nhs greater glasgow & clyde advancing skills in stroke care swallowing problems after stroke

NHS Greater Glasgow & Clyde

Advancing Skills in Stroke Care

Swallowing problems after stroke

Stroke and dysphagia

• Dysphagia is the term used for swallowing difficulties

• Approx 60% of stroke patients will have some degree of dysphagia at the acute phase.

• Approx. 20% of stroke patients with dysphagia develop aspiration pneumonia.

• More frequent in patients with haemorrhagic stroke.

• The majority of people will improve within 6-7 weeks post stroke.

Normal Swallow

1. Oral stage2. Pharyngeal stage3. Oesophageal stage

Factors which can influence the oral stage:

• Consistency • Hunger/Thirst• Taste• Texture• Visual• Smell

Oral Stage

• Voluntary control• Bolus is propelled backwards

along tongue• Bolus passes faucial arches

and swallow is triggered.

Pharyngeal Stage

• Involuntary stage• Soft palate elevates• Pharyngeal muscles contract,

pulling the food through the pharynx

• Breathing is halted

• The larynx rises and tips to protect the airway from food/fluids passing through the pharynx

• The sphincter at the top of the oesophagus opens to allow the food and drink to enter it

Pharynx

TracheaOesophag

us

Oesophageal stage

• This stage is also under involuntary control

• This stage involves the passage of food/fluids from the oesophagus to the stomach.

Oral stage problems

• Drooling/Loss of food or fluids from lips

• Residue of foodstuffs in the mouth• Loss of taste or smell • Incomplete soft palate seal• Loss of food/fluids into the pharynx

before the swallow is triggered

Pharyngeal stage problems

• Unable to trigger swallow

• Delayed swallow trigger

• Reduced protection of the airway - leading to penetration/aspiration

• No cough reflex

• Pharyngeal muscles are weak

• Upper oesophageal sphincter dysfunction

Penetration of airway

Oesophageal stage problems

• The speech and language therapist is not really involved in problems at this stage as they are unable to assist with problems of oesophageal function

• Medical team investigation and management

Aetiologies of Dysphagia• NEUROLOGICAL• CVA• Motor Neurone Disease• Parkinson’s Disease• Multiple Sclerosis• Myasthenia Gravis• Guillain-Barre Disease• Cerebral Palsy• Dementia (also behavioural)• Brain Tumour• Head Injury

SLT assessment(Bedside Assessment)

• Observational assessment• Oral examination• Food /fluid trials• Recommendations/Documentation• Videofluorscopy

Food Consistencies

• Texture A - a smooth, pouring consistency that cannot be eaten with a fork eg tinned tomato soup.

• Texture B – smooth consistency, drops rather than pours from spoon eg thick custard.

• Texture C – a thick, smooth consistency. Can be eaten with a fork and can be moulded layered and piped eg mousse

• Texture D – food that is moist with some variation in texture. Easily mashed with fork and little chewing required eg flaked fish in sauce / macaroni cheese

• Texture E – Soft moist food that can be broken into pieces with a fork eg sponge and custard, tender meat casserole

Thickened Fluids

• Stage 1 (syrup) can be drunk through a straw and from a cup. Leaves a thin layer on the back of the spoon.

• Stage 2 (custard) Cannot be drunk through a straw, can be drunk from a cup. Leaves a thick coat on back of the spoon.

• Stage 3 (pudding) cannot be drunk from a straw or cup. Needs to be spooned. A bit like thick custard

Videofluorscopy

• X-ray examination of the movement of f ood/ fluids through the oral cavity, pharynx and upper oesophagus.

• This data is videotaped which permits a f rame by f rame analysis of the 3 stages of the swallow.

Short-term signs of dysphagia

• Choking or coughing when eating/drinking

• Change of colour during or eating/drinking

• Wet, gurgly voice• Shortness of breath• Loss of food or drink from the mouth• Pocketing of food or drink in the mouth• Nasal regurgitation

Long-term signs of dysphagia

• Loss of weight with anorexia and dehydration

• Recurrent chest infections• Frequent episodes of high

temperatures

Points to Consider when Feeding

� Is the person alert?� Is the person positioned upright with

their body in mid-line?� Is the person’s mouth clean?� Discourage conversation when eating� Use small spoonfuls� Check the person has swallowed

before giving the next spoonful

� Tell the patient what food or drink you are giving them

� Sit in front of the person or on their ‘good’ side if they have a neglect

� Check in the mouth at the end of meal for pocketing in the cheeks

� Keep the person upright for 30 minutes after a meal

• Watch out with ice -cream as it starts off as a puree but melts in the throat to a normal fluid.

Dysphagia and Quality of Life

• Ekberg et al (2002) article on effects of dysphagia on quality of life.

• Only 45% of the 360 patients in the study enjoyed mealtimes.

• 41% felt anxious or panicky when eating.

• 36% avoided eating in public

• 1/3 of those on modified consistencies still felt hungry/thirsty after a meal.

• Affects, self-esteem, socialization and dignity.

How to refer to SLT ?

Swallowing Video

Endoscope Views of Normal Swallow

PLAY