List some oral health factors that can contribute to older adults' eating and swallowing.
Chronic dry mouth, impaired dentition, medications/xerostomia/poor hygiene which can affect taste
T or F?: If a voluntary cough was noted previously, this ensures that a reflexive cough is still present.
FALSE; if a voluntary cough was noted previously this does not ensure that a reflexive cough is present.
T or F?: Globus sensation complaints are an indication for a MBSS.
TRUE
T or F?: Patients with decreased alertness and poor cough reflex are not at risk for aspiration pneumonia if they are being tube fed.
FALSE
List 3 PRIMITIVE reflexes that may present in cases of extensive brain damage.
Sucking reflex, snout reflex, & tonic bite reflex
List some laryngeal age-related changes.
reduced motor unit firing rate, atrophy & loss of laryngeal muscle fibers, ossification of laryngeal cartilage, & reduced sensation in the pharynx and larynx
Which cranial nerve is primarily associated with lip closure & buccal strength?
VII: Facial
Explain palatal reflex vs gag reflex
Palatal reflex = elevation of soft palate w/o wall contraction; gag reflex = soft palate elevation plus pharyngeal wall contraction
You want to examine the movement of multiple structures at the height of a patient's swallow...Which instrumental assessment is preferred?
MBSS
What is the difference between FEES and FEEST?
FEEST emits a puff of air out of the endoscope to test protective cough reflex (@ risk for silent aspiration)
Which cranial nerves are crucial to test during oral mech for swallowing?
V trigeminal, VII facial, IX glossopharyngeal, X vagus, XI spinal accessory, & XII hypoglossal
Which cranial nerve is primarily associated with tongue strength and range of motion?
XII: Hypoglossal
In VFSS, what physiological impairments may cause the bolus to spread throughout the oral cavity?
reduced tongue coordination, difficulty forming food into a cohesive bolus during mastication, tongue weakness
During MBSS, which stage would you check the adequacy of PES relaxation/opening?
Pharyngeal Stage
The supraglottic swallow is ideal for patients who have issues with ______ ________.
Airway Protection; cancer pts. with epiglottis removed etc
During MBSS, name the stage you would check for oral residue.
Oral Stage
During MBSS, which stage would you check for backflow of food/liquid from the esophagus?
Esophageal Stage
What type of trach is mostly used for persons on a vent to keep air from escaping out the larynx when the lungs are inflated?
Cuffed
T or F?: When performing a "head turn", the pt. should turn their head TOWARD the side where the residue is.
TRUE
Pt. has a unilateral collection of material in the pharynx. What maneuver should be used?
Head Turn
T or F?: "Informed consent" can be defined as "a voluntary choice made without coercion".
TRUE
What do you call "a document that enables people to express their wishes about their health care in a form that will tell others how to care for them and to make decisions for them if and when the time comes that they are unable”?
Advanced directive
This maneuver is most useful for pts. with reduced hyolaryngeal elevation...
Mendelsohn; helps engage muscles, UES will remain open to allow bolus to enter esophagus
What are the 4 levels of diet modifications for solids according to the National Dysphagia Diet?
Puree, Soft-ground (mechanical soft), Chopped (mechanical soft), Regular consistency diet
What is the ultimate goal of management for PO patients with dysphagia?
ideally resume prior level of diet or tolerate least restrictive diet
Which maneuver helps bring the base of the tongue to the posterior pharyngeal wall?
Chin tuck; strengthens the push against the wall, uses the back of the throat to push food down, widens valleculae
What are the 2 types of behavioral treatment approaches?
compensatory strategies (indirect) and rehabilitative treatment (direct)
What is direct treatment and what are some examples of direct treatment approaches?
tx focused on changing the swallowing physiology to restore function and directed at improving neuromuscular control; rehab tx like auditory feedback etc
In VFSS, what physiological impairments may result in nasal regurgitation?
poor VP closure, poor coordination of velum
What is the ultimate goal of management for NPO patients with dysphagia?
resume oral intake; total oral feeding may not be possible but determine how patient can feed for oral gratification in order to improve QOL
Your patient has severe dysphagia and poor pulmonary clearance...Which instrumental assessment is preferred?
FEES
During MBSS, which stage would you check the adequacy of hyoid movement/laryngeal elevation?
Pharyngeal Stage
SpO2 levels below ____ are considered "pathologic"? A. 83-85%. B. 48-50%. C. 75-77%. D. 92-94%
D. 92-94%
Define "dyspenia".
Difficulty breathing
T or F?: You should try various maneuvers before MBSS to see which posture works best.
FALSE: Complete MBSS first
This maneuver involves training the pt to elevate their larynx for 2-4 seconds before swallowing...
Mendelsohn
During MBSS, which stage would you check the adequacy of epiglottic inversion/retroflexion?
Pharyngeal Stage
Why do people aspirate when there is a delayed swallow?
The bolus fills the pyriform sinuses/when space is filled it'll go into the larynx
What is the preferred assessment given to patients with tracheostomy tubes?
Blue Dye Swallowing Test
T or F?: A medically fragile patient is a good candidate for MBSS?
FALSE; use FEES
What exercise can help strengthen suprahyoidal muscles around the larynx?
Shaker exercises
List some esophageal disorders.
Zenker's Diverticulum, strictures/constrictions, GERD, trachoesophageal fistula
In VFSS, what physiological impairments may result in penetration and/or aspiration?
poor airway protection, poor vf closure, delayed trigger of swallowing, reduced laryngeal elevation
Atrophy and fasciculations are indicative of damage to what?
LMNs
Which cranial nerve is primarily associated with the jaw, lip, and hyolaryngeal excursion?
V: Trigeminal
Which patients are good candidates for thicker liquids?
pts with tongue base weakness, delayed trigger, reduced laryngeal closure/airway protection
List the 4 mechanisms of airway protection.
1) hyoid/laryngeal elevation 2) epiglottic retroflexion 3) adduction of true VFs 4) closure of laryngeal vestibule
In VFSS, what physiological impairments may cause food to fall out of the mouth?
weak lip closure, loss of sensation in mouth, lack of awareness of food in mouth due to cognitive deficits (i.e., dementia)
What is the first screening given to a new patient?
Bedside Evaluation
What are some advantages to the FEES?
No radiation is involved, can watch someone eat a whole meal, portable, can be used for bigger patients
What are some cons to the FEES?
only sees what's happening in the pharynx & camera gets blocked during swallow
Who on the medical team is needed to competently describe any abnormalities in the esophageal stage?
Radiologist
List some esophageal MOTILITY disorders.
Diffuse Esophageal Spasms (DES), achalasia (failure of LES to relax)
This maneuver involves putting liquid in the mouth, holding it, swallowing it, then coughing to clear the epiglottis...
Supraglottic swallow
What type of exercises are preferred for a patient demonstrating weakness or incoordination in muscles/structures that might benefit from strengthening or practicing patterns of movement?
Oral Motor Exercises
Define "trachypenia".
Rapid breathing
Which 2 thermal/tactile stimulations tend to be stronger triggers of swallow?
COLD temperature and sour taste
List 4 neurogenic based swallowing disorders.
Strokes, TBI, brain tumors, degenerative neurologic diseases
How should pills be given to patients with oropharyngeal dysphagia?
pills should be crushed and mixed with applesauce, yogurt, pudding, or thickened liquids
What is indirect treatment and what are some examples of indirect treatment approaches?
tx that circumvents the problem using compensatory strategies to alter bolus flow; includes posture, sensory procedures, maneuvers, diet changes, etc
Name some overall BURDENS of feeding tubes.
Can't be absorbed from the gut; doesn't abate “failure to thrive” (eg Alzheimer’s), Physical pain, Cant help because underlying condition is hopeless, etc
Which of the following promotes passage of the bolus through the stronger side of the pharynx?
Mendelsohn maneuver
Effortful Swallow
Head turn
Chin tuck
Which patients are good candidates for thin liquids?
pts with good airway protection but overall tongue dysfunction, reduced UES opening, or reduced pharyngeal constriction
Name some overall BENEFITS of feeding tubes.
Increased life span/ability to recover/possibility of returning to useful functioning/QOL/psychological & physiological state/resistance to infection
Name some universal aspiration precautions
Chew your food, take your time, pay attention, don't eat too fast, take small bites, sit upright...