October 1, 2013 Departments

Overheard: Essential Knowledge for Dysphagia Treatment

Dysphagia expert James Coyle chatted recently with online conference attendees about adapting procedures to accommodate older patients’ special needs. The Leader was there.

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Olga Goncharov: What [are] normal pharyngeal propulsion delay times? Or swallow-onset times in older adults? How delayed is a "normal" delay?

James Coyle: The normal elderly person will initiate a pharyngeal stage within 1 to 2 seconds or so of the bolus entering the pharynx. The range there depends on things like the volume, consistency and other aspects of the bolus. This is in comparison to 0 to about 1 second in young people, depending on the same variables. So if a very old person has a two-second stage transition with a puree, it is not necessarily an impairment.

Jaime Faitlowicz: I find that I will occasionally have trouble getting through to those patients that are alert, and have hospital-acquired dysphagia, especially if they were first admitted, for example, status post fall with a hip fracture. Even when explaining the risks of aspiration, signs and symptoms of aspiration, risk of aspiration pneumonia, they may not be compliant with safety precautions and/or safe swallow protocol. Do you have any recommendations?

Coyle: It is very difficult to convince someone that they need to fix something that they do not perceive as broken. Most people, when you say, "you are aspirating," do not understand what you mean. My approach with patients who have had adverse events because of aspiration is to remind them of those events—pneumonia, etc.—and then sort of probe what they felt like and whether they admit to it being a "bad" outcome before going forward. Patients who have never had an adverse event or those who cannot remember, are very hard to manage with interventions.

Emily Bartolotta: I'm wondering what advice or insight you may have for home-care dysphagia therapy where Medicare covers only short-term treatment at times.

Coyle: The caregivers are the target of a lot of resources in this situation. Since you personally have a limited access to the patient and the goals may not be reached in that limited time, the caregiver needs to be "employed" as a collaborator. Doing this may help you to extend the duration of a treatment program by letting you see patient less frequently over a longer period of time, or start with the most important interventions first while working hard on the others. This has to be one of the most frustrating situations for the clinician.

Kerry Church: Do you recommend quarterly and annual screenings or a full evaluation to re-assess swallowing function for long-term-care residents?

Coyle: Screening is supposed to predict who, among asymptomatic people, may have a disorder. In residents in long-term care, many are at risk because of underlying diseases. I think there has to be a reason to screen patients. So I would favor a more efficient system that identifies patients with elevated risk profiles—being old is not enough—such as those with diagnoses known to cause dysphagia, those with prior history or new onset of dysphagia-related illnesses, and so on. I think it would be more effective and efficient to screen using a risk profile. It is also a question of resources.

Sara Murphy: Could you please elaborate on [that answer], and address diet upgrades for patients on modified diets, especially thickened liquids and purees?

Coyle: The question was about routine screenings—quarterly, annual—and I suggested that I thought there should be criteria for determining who to screen ... not just their presence in the facility. But dietary upgrades and such are different because we are supposed to try all of our tricks to get patients on the least restrictive diet. So, if there was good evidence a patient needs to be on a restricted diet, and that situation has changed, that is a good reason for a reassessment. Is that what you are asking? Sorry if I misunderstood it.

Diana Sonnega: What other options are there for folks with gastroesophageal reflux who are taking PPIs [proton-pump inhibitors] and don't have their reflux symptoms under control?

Coyle: I think that managing gastroesophageal reflux is outside of the scope of practice for the SLP but I understand that we are often the front-line clinician for people with upper digestive conditions. Conservative anti-reflux measures have been used for decades to control this problem. Many people don't like to do them because they are inconvenient—imagine not getting to eat chocolate or drink coffee—and in our culture people want the doctor to give them a pill to cure their problem when often there are healthier behaviors that can achieve the goal. I would first be sure the patient does not have a condition needing medical treatment. So [in the case of] a GI consult, it would be bad to have missed something and then obtain a gastroenterologist's advice regarding what kinds of conservative measures will work. Also, it is known that PPIs elevate pneumonia risk so some [doctors] are trying to use them less, so this issue may increase in prevalence.

Mary Burke: Is there a specific age when we start calling a patient an "older adult" and these swallowing changes that occur with aging apply?

Coyle: The older I get, the bigger that number is for me. Most studies use around 65 as the cutoff for "old," but AARP has been sending me applications to join up for years. The aging process is a continuum, so there may be a 50-year-old whose physiology is the same as another 80-year-old. It is logical to expect to see age-related physiologic changes in many systems ... most research divides subjects into three groups—young, middle, old—and we see changes starting in the 40s (swallowing-wise).

Wendy Roger: Would you support a split in our academic programs between medical and developmental speech-language pathology? I started my program determined I would go into early intervention before falling in love with the medical side of it, so I wouldn't have wanted to see a split too early, but when I think of my training and the huge number of classes I had in language sampling in toddlers versus half of one semester in swallowing, it's ridiculous. In the United Kingdom where I live now, SLPs are required to have a postgraduate dysphagia certification—generally a week-long course followed by a case study and an exam. While I don't see that their therapists are better trained than in the U.S., it is a useful idea. What do you think?

Coyle: This is going to get me into trouble, but I do not believe that the speed of increasing demands on the background knowledge base for the medical SLP is being kept up with by our academic programs, which are forced to cram into two years everything that is required plus how lungs and stomachs and other organs work. Until our profession recognizes the dramatic difference in necessary background knowledge between educational and medical SLPs, the profession will continue to think it can educate both equally well under the current format of education. We are completely dependent on continuing education to bring ourselves up to speed and maintain expertise. Specialty certification is another route for this as I do not see this situation changing soon.

Robin Winchester: Could you please clarify/define the term "sundowning"? Is it confusion only in the evening, or any time of day? How best can it be alleviated?

Coyle: Honestly, I do not know much about that subject. I understand sundowning to mean a sort of reversal of the sleep-wake cycle associated with confusion. I have read that there are programs that address it by doing things that reorient the patient to a more ordinary schedule. One problem is that when institutionalized, many people lose all of the cues that indicate what is "normal," especially when dementia is a factor. But again, this is definitely not my area of knowledge.

Layla Vise: Do you see a positive trend in more age-appropriate therapy goals with clinicians having increased training and research-based therapy regarding homeostenosis?

Coyle: I think that when the clinician can apportion the effects of aging into their treatment plans, and when they establish good long term goals—like lowering risk of premature death due to dysphagia—instead of objectives like elimination of aspiration, that they are much better able to balance risks and benefits, advantages and disadvantages of various interventions, and to help the patient determine what is best for them given their values and expectations. Since quality of life has been legitimized by the World Health Organization as a goal, we need to also integrate that into our goal making. There is too much focus on short-term objectives as goals. I work in acute care so I personally do not see the change you are asking about but I would bet that it is happening in extended care.

Malinda Via: If you recognize that a patient has a functional swallow for age, but still feel they could benefit from short-term strengthening, then how do you best suggest documenting this to insurance so as to still get the patient coverage?

Coyle: If SLP services are not medically indicated—even though they might provide some benefit in terms of slowing the effects of aging—I think that we should minimize the billable services by initiating home programs with caregiver assistance and only limited follow-up. That patient may need their medical insurance resources in the future, and I usually do not want to use it up. Now, if you have evidence that the age-related change is interacting with disease-related change, you may be able to justify more aggressive intervention, but we need to demonstrate elevated risk. Medicine is about prevention and risk reduction.

Samantha Canelakes: In an acute hospital setting, would you agree that we should not be treating elderly patients for dysphagia unless they have an acute/related etiology for dysphagia, because otherwise we are trying to "treat" the natural breakdown in swallow function that occurs with age?

Coyle: No. Elderly people are admitted to hospitals when they are acutely ill, and even though the effects of aging are present, their impairments at the acute care level are associated with their acute illness, so our job is to prevent hospital-acquired adverse events that could shorten life more than the natural processes of aging while patient is treated for the acute condition. I would argue that the premise that you have described might be better applied to extended care. Dysphagia is a disorder and aging is not; I appreciate your description of the natural breakdown of function related to age. I do not think that this breakdown should independently be used as a rationale for intervention. But a physician first needs to make the judgment as to whether we have one situation of the other first because that is their job, not ours. That is only my opinion. OK, so here is a good case. I saw a patient yesterday who is 88 years old, stroke, has a large Zenker's diverticulum, has his first pneumonia, and aspirates a little. Since there is only one sentinel event—pneumonia—we pragmatically developed a plan to watch him like a hawk, not stop oral intake. As the aging process unfolds, his risk profile will change.

Sandy Storm: What is your opinion of the Frazier Water Protocol?

Coyle: I believe that nothing is free. There are now a few studies of this method, which was developed without any direct evidence of its efficacy, effectiveness or safety—only anecdote. In one study presented at the ASHA convention in 2008, two patients in the water protocol group of a small randomized trial of this method died. Two other studies since then—Karagiannis et al., 2011, and Carlaw et al., 2012 [see sources below]—have found increased adverse events and no adverse events respectively. I also think that we overreact a little bit to aspiration in many cases, so that the fear of aspiration may be overblown. That said, and as with all treatments, decisions should be made on a case-by-case basis. Nothing is free.

Kara Jones: Regardless of the "chicken or the egg," should we still be providing similar interventions for suspected aspiration?

Coyle: I think that suspected aspiration should be confirmed or refuted before anything is done about it. If we need to intervene temporarily because we have evidence of potential imminent harm, we have to treat now while awaiting testing, but aspiration alone is not enough to cause pneumonia and managing other risk factors may be more effective that focusing just on aspiration.

Angie Weber: How will we diagnose, qualify and/or treat the dysphagia differently if we believe that it is an effect, rather than a cause, of pneumonia?

Coyle: OK ... if the patient has an acute dysphagia, then they will be returning to their baseline sooner rather than later. In these situations, many patients end up being discharged from hospital with restrictive interventions that stick for far too long. We need to better follow up so that as the patient recovers, the necessary and restrictive interventions are lifted when appropriate. Lastly, we should also know enough about the disease process causing acute dysphagia to understand how there might be more permanent effects.

Dorothy Harris: In view of the aging swallow, would a "swallow aerobics" plan be of benefit to those over 40 to help maintain the integrity of the swallow mechanism?

Coyle: I see no problem whatsoever with exercise to combat the effects of aging. Physicians have been telling my 80-year-old mom to walk around the block every day for this reason, and when she fell she did not break a hip. So I think that is a good idea. I do not think, however, that this is a medically necessary service. Teaching it, yes, but having the patient come in every week for me to watch them do the exercises—no.

Catherine Ross: Have any studies been made that suggest dysphagia may be genetic?

Coyle: I have not seen anything like that in the literature, but some craniofacial anomalies and other disease processes are genetic. It is always the underlying disease process that causes dysphagia, which it just a symptom/sign/outcome of disease.

Liz Reiss: What is the normal apnea during the swallow for an older person? I heard of a screening tool as follows: If you can't hold your breath for at least three seconds without discomfort, you are likely to have difficulty coordinating breathing and swallowing. Is there any truth to this?

Coyle: I have never heard that, but a better index of respiratory swallow incoordination is respiratory rate. A rate at or over 30 breaths/minute creates competition for the pharynx because it takes one to two seconds to swallow too, so at a respiratory rate of 30, each breath and each swallow is two seconds long and they can overlap. Another thing we do is literally listen and watch for airflow direction after the swallow. Apnea should last as long as the pharyngeal stage, but it is the direction of airflow that is important. Incidentally, it is a lot easier to train patients to simply inhale before swallowing, than to go through the whole shenanigans of a supraglottic swallow with inpatients who have trouble learning complex things.

Coyle: Thank you all for participating in this conference. Have a good day everyone and thanks again. Cheers.

James L. Coyle, PhD, CCC-SLP, BRS-S, is an associate professor of communication sciences and disorders at the University of Pittsburgh. He is an affiliate of Special Interest Group 13, Swallowing and Swallowing Disorders (Dysphagia). jcoyle@pitt.edu

cite as: Coyle, J. L. (2013, October 01). Overheard: Essential Knowledge for Dysphagia Treatment. The ASHA Leader.

Sources

Carlaw, C., Finlayson, H., Beggs, K., Visser, T., Marcoux, C., Coney, D., & Steele, C. M. (2012). Outcomes of a pilot water protocol project in a rehabilitation setting. Dysphagia, 27(3), 297–306.

Karagiannis, M. J. P., Chivers, L., & Karagiannis, T. C. (2011). Effects of oral intake of water in patients with oropharyngeal dysphagia. BMC Geriatrics, 11, 9.



  

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