How Swallowing Problems Threaten the Elderly and Others
Overview of Causes of Swallowing Difficulty
Loss of smell or taste sensation; lack of saliva; weak chewing muscles; painful gums, cheeks; poorly-fitting dentures; poor tongue control; mouth-breathing
Part of tongue missing, impaired tongue control, sensory loss
Absent or delayed reflex, muscle paralysis or weakness, sensory loss, diverticula, lack of coordination with breathing
Malfunction of upper and lower esophageal sphincters (achalasia, GERD); lack of esophageal motility; stiffness, stricture, or compression of esophagus
A Structural, Neurologic, or General Disease Process Can Act at Any Phase.
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Chapter 7: Treating Swallowing Problems
Treatment is not “one size fits all.” It’s individually tailored to meet the needs of your loved one. The swallowing specialist will look at the particulars of the swallowing problem and come up with a specific treatment plan.
The goals of treatment are:
- to get to a state where swallowing accomplished as safely as possible (minimizing the risk of choking or aspiration),
- to ensure adequate nutrition and hydration, and
- to accomplish the first two goals as pleasantly as possible.
Treatment does not take place in a vacuum. It involves the whole person as well as the family or other support system. Anything that improves a person’s overall condition — strength, stamina, motivation, and emotional state — is likely to help with swallowing. And a safe, reliable swallow is likely to help overall condition.
The treatment plan begins with an understanding of what is wrong with swallowing. By this point, you should have a basic knowledge of swallowing, a sense of where things can go wrong, and why:
- a medical condition (congestive heart failure or pulmonary disease),
- a neurologic disorder (stroke or Parkinson disease),
- a structural problem (cancer surgery removing part of the tongue), and
- complicating effects of medication (dry mouth or altered sense of smell).
Whatever the swallowing issues may be, the setting is important. Close doors to reduce traffic (grandchildren, pets, repairmen, and the like).
If your loved one is easily distracted, turn off the TV and keep mealtime conversation to a minimum. It’s perfectly fine, though, to provide reminders to chew thoroughly or carry out a particular swallowing maneuver. Don’t forget to silence your cell phone.
We’re not advocating an excessively somber atmosphere. But be careful about cracking jokes during a meal. Laughter (even talking) alters a person’s breathing pattern and can cause an unsafe swallow.
Obviously, a person shouldn’t eat (or be fed) if sleepy, confused, or agitated. Likewise, don’t try to feed someone who is unusually weak or out of breath.
The Treatment Plan
- Understanding the problem
- The setting
- Proper food choices
- Safe swallowing strategies
- Diet modification
- Swallowing maneuvers
- Swallowing exercises
- Sensory stimulation
- Prostheses and surgery
- Oral care
- Pneumococcal vaccine
- Follow-up evaluation
Sitting upright, not tilted back or slumped to the side, helps breathing and swallowing. Sitting stably, feet on the floor if possible, facilitates breathing and feeding oneself.
If your mother takes her meals in bed, have her sit as upright as possible. Make sure her head does not fall back. Place pillows at the side and behind the head so her trunk and head are straight.
Positioning after the meal is important, too. Don’t rush your father to bed. A person should remain upright for thirty to forty-five minutes after eating or taking medication. This puts gravity to work, helping move the bolus through the esophagus and into the stomach, reducing the likelihood of aspiration and reflux.
Even if your loved one takes medication for reflux, don’t count on that being 100 percent effective. At bedtime, elevate the upper part of the body 30 degrees by placing wedge pillows at the top of the bed to reduce the risk of reflux and aspiration during sleep.
Taking Care with Food and Drink
Avoid foods that have caused problems in the past, like steak, crusty bread, toast, popcorn, raw vegetables, whole nuts, banana, peanut butter, and pastries dusted with sugar.
Watch out for foods of mixed consistency. A mouthful of food may contain both liquid and solid elements. That can make swallowing tricky.
Consider dry cereal with milk. Your uncle may be able to handle cornflakes without a problem. But milk flowing willy-nilly to the back of his throat can cause him to cough and aspirate.
The solution may simply be to give the cornflakes time to get mushy. Less crunch, greater safety.
What about salad? It certainly looks harmless. But salad can be hazardous. It can be difficult to reduce lettuce to a pasty, manageable bolus. Pieces stick to the tongue, hide out in the throat, or get trapped between cheek and gum in a position to be aspirated.
Salad dressing is an additional concern. As with milk and dry cereal, the vinaigrette can rush ahead of the lettuce to an unprotected airway and be sucked into the lungs with the next breath.
Likewise, be careful with fruit. They are usually of mixed consistency. Take a grape, for example. It’s made up of skin, fruit, pit, and juice. All four must be reckoned with when it comes to chewing and swallowing.
Watch out, too, for carbonated beverages, which combine water and gas. Bubbles can tickle the throat to cause coughing or sneezing that interferes with the interplay between breathing and swallowing. The swallowing specialist may make soda a “No-no.” Don’t cheat.
Keep in mind that ice cream and some gelatin preparations start out as solids. But in a serving dish, in a spoon, or in the mouth, they melt to become a thin liquid — which your loved one may not be able to handle.
From “SWALLOW SAFELY: How Swallowing Problems Threaten the Elderly and Others. A Caregiver’s Guide to Recognition, Treatment, and Prevention” by Roya Sayadi and Joel Herskowitz © 2010. Reprinted with permission of the publisher, Inside/Outside Press, www.SwallowSafely.com.