All clinicians need to be aware of the swallowing issues faced by an aging population.
By Mary Barker, MEd, CCC-SLP
October 1, 2013
NPs, PAs, nurses, CNAs, dining room staff and volunteers-all should be looking for issues associated with swallowing to prevent injury and to be sure long-term care residents are getting the nutrition they need.
Swallowing involves a complex series of emotional and physical responses that are essential for maintaining health and wellness. The swallowing process begins with the sensory experience when the food is first presented: you see and smell the food. If food looks or smells unappealing, the appetite and desire to eat may be reduced.
The visual and olfactory impact on appetite should not be overlooked, and are highly individualized. Some people will not eat foods that touch other foods. Some people are nauseated by seeing foods mixed together on their plate. Some people lose their appetite if they see too much food on the plate. Some people are totally turned off to eating if they smell things they consider noxious (i.e., broccoli or liver). Recognize if a resident has a personal preference or reaction to the presentation of food and accommodate it.
Once the food is in the mouth, again many senses are utilized: you taste the food, feel its temperature and texture, hear the food crunch as you chew.
Even if all the musculature is working properly, a person may have diminished oral intake if their sensory experience is adverse. A prime example of this is people who are supposed to drink thickened liquids. That cup of nectar- thick coffee might taste the same, but it feels different and that may become a noxious stimulus. People on thickened liquids have a very high risk of dehydration for this reason.
People with cancer who have undergone radiation to the neck and have reduced saliva flow will have altered taste. Saliva is the primary means of transporting food to the taste buds. Often people are not able to sustain nutrition orally after radiation treatment. The food doesn't taste right, resulting in a reduced desire to eat.
Physical Aspects of Swallowing
• Lips close to keep food from dribbling out.
• Tongue and cheeks work to form food into a ball.
• Tongue lifts the food up from front to back and moves the food (bolus) back toward the throat.
As the food gets close to the opening of the throat the swallow reflex triggers:
• You begin to hold your breath.
• The soft palate lifts to block the nasal passage.
• The base of the tongue pushes back to touch the back wall of the throat (pharynx) to create pressure to push food down the throat.
• A flap (epiglottis) in the throat drops to cover the top of the airway so the food doesn't get into the airway.
• Muscles in the throat lift up toward the flap to protect the airway (Adams Apple lifts up).
• The cricopharyngeal muscle at the top of the esophagus (tube to the stomach) opens up to let the food move out of the throat toward the stomach.
• The esophagus uses peristalsis and pressure from above to propel the bolus toward the stomach.
Signs of Swallowing Problems
Swallowing problems can lead to dangerous complications. As a care provider you should look for signs of difficulty, which may include:
• trouble keeping food and saliva in the mouth (drooling)
• chewing the food for a long time
• trouble moving food out of the mouth
• food or liquid getting stuck in the mouth
• spitting out food
• collection of food pockets (in the cheeks or along the gums)
• need to swallow several times to clear food out of the mouth
• coughing during or right after eating or drinking
• clearing throat during meal more than usual
• voice becomes wet and gurgly during or just after meals
• food clears out of mouth without the Adam's Apple rising
• weight loss or dehydration
• recurring pneumonia or chest congestion after eating
• slightly elevated temperature
• unexplained loss of desire to eat
• refusal to eat
• reports of food sticking in the throat
• reports of food sticking in the chest
Safe Swallowing Strategies
There are few absolute rules for safe swallowing, but these techniques are true for most people. If you are assisting with feeding, following these guidelines:
• The resident should be sitting up straight for all eating and drinking, preferably out of bed.
• The resident should sit with head bent forward slightly. Prop a pillow behind the head if needed.
• Make sure dentures are in and eyeglasses are on.
• Turn off televisions, radios and other noisy distractions.
• Do not mix the foods together unless the resident specifically requests it and the speech therapist tells you it is safe.
• Sit on the same level as the person you are feeding.
• Begin meals with something to drink as it is harder to swallow when the mouth is dry.
• Ask the resident what food/drink he wants. Give him some control.
• Give small bites of food/small sips of liquid.
• Tell the resident what food/drink is coming next so he knows what is coming and has a chance to request something different.
• Give plenty of time between bites/sips. Watch for Adam's Apple to lift.
• Check that the person's mouth is clear before giving more food.
• Never tilt a person's head back to help clear the food out of the mouth.
• Stroke under the chin - front to back - if the person is holding food in the mouth.
• Give a drink after every two or three bites of food.
• Encourage the person to take an extra (dry) swallow between bites of food.
• Meals are typically social times for us all; talk to the resident, not to your co-workers.
• Talk to residents between bites when their mouths are empty. Be quiet while the food is in the mouth. No talking with mouths full.
• Listen to the resident's voice. If it sounds wet and gurgly, let the nurse know.
• Stop feeding the resident and tell the nurse if the resident chokes or coughs.
• Let the nurse know if you see any of the symptoms of swallowing problems.
• Have the resident sit upright for 30 minutes after a meal or drink.
There is no industry standard for diet textures, but many skilled nursing facilities use some variation of the following guidelines.
• Thin, such as water, coffee, tea, soda, most juices, milk, ice cream, Jello, candies that melt.
• Nectar-like, including all thin drinks need to be thickened to be like syrup or prune juice. No ice cream, Jello, hard candies or frappes. May have Magic Cups.
• Honey-like, includes drinks thickened to be like honey. If you dip a spoon in and take it out, the drink will coat the spoon.
• Pudding-like, or that which does not pour from a cup and must be spooned.
A speech therapist might recommend some additional special liquid considerations, such as no mixed textures, meaning the resident cannot have liquids containing solid chunks. Soups must be pureed, no cold cereal with milk, and no fruit with syrup.
Residents may also be on a free water protocol, meaning they can have water between meals with no food. They must have thorough mouth care prior to taking water. If the resident has any food (meal or snacks), drinks must be thickened.
• Regular. All foods allowed.
• Ground. Meats are ground up. Regular fish, pasta and breads are typically allowed.
• Puree. All food must be smooth and creamy.
Sandwiches and bread products may not be allowed for some people on a ground texture diet, based on the person's ability to manage those food items.
Often a speech therapist will request a mixed diet such as ground with pureed fruits and vegetables or puree with ground meat: all food is smooth and creamy, but ground meats and regular pasta is allowed.
The risks of residents not having swallowing problems identified, not having the right texture diet, and not following safe swallowing strategies may include choking, weight loss, malnutrition, or aspiration.
Aspiration occurs when the food/drink gets to the lungs, which can cause the resident to become very sick and possibly even die due to pneumonia. This differs from airway penetration, which occurs when the food/drink enters the airway, but is spontaneously cleared without getting to the lungs. There is a cough reflex that typically occurs when food/drink "goes down the wrong way." The force of the air coming from the lungs helps to clear the airway.
Some people have lost that protective cough reflex. Food or drink may get into the airway without the protective cough reflex triggering. There is no outward sign that anything is wrong. There is no cough to try to clear out the food/drink and prevent it from getting to the lungs. Forty percent of people with a neurological diagnosis are silent aspirators. Diet textures and sometimes swallowing strategies are ordered by the doctor and are typically recommended by a speech-language pathologist.
Modified Barium Swallow
A modified barium swallow (MBS) is a highly specialized x-ray connected to a DVD or VCR that allows the speech-language pathologist and radiologist to watch what happens to food and drink as the person swallows. The food/drink can be tracked from the time it enters the mouth until it gets to the stomach, and the motion of the swallowing is evaluated, sometimes revealing a problem with coordination and timing of the movements.
Even the most skilled speech-language pathologist can only guess about what happens in the pharyngeal and esophageal phases of swallowing. The only way to know for sure what is happening, if there is a problem, and if so what is causing the problem, is for an objective study such as the MBS. Most times a pharyngeal or esophageal phase problem is suspected, and MBS will be indicated. We cannot know for sure if a person is aspirating without an MBS. An MBS will also let the SLP and clinician watch for silent aspiration or silent penetration. Different feeding and swallowing strategies can be trialed during the MBS to help determine the best strategies for safe swallowing.
Mary Baker is the senior clinical supervisor for Speech Therapy Group in Beverly, Mass., and an SLP at DenMar Nusing and Rehabilitation Center for Kindred Rehab Service, Inc.