if severe dysphagia

Map Branches

• management
  • holistic considerations
    • PD features:
      • depression
      • Cognitive impairment
      • Medication on/off cycles
  • assessments
    • clinical bedside
      • VF
      • FEES
      • CA
  • treatment approach
    • mainly compensatory strategies
      • body posture/head position
        • liaise with
          • PT
          • OT
      • consistency adaptation advice
        • liaise with
          • dietician
        • most nutritional and safest for swallowing consistencies
        • oral stage disorder:
          • hard consistencies likely difficult
          • assess impact individually
          • thickened fluids necessary?
      • alter bolus size
        • sensory stimulation
          • pharyngeal swallow delay
          • El Sharkawi et al 2002
      • MDT/dietitian liason
        • food and fluid intake
          • limiting factors
            • fatigue
            • Poor concentration
            • slowness
          • small high calorie snacks appropriate?
      • + cognitive impairment:
        • verbal timely oral routine for swallow
      • thermochemical stimulation
        • ice cold citrus drink
          • traditionally viewed to assist in triggering swallow
          • Hamdy et al 2003: (stroke pts and normals)
            • time/swallow
              • ability to control slower bolus?
            • sip capacity
              • risk of valleculae residue overspill?
      • c/o food sticking in pharynx
        • alter head position
        • alternate solids/liquids
          • clear remaining residue post solid swallows
      • medication
        • No PD meds in syrup form
        • controlled release tablets
          • crushing
        • Dispersable Madopar
          • dissolved and thickened
        • if severe dysphagia
          • NG with Dispersable Madopar
          • Apomorphine injection
            • UK approved 1993
              • same effect as levodopa but avoidance of on/off cycling
                • agonist to LD side effects
                • low incidence neuro-psych problems
              • Paraenteral delivery
                • infusion
                • injection
            • Expensive:
              • underused
        • research ongoing
          • medication delivery methods
      • alert carers:
        • signs of aspiration
        • emergency procedure for choking
        • food pocketing likelihood
        • oral hygiene issues
          • regular dental apts needed
        • medications causing mouth dryness
        • safe feeding techniques (if PT unable to feed self)
          • Pts dependent on others for feeding
            • aspiration risk
              • Langmore et al 1998
        • give:
          • accurate, individualised advice:
            • feeding
            • Swallowing
            • verbal
            • written
    • direct therapy
      • LSVT improves swallowing
        • El Sharkawi et al 2002
          • 51% in VF observed swallowing motility disorders
        • neuromuscular control
        • overflow: increased effort
• saliva management
  • therapeutic
    • head and body positioning
    • verbal/electronic reminders to swallow
    • fluid intake if drooling causes excessive fluid 
      • liaise with:
        • dietician
        • Patient and carers
  • Pharmacological
    • Hyosine patch
      • SE's in older people:
        • hallucination
        • Confusion
    • sublingual atropine
      • effective
      • Occasional SEs
      • easy and inexpensive
    • Botulinum toxin
      • for ++ severe cases
      • wears off over few months
        • repeated injections
      • SE: toxin spreads into pharyngeal MM.
        • swallowing difficulty
  • Surgical
    • excision/rerouting
      • not preferred option in older, later stage PD
  • QOL impact
    • drooling: often late stage feature
    • most pts have this to some degree
    • Embarrassment / frustration
• Prevelance
  •  95% of PD sufferers
    • Logemann et al 1975
• severity
  • still significant feature of condition
    • manage
    • assess
  • usually not severe enough to require non-oral feeding
• presentation
  • VF shows motility disorders in all swallow stages (Logemann 1988)
    • oesophageal
    • phayrngeal
      • aspiration
        • silent aspiration
      • laryngeal elevation/closure
      • delayed swallow trigger
    • oral
      • disturbed lingual movements
        • ROM/coordination
          • ant-post bolus movement
          • bolus control
          • chewing
        • tongue based retraction
          • causes erratic tablet absorption
            • response to
          • residue in valleculae
        • impact on saliva control
        • rocking/pumping tongue motion

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