American Dysphagia Network logo
A network for the prevention, diagnosis & treatment of swallowing disorders.

"Diagnosis and Management of Dysphagia in Seniors"

Get Adobe Reader

Long Beach Memorial Medical Center logoSponsored by Long Beach Memorial Medical Center

Authors:

Jeri Logemann, Ph.D.
Charles Stewart, M.D.
Jane Hurd, MPA
Diane Aschman, MS
Nancy Matthews, MA

Release Date:

January 2008
Review/Renewal date: July 2011
Termination date: July 2014

Target Audience:

This activity was developed for primary care physicians working with seniors.

Accreditation:

Continuing Medical Education Committee logo Long Beach Memorial Medical Center is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to provide continuing medical education for physicians. Long Beach Memorial Medical Center takes responsibility for the content, quality and scientific integrity of this CME activity.

Goal for this educational activity:

Educate primary care physicians, clinicians and other care providers regarding the diagnosis and treatment of swallowing issues, in an effort to improve quality of life for patients with dysphagia.

Designation

Long Beach Memorial Medical Center designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This credit may also be applied to the CMA Certification in Continuing Medical Education.

The California Board of Registered Nursing recognizes category 1 courses approved for credit by the American Medical Association toward meeting the continuing education requirements for license renewal.

Coursework which meets the standard of relevance to pharmacy practice and has been approved for continuing education by the Medical Board of California, shall, upon satisfactory completion, be considered approved continuing education for pharmacists.

Course Development

The online content was developed through a collaboration of a nationally-noted dysphagia expert who is a speech language pathologist (Jeri Logemann, Ph.D.), a radiologist (Charles Stewart, M.D.), and a pharmacist (Diane Aschman, MS) as a part of the project Dysphagia Care Among Seniors in Los Angeles County funded by the UniHealth Foundation.

Dysphagia Care Among Seniors in Los Angeles County is a screening and education program targeted at residents of independent and assisted living facilities in Los Angeles County suffering from undiagnosed, untreated or under-treated swallowing disorders. With this pilot program, screening and education materials have been developed, and apparently healthy residents benefited from early identification and treatment for this potentially debilitating condition.

"Diagnosis and Management of Dyspagia in Seniors" was developed as an education program for clinicians, assisted/independent living residents, their families and caregivers about the risks of dysphagia, its sequellae as well as the potential intervention strategies.

Course Directions

Participants are instructed to read the 14 sections of course material and then fill in the information fields before taking the Exam. When finished answering ALL of the questions, click on the 'Submit My Test Now' button. Your results will come back to you immediately. Please print the results page as your course completion verification.

Course Time

The estimated time to complete this educational activity is 1 hour. Long Beach Memorial Medical Center designates this educational activity for a maximum of 1. AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Educational Objectives

Upon completion of this educational program, primary care physicians will be able to:
  1. Recognize the presence or occurrence of undiagnosed dysphagia in a senior population.
  2. Outline the risks of dysphagia and the importance of early diagnosis.
  3. Describe clinical screening and diagnostic processes for dysphagia.
  4. Explain the importance of minimum standards for the Modified Barium Swallow1 (MBS) in detecting some swallowing issues.
  5. Recognize medications associated with swallowing issues.
  6. List 5 of the 10 observable signs of potential swallowing problems.
  7. Explain how and to whom to make referrals for potential dysphagia patients.
  8. Identify potential intervention and treatment strategies.

Definition and Etiology of Dysphagia

An average of 10 million Americans is evaluated annually for swallowing disorders.2 Dysphagia is more specifically defined as unsafe or inefficient swallowing secondary to changes in oropharyngeal physiology. It is most common in older individuals and can adversely affect their quality of life, or can lead to more serious medical issues.

Many causes have been identified for dysphagia in the elderly, including:

  • Neurogenic Dysphagia

    Neurologic disorders often result in dysphagia due to the loss of muscle function and/or coordination. Because the swallowing process involves more than 25 muscles and the complicated coordination of their movements, patients with neurologic dysfunction are at high risk for dysphagia. Some of the neurologic disorders which may produce dysphagia include:
    • Stroke
    • Brain injury
    • Spinal cord injury
    • Parkinson's disease
    • Multiple sclerosis
    • Amyotropic lateral sclerosis (ALS)
    • Muscular dystrophy
    • Cerebral palsy
    • Alzheimer's disease

  • Problems affecting the head and neck, including:

    • Cancer in the head, neck, or esophagus

      Dysphagia can occur as a result of surgical removal of cancerous sections, affecting the movement and control of food during the swallowing process. It can also be caused by radiation therapy, which can produce sores in the mouth and throat, reduce the production of saliva, and restrict movement of remaining structures.

    • Injury or surgery involving the head and neck

    • Decayed or missing teeth, or poorly fitting dentures

  • Medications

    Dysphagia can be drug induced as well. Swallowing disorders may be a side effect of medications used to treat a number of conditions, including, but not limited to anxiety, arthritis, hypertension, and pain. The table below lists some of the medications that may be associated with swallowing disorders, along with descriptions of how they affect the swallowing process.3 4

    medications

    A recent study (Dysphagia Among Seniors in Los Angeles County)5 compared a list of 40 categories of medications to the results of the Modified Barium Swallow, which is the gold standard for diagnosis of dysphagia. This study included 128 individuals and found that 3 of the 40 categories were significantly associated with swallowing difficulties:
    • Selective Serotonin Reuptake Inhibitors (SSRIs)
    • Aspirin/Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
    • Dopamine Agonists/CNS Agents

    Dysphagia does occur in pediatric populations as well, but the causes and complications are generally different from those described above for adults. For example, gastroesophageal reflux is common in infants and children, potentially affecting the larynx, ears, nose, paranasal sinuses, and oral cavity. Gastroesophageal reflux can also be a trigger for asthma in children. In premature infants, aspiration can be a problem due to their inability to coordinate sucking, swallowing, and breathing. Aspiration is also a risk for neurologically impaired children due to the lack of coordination of the oral and pharyngeal muscles.

    Although dysphagia is not uncommon in children, and the risks associated are serious, the prevalence is much greater in adults, particularly those over the age of 50. The prevalence of dysphagia and the complications presented in older populations are addressed in the following section.

Prevalence of Dysphagia

The prevalence of dysphagia increases with age and is particularly problematic for older patients. The risks—including weight loss, dehydration, and aspiration—can be devastating to this population of patients.6 7 Early identification and treatment of swallowing problems can have a significant positive impact on overall health and quality of life.

  • Approximately 7%-10% of adults older than 50 years have dysphagia, although this number may be artificially low because many patients with this problem may never seek medical care.8
  • In people over 60, the prevalence of dysphagia is 15% to 40%. The reported prevalence of dysphagia in long-term care facilities, including assisted living and nursing homes reached up to 66% in some studies.9 10
  • Another study looking at a hospitalized elderly population revealed that only 39% of dysphagic subjects were identified by the staff.
  • This same study found that only 22% of dysphagic subjects included any reference to the symptoms or condition.11
A recent study (Dysphagia Among Seniors in Los Angeles County) was conducted to determine the prevalence of undiagnosed dysphagia in seniors in independent senior living centers or associated with senior care networks. Three hundred seventy-nine (379) seniors signed consents and completed an evaluation with a speech-language pathologist (SLP). A random sample of 162 also completed a Modified Barium Swallow exam (MBS) and responded to a newly developed observable signs of dysphagia questionnaire. The results of the MBS were used to determine prevalence and to validate the new questionnaire. The MBS identified a prevalence of 10.5% dysphagia in this sample of previously undiagnosed seniors.12 This percentage of seniors living independently is significant considering the risks they face if they remain undiagnosed and untreated.

Risks Associated with Dysphagia

The identification of dysphagia is critical to the management of both physical and emotional risks associated with this disorder. According to the American Speech-Language Hearing Association, dysphagia can result in:

  • Poor nutrition or dehydration13
  • Risk of aspiration of food or liquid, possibly leading to pneumonia and chronic lung disease13
  • Decreased enjoyment of eating or drinking
  • Isolation or embarrassment in social situations involving eating

"The consequences of dysphagia vary from social isolation to the embarrassment of choking or coughing at mealtime, to physical discomfort, and to potentially life-threatening conditions. Both overt aspiration and silent aspiration may lead to pneumonia, exacerbation of chronic lung disease, or even asphyxiation and death."14

Clinical Screening and Diagnosis

Although the screening and diagnosis of dysphagia are not difficult, many patients remain undiagnosed due to a number of factors:
  • Lack of education as to the prevalence of the disorder
  • Lack of education regarding causes of dysphagia
  • Inadequate training on the screening, diagnosis, and referral processes
  • Confusion regarding the distinction between normal variations in swallowing (as a result of aging) and dysphagia
    • Some of the swallowing changes that occur normally with aging include slower swallowing, a slight delay in triggering certain phases of the swallowing process, and a slight increase in the amount of food left behind in the mouth and pharynx after swallowing.
  • The unwillingness of patients to report problems to their primary care physician

Many patients will not volunteer information about swallowing issues because they:
  • Are unaware of the signs
  • Dismiss their symptoms
  • Accept the problems as a normal part of the aging process
  • Are unaware of safe swallowing strategies
  • Are unaware that Speech-Language Pathologists (SLPs) address these problems
  • View swallowing issues as insignificant
  • Are unaware of potential risks, or
  • Fear a loss of independence (by admitting the issue)

Therefore it is important for physicians to be aware of all these factors that allow seniors to remain undiagnosed. By educating themselves and their patients, these seniors can more easily be identified and treated. The first step is to understand the complexities of the swallowing process. The following section details this process and is followed by descriptions of the observable signs most helpful in screening for dysphagia.

The Swallowing Process15 16 17

Understanding the swallowing process is often helpful in recognizing a swallowing disorder and is critical in developing a treatment protocol. Normal swallowing can be divided into the following 3 phases:
  1. Oral phase, which involves oral preparatory phase and oral transit phase
  2. Pharyngeal phase
  3. Esophageal phase

the swallowing process

Oral Phase

Oral Preparatory Phase

In Image A18, food, the material colored green is being prepared for swallowing. This involves the use of the lingual, mandibular and labial musculature for mastication with the food formed into a bolus and held anterolaterally against the hard palate by the tongue. This process requires the taste, temperature, touch, and proprioception senses for formation of a bolus the right size for the consistency being swallowed.

Oral Transit Phase

The oral transit phase (images B and C) involves lifting the bolus on to the front of the tongue and then pushing it posteriorly, toward the pharynx. Sequential anterior-toposterior tongue elevation contributes to triggering the pharyngeal phase of the swallow as the bolus moves into the pharynx.

Pharyngeal Phase

Images D and E demonstrate how the bolus moves through the pharynx. Elevation and retraction of the velum, lead to velopharyngeal closure. This prevents material from entering the nasal cavity. The bolus is then pushed further into the pharynx toward the cricopharyngeal sphincter by backward movement of the tongue base and the sequential contraction of the pharyngeal constrictor muscles. The larynx closes at three levels: the true vocal folds, soft (false) vocal folds, and arytenoid cartilages, preventing material from entering the airway. The elevation of the hyoid bone and larynx is followed by relaxation of the cricopharyngeal muscle and opening of the upper esophageal sphincter, allowing the bolus to pass into the esophagus.

Esophageal Phase

Image F shows the final phase of the swallowing process. In this phase a peristaltic wave pushes the bolus sequentially from the cervical esophagus down through the esophagealgastric sphincter into the stomach. The act of swallowing usually interrupts the expiratory phase of breathing, while the completion of expiration occurs when swallowing ends. In situations where the swallowing is initiated during the inspiratory phase of ventilation, a brief expiration may ensue after completion of swallowing. Abnormalities of swallowing could result from defects in any of the components of the stages of swallowing enumerated above.

Observable Signs

A thorough patient history can reveal many of the symptoms that patients are unwilling to volunteer. The most obvious observable signs to ask the patient about fall into one of the following categories:
  • Choking or coughing while eating
    • Choking or coughing when eating solid foods or swallowing liquids
  • Weight loss/skipped meals
    • Loss of weight because eating is now difficult or unpleasant
    • Not eating because it is less enjoyable than it used to be
  • Ineffective swallowing
    • Difficulty swallowing medications
    • Difficulty swallowing a specific food or liquid
    • Getting the feeling that food is stuck in the throat
    • Having trouble clearing food from the mouth in one swallow
  • Airway issues
    • Food going down the "wrong pipe"
    • Voice sounds "gurgly" or wet when eating
    • Having repeated episodes of pneumonia and/or respiratory illness

The questionnaire below is a quick way to have your patients self assess these observable signs and to determine if your patient is at risk for dysphagia. This questionnaire was validated by comparing responses to the results of the MBS procedure. The 10 items on the Self-Test below were found to be the most effective in predicting the presence or absence of dysphagia.5

Dysphagia Self-Test

 
  1. Does food sometimes go down the wrong pipe?
 
  1. Does your voice sometimes sound "gurgly" or wet when you eat?
 
  1. Is eating sometimes less enjoyable than it used to be?
 
  1. Do you sometimes have trouble clearing food from your mouth in one swallow?
 
  1. Do you sometimes get the feeling that food is stuck in your throat?
 
  1. Have you had repeated pneumonia or other respiratory illnesses?
 
  1. Have you ever lost weight without trying?
 
  1. Do you often have trouble swallowing medications?
 
  1. Do you often choke or cough when you eat solid foods or swallow liquids?
 
  1. Do you often have difficulty swallowing a specific food or liquid?
 

To Calculate a Score:

  • Count your "Yes" answers.
  • Add 2 points if you answered "Yes" to Questions 1, 2, and 3.
  • Add 2 points if you answered "Yes" to Questions 3, 4, and 5.
  • If your age is 70 through 74, add 2 points.
  • If your age is 75 through 79, add 3 points.
  • If your age is 80 through 85, add 4 points.

Total Score: ____*

*If your total score is 7 or greater you should consider consulting your physician.

This self-test is a guide only and not a diagnosis of dysphagia. It is possible to have a total score of zero and still have dysphagia. It is also possible to have a score greater than 7 and not have dysphagia. However, the higher your score the more likely it is that you have some form of dysphagia.

Reference: Logemann JA, Stewart C, Hurd J, Aschman D, Matthews N, Reimer T, Calahan S, Taylor S, & Burton W (2008, February). Dysphagia Care Among Seniors in Los Angeles County: Planning and Pilot Study. (UniHealth Foundation, Grant 912). Los Angeles, CA.

If a patient is determined to be at risk (i.e. a score of 7 or greater), they can be referred to an ASHA (American Speech-Language-Hearing Association) certified SLP (Speech- Language Pathologist), who can perform a more thorough evaluation of feeding and swallowing. ProSearch is a searchable database that contains ASHA's online listings of more than 10,300 programs that employ audiologists and SLPs who hold the Certificate of Clinical Competence (CCC) from the American Speech-Language-Hearing Association (ASHA). The following is a link to this database: http://www.asha.org/findpro/

Programs and private practitioners who appear within this listing do so voluntarily and currently represent only a percentage of SLPs and audiologists who hold ASHA's Certificate. For more information, please contact the Action Center at: actioncenter@asha.org

Once a patient is referred, the SLP will take a careful history of medical conditions and symptoms, look at the strength and movement of the muscles involved in swallowing, and will observe feeding to see posture, behavior, and oral movements during eating and drinking. They may also perform special tests to evaluate the swallowing process mentioned above. This will often include a Modified Barium Swallow (MBS), which is a videofluoroscopic study of the oral cavity and the pharynx. The protocol for the MBS allows for diagnosis of oropharyngeal dysphagia, while maintaining a low risk for aspiration. The MBS is the most frequently used diagnostic study and is considered to be the gold standard. However, a specific protocol for the MBS must be followed in order to achieve accurate results.

The Modified Barium Swallow Protocol1 19

Assessment of oropharyngeal swallowing typically begins with a modified barium swallow (MBS), the 'gold standard' for assessment of the oral cavity, pharynx, larynx, and cervical esophagus during swallow. The patient is typically given 2 swallows each of small to large amounts (1, 3, 5, 10 ml) of thin liquids, followed by two swallows of pudding consistency barium and two swallows of ¼ of a Lorna Doone® cookie coated with barium pudding (3 ml). This examination enables the clinicians to determine the normalcy of the oropharyngeal swallow as it adjusts to accommodate various bolus volumes and viscosities. If the esophagus is of interest, then a barium swallow should be completed, not a modified barium swallow. Fiberoptic endoscopic examination of swallowing is also a possible assessment tool, particularly for examination of the anatomy of the pharynx and larynx before and after swallowing. During the swallow, the pharynx and larynx close and cannot be seen.

The modified barium swallow is usually conducted by a speech-language pathologist and a radiologist as a team. During the MBS, should the patient exhibit significant swallow impairment, treatment strategies are introduced to improve the swallow. Such treatments may include postural changes to redirect food, heightened sensory input via the taste and texture of the bolus when placed in the oral cavity, voluntary changes in swallow such as holding the airway closed sooner or later or prolonging the opening of the upper esophageal sphincter and finally, exercises to strengthen musculature in the oral cavity, pharynx, and/or larynx. The goal of the MBS is to keep the patient eating by mouth safely and efficiently.

MBS Requires at least 30 Frames Per Second

A recent study revealed that 'in order for the disorders of the pharyngeal stage of swallow to be seen and recorded, the videofluoroscopic study must be recorded at least at 30 frames per second.'1 While this was a small study, it did report that for 30% of the patients, aspiration was only visible for 1/30 of a second. Similarly, the duration of visibility of a tracheo-esophageal fistula was 1/30 of a second in 50% of the patients. Thirty frames per second has been standard protocol for MBS studies of oral and pharyngeal swallowing for over 30 years. A multi-institutional study conducted by Brandt et al. 20 required that all MBS studies be recorded at a uniform 30 frames/second, allowing sufficient precision to visualize some swallowing disorders. CAUTION: newer digital fluoroscopic equipment is sometimes run at 15 to 20 frames per second. At those speeds, any disorder with a duration of less than 1/20 per second could be missed by the examiner. As institutions are considering the purchase of new video recording and fluoroscopy equipment, they should ensure that the equipment has the capability to record at least 30 frames per second.

Patient Referral and Diagnosis

patient referral and diagnosis

Intervention and Treatment Strategies

Once the speech-language pathologist (SLP) determines a patient to be positive for dysphagia, they will devise a treatment plan for the patient. Treatment varies greatly depending on the cause, symptoms, and type of swallowing problem. A SLP can recommend the best treatment strategy, but most therapies involve three components.

  • Modifications to the consistency of foods

    • Depending on the type and severity of the swallowing disorder, a specific diet may be recommended. These diets vary from thin liquids, to thick liquids, to soft foods, and to mixed textures.
    • Dietary modifications are not always intuitive. For example, swallowing thin liquids requires finer motor skills than thick liquids. Therefore, a diet of thick liquids might be the best strategy for patients with severe dysfunction.

  • Strategies to reduce the risk of aspiration

    • These strategies often involve various head positions and swallowing techniques intended to reduce the size and duration of airway openings during the swallowing process.
    • The use of prosthetic devices can restore safe oral functioning.

  • Exercises to improve swallowing effectiveness

    • The focus here is on range of motion and strengthening muscles in the jaw, cheek, lips, tongue, soft palate, and vocal cords. Below is an example of the types of exercises that might be recommended.

Healthy Aging: Keeping Your Swallowing Intact

Normal swallowing requires that the muscles in your mouth and throat and tongue remain flexible and that your swallow reflex remains intact. As we age, the neuromuscular system and body reflexes needed for swallowing tend to become slower. This is not much different than the impact of aging on the rest of the body. There is evidence that exercise in aging seniors can help to keep your body flexible and strong as you become older and help you to maintain function, decrease falls, etc. To keep your swallow flexible and normal as you age, it is recommended that you do each of these aerobic exercises 2-3 times a day. You might want to add them to an aerobics class if you are taking one, or do them with your friends. Each cycle should take about 5 minutes. If you experience any problems doing these exercises, contact your doctor or speech pathologist.

  • Muscles of the Mouth and Throat

    • Take a small amount of pudding into your mouth. Swallow forcefully. Squeeze the muscles hard as you swallow.

  • Closing the Top of the Windpipe

    • Take a deep breath. With your mouth closed, hold your breath for 5 seconds. Then relax.

  • Strengthening the Tongue

    • Take a wooden tongue blade (a popsicle stick or small blunt butter knife) and place it flat on your tongue. Push down with the tongue blade while pushing up with your tongue.

  • Range of Motion for Lips - 1

    • Spread your lips as far as you can horizontally (as when you are saying 'ee'). Hold for 5 seconds; then relax.

  • Range of Motion for Lips - 2

    • Pucker your lips as much as you can (as when you are saying 'oo'). Hold for 5 seconds; then relax.

  • Range of Motion for Lips - 3

    • Pull your lips to one side as hard as you can. Hold for a couple of seconds. Repeat by pulling your lips to the other side and holding for another couple of seconds.

  • Swallow Mechanism in Throat

    • Start to swallow. When you feel all the muscles in your throat squeezing together, then, hold tightly. Then relax.

These therapies are the gold standard in the management of dysphagia. However, their success depends on the patient's ability to understand the recommended strategies and the willingness to follow their treatment plan. The primary care physician could play a major role in ensuring that patients follow their plans and achieve a successful outcome.

Most patients will recover and/or improve with clinical treatment. Many of the preferred treatments are behavioral but there are surgical options as well. The greatest barrier to the successful treatment of dysphagia is lack of education.

Acknowledgements

This educational program was made possible by a grant from the UniHealth Foundation.

The authors would like to thank the clinicians at Rancho Los Amigos National Rehabilitation Center in Downey, California and Casa Colina Centers for Rehabilitation in Pomona, California for completing the study screenings and video fluoroscopies. We would also like to acknowledge Muveddet Harris in the Northwestern University Swallow Physiology Lab and Mary Smessaert in the Department of Communication Sciences and Disorders at Northwestern University who under the direction of Dr. Jeri Logemann evaluated all data.

Author Affiliations

Charles A. Stewart, M.D. and Jane Hurd, MPA are co-principal investigators of the Dysphagia Among Seniors in Los Angeles County: Planning and Pilot Study (2008). Charles A. Stewart, M.D. is the Chairman of the Department of Medical Imaging and Acting Chief Medical Officer at Rancho Los Amigos National Rehabilitation Center, and Clinical Associate Professor of Radiological Science at the David Geffen-UCLA School of Medicine. Jane Hurd, MPA is a healthcare administrator with experience at hospitals affiliated with both the USC School of Medicine and David Geffen-UCLA School of Medicine. She holds an MPA from the University of Southern California.

Diane J. Aschman, MS, a pharmacist entrepreneur with over 25 years in the healthcare industry, is President of Advancing Health LLC.

Jeri Logemann, Ph.D. is Ralph and Jean Sundin Professor of Communication Sciences and Disorders at Northwestern University, and Professor of Otolaryngology and Maxillofacial Surgery and Neurology at Northwestern University Medical School. She has published and lectured widely both nationally and internationally on evaluation and treatment of swallowing disorders.

Nancy L. Matthews, MA, manager of the Dysphagia Among Seniors in Los Angeles County: Planning and Pilot Study (2007), has over 20 years experience developing and managing 'Quality of Life' programs and services which serve the community and currently is a lecturer at California State University, Long Beach.

Diagnosis and Management of Dysphagia in Seniors

Please fill in the information fields below before you take the Exam. When you have finished answering ALL of the questions, click on the 'Submit My Test Now' button. Your results will come back to you immediately.

Please print the results page as your course completion verification.

QUESTION 1

Based on the information presented here, which of the following drugs is the least likely to be associated with dysphagia?

QUESTION 2

In long-term care facilities (e.g. nursing homes), the chance that any given patient is dysphagic has been reported to be as high as:

QUESTION 3

Based on recent data (Dysphagia Care Among Seniors in Los Angeles), the prevalence of undiagnosed dysphagia in seniors living largely independently is estimated to be:

QUESTION 4

Many of the clinical risks associated with dysphagia can be prevented or mitigated with early identification and treatment. The more serious risks of pneumonia, chronic lung disease, and asphyxiation can all be reduced by reducing the occurrence of which of the following:

QUESTION 5

The primary care physician (PCP) plays a critical role in identifying patients with dysphagia. Which of the following components of the screening and diagnostic process is primarily the responsibility of the PCP?

QUESTION 6

Patient A is a 62 year-old female. She is positive for a history of squamous cell carcinoma of the neck in 2006. She normally takes a multi-vitamin every day and an aspirin occasionally, but states that lately she is having trouble swallowing the pills, so she has not been taking them. She has lost 12 pounds in the last 4 months, but has not been dieting intentionally, adding that eating is not as enjoyable as it used to be. She states that it usually takes multiple swallows to get food down, particularly pieces of meat. She has never had pneumonia and claims to have no issues with choking, coughing, or getting food stuck in her throat. Based on this information, what would this patient's score be on the Self-Test provided above?

QUESTION 7

When conducting a Modified Barium Swallow, it is critical that the videofluoroscopic equipment record at a speed of at least 30 frames per second. This minimum recording speed has been established because:

QUESTION 8

Place the following actions in the sequence appropriate for management of a potential dysphagic patient. (Type 1 in the box preceding the action that should occur first and 4 preceding the action that should occur last.)

QUESTION 9

Patient B is a 73 y/o male with a history of Parkinson's disease and stroke. He was evaluated by his primary care practitioner. He took the Self-Test, scoring 8. The PCP referred him to a qualified SLP, who evaluated the patient and performed a MBS procedure (along with a radiologist). The MBS detected aspiration. What is the next step in managing this patient?

QUESTION 10

Treatment strategies for dysphagia vary greatly depending on the cause, the symptoms, and the type of swallowing problem. However, the treatment of most patients will involve all the following components, except one. Which of the following IS NOT considered standard in the management of dysphagia?

Your results will come back to you immediately.

References:

1Logemann, J.A. (1993). Manual for the videofluorographic study of swallowing (2nd ed.). Austin, TX: Pro-Ed.
2Logemann, J. A. (2001). Dysphagia. In G.L. Maddox et al. (Eds.), The encyclopedia of aging, (3rd ed., pp. 743-744). New York: Springer.
3Balzer, K.M., (2000). Drug-induced dysphagia. International Journal of MS Care, 3, 29-34.
4Med Line Plus - Drugs and Supplements; MedMaster ™ database, ©American Society of Health Systems Pharmacists. Retrieved June 1, 2006 from http://nlm.nih.gov/medlineplus/druginformation.html
5Logemann, J.A., Stewart, C., Hurd, J., Aschman, D., Matthews, N., Reimer, T., Calahan, S., Taylor, S., & Burton W (2008, February). Dysphagia care among seniors in Los Angeles County: Planning and pilot study. (UniHealth Foundation, Grant 912). Los Angeles, CA.
6Morris, H. (2006). Dysphagia in the elderly – a management challenge for nurses. British Journal of Nursing, 15(10), 558-562
7Wilkins, T., et al. (2007). The prevalence of dysphagia in primary care patients: a HamesNet Research Network study. The Journal of the American Board of Family Medicine, 20(2), 144-150.
8Spieker, M.R. (2000). Evaluating dysphagia. American Family Physician, 61, 3639-3648.
9Robbins, J., & Barczi, S. (2003). Disorders of swallowing. In W.R. Hazzard, J.P. Blass, J.B. Halter, et al. Principles of Geriatric Medicine and Gerontology (5th ed., pp. 1193- 1212). New York: McGraw-Hill, Inc.
10European Study Group for Diagnosis and Therapy of Dysphagia and Globus (EGDG), & Dysphagia Working Group (RCSLT), Recommendations for Pre and Post Registration Dysphagia Education and Training 1999. Retrieved January 15, 2008 from http://www.cplol.org/files/CPLOL_dysphagiareport_en.pdf.
11Hare, S., Tam, T., Ibarra, M., & Edwards, W. Malnutrition in hospitalized elderly in the capital health region, Grey Nuns Community Hospital and Health Centre. Edmonton, Alberta.
12Reimer, T., Calahan, S., Taylor, S., & Burton, W. (2008, April) Prevalence of and screening for undiagnosed dysphagia in a senior population. Poster session accepted for presentation at the annual convention of the California Speech-Language Hearing Association, Monterey, CA.
13Palmer, J.B., Drennan, J.C., & Baba, M. (2000). Evaluation and treatment of swallowing impairments. American Family Physician, 61, 2453-2462.
14Robbins, J. (2002). The current state of clinical geriatric dysphagia research. Journal of Rehabilitative Research and Development, 39(4), vii-ix.
15Dawodu, S.T. (2007). Swallowing disorders. eMedicine Specialties: Rehabilitation protocols. E.C. Hills, F. Talavera, R. Salcido, K.L. Allen, & R. Cailliet (Eds.) Retrieved November 20, 2007 from http://www.emedicine.com/pmr/TOPIC_152.HTM
16Logemann, J. A. (2006). Upper digestive tract anatomy and physiology (Chapter 48). In B. J. Bailey & K. H. Calhoun, et al. (Eds.), Head and neck surgery – Otolaryngology (4th ed.). Philadelphia: Lippincott Williams and Wilkins.
17Logemann J. (in press). Mechanisms of normal and abnormal swallowing. In C. Cummings, P. W. Flint, B. H. Haughey, M. A. Richardson, et al. (Eds.), Cummings otolaryngology – Head and neck surgery, Part 6, Section 3 (5th ed., pp. 1437-1447). Philadelphia: Elsevier Mosby.
18Images A-F © KO Studios, 2002. All rights reserved.
19Brandt, D. K., Hind, J. A., Robbins, J., Lindblad, A. S., Gensler, G., Gill, G., Baum, H., Lilienfeld, D., Logemann, J. A., and the Communication Sciences and Disorders Clinical Trials Research Group (CSDRG) (2006). Randomized study of two interventions for liquid aspiration: Short- and long-term effects. Clinical Trials: Journal of the Society for Clinical Trials, 3, 457-468.