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
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