Dysphagia In-service for Certified Nursing Assistants(CNAs) and Cafeteria Staff in a Nursing Home

Blair Ridgley, MCD CCC-SLP

Presentation is the handout for the in-service

What is Dysphagia?

•Dysphagia means difficulty eating or swallowing▫Dys: Difficult▫Phagein: To eat

•A person can have difficulty with eating or swallowing, classified as dysphagia, relating to any of these three stages:▫Oral▫Pharyngeal▫Esophageal

(Nazarko, 2008)

Four Phases of a Normal SwallowPhase Oral

Preparatory Oral Pharyngeal Esophageal

Relevant Anatomy •Lips•Teeth•Hard/Soft Palate•Cheeks•Floor of mouth•Mandible•Tongue

•Tongue •Hard/Soft Palate•Cheeks•Faucial Arches

•Pharyngeal Muscles•Soft Palate•Epiglottis•Valleculae•Pyriform Sinus•Hyoid Bone•Larynx

•Cricopharyngeal Muscle•Esophagus•Upper Esophageal Sphincter

Actions •Accepting and holding bolus in mouth•Chewing of food•Mixing/grinding bolus with saliva•Centering bolus into position on tongue in preparation for swallow

•Tongue moves bolus to back of mouth by pushing up against hard palate•Triggering the pharyngeal swallow when the bolus passes the faucial arches

•Soft palate elevates•Pharyngeal constrictor muscles push food through the pharynx•Larynx moves forward, elevates, and closes to protect the airway

•Larynx lowers•Esophageal peristalsis moves food from the esophagus to lower esophageal sphincter•Cricopharyngeal muscle contracts to prevent reflux•Peristalsis continues to move bolus to stomach(Terrado, Russell & Bowman, 2001)

Anatomy in View

Valleculae

More Anatomy!

Take Note of All the Structures!

Signs/Symptoms of Problems in Swallowing

Oral Preparatory/Oral Pharyngeal Esophageal

•Drooling•Spitting food out of the mouth•Takes too long to chew•Difficulty chewing•Dry mouth•Meal times are prolonged•Changes in taste•Excessive oral secretions•Excessive or uncontrolled tongue movements •Difficulty managing foods of specific tastes or textures•Avoids foods that require chewing•Cannot suck threw a straw

•Food sticking in the throat•Voice sounds hoarse or different •Nasal sounding voice•Nasal burning or dripping, sniffling during a meal•Nasal regurgitation•Wet or gurgly voice after swallow•Coughing or choking before, during , or after a swallow•Stridor•Excessive saliva or mucous•Saliva is difficult to swallow•Fluids difficult to swallow

•Unpleasant taste to mouth when waking up•Acidic smelling breathe•Excessive burping•Regurgitation of gastric contents or wet burps•Food sticking in the throat•Heartburn or epigastric pain•Repetitive swallowing

(Terrado, et al, 2001)

Possible Risks Without Management

• Penetration▫ Material moves into the area above the true vocal folds

• Aspiration▫ Material breaches vocal folds into trachea and potentially into lungs▫ Aspiration Pneumonia

▫ When material is in the lungs▫ Please note Aspiration does not occur only at meal times**! It can

occur any time!▫ Silent Aspiration

Aspiration occurs but without any coughing or choking• Malnourishment/Undernourishment/Dehydration

▫ Due to decreased intake of the appropriate amount of nutrients and liquids

• Permanent Lung Damage• Inability to take required oral medications•Death!!

Signs and Symptoms of Silent Aspiration

• Just because a patient is not coughing or choking after a swallow does not mean that they have not ASPIRATED!!

• This may occur due to the patient losing the ability to feel that something is in their mouth or has entered their airway.

• Around 50% of patients who aspirate are silent aspirators

• Some signs to recognize silent aspiration:▫Eyes watering▫Nose running▫Patient turning a different color

(Logemann, 1998)

Treatments

•Dietary/Texture Modifications▫Will go over in depth

•Adjusting the Environment▫Have the patient eat in the cafeteria instead

of their room.

•Patient Training in Compensatory Techniques▫i.e. chin tuck, head turn

How Can We Modify the Patient’s Diet?

• No Set Standard▫The American Speech-Language Hearing

Association (ASHA) has no set standard for textures or modified foods and thickened liquids.

• ASHA does not have guidelines currently about food types that should be included on different diet texture levels.

• The National Dysphagia Diet (NDD)▫Published in 2002 by the National Dietetic

Association▫ It outlines 3 modified solid textures and 3

thickened liquid levels

(American Speech-Language Hearing Association, 1997-2014)

(American Speech-Language Hearing Association, 1997-2014)

(McCullough, Pelletier, & Steele, 2003)

National Dyphagia Diet: 3 Solids

• NDD Level 1: Dysphagia-Pureed (homogenous, very cohesive, pudding-like, requiring very little chewing ability).

• NDD Level 2: Dysphagia-Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing).

• NDD Level 3: Dysphagia-Advanced (soft foods that require more chewing ability).

• Regular Diet: all foods allowed(McCullough, et al, 2003)

Level 1:National Dysphagia Diet

•Appropriate foods possibly included in Level 1:▫ Purreed meats (pureed to pudding like consistency; hummus like

consistency; pureed bread mixes▫ Pregelled slurried breads, pancakes, french toast, waffles, or sweet

rolls; smooth cooked cereals, such as farina-type cereals with a pudding like consistency

▫ Pureed fruit; well mashed fresh bananas; pureed vegetables without lumps, pulp, or seeds; tomato sauce without seeds

▫ Mashed potatoes and pureed potatoes with gravy, butter, margarine, or sour cream; well cooked pasta, noodles, or pureed rice (blended to smooth consistency)

▫ Smooth pudding custards; yogurt; pureed desserts and soufflés

(Nutrition411, 2011)

Level 2: National Dysphagia Diet•Appropriate foods possibly included in

Level 2:▫ Moistened ground or cooked meat, poultry, or fish (serve with sauces);

casseroles without rice; moist, well cooked pasta; moist meat loaf or meatballs; poached, scrambled, or soft cooked eggs; tofu; well-cooked and moist mashed potatoes legumes and beans

▫ Soft well, moistened pancakes; pureed bread mixes or slurried breads; cooked cereals with little texture, including oatmeal; slightly moistened dry cereals with little texture

▫ Soft and drained canned or cooked fruits without seeds or skin; ripe bananas; all soft, well cooked vegetables that are in small pieces and mashable with a fork; well cooked and moistened boiled, baked, shredded, or mashed potatoes; well cooked pasta noodles in sauce

▫ Pudding and custards; soft fruit pies (bottom crust only); crisps and cobblers with soft topping and no seeds; moist canned fruits; soft moist cakes with icing or slurried cakes

(Nutrition411, 2011)

Level 3: National Dysphagia Diet

•Appropriate foods possibly included in level 3:▫ Thin sliced, tender, or ground meats or poultry well moistened; fish;

eggs (any preparation acceptable); yogurt (no nuts or coconut); casseroles with small chunks of tender or ground meat

▫ Well-moistened breads, biscuits, muffins, pancakes, waffles, etc (add jelly, margarine, and other topping to moisten well); well moistened cereals

▫ All canned and cooked fruits, soft, peeled, ripe fresh fruits, such as peaches, kiwi, mangos, cantaloupe; soft berries with small seeds, such as strawberries

▫ All cooked tender vegetables; shredded lettuce; rice; and tender fried potatoes

(Nutrition411, 2011)

National Dysphagia Diet: Thickened Liquid Levels

•Nectar-like

•Honey-like

•Pudding (spoon) thick

(McCullough, et al, 2003)

Now You Try It!!

•First open the prepackaged nectar thick.

▫How was it?!•Now try the prepackaged honey thick.

▫How was it?!•Last try the pudding thickened water

▫This one has been mixed with water for each of you already in the styrofoam cup▫How was it?!

• When feeding the patient be on the look out for those signs and symptoms we talked about earlier.▫ Choking, coughing, wet or gurgly voice quality, eyes watering, nose running, etc.

• If the patient is known to have weakness on one side make sure to place the food on the strong side of the mouth, so chewing can be done appropriately.

• Give verbal and visual cues if necessary for the patient▫ “alright now let’s clear the side of your mouth, so take your finger and

move that food onto your tongue”▫ Say this while showing the patient what to do with your finger in your

mouth• Make sure the patient is using compensatory strategies while eating

▫ Chin tucks, head turns, etc.▫ If the patient has a delayed swallow a functional way to help the problem is to give

them a bite of food then give them a bite of sherbet to wake up the swallowing system and initiate a swallow reflex

• Look for any signs above or near the patient’s bed for specific diets!• Position the patient appropriately!

What should you do while feeding the patient?

Positioning is HUGE!!!

•Make sure they are sitting at a 90° angle!!▫ The patient also needs to stay at this position for at least 30

minutes after feeding

•Not 30!•Not 45!

An Example of What You May See in Patient’s Room

What should you NOT do while feeding a patient?

• DO NOT:▫Add ice or water to already thickened liquids

This makes the liquid thin again which can cause the patient to possibly aspirate We want to follow the diets given strictly!!!

▫Feed the patient when they are lethargic or sleeping

▫Use straws when giving the patient thickened liquids Instruct them to take small sips of their liquid

▫Let the thickened liquid sit for a long time It will get thicker as it sits and may cause problems for

the patient

You Are a Part of Our Dysphagia Team!

• All of us use standard recipes for food preparation to ensure the texture and consistency are appropriate for the patient.

• Nursing Assistants make sure food for every meal is of the right texture.• Nursing Assistants also help us educate the family of what foods are safe for

the patient.• Cafeteria staff can present any modified food in a way that is appealing to

the patient.▫ Shaping pureed food into something it would look like if not pureed.

i.e. food molds

• Cafeteria staff prepare the meals for our patients with modified diets.▫ Knowing the importance of the diet helps keep our patients HEALTHY!

• You are our eyes and ears for any possible issues when we are not around!!

Let’s Test What You’ve Learned!!

• If the patient complains their thickened water isn’t cold enough, you can put ice chips in it to make it cold.▫ True or False?

• What angle should a patient be sitting at when eating?▫ 30°, 40°, 90°

• You shouldn’t worry about aspiration if the patient isn’t coughing or choking, but their eyes are watering. ▫ True or False?

• What are some examples of signs and symptoms involved with issues in swallowing?

• If a patient is recommended a Level 1 diet, they are able to eat foods that need a large amount of chewing.▫ True or False?

Questions???