Dysphagia Guide E-learning Resource

A free dysphagia e-learning programme to support health and care staff: https://www.e-lfh.org.uk/programmes/dysphagiaguide/

There are six separate sessions:

• Essentials for Health and Care Staff
• Essentials for Cooks
• Managers
• Balancing Risk and End of Life Care
• Training Resources and Recipes
• Dysphagia and Medicines

This may be useful for care home staff, including managers, nurses, care workers, catering staff and the wider NHS team.

What is Dysphagia?

Dysphagia is a disorder of swallowing.

People with dysphagia may have difficulty holding food or fluid in their mouth, chewing, moving food to the back of the mouth, swallowing at the right time, protecting the airway when swallowing, clearing food from their throat or getting food or fluid to pass down in to the food pipe.

Why does it happen?

Dysphagia can happen if there is damage to the muscles used for swallowing, or if a person becomes less aware of what is in their mouth.

Dysphagia can be caused by stroke, head injury or other neurological conditions – including Parkinson’s Disease, Multiple Sclerosis and Motor Neurone Disease. It can be caused by some respiratory conditions.

Why is dysphagia a problem?

People with dysphagia are at higher risk of food or fluid going down the wrong way (i.e. going into the lungs instead of the stomach). This is known as aspiration. Aspiration can cause chest infections and pneumonia.

Swallowing difficulties can lead to malnutrition and dehydration if they are not managed properly.

Will it improve?

Improvement and recovery will vary from person to person and can be difficult to predict. Your speech and language therapist will be able to discuss this with you in more detail.

Symptoms of dysphagia

• Coughing or choking on food or drink
• Wet / gurgly voice after swallowing
• Shortness of breath after swallowing
• A feeling of food sticking in the throat
• Difficulty chewing food
• Food or drink residue left in the mouth
• Loss of appetite or reluctance to eat certain things
• Serious weight loss
• Repeated chest infections

What can help with swallowing?

• Sitting as upright as possible when eating and drinking (not leaning forward, back or to one side) – ideally in a chair.
• Avoid tipping your head back to swallow.
• Take small mouthfuls of food or drink.
• Eat and drink slowly and leave plenty of time between mouthfuls.
• Chew food thoroughly and carefully.
• Don’t eat or drink if you’re feeling too tired or unwell – wait until later.
• Try not to mix mouthfuls of food and drink together.
• Don’t talk whilst eating or drinking.
• Avoid distractions e.g. TV / radio if this stops you following the advice above.
• Don’t use spouts or straws, unless they’ve been specifically recommended.
• If you have dentures, make sure they fit properly. If not, try a fixative- and wear them, if comfortable, to help with chewing.
• Try to stay sitting upright for at least 15 minutes after eating or drinking.

Who can help?

Speech and language therapists are trained to assess swallowing.

Your speech and language therapist can recommend food and drinks that are safe to swallow. It may be beneficial to have a modified diet or thickened fluids.

If your swallowing is unsafe, it may be necessary to remain nil by mouth (NBM). Your doctor may recommend that you have a temporary nasogastric feeding tube (NG tube).

Other members of the team can also help:

• Dieticians may help to ensure nutrition and hydration is adequate.
• Physiotherapists may help with sitting position.
• Occupational therapists may suggest ways to help you eat and drink.
• Nurses may assist with eating and drinking and with keeping the mouth and teeth clean and healthy, particularly if you are NBM.
• Pharmacists may suggest medicines are given in a different form e.g. syrups rather than tablets.

When considering making a referral:

• Look at the existing Is it being followed properly? Is it still meeting the patient’s needs?
• Is your resident coughing or struggling on a normal diet? It is often reasonable to opt for a Level 7 Easy Chew diet without needing to refer. Small changes may be enough to help the resident stay safe and comfortable.

Please refer to our Level 7 Easy Chew leaflet on this website.

Think about what the resident is eating/ drinking as snacks, not just the main meals.

• What else may be impacting which could be improved with help from other services? Eg teeth/ dentures, oral thrush,  difficulty sitting upright, reflux.
• Research has shown us the importance of really good mouthcare in reducing risk of aspiration pneumonia. See ‘oral care ‘section on this website

Ensure the mouth is clear at the end of a meal

• If a resident struggles with drinks – always try with an open cup.

Most people swallow better with an open cup, though they may need more support to lift it. Only use spouts or straws when there is no alternative safe option.

• It may be useful to keep a ‘cough diary’ to help identify patterns and frequency

Swallowing difficulties (dysphagia)

Dysphagia is a disorder of swallowing.

People with dysphagia may have difficulty holding food or fluid in their mouth, chewing, moving food to the back of the mouth, swallowing at the right time, protecting the airway when swallowing, clearing food from their throat or getting food or fluid to pass down into the food pipe.

Referrals

The Speech & Swallowing Team receive a very high number of referrals for people with dysphagia. It is important that the referrals we do receive are appropriate for our service to ensure that those who will benefit from our input are seen as soon as possible.

Referral criteria

Speech and Language Therapists (SLTs) are specialists in oropharyngeal dysphagia. Oropharyngeal dysphagia describes swallowing difficulties occurring in the mouth and/or the throat.

Please refer anyone with signs of dysphagia such as:

• Coughing or choking on food or drink
• Wet/gurgly voice after swallowing
• Shortness of breath after swallowing
• A feeling of food sticking in the throat
• Difficulty chewing food
• Food or drink residue left in the mouth
• Reluctance to eat certain textures of food
• Serious weight loss
• Repeated chest infections

Definition of choking:

– Severe choking:  Where choking is severe; the person will not be able to speak, cry, cough or breathe. Without help, they’ll eventually become unconscious. Requires back slaps and abdominal thrusts to clear.

– Mild choking:  If the airway is only partly blocked, the person will usually be able to speak, cry, cough or breathe. They’ll usually be able to clear the blockage themselves.

Referrals considered inappropriate:

If you have any concerns or would like to discuss a referral, please contact the Speech and Swallowing Team.

Thickener can be a useful tool for managing swallowing difficulties (Dysphagia) it can be recommended by a SLT in the management of swallow safety.

In recent years there has been increasing reliance on thickener to manage swallowing difficulties and it has been prescribed without full assessment by SLT.

Research findings have revealed that the use of thickener can INCREASE the risk of chest complications and that aspiration of thin fluids is of lesser risk.

Does my patient need thickener? What to consider first:

• Have they been assessed by Speech and Language Therapy previously? If so, were recommendations made?
• Is the person positioned upright for all food and drink?
• Do they sit comfortably in their dining chair? e.g. Not leaning back, feet resting on the floor
• Is the person fully supported by their carer? If not, this may be beneficial
• Do they use a spouted beaker? Open cup is preferable to a straw or spouted beaker where possible
• Does fluid pour from their mouth when drinking? Thicker fluids may be useful to control the fluid
• Are they coughing with every drink they have and ONLY with drinks? thickener could be useful

Cough is not necessarily bad- it indicates airway protection and sensation around the airway

When thickener is not indicated

• Are they struggling with food? Thickener cannot help with management of food
• Are they struggling with saliva/secretion management only? Thickener is of no benefit, trial medication to reduce saliva production e.g. hyoscene and input from respiratory team
• Are they coughing all the time, not just when eating or drinking? Might be reflux- use the reflux symptom index as a guide for assessment and trial treatment accordingly
• Have they got respiratory condition (COPD, advanced asthma, emphysema) – thickened fluids required more effort and can result in more difficulties

The importance of oral hygiene

Oral hygiene is integral in the prevention of aspiration pneumonia.

Research confirms that for aspiration pneumonia to occur it requires: Impaired health, poor oral hygiene and Dysphagia

If good health and oral hygiene can be maintained, the risk of aspiration pneumonia from dysphagia is low (It cannot be eliminated completely even with thickener)

Things to consider with swallowing difficulties

1. Thickener used inappropriately can increase the risk of chest complications- aspirating thickened fluids is worse than aspirating normal fluids
2. Aspirating thickened fluids is more likely to cause chest infection than aspirating normal fluids
3. Thickener can make swallowing more effortful, causing fatigue and increasing the risk of aspiration
4. Ensure all thickener is prescribed with a specific dosage according to each manufacturers guidelines, without dosage there will be inconsistency which affects safety but also patient experience
5. Cough is good – Cough indicates airway sensation and protection
6. Thickener can reduce distress from excessive coughing when drinking

Top tips for prescribing thickener

• Resource Thicken Up Clear is the preferred thickener in Leeds
• Other thickeners have a different dosage and interact differently in fluid.
• Always provide a dosage for the patient so that carers have guidance to follow, usually start with a low dosage to begin with (e.g. Level 1)
• Other considerations: Any evidence of dry mouth, oral thrush, reflux, respiratory disorders?
• Supplement drinks can be prescribed in a pre-thickened consistency

DIFFERENT THICKENERS HAVE DIFFERENT DOSAGE

Contact the Speech and Swallowing Team for queries and clinical discussion around swallowing concerns 0113 843 3126

Thickening fluids:

How to prepare thickened fluids with Thicken up Clear:

Step 1: Accurately measure 200mls of a drink made to your taste (e.g. with milk, sugar or cordial) – ideally in a measuring jug.

Step 2: Take a clean cup / glass / beaker and put the stated number of flat scoops of Thicken Up

Clear in first.

Step 3: Pour the drink over the powder.

Step 4: Start stirring with a spoon immediately until the powder is dissolved.

Step 5: Leave to stand for one minute (for water, tea and coffee) or a few minutes (for juices and

milk) until the powder is dissolved.

Top tips:

• If you need to thicken drinks in advance, check the consistency is correct before serving. Your Speech and Language Therapist can discuss this in more detail.
• If your resident has nutritional supplements the method for thickening these is slightly different. Please ask your Speech and Language Therapist for further advice.

What is supported conversation?

Conversation is important to the enjoyment of our everyday lives. It is often very difficult for people with aphasia (a language difficulty) to take part in conversations without any help.  Supported conversation aims to make sure that the person with aphasia can make their feelings, opinions and thoughts heard in the most natural way.  It involves the communication partner being equally responsible for the success of a conversation; making sure the person with aphasia has understood the intended message and has been able to get their message out.

The following advice can be used to help support communication:

Help to get the message in:

• Before a conversation:
  • Consider where and when the conversation is best to take place, i.e. turn off the TV and make sure you sit face to face so you can pick up on the person’s facial expressions and vice versa.
• During a conversation:
  • Take your time
    • Let the conversation happen at a relaxed pace
    • Check your own rate of speech – don’t give information that is too fast / too slow
  • Stick to one topic at a time
  • Write down important words as the conversation progresses
    • Circle key words
• Make sentences short and simple – one main point per sentence
• Use lots of expression in your voice
• Use gestures and/or pointing to support your speech
• Use supporting pictures or drawings to highlight what you want to say.
• Check that the person is following
  • Check face and body language – do they look puzzled?
  • Ask if that is clear / have they understood / it makes sense etc.
• It may help to say it again or re-phrase what you have said
• Show that it is ok to for them to indicate they haven’t understood something
• Acknowledge when you have not explained something clearly
• Give a clear signal if you are moving on to another topic

Helping to get the message out:

• Before a conversation:
  • Think in advance:
    • Think of any conversational supports you may need (i.e. pen & paper/ pictures / photos/ maps / communication books/ipad)

• During a conversation:
  • Always have a pen and paper handy
  • Encourage writing and drawing by using it yourself.
  • Identify the general topic first through general questions and narrow it down by asking more specific questions
  • Encourage them to indicate yes/no if you need to clarify something.
  • Keep checking where you have got so far.
    • g. “So it’s something to do with your family, but it’s not your husband or your daughter?”
    • Say when you don’t understand;
  • Give the person time – don’t pressurise them. Show them that you have time to keep trying.  If you don’t have time, explain clearly why the conversation cannot be carried on at that time and try to give an alternative time.
  • Don’t be afraid of silence.
  • Encourage the person to use their communication strengths

What is Dysarthria?

Dysarthria is a disorder of speech.

Speech means talking aloud. It involves a highly complex set of movements in the mouth and throat, and well controlled breath support.

Dysarthria can happen when nerves are damaged and the lips, tongue, roof of the mouth, voice box or breathing muscles are not working properly.

Why does it happen?

Dysarthria can happen if there is damage to the muscles used for speaking. It can be caused by stroke, head injury or other neurological conditions – including Parkinson’s Disease, Multiple Sclerosis and Motor Neurone Disease.

Symptoms

Dysarthric speech can be difficult to understand, and may sound slurred, quiet, soft, hoarse, strained, mumbly, too slow, too fast, monotone, jerky or unsteady.

Dysarthria does not affect your hearing, understanding or intelligence.

Common problems

It may be difficult to talk to friends or family, take your turn in a conversation or use the telephone.

It may feel easier to take a backseat and let others do the talking or avoid talking to new people or in large groups.

Tiredness, stress or hurrying will often make communication more difficult.

How can Speech and Language Therapy help?

Your speech and language therapist can take a close look at your speech. We can assess how the speech muscles are working and suggest useful ways to help you communicate. We may give you exercises to improve the clarity of your speech or help the muscles recover.

Tips

These tips may help to make your speech clearer:

• Take deeper breaths or extra ‘top up’ breaths
• Keep sentences short
• Speak louder than feels natural (as if in a large room)
• Put extra effort into stressing key words
• Slow down
• Exaggerate your mouth movements
• Leave a clear space between each word

Ideas to get your message across

• Try to get your message across in another way – e.g. write it down, draw it, gesture, facial expression
• Be aware of signs that the listener is not understanding – e.g. nodding inappropriately, or changing the subject
• Attract the listener’s attention (e.g. by touch or calling their name) before you begin talking to them
• Repeat what you said using techniques to make your speech clearer

Ways to make it easier

It will be more difficult for the person with dysarthria, and the person listening, if there are lots of competing noises or distractions.

Everyone can help to make things easier by:

• Reducing background noise – switch off the TV / radio
• Make sure you are face to face – make eye contact, look at the speaker’s mouth
• Limit your distance – make sure you are in the same room when talking
• Avoid long conversations if you are feeling tired

Trying to communicate with someone with dysarthria can feel frustrating, upsetting, tiring or embarrassing. You can help by:

• Paying full attention
• Showing that you’re listening – by making eye contact, stopping other activities and non verbal cues e.g. nodding
• Being patient – letting the speaker finish what they are saying and not interrupting
• Giving feedback – I did understand, or I didn’t understand, or I understood the first bit but not the end (don’t make them repeat the whole thing unnecessarily)
• Not pretending to understand if you have not
• Prompting them to slow down / speak louder / overarticulate / write it down (depending on what helps)
• Asking closed questions to determine the context (e.g. are you talking about the appointment?)

What is Dementia?

Dementia is a disease which causes a decline in mental abilities which can affect a person’s daily life.

Dementia happens as a result of damage to the brain caused by diseases such as Alzheimer’s or a series of strokes.

Dementia can affect people in different ways, especially in the early stages.

People can be helped to live well with dementia. It is important to consider the person’s environment and ways to support them.

Dementia often causes difficulties with communication. Here are some common problems:

• Concentration
• Having thoughts and thinking them through
• Understanding
• Following conversation
• Responding quickly
• Remembering conversations and experiences
• Finding the right word for something
• Loss of memory
• Reasoning or problem solving.

Tips for family, friends and carers

• Be patient
• Use simple vocabulary and short sentences
• Be direct, say what you mean
• Slow pace of conversation
• Repeat and paraphrase
• Use gesture as well as speech
• Use visual cues e.g. pictures, objects or written words
• Use humour to take the pressure off
• Avoid asking too many direct questions
• Avoid demanding that the person makes complicated decisions
• Match your body language and facial expression to what you are saying
• Don’t shout or over exaggerate your words.

Activities to encourage communication:

• Use photographs to support a conversation about family, friends, pets, holidays or other topics of interest – talk about the photograph
• Use magazines, newspapers and books – comment on stories, share interests and hobbies
• Make a family scrapbook – make a note of events and photographs as a memory aid
• Make a life story book – use as a memory aid for recalling life events.

Information and support:

Alzheimer’s Society- www.alzheimers.org.uk

National helpline: 0845 300 0336

Leeds helpline: 0113 231 1727 AgeUK – www.ageuk.org.uk

Helpline: 0800 169 6565

Dementia Web – www.dementiaweb.org.uk

Helpline: 0845 120 4048