Dysphagia in the Elderly Implications in Long-Term Care

1. Dysphagia in the ElderlyImplications in Long-Term Care Annette T. Carron, DO Director Geriatrics & Palliative Care Botsford Hospital

2. 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

3. NormalSwallowMechanism 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)

4. 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)

5. 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 Slide 5

6. 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)

7. 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

8. 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

9. DYSPHAGIA Oropharyngeal dysphagia—Patients complain of foods getting “stuck,” inability to initiate a swallow, impaired ability to transfer food from mouth to esophagus, nasal regurgitation, coughing Esophageal dysphagia—Patients 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

10. 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

11. 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

12. 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

13. 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

14. Dysphagia Symptoms Prolonged oral preparation Increased time to consume meal Unusual head or neck posturing with swallow Pain with swallow Decreased oral/pharyngeal sensation Slide 14

15. 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 Slide 15

16. 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?

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

18. 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

19. 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

20. 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

21. 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 Pepticstricture

22. 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

23. Dysphagia • Assessment and Diagnosis • Consultants • Otolaryngologist • Gastroenterologist • Neurologist • Speech therapist • Radiologist

24. 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

25. 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

26. 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 Slide 26

27. 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

28. 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

29. 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 Slide 29

30. 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

31. 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

32. 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 resident’s clinical condition demonstrates this is not possible, and receives a therapeutic diet when there is a nutritional problem Slide 32

33. 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)

34. 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 Slide 34

35. Dysphagia • Training nursing assistants • In-service after have worked with feeding residents • Meal Time Matters – IDEAS Institute • Interactive Institute • http://www.ideasinstitute.org Slide 35

36. 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 Slide 36

37. 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? Slide 37

38. 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 Slide 38

39. 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 Slide 39

40. 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 Slide 40

41. 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 resident’s 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 resident’s ordinary and special dietary needs • Treatable causes • Monitor progress Slide 41

42. 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) Slide 42

43. Summary Oropharyngeal dysphagia may be life-threatening All team members important Pt/Family important Don’t have to put in a tube feeding QOL

44. 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

45. 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 H&P 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 Slide 45

46. CASE 1 • Physician H&P 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 Slide 46

47. CASE 1 • What should surveyor expect to be on chart when arrives? • What is reasonable to expect that all staff knew about resident’s care? • Is anything reasonable to expect from doctor in terms of resident’s care • If cited what would you include in IDR? Slide 47