Dysphagia, Swallowing, Treatment

[caregiver222]

These are some observations regarding treatment for swallowing disorders.

[caregiver222]

These are some personal observations regarding treatment of the patient with swallowing difficulties. I find the current guidance available inadequate and irrelevant. There is ample material available on the internet regarding the mechanism of swallowing, so I will not cover this. Individuals are different and the degree of disability different. These procedures may not help everyone. My observations lead me to the following: Swallowing difficulties are often intermittant, and may be regulated by the circadian rhythym. There is generally a "window of opportunity" to utilize and it may take place at very odd hours of the day. The rule is that feeding and hydration should take place within this window. Often the window is late at night or after midnight. During this "window" there is an improvement in the ability to swallow. This improvement may be miniscule. Feeding such a patient involves infinite patience. It took me two hours between 11 P.M. and 1 P.M. to get four ounces of protein enriched supplement into the tummy of my sweet little 103 year old last night. The drill is as follows: The patient should be brought up to the point where they can hold a two ounce plastic cup. The cup is placed in the hand and the patient takes a sip by themselves, without the cup being pushed to the lips. NEVER FORCE FEED a person with swallowing difficulties. If they wave the cup away, try ten minutes later, by offering it again. Often you will get a single sip and a wave of the hand. Now comes step two. Observe for "cheeking". Keep the patient supported with the spine vertical, hand on the back. If there is cheeking, place your hand under the mouth and permit the patient to regurgitate the fluid into your hand. If they resist regurgitation, it suggests they want to swallow. Take a tiny piece of banana and offer it. The substantive nature of the banana piece will cause muscular action that will permit the swallowing of the fluid. At every feeding cycle or snack, the aid must offer a small quantity of food, then OBSERVE FOR CHEEKING. Before leaving the patient or permitting them to lie down or fall asleep insure there is no food remaining in the mouth. Much is made of the dangers of aspiration pneumonia, when food goes down the trachea into the lung and causes infection. The true hazard is laranygospasm. Drowning victims are often found with lungs clear of water. They die because of a muscle spasm induced by fluid into the trachea. In an elderly stroke patient a bit of fluid or food into the trachea may cause such a spasm. It is helpful to attend a basic training course in CPR, with emphasis on learning how to clear an airway. People with swallowing disorders must be watched like hawks. If there if coughing, or evididence of discomfort, lean them foward and encourage them to spit out the food/liquid. It may be necessary to place your finger in the mouth to clear the food, but do not permit your fionger to go down so deep as to stimulate a "gag" reflex". The finger should only be within the cheek pocket. This is an emergency and don;t worry about washing your hands.  You should wash them before feeding, in any event. Don't take time to get a glove.  Hold them upright and offer reassurance and comfort. If food has been aspirated close monitering of lung function over the next 48 hours is necessary. Purchasing a good stethascope and learning how to auscultate lung fields, four quadrants, anterior and posterior, is an excellent investment in time. The lung can handle small quanties of fluid. Initial wheezing for an hour or two mis not significant. If the wheezing continues after 12 hours, professional medical assistancde is required. After ingestion of even a tiny bit of fluid, maintain the patient in an upright position for at least an hour, all the time remaining next to them, holding their hand or wrist and providing reassurance. Open the window wide to increase air circulation. While there is normally 21% oxygen in a room, in a closed room this percentage may easily drop to 19%. Opening the window wide increased the unit volume of oxygen. If you have an emergency oxygen tank, something physicians are reluctant to supply, use a nasal cannula at 2 liters per minute for an hour following such an episode. The spasms that close the trachea can reoccur, but this will usually take place within 15-30 minutes. If they don't by that time you are free and clear. I find oyster crackers to be idea to provoke good swallowing. Soak them in the thick soup to soften (do not crush) and serve a tiny spoonful of soup with one oyster cracker. Similarly, well smoothed egg salad or a bit of chicken liver puree on an oyster cracker is helpful in promoting swallowing. Swallowing difficulties can persist for 48 hours, and then suddenly disappear for a few hours. There can be a day or two days of extreme sleepiness followed by alertness. The important thing is to maintain a daily calorie count, as well as a record of fluid intake. With a person having swallowing difficulties, it is easy to get behind the power curve. Dehydration causes a cascade of problems, from constipation to the danger of blackout when straining on the toilet, to cardiac arythymias. Never ever feed a stroke patient who has not been given a food/liquid challange or is too sleepy. With most aides the time of feeding becomes something arbitrary. If the patient cannot hold a cup themselves, they are too lethargic to feed or take liquids. You may end up with a situation where feeding can only be successfully acomplished between 10 P.M. and 3 A.M. due to the disurbance in cicardian rhythym. Convincing an aide to perform this kind of feeding is trying. If you try to do it, they will complaoin about their sleep cycle being interrupted. The aide is there for the conveneience of the patient. Not vice-verdsa. If they feel inconvenienced, "that's how it goes moving west". If they complain enough, find another aide. One solution may be 12 hour shifts, where an aide comes on an 9 P.M. and leaves at 9 A.M., with the understanding they have to stay awake to provide feeding as part of the job. A detailed record of caloric intake and quantity of food is a mjust, and for the most part the aides will resist. "She eat a lot," may be the best thing you can get out of an aide. You must not permit the aides to discard the food. A helpful way to moniter this is to have the aides digitally photograph the meal before eating and do the same afterwards. This costs nothing because you can erase the image on the electronic storage card. If you do not insist on this protocol you will find a notation "ate half banana" when in fact one fourth of a banana has been provided and only a single bite taken out of that. Monthly weighings are indicated, and every other month at a minimum. If dehydration occurs, you may have to take the patient in for intravenous hydration. Pre-arrange this with your geriatric practicioner, who will provide you with guidelines as to when it may be necessary. The ER is an option, but a poor one. After every single meal the aide should make a cell phone report to a responsible individual and state the quantity of food and liquid ingested and the degree of swallowing.

[caregiver222]

Let's go on to additional hints regarding the management and treatment of dysphagia and stroke related swallowing disorders. In the swallowing situation, obtain a large dry-erase board with markers. There are three areas of concern. These are (1) Hydration (2) caloric intake (3) nutrition. Every single day there must be a goal set for each of these. Some days you will meet them. Other days you will come close. On really bad days (usually "sleepy" days) you will be very discouraged.  The important thing is to not "get behind the power curve".  Every single day these criterion must be evaluated. Hydration refers fluid intake. It is extremely important! Caloric intake refers to...calories! Look up from one of the many charts the minimum calories necessary for your patient of given height, weight and age requires to maintain body weight. (4) Nutrition refers to a breakdown of the days meals into protein, carbohydrates, vitamins and supplements. Let's take an example. My little 103 year old sweety-pie requires 980 calories a day to maintain her body weight and muscle mass. At the end of every day I do a tabulation.  A rough one. You don't have to be exact. Her breakfast yesterday consisted of three tablespoons of apple sauce, one scrambled egg with jelly, and she ate four of six ounces of oatmeal with protein supplement and maple syrup. The apple sauce is 30 calories. The egg with jelly 110 calories. The oatmeal with syrup 110 calories. 250 calories total. In the afternoon she snacked on a small four-inch lemon desert pie. 370 calories. In the evening she ate two pureed hard-boiled organic eggs with mayo, four ounces of pureed home-made split pea soup, and two tablespoons of yogurt. 180 calories for the eggs and mayo. 100 calories for the soup. 40 calories for the yogurt. 310 calories. During the day she snacked on 1/2 banana. 50 calories. 980 calories! Voila! Now we come to her hydration (which added calories). I uses two ounce plastic cups, which are stacked. I know how many calories are in every two ounce cup. At the end of the day we have 14 cups stacked. 28 ounces of fluid intake (plus the four ounces of soup). These  drinks are protein and carbogdrate enriched mixtures I prepare myself from carbohydrate supplement, whey protein, egg protein, and flavors (banana, strawberry, maple and vanilla). I know every ounce contains 25 calories. Probably a bit more. So I do another calculation. There are the 14 cups, but she has another half-filled cup so that makes 29 ounces of supplement. That totals 725 calories. During the afternoon and evening she has an additional snack of hot chocolate. She drinks one ounce in the afternoon and two ounces at midnight. 3 ounces at 20 calories an ounce. 60 calories. So on the board I write a total of 1725 calories, 33 ounces of fluid. I know the number of grams of protein, which will vary with your choice of food and I write that on the board. She has had two "sleepy days" previously in which she did not quite meet her caloric or hydration goals. So today is a day for celebration. So at the end of the day I have a little discussion with the aide and we take the figures off the dry-erase board and enter them in the little permanently bound children's marble covered logbook. Remember that you will have good days and bad days. If you have several bad days you then have a "condition yellow" period. If the swallowing, hydration and nutritional intake continues into deficit I might have to take her to the doctor's office. This hasn't happened. But I pre-arranged for her to obtain emergency intravenous fluid and nutrition, in such a case bypassing the emergency room. It hasn't happened yet.  In a worst case she might have to have a nasogastric tube placed for a short period. These are worse-case options, but should be discussed beforehand, or you will end up a low priority in an overworked emergency room, the employees of which are is very prepared to suggest a DNR order at the drop of a hat. As far as nutrition goes, every morning she gets a small teaspoon filled with flavored cod-liver oil. One of the two ounce cups has a finely crushed high-quality vitamin supplement. She gets 120 mg of Co-enzyme Q-10. This is low. 25 mg of DHEA. 112 mg of synthroid (based upon her TSO values obtained in the lab). A supplement of magnesium glycinate and vitamin D. Sublingual Vitamin B-12 with folic acid (cherry flavored). A B-12 capsule emptied in one of the drinks. And I have a small regiman of other supplements administered in small quantities, such as B vitamins, zinc, chromium GTF, an anti-oxident. In her case I do not provide high vitamin C supplements because they have a diuretic effect. But she gets 300-400 mg of crystal form C dissolved in the drink supplements. I consider "high" as being above 500 mg.  On good days she has more conventional meals, and enjoys creamed spinich and melt-in-your-mouth filet of fish, but those are only on days when she has good swallowing. Every day, we take one at a time. If you don't keep meticulous track of fluid and nutritional intake you end up with "nonsense" from the aides, such as "she eat good".  When you poke and probe, you find this often means "she eat bad". There has to be a captain of the ship, and that captain must take the helm. You don't have to be a rocket-ship scientist or an M.D. or have a degree in nutrition to do so. As far as eating goes I prefer an "ad-lib" eating situation. Every breakfast consists of two scrambled eggs. Sometimes she eats one. Sometimes two. But two are always prepared. Plus nutritionally enriched oatmeal and lactose-free milk. I enrich the oatmeal with whey protein, which adds a nut like flavor, plus a lot of butter and maple syrup. I prefer not to use soy protein, which, according so some literature, depresses thyroid function. In the case of my sweety-pie this is significant.

[caregiver222]

There are other rules for caregivers I have formulated that may prove helpful in the treatment and care of those with stroke related swallowing disorders. The first rule is that of periodicity. That is to say the regular presentation of food/liquids throughout the day at regular intervals. A suggested interval is every two hours. The second rule is the rule of consecutive presentations. This rule states that if food/liquid is swallowed, then wait five to ten minutes and make a second presentation. If that offering of food/liquid is accepted wait another five minutes and make another presentation. Always remember that a wave of the hand doesn't necessarily mean "no". It means later. The third rule is to "strike while the iron is hot". When the patient is accepting food/liquids, continue presentations until no more food/liquid is accepted. In other words optimize the nutritional intake and the hydration. If you start feeding and then go off to make a telephone call when you come back the patient may be asleep. The fourth rule is to schedule feeding and hydration around the patients day-night cycle, and not that of the aides or yourself. This cycle often involves sleeping during the day and alertness starting in the evening and continueing well after midnight. Or even starting at 11 P.M. and continueing until 6 P.M.  Since many home-care aides work on a 24 hour cycle and expect to sleep at night this may require split shifts of 9 P.M. until 9 A.M. with the aide instructed they are to remain awake and feed/hydrate the patient all night if necessary. The day night cycle can be altered, but that is another topic,  Yes, this is difficult. But often the swallowing difficulties will disappear if the patient is stabilized and other areas of the brain gradually regain control of the muscles necessary to swallow. The five minute interval is only a guideline. If possible this may be reduced to a minute. Experiment. The thing to avoid at all costs is force feeding. It often takes a long time for the food/liquid to be swallowed and the patient ready for another mouthful. And patience is the watchword. With a little bit of luck the feeding situation will gradually improve over a period of weeks or months. The intervals between acceptance become shorter. If at all possible the patient should feed him or her self. Take the two ounce plastic cup in their hand and let them bring it to their lips. Put the spoon in their hand and encourage them to place the spoon in the mouth. Yes, the elderly often enjoy being "spoon fed", but this can interfere with rehabilitation. The more use they get out of their fingers, arms and hands, the more improvement. I recognize that you may have to "spoon feed", but ideally you want the patient to be ab active participant. When there is suffficient improvement you can schedule regular meals with the proviso that these meal periods may last a long time.  At least an hour and perhaps two. If you get to the point where swallowing is sufficient to permit regular meals, do not feed in the chair in which the patient sits all day. Instead, get a little four-wheeled wheelchair and make the meals a highlight of the day. Serve the food properly on a tray, attractively presented with condiments, just like in a restaurant. Make the meals part of the rehabilitation process. Something for the patient to look foward to. Place the food where the patient can reach everything. And if they spill things of mix foods inappropriately don't interfere. I have observed aides who believe they are the "food police". If the little one wants to put a little orange juice on her mashed potatoes, simply observe and smile. Don't grab his/her hand. There should be good light over the meal area. I use a Luxor fixture which simulates daylight. It has a flourescent circular luminaire and an incandescent in the middle on an extensible arm. They are available in art supply stores.