Download clinical swallowing evaluation

Clinical Swallowing Evaluation Across the Life Span:
The Science & the Art
Memorie Gosa
Donna Scarborough
Michelle Ciucci
Pam Smith
Disclosures
• Memorie Gosa
– Receives salary from the University of Alabama, Member of Coordinating Committee for SIG 13, Member of ASHA Program Committee 2014, Member of the Board of the AB‐SSD
• Michelle Ciucci
– Receives salary from the University of Wisconsin, • Donna Scarborough
– Receives salary from Miami University, Member of ASHA Program Committee 2014
• Pam Smith
– Receives salary from Bloomsburg University, Member of ASHA Program Committee 2014, Coordinating Committee for SIG 15
Bedside Assessments/Evaluation
Has order been received?
By whom?
Chart Review
Discussion with other professionals
Meet patient
Cognition/Language
Position
Pulmonary
Voice
Medical Equipment
Sensorimotor Examination
Oral Mechanism
Cranial nerve exam
Introducing Liquids/Foods
Observations
Impressions
Recommendations
This process typically takes 15 minutes to 60 minutes
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INFANT FEEDING AND SWALLOWING: CLINICAL SWALLOWING EVALUATION
Memorie M. Gosa
[email protected]
Infant Clinical Swallowing Evaluation
Causes of Pediatric Feeding Problems Disorders of Appetite
Mucosal Infections & Inflammatory Disorders
Metabolic Diseases
Disorders affecting Neuromuscul
ar Coordination of Swallowing
Disorders affecting Sucking‐
Swallowing‐
Breathing
Sensory Defects
Conditioned Dysphagia
Anatomic Abnormalities of the Oropharynx, Larynx, Trachea, & Esophagus
Rudolph CD & Link DT (2002) Feeding Disorders in Infants and Children. Pediatric Gastroenterology & Nutrition, 49(1), 97‐112.
“Normal” Feeding Skills
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0-4 Months of Age
Exclusive bottle/breast feeding
Reflexive suckling pattern dominates intake of fluid from breast or bottle
Newborns eat on demand every 1.5 – 2.0 hours
1-4 months of age, baby eats on demand every 2-3 hours
4-6 Months of Age
• Continue bottle or breast feeding on demand, usually every 3-4 hours
• Transitions from reflexive suckling to learned, mature sucking pattern between 4-6
months of age
• Introduction of baby cereal from a spoon when baby has:
• Steady head control
• Sits independently for 10 – 30 seconds
6-9 Months of Age
• Continue bottle or breast feeding on demand, usually every 3.5-4 hours
• Introduction of baby food- Stage 1 as baby uses mature spoon feeding skills
• Baby begins hand to mouth play at ~6 months, sits independently for more than 3-5
minutes at 6-7 months, and has stable head control with no head bobbing by 6-7
months
9-12 Months of Age
• Continue bottle or breast feeding on demand, usually every 4-6-8 hours
• Baby begins munching and moving food from side to side in mouth around 9
months of age as they are learning a mature chewing pattern
• Baby’s chewing skills advance to a circular pattern, tongue actively moves food
from side to side in mouth
Morris, S. E., & Klein, M. D., (2000). Pre‐feeding skills: A Comprehensive resource for feeding development
(2nd ed.). Tucson, AZ: Therapy Skill Builders. General History
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Weight/Height Growth Charts
Medications
Birth Hx
Neurologic Hx
Cardiac Hx
Respiratory/Airway Hx
GI Hx
Renal Hx
Craniofacial Hx
Hemolytic Hx
Allergy Hx
http://www.asha.org/Practice‐Portal/Templates/
Infant
Medical/Feeding History & Assessment Form
(Infant 6 month s and youn ger)|1
A. Identifying information
Patient Name: ______________________________
DOB: _____________________________________
Date of Admission: __________________________
Admitting Diagnosis: __ _______________________
Reason for Referral: _________________________
Yes
No
Outside Tx in place:
Chronological Age: __________________________
Adjusted Age: ______________________________
Current weight: _____________________________
WHO Growth Chart: ______________% Height _________ ______% Weight
Yes
No
Concerns about weight loss/gain:
Yes
No
Nutrition/Hydration consult:
Primary Caregiver: __________________________
Informant for the Evaluation: _____ _____________
Primary Language: __________________________
Yes
No
Interpreter needed:
Yes
No
Interpreter present:
Patient/Family Goals/Concerns:____ _______________________________________________
____________________________________________________________________________
Noted Barriers to Learning: _______ _______________________________________________
B. Pertinent past and current medical information
B1. Medications
Medications currently taking: _____ _______________________________________________
B2. Birth History:
Gestation: ________________ weeks ________ ______days
Birth weight: ______________ pounds _______ ______ ounces
Average
Low Birth weight (1500-2499 g)
Very Low Birth weight (1000-1499 g)
Extremely Low Birth weight (<1000 g)
APGAR Scores: _____at 1 minute _____at 5 minutes ___ __at 7 minutes
Multiple Birth (Twin/Triplet/Quadruplet/Quintuplet/Sextuplet)
Single Birth
Pregnancy Complications: ______ ________________________________________________
____________________________________________________________________________
Vaginal
Cesarean-section
Type of Delivery:
Delivery Complications: _________________________________________________________
Templates are consensus-based and provided as a resource for members of the American SpeechLanguage-Hearing Association (ASHA). Information included in these templates does not represent official
ASHA policy.
Infant
Medical/Feeding History & Assessment Form
(Infant 6 month s and youn ger)|2
B3. Neurologic History
No history of neurologic issue s
Seizures
CVA
Anoxia
Ataxia
Brain Tumor
Hydrocephalis
Paralysis
TIAs
Microcephaly
Nystagmus
CP
Tremor
Hypotonia
Hypertonia
Mixed muscle tone
IVH/PVL
Craniofacial anomalies
Syndrome/association/Sequence
Other:___________________
Current neurologic impairment:___________________________________________________
B4. Cardiac History
Yes
No
History of cardiac proble ms?
If yes:
Type of problem:________________________________________________________
Related surgeries:_______________________________________________________
Yes
No
Episodes of cyanosis:
Yes
No
Alteration of activity level:
Body positions limited secondary to cardiac condition:______ _____________________
Known complications from cardiac condition:
CVAs
TIAs
Vocal fold paralysis
Reduced Endurance/Fatigue
Other:____________________________________________________________________
B5. Respiratory/Airway History
No history of respirator y/airway issues
Pneumonia
BPD/Bronchopulmonary Dysplasia
Asthma
Frequency: ____________
Tracheomalacia
Aspiration Pneumonia
Laryngomalacia
Frequent colds (# per year: _____)
Bronchomalacia
Frequent upper respiratory infections (# per year: _______)
Tracheal stenosis
TE Fistula
Vocal fold paralysis
Left / Right / Bilateral
Median / Paramedian
Stridor
Inspiratory / Expiratory
Supplemental oxygen
NA
Current
In the past
Nasal Cannula
Trach shield
Via:
Frequency: _______________
Amount: _________% O2
______ ___ Liter Flow
Templates are consensus-based and provided as a resource for members of the American SpeechLanguage-Hearing Association (ASHA). Information included in these templates does not represent official
ASHA policy.
Infant
Medical/Feeding History & Assessment Form
(Infant 6 month s and youn ger)|3
Not Applicable
Tracheostomy tube
Brand/Size:___________________________________________________________________
Reason for placement __________________________________________________________
Length of time with trach:________________________________________________________
Complications (granuloma tissue build-up, etc.):______________________________________
Most recent endoscopy results:____ _______________________________________________
Yes
No
Tolerance of speaking valve/capping
Frequency of suctioning: _____________ Viscosity/Color of secretions:_ _________________
No
Current
Previous
Ventilator dependency?
Nasal How long? __________________________________________________________
Oral
How long? __________________________________________________________
Details:________________________________________________________________
B6. Gastrointestinal History
No history of GI issues
Fundoplication
Constipation
G-tube
NG-tube
Lactose intolerance
Short bowel syndrome
Diabetes
Failure to thrive
Slow gastric emptying
Pylorotomy
Bowel obstruction
Reflux/GERD
PEG tube
J-tube
GJ tube
Chronic diarrhea
GI bleeding
Crohn’s disease
Dehydration
Celiac Disease
Hypoglycemia
Dumping Syndrome
Esophagitis/Eosinophilic
Gastroschesis
Esophagitis
Other: ____________________________________________
B7. Renal History
No history of renal pro blems
Acute renal failure
Chronic renal failure
Dialysis:
No
Current (Frequency: ___________)
Previous
Structural deviations: ___________________________________________________________
Related surgeries: _____________________________________________________________
Food restrictions due to renal problems (i.e. protein, potassium, sodium, fluid, ca lcium, and
phosphorous intake):___________________________________________________________
____________________________________________________________________________
Templates are consensus-based and provided as a resource for members of the American SpeechLanguage-Hearing Association (ASHA). Information included in these templates does not represent official
ASHA policy.
Infant
Medical/Feeding History & Assessment Form
(Infant 6 month s and youn ger)|4
B8. Craniofacial History
No known defects of the palate
Submucousal Cleft
Cleft Lip
Unilateral (R or L)
Bilateral
Complete
Incomplete
Cleft palate (Hard Palate)
Unilateral (R or L)
Bilateral
Complete
Incomplete
Cleft palate (Soft Palate)
Unilateral (R or L)
Bilateral
Complete
Incomplete
Retrognathia
Nasal Regurgitation
Dental abnormalities: ________________________________________________________
Other: ____________________________________________________________________
Detail surgical history including dates & success of surgeries:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
B9. Hemolytic History
No hemolytic disorders
Anemia
Polycythemia
Jaundice
Sepsis
Other: ________________________________
B10. Allergy History
Soy
Gluten
Milk/Dairy
Egg
Peanut
Other:______________
Food intolerance:
Other Environmental/Drug Allergies: _______________________________________________
Feeding History
C. Swallowing & Feeding History
C1. Nipple Feeding Status & History
Current diet: __________________________________________________________________
Bottle/Nipple used for Non-breast fe eding:___________________________________________
Feeders (Mom, Dad, etc.): _______________________________________________________
Position for feeding:
Supine
Side-lying
Elevated
Other:
Warmed
Chilled
Variable
Food/liquid temperature preferences:
Typical feeding schedule:________________________________________________________
< 5 minutes
5-20 minutes
30 minutes or more
Length of average meal times:
Templates are consensus-based and provided as a resource for members of the American SpeechLanguage-Hearing Association (ASHA). Information included in these templates does not represent official
ASHA policy.
Infant
Medical/Feeding History & Assessment Form
(Infant 6 month s and youn ger)|5
Volume (daily intake)
Formula _________________________
Breast Milk ____________________________
Water ________________________________
Chronology of formulas:_________________________________________________________
Additive/supplement
Modifications to Feeds:__________________________ cal/o z.
C2. Breastfeeding history :
Time length: _______________________ Stated reason for weaning: ____________________
Yes
No
Time spent per breast: R ______, L _________ Nipple Shield:
Preferred Position: Cra dle, Football, Cross-Cradle, Other: ______________________________
Any position infant seemed uncomfortable? ____ _____________________________________
Perception of milk production: ____________________________________________________
Schedule or On-Demand: (Provide details of schedule or give average day description if fed on
demand)_____________________________________________________________________
____________________________________________________________________________
Infant’s Response During Nursing: Vigorous / Lethargic / Fussy / Quiet – Comfortabl e / Variable
Mother’s perception of br eastfeeding: ______________________________________________
____________________________________________________________________________
____________________________________________________________________________
Parent report of:
Cough up to 30 minutes after mealtime
Wet / gurgly vocal quality during or after meals
Sialorrhea / Drooling
C3. Alternate Nutrition
TPN (Start date/End date: __________________________)
Enteral Feeds
Nasogastric Tube
Gastrostomy Tube
Bolus/Gavage
Continuous drip
Type of feeding:
Current rate: _________ __________________________________________________
Night time: On / Off
Current schedule: ____ _________________________
Typical Positioning durin g feeding: _________________________________________
Adverse behaviors during tube feed ing:
Gagging
Sweat
Frequent burping
Hiccups
Become lethargic
Retch
Wet burps
Regurgitation
Scream
Spit up
Nasal regurgitation
Arch back
Details: _____________________________________________________________________
If your child has reflux, have you ever noted coughing or a gurgly voice after the episo de?
Yes
No
Templates are consensus-based and provided as a resource for members of the American SpeechLanguage-Hearing Association (ASHA). Information included in these templates does not represent official
ASHA policy.
Infant
Medical/Feeding History & Assessment Form
(Infant 6 month s and youn ger)|6
Diagnostic Procedures Completed (Date & Results)
MBS/VFSS:________________________________________________________________
FEES: ____________________________________________________________________
pH/impedance probe: ________________________________________________________
Upper GI:__________________________________________________________________
Sialogram:_________________________________________________________________
Gastric Emptying/Milk Scan:___________________________________________________
Other: ____________________________________________________________________
D. Hearing and vision history
D1. Hearing
WFL (Within Functional Limits)
Impaired Right
Impaired Left
Impaired Bilateral
Unknown
Details of hearing loss: _________________________________________________________
Hearing aid Right
Hearing aid Left
Cochlear Implant Right
Cochlear Implant Left
Cochlear Implant Bilateral
D2. Vision
WFL
Corrected:
Impaired Right
Impaired Left
Impaired Bilateral
Unknown
Glasses
Details of vision loss: __ _________________________________
E. Developmental milestones
E1. Speech/Communication Skills
WFL
Delayed
Details:______________________________________________________________________
E2. Gross Motor Skills
WFL
Delayed
Note if impaired head control, trunk control, tone, mobility:______________________________
E3. Primitive/abnormal reflexes (check if present):
Rooting
Bite
Grasp
Transverse tongue
Suckle
ATNR/Asymmetrical tonic neck reflex
Suck
Arching
Babinski
Posturing
Startle
Munching
Comments: __________________________________________________________________
Templates are consensus-based and provided as a resource for members of the American SpeechLanguage-Hearing Association (ASHA). Information included in these templates does not represent official
ASHA policy.
Reflexes
https://www.youtube.com/watch?v=0V4x0iQODTk
Oral Reflex
Extinct
???
Permanent
Gag
18 weeks GA
Permanent
Swallow
14 weeks GA
Permanent
Transverse
Tongue
28 weeks GA
Permanent
Phasic Bite
28 weeks GA
9-12 months
Tongue
Protrusion
Birth
4-6 months
Santmyer
34 weeks GA
1-2 years
Birth
3-4 months
Rooting
32 weeks GA
3-6 months
Suckle
17 weeks GA
3-4 months
Cough
Palmomental
Oral Reflexes
Present
Cranial Nerve Assessment
Nerve
Symptoms
V- Trigeminal
Reduced mandibular
movements
VII- Facial
Facial asymmetry, reduced
facial movements, weak lip
closure
X- Vagus
VF paralysis, weak cry,
hypernasality, nasal
regurgitation
XII- Hypoglossal
Reduced tongue
movements, poor suck
Non‐Nutritive Sucking
• Non‐nutritive suckling / sucking
– Pacifier
– Repetitive patterns of bursts and pauses
– Usually 7‐8 sucks per burst and 6‐7 sec pause between bursts
– Suck rate = 2 per sec (faster – no milk being drawn in)
– Suck: swallow ratio = 6:1 to 8:1 (no milk to swallow)
Nutritive Suckling/Sucking
• Suckle / Suck
– Stroke top lip in midline, top of tongue, middle of hard palate
– Suckle (forward‐backward motion)
Suck (up‐down motion)
– Suckle 28 weeks CA (12 weeks in utero)
Suck 6 months – Obtains nutrition
– Suckle integrates into more mature sucking pattern
Nutritive Suckling
• Nutritive suckling / sucking
– Used during feeding
– Initial continuous suck 60‐80 seconds
– Duration of sucking bursts decrease and length of pauses increase as feed proceeds • By end of feed, only 2‐3 sucks per burst with 4‐5 second pauses
– Suck rate = 1 per sec
– Suck: swallow ratio • = 1:1 initially (high milk flow)
• = 2:1 or 3:1 by end of feed Swallow
– Bolus in mouth (saliva, fluid, food)
– Laryngeal excursion, apnea
– 28 weeks CA (12 weeks in utero)
– Transports bolus into esophagus, of airway
– Continues throughout lifetime
protection Suck‐Swallow‐Breath Coordination
– By 24 weeks CA, suckling present (12‐18 weeks in utero), swallowing present (12 – 18 weeks in utero)
– By 28 weeks CA, suckling reflex present, swallowing reflex present, but both slow & ineffective
– 34 weeks CA, emergence of suck‐swallow‐breath sequence, but inefficient, and endurance poor
– By 36 weeks CA, suck‐swallow‐breath sequence co‐ordinated, but may not be fully efficient
During Feeding
– State control
• Deep sleep  Awake  Crying
– Stress
• State & Attention: Irritability, crying, state fluctuation
• Motoric: Tone, flexion/extension
• Autonomic: Sweating, sneezing, hiccoughs, respiratory and heart rate changes, color change
– Responses to tactile input
• Sensitivity (Hypo vs Hyper)
– Suckle feeding position
• Support for head/neck/trunk/hips/knees
– Oral motor control
• Cheeks, Tongue, Palate, Size of oral cavity
– Physiological control
• Respiratory rate, heart rate, endurance
– Co‐ordination of suckling, swallowing, and breathing
• Airway closure, airway re‐opening; Swallowing problems are not just caused by aspiration
Suckling, Swallowing, Breathing
• Breathing‐ observe for changes in the following:
– Sounds of respirations – Respiratory effort – Respiratory pattern Outcomes
– Volume taken
– Duration of feed
– Number of feeds
– Fussing/ refusal during feed
– Physiologic measures
Observations from Bedside Assessment
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Poor endurance
Significant oral residue after the swallow
Drooling
Prolonged mealtimes
Excessive gagging
Lip retraction/Limited upper lip movement
Poor labial seal
Jaw thrust/clenching/retraction/instability/
Tonic or phasic bite
Tongue thrust/retraction/hypotonia/deviation/limited ROM
Reduced buccal tone/sensory awareness
Poor bolus formation and/or transport
Delayed or difficult swallow initiation
Multiple swallows to clear oral residue
INFORMAL CHECKLISTS
• Morris SE, Klein MD. (2000). Pre‐Feeding Skills: A Comprehensive Resource for Mealtime Development. Texas. Therapy Skill Builders.
• Dailey Hall K. (2001). Pediatric Dysphagia Resource Guide. San Diego: Singular Thomson Learning.
FORMAL ASSESSMENTS
Schedule for Oral Motor Assessment (SOMA)
• (Reilly, Skuse, Wolke, 1995)
• Published assessment
• Reliable
• Used in several published studies
• Skills judged from observation and video taping
FORMAL ASSESSMENTS
Schedule for Oral Motor Assessment (SOMA)
Seven oral motor challenge (OMC) categories:
1. Puree
2. Semisolids
3. Solids
4. Cracker
5. Liquid from bottle/ breast
6. Liquid from trainer cup
7. Liquid from a cup
Each OMC can be described on three levels:
1. Functional areas (FA)
2. Functional units (FU)
3. Discrete oral motor behaviours (DOMs)
FORMAL ASSESSMENTS
Pre‐Feeding Checklist (PFC)
– Morris & Klein (2000)
– Published in text book (Pre‐Feeding Skills)
– Used in published studies
– Skills judged from observation and videotaping
FORMAL ASSESSMENTS
Pre‐Feeding Checklist (PFC)
– Sequential Approach
• Skill areas
– Feeding positions, Food quantity, Food types eaten
– Sucking liquids from the bottle or breast, Sucking liquids from the cup, Sucking soft solid or pureed foods from the spoon
– Swallowing liquids, Swallowing semi‐solids, Swallowing solids – Jaw movements in chewing, Tongue movements in chewing, Lip movements in chewing – Coordination of sucking, swallowing, and breathing, Control of drooling – Jaw movement in biting
– Global approach
• Month by month
PEDIATRIC FEEDING AND SWALLOWING: CLINICAL SWALLOWING EVALUATION
Donna Scarborough
[email protected]
Prevalence of picky Eating
2-6 years
(Adapted from Dovey, 2010)
Older adults
Adolescence and Adulthood
Lifespan
cognitive
sensory
Understanding Typical •Developmental Levels
•Critical Anatomic and Physiologic time periods
social
play
physiologic
(Scarborough, 2011)
Complex puzzle
of pediatric feeding/
swallowing: Consider
the whole child
neurologic
Results of assessment •Leads to treatment in following broad areas
•Sensory
•Motor
•Physiologic
•Behavioral
36
•Regulatory
Pediatric Bedside Template (ASHA)
• Special Interest Group 13 (Swallowing and Swallowing Disorders [Dysphagia]
• Assist, particularly with complex cases
• Thorough, 21 pages
• http://www.asha.org/SLP/child‐templates/
SR‐Pierre Robin
Sequence
SL‐ Rare genetic defect
Pertinent past and current medical information •
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B1. Prenatal/birth history
B2. Hospitalization/surgical history B3. Known precautions/allergies
B4. Current Medications B5. Neurologic History/Current Concerns
B6. Cardiac History/Current Concerns
B7. Respiratory History/Current Respiratory Concerns
B8. Gastrointestinal History/Current Gastrointestinal (GI) Concerns B9. Renal History/Current Renal Concerns B10. Craniofacial history/Current Craniofacial Concerns
B11. Dental History/Current Dental Concerns
B12. Hearing & Vision History / Current Hearing & Vision Concerns
B13. Other, such as Psychology, Psychiatry, Dermatology
Past Medical History/Current Concerns
• 24 weeks GA(VLBW)
• Grade 2 IVH
• Mild, cardiac issues, resolved on own
• No Renal Issues
• Retinopathy of Prematurity (ROP)
• 100% g‐tube fed
(no fundo)
24 weeks GA (VLBW)
Grade 1 & 2 IVH
No cardiac issues
No renal issues
Retinopathy of Prematurity (ROP)
• 100% g‐tube fed (no fundo)
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Past Medical History/Current Concerns
• Respiratory compromise early, weaned off of O2 late
– No hx of chronic URI’s
– Manages own secretions/strong cough
• Class 3 malocclusion
• Failed a behavioral program for feeding
• Extensive food intolerances‐
gluten free and lactose free diet
– On home made tube diet
• Currently on maximum amount of reflux meds
• Minimal respiratory complications as an infant yet
– Difficulty protecting the airway
– Diminished cough response/hx of chest infections/ “gurgly” voice
• High arched palate and missing primary teeth
• Cholesteatoma in Left ear
– Surgically removed with ossicles
• Endocrine disorder?
• No meds
• Altered regulatory b/h
– Struggled with self‐regulation
Developmental Milestones
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C1. Current speech/communication skills
C2. Cognition
C3. Current gross motor skills
C4. Current fine motor skills C5. Current Sensory Skills
C6. Current Nutritional Status/Feeding C7. History/Responses to Liquid/Food/Current Skills
– Smell and Taste
– Meal time routines and introduction of new foods
Information from Developmental Milestones
• Help you determine how you will most effectively communicate with the child
• Level of difficulty of the task/the amount of resistance you may get
• Overall motor skill impression
• How much you will need to consider from a sensory perspective
• If meal routines have been established and the types of foods/liquids you may be begin to initiate
Developmental Milestones
• Initially home‐schooled
• About a year behind academically
• Ambulatory
• Excellent fine motor
• Sees an OT for sensory processing
• Tolerates tastes of smooth puree—100% tube fed
• Hyperactive gag
• Public school
• Is verbal (sentence level)
– Perseverate
• Academically about 4 years behind • Ambulatory
• Excellent fine motor
• Inconsistent sensory processing, no OT
• Tolerates tastes of smooth puree—100% tube fed
• Hyperactive gag
“Bedside” evaluation should involve a “hands‐on” approach • One goal of the bedside is to be able to complete a thorough oral mechanism exam
– Thorough examination of structures
Ankyloglossia
(tongue tied)
Normal
Submucous cleft
“Bedside” evaluation should involve a “hands‐on” approach • For some children….must first be able to process sensory information AND
• Child has to be able to have some core sensory processing before initiating motor plan
– Want to physically touch lips, cheeks
• Tone often feels different than looks
– Eventually also want to assess tongue tone and palate
• Need to consider bite reflexes
• Ways to protect your fingers from getting bit
ASSESSMENT (CLINICIAN OBSERVED OR ELICITED)
• The pediatric template will walk you through the steps including:
• D1. Postural control (muscle tone and movement pattern)
– Mobility
– Tone
– Reflexes
AB‐g‐tube fed
Poor oral musculature mobility and endurance
Never know if just visually
inspecting
ASSESSMENT (CLINICIAN OBSERVED OR ELICITED)
• D2. Oral sensorimotor/peripheral examination
– Sensory assessment
– Structural observations
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Face (Both upper and lower quadrants)
Jaw
Lips
Tongue
Cheeks
Teeth
Palate
Voice
Resonance
Cough (unrelated to food presentation)
Secretion management
Respiratory status during assessment (prior to feeding)
Oral Feeding Assessment
• Feeding position (observed in session):
• Foods trialed during the assessment Food given
Reaction normal
Hypersensitive
Hyposensitive
Texture
Reaction ( + or ‐):
Taste
Temperature
Color
• Were foods given from a spoon/utensil? • Were foods given that required mastication? • Were liquids given?
Initial Plan of Care
• Reflux management—saw GI and changed meds
– Used reflux precautions
• Avoided triggers in tx, i.e. cold foods
• Normalized the gag reflex
• Initiated motor program to initially increase the ROM/endurance of oral musculature
• Increased tastes gradually
– Wide variety of smooth purees
• Increased ability to protect airway
– Modeling, increasing awareness
• Normalized the gag reflex, then moved to aggressive oromotor program
• Gradually decreased the number of breaks needed in a therapy session
• Positively reinforced
• Gradually increased tastes
• Taught new vocabulary for different senses PEDIATRIC CLINICIANS HAVE THE CHALLENGING TASK OF EXAMINING AND INTERPRETING ANATOMIC, SENSORY, MOTOR, AND BEHAVIORAL COMPONENTS OF FEEDING AND/OR SWALLOWING WITHIN THE CONTEXT OF MULTIPLE PERIODS OF GROWTH AND DEVELOPMENT THAT OCCUR FROM 6 MONTHS TO PUBERTY
If we tie everything together needed to assess pediatrics, as a new clinician…..
1. BECOME MASTER OBSERVERS 2. LEARN TO ORGANIZE, PRIORITIZE, AND LIMIT THE NUMBER OF SHORT‐TERM GOALS AS TO NOT TO OVERWHELM THE CHILD/FAMILY
3. BE PATIENT Patience pays off….
Four years after therapy began, Gabe is only using the g‐tube for hydration during illness and one medicine that is not palatable. He has a wide repertoire of foods, although prefers purees and liquids. He still struggles with appetite drive, but he is thriving and he and the family are thrilled! Two years later, DC’d from therapy
From no skill to soft masticated. Unable to advance to more difficult textures/ hard to grind textures 2ndary to dental issues. Eating lobster bisque to celebrate with family.
References
• Dovey, T.M., Staples, P.A., Gibson, E.L., & Halford, J.C.G. (2008). Food neophobia and ‘picky/fussy’ eating in children: A review. Appetite, 50, 181‐193.
• Scarborough, D.R. (2011) Abnormal physiologic responses to touch in feeding. In Ed. V.R. Preedy. International Handbook of Behavior, Diet, and Nutrition. Springer: London, 1273‐1281. CLINICAL SWALLOWING EVALUATION IN ADULTS
Michelle Ciucci
[email protected]
Goals of Intervention
• Maintain nutrition and hydration in the least restrictive manner
• Protect the airway
• Preserve/facilitate quality of life
• Evaluation is the crucial first step in achieving these goals.
Screening vs. In‐depth evaluation
• A screen is used to answer the question: Does this person have dysphagia?
• An evaluation is used to determine the salient characteristics contributing to dysphagia in order to treat.
Screening
Does this person have dysphagia?
You are looking for indirect evidence of dysphagia
• Performed in – hospital, outpatient clinic, other medical facilities, schools, or even at home
• Performed by
– SLPs, Nursing, Other?
• Screenings are quick, low risk, and low cost.
Purpose of Screening
1. Presence or Absence of dysphagia
2. To Determine the Patient’s:
• Need for future testing
• Readiness for further testing if needed
– Bedside
– Instrumental testing
– Status ‐ physical, mental, emotional
Murry, J & Carrau, R. Clinical Management of Swallowing Disorders, 3rd
edition. Plural Publishing, Inc., San Diego. ISBN10: 1597564257 Sensitivity is the ability to detect true positives and specificity is the ability to detect true negatives. Screening Tools
• Validated, published tools
• Criterion‐referenced
• 3oz water test
– Suiter & Leder, 2008
Yes, this person likely has dysphagia.
• Clinical swallow evaluation
• Instrumental evaluation
Evaluation: Hypotheses about underlying cause of dysphagia • Information gathering
– Chart review, interview, clinical swallow evaluation
• Information synthesis in order to determine
1.
2.
3.
4.
5.
Is further testing warranted?
What are the diet recommendations?
What are the therapy recommendations?
What kind of education is needed?
What kind of follow‐up and referrals are needed?
Cranial Nerve Examination
• Vital to your evaluation
• Sensory and Motor Function
• Helps to define the types and levels of injuries to the nervous system –
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Muscle
Neuromuscular junction
Sensory innervation or processing
Lower motoneuron
Upper motoneuron
Cortex
Control circuits
Considerations in Neurogenic Populations
• Knowing the disease/condition intimately
• Onset
– Rapid/Acute
– Slow/Chronic
• Insidious
• Course
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–
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Stable
Improving
Progressive
Relapsing/Remitting
Knowing the disease/condition
• Medical treatments
– Medication
• Side effects
– Respiratory issues
• Coordination of swallowing and breathing
• Cough
– Surgical interventions
– Interactions with other co‐morbidities
– How communication and cognition are affected
• Disease prognosis  Recovery‐full or partial
 Fatal
Patient‐Centered Care
• Dysphagia team
– SLP
– Dietician
– Physicians (Physiatry, Radiology, PCP, ENT Neurology, Pulmonology, GI)
– Nursing
– Social work
– OT/PT
Patient and Family!
Quality of Life
Evaluation Tools
Videofluoroscopy (VFE) or Modified Barium Swallow Study
Fiberoptic Endoscopic Examination of Swallowing
Which instrument should I choose?
Assessment
VFE
FEES
Oral stasis
✔
Lingual function
✔
Oral transport
✔
Trigger of swallow relative to position of bolus
✔
?
Penetration
✔
✔
Aspiration
✔
✔
Penetration‐Aspiration Scale
✔
✔
Pharyngeal stasis
✔
✔
Assessment
Epiglottic retroflexion
VFE
✔
Hyolarygneal Excursion
✔
FEES
?
Vocal fold function
✔
Secretions management
✔
Respiration/swallow coordination
✔
Cough/airway protection
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Velopharyngeal function
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UES dysfunction
✔
Esophageal stage
✔
Therapeutic maneuvers
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Contraindications/Other considerations
VFE
Facial trauma
✔
Bleeding disorders
✔
Severe dyskinesia
✔
FEES
Radiation concerns
✔
Assess swallow without bolus
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Assess for a longer time period
✔
Direct view of anatomy
✔
Evaluation: Adult Neurogenic Populations
• Highlight the important features of some common diseases that cause neurogenic dysphagia
Factors to Consider
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•
•
•
•
Knowing the disease/condition intimately
Onset
Course
Treatments
Prognosis
Example: Stroke
• Extent of oropharyngeal dysphagia is dependent upon
– Location/type of injury
• Ischemic vs. hemorrhagic
– Extent of injury
– Patient factors (age, resilience, co‐morbidities)
– Example: brainstem strokes are likely to be more devastating to sensory and motor function of cranial nerves as well as central pattern generators.
Example: Stroke
• Presentation is heterogeneous
• Although site and size of lesion is important, we must consider that functional connectivity is also affected and the damage may be more widespread than estimated on imaging studies.
• Typically, we do expect recovery of function
– Spontaneous
– Interventions
Factors to Consider: Stroke
• Knowing the disease/condition intimately:
heterogeneous, depends on site of lesion/extent
• Onset: Acute
• Course: Improving
• Treatments: typically don’t interfere with swallowing
• Prognosis: Typically good, but depends on site of lesion
Example: Parkinson disease
• May have an early onset without recognition of signs of dysphagia by patient or neurologist
– Progressive disorder that requires frequent monitoring
– Traditional medical therapies do not improve or may worsen dysphagia
– Role for exercise
• Aspiration pneumonia
– Leading cause of death related to PD
Beyer, Herlofson, Arsland, & Larsen, 2001; Clarke, 2000; D’Amelio et al., 2006
Factors to Consider: Parkinson’s
• Knowing the disease/condition intimately: early onset of swallow deficits that are progressive and under‐recognized by patient, aspiration pneumonia is a concern
• Onset: slow/insidious
• Course: progressive, generally slow
• Treatments: can worsen swallowing
• Prognosis: poor, but can maintain swallow function and QOL with treatment
Example: Amyotrophic Lateral Sclerosis (ALS)
• Compromise of corticobulbar tracts (upper motoneurons) and lower motoneurons
– Phenotypes: bulbar onset
– Rapidly progressing disease – Respiratory issues may confound swallow issues
– End of life decisions/ethics become a major part of care plan
Factors to Consider: ALS
• Knowing the disease/condition intimately: Devastating to communication and swallow, bulbar onset has worse prognosis
• Onset: Relatively acute
• Course: Rapidly progressing
• Treatments: Respiratory issues may take precedence
• Prognosis: Fatal, QOL is main concern
Key points:
• Neurogenic dysphagia can manifest as progressive, stable, remitting/relapsing, improving, or in other words‐it’s a moving target.
– Timing of evaluation and intervention
– Follow‐up • Understanding the underlying disease process is vital to developing appropriate evaluations and treatment strategies.
• Patient‐centered care and QOL
Clinical Swallowing Evaluation:
Geriatric
Pamela Smith
[email protected]
Special Considerations in Aging
Aging: A Process, Not a Disease
• “Senescence”
• se·nes·cence noun
• the state of being old : the process of
becoming old
• Comes with some changes which are normal.
• Social, physiological, psychological, as well as
chronological. (Whitbourne, 2002)
Normal vs. Abnormal Aging
• Normal aging: NOT compounded by disease processes.
• Abnormal aging: Sometimes called “diseased aging” ‐ the changes come from disease processes that tend to be seen in older people.
• Alzheimer’s disease/dementia are NOT part of normal aging.
• Strokes/Parkinson’s/etc. are NOT part of normal aging.
Swallowing Evaluations with Older People….
• ….generally include some type of abnormal process IN ADDITION TO the normal aging process.
• These abnormal processes are usually MORE PROBLEMATIC for older individuals
• Functional Reserve: Capacity of an organism to retain function in the face of impairment.
• Sarcopenia – loss of muscle mass and strength (1).
• Frailty – syndrome of decreased resistance to stressors across multiple physiological systems. (2)
Many older individuals have….
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•
•
•
•
•
•
•
Impaired hearing and vision
Impaired working memory
Slowed processing Polypharmacy
Xerostomia
Reduced senses of smell and taste
Dental issues
Orthopedic issues
To Evaluate Them
Interpret in the context of aging as a baseline.
• Presbyphagia is not dysphagia
• But older people requiring evaluations likely have both
• The Alphabet Soup of Medical Diagnoses
Normally aging swallow
New dx
Deficits from this event
Current status
The Aging Swallow (The Baseline) (3)
• Changes in motor (atrophy) and sensory function in oral phase
• Slower mastication and transfer
• Reduced oral containment
– Greater “spillage” to the valleculae or pyriforms
prior to swallow
– Delayed pharyngeal response vs. impaired oral control
The Aging Swallow (Baseline) (3)
Changes in pharyngeal phase
– Reduced hyolaryngeal elevation
– Slower laryngeal closure
– Reduced pharyngeal constriction
• Penetration
• Residual
• Reduced sensation for these
The Aging Swallow
• Bolus spends a longer time past an open airway.
– Often NOT a new issue. – With a new dx, may become more problematic.
• Slowed esophageal transit (reduced primary and secondary peristalsis) • Cannot see any of these on the clinical eval.
• Video
Norms
Food for thought
• The geriatric patient may be able to easily do all the tasks you ask… or may not.
– Be prepared to complete skilled observation
• The patient may have a very different view of “good” intervention than you do.
– Be prepared to think differently
• The patient may not be concerned about aspiration… or any consequences of it.
– Be prepared to educate and accept.
Food for thought
• Many older people are chronically dehydrated
• The sociology of the single older community dwelling adult.
– Malnutrition/dehydration
– Social and personal routines
– Financial
– Pragmatic
• These issues did not develop overnight.
Food for Thought • Default diet level in facilities is to be regular. (CMS guideline)
• Many people don’t like altered consistencies
• Patients may not have the cognitive ability to use postures, maneuvers.
• Advance directives must be followed
• No evidence of tube feedings prolonging health at end of life. History (chart review) is vital
Look for…
… might suggest
• Primary diagnoses
• Progressive?
• Comorbidities/secondary diagnoses
• Timing: New onset or long term?
• Medications
• Advanced Directive
• Lab results
• Specific symptomatology
• Likely to worsen? • Processes or conditions that exacerbate the primary
• Prognostic information: What can we fix?
• Side effects
• Care desired
• Indicators of nutrition/hydration
Chart Example
• 83 year old female, new CVA, hx includes NIDDM, HTN, CHF, CAD, osteoarthritis, osteoporosis, dementia. Check med list.
• New Dx: CVA; specific symptoms?
• Additional dx: Osteoarthritis, dementia
• Exacerbating: CHF, NIDDM.
• Medications: side effects
Chart Example
• CVA: May have motor and/or sensory disturbances secondary to CVA.
• Osteoarthritis and dementia: Possible osteophytes, cognitive decline (not new problems)
• CHF, NIDDM: Reduced functional reserve.
• Meds: Side effects – xerostomia, chronic cough, esophageal dysfunction. • Obtain enough information from the chart for the interview.
General Overall Observations
Meet Patient (Resident)
• Be at eye level.
• Use gentle touch, slow‐normal rate of speech.
• Establish rapport. Informally observe:
– Cognitive ability in response to questions
– Language ability – receptive/expressive. • Are there more effective modalities?
– Voice quality, pitch range and presence of breaks
– Adequacy of breath support, phrasing.
– Presence of cough, throat clear
Can you complete a formal cranial nerve and oral motor evaluation?
• Search for the neuro report … and observe.
• Symmetry of face at rest and upon spontaneous and volitional movement.
• Management of saliva. Dental status. Oral hygiene.
• Hypernasality/nasal emission
• Vocal quality, pitch range and breaks.
• Lingual movements via articulatory rate and precision.
• Cachexia? Evidence of a long term problem?
Cachexia and
Temporal Wasting
Can you complete a formal cranial nerve and oral motor evaluation?
• Not all edentulous patients need pureed food.
• The presence of functional dental units is more important than presence of spaces alone.
• Dental and gum health matters in overall health status.
Presentation of Food
• Self feeding preferable if patient is able.
• Observe for unilateral vs. bilateral symptoms
• Sensory vs motor
– Texture sometimes helps
– Stimulus value of the bolus
– Effect of the environment
– Social vs. distraction
– Pragmatic
Impressions?
• Are the results seen consistent with the aging swallow? • Do the results suggest a problem IN ADDITION to the aging swallow?
– Normal aging can lead to longer mastication, repeated swallows, vocal quality changes, mild oral residual.
– Normal aging should NOT lead to new pulmonary issues.
– ALWAYS keep in mind hydration and oral care.
Recommendations
• Need to be able to answer the questions posed by the evaluation. • Patients deserve the most normal diet they are able to manage.
• Do you need an instrumental assessment?
• http://www.asha.org/docs/html/GL2000‐00047.html
• ASHA guidelines do not recommend an instrumental assessment if the results would not change the plan of care.
Recommendations
• Are rarely cut and dry. May not BE a “good plan” May be a “least bad.” Maybe not.
• End of life cases have their own ethical issues. (4,5)
• SLP role is to provide education and alternatives in care, including risks and benefits.
• Individual and/or family can then make informed decisions. • May NOT be the decision YOU would make.
The “Noncompliant” Patient
• Has the right to make choices.
• Has not relinquished that right due to age or disease.
• Does not need to choose between following your recommendations and receiving care.
• The SLP’s job is to educate and provide risks and benefits of possible plans of care.
Articles – Public Access
• 1. Sarcopenia: http://www.stuurgroepondervoeding.nl/filead
min/inhoud/verpleeg_verzorging/documente
n/literatuur___achtergrond/consensus_definit
ie_ondervoeding_ESPEN_2010.pdf
• 2. Frailty
• http://web.missouri.edu/~brownmb/pt415/M
b/2007/articles/1.fried.pdf
3. The aging swallow
• http://www.ncbi.nlm.nih.gov/pmc/articles/P
MC3182519/pdf/nihms79128.pdf
• http://www.ncbi.nlm.nih.gov/pmc/articles/P
MC2630466/pdf/nihms‐81700.pdf
• http://www.jgld.ro/2014/3/6.pdf
• http://ghrnet.org/index.php/joghr/article/vie
w/693/809
4. End of life and tubes
• http://www.ualberta.ca/~loewen/Medicine/G
IM%20Residents%20Core%20Reading/ANORE
XIA%20AND%20WEIGHT%20LOSS/Pegs%20de
mentia%20editorial.pdf
• http://www.ncbi.nlm.nih.gov/pmc/articles/P
MC3254052/pdf/nihms‐346507.pdf
• http://alliedhealth.ceconnection.com/ah/files
/TLD0212D‐1337959485357.pdf
5. Ethics • http://www.asha.org/SLP/Patient‐Rights‐and‐
Patient‐Choices/
• http://faculty.washington.edu/jul2/Readings/s
wallowing.pdf
• http://www.asha.org/slp/clinical/dysphagia/d
ysphagiaSID/