Dysphagia - Assessment

STROKE
1. (national CLin guidelines for Stroke 2009)
2. Approx 40% of patients after stroke exp dyspagia
3. Malnutrition common inpatients and dehydration sometimes
4. 30-40% concious patients have sig dys on day of stroke, 15-20% one week post, 2% one month post (RCSLT, 2005)
5. SCREEN should be within first 4 hours (RCP)
  1. Many screens fail on reliability, validity and feasibility (Schepp)
Assessment should consider whole person
1. Ability to eat in social settings, eat in diff locations
  1. Well being / mood
    1. Motor skills (gen), cognition, oral sensitivity, dental health, structure, resp status
      1. ACT: Management of secretions, need to use special utensils, positioning
      2. Comorbid diseases: UTI (red awareness / appetite), cardiac / respiratory affect how easy to endure apnoeic period
ORO-MOTOR
1. Important to know if have a phasic / tonic bite
2. 1. Observe patient at rest
3. Saliva colour - excessive drooling?
  1. 2. Oral mucosa pink
  2. 3. Pooling of saliva in oral cavity - dyspagia
    1. Lat medullary stroke (Huckabee)
  3. Dehydration, cracking / flaking
4. 4. Dentition? Decay? Cracked ... Increased risk asp (Langmore et al 98)
5. Lip symmetry, range of motion, resistance (CNVII)
6. TONGUE: at rest, fasiculations, musc. wasting, range, symmetry, strength. Protrusion, lateral, elevation. Anterior - posterior movmeent 'str'. TASTE & TOUCH surface.
7. PALATE: VP sensation via touch, symmetry on phonation, gag elicitation. Puff out cheeks. Elevation on 'ah' 'ah', alternate ng/ah
  1. PHARYNX: Palpation of thyroid cart. laryn excursion - presence only. VF NEC.
  2. Leder 96 says pres or abs of gag does not predict swallow ability / protection
8. LARYNX: Vocal qual. glottal coup and cough, pitch range - clues about lar function. VF NEC.
  1. SPEECH: Not robust ass. w swallow (except LMN . /g/ /k/ useful
  2. DRY SWALLOW
9. BILATERAL LMN - softens clinical pres over time
  1. strong ASYMMETRY (not lower face) beyond actute = ipsilesional LMN
    1. LATERALISING presnetation hard to specify, could be ipsilesional LMN or contralesional UMN damage not yet softened coz bilateral inputs
10. RANGE, STRENGTH, CONTROL
11. Facial movement & symm. (CN VII)
Consider:
1. Intrinsic variables - such as ageing
  1. With age cartilages ossify, arthritis increases,
    1. Decreased hyoid movement
  2. Strength decreases (tongue pressure), neuro musc funcs slow w age (Kendall et al 04)
    1. However sometimes inc volume to initiate phar swallow
  3. Some older adults use a DIPPER swallow, where bolus under tongue and tongue has to go under
  4. Inc oral transit time (Robbins et al 92)
2. Extrinsic variables - such as bolus volume / viscocity
  1. Bigger mouthfuls require longer apnoeic period and simulataneous oral and pharyngeal action (Logemann 98)
  2. Increased viscosity (marshmallow) reduces transit speed and leads to increased oral pressure (not good if muscles weak)
  3. Taste / Temperature - identifying bolus
  4. Cup drinking: decreased transit time. Sequential can mean airway closure doesn't let up
  5. Straw: Problem in sucked in by inhalation, not oral suction
  6. Food consistency: e.g. cornflakes, issue with tongue and palate seal and OVERSPILL risk (Saitoh et al 07)
3. Questions:
  1. 1. Do they have dysphagia?
    1. 2. What are areas of breakdown?
      1. 3. Are there any signs of aspiration / penetration?
        4. Is there risk of malnutrition / dehydration?
        5. Is there any thing else you need to know?
  2. What is the impact?
    1. SWAL-QOL McHorney et al ( 2002) (Swallowing related qual. of life surveys)
    2. Family
    3. Carers
    4. Functional assessment scales, e.g. EAT 10 (Belafsky 2008)
    5. Functional Oral intake scale (FOIS) (Crary et al 05)
ASPIRATION: Before, during or after swallow?
1. Penetration only airway above VF's
  1. Does client have protective cough? (May clear aspiration)
    1. SIGNS OF ASPIRATION
      1. Recurrent chest infections
      2. Wet / gurgly voice
      3. Weight loss
      4. Coughing / choking on food, drink or saliva (or exces s. not swallowed)
      5. Refusal to eat
      6. Actute: Spiking temp. Change of colour, sounds of resp diff, inc heart rate, watery eyes
      7. SIGNS indicating DYSPHAGIA
        Dysarthria
        Pulmonary cond.
        Drooling
        Long meal time
        |Nasal regurgitation
        Hypernasality
        Sensation of obstruction
2. Can be silent
BEDSIDE SWALLOW ASS. - ORAL TRIALS
1. 1. ice chips - patient with cog probs
2. 2. Thin liquids: more likely to asp if neurogenic dys (CLAVE et al 06). 3ml, 5ml then sips
3. 3. Thickened liquids, St I, II, III. (Need inst. exam to determine if effective (Daniels & Huckabee et al. 14))
4. 4. Puree (.e.g apple sauce or up to pudding or masked potatoes)
5. 5. Mashable moist solid (mashes but you can pick it up, e.g. ripe banana)
6. 6. Firm solid (may iden pat with spec imp of cricopharyngeus)
7. For all consistency - use three trials Daniels and Huckabee (2013)
  1. Controlled ingestion
  2. Monitored ingestion
    1. Perf. on continuous swallow of rapid sips?
    2. SIZE? SPEED?
    3. Ant. leakage?
    4. Bolus transfer?
    5. Laryngeal bobbing?
      1. Swallows to clear?
  3. Independent ingestion
8. CASE HISTORY from everyone in contact w. patient inc OT etc.
  1. P.C.
    1. P.M.H
  2. D.H.
    1. Soc.H
  3. Phys status inc chest
    1. Cog. status
9. Reflex ass. Sensitvity, gag, bite, cough
10. LOOK, LISTEN, FEEL
  1. Alertness?
  2. Fatigue
  3. Resp. status
  4. Bedside misses 40% people who asp (Leder et al. 98)
11. Sitting up 90 deg. dentures in
12. Mann Assessment of Swallowing Ability (MASA- Mann 2002). (Standardised) no CN Ax
ASP / PEN warning signs
1. RAPID HEART RATE
2. SPIKING TEMP
3. WATERY EYES
4. CHANGE in COLOUR
5. Food / fluids in secretions on suctioning

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Dysphagia - Assessment

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	Created by Heather Snaith about 8 years ago