Swallow Safely

Overview of Causes of Swallowing Difficulty

Preparatory
Loss of smell or taste sensation; lack of saliva; weak chewing muscles; painful gums, cheeks; poorly-fitting dentures; poor tongue control; mouth-breathing

Oral
Part of tongue missing, impaired tongue control, sensory loss

Pharyngeal
Absent or delayed reflex, muscle paralysis or weakness, sensory loss, diverticula, lack of coordination with breathing

Esophageal
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.

* * *

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.

Proper Positioning
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.

Mealtime Strategies
Involving the person you are caring for in the process of food preparation can get her psyched up for the meal. That helps build her appetite and promotes saliva flow, which we know is a good thing.

Take plenty of time for eating. A caregiver must realize that rushing through a meal is an invitation to aspiration or a choking disaster.

Eat a small amount at a time. Never has it been more true that you shouldn’t bite off more than you can chew.

Chew thoroughly. We’re not suggesting that you or your aunt count the number of chews. But we do recommend chewing until food reaches a soft, pasty, easy-to-swallow state.

Don’t talk and eat at the same time. Talking is intimately connected with breathing. When you’re excited about sharing something that’s on your mind, it’s easy to forget you have food or liquid in your mouth. So hold on to that thought and spare yourself a trip to the hospital.

Make sure that one swallow has been successfully completed before you begin another. After the swallow, make sure there’s nothing left behind. Sweep the pockets between cheek and gum with the tongue (or finger, if necessary) to make sure nothing’s left over that can be aspirated.

Alternate solids with liquids to moisten the mouth and throat. This helps move the bolus along and wash away food remnants.

Between swallows, clear the throat with a gentle cough, then swallow again. This helps remove food residue. Repeat as needed.

Arrange for smaller, more frequent meals if weakness, fatigue, or shortness of breath reduces the effectiveness of swallowing muscles. A person who eats with vigor at the start of a meal may become tired and distressed as the meal progresses.

Sip — Don’t Guzzle or Gulp
As discussed in Chapter 3, drinking from a cup can be a challenge for many, especially for mouth-breathers. A series of gulps requires that breathing stop for several seconds, which can create considerable anxiety

Taking in a large amount of liquid at one time — gulping, guzzling, or chugging — can be risky for anyone with a swallowing problem. So, for the sake of safety as well as enjoyment, take it one sip at a time.

As mentioned in Chapter 6, specially designed cups can deliver a small, fixed amount of liquid per swallow.

Using a straw can help, too. But take care. A large squirt of liquid that arrives suddenly at the throat can cause a person to aspirate. Flexible straws allow for greater control. Be sure the straw is not too far back in the mouth, and keep the sips small.

Therapeutic straws come in various sizes that require different pressures for sucking. Your swallowing specialist will let you know whether such straws are appropriate — or whether any straw is advisable.

Be On the Lookout
At all times, watch for signs of distress (such as choking, coughing, tearing, or regurgitation through the nose). Be ready to carry out the Heimlich maneuver if necessary (see Chapter 4).

Watch the Adam’s apple. Does it go all the way up with the swallow? If it doesn’t, be suspicious that the swallow was ineffective. Food may still be in the throat.

Have the person swallow again. If the Adam’s apple does move, that’s a good sign — though it takes a swallowing specialist to know if it moves enough.

Don’t reload the fork or spoon until you’re confident that a successful swallow has been completed. Remember — no food should be left behind.

Diet Modification
Modification of the diet can be a cornerstone of the treatment plan. It is, however, something that many people fear. But if you understand why it is being called into play, you can explain to your loved one and others involved in providing care why it is necessary at this time.

Let’s say, for example, your aunt has been found to aspirate “thin” liquids such as juice or tea and this has led to two episodes of pneumonia. Mixing these drinks with a taste-free thickening agent will allow her greater control in swallowing and can reduce the risk of aspiration.

Liquids are categorized as thin (like water), nectar-thick, honey-thick, and pudding-thick. Thickening agents or prepared drinks are readily available through your local pharmacy or online providers.

Changing the consistency of solid foods, too, can make swallowing safer. Softer foods place fewer demands upon jaw muscles that are weak or tire easily. Ground meat, tofu, and pudding don’t require much of loosely fitting dentures. Plus, these foods are kinder to inflamed cheek and gum tissues.

It Can Get Emotional
People don’t like to hear about changes in their diet. They often feel that something precious is being taken away from them.

We understand. At this point, they may have lost many of their most private and personal habits, routines, and pleasures. When a change in diet is recommended, they often respond emotionally — with fear, anger, or denial.

The thought of “baby food” three times a day can bring a person to despair. “All purée all the time” is not a pleasant prospect.

For now, however, the change may be necessary for their survival  to prevent choking and aspiration while ensuring nutrition and hydration. The dietary change may not be permanent. That will depend upon the particular swallowing problem and the response to treatment.

For those who require a modified diet, they should know there’s a lot of delicious food available. See the Notes for this chapter for two excellent cookbooks.

Swallowing Maneuvers
As directed by your swallowing specialist, maneuvers of the head and neck can facilitate swallowing. A common maneuver is the chin tuck, also called the chin-down posture. This involves tucking the chin to the chest while swallowing. The therapist may assist with a gentle touch to the head.

Keep in mind that maintaining eye contact with a caregiver can interfere with the chin tuck maneuver. So if you are feeding your mother, you may want to bow your head and break eye contact momentarily to avoid this problem.

Another maneuver involves turning the head to one side during the swallow. With stroke patients this maneuver takes advantage of swallowing muscles that continue to function relatively normally, working around the paralyzed side and exploiting gravity.

The therapist may combine these maneuvers with an effortful swallow (see Chapter 6).

Exercises for Swallowing
Muscles of the face, tongue, lips, cheeks, and larynx can be exercised to enhance speed, range of motion, strength, and endurance. Involving muscles of the abdomen and chest helps, too, because of their role in breathing and coughing.

Even the upper esophageal sphincter can benefit from exercise. Lying flat and elevating the head according to the Shaker (“shah-KAIR”) exercise protocol can extend the time that the upper esophageal sphincter stays open, allowing for a safer, more complete passage of a bolus.

Regular visits to the “swallowing gym” can be supplemented by “dance lessons” devoted to improving coordination of muscles involved in swallowing and breathing.

Even though they’re not running a mile, elderly persons with cardiac and respiratory conditions should take special care when it comes to swallowing exercises. Such exercises may simply be too strenuous. Check with your doctor and swallowing specialist before embarking upon any exercise program.

Keep in mind that participating in an exercise program requires understanding, attention, and motivation. Persons with cognitive limitations, such as those associated with advanced Alzheimer disease or following severe head trauma, will generally require cognitive as well as swallowing therapy.

Once the speech-language pathologist has developed a suitable exercise program, she can instruct family members and other caregivers in carrying out this part of the treatment plan.

Sensory Stimulation
The swallowing reflex — indeed, any reflex — depends upon sensation. If the throat cannot detect the presence of food, the swallowing reflex will not be triggered. Food can remain dangerously behind, putting a person at risk of choking or aspiration.

To enhance the sensory arm of the swallowing reflex, the therapist uses an ice-cold cotton-tipped applicator dipped in lemon juice to stimulate the throat. This technique of thermal-tactile stimulation can make the swallow brisker and stronger not just once but several times after a single application.

Stimulation of the throat by means of electrodes applied to the skin (transcutaneous electrical stimulation) appears to benefit some persons with swallowing difficulty.

“Nothing By Mouth”
Under some circumstances, it may be necessary to bypass swallowing altogether for a period of time. After a stroke, for example, a person may be required to take “nothing by mouth” — or, in medical lingo, to be “NPO,” from the Latin nil per os.

For shorter-term use, say, thirty days or less, a nasogastric tube extending from nose to stomach may be used for feeding.

For longer periods, a tube may be placed directly into the stomach. This is called a gastrostomy tube, or G-tube. Because it is inserted by way of an endoscope, it is commonly known as a PEG-tube, for percutaneous endoscopic gastrostomy.

Keep in mind that even with tube feeding a person can aspirate. The combination of saliva, bacteria, and a faulty swallowing mechanism can result in aspiration pneumonia.

Diet modification and tube feeding can serve as a bridge to the future — a future with a functional, relatively safe swallow. Many stroke patients, for example, will be able to resume eating a normal diet within a few weeks to a few months. So be patient. Follow the treatment plan.

While healing and therapy are underway, your understanding and support as a loving caregiver can help prevent dangerous slip-ups. Make sure your family knows, as you do, why sneaking a cheeseburger to Uncle Billy for his birthday — while he’s recovering from a stroke — will not be doing him a favor. It could cost him his life.

Prostheses and Surgery
In some patients with head and neck cancer, a prosthetic soft palate can be designed to prevent nasal regurgitation. For palatal paralysis after a stroke, surgical attachment of the paralyzed portion to the throat can reduce nasal regurgitation and lessen the risk of aspiration.

Direct injection of botulinum toxin into the lower esophageal sphincter can cause it to relax, allowing for months of symptomatic benefit. Surgical procedures include stretching or cutting the LES to widen it.

A Zenker diverticulum may require surgical treatment, depending upon a person’s symptoms and taking into account risks of choking and aspiration.

Another thing you can do to help prevent pneumonia that results from aspiration of oral contents is to discuss the use of pneumococcal vaccine with your loved one’s primary physician.

Suggestions for Swallowing Safely
We’ve put together a set of wide-ranging suggestions that can help your loved one swallow more safely (see Appendix B). They touch upon the following:

• the mental and physical state of the person you’re caring for
• the setting
• positioning
• food preparation
• mealtime strategies
• taking medication comfortably and safely
• things to do after meals
• things to do between meals

Not all suggestions will apply to every situation. Highlight those you consider most useful, or transfer to another sheet of paper. Check with your swallowing specialist as to what suits your particular circumstances.

Post your list in the kitchen, dining room, or other eating area. Copy and share with other caregivers.

Ongoing Evaluation and Treatment
Treatment of swallowing problems is an ongoing process. Several sessions over several months may be required to meet treatment goals.

The initial plan may not be the final plan. The swallowing specialist will follow the patient over time, monitoring progress at the bedside or in the office. She will arrange for further testing as needed and make necessary adjustments to the diet.

Be sure to keep the doctor, nurse, and swallowing specialist informed as to advance directives and changes in your loved one’s condition. If you think the treatment plan is no longer suitable, let them know in what way as soon as possible.

In the next chapter, we will show you how to put your questions, observations, and concerns to use in getting help for your loved one.

* * *

Appendix B: Suggestions for Swallowing Safely

Mental and Physical State

• Don’t eat if drowsy, confused, or agitated.
• Don’t eat if unusually weak or out of breath.

Setting

• Reduce distractions: Turn off TV, radio, cell phone.
• Relaxing music is OK.
• Close doors to reduce traffic.
• Don’t overdo conversation or promote laughter while eating.

Positioning

• Sit upright, not tilted back or slumped to the side.
• Provide firm support for legs.

Food Preparation

• Involve the person with a swallowing problem in preparing food to promote saliva flow and overall enthusiasm for eating.
• Check temperature of food and liquids to make sure they are not excessively hot or annoyingly cold.
• Avoid difficult-to-swallow foods such as crusty bread, toast, popcorn, raw vegetables (celery, lettuce, etc.), whole nuts, and peanut butter.
• Avoid crumbly, flaky foods and pastries dusted with sugar.
• Be careful with (or avoid altogether) carbonated beverages.
• Watch out for foods of mixed consistency such as some fruit and cereal with milk.
• Be careful with foods (like ice cream or Jello) that melt.
• Avoid foods or liquids that have caused prior difficulty.
• Provide tasty foods of suitable consistency.
• Thicken liquids as directed.

Mealtime Strategies

• Don’t rush.
• Eat a small amount at a time.
• Chew thoroughly.
• Don’t talk and eat at the same time.
• Use the chin tuck maneuver, as directed.
• Swallow, clear throat with a gentle cough, and swallow again before taking in more food.
• Finish the swallow before reloading spoon or fork.
• After the swallow, check mouth for left-over food or pill.
• Clear the mouth, if needed, by tongue, hand, or mechanical suction.
• Alternate solids and liquids to facilitate passage of the bolus and wash away residue.
• Watch for fatigue; finish meal another time, if necessary.
• Arrange for smaller, more frequent meals.
• Note cough, sputter, choke, gag, tearing, runny nose, nasal regurgitation, or other problems.
• If someone coughs or chokes, do not slap on the back.
• Be prepared to carry out the Heimlich maneuver.
• If a choking person leaves the room, follow him or her. Do not leave alone until the incident is resolved.

Taking Medication

• Stay calm.
• Sit upright.
• Take one pill at a time.
• Swallow pills with plenty of liquid to make swallowing easier and to protect the esophagus.
• Don’t exceed daily fluid requirements.
• Use applesauce to facilitate pill-taking.
• Replace difficult-to-swallow pills with more suitable preparations, as approved by a pharmacist.
• Use a specialized cup, if allowed.
• Take medications as early in the day as possible.
• Remain upright for 30 minutes after taking pills.
• In general, use the same strategies that work for swallowing solids and liquids (e.g., effortful swallow, chin tuck).

After Meals

• Do not lie down for 30-45 minutes after eating.
• Walk for several minutes if permitted.
• Clean teeth, gums, and dentures several times per day.
• Use an antibacterial mouth rinse as prescribed.
• Swab lips, tongue, and cheeks to moisturize and lubricate the mouth.
• Suction pooled saliva to reduce the bacterial load.
• Arrange for regular dental care.

Between Meals

• Watch for respiratory difficulty (such as cough, rapid breathing, or wheezing), chest pain, or voice change.
• Carry out approved swallowing-related exercises that involve breathing, coughing, and chewing.
• Work on overall fitness, muscle strength, balance, and posture.
• Keep mind and body active with reading, playing bridge and Scrabble, doing word puzzles and Sudoku, mentoring, and other activities.
• At bedtime, elevate the head of bed to 30 degrees to help prevent aspiration or reflux during sleep.