Swallowing Awareness Day 2018 is on March 14th and provides us with a good opportunity to reflect on how Dysphagia (the medical term for swallowing difficulties) can affect people’s lives.
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 (e.g about drooling) that may prevent the enjoyment of meals and encourage isolation.
What are the signs and symptoms of Dysphagia?
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 (SLTs). Signs of Dysphagia can include:
- Difficult, painful chewing or swallowing
- Taking a long time to chew
- Controlling food in the mouth
- 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 or nasal voice
- Changes in eating habits
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.
How Common is Dysphagia?
It is quite difficult to ascertain accurately how common Dysphagia is as it is frequently reported as part of other health conditions rather than as a condition in its own right. Dysphagia can occur in children with a developmental or learning disability. Dysphagia in adults is associated with a number of different conditions, for example Progressive Neurological Disorders, including Dementia, Parkinson’s Disease, Motor Neurone Disease, Multiple Sclerosis, Muscular Dystrophy, and head and neck, lung, and Oesophageal Cancer. High Rates of Dysphagia are most noted in the older adults where related conditions such as stroke and Dementia are more common. The Royal College of Speech and Language estimates that Dysphagia affects 68% of people with Dementia in care homes and 65% of people who have had a stroke.
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.
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.
New IDDSI Texture Descriptors
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. However more recently, further to consultation, the British Dietetic Association (BDA) and the Royal College of Speech and Language Therapists (RCSLT) have moved to support implementation of the International Dysphagia Diet Standardised Initiative (IDDSI) from April 2018.
IDDSI is an international standardised framework for people with Dysphagia that consists of a continuum of levels from 0 -7 and includes texture descriptors and testing methods for both drink thickness and food texture levels. To help with implementation, the BDA is producing an implementation as well as a resource pack (for more information see http://bit.ly/2CdgEI0). One of the benefits of the new framework is that it contains levels for fluids as well as foods, so safety for both eating and drinking is accounted for. The current UK descriptors do not include fluids.
Manufacturer’s will be implementing IDDSI from April 2018, and changes will be made to labels as well as ensuring the product textures align with the new IDDSI Framework. It is likely to take months for all products and their labels to be changed over to IDDSI, but it is anticipated that the IDDSI will be fully implemented in the UK by April 2019.
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.
Caring for the Individual with Dysphagia
As well as the importance of the correct texture for safety of service users, it is important to note that we evaluate food by sight. Piping, moulding and shaping purees may look more appealing, and thinner purees can be presented on compartmentalised plates to separate components. One of the key questions we can ask when serving texture modified food is would I eat this? If not, improve your service to service users with Dementia.