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RS4270 LECT 07 Swallowing & Feeding II MGT 20231016 WONG Rebecca
RS4270 LECT 07 Swallowing & Feeding II MGT 20231016 WONG Rebecca
35 min Common conditions with older adults having dysphagia Understand the diversify
& assisting clinical
reasoning for
management
10 min New initiatives in local practice
10 min Round up
5. Modify/ Manipulate the environment to suit the need of the patient (to be
discussed with demented cases)
6. Client & caregiver education: establish a feeding plan (to be discussed in
Careful Hand Feeding Program)
R Wong 2023 BScOT Geri 5
Neuromuscular:
stroke
Brain tumours
Progressive conditions:
Alzheimer & dementia disease
Parkinson disease
Multiple sclerosis……….
Medical & Orthopaedic conditions
RA, thyroid
Tumours
End stage of chronic medical conditions
Congested Heart Failure (AHF)
COPD
Aged cerebral palsy & mentally challenged
individuals
• Put the food onto the less affected side of the tongue
• Check unilateral food pocketing
– Unilateral pocketing
– tone + sensation, tongue deviation to sound side, unilateral bodily neglect
Dementia
• 85% having feeding problems in last 1.5 • Common among moderately→ late stage demented
yrs before death.
• 6 month mortality rate (after the occurrence • In a study: end stage 24% self-feed themselves, 18% assisted
of dysphagia)= 39% feeding, refuse feeding (26%) or choke on food (32%).
(Mitchell S, NEJM, 2009)
• E.g. prevalence among moderate to severe Alzheimer's (84-93%)
• Neurodegenerative+ Behavioral problem
• VFSS may not be feasible
• Mx: adaptation** + use of available abilities (promote
self feeding, safest), caregiver education**
Some info from: Hong Kong Med J ⎥ Volume 23 Number 3 ⎥ June 2017 ⎥ www.hkmj.org
Some info from: Hong Kong Med J ⎥ Volume 23 Number 3 ⎥ June 2017 ⎥ www.hkmj.org
插唔插喉
SKILL LAB II
– semi-solid food:
• bolus control for ligneal co-ordination problem
– Cold / hot vs food at room temperature
– Carbonated thin liquid may reduce aspiration in neurogenic dysphagia
– Careful with mix of texture
Note:
1. Thickener lead to persistent feeling a full stomach → client may defer the needs for more
fluid.
2. Taste is plain → may not be motivated to take adequate amount of thickened liquid → risk
of dehydration
3. Water would be separated from thickened liquid if it is left unattended for sometime, or
when stored in mouth
正餐餐 (Normal)
稀流質 (Thin)
(例如:清水)
• A group of 2 students, create 100ml of mildly thick liquid & moderately thick liquid each (cup, water,
thickener, 10ml syringe, stop watch)
• perform IDDSI test with 10ml of liquids to define level of IDDSI
軟餐 將正常餐炆稔、煮 適合咀嚼有困難,要求少量咀嚼
(Soft) 稔、燉熟 the meal is prepared for the person who has some
difficulties with chewing
碎餐 將食物切碎或攪碎 適合咀嚼或吞咽有困難的長者,若舌頭活動不良,
可加入獻汁,製成濕潤的碎餐
(Minced) All food are minced into small particles so that
minimal chewing is required. Please note that the
small bits, if dry, may be very difficult for those with
impaired tongue movement to manipulate into a
cohesive bolus. A moist minced diet is
recommended under these conditions.
糊餐 將食物攪拌至幼滑 無需咀嚼,只須少量舌頭活動控制吞咽。
Composed of fine particles Compensate for decrease in strengthen Congee with pureed meat
由幼細粒子形成的 of chewing X congee with diced meat
Moist 潮濕的 Compensate for limited saliva secretion Pudding, egg custard, soften pumpkin/ squash,
補充不充分的唾液 X biscuit/ egg roll
Cohesive (sticking together) Improve sensation and compensate for Pudding, egg custard
內聚的 weak tongue movements 增強感覺,補
救無力的舌頭運動,亦減少脫落和殘留物
Examples of Problematic solid food
Types 種 類 Examples 例 子
Too hard 太硬 Candy 糖果, nuts
Too dry & crispy – easily broken into pieces太乾、易碎 Biscuit 餅乾, egg roll
Too sticky 太黏稠 Sticky rice, peanut butter, banana, bread 糯米飯、花生醬、香蕉
、白麵包
Too large in size 太大 Fish ball 魚球、燒賣
Slippery onto pharynx 潤滑的 Rice dumpling 湯圓…..soft banana…
Various textures mixed together Noodle with thin sauce, Congee with diced meat 肉碎粥, fruit with
不同質感 seeds
Pharyngeal residue due to poor P Thin liquid may be Avoid sticky food
contraction more preferrable.
Avoid liquid with
Pharyngeal residue due to poor high viscosity (e.g.
UE opening assess suitability of
level III & IV liquid)
syringe
straw
– Consider:
• Feeder position****
• Drinking with a cup vs cut-out cup
– cut-out cup may prevent neck extension when clearing
last fluid content at the base of the cup
– Use a cup with board opening
Presentation
of spoon
Last
slide
• Head tilt to R or L
– For those with unilateral oral & pharyngeal residue
– → Use of gravity to guide food/fluid flow, e.g. head towards sound side in CVA cases
• Likely combine with the use of thickened liquid
• Presentation of spoon
• To the non-affected in unilateral stroke with tongue deviation, decreased sensation/
unilateral (bodily) neglect
R Wong 2023 BScOT Geri 45
Adapt to different ways of feeding/eating
Effortful swallow ……. & others
• Purpose:
– To improve tongue base retraction & residue in valleculae
– (can be an strengthening exercise: discuss later)
• For:
– Patients who have residue in valleculae
• Technique:
– ask patient to squeeze very hard throughout the swallow.
• Excess effort should be clearly visible in the neck during the swallow.
• Can be a strengthening exercise if patient practice in dry swallow
Check oral
residue
Sitting upright
Follow principles for seating:
• pelvic position in maintaining upright…, neutral alignment, symmetrical & even
weight bearing
• UL on table…..
• Close to table…..
• Self feed vs Feeding with feeder (Total assist [Facilitate safe bolus
formation] →Cueing → hands on supervision [monitoring self feeding]
– *however, in demented case, swallowing *may be easier to manage with self-
feeding (especially some chewing is needed to be maintained)
• Feeder’s position: sit in front of the person, eye contact can be made at
or slightly below the person’s eye level
a) ***Enables the patient to maintain their chin in the neutral to chin down
position
b) Promotes social interaction between the person and feeder (can be a
distraction for demented cases).
c) Allows the feeder to monitor the patient’s swallowing by *observing
laryngeal elevation.
d) Avoid putting the food too far at the back of the tongue → induce gag
reflex
• Immediately following a meal, clear with a toothette (or finger wrapped with a
disinfected gauze & distilled water).
LOCAL PRACTICE
Acknowledgement: Part of the information is from Dr Bobby Ng
Comfort Feeding
• Comfort-oriented (least invasive)
• Quantity not main focus
• Taste favourite foods
• Risk of aspiration
Source:
https://www.hkag.org/EOL/pdf/23%20Aug%202019%20Ms%20S
abrina%20Ho%20talk%20on%20Comfort%20feeding%20and%2
0Careful%20hand%20feeding.pdf
Hong Kong Med J ⎥ Volume 23 Number 3
⎥ June 2017 ⎥ www.hkmj.org
R Wong 2023 BScOT Geri 55
EIGHT Standards for Low-Risk Feeding (Oral Feeding)
• Feeding standards are adopted from :
• EIGHT Standard Procedures
for feeder (developing a feeding plan & feeder education)
1. Reviewing feeding
“Facilitating Effective Eating in Recommendations
Dysphagia” (FEED) Program 2. Positioning for Oral Intake
3. Food Check (consistency)
• A Self-Directed Learning Program
4. Feeder Position
for Feeding Assistant 5. Amount & Rate
6. Clearing the Oral Cavity
7. Post Meal Position
8. Documentation
界別 用餐時間 員工:弱老
Level of Assistance Required Meal Time Staff : Elderly ratio
I - 監督 每日3餐,每餐 30 分鐘 1:10
Supervised
II - 輔助 每日3餐,每餐 30 分鐘 1:4
Assisted
*員工需接受餵食技巧訓練 Involved staff would required training in “Low Risk Feeding” procedures
•GOAL:
–Track changes
– communication with team member
•Should contain info as in a logbook:
–type of liquid & food taken
–quantity of food and fluids taken
–Any unusual (or significant) incidents occur during a meal: e.g.
coughing, spillage, energy level,
–Any action taken
–Who is the feeder
–………
INTERVENTIONS: TREATMENT
6. Acupuncture
• Caution: Many exercises involve isometric contraction of neck/UL. Caution must be taken
with patients with uncontrolled high blood pressure/ poor cardiac conditions as bearing
down/ holding breath may raise blood pressure. Also for patients with poor pulmonary
conditions/ end of life stage.
Supraglottic Swallow
• Purpose: to improve epiglottic closure before swallow & clear of residue after swallow
• For: patient with delayed/ reduced epiglottic closure, delayed pharyngeal contraction,
poor oral control of liquid & pre-mature spillage onto pharynx.
• How: Take a deep breath and hold it→ Keep holding your breath while you swallow→
Cough immediately after swallowing.
source: https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/swallowing-exercises-closure-of-the-larynx-exercises
• Purpose:
– To increase laryngeal elevation + “pull-open” UE sphincter by strengthening
upward and forward movement of the hyolaryngeal
Vital Stim
• Purpose:
– Strengthening (muscles are important for breathing
out forcefully, coughing, and swallowing) & improve
expiratory pressures for better airway protection
– How: The muscles are exercised by blowing into
the device until you generate enough pressure to
open the spring-loaded valve
3. Protection of airway from bolus misdirection safely (range & strength, co-
ordination/ timeliness)
– Risk of aspiration