Swallowing Problems in Long Term Care 7 th Care By Design Long Term Care Conference IL Epstein, MD, FRCPC Assistant Professor Department of Medicine, Dalhousie University Friday Nov 24, 2017
Swallowing Problems in
Long Term Care
7th Care By Design Long Term Care Conference
IL Epstein, MD, FRCPC
Assistant Professor
Department of Medicine, Dalhousie University
Friday Nov 24, 2017
Disclosures
2017 Ad Board Attendee:
Takeda
Abbvie
No conflicts with any products discussed in
this presentation
Thanks
Dr. Melissa Andrew
Dr. Alison Rodger
Dr. Erin Awalt
Objectives
1. Distinguish between common causes of
swallowing problems in LTC
2. Develop a practical approach for
assessment and interventions in dysphagia in
the elderly
3. Evaluate the use of G tubes in LTC
1. DISTINGUISH BETWEEN
COMMON CAUSES OF
SWALLOWING PROBLEMS IN
LTC
Swallowing
Complex voluntary & involuntary process
25 muscles, 5 cranial nerves
People swallow at least 600 times daily
Consequences of dysfunction include:
Malnutrition, dehydration
Airway obstruction, aspiration,
pneumonia/pneumonitis
Reduced rehab potential & QOL, social isolation
Oral phase: voluntary; chewing, bolus delivered
by tongue to posterior pharynx
Pharyngeal phase: involuntary; constrictor
muscles contract, bolus propelled towards UES;
soft palate closes nasopharynx & epiglottis
protects trachea
Esophageal phase: involuntary; UES relaxes,
peristalsis propels bolus down esophagus
dysphagiaonline.com, http://www.med.nyu.edu/voicecenter/patient/speech/howswallow.html
Dysphagia
Subjective sensation of difficulty or
abnormality of swallowing
Oropharyngeal:
Difficulty initiating a swallow
Nasopharyngeal regurgitation, aspiration
Sensation of residual food remaining in pharynx
Esophageal:
Difficulty swallowing seconds after initiating
Sensation of food getting stuck
https://www.uptodate.com/contents/approach-to-the-evaluation-of-dysphagia-in-adults?source=see_link
Oral: jaw weakness/dysfunction, decreased saliva →
poor bolus formation, spillage into trachea, poor setup of
pharyngeal phase
Pharyngeal: delayed swallowing onset → poor
initiation of this phase; reduced throat sensation
→ tracheal spillage; weak/uncoordinated throat
muscles → aspiration
Esophageal: Zenker’s diverticulum, stricture,
regurgitation, cancer
http://www.med.nyu.edu/voicecenter/patient/speech/howswallow.html
Dysphagia: 3 types
Dysphagia: differential
diagnosis
In older adults
dysphagia should not
be attributed to
normal aging
aging alone causes
mild esophageal
motility abnormalities,
rarely symptomatic
Differential dx esophageal
dysphagia: symptom-based
Solids, gradually progressive:
Esophageal stricture (GERD, radiation, post-
surgical)
Solids, rapidly progressive:
Cancer of esophagus or gastric cardia
Progresses to include liquids
Anorexia, anemia, weight loss
https://www.uptodate.com/contents/approach-to-the-evaluation-of-dysphagia-in-adults?source=see_link
Differential dx esophageal
dysphagia: symptom-based
Solids, intermittent:
Eosinophilic esophagitis, esophageal web/ring,
vascular anomaly (double aortic arch..)
Liquids +/- solids:
Achalasia
Hypertensive/spastic esophagus (DES,
hypercontractile esophagus, scleroderma)
Absent / ineffective esophageal motility
(scleroderma, Sjogren’s, mixed CT disorder)
Functional dysphagia
https://www.uptodate.com/contents/approach-to-the-evaluation-of-dysphagia-in-adults?source=see_link
Differential dx esophageal
dysphagia: symptom-based
Dysphagia + odynophagia:
Infectious (HSV, CMV, candida)
Medication-induced:
Swallowing pill without water, *bedtime
Tetracyclines, potassium supplements, NSAIDs,
alendronate, quinidine1
https://www.uptodate.com/contents/approach-to-the-evaluation-of-dysphagia-in-adults?source=see_link
1. Aslam et al. Gastroenterology & Hepatology 2013;9(12):784.
Candida Esophagitis Takeshi Kondo, M.D., and Kazuhiko Terada, M.D. N Engl J Med 2017; 376:1574April 20,
2017DOI: 10.1056/NEJMicm1614893
Medications causing dysphagia
Chemotherapy immunosuppression, long-
term antibiotics
Via strictures, opportunistic esophageal infections
Pill esophagitis as mentioned
Sedating medications
Elderly especially at risk
2. DEVELOP A PRACTICAL
APPROACH FOR
ASSESSMENT AND
INTERVENTIONS IN
DYSPHAGIA IN THE ELDERLY
Special considerations:
Older, frail, end-of-life
Liquid & solid dysphagia is frequent in the
general debility near end-of-life
Especially prominent in neurologic disorders
Stroke (45% initially), ALS, PD, MS, dementia
Major social importance of food
Inability to eat is socially isolating
Families associate nurturing & well-being with food
Caregivers with good intentions may shift focus from
patient’s experience to the importance of food
https://www.uptodate.com/contents/swallowing-disorders-and-aspiration-in-palliative-care-definition-consequences-pathophysiology-and-
etiology?source=search_result&search=dysphagia%20neurologic&selectedTitle=3~150
Bedside swallowing assessment
Assess LOC, posture, ability to cooperate, gross
oromotor function, gag (poor correlation),
voluntary cough
If it seems safe:
Sips of water (start 1 tsp), monitor for cough, resp
distress, wet voice, laryngeal movement
If ok:
Progress to larger volumes, then yogurt, then food
Moderate sensitivity/specificity
May miss silent aspiration but significance of this is
uncertain1
1. Ramsey et al. Early Assessments of Dysphagia and Aspiration Risk in Acute Stroke Patients. Stroke 2003
Trapl et al Dysphagia Bedside Screening for Acute-Stroke Patients:
The Gugging Swallowing Screen Stroke 2007; 38(11), pp 2948-2952
Invasive swallowing assessment
Videofluoroscopic swallowing study
VFSS or MBS
Foods & fluids prepped with radio-opaque contrast
Imaging of bolus flow from mouth to esophagus
Can assess effects of
positioning,
compensatory
maneuvers, bolus size,
sensory enhancement
techniques
VFSS: Problems
Must be able to maintain upright posture
Radiation exposure - repeated study
inappropriate; risk of aspiration
Unrealistic conditions
Test-retest variability, complex interpretation
Further investigation must align with patient’s
goals & preferences
Invasive Swallowing Assessment
Fiberoptic Endoscopic Evaluation of
Swallowing
FEES
Done via nasoendoscope
Provides direct view of the larynx and pharynx
Functional evaluation of the oropharyngeal phase
specifically
Invasive Swallowing Assessment
Esophago-Gastro-Duodenoscopy or
“Gastroscopy”
Essential in esophageal dysphagia
May be therapeutic and provide tissue diagnosis
Study of choice if odynophagia is present
May be complemented by barium swallow especially if
prior head/neck surgery, or suspected radiation /
caustic injury or motility disorder
Aslam et al. Gastroenterology & Hepatology 2013;9(12):784.
Interventions
Goal is to maintain safe & effective oral
feeding for as long as possible
Postural:
Chin tuck, head rotation
Thickened liquids: patients dislike them
Assoc with more dehydration, UTI, & fevers1
Slows flow, less likely to misdirect into airway in
oral/pharyngeal dysfunction
One approach – water between meals, thickened
liquids with meals2
1. Robbins et al. Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a RCT. Ann Intern Med 2008;148:509-518
2. Karagiannis et al. Effects of oral intake of water in patients with oropharyngeal dysphagia. BMC geriatr 2011;11:9.
Alternatives to tube feeds in
dementia
Position: reduce time supine
Finger foods & preferred
foods
Strong flavours, real
temperatures (not tepid)
gravy, juices, cream…
Reminders to swallow
multiple times/bolus
Gentle coughs after each
swallow
Small bolus size (<1 tsp
Liquid supplements
Brushing, vibration, icing cheeks
and neck
Help with feeding
r/o other illnesses especially
depression
Place food well into mouth
Optimize the environment:
reduce noise, distractions
Finucane et al JAMA review, 1999
3. EVALUATE THE USE OF G
TUBES IN LTC
G Tubes: Common Indications
Neurological diseases and
psychomotor retardation
Cerebrovascular disease
Motor neuron disease
(amyotrophic lateral
sclerosis)
Multiple sclerosis
Parkinson’s disease
Cerebral palsy
Dementia
Cerebral tumor
Psychomotor retardation
Impaired LOC
Head injury
Prolonged coma
Cancer
HEENT
Esophageal
Palliative gastric venting for
abdominal malignancies
Gastroparesis
Interventions: Tube feeds in
elderly patients
Prevention of aspiration with tube feeding is
unproven
Tubes may increase reflux
6-58% risk of aspiration with tube feeding in
12 studies of mixed dysphagia, mean age 70
Risk factors: history of pneumonia, esophagitis,
advanced age, stroke
Patel & Thomas J Clin Gastroenterology 1990
Interventions: Tube feeds in
advanced dementia
US survey of 186,835 NH patients with
advanced cognitive impairment
34% tube fed
No RCTs, no evidence of survival or
nutritional benefit
Conclusions: “Insufficient evidence to
suggest that enteral tube feeding is beneficial
in people with advanced dementia”
Cochrane systematic review 2009; Goldberg et al. Clinical interventions in aging Oct 2014.
Interventions: Perceived benefits
of PEG feeding in dementia
Preventing weight loss /
malnutrition
Healing pressure ulcers
Reducing aspiration
pneumonia
Preventing suffering from
hunger or thirst
Palecek et al. J Am Geriatr Soc March 2011.
Evidence does not suggest
PEG feeding confers
benefit in these ways
Terminally ill patients may
not suffer from hunger or
thirst, and when present,
such symptoms may be
alleviated with minimal oral
intake
Disadvantages of tube feeds
NG tubes:
Nasal wing
Chronic sinusitis
Worsening of GERD
Aspiration pneumonia not prevented
PEG tubes:
Aspiration & mortality not prevented
No survival benefit in nursing home residents
High rates of complications (up to 10.3%)*
The role of endoscopy in enteral feeding. Gastrointest Endosc 2011:74:7-12 Reviewed and reapproved May 2016 / DOI:
http://dx.doi.org/10.1016/j.gie.2010.10.021
Complications
Minor:
Wound infection
Tube leakage to abdominal
cavity (peritonitis)
Stoma leakage
Inadvertent PEG removal
Tube blockage
Pneumoperitoneum
Gastric outlet obstruction
Peritonitis
Major:
Aspiration pneumonia
Hemorrhage
Buried bumper syndrome
Perforation of bowel
Necrotizing fasciitis
Metastatic seeding
Rahnemai-Azar AA, Rahnemaiazar AA, Naghshizadian R, Kurtz A, Farkas DT. Percutaneous endoscopic gastrostomy: Indications, technique,
complications and management. World Journal of Gastroenterology : WJG. 2014;20(24):7739-7751. doi:10.3748/wjg.v20.i24.7739.
Cardin F. Special considerations for endoscopists on PEG indications in older patients. ISRN Gastroenterology 2012.
Tube Placement
Tube Blockage
If the feeding tube becomes clogged or
resistance is felt:
A. First, try to flush tube with 10-30 mL of warm
water. Clamp tube and wait 15 minutes.
B. If not successful, mix a 500 mg tablet of
Sodium bicarbonate with the contents of 1
capsule of Cotazym and 5 mL of warm water. The
Cotazym must be activated, by mixing it with
water and the sodium bicarbonate, prior to
insertion. Clamp the tube for 2-3 hours and then
re-try
Tube Changes
When?
Leaking
Cracking
Blocked
Pain
Redness
Infections
Buried bumper
Fell out (< 24 hrs)
How?
Resite
Rescope with pull
through
Foley
Percutaneous balloon
tube
Buttons
Cages, Bumpers,
Balloons
Buttons
Removal
Recommended when tube is no longer
needed or if complications (eg buried
bumper)
Can not be performed with new tube (< 6 - 8
weeks)
Techniques
Endoscopic retrieval of internal bumper
“Cut and Push”
Traction removal
Take Home Points
1. Swallowing problems are common in LTC.
2. Differential diagnosis is similar to all
causes of dysphagia, but likely higher rates of
oropharyngeal due to neurologic conditions,
and medication induced.
3. Consider bedside assessment, address
patient goals, before invasive testing.
4. G Tubes do not help long term outcomes.
Careful selection required.
Questions & Discussion