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Speech Therapy: Dysphagia and Cognitive Communication Impairments

Julie Fuith-Costa

DYSPHAGIA

Background

Definition

Dysphagia is a condition characterized by abnormality in the transfer of a bolus from the mouth to the stomach. Dysphagia results in unsafe or inefficient oral intake, which can cause aspiration, pneumonia, discomfort, and/or poor caloric intake. Behaviors associated with traumatic brain injury (TBI) such as impulsivity and unawareness can affect the safety and efficiency of oral intake [1].

Epidemiology

Incidence is not well documented, although dysphagia is estimated to occur in approximately 33% of all patients with a TBI (includes mild-to-severe injuries) [2]. Incidence is as high as 61% in patients following severe TBI; there is a relationship between length of coma, presence of a tracheostomy tube and/or mechanical ventilation, and severity of dysphagia [3].

Etiology

A delay in triggering the pharyngeal swallow is the most prevalent cause of dysphagia and aspiration in individuals following TBI. Other problems include structural injuries to the oral cavity, pharynx, and/or esophagus; atrophy/weakness due to prolonged intubation and cognitive deficits; or behaviors that interfere with oral intake [4].

Pathophysiology

Swallowing is typically described in four phases: (a) The oral preparatory phase, when liquid or food (the bolus) is manipulated in the mouth and masticated, if necessary, to ready it for the swallow; (b) The oral phase, when the tongue propels food posteriorly until the pharyngeal swallow is triggered; (c) The pharyngeal phase, when the pharyngeal swallow is triggered and the bolus moves through the pharynx; and (d) The esophageal phase, when peristalsis carries the bolus through the esophagus and into the stomach. Dysphagia results when one or more of these phases is disrupted [4].

Assessment

Risk Factors

Low Glasgow Coma Scale (GCS) scores and low scores on the Ranchos Los Amigos (RLA) scale of cognitive function are associated with aspiration. Additionally, low GCS scores, low RLA levels, the presence of a tracheostomy tube, and increased ventilation time are associated with impairments affecting oral intake [5].

Signs and Symptoms

These include, but are not limited to:

Bedside Swallowing Evaluation

•   Preparatory examination

        Patient chart review

        Observation of level of alertness and awareness

        Observation of respiratory status and secretion management

        Suction patient orally and/or via the tracheostomy tube, if applicable

        Oral examination

        Oral motor control examination

        Laryngeal function examination

•   Initial swallowing examination: The clinician determines if trial swallows are safe based on the information obtained from the preparatory examination. If the patient is acutely ill, has significant pulmonary complications, is not alert, has poor secretion management, and/or an obvious pharyngeal swallowing disorder, trial swallows may not be indicated. The patient is then suctioned orally and through the tracheostomy tube, when applicable, and observations are made during trial swallows that lead to recommendations.

Instrumental Evaluation

The following instrumental swallow studies are commonly used to study various aspects of the swallow. Following the initial swallowing examination, a referral for an instrumental study is appropriate for any patient who is suspected to be aspirating or have a pharyngeal phase dysphagia.

Management

Compensatory Treatment Procedures

•   Postural techniques

        Chin tuck—Patient puts chin to chest and pulls up: helpful for patients with a delayed swallow, reduced airway closure, and/or problems with residue in the valleculae

        Head rotation—Turning the head to the affected side closes the pharynx on that side so that the bolus flows down the unaffected side: helpful for patients with a unilateral vocal fold paralysis or unilateral pharyngeal wall problem

        Head tilt—Tilting head to the strong side allows food to drain down the strong side: helpful for patients with oral and pharyngeal problems on the same side

•   Techniques to improve oral sensory awareness—The following techniques may be utilized with patients with swallow apraxia, tactile agnosia of food, reduced oral sensation, and delayed onset of the oral and/or pharyngeal swallow

        Thermal tactile stimulation: contacting the tongue or faucial arches with a cold laryngeal mirror or metal spoon

        Increasing downward pressure of the spoon against the tongue when presenting food

        Varying taste, volume, and/or texture of bolus (i.e., sour, cold, solid)

•   Diet changes: The diet should be changed only if other compensatory or therapy strategies are not effective or feasible given behavior, cognition, physical impairments, or other reasons.

        Liquids—thin, nectar thick, honey thick, pudding thick; initially thickened liquids are easier for a patient to control and manage, reducing the risk of aspiration

        National Dysphagia Diets (NDDs):

             NDD Level 1 (pureed): homogenous, very cohesive, pudding-like, require very little chewing ability

             NDD Level 2 (mechanically altered, mechanical soft, ground): cohesive, moist, semisolid foods that require some chewing

             NDD Level 3 (advanced, soft): soft foods that require more chewing ability, no hard, sticky, or crunchy items

             Regular or general diet [6]

Swallowing Therapy

•   Direct therapy—involves presenting food or liquid to the patient and asking him or her to swallow while the therapist manipulates the bolus or the patient follows specific instructions

•   Indirect therapy—involves exercise programs or swallows of saliva, but no food or liquid is given: typically used with patients who are at high risk of aspiration

•   Types of direct and indirect therapy include exercises for oral manipulation, bolus propulsion, tongue base retraction, laryngeal elevation and/or vocal fold adduction, thermal tactile stimulation, and swallow maneuvers. Exercises and swallow maneuvers require good attention and ability to follow complex instructions and are not indicated for patients with significant cognitive or language impairments

Other Modifications

When patients cannot follow instructions due to cognitive or language impairments, the following suggestions can help prevent aspiration and pneumonia in dysphagic patients.

Related posts:

Selected Somatic Disorders Associated With Mild Traumatic Brain Injury: Fatigue, Dizziness and Balance Impairment, and Whiplash Injury Heterotopic Ossification Resources for Traumatic Brain Injury Survivors and Caregivers Ethical Considerations Complementary and Alternative Medicine in Traumatic Brain Injury Recognizing Manifestations of Posttraumatic Stress Disorder in Patients With Traumatic Brain Injury

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