Project ECHO AIIHPC & TUH ARHC webinars for Nursing Homes during COVID-19 Speech and Language Therapy Update for Nursing Homes: COVID-19 Sarah Rowland, Speech and Language Therapist
Common Causes of Orophary ryngeal Dysphagia (1) neurological impairment (Dementia, Stroke or progressive neurological conditions) (2) structural damage (e.g., trauma caused by the intubation or malignancies) (3) medication or toxic/ drug side-effects (4) presbyphagia (aging swallow) (5) phagophobia (psychogenic dysphagia) (Reiter & Brosch, 2012)
Signs and Symptoms of f Dysphagia • Drooling • Difficulty chewing • Unable to clear food residue from their mouth • Coughing or choking when eating or drinking • Wet gurgly voice when eating or drinking • Shortness of breath • Eye watering
Signs and Symptoms of Dysphagia continued… • History of repeated chest infections • Weight loss • Taking a long time to finish meals • Complaining of difficulty eating or drinking • Reluctance to eat certain consistencies
Patient Presentation in COVID-19 19 Critical care interventions following severe acute respiratory syndrome (ARDS), including prolonged trans-laryngeal intubation, ventilation, proning may result in patients experiencing the following: ● Voice problems (dysphonia) ● Swallowing difficulties (dysphagia) ● Cognitive-communication difficulties ● Chronic upper airway and respiratory problems (RCSLT, 2020)
Other Risk Factors for Dysphagia in COVID-19 • Reduced alertness or consciousness • Delirium or increased confusion • A possible primary respiratory dysphagia due to tachypnoeia potentially affecting safety of patients swallow (RR >25) • Effect of intubation/non-invasive ventilation • Deconditioning/increased fatigue potentially affecting the efficiency of patients swallow function
Signs and Symptoms of f Dysphagia in COVID-19 19 • Loss of appetite secondary to anosmia or lack of taste • Coughing on food or fluids due to worsening respiratory status (e.g. increase RR) • Differentiate from coughing at rest due to COVID-19 • Difficulty chewing due to fatigue/ deconditioning/shortness of breath • Difficulty recognising food or fluid bolus due to confusion +/- delirium
Consequences of f Untreated Dysphagia • Malnutrition • Embarrassment • Dehydration Emotional • Frustration • Weight Loss • Confusion • Chest • Anger Infections • Pneumonia Social • Death Medical • Withdraw from mealtimes • Avoid social occasions that involve eating/ drinking
Safe Feeding Routine Algorithm Contact your usual SLT If you are not already service (HSE/private) linked with an SLT to refer the resident service, contact • your G.P. (or) Request a telepractice If you notice • the local HSE or telephone consult your resident is community SLT for individualised presenting with clinic (or) advice if possible • the local SLT signs or symptoms of Department in your nearby dysphagia Revise “Steps to hospital promote safe oral for advice intake” in the interim
Steps to Promote Safe Oral In Intake If feeding the Positioning resident: Ensure patient is position yourself at eye- properly positioned, level to try help patients sitting upright out of keep a neutral, upright bed (where Distraction: position appropriate). reduce . Alertness distractions at do not offer a mealtimes. resident food or drink if drowsy Dentures Check Dysphagia Care Plan Make sure they are in It is the right diet? situ and fitting Are the fluids modified properly. correctly? (RCSLT, 2018)
Steps to Promote Safe Oral In Intake Independence: Time: residents should be encouraged to Reduced taste feed and drink themselves using allow try fizzy drinks or recommended utensils. adequate time foods of different to support the tastes, textures or Vary the amount of assistance resident to eat temperatures according to individual need (e.g. and drink . verbal prompts, volume control e.g. sip/teaspoon, hand over hand feeding etc). Oral Hygiene: ensure the mouth is clean and Portion size: free from residue at the end of the meal. people who are frail or fatigued should be given Encourage a ‘clearing small portions little and swallow’ or taking a drink to often. You could try add assist in clearing residue from sauce and finely chop food the mouth. to see if this helps . (RCSLT, 2018)
Thickened fl fluids? Modified Diet? • As per RCSLT (2018), it not possible to predict which residents will benefit from changes in fluids using thickeners owing to complex conditions. • Thickened fluids can cause more difficulty for some residents: Need increased intra-bolus pressure orally and at the upper esophageal sphincter (UES) Thicker consistencies may cause increased residue Higher rates of silent aspiration when patients aspirated thick fluids, whereas patients tended to cough when they aspirated thin fluids Risk of increased dehydration on thicker fluids (Cichero, 2013; Steele et al., 2015; Hind et al. 2012; Miles et al. 2018; Lazenby-Paterson, 2020) • Modified fluids/diet should be used with caution and only following recommendation by SLT .
COVID-19 Resources https://covidpatientsupport.lthtr.nhs.uk/#/lessons/7iKjxFnj8B8T44HpKhLsfkIPXxpTtxww
Dysphagia Resources Nutilis Clear individual posters for each level and simple mixing guidelines On site and online staff training on dysphagia and IDDSI Nutilis Clear resources and recipe books Menu planning and Audits Workshops for chefs and catering staff led by our expert Nutricia Dysphagia chefs https://www.nutricia.ie/
Dysphagia Resources https://www.fresenius-kabi.com/ie/products/fresubin-clear-thickener
Dysphagia Resources https://iddsi.org/resources/
COVID-19 Aphasia Friendly Resources http://nebula.wsimg.com/438514d864d2d7decad308 https://drive.google.com/drive/folders/1f1TVERvsjEbaySZQBTW 3254de2b35?AccessKeyId=5861B1733117182DC99B& so5VutJGJWQte disposition=0&alloworigin=1
Language Stimulation Id Ideas & & Resources Crosswords and word puzzles : help keep the words ‘alive’ in your head Reading: newspapers, magazines, books Contact with families: phone or video calls Write postcards or letters: useful way to practise spelling and hand writing https://cloudstor.aarnet.edu.au/plus/s/1tkhGC 3kyC2bJg1 Radio & television: help keep residents mind stimulated Number puzzles e.g. sudoku: help exercise residents concentration and their ability to manipulate numbers
COVID-19 Oral Care Resource https://bsdht01.worldsecuresystems.com/Covid/Mouthcare%20for%20patients%20with%20Covid-19.pdf
COVID-19 Voice Resource https://www.britishvoiceassociation.org.uk/voicecare_%20voice-problems-after-COVID-19.htm
COVID-19 19 SLT Nursing Home Service Provision • Contact your local SLT (HSE or private) • “Assessments that may prevent hospital admission and expedite discharge from acute services may be deemed a priority” (IASLT, 2020) • See what support they can offer? Can they offer telephone or tele-practice initial assessments or reviews and advice? • Recommendations are highly individualised so follow SLT guidance.
References • Cichero, J. (2013). Thickening agents used for dysphagia management: Effect on bioavailability of water, medication and feelings of satiety. Nutrition Journal, 12 (1), 1-54. • Hind, J., Divyak, E., Zielinski, J., Taylor, A., Hartman, M., Gangnon, R. & Robbins, J. (2012). Comparison of standardized bariums with varying rheological parameters on swallowing kinematics in males. Journal of Rehabilitation Research & Development , 49 (9), 1399-1404. • Irish Speech and Language Therapist Association (2020). IASLT Statement on Telepractice Published in response to COVID-19. Retrieved from https://www.iaslt.ie/membership/documents/Position%20papers%20and%20Submissions/IASLT%20Telepractice%20180320.pdf [Accessed on 20 th May 2020]. • Lazenby-Paterson (2020). Thickened Liquids: Do They Still Have a Place in the Dysphagia Toolkit? Current Opinion in Otolaryngology & Head and Neck Surgery, 28(3 ):145-154. • Miles, A., McFarlane, M., Scott, S. & Hunting A. (2018). Cough response to aspiration inthin and thick fluids during FEES in hospitalized inpatients. International Journal of Language Communication Disorders , 53 (1), 909 – 918. • Reiter, R., & Brosch, S. (2012). Update oropharyngeal dysphagia part 2: etiology and therapy. Laryngo-Rhino-Otologie , 91 (5), 291 – 299. • Royal College of Speech and Language Therapy (2018). Guidance on the Management of Dysphagia in Care Homes. Retrieved from https://www.rcslt.org/-/media/Project/RCSLT/guidance-on-the-management-of-dysphagia-in-care-homes.pdf [Accessed on 22nd May 2020]. • Royal College of Speech and Language Therapy (2020). COVID-19 speech and language therapy rehabilitation pathway Part of the Intensive Care Society Rehabilitation Working Party. Retrieved from https://www.rcslt.org/-/media/docs/Covid/Redeployment-of- SLTs.pdf?la=en&hash=3C2813F34D7A8B3F44D4A72CCBAD9FECF28ADE3F [Accessed on 18 th May 2020]. • Steele, C., Alsanei, W., Ayanikalath, S., Barbon, C., Chen, J., Cichero, J., Coutts, K., Dantas, R., Duivestein, J., Giosa, L., Hanson, B., Lam, P., Lecko, C., Leigh, C., Nagy, A., Namasivayam, A., Nascimento, W., Odendaal, I., Smith, C. & Wang, H. (2015). The influence of food texture and liquid consistency modification on swallowing physiology and function: A systematic review. Dysphagia, 30 (1), 2-26.
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