Red flags for dysphagia

Red flags for dysphagia 

Written by Gilheaney,Orla
CATTS Speech & Language Therapist
Keywords: Red Flags, Dementia Best Practice, Staff Empowerment, Total Well-being

CATTS: Permission to reprint for personal or educational use only.

What happens when we swallow?

When we swallow, we transfer food/liquid from our mouth to our stomach. While this seems simple, it actually involves multiple complex manoeuvres spanning voluntary (e.g.: using your teeth to mash crunchy food) and involuntary movements (e.g.: reflexive muscle movement that propels food through the throat).

First, you take food off the fork/spoon using your lips and tongue, and subsequently mould the food into a small ball (bolus) that is suitable for swallowing. Then, your tongue propels the food backwards into your throat (pharynx). In typical swallowing, your wind-pipe (trachea) is protected during swallowing by a flap of muscle called the epiglottis. This stops food going into your lungs. Food then moves down into you food pipe (oesophagus) and finally into your stomach.

What is dysphagia?

Dysphagia is a swallowing disorder characterized by difficulty transferring food/fluids from the mouth to the stomach, and is associated with emotional, cognitive, sensory and/or motor problems (Tanner, 2006). Dysphagia may result in penetration, aspiration or choking:

  • Penetration: Penetration is the misdirection of food/fluid into the laryngeal vestibule
  • Aspiration: Aspiration occurs when this food/fluid moves into the lower respiratory tract/lungs (Marik & Kaplan, 2003). Penetration or aspiration of food/fluids makes oral feeding a significant safety risk (Ramsey, Smithard & Kalra, 2003).
  • Choking: Choking happens when food/objects get stuck in the throat and block airflow.

What are the consequences of dysphagia?

Dysphagia can have far-reaching consequences on both patients and their caregivers. Firstly aspiration can result in aspiration pneumonia which often necessitated hospitalisation and can have serious health consequences. Similarly, choking can result in suffocating. If dysphagia is severe, the patient may experience severe weight loss, necessitating non-oral feeding methods like feeding tubes to support nutrition. Your speech and language therapist and dietician may recommend special diets, if needed.

Having difficulties with eating and drinking can cause people embarrassment and reduce their social participation. For example: the patient may not want to go out for dinner because they are embarrassed. Similarly, caregivers may have reduced quality of life because they feel helpless and unable to provide relief to their loved ones.

What are the red flags for dysphagia?

Certain clinical groups are at a higher risk of developing dysphagia than others due to a variety of reasons. We have compiled a list of these below:

Clinical Group

Reason

Research

People with Intellectual Disability The person may have neurological conditions, complications resulting from medication, anatomical issues (e.g. cleft palate, flaccid tongue etc.), surgical injuries, institutionalisation or behavioural issues such as impulsiveness

Calis et al., (2008)

Chadwick & Joliffe (2009)

People with head and neck cancer (e.g.: thyroid or throat cancer) The person may have reduced range of motion of structures due to tumour growth, or the results of treatments such as surgery or radiation therapy. Similarly, treatment may cause dry mouth or reduced strength causing the person to need to swallow multiple times

Chen et al., (2001)

Rosenthal, Lewin & Eisbruch (2006)

Nguyen et al., (2004)

Nguyen et al.,(2005)

Caudell et al., (2009)

People with dementia The person may have motor planning problems which make coordination of swallowing difficult. Cognitive difficulties can result in the person forgetting meals, or forgetting to swallow mouthfuls, increasing the risk of choking

Easterling & Robbins (2008)

Chouinard, Lavigne & Villeneuve (1998)

People with gastroenterology problems (e.g.: reflux/ gastrointestinal surgery) The person may have trouble moving the food through their oesophagus, or the food/liquid may return up their oesophagus as reflux. This can damage tissues in the throat and create a “lump in the throat” feeling

Attwood, Smyrk, Demeester & Jones (1993)

DeMeester, Bonavina & Albertucci (1986)

People with mental health issues (e.g.: schizophrenia) The person may have behavioural issues such as impulsiveness, or may have side effects to medication which makes them drowsy and at risk of choking. They may have co-occurring neurological issues or experience the effects of institutionalisation Regan, Sowman & Walsh (2006)
People with neurological conditions (e.g.: stroke, motor neurone disorder, Parkinson’s disease) The person may experience decreased control of muscles or range of motion issues due to neurological problems. The person may have sensory issues which makes swallowing difficult, also

Price, Jones, Charlton & Allen (1987)

Smithard, Smeeton & Wolfe (2007)

Falsetti et al., (2009)

People who have undergone surgery Certain surgeries (e.g.: cervical spine surgery) may result in transient or permanent dysphagia in certain cases.

Bazaz, Lee & Yoo (2002)

Riley-III, Skolasky, Albert, Vaccaro & Heller (2005)

Hunter, Swanstrom & Waring (1996)

Lee, Bazaz, Furey & Yoo (2007)

Fogel & McDonnell (2005)

Children who are born with congenital conditions (e.g.: cerebral palsy) Due to damage to the nervous system, the child may have altered muscle tone or reduced coordination which makes it difficult to swallow or feed safely. Similarly, if the child has cognitive difficulties, this may affect feeding overall.

Rogers, Arvedson, Buck, Smart & Msall (1994)

Calis et al., (2008)

Reilly, Skuse & Poblete (1996)

Mirrett, Roski, Glascott & Johnson (1994)

People taking certain medications (e.g.: sedatives) Medications may have sedative effects on the central nervous system making it difficult to control muscles. Similarly, it may make the person drowsy, increasing the risk of choking

Stoschus & Allescher (1993)

Regan, Sowman & Walsh (2006)

People who are elderly People who are elderly may experience reductions in strength which increases risk of dysphagia. Also, with increasing age, the risk of having other conditions which cause dysphagia increases

Marik & Kaplan (2003)

Robbins, Bridges & Taylor (2006)

Logemann, Curro, Pauloski & Gensler (2013)

Similarly, certain signs that you may notice act as red flags for dysphagia.

The list below outlines some of these (please note that this list is not exhaustive):

Sign

Reason

Taking longer than usual to finish a meal The person may be having trouble chewing/swallowing the food, resulting in longer mealtime
Changing regular diet habits due to difficulty eating The person may recognise that they are having difficulty eating/swallowing and to avoid embarrassment or visiting the doctor, may change habits subtly
Difficulty chewing This may be due to changes in muscle function in the jaw or dental issues. The person may have to swallow large pieces of food which can be dangerous
Build-up of food inside mouth After swallowing, the person may have a build-up of food inside the cheeks/under the tongue. This may be due to a sensory difficulty of not recognizing the food in the mouth or a difficulty with the tongue not being able to collect the food
Nasal regurgitation This may be due to a motor problem as the muscles cannot direct the food the right way. Also, the sphincter at the top of the oesophagus/food-pipe may be too tight and not letting food go down
Unexplained weight loss This may indicate that the person is not receiving nutrients from the food they are eating possibly due to structural issues. The person should see their GP regarding this issue
Reflux This may indicate that food is pocketing in a diverticula/pouch off the oesophagus and then being regurgitated. Otherwise, it may indicate low tone in the sphincters of your oesophagus
Cough before, during and after swallow This may be due to the food/fluid touching/entering the laryngeal vestibule/wind-pipe and causing irritation
Choking The person may get food/foreign objects lodged in their throat and not be able to remove this due to constriction/reduced muscle strength
Dry mouth When a person has a dry mouth, it is more difficult to swallow as they cannot form a moist and cohesive bolus to swallow
Needing to swallow several times per mouthful This may be normal if the food is particularly hard or crunchy, or if you took a very large mouthful. However, it may indicate reduced muscle strength
Drooling The person may have reduced muscle strength in the cheeks, tongue and lips, and/or sensory difficulties in recognizing the drool on their face
Cyanosis/turning “blue” while eating This may indicate an inability to coordinate breathing and swallowing and indicates a significant safety risk
Child arching their back Oftentimes children with swallowing difficulty arch their back to indicate difficulty or discomfort during swallowing
“Wet” voice The person may not be able to clear liquids/secretions/food from their laryngeal vestibule causing their voice to sound “wet” or “bubbly”
Recurrent chest infections/aspiration pneumonia This may indicate that the food/fluids is going into the wind-pipe/trachea and lungs rather than the oesophagus/food pipe
Difficulty managing oral medications Oral medications such as tablets may be difficult to swallow as they are often large and hard. If they get “stuck” in the throat, it may indicate reduced muscular strength
Difficulty maintaining upright posture during feeding If the person is in a slumped position with their head down/tilted it may cause difficulty directing the bolus appropriately
Ill-fitting dentures This predisposes the person to difficulties chewing and mashing food appropriately which can lead to swallowing problems
Pain while swallowing The person may have an infection, a structural problem or difficulties with their oesophagus. Visit your GP in this case
Forgets that food is in their mouth The person is predisposed to choking/aspiration as they are not prepared to swallow
Child is irritable during feed This may indicate difficulty swallowing/discomfort on swallowing
Food refusal This may indicate that the person is aware of swallowing difficulties and does not want to risk eating
Vomiting during/after food This may indicate a problem with the oesophagus/food pipe or stomach

What do I do if I think I/my loved one has dysphagia?

  • If you think you or your loved one has some red flags for dysphagia, you should contact your G.P/Public Health nurse.
  • Alternatively, you can present to your local Accident and Emergency department if symptoms are severe.
  • Finally, you can contact CATTS Ireland for a consultation on 086 888 2765.

References

  1. Attwood, S. E., Smyrk, T. C., Demeester, T. R., & Jones, J. B. (1993). Esophageal eosinophilia with dysphagia. Digestive diseases and sciences, 38(1), 109-116.
  2. Bazaz, R., Lee, M. J., & Yoo, J. U. (2002). Incidence of dysphagia after anterior cervical spine surgery: a prospective study. Spine, 27(22), 2453-2458.
  3. Calis, E. A., Veugelers, R., Sheppard, J. J., Tibboel, D., Evenhuis, H. M., & Penning, C. (2008). Dysphagia in children with severe generalized cerebral palsy and intellectual disability. Developmental Medicine & Child Neurology, 50(8), 625-630.
  4. Caudell, J. J., Schaner, P. E., Meredith, R. F., Locher, J. L., Nabell, L. M., Carroll, W. R., … Bonner, J. A. (2009). Factors associated with long-term dysphagia after definitive radiotherapy for locally advanced head-and-neck cancer. International Journal of Radiation Oncology* Biology* Physics, 73(2), 410-415.
  5. Chadwick, D. D., & Jolliffe, J. (2009). A descriptive investigation of dysphagia in adults with intellectual disabilities. Journal of Intellectual Disability Research, 53(1), 29-43.
  6. Chen, A. Y., Frankowski, R., Bishop-Leone, J., Hebert, T., Leyk, S., Lewin, J., & Goepfert, H. (2001). The development and validation of a dysphagia-specific quality-of-life questionnaire for patients with head and neck cancer: the MD Anderson dysphagia inventory. Archives of Otolaryngology–Head & Neck Surgery, 127(7), 870-876.
  7. Chouinard, J., Lavigne, E., & Villeneuve, C. (1998). Weight loss, dysphagia, and outcome in advanced dementia. Dysphagia, 13(3), 151-155.
  8. DeMeester, T. R., Bonavina, L., & Albertucci, M., (1986). Nissen fundoplication for gastroesophageal reflux disease. Evaluation of primary repair in 100 consecutive patients. Annals of Surgery, 204(1), 9.
  9. Easterling, C. S., & Robbins, E. (2008). Dementia and dysphagia. Geriatric Nursing, 29(4), 275-285.
  10. Falsetti, P., Acciai, C., Palilla, R., Bosi, M., Carpinteri, F., Zingarelli, A., … Lenzi, L. (2009). Oropharyngeal dysphagia after stroke: incidence, diagnosis, and clinical predictors in patients admitted to a neurorehabilitation unit. Journal of Stroke and Cerebrovascular Diseases, 18(5), 329-335.
  11. Fogel, G. R., & McDonnell, M. F. (2005). Surgical treatment of dysphagia after anterior cervical interbody fusion. The Spine Journal, 5(2), 140-144.
  12. Hunter, J. G., Swanstrom, L., & Waring, J. P. (1996). Dysphagia after laparoscopic antireflux surgery. The impact of operative technique. Annals of Surgery, 224(1), 51.
  13. Lee, M. J., Bazaz, R., Furey, C. G., & Yoo, J. (2007). Risk factors for dysphagia after anterior cervical spine surgery: a two-year prospective cohort study. The Spine Journal, 7(2), 141-147.
  14. Logemann, J., Curro, F., Pauloski, B., & Gensler, G. (2013). Aging effects on oropharyngeal swallow and the role of dental care in oropharyngeal dysphagia. Oral Diseases, 19(8), 733–737. http://doi.org/10.1111/odi.12104.
  15. Marik, P. E., & Kaplan, D. (2003). Aspiration pneumonia and dysphagia in the elderly. CHEST Journal, 124(1), 328-336.
  16. Mirrett, P. L., Riski, J. E., Glascott, J., & Johnson, V. (1994). Videofluoroscopic assessment of dysphagia in children with severe spastic cerebral palsy. Dysphagia, 9(3), 174-179.
  17. Nguyen, N. P., Frank, C., Moltz, C. C., Vos, P., Smith, H. J., Karlsson, U., … Sallah, S. (2005). Impact of dysphagia on quality of life after treatment of head-and-neck cancer. International Journal of Radiation Oncology* Biology* Physics, 61(3), 772-778.
  18. Nguyen, N. P., Moltz, C. C., Frank, C., Vos, P., Smith, H. J., Karlsson, U., … Sallah, S. (2004). Dysphagia following chemoradiation for locally advanced head and neck cancer. Annals of Oncology, 15(3), 383-388.
  19. Price, G. J., Jones, C. J., Charlton, R. A., & Allen, C. (1987). A combined approach to the assessment of neurological dysphagia. Clinical Otolaryngology & Allied Sciences, 12(3), 197-201.
  20. Ramsey, D. J. C., Smithard, D. G., & Kalra, L. (2003). Early assessments of dysphagia and aspiration risk in acute stroke patients. Stroke, 34(5), 1252–1257.
  21. Regan, J., Sowman, R., & Walsh, I. (2006). Prevalence of dysphagia in acute and community mental health settings. Dysphagia, 21(2), 95-101.
  22. Reilly, S., Skuse, D., & Poblete, X. (1996). Prevalence of feeding problems and oral motor dysfunction in children with cerebral palsy: a community survey. The Journal of Pediatrics, 129(6), 877-882.
  23. Riley III, L. H., Skolasky, R. L., Albert, T. J., Vaccaro, A. R., & Heller, J. G. (2005). Dysphagia after anterior cervical decompression and fusion: prevalence and risk factors from a longitudinal cohort study (presented at the 2004 CSRS Meeting). Spine, 30(22), 2564-2569.
  24. Robbins, J., Bridges, A. D., & Taylor, A. (2006). Oral, pharyngeal and esophageal motor function in aging. GI Motility Online. http://doi.org/10.1038/gimo39.
  25. Rogers, B., Arvedson, J., Buck, G., Smart, P., & Msall, M. (1994). Characteristics of dysphagia in children with cerebral palsy. Dysphagia, 9(1), 69-73.
  26. Rosenthal, D. I., Lewin, J. S., & Eisbruch, A. (2006). Prevention and treatment of dysphagia and aspiration after chemoradiation for head and neck cancer. Journal of Clinical Oncology, 24(17), 2636-2643.
  27. Smithard, D. G., Smeeton, N. C., & Wolfe, C. D. A. (2007). Long-term outcome after stroke: does dysphagia matter?. Age and Ageing, 36(1), 90-94.
  28. Stoschus, B., & Allescher, H. D. (1993). Drug-induced dysphagia. Dysphagia,8(2), 154-159.
  29. Tanner, D, C. (2006). Case studies in communicative sciences and disorders. Columbus: Pearson Prentice Hall.

 

If you have any questions about any of the above, please don’t hesitate to contact us.

 

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