Dysphagia Basics for Occupational Therapists

As humans, we often take for granted our ability to eat and drink, but for many older adults, the seemingly simple act of swallowing can become difficult or even impossible. Swallowing is, in fact, a highly complex process involving roughly fifty pairs of muscles and an intricate network of nerves to help food travel from the mouth into the stomach.  When any part of process is interrupted, a person can suffer from dysphagia.

According to the National Institutes of Health, “Dysphagia occurs when there is a problem with the neural control or the structures involved in any part of the swallowing process.”[i] This may be caused by a variety of factors, including: a weakening of the tongue or cheek muscles (which inhibits the chewing process); a stroke or other nervous system disorder which can affect the natural swallowing response; or a weakening of the throat muscles such as after cancer surgery. Dysphagia may also result from disorders of the esophagus.

Conducting a Thorough Evaluation

Because of the seriousness of the disorder, a thorough evaluation must be performed if a diagnosis of dysphagia is suspected. Such an evaluation must take into account a broad range of factors, such as the patient’s swallowing ability as well as his or her vocal quality, breathing patterns and mental status. Below are some important tips for getting started.

Read the Chart

Begin by reading the patient’s entire chart, including:

• Past medical history
• Present concerns
• Dietary notes
• Social services notes
• Lab work
• X-ray reports
• PT and OT notes

Look for information that may indicate swallowing trouble. This includes any neurological changes or disorders as well as anatomical or physiological concerns with regard to the oral, pharyngeal, or esophageal areas. Pay close attention to current medications, as many medications have the potential to cause swallowing difficulty or symptoms that can lead to dysphagia (such as dry mouth).

Abnormal lab values may provide some insight as well. For example, a high albumin level may indicate dehydration. The same goes for high creatinine, sodium, or BUN (Blood Urea Nitrogen) levels. Dehydration may be caused by a variety of factors, dysphagia being among them. Look also for an unplanned weight loss.

Talk to the Patient

If cognitive function is intact and the patient is sound, he will be able to communicate what he is experiencing while eating. Use leading questions/statements such as:

• Do you cough and/or choke while eating or drinking?
• Does your food feel like it is “going down the wrong way”?
• Does any of the food or liquid you are eating spill out of your mouth, and how much?
• Tell me about your appetite.

Talk to the Facility Staff

Speak with nurses, dietitians, nursing aides, recreational therapists, social services, and any other employees or volunteers who may have had contact with the patient while he or she was eating. Find out what they have observed, and note whether or not the patient is on a nutritionally altered diet (e.g. low sodium, low protein, no concentrated sweets, etc.)

Conduct the Clinical Bedside Swallowing Evaluation

The bedside swallowing evaluation requires a few key tools, and many facilities will have a dysphagia evaluation kit already made up including items such as:

• Spoon
• Light pen
• Gauze
• Tongue blades
• Straws
• Cups
• Protective gear (gloves, gown, eye protection)

Gloves should always be worn during a dysphagia exam to avoid exposure to germs. The need for gown and eye protection will depend upon the fragility and medical condition of the patient. Foods of various textures (puree, mechanical soft, regular, thin and thick liquids) will also be necessary; avoid food with mixed textures, such as vegetable soup.

Some Things to Remember

As you conduct the swallowing evaluation, be sure to observe the general appearance of the patient. Things to note are:

• Posture and positioning: Some swallowing deficits can be ameliorated by properly positioning the patient upright with his or her hips and knees at 90 degrees.
• Breathing patterns: Is breathing labored? Is the patient short of breath? Does he or she have a chronic cough?
• Vocal quality: Gurgling may indicate inadequate swallowing of secretions; If the patient is breathy, the vocal folds may not be making an adequate seal when they close.
• Does the patient have a tracheostomy tube or a feeding tube?
• Is suctioning equipment and/or oxygen being used?
• Mental status: Take note of the patient’s expressions, attention, comprehension and memory.
• Face and mouth: Is there a facial droop? Can the patient’s lips form an adequate seal to prevent food and/or liquid from spilling out? Also observe the mouth for secretions, hygiene, and tissue color.
• Teeth and tongue: Are dentures present and do they fit well? What is the ROM of the tongue?

Improving Quality of Life

While many people experience occasional difficulty swallowing, persistent symptoms may indicate a more serious underlying condition. Because the goal of the occupational therapist is to assist patients with performing everyday activities such as eating and drinking, being able to recognize the signs and symptoms of dysphagia is a critical part of promoting optimal health in each individual. Through ongoing education and quality one-on-one care, today’s occupational therapists can help dysphagia sufferers restore healthy swallowing function and improve overall quality of life.

For a more detailed look at working with dysphagia patients—including how to determine at-risk patients, conduct a thorough evaluation and develop a treatment plan—view our comprehensive course Basic Dysphagia for Occupational Therapy Professionals.

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