WHY EVERY SLP NEEDS TO UNDERSTAND DYSPHAGIA
by: Dr. Jennifer Jones, Ph.D., CCC-SLP, BCS-S
As a Board Certified Swallowing Specialist, I am asked on a regular basis about why other therapists, nurses, physicians and general population need to know more about dysphagia and the symptoms.
Dysphagia is a growing health problem in the United States and the prevalence will increase significantly over the next 50 years. According to the US Census Bureau, between 2012 and 2060, the U.S. population is projected to grow from 314 million to 420 million, an increase of 34 percent. The population is also expected to be older. People over the age of 65 experience age-related swallowing difficulties and diseases that cause dysphagia.
By 2030, more than 20 percent of U.S. residents are projected to be aged 65 and over, compared with 13 percent in 2010. The US Census Bureau indicates that in 2010, the population of persons above the age of 65 was 40 million. Taken together, this suggests that up to 6 million older adults could be considered at risk for dysphagia. This will mean that someone you know, either a family member or a patient, will most likely have dysphagia.
Any disruption in the swallowing process, from the mouth, pharynx, larynx, and into the esophagus, could be defined as dysphagia.  Most people who experience mild dysphagia symptoms create compensatory strategies that will allow them to continue to eat by mouth, like eating less or eating foods that are easier to chew. Many of these cases go undetected because the doctor is never contacted about the difficulties.
However, despite using these self-designed strategies, dysphagia often contributes to increased risk of malnutrition and pneumonia. A referral to a trained Speech-Language Pathologist (SLP) to diagnose the specific cause of the dysphagia is paramount. The training of the SLP is also very important, because not all SLPs are trained extensively in dysphagia. It is imperative that your patient or family member receives the best assessment possible for dysphagia to detect difficulties that could lead to pneumonia.
The prevalence of pneumonia in elderly adults is rising, with a greater risk of infection in those older than 75 years.  In addition, deaths from pneumonitis due to aspiration of solids and liquids (e.g., aspiration pneumonia) are increasing and are currently ranked 15th on the CDC list of common causes of mortality.
The elderly population is only part of the picture. We must also keep in mind that there are many infants and children who need dysphagia evaluation and therapy services. Infants with feeding and swallowing difficulties can begin to receive services through Early Intervention as soon as they are discharged from the hospital after birth.
The most recent studies in 2012 (NICHCY, 2012) stated that there were approximately 350,000 infants / toddlers receiving Early Intervention services in the United States, which would calculate to approximately 3.0% of the 11.5 million live births over a 3 year period. Also, over that same 3-year period, about 3.4% of those infants born were less than 34 weeks gestation, which places them in a high-risk group for feeding and swallowing impairments. These estimations don’t even include the high-risk populations such as craniofacial anomalies, congenital heart defects, tracheotomies, cerebral palsy and genetic syndromes that are seen in the toddler years.
Another population to consider, but definitely not the last population, is school-aged children. School-based speech-language pathologists previously believed that by working in the school setting that they did not need to understand feeding and swallowing difficulties to the level of the modified barium swallow study and other medical involvements. This is no longer the case.
The ASHA 2014 Schools Survey found that 14% of the school-based speech-language pathologists serve students who have dysphagia. The speech-language pathologist serving preschoolers reports that the dysphagia population is 25.2%, elementary students was 9.7% and 11% for secondary schools. The highest numbers were reported for special day and residential schools at 40.6%.
Students with dysphagia have a wide variety of primary etiologies that contribute to dysphagia, which include developmental disabilities, neurological disorders, genetic syndromes, cleft lip and/or palate, traumatic brain injuries, and an array of other medical conditions. Manikam & Perman (2000) researched pediatric feeding disorders and found that feeding and swallowing disorders were also seen in typically developing children at a rate of approximately 25-45% due to causes such as medication side effects and/or behavioral or sensory issues.
The scope and practice of evaluation and treatment of dysphagia falls within the role and responsibilities of the speech-language pathologist. Across most settings and age throughout the lifespan the speech-language pathologist serves as the lead on coordinating dysphagia therapy and care. However, most SLPs do not seek or receive enough training for treating clients with dysphagia.
None the less, the services must be performed, especially if the student has dysphagia services written into the Individualized Educational Plan (IEP). These services typically fall under Other Health Impairments (OHI) and would be mandated that they are performed during school hours. Eating and drinking are a part of every student’s day and contribute to their readiness to learn. Therefore, the school-based speech-language pathologist is in need of just as much dysphagia training as those who are medically-based.
A dysphagia evaluation typically begins with a clinical assessment in the therapist’s office, patient’s home or bedside at the hospital. If there are concerns for pharyngeal difficulties then the patient will be referred for a radiologic imaging study called a Modified Barium Swallow Study (MBSS). The importance of the MBSS is primarily to view the activity of the pharynx before,during and after the swallow because the pharynx cannot be fully evaluated during the clinical assessment.
The SLP can only make assumptions about the integrity of the pharyngeal musculature based on symptoms that are observed. Performing an MBSS is the only true way to diagnose the pharyngeal phase during the swallow. Some therapists may perform a Flexible Endoscopic Evaluation of Swallowing (FEES) instead of the MBSS. However, there is no way to observe the pharyngeal phase during the swallow because of the “white out” that occurs due to epiglottic inversion. During the MBSS, the trained SLP will observe the normal swallow with food and liquids and then implement different compensatory strategies to help the patient eat and drink safely.
These strategies are considered temporary and are intended to decrease residue and aspiration risks. Compensatory strategies may include postural adjustments, like a head turn or chin tuck, swallowing maneuvers, such as a Mendelsohn maneuver or supraglottic swallow and/or diet modifications. It is imperative that these strategies are observed during the MBSS because they don’t always make the swallow better and can often times make the swallow more compromised. Therefore, it is not wise to recommend that a patient perform a compensatory strategy just because it worked with another patient with a similar impairment.
The speech-language pathologist performing the MBSS should write a thorough report with clear recommendations and expectations for improvement. Reports should be detailed when describing the impairments and therapy strategies. It is preferred that the treating clinician view the MBSS. However, a detailed report can be used to help analyze what they are seeing and plan treatment based on the outcomes of the patients swallow. Otherwise, the treating speech-language pathologist is totally reliant on the recommendations in the written report whether they are providing decreased dysphagia symptoms or not.
Therefore, it is paramount that all speech-language pathologists take continuing education courses that focus on the ability to execute and interpret a Modified Barium Swallow Study and to plan treatment based on the outcome of the study.
Dr. Jennifer Jones is an ASHA certified Speech-Language Pathologist and ACE recipient with over 20 years experience. She earned a Bachelor of Arts degree in Deaf Education and Elementary Education from Converse College in 1992, completed her Masters in Speech Pathology (M.S.P.) in 1996 and her Ph.D. in Speech-Language Pathology and Audiology in 2003 from the University of South Carolina. Dr. Jones earned Board Certification in Swallowing and Swallowing Disorders in 2008 through her extensive training and experience in the field of dysphagia.
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 This report is based on projections for the years 2013 to 2060. The Census Bureau’s official population estimates are used for 2012. (U.S. Census Bureau, 2012b). When both population estimates and projections are available, as is the case for 2012, estimates are the preferred data. The population estimates are available at www.census.gov/popest>.
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