, the tongue and teeth/dentures. Look for signs of candidasis or signs of xerostomia and check chewing and swallowing ability. Remember that the environment of the oral cavity can change very quickly when health status, medications or dependency change.

Oral Care Program Includes brushing at least twice daily, Suctioning oral secretions to decrease the bacterial load Keeping the oral mucosa moist with adequate hydration or saliva substitutes and moisturizers. Tools should be available in a place near the patient to allow for convenient cleansing. Brushing with simple non-detergent toothpaste or baking soda is most effective.

Deep Cleaning Only swab with dental sponges between brushings to mop up secretions and other oral contaminants. Suction toothbrushes are available for known aspirators.

A method for deep cleaning should be available when needed. Chlorhexidine can be prescribed for this. Dentures require the same care as teeth. The oral care team must develop a policy and procedures for changing out and replacing suction equipment, implementing special cleaning techniques for ventilators, and looking at ways to improve overall health in the at-risk patient.

ORAL CARE TEAM MANAGEMENT

The team should include speech-language pathologists, nurses, respiratory therapists, dietitians and nursing assistants, who most likely will perform the care. Physicians such as pulmonologists or internists would be helpful; and a dentist or dental hygienist, if available, would be very valuable. It is not the speech-language pathologist's responsibility to build and execute the protocol but to provide expertise, education and quality assurance support as a member of the team

Role of the SLP in Oral Care The speech-language pathologist usually is best equipped to meet this challenge and help to develop teams within settings. We have a unique knowledge of oral structures and functions and know how disease and trauma can change the status of the oral environment and how to combat aspiration pneumonia. No one protocol meets the needs of patients in all settings. A team should develop a protocol in each setting.

Who is at risk? Patients at risk include those who are:

dependent for oral care

have large numbers of missing teeth or dentures have limited hand dexterity or decreased mental capacity

have multiple medical co-morbidities are immunosuppressed or ventilator dependent, receive non-prandial feedings

Who is at risk?  have had a stroke or are neurologically impaired, have severe xerostomia, and have known dysphagia.

Aspiration Oral care can decrease aspiration pneumonia rates, according to a growing body of evidence.

Physicians, nursing staff, patients and families do not understand the need for oral care.

SLPs must improve education, training and commitment from facility leadership to decrease the rate of aspiration pneumonia.

3 categories of risk factors that lead to aspiration pneumonia:

Any factor that increases the bacterial load or colonization in the oral-pharyngeal cavity (e.g., lack of daily tooth brushing or xerostomia)

factor that decreases the patient's resistance to the inoculum (e.g., malnutrition or ventilator dependency)

factor that increases the risk of aspiration (e.g., paralysis from stroke or chronic neurological disease affecting the muscles and nerves involved in swallowing).

Challenges for the SLP O How to help prevent the aspiration of bacteria-

laden saliva and foster better oral care in their settings and further reduce the incidence of aspiration pneumonia.

Medication O Conduct a chart review for medical dx and

meds

O Evaluation is important

O Bedside assessments -standardized

O Bedside tools O Recommendation for nutrition, hydration,

further assessment

Medications O Food and drug interactions O Increased risk O Meds taken for long periods of

time O Several meals taken at a time O Questionable nutritional status O

metabolic, disease status O Food changes effect of drug O Reduces efficiency of drug O Promotes nutritional

deficiencies O Influences intake O Creates toxic reaction

O Liquids with medication

O Follow meds with 100ml of liquids

O Never take medications with grapefruit juice

O Negates effect of medication

O Allow it to build up/unable to breakdown

Medications O Concerns regarding medications

O None of the studies evaluate safe medication swallowing

O Videofluroroscopic studies do not necessarily

include pill swallowing performance O Swallowing pills is a different process than

swallowing fluids or food O Patients vary considerably in their pill taking

behavior

Pill Swallowing

Assessment of Dysphagia O Prove medical necessity O Defensive documentation O Chart review-diagnoses O Test/measures O Comprehensive evaluation & Prognosis-

judgment call O Plan of care interventions O

Dysphagia Evaluation/Screening

O Bedside Swallow Assessment (water by spoon/cup)

O Gugging (semi-solid, liquid, solid) O Standardized Swallowing Assessment

(SSA 3 tsps and ½ glass of water) O Kidd Water Test (50 ml in 5 ml

increments)

Bed Screen

O Massey Bedside (1 tsp. , 1 glass water O Mass. General Hospital Swallow Screen

Test (MGH-SST) O 3 oz water swallow O Toronto Bedside Swallowing Screening

Test (TOR-BSST) 4 hour training O EATS (semisolid, liquid, solid)

3 Ounce Water Test O 3 ounces of water w/out stopping O Fail to cough, stop, choke, wet hoarse

vocal quality in test/1 min

O If failed: O MBS/FEES, not BEDSIDE EXAM (GO FOR

FEES) O Bedside screen misses 20% of patients O Good predictor of ability to tolerate thin

liquids

Dysphagia Screening/Assessment

O Swallowing ability should be screened using a simple, valid, reliable tool before initiating oral intake of medications, fluids or food

Bedside Evaluation O Frenchay Dysarthria Assessment O Clinical Observational Dysphagia Assessment O (CODA) Alimed (Cranial Nerve Test) O Mann Assessment of Swallowing Ability (MASA) O Bedside Evaluation of Dysphagia (BED) O Swallowing Ability and Function Evaluation (SAFE) O Feeding and Swallowing Disorders in Dementia O Dysphagia 2 go app O Observation O Cervical Auscultation

Nutrition O Why do we worry about dysphagia?

O Nutritional status assess using a validated tool or

measure, to avoid malnutrition

O Explain the nature of the dysphagia, recommendations, follow-up & re-ax to patients, family & care providers

O Provide client and/or legal decision maker with enough info to allow informed decision making

O Reassess those receiving modified texture diets or enteral feeding for changes in swallowing status

Mealtime Tips: Setting the Stage

O Glasses on, hearing aids in O Dentures in, unless very poor fitting (e.g.

muscle tone/weight loss makes them

O In general, TV & radio off O Normal table O Prescribed, adapted equipment/utensils

available at every meal O Prescribed medication delivery adhered to

Mealtime Tips: Setting the Stage  

Hemiplegia (muscle weakening, usually on 1 side)

Ensure tray is in reach Model creativity e.g. rip packages with teeth

Persons with language changes (aphasia) Short, clear directions

statements

they are a competent adult

Attention/Orientation Challenges Say their name & get eye contact before

giving directions

Oral Care Protocol Healthy Fair Poor Very Poor

Lips

Gums & Tissues Tongue

Mouth Odor

Oral Cleanliness Saliva

Dentures

Teeth (shape, cavities, color)

Enwefa, S, Enwefa, R. and Brewster, C. 2013

WE THANK YOU!