Multiple Sclerosis
Dysphagia occurs more frequently in advanced stages of MS, although it can occur at any time during the disease course. Its real prevalence can be estimated to be around 30%–40%. Dysphagia is life-threatening if not managed properly. In fact, its complications such as dehydration and aspiration pneumonia are a common cause of death and morbidity in late MS.
Multiple Sclerosis (MS) is an autoimmune disease of the central nervous system (CNS) in which the material that surrounds and protects nerve cells, the myelin sheath, is attacked resulting in subsequent decreased functioning. There is a wide variability in swallowing disorders in individuals with MS. This is because of the wide variability in central nervous system damage, the wide range of disease severity, and the patterns of exacerbation and remission.
Common signs and symptoms of Dysphagia:
1. Pharyngeal delay – may result in difficulty swallowing thin liquids, or frequently having a mouthful of saliva and sometimes choking on it. MS experience more difficulty swallowing liquids, particularly if there is a delay between the end of the oral stage of swallowing and the beginning of the pharyngeal stage. During the delay the airway remains open until the swallow is triggered. This delay increases the risk of the liquid penetrating into the airway and aspirating into lungs
2. Reduced Pharyengeal Contraction – food/liquid retention and residue can remain in the pharynx after the swallow. The residual food may progress or be inhaled into the open airway when the patient breathes after the swallow
3. Oral phase delay – the longer a thickened liquid is held in the mouth the viscosity will change starting at around 10 sec
4. Decreased hyolaryngeal excursion – which effects the anterior movement and laryngeal elevation
5. Poor coordination of laryngeal and UES function – tend to present early in the progression of the disease process., can result in pyriform sinus retention
6. Penetration and/or aspiration – become apparent in more severe cases and can be life threatening if not identified and managed appropriately.
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Fatigue and Dysphagia in MS
All too often overlooked is the interaction between fatigue and dysphagia. A person with MS may have no swallowing difficulty at the beginning of a meal, but may develop swallowing problems during a long meal, especially one involving prolonged mastication/chewing. Solid foods require much more effort and lingual pressure to push backward through the mouth than liquids do, and generating this additional pressure demands greater muscle strength. This can result in muscle weakness, which can then increase dysphagia.
Recommendations
1. Frequent rest periods during meals or eating, smaller meals, for a shorter period of time. May be required for an MS patient and their continuedPOstatus. Frequent rest period during treatment as well.
2. Chewing exercises. Swallowing therapy often involves exercises to strengthen the muscles used in swallowing and to improve the muscle coordination during the swallowing process, along with learning safe swallowing strategies. But fatigue must be monitored during therapy.
3. Chopping food into small bites before eating can help significantly or it may be required to downgrade to a puree consistency.
4. Therapy treatment to improve the ability to coordinate breathing and swallowing. This will help protect the airway so no food or liquid enters the lungs.
5. Oral- motor exercises – Specific exercises to strengthen tongue and lip function to promote faster swallowing may also be utilized. Monitor for fatigue during treatment.
6. Dietary changes such as adding a thickening agent to liquids, or avoiding certain types of foods that may result in choking or aspiration.
7. Postural adjustments can also be beneficial.
8. In severe cases, feeding tubes may be necessary, if chosen as an option by the patient and/or family.
8. Saliva production – They may suck on a lozenge to stimulate saliva production, which will stimulate more swallowing. (A sour candy stimulates more swallows than a milder or less flavorful lozenge.) Make sure this is safe for them considering their level of dysphagia.
Dysphagia will gradually worsens over the course of the disease, whereas others experience temporary difficulty that gradually improves from time to time.
What can caregivers do?
Caregivers should be observant during mealtime to determine if swallowing and eating are slowing down or becoming more difficult. The caregiver can provide reminders about strategies that have been recommended by the SLP. Practice is needed with strategies as sometimes in the course of a meal, a person may forget the proper head position, the proper amount of food or liquid taken per swallow and the time between a successful and unsuccessful swallow. Once the SLP has recommended specific strategies, the caregiver can provide gentle reminders/cues for the person to use these strategies successfully.
Also, the caregiver should be familiar with the Heimlich maneuver,. Remember that if the person who is choking is able to talk or cry, the Heimlich maneuver is not appropriate. For more information on the Heimlich Maneuver, visit the American Heart Association website at www.amhrt.org. There is little published research about MS and dysphagia treatment.