[Dysphagia] Cardiac problems and oral stage difficulties

[Paula.Leslie at newcastle.ac.uk (Paula Leslie)]

Hello All

I have a puzzling (to me) case:

PC:
83 year old lady, non smoker, fairly independent, carer visit 1/day
Can't chew solids or semi solids, liquids OK.  Does not appear to be 
progressive in nature as such.  Lost ++ weight over last 6 months because 
can't eat.  Now stabilised because GP has prescribed "Ensure".  No dietetics 
input according to daughter so far.

PMH:
1999 CVI: L TACS.  Short term swallow probs resolved, some residual higher 
level language probs
1999 Heart failure and ongoing medication
2004 (Aug) admitted with heart failure, review of meds
Nil else reported by physician or client

HPC:
2004 (Aug) start of problems with solids, oral stage "can't swallow"
Not associated with any acute event eg choking, etc except "it started around 
the time I went in for my heart"
NO reported laryngo/pharygno/oesophageal, refluxy type symptoms.
NO chest infections or other clinical signs of aspiration linked problems, 
rarely coughs on food.  But does have a good cough reflex.

VFSS Summary
2004 Nov (not done by me but v detailed report at a good clinic)
Oral - prolonged holding of liquids in mouth prior to initiating the swallow
       (but this doesn't happen outside of the VF suite)
     - prolonged chewing with some piecemeal swallowing
Pharyngeal  - "appeared essentially normal"
Oesophageal - "poor clearance of barium from oesophagus, disordered distal 
oes. contractions with intra-oes. reflux demonstrated during fluoroscopy"

This lady does have shortness of breath linked to cardiac probs but so do lots 
of people.  What I don't understand is the severity of her difficulties with 
oral stage solids.  She can't tell me what will/might happen if she does 
swallow.  I think there could be a big anxiety component here.  Maybe anxiety 
response to physical event and now has developed behaviours in response to 
anxiety.

I've made an urgent referral to community dietetics.  I intend to assess the 
lady in clinic (rather than at her home where I first met her) with the 
daughter who is +++ anxious.  Daughter is to encourage trials of more 
"challenging" foods over the next couple of weeks and to note exactly what 
does happen and what the lady feels.  We will go over this and watch the VF 
tape to try to allay fears about an "unsafe swallow".  Address the anxiety for 
both mother and daughter.

Have I missed something obvious?  Not really much knowledge of cardiac issues.
 Interesting that although VFSS showed reflux problems, there are absolutely 
no symptoms reported.  Words of wisdom much appreciated!

Thanks

Paula