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Do's and don'ts for dysphagia


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#1 jas1125

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Posted 23 October 2013 - 09:30 AM

Hello:

My mother, age 84 just did a modified barium swallow and it was found she silently aspirates thin liquids. As such, she will now need to be on nectar thick liquids. She is in assisted living, and they have in house therapy, so speech therapy will begin shortly. After a 6 week program, they want her re-tested to see if there is any improvement. This is a deterioration from 18 months ago, when the same test showed only silent aspiration when using a straw. She was given exercises to do, however her compliance was not a dedicated as I had hoped despite prompting.

 

Her facility has thickening agents, as well as the pre-mixed flavored water and I want to make sure that she stays hydrated, as she is prone to UTIs. In reading various sources, it stated some over the counter thick fruit juices are ok to give, such as apricot nectar or tomato juice, however her therapist indicates no, everything must be thickened. I'm looking into different ways to do this, such as adding MIO flavor enhancers to thickened water and to give it some variety. Is there a specific lists of do's and don'ts that I should be aware of?

Also, she takes liquid Tylenol for pain and a liquid multi-vitamin....do they also need to be added to thickened water? How about vitamin gummies? She enjoys those and they seem like they would be OK, but I want to make sure.

 

This all came about when a new finding of pulmonary fibrosis was given 2 months ago, and her pulmonologist wanted a repeated swallow test to determine the cause. Although this is something new that must be dealt with, I'm hopeful this will help to reducet her risk of pneumonia, which she's had a few times over the last 3 years.

 

My apologies for the length of this post, but since I'm proactive in her care, I want to make sure I do the right things for her.

 

Thanks very much for any information that you can provide.



#2 Dr. Mahler

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Posted 25 October 2013 - 01:18 PM

The motor changes associated with PD can definitely affect swallowing.  Although people with PD share a common etiology there is great heterogeneity within the population regarding the cause of swallow problems so it is good that your mother is getting consistent treatment.  If the SLP's recommendation was for thickened liquids then typically even water needs to be thickened.  Her SLP is in a better position to advise you about the liquid Tylenol than I since she has seen her in person. 

 

Research literature teaches us that people with PD can benefit from exercise treatment to improve swallowing. 

Muscle strengthening exercises may increase tongue strength and range of motion in elderly and may also help people with PD.  (El Sharkawi et al., 2002; Logemann, 1998; Robbins, et al., 2005).  A randomized study of 3 interventions on immediate aspiration of thin liquids in patients with PD (with and without dementia) was completed by Logemann, Gensler, Robbins, Lindblad, Brandt, Hind, Kosek, et al., (2008).  They compared nectar thickened liquids, honey thickened liquids and chin tuck.  They found that honey thickened liquids were best at eliminating immediate aspiration but there were other complications that resulted from decreased fluid intake.  Compensatory strategies may prevent aspiration but do not influence or improve the underlying pathophysiology of the swallow.  Principles of exercise applied to the behavioral treatment of swallowing disorders have demonstrated improved swallow function.  Those principles include: intensity, specificity, and transference (Burkhead, Sapienza, & Rosenbek, 2007; Robbins et al., 2007).

 

Talk with your mother's SLP about whether she might be a candidate for a daily swallowing exercise program to maintain or possibly improve the safety and efficiency of her swallow before the repeat modified barium swallow study.

 

Please write again if you have any additional questions.

 

 

 

Sincerely,

 

Leslie Mahler


Leslie Mahler, PhD, CCC-SLP

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University of Rhode Island

#3 jas1125

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Posted 22 April 2014 - 04:43 PM

Leslie:

 

As a follow up to my original post, a repeat MBS was done today and she has improved. No silent aspiration was noted and no other issues. She was pretty good in attending and doing her swallowing exercises. One thing to note was that the test was done during a time when her Stalevo dose was at it most effective. Going forward, it is "safe" for her to return to thin liquids? Assuming she continues to do her swallowing exercises as diligently as before (which was an issue before), how would be able to tell she starts to have problems again. If she is having an off-time with her meds or a bad Parkinson day, would that cause another silent aspiration?

 

Since she tolerated nectar thick liquids ( I bought her pre-mixed water and juices) is it better for her to just stay on this regime? In the past, she's had repeated bouts of pneumonia and has COPD as I stated in my original post, but since being on nectar thickened liquids, she's been doing better. I'm also checking with her pulmonary doc for her opinion.

 

Any advice or suggestions going forward would be appreciated. I just want to make sure she is being as conservative as possible to keep her healthy.

 

Thank you.



#4 Dr. Mahler

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Posted 24 April 2014 - 06:20 PM

Yeah for improvement in swallow function!  I am very glad to hear that.  It isn't possible for me to answer your question about whether it is safe to advance to thin liquids without seeing your mother in person.  If she keeps doing exercises intensively (daily) then she may continue to improve.  On the surface it seems as though liquids should be the easiest thing to drink but that is not actually true.  Water is thin and so it is harder to control than thicker liquids.  People with PD typically have delayed swallows and so thin liquids can be problematic.  Pre-mixed drinks are great because then you will have her drinking safe consistencies throughout the day.  Remember that signs of aspiration may not be obvious so you need to rely on the report from the speech-language pathologist who did the swallow study.  Sounds like you are doing a fantastic job!

 

Keep doing the exercises.  People with PD can improve with exercise even in the area of swallowing.

 

Sincerely,

 

Leslie Mahler


Leslie Mahler, PhD, CCC-SLP

Associate Professor

University of Rhode Island




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