NHS Greater Glasgow & Clyde
Advancing Skills in Stroke Care
Swallowing problems after
stroke
Stroke and dysphagia
• Dysphagia is the term used for swallowing
difficulties
• Approx 60% of stroke patients will have
some degree of dysphagia at the acute
phase.
• Approx. 20% of stroke patients with
dysphagia develop aspiration pneumonia.
• More frequent in patients with
haemorrhagic stroke.
• The majority of people will improve within
6-7 weeks post stroke.
Normal Swallow
1. Oral stage
2. Pharyngeal stage
3. Oesophageal stage
Factors which can influence the
oral stage:
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Consistency
Hunger/Thirst
Taste
Texture
Visual
Smell
Oral Stage
• Voluntary control
• Bolus is propelled backwards
along tongue
• Bolus passes faucial arches and
swallow is triggered.
Pharyngeal Stage
• Involuntary stage
• Soft palate elevates
• Pharyngeal muscles contract, pulling
the food through the pharynx
• Breathing is halted
• The larynx rises and tips to protect
the airway from food/fluids passing
through the pharynx
• The sphincter at the top of the
oesophagus opens to allow the food
and drink to enter it
Pharynx
Trachea
Oesophagus
Oesophageal stage
• This stage is also under
involuntary control
• This stage involves the
passage of food/fluids
from the oesophagus to
the stomach.
Oral stage problems
• Drooling/Loss of food or fluids from lips
• Residue of foodstuffs in the mouth
• Loss of taste or smell
• Incomplete soft palate seal
• Loss of food/fluids into the pharynx
before the swallow is triggered
Pharyngeal stage problems
• Unable to trigger swallow
• Delayed swallow trigger
• Reduced protection of the airway - leading to
penetration/aspiration
• No cough reflex
• Pharyngeal muscles are weak
• Upper oesophageal sphincter dysfunction
Penetration
of airway
Oesophageal stage problems
• The speech and language therapist is
not really involved in problems at this
stage as they are unable to assist
with problems of oesophageal
function
• Medical team investigation and
management
Aetiologies of Dysphagia
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NEUROLOGICAL
CVA
Motor Neurone Disease
Parkinson’s Disease
Multiple Sclerosis
Myasthenia Gravis
Guillain-Barre Disease
Cerebral Palsy
Dementia (also behavioural)
Brain Tumour
Head Injury
SLT assessment
(Bedside Assessment)
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Observational assessment
Oral examination
Food /fluid trials
Recommendations/Documentation
Videofluorscopy
Food Consistencies
• Texture A - a smooth, pouring consistency
that cannot be eaten with a fork eg tinned
tomato soup.
• Texture B – smooth consistency, drops
rather than pours from spoon eg thick
custard.
• Texture C – a thick, smooth consistency.
Can be eaten with a fork and can be
moulded layered and piped eg mousse
• Texture D – food that is moist with
some variation in texture. Easily
mashed with fork and little chewing
required eg flaked fish in sauce /
macaroni cheese
• Texture E – Soft moist food that can
be broken into pieces with a fork eg
sponge and custard, tender meat
casserole
Thickened Fluids
• Stage 1 (syrup) can be drunk through a
straw and from a cup. Leaves a thin layer
on the back of the spoon.
• Stage 2 (custard) Cannot be drunk
through a straw, can be drunk from a cup.
Leaves a thick coat on back of the spoon.
• Stage 3 (pudding) cannot be drunk from a
straw or cup. Needs to be spooned. A bit
like thick custard
Videofluorscopy
• X-ray examination of the movement
of food/fluids through the oral
cavity, pharynx and upper oesophagus.
• This data is videotaped which permits
a frame by frame analysis of the 3
stages of the swallow.
Short-term signs of dysphagia
• Choking or coughing when eating/drinking
• Change of colour during or
eating/drinking
• Wet, gurgly voice
• Shortness of breath
• Loss of food or drink from the mouth
• Pocketing of food or drink in the mouth
• Nasal regurgitation
Long-term signs of dysphagia
• Loss of weight with anorexia and
dehydration
• Recurrent chest infections
• Frequent episodes of high
temperatures
Points to Consider when Feeding
• Is the person alert?
• Is the person positioned upright with
their body in mid-line?
• Is the person’s mouth clean?
• Discourage conversation when eating
• Use small spoonfuls
• Check the person has swallowed
before giving the next spoonful
• Tell the patient what food or drink
you are giving them
• Sit in front of the person or on their
‘good’ side if they have a neglect
• Check in the mouth at the end of
meal for pocketing in the cheeks
• Keep the person upright for 30
minutes after a meal
• Watch out with ice -cream as it starts off
as a puree but melts in the throat to a
normal fluid.
Dysphagia and Quality of Life
• Ekberg et al (2002)
article on effects of
dysphagia on quality
of life.
• Only 45% of the 360
patients in the study
enjoyed mealtimes.
• 41% felt anxious or
panicky when eating.
• 36% avoided eating in
public
• 1/3 of those on
modified consistencies
still felt hungry/thirsty
after a meal.
• Affects, self-esteem,
socialization and
dignity.
How to refer to SLT ?
Swallowing Video
Endoscope Views of Normal
Swallow
PLAY