| Clare Morris - Speech &
Language Therapist, St Charles Hospital, Exmoor Street, London W10 6DZ
Mitch Murray - Speech and
Language Therapist, St. Mary's Hospital Trust.
THE SWALLOW MECHANISM
The purpose of swallowing is to get food
from the mouth, through the throat (pharynx), to the stomach, without allowing
it to go down the nose or down the windpipe (trachea). Your throat is like
a dual carriageway: food goes down to the stomach (and in some circumstances
back up!) and air goes up and down it to the lungs.
The pharynx divides into two near the
top: the tube at the front is the windpipe which goes to the lungs; and
the tube at the back goes to the stomach (oesophagus). Before swallowing
food is chewed and held in the mouth. There is nothing in the throat, the
windpipe is open and breathing occurs. When you swallow, the food is pushed
into the throat, and the windpipe closes off . Food then slips down the
tube at the back leading to the stomach. Because the windpipe is closed,
you momentarily stop breathing. Once the food has passed through the throat,
the windpipe opens up again and breathing can resume.
If you have any food or drink in your
throat when your windpipe is open and you are breathing, there is a chance
it could fall into the windpipe. This is experienced as 'going down the
wrong way' and coughing and spluttering usually ensues.
Difficulties in eating and/or swallowing
can develop for a variety of reasons. The problem is best understood by
looking at the three different stages involved in swallowing, and associated
behaviours, separately.
1) Oral Preparation Stage
The lips, tongue, teeth and cheeks break
up food, mix it with saliva and form a soft ball that can be swallowed.
In the case of liquids, it is a question of control. The tongue forms a
cupped shape around the liquid and holds it ready for swallowing.
2) Pharyngeal Stage and the Swallow Reflex
The tongue squeezes the food or liquid
to the back of the mouth and the swallow reflex is triggered: the windpipe
is closed off and food/liquid is passed through the back of the throat,
down to the stomach, and then the windpipe opens again. Muscles in the
wall of the throat assist movement of food/drink downwards by wave like
movements called peristalsis.
If you touch the front of your throat
and swallow you can feel the Adam's Apple (larynx) move up and down. This
is the mechanism which closes the windpipe and is part of the swallowing
reflex. You need to have something in your mouth to swallow: try swallowing
repeatedly; after three or four swallows it becomes difficult as your mouth
becomes empty of saliva.
3) Oesophageal Stage
This is the movement of food from the
lower part of the throat, through the gullet (oesophagus) to the stomach,
assisted by a continuation of the peristaltic wave.
Cough
A cough is the body's response to 'foreign
bodies' entering the airway or windpipe. It is our way of protecting our
lungs from getting clogged up and interfering with breathing. It is under
neurological control and can therefore be affected in dementia. The important
thing to understand is that if someone can cough when you ask them to,
it doesn't necessarily mean they will cough to clear their windpipe. Likewise,
if someone is unable to cough on request, it may be that they will have
an adequate 'protective' cough.
Aspiration
Aspiration is when liquids or food do
go down the wrong way and are not removed by coughing.
Gag Reflex
Contrary to popular belief the presence
or absence of a gag reflex has no relationship to someone's ability or
inability to swallow safely.
SWALLOWING PROBLEMS (DYSPHAGIA)
Problems with swallowing in dementia can
arise at any of the stages, either in isolation or in combination. Muscle
movements may become slow or uncoordinated; the swallow reflex can become
delayed or incomplete; or the coordination of all three stages can become
unbalanced. Whilst most problems can be diagnosed on examination sometimes
it is necessary to confirm this by 'videofluoroscopy'. This is a video
X-ray to show exactly what is happening when food and drink of different
consistencies is swallowed.
Below are listed some common problems
and strategies used to facilitate swallowing. It is, however, recommended
that the advice of a speech and language therapist is sought, as strategies
recommended will vary according to the stages of the swallow affected and
the client. You can obtain a referral through your GP, or if necessary
contact your local hospital or the Royal College of Speech and language
Therapists for information on services locally. Other professionals, such
as a dietician, occupational therapist, physiotherapist, or district nurse,
may need to be involved.
Common problems that you may notice
-
being unaware of food when it arrives
-
failing to do anything with food in the
mouth, just holding it there
-
difficulty chewing and/or difficulty moving
food to the back of the mouth
-
spitting lumps of food out
-
eating very fast or putting too much into
the mouth
-
eating insufficient amounts or refusing
food and/or drink
-
talking with food or drink in the mouth
and forgetting to swallow causing coughing
-
coughing/choking on food and /or liquids
-
complaints of food not going down or getting
stuck in their throat
-
a 'wet' or 'gurgly' voice after swallowing
-
difficulty swallowing tablets
-
dribbling
-
chronic chestiness or recurring chest
infections
Ways to promote safe eating that may be
suggested by a speech and language therapist
-
Strategies
-
Sitting upright, keeping the chin down.
If you put your head back to drink, you are opening up the airway more,
therefore if the swallow reflex is slow, it is easier for food and drink
to go down the wrong way.
-
Take small sips of drink, perhaps from
a teaspoon. Avoid the use of drinking vessels that encourage the head to
tip back (eg feeder beakers)
-
Take small mouthfuls of food.
-
Alternate food and drink to help clear
the mouth of food: this should be discussed with a speech and language
therapist.
-
Try encouraging the swallowing of each
mouthful twice to clear any food or drink that may remain in the mouth
or in the throat after the first swallow.
-
If the person has not swallowed what is
in their mouth, sometimes it helps to present an empty teaspoon rather
than more food. This can encourage the second swallow mentioned above.
-
Frequent swallows to counteract dribbling.
-
Check mouth after finishing eating to
ensure no food or fluid remains.
-
You may have to sit with the person to
remind them to use these strategies, and you may find that mealtimes take
much longer.
-
Changes to diet
Special diets (soft or puree),
merely avoiding certain foods, or preparing them differently can make a
big difference. Foods that may present difficulty for someone with a swallowing
problem include:
-
mixed textures eg food in a lot of fluids
like ministrone soup, or cornflakes and milk;
-
stringy textures eg bacon, cabbage, runner
beans
-
floppy textures eg lettuce, cucumber
-
small, hard textures such as peanuts,
peas, sweet corn and broad beans
Cooking food longer so it becomes softer;
mashing food with the back of a fork; or liquidising it in a blender can
help.
Thickening fluids to yoghurt or sometimes
porridge consistencies may help as they are easier to control. There are
a number of thickening agents available through your GP or from a dietician.
It is important to speak to a speech and language therapist about this,
and it can also be helpful to have guidance in using thickeners as the
fluids may become lumpy which does not look appealing and may be off putting!
The use of nutritional supplements
if necessary.
Crushing tablets or using a syrup form
may be easier for someone with a swallowing problem but seek advice from
your GP as some tablets need to be taken whole.
Equipment
Specially designed cups which allow drinking
whilst keeping the chin down; cutlery, plates and non slip mats are available.
An occupational therapist can advise you on this.
Sometimes these strategies may be insufficient
to ensure an adequate dietary intake. After discussion with your doctor
it is may be decided to feed via a tube directly into the stomach. This
is called a gastrostomy, and it can be used in conjunction with eating
small amounts orally, or can be used alone.
Food and eating is central to living
in terms of pleasure and socialising as well as survival, therefore eating
and swallowing problems have a major impact both on the person directly
affected and those caring for them. It is possible to compensate for many
difficulties, and support and guidance from a speech and language therapist
can make the difference.
Information about dementia and speech
and language therapy services is available from:
C.A.N.D.I.D (Counselling and Diagnosis
in Dementia)
The National Hospital for Neurology
and Neurosurgery,
Queen Square,
London WC1N 3BG.
Tel: 0171 837 3611 ext 3855
Fax: 0171 209 0182
E-mail: p.roques@ion.bpmf.ac.uk
The Royal College of Speech and
Language Therapists
7, Bath Place,
Rivington Street,
London EC2A 3DR
Tel: 0171 613 3855
Fax: 0171 613 3854
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