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Swallowing problems after stroke

Swallowing is a complex activity that involves the co-ordination of many nerves and muscles. At least 40 per cent of stroke survivors will initially experience some difficulty swallowing, although for many people it improves quite quickly. This factsheet explains the signs of swallowing problems, the complications that can happen, the key ways to manage these difficulties, and some tips for safer swallowing.

How can a stroke affect swallowing?

Swallowing problems occur after stroke when the parts of your brain that control swallowing are affected. The medical term used to describe any difficulties or pain in eating, chewing, drinking or swallowing is dysphagia. Muscle weakness, problems with attention and concentration, balance difficulties and poor co-ordination can also affect your ability to swallow food and drink safely. Most people regain the ability to swallow safely within several weeks. How long it takes depends on the severity of your stroke and the parts of your brain which have been affected. Recovery is different for everyone.

What are the signs of swallowing problems?

Common signs include: not being able to swallow difficulty chewing or swallowing coughing or choking before, during or after swallowing difficulty controlling food or fluid in the mouth bringing food back up, sometimes through the nose drooling a hoarse voice a gargly or a wet sounding voice the sensation of food or drink catching in your throat. In the long term symptoms may include unexplained weight loss or frequent chest infections.

What are the hazards?

The costs of printing this factsheet have been paid for by Fresenius Kabi. The Stroke Association retains independent editorial control over all content.

There are several reasons why swallowing problems need to be managed properly: Aspiration This is the medical term

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used to describe something going down the wrong way. The entrances to your airway and your stomach are very close together. Aspiration occurs when food, fluid and/or saliva enters your airway and lungs. Usually if this happens you will cough. However, the effects of the stroke may mean you are not aware something has gone down the wrong way and the coughing reflex may not happen. Signs of aspiration can include coughing and a change in your voice. Sometimes people do not have any noticeable signs of aspiration and this is known as silent aspiration. Aspiration pneumonia This is a chest infection that occurs when food or fluid get into your lungs then irritate and damage them. Symptoms of aspiration pneumonia include a cough, high temperature, chest pain and difficulty breathing. The condition will usually be treated with antibiotics. Malnutrition If you are not able to swallow properly, you may not be able to eat a balanced diet that includes all the nutrients you need and you may develop malnutrition. Dehydration It is important that your body gets enough water and remains hydrated. If you have difficulty swallowing, you may become dehydrated. trained healthcare professional, such as a nurse, doctor or speech and language therapist. This should happen before you are given anything to eat or drink or any medication to swallow. Ideally this should take place within four hours of you being admitted. They will usually ask you to swallow a small amount of water and may ask you to swallow different consistencies in order to observe your swallowing ability. Assessment If the screen identifies problems you should then have a specialist assessment of your swallowing. This should take place no more than 72 hours after your admission to hospital and ideally within 24 hours. The assessment will usually be carried out by a speech and language therapist or another specially trained professional. It may include advice on how to manage your swallowing problems and may include a referral for further investigation. For more information about the role of the speech and language therapist see our factsheet F14, Speech and language therapy after stroke. Further investigation The following two tests are common; A videofluoroscopy is a procedure that involves taking a series of x-ray images of the parts of your body involved in swallowing. You may be asked to swallow food and drink of different consistencies that are mixed with a non-toxic solution, which will show up on an x-ray. The images will show if the food or drink is going down the wrong way into your airway. These images may identify what is wrong with your swallowing and may help Stroke Association April 2012

How are swallowing problems assessed?

Immediate screening After you have been admitted to hospital, your swallowing should be screened by a

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identify strategies that may help. A fibreoptic endoscopic evaluation of swallowing (FEES) involves a long thin, flexible tube that has a light and a camera on the end (endoscope). It is placed up one nostril and moved into position so that it can view images of the back of your throat and the structures involved in swallowing. The findings may show what happened to the food and drink before and after the swallow. It may also identify the nature and cause of aspiration and be helpful in deciding on treatment and rehabilitation. The advantages of this test are that it is easy and safe to do with relatively little discomfort and it can be completed at the bed side. Hydration assessment Your bodys level of hydration should be assessed when you are admitted. This is done by taking a blood or urine test. This should then be monitored to make sure you do not become dehydrated. Malnutrition screening Different screening tools for malnutrition may be used, for example the MUST the Malnutrition Universal Screening Tool. Screening involves measuring your height and weight to calculate your body mass index (BMI), noting any unplanned weight loss and any illnesses. Screening should be repeated weekly whilst you are in hospital or when there is concern that you may be malnourished. Nil by mouth If the health care team feel that your swallow is unsafe, they may advise that you should not eat or drink anything until you have your swallow assessed. Whilst you are nil by mouth you should be given fluids and foods Stroke Association April 2012 by other means to keep you hydrated and maintain your nutrition levels.

How are swallowing problems treated and managed?

A team of different healthcare professionals, usually including a doctor, speech and language therapist, dietitian and nutrition nurse, will work closely with you, your family and any carers to manage your swallowing difficulties. The aim of managing your swallowing problems will be to avoid aspiration, to help you swallow safely, to make sure your body remains hydrated, to make sure you get the nutrients you need to stay healthy and to maximise your quality of life. Swallowing problems can impact on your overall recovery from stroke, so it is important you get the right help. The health care team should involve you and your family in any decisions and provide you with information. Until you are able to swallow safely, written guidance should be provided to any staff or carers involved in giving you nutrition or fluids. Any methods you use to manage your swallowing problems should be reviewed regularly to ensure they continue to be suitable. The methods listed below may help you to manage your swallowing difficulties. These may be included in a programme of swallowing therapy designed and monitored specifically for you. Food and fluid alterations The presentation of your food may need changing to ensure you can swallow it safely. This may involve altering the temperature, texture, taste and thickness. For example, fruit and vegetables might be pureed or a thickener

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may be added to a drink. Commercial thickeners can be used to vary the consistency of your food from solid to liquid and from thin to puddinglike. If you require food or fluid alterations, you should be referred to a dietitian or nutrition team so they can make sure you get the right balance of nutrients and this is monitored. As your swallowing improves, you may be able to progress to a normal diet. Meal changes The time, how often you eat, and the size of your portions may need to be changed, particularly if you are finding eating tiring, have difficulty concentrating and are sometimes not hungry. Postural/swallowing techniques You may be advised to undertake different postures and swallowing techniques that change the way you swallow your food and drink. These can help you to swallow more easily and safely. You may also be provided with specialist seating equipment to help you sit in the best position. A physiotherapist and occupational therapist may assist with this. Environmental changes Your environment affects the way that you swallow. To make meal times as safe and pleasurable as possible, it is important to make the environment as suitable as possible. This may involve reducing distractions and noise, getting the right lighting levels and helping you to have some social interaction at mealtimes. Exercises You may be given a number of chewing and swallowing exercises to help maintain and improve the muscles you use for eating and drinking. Practical help You may find it takes you a long time to eat. You may be offered assistance at mealtimes or given equipment or utensils to help you eat independently and safely. For example, you may be provided with cutlery that is easier to grip, a non-slip mat to place items on, or a cup that is specially shaped so you dont have to tilt your head back when drinking.

Other feeding methods

If you are unable to get the nutrition and fluids you need by eating and drinking then you may be given food and drink by a tube (enteral feeding.) The medical professionals should discuss their expectations for the use of tube feeding with you, including what would happen without tube feeding, the quality of life you will have with or without tube feeding and the impact on you and your carers. The most common types of tube feeding you may be given are: Nasogastric (NG) tube This is a thin tube that goes up your nose, down the back of your throat, and into your stomach to enable you to be fed a liquid containing all the nutrients your body needs. The tube is connected to a container of liquid feed and you are given doses of feed continuously or at regular intervals called bolus feeds. The tube may cause some irritation but, once in place, the tube is usually comfortable and you will soon forget it is there. If you are going to have a nasogastric tube, it should be put in place within 24 hours of admission to hospital. If you Stroke Association April 2012

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tolerate an NG tube well and dont need it for longer than six weeks then you shouldnt need to have a PEG tube as described below. Percutaneous endoscopic gastrostomy (PEG) tube If you have longer-term swallowing problems, you may need to be fed through a PEG tube. This is a tube that is inserted directly through the wall of your abdomen into your stomach and can be easily hidden by your clothes. It is inserted whilst you are awake, but sedated. There is a possibility of complications including the tube getting out of place, becoming blocked or leaking, and there is a risk of infection and internal bleeding. If you have not eaten for some time before the tube is fitted, it can also take time for your bowel to get used to the feeds. You may experience diarrhoea, bloating, constipation and reflux or vomiting at first. There are both advantages and disadvantages associated with naso-gastric and percutaneous endoscopic gastrostomy tubes. These should be discussed with you before any decision is made. Both tubes offer an alternative to eating and drinking or they may be used to give you vital nutrition and fluids if you are only eating or drinking small amounts. Your health care team will advise you which approach they feel is appropriate for you. Both tubes may be removed on medical advice if your swallow improves. rich foods, dietary advice and/or tube feeding. The aim will be to ensure you get the right balance of nutrients. This is important as malnutrition is associated with a slower recovery and poorer outcome for stroke survivors. If you have not eaten anything for a while, food may need to be reintroduced gradually. Your nutrition support should be reviewed regularly. Oral care It is important to look after your mouth, teeth and gums to make sure your mouth does not become dry or sore. Some medication can also add to difficulties by giving you a dry mouth or affecting your ability to manage your saliva. If you are not able to swallow, you or your carer should regularly take steps to maintain good oral health (ideally every four hours). These include brushing your teeth, cleaning your gums and cleaning any dentures. You may need to keep your mouth moist by using wet swabs and putting some petroleum jelly around your lips. Your health care team may be able to offer further advice about oral care to suit your needs.

Coping with swallowing problems in the long term

Eating and drinking are a large part of daily life. As well as ensuring your body gets the necessary fluids and nutrients to maintain good health, they are also pleasurable and social activities. If you have long-term swallowing difficulties you may feel you have lost the enjoyable experience of eating, both alone and in company. This can also have an impact on your family. You may need to be fed through a tube in the long term or continue to have modified foods. Once you leave hospital, you and your

Maintaining good health

Nutrition support If you are at risk of malnutrition, you may be given nutrition support. This could be nutritional supplements, special nutrientStroke Association April 2012

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carers should be provided with support and information to manage any ongoing swallowing problems. This should include details of your difficulties, the support you need, how to put into practice any eating and drinking plans and when to ask for further support. Support may include the following: Tube feeding support If you need NG or PEG tube feeding on a long -term basis you should be supported in the community by a team of different health care professionals including a dietitian, nurses, your GP, pharmacist and, if appropriate, a speech and language therapist. You should be given: an individual care plan covering the aims of your treatment and the plans for monitoring this an opportunity to discuss your treatment options and the physical, psychological and social issues your tube feeding brings training for you and your carer and an instruction manual covering all aspects of your tube feeding such as how to overcome common problems regular check ups at a specialist clinic general and emergency contact numbers for a relevant professional you can contact if you have any questions and for relevant support organisations information about your tube feeding equipment delivery arrangements. Products You should be provided with any products you need, such as a food thickener which is available from your GP. You may like to use moulds to shape pureed food so it looks more attractive. Training and support from others You and/or your carer should be given training to manage your swallowing difficulties. For example, your carer may be shown a particular technique to help you swallow. Your carer should know how to create the best environment for safe, efficient and pleasurable eating and drinking. They should be able to identify problems and know when to ask for a review of your swallowing difficulties. If you have difficulties with memory and attention, your carer may need to prompt you to eat meals or snacks and sit with you till you finish a meal. If you dont feel like eating, your family may be able to help by identifying foods you particularly like. Support in a care home If you move into a care home, any staff involved in your care should be trained in recognising and managing swallowing difficulties and oral hygiene. The care home should make sure they have enough staff to assist you if you take longer to eat.

Tips for safe swallowing

Everyone is different but the following suggestions may help you swallow more safely. Always check with a medical professional if you are unsure of what will help you. Allow yourself time. Eat in a quiet environment, free from distractions and interruptions. Try to remain calm. Being tense makes Stroke Association April 2012

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swallowing more difficult. Take one mouthful at a time, ensuring that all the food has been swallowed before taking the next. Make sure the food is a temperature and consistency you can swallow safely. Do not mix food and drink in the same mouthful. Arrange comfortable and safe seating for you and anyone helping you to eat. Remain sitting upright for 30 minutes after eating or drinking. Make sure you get any medication prescribed in a suitable form, e.g liquid. Make food look attractive so you feel more like eating it. Persist with thickeners and drink supplements, as prescribed, to ensure you swallow safely. Have meals at regular times and possibly try having smaller meals more frequently. Write yourself reminders to eat or ask family and carers to remind you. Make sure your carers and family understand your swallowing problems and how they can support and encourage you. Speak to your doctor, nurse, speech and language therapist or another health care professional should you need more help and information.

Further information
Stroke Association Stroke Helpline: 0303 3033 100 Website: stroke.org.uk Email: info@stroke.org.uk Contact us for information about stroke, emotional support and details of local services and support groups.

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Produced by the Stroke Associations Information Service. For sources used, visit stroke.org.uk Stroke Association Factsheet 05, version 01 published April 2012 (next review due December 2013)
Item code: A01F05

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