Dysphagia and Your Loved Ones

Following a dysphagia diet Aynsley Brian, M.A. (Family Members/Caregivers of those affected by Dysphagia) Before we begin

Important mechanisms for swallow: Lips, teeth, tongue: for chewing and moving foodPharynx: passageway of food from mouth to esophagusEpiglottis: protects the airwayTrachea: airway or wind pipe leading to lungsEsophagus: tube for food to travel to stomachExplain basic parts of anatomy used during swallow. 2What Is Dysphagia?Difficulty or complete inability to swallow food or drink. The affected person may experience pain, discomfort, choking or aspiration. Dysphagia can be caused by aging, stroke, neurodegenerative diseases (i.e. ALS), neuromuscular disease (i.e. cerebral palsy), radiation therapy associated with throat or mouth cancer, or gastro esophageal reflux disease (GERD). Basic signs/symptomsDroolingChokingGaggingPocketing of food (between gums and cheeks)Taking longer than 10 seconds to swallowComplaints of pain or sticking sensation in throatCoughing up food that was just swallowedThroat clearingWet or gurgly voiceDysphagia phases/typesThere are 4 basic steps in the swallowOral preparatory phase (chewing up the food and placing it on tongue for transport)Oral transit phase (using your tongue to move food/liquid towards the back of the pharynxt)Pharyngeal phase (food/liquid begins the descent towards esophagus; epiglottis kicks back to cover airway) Esophageal phase (esophageal sphincters open and close so that food can make its way into the stomach) Patient my have problems in one, some or all of these stages of swallowing! Vocabulary to elaborate on: pharynx, esophagus/sphincters, and epiglottis5

Oral PhasesPharyngeal PhaseEsophageal PhasePHASESWhat is aspiration?Aspiration occurs when a persons epiglottis does not correctly cover the trachea (airway) allowing food, liquid, or saliva to enter. When materials enter the airway and travel below the patients vocal cords, there is a risk that the material will enter the lungs. If the materials enters the airway but remains above the vocal cords, it is easier to cough up material; this is called penetration. Silent AspirationA normal persons response would be to cough and clear the airway.Dysphagia patients may have impaired coughing abilities.Silent aspiration occurs when there are nooutward signsof swallowing difficulty. Secretions, food, or liquid enter into the airway, past the vocal folds, with no coughing, throat clearing, or signs of distress.However, patient may appear to turn blue.

Why does aspiration matter?What happens if food, liquid, saliva or secretions enter the airway and/or lungs? Choking/lack of oxygenAspiration pneumoniaDeath

(play animation)Play Animation: Red=bad; food entering airwayGreen= good; epiglottis directed food into esophagus9Aspiration PreventionSome foods, liquids, and consistencies may be easier for the patient to swallow than others. One of the most effective ways to prevent Aspiration is to follow a the diet recommended by your speech-language-pathologist!

Diet recommendations may include: Manipulating the food in some way:Thinner liquidsThickened liquids (to the consistency of honey or nectar)Smooth puree (ex: yogurt, pudding)Textured puree (ex: mashed peas)Soft chopped (dicing soft food into smaller bites)Regular (solid food)

American Dietetic Association Levels:Food consistenciesLevel 4 RegularAll foods are acceptable.Level 3 Dysphagia AdvancedA near-regular diet with the exception of very hard, sticky or crunchy foods. Foods should be bite-size. Avoid crusty or dry bread, nuts, apples, dry fruit, coconut, raw vegetables and corn.Level 2 Dysphagia Advanced AlteredFoods are moist, soft and cohesive. Meats are ground or minced. Avoid rice, corn, bread, soups and casseroles that contain large chunks, nuts, and chewy, stringy or dry foods.Level 1 Dysphagia PureedPureed and cohesive foods, no mixed textures, everything is "pudding-like." Nothing that requires chewing is allowed.Resource: http://www.nestlenutritionstore.com/Pages/ConsistencyGuide.aspx

Resource: http://www.nestlenutritionstore.com/Pages/ConsistencyGuide.aspx

12Why follow the diet?Patient may aspirateChoking, lack of oxygenRisk for aspiration pneumonia Risk for malnutrition and dehydrationCan they swallow enough nutrition and liquids each day to stay healthy? Pain or discomfort when swallowing wrong consistencyMay lead to FEAR of eatingDeath

Aspiration Pneumonia: VERY SERIOUS may result in death. 13Tips to modify the dietKnow the patients recommended diet levelPurchase liquid thickeners/add them to drinks (ex. Thick-it)Put soft or solid foods into a food processor to puree. If patient can have almost normal diet, cut food into small, chewable bites. Alter temperature of food (hotter or colder) to increase awareness/sensation of food in the mouth. Be sure to make food look appetizing!

Tips(cont.)If your family member has a progressive disease or disorderThe original recommended diet may become too difficult for them to swallowWatch for the signs/symptoms SLP may recommend changing the diet to better suit the progressionIf the your family member is regaining their swallow functionSLP may recommend moving back towards solid/regular foods

BUT...It is CRUCIAL that you do not make these decisions on your own!!Talk to your SLP if you have questions or concerns!

PositioningThe seated position of the patient during feeding varies patient to patient. Certain disorders/diseases may require special positioning.Often times, sitting completely upright is the safest eating method.However, you may find that this creates complications. Talk to your SLP about which method is safe for your loved one. Tips to prevent discomfort after eatingEven following a strict diet, the patient may experience Gastroesophageal Reflux Disorder (GERD), commonly known as acid reflux. Avoid highly acidic foods, caffeinated drinks or carbonated beverages.Remain sitting upright for at least 1-2 hours after mealsSleep with a bed-wedge to remain propped up at a 45 degree angle, allowing for better digestion Ask your doctor about reflux management medicationsInformation gathered from observing the SLP at the VA Hospital in the ALS clinic. 18Artificial feedingNPO=Not By MouthPatient may have: Nasogastric (NG Tube), Percutaneous Endoscopic Gastronomy (PEG tube), or Gastronomy Tube (G Tube)If your loved one is fed by a feeding tube, you will need proper formulas and diet supplements to maintain adequate nutrition and hydration. Ask your dietician or physician for information on feeding substances and quantities. Lets taste textures How can you prepare it if youve never tasted it!At each table you will find 4 drink/food itemsItem 1: Nectar Thick LiquidItem 2: Honey Thick LiquidItem 3: Soft chopped food (diced peach)Item 4: Textured Puree (pureed peas)Take two straws and two spoons; taste each item!(please dispose of a used utensil after one taste)If time allows, a few minutes for discussion about what the audience thought of the items. 20

1. Nectar Thick Water2. Honey Thick Water3. Soft Diced Peaches4. Pureed PeasThank you!Questions?