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Issue 102, September 2008

Swallowing Difficulties in HD

HD patients often experience difficulty with chewing, drinking and swallowing. Dysphagia is the term used to describe this. Difficulties can occur in the mouth and throat and create a risk of food and liquid going into the lungs instead of the stomach. This in turn can lead to chest infections or pneumonia.

Dysphagia results from impaired voluntary control of the mouth and tongue, impaired respiratory control due to chorea, and impaired judgment, resulting in eating too rapidly, or taking overly large bites of food and gulps of liquid.

Dry mouth, which can be brought on by neuroleptics, antidepressants, and anticholinergics, may worsen the problem. There are many warning signs which may suggest swallowing problems.

The following are some indicators to look out for:
  • Coughing or choking on food and drink
  • Difficulty chewing food in the mouth
  • Spillage of food or liquid from the mouth
  • Food or liquid left in the mouth after swallow
  • Gurgly voice especially after eating / drinking
  • Frequent throat clearing
  • Recurrent chest infections /pneumonia
  • Frequent temperatures
In order to avoid problems the following tips should be considered:
  • Eat slowly and without distractions.
  • Prepare foods with appropriate size and texture.
  • If a patient has problems their carer should supervise at eating times.
  • Carers should know the Heimlich manoeuvre.

Early referral to a speech-language therapist will help identify swallowing difficulties, and periodic reassessment can identify changes in swallowing ability and suggest appropriate non-pharmacologic interventions such as a change in food consistency.

How the Speech and Language Therapist can help The Speech and Language Therapist (SLT) is involved at all stages of the disease. The SLT firstly assesses the swallow. There are a number of assessment options available. Frequently, the SLT will trial the person with a number of different food and liquid consistencies and observe for clinical signs of aspiration. Another assessment tool that is used regularly is known as video fluoroscopy. This procedure involves adding barium to various food and liquid consistencies. A moving x-ray is then taken while the person is eating and drinking. This helps determine if aspiration is occurring on a particular consistency. It can also be a useful tool in developing strategies for safe swallowing.

The SLT will then make a number of recommendations based on the assessment results for example introducing techniques to ensure safe swallowing or giving advice on optimal positioning.

It may be necessary to make food and / or liquid consistency changes. Dry, crumbly and chewy foods can be difficult to swallow safely so the SLT may recommend a softer smoother option. Similarly, drinks can be difficult to swallow safely as liquid moves very fast through the mouth and throat. The SLT may recommend thicker drinks which are slow moving. As there are many different grades of thickened drinks, the SLT will advise on the liquid consistency most suited to the swallow abilities. Changing food and liquid consistency can be an effective way of reducing the risk of aspiration. Each person is assessed on an individual basis and the SLT will therefore recommend a tailored plan. Depending on the severity of the dysphagia, it may not be safe to take any food or drink orally. In these instances, the SLT may advise non-oral methods of feeding (e.g. a tube may be placed in the stomach to supplement what you eat). This decision is made in conjunction with the patient, family, dieticians and medical team.

Swallowing difficulties range from mild to severe. At all times, patient dignity and comfort are central to all decisions made regarding management.

Thanks to Eimear Collins, Speech and Language Therapist, South Infirmary, Victoria University Hospital, Cork, Ireland. ASSOCIATION OF IRELAND

Acknowledgement: Hope Ireland Issue No. 34, Q2 08 HDNL 2008

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