Nestle Supplement 2

NUTRITION AND THE OLDER PERSON Figure 6. Diagrams showing the 4 steps of supraglottic swallow to protect the airway from aspiration. Commands for the patient are: 1) take a deep breath; 2) hold your breath; 3) hold your breath while swallowing; and 4) cough immediately after you swallow. motility of oral structures, particularly the lips and tongue, and pharyngeal structures). Lingual control and propulsion may be improved by using rehabilitation and biofeedback techniques.13 Of late, the rehabilitation of hyoid muscles with cervical flexion exercises has been shown to improve hyoid and laryngeal elevation, to increase UES aperture, to reduce pharyngeal residue, and to improve dysphagia symptoms in patients with neurogenic dysphagia.38 The management of patients with impaired UES aperture as a consequence of propulsive deficiencies should be basically oriented to increase bolus propulsion force and to rehabilitate the extrinsic mechanisms of UES aperture, particularly the activity of hyoid muscles.38 Specific swallowing maneuvers. These are maneuvers the patient must be able to learn and perform in an automated way. Each maneuver is specifically directed to compensate specific biomechanical alterations:1,32 Supraglottic (super/supraglottic) deglutition. The aim of supraglottic deglutition is to close the vocal folds before and during deglutition in order to protect the airway from aspiration. It is useful in patients with penetrations or aspirations during the pharyngeal stage or slow pharyngeal motor pattern (Figure 6). Stress or forced deglutition. The aim of stress or forced deglutition is to increase the posterior motion of the tongue base during deglutition in order to improve bolus propulsion. It is useful in patients with low bolus propulsion.1,32 Double deglutition. The aim of double deglutition is to minimize post-swallow residue before a new inspiration. It is useful in patients with post-swallow residue.32 Mendelsohn’s maneuver. Mendelsohn’s maneuver allows for increased extent and duration of laryngeal elevation and, therefore, increased duration and amplitude of UES aperture. 32 Surgical/drug-based management of UES. Identifying an obstructive pattern at the UES allows patient management using a surgical cricopharyngeal section39 or an injection of botulin toxin.40 Impaired neural UES relaxation observed in spastic neurological diseases, such as Parkinson’s disease or brain injury, is characterized by delayed or absent swallow response, short hyoid motion, weak bolus propulsion, and reduced or even absent neuromuscular relaxation and reduced sphincter compliance on manometry.41 Treatment must combine treatment of neurogenic dysphagia and improvement of neuromuscular relaxation of the sphincter. Efficacy of cricopharyngeal myotomy in patients with impaired swallow response is fair to poor, and injection of botulinum toxin type A in the sphincter could be a therapeutic alternative for these patients. Patients with impaired UES opening associated with Zenker’s diverticulum or isolated cricopharyngeal bars show normal swallow response, wide hyoid motion, strong bolus propulsion, and reduced sphincter compliance caused by sphincter fibrosis.42 Treatment of this group of patients is surgical and combines cricopharyngeal myotomy and resection of the diverticulum. Surgical results in older patients with Zenker’s diverticulum and preserved swallow response are excellent.42 Videofluoroscopy will help in treatment selection depending upon the severity of efficacy or safety impairment in each individual patient: 1) patients with mild efficaDECEMBER 2007 • 15

Table of Contents Feed for the Digital Edition of Nestle Supplement 2

Nestle Supplement Table of Contents Introduction to Weight Loss in Older Persons Diagnosis and Management of Oropharyngeal Dysphagia in the Elderly The Danger of Weight Loss in the Elderly Nutrients and Frailty

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