Dysphagia is a swallowing disorder involving the oral cavity, pharynx, esophagus or gastroesophageal junction.
Consequences of dysphagia include malnutrition and dehydration, aspiration pneumonia, compromised general health, chronic lung disease, choking and even death.
Conservative estimates suggest that dysphagia rates may be:
- As low as 3% in U.S. inpatients aged 45 years or older to as high as 22% in adults over 50 years of age (Lindgren & Janzon, 1991; National Foundation of Swallowing Disorders, n.d.; Patel et al., 2018; Tibbling & Gustafsson, 1991);
- A high as 30% in elderly populations receiving inpatient medical treatment (Layne et al., 1989);
- Up to 68% for residents in long-term care settings (National Institute on Deafness and Other Communication Disorders, n.d.; Steele et al., 1997); and
- Between 13%–38% among elderly individuals who are living independently (Kawashima et al., 2004; Serra-Prat et al., 2011).
Some good news?
Post-acute care providers have gained an increased appreciation for dysphagia and its impact on quality of life and nutrition/hydration secondary to changes we have all seen with the IMPACT Act, reimbursement models and survey tools.
The Center for Medicare & Medicaid Services (CMS) Critical Element Pathway for Nutrition includes resident interview and observation questions such as:
- Do you have difficulty chewing or swallowing your food? If so, how is staff addressing this?
- How does staff involve you in decisions about your diet, food preferences and where to eat?
- Is the resident receiving OT, speech-language pathology (SLP), or restorative therapy services? If so, are staff following their instructions (e.g., head position or food placement to improve swallowing)?
- Is there any indication that the resident could benefit from therapy services that are not currently being provided (difficulty grasping utensils, difficulty swallowing)?
PDPM is another obvious example.
We have elements from MDS Section K: Swallowing and Nutritional Status included in the speech pathology case mix aimed at identifying the presence of a swallowing disorder in addition to SLP-related comorbidities for specific ICD-10 categories.
K0100 is clearly defined for us in the RAI Manual.
- K0100A, loss of liquids/solids from mouth when eating or drinking. When the resident has food or liquid in his or her mouth, the food or liquid dribbles down chin or falls out of the mouth.
- K0100B, holding food in mouth/cheeks or residual food in mouth after meals. Holding food in mouth or cheeks for prolonged periods of time (sometimes labeled pocketing) or food left in mouth because resident failed to empty mouth completely.
- K0100C, coughing or choking during meals or when swallowing medications. The resident may cough or gag, turn red, have more labored breathing, or have difficulty speaking when eating, drinking, or taking medications. The resident may frequently complain of food or medications “going down the wrong way.”
- K0100D, complaints of difficulty or pain with swallowing. Resident may refuse food because it is painful or difficult to swallow.
The MDS gives the interdisciplinary team definitions, descriptions and coding guidance for all these areas, and this is a great start!
But when do we need more?
When your medical director, speech-language pathologist or other member of the IDT recommends further evaluation, it is important to understand your options.
Generally, further assessment is needed to address patient needs when the impaired area(s) are ones that we cannot simply “see” at bedside.
Makes sense, right? As an examiner at the bedside sans additional tools, we cannot physically see what occurs in all phases of the swallow.
In these cases, instrumental assessments may be warranted.
Instrumental techniques are usually conducted either independently by the SLP or by the SLP in conjunction with other members of the interprofessional team (e.g., radiologist, radiologic technologist, physiatrist, otolaryngologist).
Speech-language pathologists (SLPs) use instrumental techniques to evaluate oral, pharyngeal, laryngeal, upper esophageal and respiratory function as they apply to normal and abnormal swallowing.
Furthermore, these instrumental procedures can be beneficial in determining use of appropriate and effective treatment strategies.
Per the American Speech-Language-Hearing Association (ASHA), in clinical settings, SLPs typically use one of two types of instrumental evaluation: the videofluoroscopic swallowing study (VFSS) or the fiber-optic endoscopic evaluation of swallowing (FEES).
- The VFSS is also known as the modified barium swallow study (MBSS) and is a radiographic procedure used to gain further information regarding dysphagia.
- The FEES is a portable procedure that may be completed in an outpatient clinic space or at the bedside by passing an endoscope transnasally.
Now that we understand our options, let’s discuss when these additional studies may be warranted.
ASHA provides a very helpful outline of considerations below. Indications for an instrumental exam include the following:
- Concerns regarding the safety and efficiency of swallow function (contribution of dysphagia to nutritional compromise; contribution of dysphagia to pulmonary compromise; contribution of dysphagia to concerns for airway safety, e.g., choking);
- The need to identify disordered swallowing physiology to guide management and treatment;
- The need to assist in the determination of a differential medical diagnosis related to the presence of dysphagia;
- The presence of a medical condition or diagnosis associated with a high risk of dysphagia;
- Previously identified dysphagia with a suspected change in swallow function; and
- The presence of a chronic degenerative condition with a known progression or the recovery from a condition that may require further information for the management of oropharyngeal function.
In closing, I hope you all take away that swallowing is a complex process inclusive of many phases and has a significant impact on one’s quality of life and ability to safely and effectively consume a least restrictive diet.
Let us all continue to facilitate choice and informed decisions for those we serve daily.
Intrigued? Want to learn more?
Please see ASHA’s resource on the Videofluoroscopic Swallowing Study for further information on the VFSS.
Please see ASHA’s resource on Fiberoptic Endoscopic Evaluation of Swallowing for further information on the FEES.
Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech-Language-Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.