You are sitting in a restaurant enjoying your juicy steak and garlic mashed potatoes. Laughing and talking, you are not really attending to what’s in your mouth. Before you swallow, you begin to laugh. Upon inhale, a large chunk of un-chewed meat gets sucked into your airway. You try to scream, only to hear tiny whistles from your throat and then you begin to panic. Unable to breathe, you grab your throat in the universal choking sign. Luckily, you are with someone who is competent at the Heimlich maneuver and before you turn blue, your offending chunk has been projected across the room onto a neighboring plate.
You have just aspirated food lodged in your airway. This is something that happens to many people at some point in their lives. Perhaps your experience was simply that some water just “went down the wrong pipe,” causing you to cough and sputter in violent spasms. Or, worse yet, you could suffer from dysphagia, the medical term for a swallowing disorder that has turned your life around, dictating what, when and how you must eat.
Dysphagia is not Uncommon
It is estimated that at least 50 percent of adults over 80 experience some form of dysphagia and the consequences are far worse than a simple need for the Heimlich every once in a while. They include violent coughing, habitual throat clearing, runny nose and watery eyes, malnutrition, dehydration and ultimately, pneumonia and death.
As a Speech Language Pathologist for the geriatric population, over 80 percent of my caseload has some form of dysphagia. When I first evaluate my patients, the most common thing I hear is, “I had no idea eating was this complicated!” That’s because swallowing, like breathing, is perfectly natural and automatic. Nothing to it, right? Well for some people, those with dysphagia, swallowing can become a lot of work and worse yet, very scary.
The causes of dysphagia are numerous and can include neurological disorders, head and neck cancers, structural damage to the tissues or cartilage and cognitive disorders, such as dementia. Sometimes dysphagia has no discernable origin.
The Mechanics of Swallowing
So what exactly can go wrong with a simple swallow? For that, you have to understand a healthy swallow. But first you have to know that the esophagus, or tube to the stomach, is located immediately and adjacently behind the trachea, the tube to the lungs. When you hear that something “went down the wrong pipe” it means that it went into the trachea instead of the esophagus. And without a strong or violent cough, the material will eventually find its way to the lungs. The lungs do not like the presence of foreign materials and will react by producing fluid which is like a petri dish for bacteria and may eventually lead to pneumonia.
There are three stages of swallowing:
The first is known as the oral stage. This is the act of chewing food and directing it toward the back of the mouth. The integrity of the oral stage is directly related to saliva production, tongue strength and coordination and the state of dentition.
The second, and most complicated, stage is the pharyngeal stage. This is the stage of the actual swallow and is extremely important for our purposes because it is where everything can go wrong. During stage two the uvula rises, blocking off the nasal cavity so food doesn’t regurgitate from the nose; the thyroid cartilage (your Adam’s apple) begins to rise, forcing the epiglottis to move downward covering your airway; the vocal cords close, protecting your airway from food and liquid; and the food or liquid moves through the throat, heading for the esophagus.
The third stage is called the esophageal stage. This is the stage where the food is propelled into the stomach by a series of waves. Nothing can really go wrong here...or can it?
The most common swallowing disorders are, in fact, mild and can be treated very simply. Problems with the oral stage (stage one) are usually a result of poor dentition, dry mouth, or muscle weakness associated with a neurological condition like stroke or Parkinson’s Disease. Most of these cases can be resolved simply by softening food consistency, increasing effortful chewing and consciously using the tongue to manipulate food in the mouth. These modifications are usually needed only temporarily and can be eliminated once the dental problem is addressed or the weakness in the muscles of the face and tongue resolves.
Stage two problems are often a result of poor timing, delayed swallow onset due to neurological disease and decreased strength in the muscles that control swallowing. This is a dangerous stage to be dysfunctional. When problems in this stage appear, it means there is a very high risk of getting food and liquid into the lungs. Regardless of the cause, the deleterious effect of aspiration must be eliminated or at least reduced, to protect the lungs from infection. Solutions may be to soften food, increase the viscosity of liquids by using a thickening agent, consciously working on the timing and strength of the swallow (this takes a long time to perfect) and utilizing compensatory swallowing strategies.
Stage three dysfunction is a result of poor esophageal response or integrity. Signs of esophageal swallowing dysfunction can include an earlier than usual feeling of fullness, a feeling that something is constantly stuck in the throat, frequent regurgitation of undigested food and coughing and choking from the food and liquid that comes back up from the stomach and ends up in the airway. Treatment at this stage can include softening of the food and most importantly, utilizing a swallowing strategy called “cyclic ingestion” – the act of taking a sip after every single bite of food. This is the simplest and most effective treatment option for someone with esophageal stage dysphagia. Recommendations will most likely include sitting at a 90 degree angle during all meals and remaining upright after all meals for 45 minutes or so to let the esophagus empty into the stomach.
Sometimes the esophagus functions so poorly that it must be surgically stretched in order for the food to pass into the stomach.
If you are suffering from dysphagia, your doctor will most likely refer you to a Speech Language Pathologist (SLP or ST) who will evaluate the severity and nature of the impairment and prepare a treatment plan.
Patients and Caregivers are often scared and overwhelmed when faced with dysphagia because it affects such a core daily function and the risk of dire consequences is so great.
Home Care and Self Care for Dysphagia
The following is a guide that can help you better understand how to deal with dysphagia.
- Prepare the correct consistency of food and liquid recommended by your SLP. This is extremely important. The consistency of food and liquid are carefully selected by your SLP to compensate for a variety of factors. It is often unrealistic to expect the swallow to improve quickly so the diet and liquid modifications can compensate for the immediate swallowing difficulties, reducing the risk of further illness. If you are unsure of how to prepare the desired consistencies, work with your SLP and ask questions. You may be surprised how easy it can be when you have someone to help you.
- Always encourage eating in an upright position at the table. Never eat or allow your loved one to eat lying down or reclining. This allows for optimum transport of food and liquid to the stomach and decreases the risk of food and liquid lodging in the airway or lungs.
- If you have a loved one who requires feeding assistance, always wait until their mouth is empty before introducing a new bite or sip. They may want you to serve another bite or drink, but to do this places your loved one in more risk of washing food or liquid into the lungs.
- If your SLP provided a swallowing sequence, such as alternating solids and liquids or double swallow with chin tuck, stick to it as much as possible. These are recommended to decrease risk of further illness.
- You are the eyes and ears for the SLP. Report any coughing, choking, wet voice sounds or changes in behavior to your speech therapist. Record which consistencies you were eating or feeding when these behaviors occurred.
Special Considerations for Caregivers of Patients with Dementia
Dementia is the cognitive decline often demonstrated with advanced aging, Alzheimer’s disease, brain injury, severe stroke and other advanced neurological diseases.
People with dementia often have three intact stages of swallowing. However, poor attention and awareness impacts on the ability to persist with the task of eating. This can result in oral holding and pocketing of food and liquids, failure to recognize food as something to eat, inability to manipulate eating utensils, poor appetite and changes in food preferences. Here are some suggestions when feeding or helping an adult with a diagnosis of dementia.
- Start the meal with liquids. This will help “whet the whistle” and make the swallowing process more automatic.
- Place a utensil in a restless hand, even if you are providing the feeding assistance. This provides the appropriate feedback and normalcy of the process.
- Decrease distractions as much as possible. Quiet your family members and turn off the television during feeding.
- Provide one item at a time for the highly distractible selffeeder.
- Provide finger foods to aid in self-feeding.
- If your family member has difficulty swallowing food once it is in the mouth, try patting the lips with a napkin, introducing a new empty spoon, bring a drink to the mouth or even add a bit of ice cream between bites.
Dysphagia can be life threatening and it can also gravely impact quality of life. Often, people with dysphagia are afraid of eating in public. They avoid social situations, family events and celebrations because they are embarrassed by coughing or afraid of choking. But a speech pathologist can help return your life to normal, bringing the joy of eating back into you and your family member’s lives.
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Gwen Griffin, MA, CCC-SLP
Gwen Griffin, MA, CCC-SLP has been a licensed and certified Speech Language Pathologist for over 22 years. Gwen specializes in treating adult neurological disorders including dysphagia, voice impairments and cognitive communication deficits. She lives in Pennsylvania with her two teen-aged children.