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Nutrition and Dysphagia

1

Introduction

What is Dysphagia?

The inability to swallow normally or freely.

• Disorder in the swallowing process that does not allow safe

passing of food from the mouth to the stomach.

• It may be due to:

• Impaired function of the tongue, palate, pharynx, larynx, vocal folds, upper oesophageal sphincter or oesophagus, since all are involved in the swallowing mechanism.

• Cognitive impairment can also affect swallow function, through, for example, inattention, impulsivity, reduced awareness

• It is a symptom of disease rather than a disease itself

Dysphagia: disorder to swallowing mechanics

The swallow is a four phase process

1. Preparatory Phase: Food enters the mouth, is chewed, and mixes with saliva to ease swallowing.

2. Oral Phase: The food forms a ‘bolus’, which is propelled to the back of the mouth by the tongue in preparation for swallowing.

3. Pharyngeal Phase: This is an involuntary process in which the bolus passes down the back of the throat, controlled by the throat muscles. A small flap called the epiglottis flips over the trachea (wind pipe) to direct food down the oesophagus and protect the airway.

4. Oesophageal Phase: Smooth muscle contraction directs the bolus down the throat into the stomach.


• There are two types of dysphagia:

1. Oropharyngeal dysphagia: where difficulties in swallowing are due to problems with the mouth or throat

2. Oesophageal dysphagia: where difficulties in swallowing are due to problems in the oesophagus

The focus for this presentation will be oropharyngeal dysphagia

Causes of dysphagia

• Neurological Injuries

• Stroke

• Trauma

• Learning disabilities

• Progressive Neurological Disorders

• Motor Neurone Disease

• Parkinson's Disease

• Multiple Sclerosis

• Dementia

• Mechanical or obstructive diseases

• Head and neck cancer

• COPD (Chronic Obstructive Pulmonary Disease)

• Ageing

Signs and Symptoms of Dysphagia

• Food ‘sticking’ in the throat

• Coughing or choking

• Food or fluid escaping from the front of the mouth

• Vomiting/ regurgitation

• Weight loss

• Hoarse / wet / gurgly voice

• Avoidance of solid foods/ fluids

• Recurrent chest infections

• Aspiration Pneumonia

• UTI from reduced fluid intake

1. Martino, et al. Stroke. 2005;36 (12): 2756–63.

2. Mann, et al. Stroke. 1999; 30:744-8.

3. http://www.rcslt.org/speech_and_language_therapy/commissioning/dysphagia_manual_072014. Mar 14, 2016.

4. Alzeimer’s society. Food for thought. Alzheimer’s Society, 2000.

5. Altman, et al. Arch Otolaryngol Head Neck Surg. 2010;136 (8):784-9.

Incidence and Prevalence of Dysphagia

• Up to 78% of stroke patients1

• Of those with initial dysphagia, 76% will remain with a moderate to severe dysphagia and 15% profound dysphagia2

• More than 90% of those with Motor Neurone Disease will develop dysphagia3

• 27% of patients with Chronic Obstructive Pulmonary Disease3

• Between 50-75% of nursing home residents3

• 81% of people with dementia4

• 10% of acutely hospitalised elderly3

• Patients with dysphagia have a 40% increase in length of stay5

Possible Consequences of Dysphagia

• Time taken to eat a meal increases

• Lack of variety in the diet

• Eating is no longer a sociable activity

• Embarrassment of eating ‘sloppy/mashed diet’

• Fear of choking and self restriction

Dysphagia

Reduced food and drink intake

Dehydration

Malnutrition

Increase risk of aspiration

Increased risk of pneumonia

Consequences of Dysphagia

1. Inability to meet food and fluid needs:

• Malnutrition and weight loss1

• Dehydration2

• Urinary tract infections3

• Increased hospital length of stay4

2. Increased risk of aspiration:

• Chest infection

• Aspiration pneumonia1,2,5

• Respiratory failure1,2,5

• Increased incidence of mortality1,2,5

3. Impact on quality of life:

• Substantial physical, social and psychological impact

1. Rofes, et al. Gastroenterol Res Pract. 2011;2011:818-979.

2. Leibovitz, et al. Gerontology. 2007;53(4):179-83.

3. Mentes. Am J Nurs. 2006; 106 (6):40-9.

4. Smithard, et al. Stroke. 1996;27(7):1200-4.

5. Cabre, et al. Age Ageing. 2010;39:39-45.

Management of Dysphagia

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• Requires a multidisciplinary approach

• Aims of management:

• Assessment of swallowing problem

‒ Speech and Language Therapist

• Determine safe feeding route

‒ Oral or non-oral nutrition or a nutrition plan involving a mixture of both, depending on patients’ abilities and preferences

• Determine appropriate texture and consistency of food and fluids

• Ensure adequate nutritional intake

• Dietitian

• Therapy interventions to improve or maintain swallow function

• Speech and Language Therapist


Swallow Rehabilitation

Exercises to train

specific muscles or

muscle groups.

e.g. exercises to improve the function of the tongue muscles, so the patient is

able to make a better, bolus in the mouth prior to

swallowing.

Compensation Strategies

Patients taught how to

avoid problems during

eating and drinking (such

as choking, coughing).

Mainly focus on changing the position of the head during swallow or using

special swallowing techniques.

Dietary Adjustments

Changing specific

parameters in the

patient’s diet, commonly

consistency and food

choices.

Modifying consistency alters

the rate at which food passes through the pharynx,

to assist swallowing and reduce the risk of aspiration.

Texture Modification: Foods

Dysphagia Diet Food Texture Descriptors 2011

• Foods are modified to a consistency to give the best control over the rate food passes through the pharynx.

• Modified texture diets range from liquids to a diet with normal foods which are the least likely to cause choking.

Source: http://www.thenacc.co.uk/assets/downloads/170/Food%20Descriptors%20for%20Industry%20Final%20-%20USE.pdf. Mar 14, 2016.

Texture Modification: Fluid

Source: http://www.findusfoodservices.se/content/SE/Special%20Foods/Fakta%20&%20forskning/Konsistensanpassad%20mat/TMF_National_descriptors_UK.pdf. Mar 14, 2016.

National Descriptors for Texture Modification in Adults 2002

MODIFICATION TEXTURE – Fluid

Texture Description of Fluid Texture

Thickened Fluid Fluid to which a commercial thickener has been added to thicken consistency

Stage 1

• Can be drunk through a straw • Can be drunk from a cup if advised or preferred • Leaves a thin coat on the back of a spoon

Stage 2

• Cannot be drunk through a straw • Can be drunk from a cup • Leaves a thick coat on the back of a spoon

Stage 3

• Cannot be drunk through a straw • Cannot be drunk from a cup • Needs to be taken with a spoon

SYRUP runny sauce

ketchup

CUSTARD apple sauce

PUDDING dessert

blancmange

Fluid intake, dehydration and dysphagia

Dehydration among patients with dysphagia is common

• As many as 75% of dysphagia patients receiving dietary management are dehydrated1

• Patients receiving thickened fluids commonly fail to meet their fluid requirements2

1. Leibovitz, et al. Gerontology. 2007;53(4):179-83.

2. Finestone, et al. Arch Phys Med Rehabil. 2001;82(12):1744-6.

Thickening Agents

Not all thickeners are the same

• Standard starch-based food and fluid thickeners affect the taste and texture of thickened drinks1

• Food and fluids thickened with standard starch-based thickener fail to maintain consistency on contact with saliva1

• Implications for the hydration status and safety of swallow and associated complications, namely aspiration

1. Day, et al. Complete Nutrition. 2007;7(2):49-51.

Standard Starch Based Thickener

Amylase

An enzyme in saliva, amylase, begins the digestion of starch in the mouth. This

can result in thinning of fluids that have been thickened with a starch based

thickener either in the mouth or if saliva washes back into the cup after sipping

1. Oudhuis, et al. Clin Nutr Suppl. 2011;6(1):18(OP043).

2. Sliwinski, et al. Presented at ESSD 2012. Data on File.

3. Sliwinski E, et al. Clin Nutr Suppl. 2011;6:15.

Starch Molecule Sugar Molecules

Digestion

Thickener with Amylase Resistant Features

Nutilis Clear is a gum based thickeners. Gums are resistant to the action of

amylase and thickness at the prescribed consistency is maintained on contact

with saliva

Amylase

Starch Molecule

1. Oudhuis, et al. Clin Nutr Suppl. 2011;6(1):18(OP043).

2. Sliwinski, et al. Presented at ESSD 2012. Data on File.

3. Sliwinski E, et al. Clin Nutr Suppl. 2011;6:15.

Why is amylase resistance IMPORTANT?

Using a thickener with amylase resistant features may prevent

negative outcomes:

Fluids

thickened with

starch based

thickeners can

thin in contact

with amylase in

saliva

Bolus no longer delayed to match

swallow delay

Aspiration or aspiration pneumonia

↑ length of hospital stay

↑ costs

↑ mortality

Source: Day, et al. Complete Nutrition. 2007;7(2):49-51.

Clinical Relevance of Amylase Resistance

AMYLASE

RESISTANCE Fluid does

not thin in

the mouth

Consistency

maintained in all

circumstances

Fluid does

not thin in

the glass or

mouth

Does not thin if fluid

collects in vocal folds

Promotes safer

swallowing

Does not

thicken in

glass on

standing

Dysphagia and Malnutrition

Up to 48% of dysphagia patients suffer with malnutrition1

• Dysphagia increases risk of malnutrition due to:

• Physical effects of dysphagia making the process of eating slow, difficult and tiring2

• Limitations and preparation of texture modified diets3

• Reduction in quality and quantity of food consumed2

• Fear of choking or aspirating resulting in reduced variety of foods consumed2

1. Felt. Healthcare Cateres International (HCI). 2006;1(2):11-4.

2. Copeman, et al. In: Manual of dietetic practice. 5th ed. British Dietetic Association, 2014.

3. Thomas., et al. Manual of dietetic Practice. 4th Ed. Blackwell Publishing Ltd, 2007.

Nutritional intake, Malnutrition and Dysphagia

Patients consuming a texture modified diet have significantly lower energy and protein intakes1

Normal diet (n=25)

Dysphagia diet (n=30)

Energy consumed (kcal) 1460 926*

Protein consumed (g) 60 40*

Energy deficit^ (kcal) 85 609*

Protein deficit^ (g) -6 -22*

% meeting energy requirements 50% 0%

% meeting protein requirements 60% 7%

Ave % energy requirements met 95% 60%

Ave % protein requirements met 91% 55%

Study population: adults ≥ 60 years admitted to acute hospital

^ intake compared to requirements * Significantly different from ‘normal diet’ group; p<0.02

Source: Wright, et al. J Hum Nutr. 2005;18:213-9.

Pre-Thickened ONS

Texture modified food may not be enough to address malnutrition1,2

• It is extremely difficult to thicken an ONS to a safe, uniform consistency with the manual addition of a powder thickener1

• There is a wide variation and inconsistency in how drinks are thickened by patients, staff and carers2,3

Incorporating pre-thickened ONS into a patient’s diet can help fill the nutritional gap3

• Correct consistency is guaranteed

• High in energy, contains protein and micronutrients

• Increased convenience for patients and carers

1. Bedson. CN. 2009;9:47-9.

2. Garcia, et al. J Clin Nurs. 2010;19:1618-24.

3. Thomas, et al. Manual of dietetic Practice. 4th Ed. Blackwell Publishing Ltd, 2007.

Thickening Agents and Food Moulds

• Meals are more attractive, enhancing appeal which may result in:

• Improved nutritional intake

• Reduced wastage

• Moulded meal system can be adapted to any catering system

• Improves choice for dysphagic patients

• Increases patient satisfaction with the meals provided

• Can be adapted to fit in with existing hospital menu

• Meals can be fortified to improve the nutritional profile

• Foods maintain a uniform consistency which may reduce the risk of

aspiration and choking

Summary

3

Summary

• Dysphagia is a disorder in the swallowing process that does not allow safe passing of food from the mouth to the stomach

• It is highly prevalent in the UK and a common consequence of the following conditions:

• Neurological injury

• Learning disabilities

• Progressive neurological disease

• Mechanical or obstructive diseases

• Ageing

• The consequences can be serious, including dehydration, aspiration pneumonia, malnutrition and increased risk of mortality

• Modification to texture of food and thickness of fluids may be required as part of nutritional management

• Thickening agents can assist with texture modification

• Pre-thickened ONS are available to manage or prevent malnutrition

References

Altman KW, Yu G, Schafer SD. Consequence of dysphagia in the hospitalized patient. Arch Otolaryngol Head Neck Surg. 2010;136:784-9.

Alzeimer’s society (2000) Food for thought: London Alzheimer’s Society

Bedson JV. Are dysphagic patients receiving thickened nutritional supplement drinks? Dietetic recommendations and nursing practice. CN;9:47-9.

British Dietetic Association, Royal College of Speech and Language Therapists. National Texture Guidelines for Texture Modification in Adults 2002

Cabre M, Serra-Prat M, Palomera E, et al. Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing, 2010;39:39-45.

Day C, Pell D. How safe is that thickened drink? Complete Nutrition, 2007;7:49-51.

Felt P. Nutritional management of dysphagia in the healthcare setting. Healthcare Cateres International. 2006;1:11-4.

Finestone HM, Foley NC, Woodbury MG, et al. Quantifying fluid intake in dysphagic stroke patients: a preliminary comparison of oral and nonoral strategies. Arch Phys Med Rehabil. 2001;82:1744-6.

Garcia JM, Chambers E 4th, Clark M, et al. Quality of care issues for dysphagia: modifications involving oral fluids. J Clin Nurs. 2010;19:1618-24.

Leibovitz A, Baumoehl Y, Lubart E, et al. Dehydration among long term care elderly patients with oropharyngeal dysphagia. Gerontology. 2007;53:179-83.

Mann G, Hankey GJ, Cameron D. Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke. 1999;30:744-8.

Martino R, Foley N, Bhogal S, et al. Dysphagia after stroke: incidence, diagnosis and pulmonary complications. Stroke. 2005;36:2756-63.

References

Mentes J. Oral hydration in older adults. Am J Nurs. 2006;106:40-9.

National Patient Safety Agency (NPSA) Dysphagia Expert Reference Group . Dysphagia Diet Food Texture Descriptors. April 2011. Available online.

Oudhuis L, Vallons K. Viscosity of thickened drinks and ready-to-use food products targeted for dysphagia patients. Clin Nutr. 2001;6(Suppl 2):15.

Oudhuis L, Vallons K, Sliwinski E. The effect of human saliva on the consistency of drinks thickened with a new thickener for dysphagia patients compared to a standard food thickener. Clin Nutr Suppl. 2011;6:18(OP043).

RCSLT. RCSLT resource manual for commissioning and planning services for slcn: Dysphagia. 2014. Accessed via http://www.rcslt.org/speech_and_language_therapy/commissioning/dysphagia_manual_072014

Rofes L, Arreola V, Almirall J, et al. Diagnosis and management of oropharyngeal dysphagia and its nutritional and respiratory complications in the elderly. Gastroenterol Res Pract. 2011;818979.

Sliwinski E, Faille S, Oudhuis L. Effect of human saliva on the consistency of thickened foods for patients with dysphagia. Clin Nutr. 2011;4:135.

Sliwinski E et al. Effect of human saliva on the consistency of a newly developed moderately thick oral nutritional supplement for patients with dysphagia. Presented at ESSD 2012. Data on File.

Smithard DG, O’Neill PA Park C, et al. Complications and outcomes after acute stroke: does dysphagia matter? Stroke. 1996;27:1200-4.

Stroke Association. Swallowing problems after stroke, 2012. http://www.stroke.org.uk/sites/default/files/Swallowing%20problems%20after%20stroke.pdf.

Thomas B, Bishop J, Eds. Manual of dietetic practice. 4th ed. Oxford: Blackwell Scientific Publications 2007.

Whelan K. Inadequate fluids intakes in dysphagic acute stroke. Clin Nutr. 2001;20:423-8.

Wright L, Cotter D, Hickson M, et al. Comparison of energy and protein intakes of older people consuming texture modified diet with a normal hospital diet. J Hum Nutr Diet. 2005;18:213-9.

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