Compiled by Sandra Ameen, B.Sc. (Hons) and Kenneth Delia B.Sc. (Hons) Dip. Ger. MBA
Description of the Problem
One of the great joys of life is savouring good food. Enjoyment of food and drink is essential to our quality of life. However, we take this very much for granted. Not everyone experiences this joy of eating because swallowing may be impaired (known clinically as dysphagia). This occurs, as we age and even more so when other medical conditions are present. It is estimated that nineteen to thirty-three per cent of people with stroke will develop aspiration pneumonia – a chest infection due to food or liquid entering the lungs.
Approximately thirty mouth and throat muscles and multiple nerves are involved in transporting food or fluid through the mouth, pharynx and safely into the esophagus. Swallowing can be divided into 4 stages:
- Oral Preparatory Stage
- Oral Stage
- Pharyngeal Stage
- Esophageal Stage
The Oral Preparatory stage is voluntary and involves the preparation of the bolus with the aid of saliva, good lip seal, jaw movement and chewing. During the oral stage, the tongue elevates and rolls back, sequentially contacting the hard and soft palate, moving the bolus backwards.
The pharyngeal stage involves:
- Elevation and retraction of the soft palate
- Laryngeal closure and suspension of respiration
- Relaxation and opening of the sphincter at the top of the oesophagus
- Bolus is propelled into the oesophagus
Mistiming of the pharyngeal stage results in food entering the airway.
The Esophageal Stage is an involuntary process whereby food finally passes through the esophagus into the stomach.
A number of factors can affect the normal swallow. These include posture, the ability to self feed, cognitive influences including fatigue, bolus size and viscosity. Other factors include appetite, food presentation, the environment, hygiene (including odours), comfort (including bowels), mood and previous life experiences.
Dysphagia commonly occurs with stroke, Parkinson’s disease, multiple sclerosis, head injuries, cerebral palsy, Muscular Dystrophy, motor neuron disease, Alzheimer’s dementia and cancer of the mouth and throat areas . Medications may also have a major side effect due to reduced saliva (xerostomia) which makes swallowing of dry food extremely difficult.
Signs and Symptoms
A number of signs indicative of dysphagia may be present. A person’s medical condition might alert one to possible dysphagia, for example, a history of previous strokes. Sudden increases in body temperature, increased coughing or choking (especially on thin liquids) could also be present. Other signs include a raised respiratory rate, weight loss, a gurgly ‘wet’ voice, discomfort or pain during swallowing, lack of interest in food or drink as well as an intolerance to a particular or more than one type of consistency (liquids, yoghurt-like, thick soup-like or hard and lumpy food).
How to Help – Dos and Don’ts
The role of the Speech-Language Pathologist (SLP) is to obtain a holistic picture of the client’s difficulties. The aim of the assessment should be to identify the risk of aspiration, leading to preventive management. It should determine:
- whether dysphagia is present
- the client is safe to feed orally
- the risk of aspiration
- what type of consistency the client can manage
- which stage/stages is/are involved
- the severity of the problem
- the prognosis
- the need for referral to other professionals
The presence of the above signs and symptoms are of great importance to the SLP. Other important considerations include:
- the client’s positioning
- the need for assistance and feeding aids
- level of alertness
- communication and cognition
- caregiver/client interaction
- auditory and visual acuity
- oral hygiene
SLP intervention, may consist of direct treatment with the client as well as indirect treatment with carers. Direct treatment usually focuses on oro-musculature exercises and/or compensatory strategies. Another important aspect is awareness and education.
Simple Guidelines and Precautions
- Be aware of your posture – eat while sitting upright.
- Eat in a quiet, comfortable environment, for example, turn off the television or radio.
- If you wear dentures, glasses or hearing aids, make sure to wear them while eating and drinking. Keep dentures clean and fitting properly.
- Do not talk while eating.
- Do not rush mealtimes.
- Limit the amount of food or liquids in one swallow.
- If thickening of liquids is recommended, it is important that this applies to all liquids and the consistency is that recommended by the SLP. The thickening agent should always be carried with the patient, just in case one would like a drink when not at home.
- Avoid crumbly foods such as rice, biscuits, toasted bread and dry rusks.
- American Speech-Language-Hearing Association (https://www.asha.org/)
- IALP – International Association of Logopedics and Phoniatrics (https://ialpasoc.info/)
- Royal College of Speech Language Therapists (https://www.rcslt.org/)