Swallowing difficulties in the older adult if understood can prevent unnecessary hospitalization. The inability to swallow is called Dysphagia. Aspiration is when fluid or food particles enter into the lung field. Dysphagia and aspiration occur more often during the early stage of a stroke due to changes in the brain. Dysphagia can also develop during advanced stages of Parkinson’s Disease, Alzheimers and Brain Cancer, wherever there are changes to cognition. When there are changes to the brain, the common centers responsible for swallowing become impaired, which disrupts the swallowing network and debilitates the command center.
UNDERSTANDING HOW SWALLOWING WORKS
There are 3 types of swallowing.
1- subconscious swallowing (which occurs approximately once every minute);
2- reflexive swallowing (which is an airway-protective mechanism triggered by a sudden stimuli, such as the arrival of refluxate from the stomach or an inadvertent drop of food into the pharynx); a reflexive swallow activates only the sensorimotor area, commonly known as the gag reflux.
3- nutritional, or volitional, swallowing (which occurs when eating). When volition is involved, there is a swallowing network in the cerebral cortex that includes the insula, cingulate gyrus, prefrontal gyrus, somatosensory cortex, and precuneus regions. All of these areas are activated when a person takes a volitional, or nutritional, swallow.
SIGNS AND SYMPTOMS OF DYSPHAGIA
Any neurologic or muscular damage along the upper airway and upper
digestive tract can cause dysphagia. Thus, central causes of dysphagia
in stroke patients include damage to the cortex or brain stem, and
peripheral causes include damage to the nerves or muscles involved in
(a) A lack of cough in the stroke patient may signal the inability to sense a foreign substance entering the airway; a poor gag reflux, unable to perform reflexive swallowing. Coughing is good defense mechanism to clear the lung field of any aspiration.
(b) Cough after drinking fluid may signal weakness in taking an intended swallow (volitional), a lack of sensation at the back of the throat which arose from nerve damage.
(c) Weakness in Speech can be also be a sign of dysphagia as the musculature responsible for producing sounds are within the same proximity as those muscles needed to swallow.
(d) Excessive drooling from the mouth. Parkinson’s Disease produce less saliva, and the drooling is a sign of inability to do subconscious swallowing and may need to be prompted to swallow.
(e) Watch out for secondary signs such as weight loss, avoidance of certain foods, dehydration, and recurrent chest infection as secondary symptoms to a swallowing difficulties.
TESTING FOR DYSPHAGIA
All stroke patients should have a swallowing assessment prior to discharge from hospital. Technologies have advanced which allows camera to view the swallowing function and identify any deviation of food into the lung field. There are several pockets and areas where food can “park” due to nerve and muscle changes, and the use of such cameras can provide precise evaluation.
Upright sitting is advised during all meal times with shoulders back. The placement of the chin is often confused by families. While the shoulders are pressed back, the chin can be slight tilted to the chest to assist with swallowing. This facilitates positioning of the epiglottis, and narrows the entrance to the throat by the trachea or windpipe. Use this positioning the next time for individuals who experience difficulty swallowing pills and reduces the chance of choking and regurgitation.
We demonstrate with our nurses and our families the difference in drinking a sip of water with your chin slightly dipped to your chest, and with your chin elevate away from your chest. You will feel the difference.
For those patients who are respiratory compromised such as COPD and CHF, supplemental oxygen through nasal cannula during meal times may be required to provide sufficient oxygenation while the throat focuses on delivering the food to the stomach. The use of oxygen does require a physician evaluation and medical order.
HOME NURSING AND PHYSIOTHERAPY
Homecare is recommended for elders to improve muscle strength associated with swallowing. Speech Pathologist along with Physiotherapist use exercise focusing on strengthening the esophageal muscle and maintaining correct sitting position during meal time.
Home nurses from Accredited Organizations are trained to detect signs and symptoms related to dysphagia and practice proper positioning techniques to prevent aspiration.
Enayati Home Nursing is recognized by Accreditation Canada International for providing safe home nursing care. Our teams are trained in Patient Safety, Elderly Care, Parkinson’s disease, Dementia, Alzheimer Stroke/CVA .
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