Transcript ThickenedLiquidChallenge

The #thickenedliquidchallenge and How to Best
Work with Your Speech Therapist to Optimize
Quality of Life and Quality of Care
Kevin Grunden, MS, CCC-SLP
Lindsey R. Neal, MD, CMD
Speaker Disclosures
Mr. Grunden has disclosed that he has no relevant
financial relationship(s).
Dr. Neal has disclosed that she has no relevant
financial relationship(s).
Learning Objectives
By the end of the session, participants will:
• Experience what our patients experience when we write
orders for downgraded diets - #thickenedliquidchallenge.
• Understand the swallowing mechanism and differences
between imaging options.
• Balance quality of life and rights of patients with potential
aspiration.
• Understand state and federal regulations in regards to
swallowing and resident rights
#thickenedliquidchallenge
#thickenedliquidchallenge
• Social media “challenge”
• Response to #ALSicebucketchallenge - the viral
social media movement for ALS awareness
• Started by the Geripal blog (www.geripal.com)
• “Putting ourselves in the shoes of our
patients who are prescribed thickened
liquids”
#thickenedliquidchallenge
• Rules:
 12 hour challenge (All fluids for 12 hours are honey
thick)
 Mini challenge (8oz honey thick liquid)
 Video yourself and accept the challenge
 If you fail- donate $20 to geriatrics or palliative charity of
your choice
 Nominate others
 Post your video on social media with the hashtag
#thickenedliquidchallenge
#thickenedliquidchallenge
• https://www.youtube.com/watch?v=MkZLHMGdT
6Y
#thickenedliquidchallenge
• LET’S TAKE THE CHALLENGE TOGETHER
TODAY!!!!
• Pick one or 2 liquids of choice
• 2 packets of thickener to make honey thick
• DRINK
#thickenedliquidchallenge
• Why is this challenge important?
• 8% of our patients in skilled nursing facilities are
on thickened liquids!!!!!
• That’s 1 in 12 patients
• Of these, 30% honey thick
Dysphagia is common
• Average adult has an experience of “food going
the wrong way” ~ 1-2x year
• Common in elderly
 9% age 65-74
 19% age 75-80
 33% > 80
• EVEN more common in SNF
Population (up to 40-80%)
Why do we prescribe thickened liquids?
• To decrease the chances of aspiration
• Life threatening
• Any SINGLE episode can lead to aspiration pna
Where does the order for thickened
liquids come from?
 Comes from hospital on them
 Speech therapist wrote the order after eval
 Choking event - nurse wrote the order
 Coughing with meals – CNA reports to nurse
 Nursing home culture of fear
 Who knows???!!!
 Family issues
Thickened liquids
•People HATE IT.
•WHY DO WE DO IT?
•There’s got to be tons
of evidence to back up
years and years of
forcing our patients to
thicken their liquids,
right?
Comparison of 2 interventions for liquid aspiration
on pneumonia incidence: a randomized trial
Ann Intern Med. 2008 May 6;148(9):715.
 RCT with 515 hospital/NH patients with dementia/park
dz who aspirated thin liquids on MBSE
 Randomized to chin-down swallow, nectar thick liq or
honey thick liq
 Main outcome: incidence of pneumonia
• No diff in rates of pna between groups
• Nectar thick lower incidence of pna than honey thick *
• Combined outcome of at least 1 dehydration, UTI or fever more
common in thick liquids groups
• didn’t include the patients who had improved swallow with chin
down or thickened liquids during the initial MBSE (those people
could have had improvement- but maybe not?)
Leads to complicated ethical dilemmas
Anatomy of a
Swallow
• Four phases
1. Oral Preparation
2. Oral Transit
3. Pharyngeal Phase
4. Esophageal Phase
Oral Preparation
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Sensory recognition of food approaching the mouth
Food / drink introduced into the oral cavity
Lips / teeth / tongue remove bolus from utensil
Salivation has begun (helps create bolus and break down food)
Labial seal prevents food from spilling out of the oral cavity anteriorly
Nose breathing due to closed mouth
Oral Phase with Liquids and Solids
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Liquid held in oral cavity prior to oral transfer
Held between tongue and anterior hard palate
Prior to initiating the swallow, material pulled together in a cohesive bolus
If there is no active chewing, soft palate is pulled down and forward sealing
off the oral cavity from the pharynx
Oral phase for materials requiring mastication involves rotary lateral
movement of the mandible and tongue
Tongue positions material on the teeth
Need sensory feedback for correct positioning of bolus on teeth and to
prevent tongue injury during chewing
Buccal tension closes off lateral sulci and prevents food particles from falling
between mandible and cheek
During chewing soft palate is not down and premature spillage of food into
the pharynx is normal
Airway is open and nasal breathing continues
Oral Transit
• Oral Transit Phase begins when the tongue begins posterior movement of the
bolus
• Bolus is moved posteriorly due to the midline of the tongue sequentially
squeezing against the hard palate
• As food viscosity thickens, greater muscle activity is required to squeeze the
bolus back
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-If larger volumes of thicker foods are placed in the mouth, tongue
subdivides the food after chewing
forming only part of it into a bolus at one time, saving the rest on the
side of the mouth for later swallows
• Oral transit phase typically lasts approximately less than 1 to 1.5 second
• As tongue propels bolus back, sensory receptors in the oropharynx and
tongue itself are stimulated and pharyngeal swallow is triggered
Pharyngeal Swallow
Trigger
Around the level of the
anterior faucial pillars to
the valleculae, the
pharyngeal swallow is
triggered
Younger, normal
individuals trigger the
swallow around the area
of the faucial pillars
Normal, older individuals
may trigger the swallow
lower (around middle of
base of tongue)
Pharyngeal Phase
• Complete closure of the velopharyngeal port to prevent material from entering
the nasal cavity
• Elevation and anterior movement of the hyoid and larynx.
• Closure of the Larynx (vocal folds) begins in a bottom - up sequence in order
to clear any penetration. -Bottom-up sequence for VF to laryngeal vestibule to
clear penetration
• True vocal folds contract and respiration ceases
-Laryngeal vestibule closes
-False folds (Aeryepiglottic folds) contract
-Arytenoids move in a downward, forward, and inward direction which
narrows the laryngeal opening
-At same time, larynx is elevated and pulled forward which thickens the
epiglottic base
-Laryngeal framework is pulled up, the epiglottis inverts
Pharyngeal Phase (cont.)
• Epiglottis inverts and comes into contact to further protect the airway
Top to bottom contractions of pharyngeal constrictor muscles
• Opening of the cricopharyngeal sphincter to allow material to pass from
pharynx to esophagus
Tension released - Yanked open due to laryngeal elevation
Tongue base to posterior pharyngeal wall contact delivering bolus to pharynx
• Food is directed around the epiglottis
Relaxation of cricopharygeus muscle & opening of upper esophageal
sphincter region
• Pharyngeal phase ends when the esophageal phase begins as the bolus
passes through the Upper Esophageal Sphincter (UES) entirely
• Breathing is reinitiated - The reported apnea interval duration ranges from
0.5 to 3.5 s.
 Average apneic interval is typically between 1.0 to 1.5 s in most healthy adults –
Esophageal Phase
• Upon entry of the bolus through the cricopharyngeal muscle, the esophageal
phase is initiated
• Esophageal propulsion begins via muscle contractions occurring initially in
response to the arrival of a bolus that stretches the esophageal lumen and
then continue as each segment of the esophagus is stretched by the bolus in
a feed-forward fashion Here there is no spinal/brainstem mediation.
Once the bolus has entered the esophagus, it is carried to the stomach by a
mixture of esophageal peristalsis and gravity
• Esophageal transit takes approximately 8 to 20 seconds
• It normally takes two peristaltic waves to clear the esophagus
• The bolus enters the stomach, the swallowing process has finished, and
digestion begins.
Dysphagia – trouble swallowing
• Clinical presentation:
• coughing, gurgling during meals
• No symptoms (silent aspiration)
2 Categories of Dysphagia
Oropharyngeal dysphagia
Esophageal dysphagia
• Stroke
• Achalasia
• Parkinson’s
• Esophageal Spasm
• Dementia
• Scleroderma
• MS
• Esophageal Cancer
• MG
• Peptic stricture
• ALS
• Rings or webs
• Zenkers Divertic
• Vascular compression
• Other structural lesions
• Med-induced esoph injury
(ENT cancers/surgery)
AMDA Long Term Care Medicine - 2014
Dysphagia in PA/LTC
• Impaired cognitive function
 Delirium
 Cognitive frailty
 Dementia
 Other neurologic condition
• Physical debility
 Muscle weakness
 Iatrogenic disabilty
 Multi-morbidity
Dysphagia
• Rarely a primary disorder
• Symptom of an underlying condition
Medications associated with Dysphagia
• Direct esophageal injury
 Abx, NSAIDs, bisphosphonates,
VitC, K, theophylline, iron
• Decreased LES tone / reflux
 Theophylline, nitrates,
Ca channel blockers, etoh, chocolate
• Xerostomia
 Anticholinergics, A blockers, ARBs,
Antihistamines, atrovent, antiarrythm,
Diuretics, opiods, antipsychotics
What can go wrong???
• Oral Prep:
 Impaired executive function related to dementia
• Oral Phase:
 Disorders of mastication, bolus formation / pocketing,
oral transit
• Pharyngeal Phase
 Poor pharyngeal constriction = residue
 Impaired airway protection
• Esophageal Phase
 Stricture, Cricopharygeal Dysfunction, Dysmotility
Dysphagia
• WHEN TO ASSESS
• HOW TO ASSESS
• WHAT CAN WE DO?
Role of the Speech Language Pathologist
• Identify risks related to chewing / swallowing /
nutrition.
• Determine cause of impairment without
significantly objective methods (i.e., BSE v MBS)
• Determine proper diet consistency, feeding
protocols, and liquid consistencies prior to
medication administration or meals.
• Weekend Dysphagia Protocol
• Train staff (usually the weekend staff is not
available at time of training)
Assessment of Swallow Function
• Bedside Swallow Evaluation (BSE)
 assessment takes into consideration history regarding the swallowing
problem, evaluation of the anatomy and functionality, of sensitivity and the
reflexes, of the swallowing apparatus
• Cervical Auscultation
 Cervical auscultation is the use of a listening device, typically a
stethoscope in clinical practice, to assess swallow sounds and by some
definitions airway sounds. Judgments are then made on the normality or
degree of impairment of the sounds.
• Imaging
 Modified Barium Swallow Study (MBSS)
 Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
Modified Barium Swallow
• 1. Videoflouroscopic evaluation of Oral,
Pharyngeal and, rudimentarily, Esophageal
dysphagia.
• 2. Why:
 Benefits include objective data regarding aspiration v
laryngeal penetration.
 Safe diet consistencies
 Benefit of postural maneuvers
 Ability to clear aspirated material
 Conclusive evidence of swallow function
MBS Continued
• Why Not?
 Can the patient tolerate sitting through the procedure
 Cognitively, can the patient participate?
 How much of a burden is transportation?
 Who will accompany them?
• Family? SLP? Nursing?
At what cost?
• https://www.youtube.com/v/Ri8bBhw9msQ
Fiberoptic Endoscopic Evaluation of Swallowing
(FEES)
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Pros:
Cost effective
Portability to bedside
No radiation
Uses actual meal tray items
Direct viewing of laryngeal functioning for airway protection
Quick testing and results
Assesses secretions management before risking aspiration of a
feeding trial
Better assessment of neurological status (including sensation)
More detailed rendering of the anatomy than other
methodologies
Reliable in detecting aspiration
Strong evaluation tool in the establishment of treatment and
compensatory strategies
Limits of FEES
• Cons:
 Unable to visualize during pharyngeal constriction /
apneic period. Must judge aspiration v. laryngeal
penetration based on staining prior to and after swallow.
Aspiration or Not???
• https://www.youtube.com/v/l8eICovpb28
How will it change the course of action?
• In other words…Why do you want to know the nature
of the problem?
 Will it change your treatment approach? (diet mod based on
info other than overt s/s)
 Will it significantly reduce the risk for aspiration?
 What impact will the intervention have on Nutrition? Quality
of life?
• Fact: Food is good
• Fact: Eating is a Social activity
• Fiction: Permanent diet modification will significantly improve
medical condition / safety of swallow function.( i.e., reduce risk for
aspiration and aspiration pneumonia)
 Do you want closure, reassurance?
Limitations of an SLP
• Fear of educated guess = possible injury.
• Need time to discuss the situation
• Help students/new grads learn
• So much we don’t know…
 Multiple factors effect swallow function
including acute and chronic medical conditions,
lab work, cognitive function, medications.
 Physicians drive the bus
 Opportunity for teamwork
CULTURE OF FEAR
Legal issues
• Examples of suits
 Failure to provide ordered
pureed diet / supervise
eating
 Resident choked on meatball, staff lacked training for
Heimlich maneuver, resident wheeled from dining room
before Heimlich and was bagged using BVM before
 Delay in treatment of choking resident. Was being fed,
began gurgling, then choking. Staff cleaned suction
equipment before suctioning patient (while resident was
choking). Also falsification of documentation.
Regulatory issues
• Resident Rights
• Documentation
• Informed consent
• Team responsibility
• Facility policies
• Screening requirements
• Goal- to encourage our residents to their highest
attainable level of functioning, and for them to
maintain the greatest possible control over their
own lives - physically, mentally, and
psychosocially
Management:
What will make a positive change?
• Treat underlying disorder
• Rehab
• Speech Therapy
 Positioning
 Exercises
 Specific techniques
 Modification of diet
Other Treatment Options
• Diligent oral hygiene
• Treat GERD
• Surgery/Myotomy/Botox
• Medications
• PEG tube
Goals of Care
Quality of life
Dysphagia at End of Life
• Functional Support Group
 Physician, Nursing, Therapy, Dietary / Dietician, Staff
Educator, Family / Caregiver
Working together
• Listen to concerns
• Make time to discuss in person
• Review results together
• Understand pressure from facility standpoint
• Understanding the culture of fear
• Understand resident’s perspective
• Try to make ST and nursing responsibilities
easier so they can provide more loving care
• Include the resident in the discussion
Typical Friday evening admit
• SNF Admission arriving late Friday afternoon –
Time TBA
• Rumors of dysphagia
• On altered diet
• Questions arise:
 Chronic v. Acute
 What is the admitting diagnosis?
 What is the patient’s history?
 What is the “REAL” story regarding this diagnosis of
dysphagia.
Admission “can’t swallow”
• 64 y.o. male
• Hx of codeleted left frontal oligodendroglioma and
seizures secondary to this.
• 6 month history of progressive decline
• Multiple UTI
• Wife report coughing with production of green
sputum
• Staff reported patient “can’t swallow.” What to do??????
“I want real food”
• Overt signs of aspiration
• Wants to eat
• Discuss with resident and family- care plan
meeting?
• Write detailed note
• Educate staff that they still need to monitor
 “Speech therapists do not universally love
thickened liquids, in fact they may be concerned
doctors rely too much on them. It is better to work
with rather than against speech therapy.”
- Christian Sinclair, MD, FAAHPM Pallimed