Dysphagia and Diet for People with Traumatic Brain InjuryRobert Trombley, Registered Dietitian

Barbara Goodman, Speech/Language Pathologist

It can happen on any given dayFrom this: To this:

Objective Define basic dysphagia terms and

diagnostic tests Understand dysphagia

recommendations and diet modifications

Identify best-practices Recognize potential pitfalls Strategies for compliance

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Unique and Lifelong

Experience

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How often does dysphagia occur and who does it affect? Statistics in the incidence of dysphagia in

the traumatic brain injury individual vary widely; one study reporting 80% effected and 16% needing assistance with eating one year post injury (Duong, Englaneder, Wright, Cifi, Greenwald and Brown, 2004)

Dysphagia prevalence increases with age, therefore, people with a TBI may acquire dysphagia as they age.

61% of adults admitted to acute trauma centers

41% of individuals in rehab settings 30% - 75% of patients in nursing homes 10 million Americans (adults and

children) are evaluated each year with swallowing difficulties

ASHA, Communication Facts: Special Populations: Dysphagia- 2008 Edition, compiled by Andrea Castrogiovannirder

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Definition:Dysphagia is defined as a difficulty in swallowing. This includes any difficulty in the process of: biting, chewing, handling and/or swallowing of food and/or liquid. One example of a swallowing problem that we can all relate to is when food or drink “goes down the wrong way”, which we all have experienced at one time or another. For people with dysphagia, this problem is occurring more frequently.

Swallowing: The Delicate Ballet

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The Normal Swallow

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http://www.radionz.co.nz/national/programmes/ourchangingworld

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People with traumatic brain injury may have damaged the cranial nerves and/or have structural abnormalities (to their jaw, neck, throat) affecting swallowing.

Symptoms: Coughing Throat clearing Hunching of shoulders Sensation of food getting caught Reddening in the face and/or facial grimacing Pain with swallowing Vomiting Wet voice Slow eating - fatigue Holding food in mouth Refusal to eat Weight loss, dehydration Heartburn or Reflux Upper respiratory infections and/or pneumonia Choking

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Stages of Swallowing:Stage One: Oral Phase Includes oral preparatory phase Mastication (chewing) of the food Forms a bolus (mass of soft chewed food) Bolus moves to the back of the oral cavity into the

oropharynx (throat) Takes approx. one second Common problems: difficulty in chewing, forming a

bolus, controlling the bolus, propelling the bolus to pharynx

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Stage Two: Pharyngeal Tongue pushes food to pharynx, which

triggers swallowing response. Larynx and epiglottis move to close off the

airway for protection, breathing stops. Reflexive, lasting one second or less. Common problems: delayed swallow,

nasal regurgitation, inadequate protection of the airway, pharyngeal stasis

Stage Three: Esophageal The bolus enters the esophagus and

travels to the stomach Reflexive, takes approx. 3 seconds,

may take longer for pill (medication) Common problems: poor peristalsis,

obstructions

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Diagnostic Tools

Flexible Endoscopic Evaluation of Swallowing (FEES)

Modified Barium Swallow Study (MBS) or Videofluoroscopic Swallow Study (VDSS)

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Modified Barium Swallow (MBS)

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Recommendations: Diet modifications Compensatory and/or Facilitation

Strategies

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1. Prepare for the MBS (if possible attend)- how is the person eating and drinking now- What is working for them and what seems to be causing problems: Symptoms Types of food or drink that work best or worse Positioning Pace of eating and drinking Bring to the MBS small sample of a simple favorite food (sandwich, pizza)

2. After the speech pathologist makes the diet recommendations: Ask, ask, ask questions What is a thickened liquid? Where do I get these thickening agents? What is a soft mechanical food? What is the best position for the person to eat? To drink? What does a chin tuck look like? How much food is a normal bite? A normal sip of a drink? How do I give medications? Will direct speech therapy help?

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A Modified and Thickened WHAT????

Published 2002NDDTF‒ Academy of Nutrition and

Dietetics‒ American Speech-Language

and Hearing AssociationThickened liquidsDietary texturesStandard of treatment

Great guide for general recommendations for food at the different levels

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Primary Food Consistencies

Regular – Level 4

Chopped – Level 3

Mechanical Soft – Level 2

Puree – Level 1

Primary Liquid Consistencies

Thin

Nectar

Honey

Pudding

Nectar Thick Honey Thick

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Denial and Confusion

“There is no problem.”“Who says I have

trouble eating and drinking?”

“Why am I eating this?”

Provide clear, simple and consistent language

Make sure that everyone is on the same page

Do not argue, accept that this is their perspective, but do follow diet recommendations

Provide praise for any positive action

Be patient

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Judgement and Memory

Taking excessivelylarge bites or sips Eating very quickly Unable to remember strategies

Precut food Pre-teach Verbal reminders Visual/auditory

reminders- pictures, clock

Special cups, silverware, plates

Adverse health outcomes

Weight lossDehydrationMalnutritionRespiratory illnessPneumoniaUpper respiratory infectionBronchitis

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The yuck factor orLost passion for food

Gaining Acceptance Increasing Compliance

What was that!

RIGHT ON!

Gaining Acceptance Increasing Compliance

• Aroma• Seasoning• Layering/Swirling• Piping• Molds

TASTE IT

Kitchen EssentialsAppliances and small wares

Kitchen EssentialsFood thickeners

Kitchen EssentialsLiquid thickeners

Powders Gells

Preparation Tips

ProteinsMarinating

Acid-based marinades

BraisedStewedEasier to prepare cold

Proteins molecules tightenwhen heated

Braising and stewing tenderizes the connective tissueNever use water Stocks, Gravies Fats/oils, Mayonnaise Milk/Cream

Preparation Tips

StarchesRicePasta, Noodles,

MacaroniPotatoesBeans

Preparation Tips

Fruits & VegetablesSkinsStringyWoodySeedsDried fruits

ApplesGrapesPineappleAsparagusBroccoli stalksCarrotsCeleryRaisins

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Go from fear and confusion….

To confidence and success

Successful Functional Outcomes: Compliance Satisfaction Limited level of distress-both the caregiver and the TBI individual Good health