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Hard to Swallow – Caring for Dysphagia
A normal swallow requires normal function and coordination of our respiratory, oral, pharyngeal, laryngeal and oesophageal structures (essentially mouth, throat or the tube that carries food from mouth to stomach). Any physical or neurological impairment in these areas may cause difficulty in swallowing.
Dysphagia can range from mild to life threatening. It can be a transient, persistent or deteriorating problem. Many cases of dysphagia can improve with treatment, but a cure is not always possible.
Who suffers from dysphagia?
People with acute and chronic neurological conditions and those that have undergone surgery or radiotherapy to the upper aero-digestive tract are at high risk of developing dysphagia.
Dysphagia may occur in individuals with:
- A condition affecting the nervous system - such as stroke, head injury, dementia or cerebral palsy
- Progressive neurological diseases like Parkinson’s disease or Multiple Sclerosis
- Cancer, such as mouth or oesophageal cancer, or radiation and chemotherapy in these areas
- Chronic obstructive pulmonary disease
Individuals with cognitive impairment may be unaware or have difficulty communicating that they have a swallowing problem.
How common is dysphagia?
The prevalence of dysphagia varies with aetiology and age. In children it can occur with a developmental or learning disability , but high rates of dysphagia are most noted in the elderly where related conditions such as stroke and dementia are more common.
It is difficult to ascertain accurate prevalence rates as dysphagia is frequently reported as part of other health conditions for which the patient is being treated. Broadly, it affects a large number of people. Studies have indicated the presence of dysphagia in 64-90% of stroke patients and it is estimated that up to 75% of people in nursing homes may be affected.
What are the signs of dysphagia?
- Difficult, painful chewing or swallowing
- Coughing or choking when eating or drinking
- Drooling or food spillage from lips
- Bringing food back up, sometimes through the nose
- A sensation that food is stuck in throat or chest
- Hoarse/wet voice
Other signs can include unintentional weight loss, dry mouth, changes in eating habits, frequent throat clearing, change in respiration pattern, recurrent chest infections, heartburn and poor oral hygiene.
People who present with indicators of dysphagia should be referred to healthcare professionals with the relevant skills in the diagnosis, assessment and management of dysphagia, typically speech and language therapists.
Why is the effective management of dysphagia important?
Dysphagia can markedly affect health and quality of life. Serious complications include increased risk of choking, which can be fatal, pulmonary aspiration (food and fluid going into the lungs) which may lead to chest infections, lung damage and aspiration pneumonia. An individual with dysphagia may be unable to eat sufficient food to maintain weight or unable to drink sufficient fluid to maintain hydration.
In addition there may be emotional and psychological problems associated with not being able to eat normally. These include a fear of choking and embarrassment (about drooling for example) that may prevent the enjoyment of meals and encourage isolation.
Raising awareness among carers and providers of services of the signs and symptoms of a swallowing impairment is important in order that a referral for specialist assessment can be made.
Dietary management of dysphagia aims to:
- Maximise health and well being
- Minimise the risk of under-nutrition and dehydration
- Minimise risk of aspiration pneumonia
- Maintain oral nutrition
Texture modification of food and drinks, and accurate communication of information regarding texture, is a key element in reducing the risks associated with dysphagia. Teamwork is important, as is education and training. Speech and language therapists, dietitians, nurses and caterers should work closely to ensure that people have the most appropriate and safe texture suitable for their swallowing abilities, and are monitored to ensure their diet meets nutrient requirements.
In response to patient safety concerns and requests for clarity from the catering industry, new national dysphagia diet food texture descriptors, primarily designed for food producers, were launched in 2011 by a cross-professional expert group.
The descriptors provide standard and easily accessed and communicated measures of textures needed by individuals who have dysphagia, and are:-
Texture C - Thick Puree Dysphagia Diet
Texture E - Fork Mashable Dysphagia Diet
Texture D - Premashed Dysphagia Diet
Texture B - Thin Puree Dysphagia Diet
All care settings should have Texture C and E available. Additionally in some care settings, Texture D and B may be required routinely.
Audit checklists have been provided so that the foods can be measured against the standards for each texture. Fluids are currently not included in descriptors but these must be considered.
Although hospital services have largely implemented these new descriptors, the position in care homes is unclear, yet critically important considering the high requirement of texture modified diets in these settings.
Catering for dysphagia can pose challenges
Food behaves differently when it’s modified. Merely blending standard meals to form a puree can be both unappetising and unsafe. By understanding the condition and texture descriptions, catering and care staff can begin to create a better and safer eating experience. Modified textures can be provided through specially designed menus prepared by in-house caterers or be produced by industry, and should complement the main menu choices.
As we evaluate food by sight, presentation is important. Piping, moulding and shaping purees may look more appealing, and thinner purees can be presented on compartmentalised plates to separate components.
Foods will invariably require blending, thickening or thinning down to the correct descriptor. Thickening agents, whether a special agent or household ingredient such as cornflour, custard, or gravy, may take a period of time to fully thicken so the consistency should be checked just prior to serving. Thinning down can reduce the nutritional value of the dish so using milk, yogurt or sauces may counteract this.
Dysphagia diet descriptors are not for individuals with normal swallow who may need a ‘soft’ diet as a result of being generally unwell, having chewing difficulties or a sore mouth. For such cases, a ‘soft food’ options should be available on the standard menu.
Caring for the individual with dysphagia
In addition to texture and fluid modification, caring for dysphagia may also involve:
- therapy to learn new swallowing techniques
- ensuring correct posture and positioning
- support with eating and drinking, which may require a longer time period
- alternative forms of feeding, such as tube feeding through the nose or stomach
- regularly monitoring and reassessment to ensure suitability of diet
- a drug review, to ascertain if current formulation and administration route remains appropriate.
The final question
When serving textured modified diet, the question ‘would I eat this?’ or would I be happy for my family to eat this? should be addressed. If the answer is no, endeavour to change and improve your service.
Ayela Spiro, British Nutrition Foundation – QCS Expert Nutrition Contributor