DysphagiaintheOlderAdultSeptember25,2019

AidaWen,MDAssociateProfessor

DepartmentofGeriatricMedicineJohnA.BurnsSchoolofMedicine

ShariGoo-YoshinoMSCCC-SLPInstructor

DepartmentofCommunicationSciencesandDisorders

JohnA.BurnsSchoolofMedicine

2

ThispresentationwassupportedinpartbytheGeriatricsWorkforceEnhancementProgram(GWEP)DHS,DHHS,BureauofHealthProfessionsawardedtothePacificIslandsGEC.Thisisalso supportedinpartbygrantNo.90ADPI0011-01-00fromtheU.S.AdministrationforCommunityLiving,DepartmentofHealthandHumanServices,Washington,D.C.20201,awardedtoCatholicCharitiesHawaiifortheAlzheimer’sDiseaseProgramInitiative.Granteesundertakingprojectswithgovernmentsponsorshipareencouragedtoexpressfreelytheirfindingsandconclusions.Therefore,pointsofvieworopinionsdonotnecessarilyrepresentofficialpoliciesfromACL,DHS,DHHS,orBHW.

Sponsoredby

University of HawaiiCenter on Aging

3

Thespeakershavenorelevantfinancialrelationshipstodisclose.

LearningObjectives

ThecommonsymptomsandcausesofdysphagiainolderadultsIdentify

TheindicationsandfunctionaloutcomesofswallowevaluationsExplain

ThemanagementandtreatmentoptionsfordysphagiaDescribe

IssuesregardingtubefeedingforadultswithdementiaDiscuss

Person-centeredcaretooptimizesafe,effective,andefficientswallowingforpleasurableparticipationinmealtime

Provide

Dysphagia(difficultyinswallowing)

• Highlyprevalentamongolderadultslivinginassistedornursingfacilities(40-60%),relatedtodementia(13to57%),stroke(37to78%),andParkinson’sdisease(35%-82%)

• Mealtimedifficulties:disinterest,selectiveeating,efforttoswallow,earlysatiety,andfatigue

• Consequences:malnutritionanddehydration,aspirationpneumonia,chroniclungdisease,choking,andmortality

• Compromisedqualityoflife– lifestylechanges• Usuallyasymptomofothermedicalconditions

Alagiakrishnan,Bhanji,&Kurian,2013;Aslam,M.,&Vaezi,M.F.,2013;Kalf,deSwart,Bloem,&Munneke,2011;Martinoetal.,2005.

OralandPharyngealDysphagia

CAUSES• Stroke,Dementia,Parkinson’s,otherneurologicalconditions

• Medications• Drymouth(anticholinergicdrugs)• Sedatingdrugs(psychotropicmeds,opioids,sleepingpills,etc.)

• Anorexia(donepezil,macrolideabx,etc.)

• Weaknessanddeconditioning• Headandneckcancers

EsophagealDysphagia

• ESOPHAGUS- troublewithfoodmovingpastthesphincters(upperandlower),troublewithperistalsisthroughtheesophagus,reflux.

• Symptoms:• Painwithswallowing(odynophagia)• Unabletoswallow• Feelingthatfoodisstuckinyourthroator

chestbehindyourbreastbone• Hoarse• Regurgitation(foodbackingup)• Frequentheartburnorfeelingacidbackingup

intoyourthroat• Havingtocutfoodintosmallerpiecesor

avoidingfoodbecauseoftroubleswallowing• Frequentrespiratoryproblems(asthma),or

infection

EsophagealDysphagia

CAUSES• Achalasia

• esophagealmotilitydisorder• Esophagealspasms

• triggerfoods,stress,GERD• Mechanicalproblems

• cancer,radiationtreatment,stricture,

• Barrett’sesophagus(preventedbyearlytreatmentofGERD)

• Weaknessanddeconditioning

OverviewofNormalSwallowing

1st:Oral:Liquidandfoodenterthemouthandaremanipulated,chewed,mixedwithsaliva,andtransferredintothepharynx

2ndPharyngeal:Foodandliquidentersandpassesthroughthepharynx

3rdEsophageal:Passageofliquidandfoodthroughtheesophagusandloweresophagealsphincter

OverviewofNormalSwallowing

1st:Oral:Liquidandfoodenterthemouthandaremanipulated,chewed,mixedwithsaliva,andtransferredintothepharynx

2ndPharyngeal:Foodandliquidentersandpassesthroughthepharynx-Aspiration

3dEsophageal:Passageofliquidandfoodthroughtheesophagusandloweresophagealsphincter

OverviewofNormalSwallowing

1st:Oral:Liquidandfoodenterthemouthandaremanipulated,chewed,mixedwithsaliva,andtransferredintothepharynx

2ndPharyngeal:Foodandliquidentersandpassesthroughthepharynx-Aspiration

3rdEsophageal:Passageofliquidandfoodthroughtheesophagusandloweresophagealsphincter

GeneralSymptomsAndSignsOfDysphagiaCoughingChoking

HoarsevoiceGlobussensation

InvoluntaryweightlossanddifficultygainingweightRecurringpneumonia,respiratoryinfection,orfever

SymptomsandSignsofOropharyngealDysphagiaCoughingduringorshortlyaftereatinganddrinkingComplaintsoffood"sticking"inthethroatHoldingfoodorliquidinmouthProlongedchewingSpilloffoodorliquidfromthelipsornasalcavityFoodorliquidremaininginthemouthDroolingDysarthriaWetvoiceduringorafterswallow

SymptomsandSignsofEsophageal DysphagiaChroniccoughingComplaintsoffood“sticking”inthethroatorchestPressureorburninginchestProgressivedifficultyinswallowingsolidstoliquidsVomiting

AdaptedfromBell,C.&Goo-Yoshino,S.(2018)

NonInstrumental- ClinicalSwallowEvaluation

• Reviewofhistoryandperceptionoftheproblem

• Examinationoforalstructuresandfunction

• Assessmentofswallowing

• Trialsofcompensatoryorrehabilitativetechniques

NonInstrumentalorClinicalSwallowEvaluationOutcomes

• Diagnosisoforalprepororalphasedysphagia• Optimumfoodandliquidtexturesbymouth/ConsiderNPO• Strategiestofacilitatesafeandefficientswallowing• Counseling,education,andtraining• Personalizedtreatmentplan• Referralforotherservicese.g.,dietician,gastroenterologist• DoesNOTdeterminepresenceorabsenceofaspirationorpharyngealphasedysphagia->Indicationsforinstrumentalswallowevaluation

IndicationsforInstrumentalSwallowEvaluation

• Symptomsorsignsofpharyngealphasedysphagia

• Uncertaintyinsafetyandefficiencyofswallowingfornutrition,pulmonaryhealth,andairwaysafety(aspiration,choking)

• Historyofmedicalconditionsassociatedwithhighriskfordysphagiaandaspiration

• Previouslyidentifieddysphagiawithasuspectedchangeinswallowfunctionthatmaychangerecommendations

Informationguidesmanagementandtreatment

InstrumentalSwallowEvaluations- VideofluoroscopicSwallowStudy/ModifiedBariumSwallowStudy

• Providesdirectvisualizationoforal,pharyngeal,andupperesophagealstructuresandfunction

• Assessswallowoffoodandliquidwithbarium

• Observeflowandclearanceofmaterialsfrommouthtoentranceintoesophagus

• Determineinfluenceofdietchangesandcompensatorystrategiesonswallowefficiencyandsafety

InstrumentalSwallowEvaluations- Fiberoptic EndoscopicEvaluationofSwallow

• Providesdirectvisualizationofpharyngealstructuresandfunction

• Assessswallowoffoodandliquid

• Observeflowandclearanceofmaterialsthroughpharynx

• Determineinfluenceofdietchangesandcompensatorystrategiesonswallowefficiencyandsafety

InstrumentalSwallowEvaluationOutcomes

• Diagnosisoforalandpharyngeal phasedysphagia• Detectionofaspiration• Optimumfoodandliquidtexturesbymouth/ConsiderNPO• Strategiestofacilitatesafeandefficientswallowing• Counseling,education,andtraining(withbiofeedback)• Referralforotherservicese.g.,dietician,gastroenterologist• Personalizedtreatmentplan

ManagementandTreatmentOptions– Person-CenteredCare

RestorativeExercises

Oralmotorswallowingexercises

Expiratorymusclestrengthtraining

Feeding/BehavioralStrategies

OptimalalertnessHeadandbodypositioning

Rateoffeeding- Bolussizeandplacement

Swallowmaneuvers

DietaryConsiderations

Appropriatetexture

Preferredfoodsanddrinks

Attractive- Propertemperature

Smaller,morefrequentmeals

Accessiblesnacks

EnvironmentalModifications

Maintainmealroutines

Seatingtoimproveposture

Calmenvironment- Reducedistractions

Supportself-feeding– Consistentprompts

Pleasantexchanges– Optimizecommunication

CounselingEducationTraining

GastricFeedingTubes

RISKSBENEFITS

• Prolonglife,gainweight• Preventaspiration• HealingofPressuresores• Improvefunctionalstatus

• DecreasedQOL(isolation,decreasedhumancontact,deniedgratificationoffood,restraints)

• Nausea,Vomiting,Diarrhea• Complications:Bleeding,Infection,

Skinirritation,Leaking,Blocked,Fallingout,Pulledout

• IncreasedriskforPressureUlcers• Morelikelytogetaspiration

pneumonia• Morelikelytogetfluidoverload

DOESNOT HELPINEND-STAGEDISEASE(Alzheimer’s,Parkinson’s,Terminalcancer,CVAwithoutimprovement,PVS,poorprognosis)

• Easier,lesstime,ensurecaloricintake

• OnlybenefitsthoseNOTinthelaststageofillness,suchas:

• acutestroke,• headtrauma• criticallyillwithgood

chanceofrecovery,• HeadandneckCA• ALS• youngpatients,• morefunctionalpatients.

NOBENEFIT

Decisionmakingprocess

• Considerboththemedicalfacts,andpersonalsubjectiveelements

• Atime-limitedtrialisalwaysanoption.• Thedecisiontoeitherinstituteartificialfeedingsortowithholdthemrarelyneedstobemadeemergently.

SlideCredit:ChristinaBell,MD

“Ican’tjustletherstarve!”

• Iftheexplanation,theclinician’sstory,ofwhyitisbelievedthatANHwouldnotbebeneficialisunderstoodsimplyasaninvalidationofthefamily’sstories,itwill,quitereasonably,berejected.

• Validateintent• Trytoreframe• Suggestalternativeinterpretationsintermsoftheirstoryline.

SlideCredit:ChristinaBell,MD

Reframing examples…

“He is dying because he is not able to eat or drink.”

Empathic validation of concern

“I understand how worrisome that must be.”

“Of course, it must seem that getting food and water into him would be important.”

Validation that their explanation, if true, would suggest the appropriateness of ANH.

“We have noticed that he only wants small amounts of food and water.”

Drawing attention to information available to suggest an alternative explanation.

“People with this illness who are dying tend not to be hungry or thirsty.”

Sharing alternative explanation that validates linkage between nutrition and dying, but in a different way, thereby reframing the issue.SlideCredit:ChristinaBell,MD

While it may seem like starvation, what

is going on is somewhat different…

Suggest possible alternative interpretation.

It would be great if tube feeding worked that way. However, in other patients with this illness we have found that tube feeding does not make

people live longer or feel better.

Share more info that suggests that ANH will not accomplish their goals, which are reasonable in and of themselves.

We can’t let him starve to death, which can be prevented

by artificial feeding.

You are right, if he were starving or thirsty and we could prolong his life through such

feeding, that would make

sense.

Validation of internal consistency of their story.

SlideCredit:ChristinaBell,MD

He may not be able to eat or drink

much, but is there some special food

he really liked?

Involve family (facilitating nurturing) concretely in a new way – feeding for pleasure vs. calories.

At this stage dry mouth is a big

problem. You could really help us care

for him by giving…

Identify how family can be of help in paying special attention, thereby forming an alliance

“So we’re just going to do nothing.”

Not at all! This is a time to pay special

attention…

Acknowledge “need to nurture” and reframe current situation in terms of this.

SlideCredit:ChristinaBell,MD

Alternatives&

Suggestions

Treatconditionsthatcausepoorappetite:constipation,depression,infection

Stopmedicinesthatmakeeatingproblemsworse

Antipsychotics/Antianxiety

Sleepingpills

BladderControlmedsAlendronate

Donepezil

DentalCare

CarefulHandfeeding,favoritefoodsforQOLfeeding

Hospicereferral

Otherwaystoshowlove(massage,read,music)

FeedingTubes

CaregiverVideo

ReferencesAlagiakrishnan,K.,Bhanji,R.A.,&Kurian,M.(2013).Evaluationandmanagementoforopharyngealdysphagiaindifferenttypesofdementia:Asystematicreview. ArchivesofGerontologyandGeriatrics, 56(1), 1–9.

AmericanSpeechLanguageHearingAssociationAdultDysphagiahttps://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942550&section=Assessment

AmericanSpeechLanguageHearingAssociationDementiahttps://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935289&section=Treatment

Aslam,M.,&Vaezi,M.F.(2013).Dysphagiaintheelderly. Gastroenterology&Hepatology, 9(12),784–795.

Baijens,L.W.,Clave,P.,Cras,P.etal(2016).Europeansocietyforswallowingdisorders—EuropeanUniongeriatricmedicinesocietywhitepaper:Oropharyngealdysphagiaasageriatricsyndrome.Clin Interv Aging,11,1403–1428.

Bath,P.M.,Lee,H.S.,&Everton,L.F.(2018).Swallowingtherapyfordysphagiainacuteandsubacutestroke.CochraneDataBaseofSystematicReviews,10.

Bell,C.,&Goo-Yoshino,S.(2018).Chapter10:NutritionalIssuesandSwallowingintheGeriatricPopulation.InCifu,D.X.,Lew,H.,&Oh-Park,M.(Eds.)GeriatricRehabilitation.St.Louis,MO:Elsevier.

Goyal&ShakerGIMotilityOn-Linehttp://www.nature.com/gimo/contents/synopsis.html

Kalf,J.G.,deSwart,B.J.M.,Bloem B.R.,&Munneke,M.(2011).PrevalenceoforopharyngealdysphagiainParkinson'sdisease:Ameta-analysis. ParkinsonismRelatedDisorders,18(4), 311–315.

Martino,R.,Foley,N.,Bhogal,S.,Diamant,N.,Speechley,M.,&Teasell,R.(2005).Dysphagiaafterstroke:Incidence,diagnosis,andpulmonarycomplications. Stroke, 36(12), 2756–2763.

vanHooren,M.R.,Baijens,L.W.,Voskuilen,S.,Oosterloo,M.,&Kremer,B.(2014).TreatmenteffectsfordysphagiainParkinson’sdisease:Asystematicreview.ParkinsonismRelat Disord,20(8),800–807.

Please complete theonline evaluation

Thank you