IADL, Meal Prep, AE, Dysphasia

Assistive Technology (AT)

any item, piece of equipment or product system whether acquired commercially, off the shelf, modified, or customized that is used to increase, maintain, or improve functional capabilities of individuals with disabilities

used interchangeably with adaptive equipment and assistive devices

low tech vs high tech

OT have great knowledge and understanding when it comes to occupations and all factors that affect occupations (skills, environment) and have the ability to analyzed tasks

Adaptive Equipment (AE)

used to compensate for a physical limitation, to promote safety and the prevent of injury

Feeding (Self Feeding)

the process of bringing food to the mouth

Eating

keeping and manipulating food or liquid in the mouth and swallowing it

Swallowing

moving food from the mouth to the stomach

involves a complicated act in which food, fluid, medication, or saliva is moved from the mouth through the pharynx and esophagus into the stomach

Dysphasia

any difficulty in the passage of food, liquid, or medicine, during any stage of swallowing that impedes the client’s ability to swallow independently or safely

Signs of Dysphasia

difficulty/inability to shape food into cohesive bolus

loss of food/liquid from mouth (drooling) or nose

coughing/frequent throat clearing before, during, after the swallow

wet or gurgling voice quality after eating or drinking

food residue remaining in mouth

loss of appetite, dehydration or weight loss

discomfort or pain when swallowing

delayed/absent swallow response

weak cough

reflux of foods after meals

heartburn

Dysphasia Related Concerns

nutrition/hydration limited

pulmonary concerns

risk of social isolation

Goals of Swallowing Program

maintain adequate nutrition/hydration

safety during feeding/eating

maintain health (avoid pneumonia)

identify swallowing risk factors that may lead to aspiration and penetration

Aspiration

entry of liquid or food into lower airway

Penetration

entry of liquid or food into laryngeal vestibule

Team Approach

patient/family

OT

PT: positioning, increasing client’s pulmonary status for breath support, chest expansion and cough

SLP: reeducating the oral and laryngeal musculature used in speaking, voice production and swallowing

respiratory therapist

nurse

physiatrist/MD

radiologist

gastroenterologist: if patient has a trachestonomy, PEG, NG tube, J tube

nutritionist

Entry Level OT

oral intake textures/consistency recommendations

positon changes

oral motor interventions

when aspiration is suspected → refer to appropriate healthcare professional

has basic knowledge and skills to provide OT services to clients with eating and feeding dysfunction: feeding, eating, swallowing interventions to enable performance (process of bringing food/liquids from plate or cup to mouth; ability to keep and manipulate food/liquids in mouth; swallowing assessment and management)

awareness of the oral structures and progression of swallowing

knowledge regarding the common causes and associated conditions for dysphasia

awareness of sighs and symptoms of aspiration

basic understanding of instrumental assessments used to evaluate dysphasia

basic understanding of compensatory swallowing techniques and food/liquid modifications

self feeding positions

Advanced OT

has expanded depth and specificity of knowledge related to evaluation and intervention

administering more complex assessments and providing interventions for clients who are medically fragile or who have complicated diagnosis or conditions resulting in feeding and swallowing problems

extensive knowledge of the anatomy and physiology of swallowing

assessment and prescription of intervention

specialized client population and settings

instrumental evlauations

specialized interventions

Oral Phase

voluntary control

1-3 seconds

bolus formed/pressed against hard palate moved posteriorly

Pharyngeal Phase

involuntary control

1-3 seconds

brainstem triggered swallow reflex

coordinated and timed

Esophageal Phase

involuntary control

8-20 seconds

contraction of sphincter muscles, food enters stomach

bolus motility via peristalsis

Dysphasia Diagnoses

head and neck cancer

CVA

TBI

ALS

Parkinson’s disease

MS

HIV/AIDS

CVA

most common cause if dysphasia

lack of postural control

presents with oral and pharyngeal phase dysfunction

muscle weakness: face, lips, tongue, throat

sensory deficits

apraxia

cognitive changes

TBI

changes similar to CVA

tracheostomy

self monitoring/impulse control deficit

bite reflex

cranial nerve damage

tonal changes in neck (flexion/extension)

agitation

Neurogenerative Disorders (MS, ALS, Parkinson’s)

weakness of muscles in oral cavity

drooling

mainly weakness in oral and pharyngeal muscles

possible cognitive impairments

Head and Neck Cancers

SLP frequently sees clients

dysphasia most commonly caused by obstruction or post surgical removal of structures

lack of saliva can interfere with oral phase

Signs of Aspiration

poor arousal

poor control of bolus

excessive coughing or choking before, during or after swallowing

no ignition of swallow at the end of the oral phase

change in voice quality (wet or no voice)

changes in skin color, respiration rate, reduces O2 saturation level

Aspiration Precautions

careful chart review

NPO: no food, liquid or medications should be administered orally

common alternative forms of nutrition: J tube (jejunostomy), G tube (gastronomy), NG tube (nasogastric) IV (intravenous)

liquid/texture modifications

positioning during/following meal

Preparing Thickening Liquid

pour 4oz beverage onto dry thickener while stirring briskly for 30 seconds

let site for 4-10 minutes: 4 minutes (water, tea, coffee, soda); 10 minutes (milk, nutrition drinks, juices, beer, wine, broth)

Compensatory Swallowing Techniques

chin tuck

head turning

sustained swallow/effortful swallow

multiple swallows

Chin Tuck

moves bolus back, narrows opening to larynx, protect airway

Head Turning

rotation of head/neck to weaker side

closes weaker side allowing stronger side to perform swallow.

Sustained Swallow/ Effortful Swallow

slow, forceful swallow

elevates base of tongue: improves transition of bolus

Multiple Swallows

repeated effort to clear pooling in various areas

4 Finger Palpation

not an entry level skill

first finger: under chin

second: base of tongue

third: over thyroid cartilage

fourth: base of throat

Food Textures

puree: pudding, apple source, blended foods

very soft/soft (mechanical soft): cooked veggies/fruits, soft pasta

soft: cookies, breads

regular/solid: broad range of mastication needed

Liquid Textures

pudding thick

honey thick: drop off the spoon like honey, nectar thicken with banana/pureed fruit, regular applesauce with juice, commercial thickener

nectar thick: kerns, extra thick milkshake/eggnog, strained creamed soups, yogurt and milk blended, V8

thin: different viscosity (can add thick it), water, coffee, tea, milk, fruit juice

water

Self Feeding Positioning

siting tall/ upright

feet supported on firm surface (knee just below the hips)

remain sitting after meals for 30 minutes minimum