Helping Patients with Swallowing Disorders

There are several treatments designed to improve swallowing. Patients can be taught exercises to increase oral muscle function and airway closure. Their swallowing reflex can be artificially stimulated to help strengthen it. They can learn to control the factors that make swallowing easier and decrease the risk of aspiration.

The following areas will be discussed in more details:

Exercises to Improve Swallowing: Patients with swallowing disorders often have paralysis or weakness of the muscles of the lips and/or tongue. There are a variety of exercises to help strengthen these muscles. There are also exercises to increase the tongue's range of motion, which is necessary  to manipulate food and liquid in preparation for swallowing. A patient whose airway is not closing completely can be taught exercises to strengthen those muscles and improve closure during swallowing.

Thermal Stimulation: The ability to swallow is dependent upon the swallowing reflex-without it, swallowing is impossible. Because people with swallowing difficulties frequently have a weakened or delayed swallow reflex, treatment may include stimulating this reflex to increase its action.

Cold tends to enhance the sensitivity of the swallowing reflex. In therapy, a cold instrument is repeatedly placed at the back of the mouth to strengthen and encourage more rapid triggering of this reflex. This treatment must be done several times each day for two to four weeks before changes are observed.

Food Consistency: Once the type and severity of the swallowing problem have been evaluated, the food consistency that is easiest and safest for the patient to swallow can be determined. Food for the patient to swallow can be determined. Food consistency varies from pureed to regular, with purees being the easiest to swallow. Patients frequently begin with pureed foods and progress in stages toward a more regular diet. 

Liquids: Liquids also vary in consistency and usually are classified as thick (such as fruit sauces), semi-thick (fruit nectars), and thin (fruit juices).

Thin liquids, particularly water, are the most difficult to swallow because they require precise tongue control to collect and hold them against the roof of the mouth until the swallowing reflex is triggered. In addition, water's lack of taste makes it difficult for the patient to determine its position in the mouth, and therefore control it.

Patients with swallowing disorders often are not allowed to have thin liquids, including water, because of the high risk of aspiration. In these cases, their diets are adjusted to provide adequate liquid intake through other sources (for example, thick liquids and purees with high liquid content). If a dry mouth becomes a problem when a patient does not drink water, it may be alleviated by frequent oral cleaning and use of a saliva substitute. 

A Word About Water: It is important for the staff and family of a patient to be in agreement, and to support the swallowing program. The most common area of disagreement is the need to withhold water.

It is difficult and often uncomfortable for the patient to be without water by mouth. However, the decision to withhold water is based upon knowledge of the normal swallowing process and the individual patient's swallowing disorder. It is not made arbitrarily, but rather to help the patient avoid the more serious consequences of aspiration and pneumonia.

The patient needs reminders and frequent encouragement from both staff and family members to observe the precautions of the swallowing program in order to avoid further medical complications.

Amounts of Food and Liquid: For patients with weakened tongues and oral muscles, small amount of food and liquid are the easiest to move into position for swallowing.

For patients with delayed or incomplete swallows, (where food remains trapped in the sinuses of the throat), eating small amounts of food and drink makes it less likely these substances will spill into the airway and cause aspiration.

All swallowing disorder patients should be encouraged to take only small amounts of food and liquids.

Positioning: The best position for swallowing is sitting as upright as possible with the hips at a right angle to the trunk. Never feed or allow a patient to eat lying down or in a reclining position, unless the speech pathologist specifically suggests these positions. Use pillow to support patients who are too ill to sit perfectly upright.

Positioning of the head also can be important in swallowing, and varies from patient to patient depending upon the type of swallowing problem.

Time Between Swallows: Patients with weakened tongues and oral muscles need more time to move food and liquid into position for swallowing. Additional food or liquid should never be placed into the mouth until after the first mouthful has been swallowed.

Patients with delayed or incomplete swallowing reflexes need to be given extra time to allow the substances to pass through the throat into the esophagus.

Clearing the throat and swallowing repeatedly often helps move the food through the throat. But placing more food or liquid in the mouth before the first mouthful is swallowed means there will be additional food in the throat and a greater chance of it spilling into the airway and causing aspiration.

Because of these factors, it usually takes much longer than normal to eat a meal. Allow adequate time for feeding and never rush a patient with a swallowing problem. Do not  place food in the mouth or allow the patient to take additional food before swallowing completely. Time and a little patience are required on the part of both the caregiver and the patient for successful feeding.

Sensory Cues: Sensory cues refer to the use of the five senses to facilitate a patient's swallowing. Curing is part of teaching, and helps to decrease the risk of aspiration.

Cues can be verbal, such as the reminder, "swallow." Gestural cues might include a caretaker pointing to his or her own lips to remind the patient to maintain lip closure during swallowing. Physical cues can include actual support of a patient's chin or head to demonstrate correct positioning. Written cues provide constant reminders to the patient and caregivers to follow swallowing precautions. Taste and food temperature also can cue a person to swallow. Cold tends to stimulate the swallowing reflex and hot liquids are a cue to go slowly and sip the drink.

Environment: Normally, eating and swallowing are routine activities not requiring much thought. A person with a swallowing problem, however, must pay very close attention to what must be done in order to facilitate swallowing and avoid aspiration.

Because of this, it is important that patients with swallowing difficulties eat in a quiet environment free of distractions. Talking and socializing during meal time can cause the patient to forget to follow the swallowing guidelines.

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