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NHS Greater Glasgow & Clyde Advancing Skills in Stroke Care

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.

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NHS Greater Glasgow & Clyde Advancing Skills in Stroke Care

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  1. NHS Greater Glasgow & ClydeAdvancing Skills in Stroke Care Swallowing problems after stroke

  2. 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.

  3. Normal Swallow 1. Oral stage 2. Pharyngeal stage 3. Oesophageal stage

  4. Factors which can influence the oral stage: • Consistency • Hunger/Thirst • Taste • Texture • Visual • Smell

  5. Oral Stage • Voluntary control • Bolus is propelled backwards along tongue • Bolus passes faucial arches and swallow is triggered.

  6. Pharyngeal Stage • Involuntary stage • Soft palate elevates • Pharyngeal muscles contract, pulling the food through the pharynx • Breathing is halted

  7. 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

  8. Pharynx Trachea Oesophagus

  9. Oesophageal stage • This stage is also under involuntary control • This stage involves the passage of food/fluids from the oesophagus to the stomach.

  10. 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

  11. 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

  12. Penetration of airway

  13. 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

  14. 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

  15. SLT assessment(Bedside Assessment) • Observational assessment • Oral examination • Food /fluid trials • Recommendations/Documentation • Videofluorscopy

  16. 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

  17. 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

  18. 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

  19. 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

  20. Long-term signs of dysphagia • Loss of weight with anorexia and dehydration • Recurrent chest infections • Frequent episodes of high temperatures

  21. 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

  22. 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

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

  24. 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. Dysphagia and Quality of Life

  25. How to refer toSLT ?

  26. Swallowing VideoEndoscope Views of Normal Swallow PLAY

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