Nutricia. Nutrition and Dysphagia

Transcription

1 Nutricia Nutrition and Dysphagia

2 1 Introduction

3 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

4 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.

5 Dysphagia: disorder to swallowing mechanics

6 Dysphagia: disorder to swallowing mechanics 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

7 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

8 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

9 Incidence and Prevalence of Dysphagia Up to 78% of stroke patients 1 Of those with initial dysphagia, 76% will remain with a moderate to severe dysphagia and 15% profound dysphagia 2 More than 90% of those with Motor Neurone Disease will develop dysphagia 3 27% of patients with Chronic Obstructive Pulmonary Disease 3 Between 50-75% of nursing home residents 3 81% of people with dementia 4 10% of acutely hospitalised elderly 3 Patients with dysphagia have a 40% increase in length of stay 5 1. Martino, et al. Stroke. 2005;36 (12): Mann, et al. Stroke. 1999; 30: Mar 14, Alzeimer s society. Food for thought. Alzheimer s Society, Altman, et al. Arch Otolaryngol Head Neck Surg. 2010;136 (8):784-9.

10 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

11 Consequences of Dysphagia 1. Inability to meet food and fluid needs: Malnutrition and weight loss 1 Dehydration 2 Urinary tract infections 3 Increased hospital length of stay 4 2. Increased risk of aspiration: Chest infection Aspiration pneumonia 1,2,5 Respiratory failure 1,2,5 Increased incidence of mortality 1,2,5 3. Impact on quality of life: Substantial physical, social and psychological impact 1. Rofes, et al. Gastroenterol Res Pract. 2011;2011: Leibovitz, et al. Gerontology. 2007;53(4): Mentes. Am J Nurs. 2006; 106 (6): Smithard, et al. Stroke. 1996;27(7): Cabre, et al. Age Ageing. 2010;39:39-45.

12 2 Management of Dysphagia

13 Management of Dysphagia 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

14 Management of Dysphagia 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.

15 Management of Dysphagia 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.

16 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: Mar 14, 2016.

17 Texture Modification: Fluid National Descriptors for Texture Modification in Adults 2002 Texture MODIFICATION TEXTURE Fluid 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 SYRUP runny sauce ketchup Stage 2 Cannot be drunk through a straw Can be drunk from a cup Leaves a thick coat on the back of a spoon CUSTARD apple sauce Stage 3 Cannot be drunk through a straw Cannot be drunk from a cup Needs to be taken with a spoon PUDDING dessert blancmange Source: Mar 14, 2016.

18 Fluid intake, dehydration and dysphagia Dehydration among patients with dysphagia is common As many as 75% of dysphagia patients receiving dietary management are dehydrated 1 Patients receiving thickened fluids commonly fail to meet their fluid requirements 2 1. Leibovitz, et al. Gerontology. 2007;53(4): Finestone, et al. Arch Phys Med Rehabil. 2001;82(12):

19 Thickening Agents Not all thickeners are the same Standard starch-based food and fluid thickeners affect the taste and texture of thickened drinks 1 Food and fluids thickened with standard starch-based thickener fail to maintain consistency on contact with saliva 1 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.

20 Standard Starch Based Thickener 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 Amylase Digestion Starch Molecule Sugar Molecules 1. Oudhuis, et al. Clin Nutr Suppl. 2011;6(1):18(OP043). 2. Sliwinski, et al. Presented at ESSD Data on File. 3. Sliwinski E, et al. Clin Nutr Suppl. 2011;6:15.

21 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 Data on File. 3. Sliwinski E, et al. Clin Nutr Suppl. 2011;6:15.

22 Why is amylase resistance IMPORTANT? Using a thickener with amylase resistant features may prevent negative outcomes: Bolus no longer delayed to match swallow delay Fluids thickened with starch based thickeners can thin in contact with amylase in saliva Aspiration or aspiration pneumonia length of hospital stay costs mortality Source: Day, et al. Complete Nutrition. 2007;7(2):49-51.

23 Clinical Relevance of Amylase Resistance Promotes safer swallowing Fluid does not thin in the glass or mouth Does not thicken in glass on standing Fluid does not thin in the mouth AMYLASE RESISTANCE Consistency maintained in all circumstances Does not thin if fluid collects in vocal folds

24 Dysphagia and Malnutrition Up to 48% of dysphagia patients suffer with malnutrition 1 Dysphagia increases risk of malnutrition due to: Physical effects of dysphagia making the process of eating slow, difficult and tiring 2 Limitations and preparation of texture modified diets 3 Reduction in quality and quantity of food consumed 2 Fear of choking or aspirating resulting in reduced variety of foods consumed 2 1. Felt. Healthcare Cateres International (HCI). 2006;1(2): Copeman, et al. In: Manual of dietetic practice. 5 th ed. British Dietetic Association, Thomas., et al. Manual of dietetic Practice. 4 th Ed. Blackwell Publishing Ltd, 2007.

25 Nutritional intake, Malnutrition and Dysphagia Patients consuming a texture modified diet have Normal significantly diet lower energy and protein intakes 1 (n=25) Dysphagia diet (n=30) Energy consumed (kcal) * Protein consumed (g) 60 40* Energy deficit^ (kcal) * 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.

26 Pre-Thickened ONS Texture modified food may not be enough to address malnutrition 1,2 It is extremely difficult to thicken an ONS to a safe, uniform consistency with the manual addition of a powder thickener 1 There is a wide variation and inconsistency in how drinks are thickened by patients, staff and carers 2,3 Incorporating pre-thickened ONS into a patient s diet can help fill the nutritional gap 3 Correct consistency is guaranteed High in energy, contains protein and micronutrients Increased convenience for patients and carers 1. Bedson. CN. 2009;9: Garcia, et al. J Clin Nurs. 2010;19: Thomas, et al. Manual of dietetic Practice. 4 th Ed. Blackwell Publishing Ltd, 2007.

27 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

28 3 Summary

29 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

30 References Altman KW, Yu G, Schafer SD. Consequence of dysphagia in the hospitalized patient. Arch Otolaryngol Head Neck Surg. 2010;136: 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: Day C, Pell D. How safe is that thickened drink? Complete Nutrition, 2007;7: 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: Garcia JM, Chambers E 4 th, Clark M, et al. Quality of care issues for dysphagia: modifications involving oral fluids. J Clin Nurs. 2010;19: Leibovitz A, Baumoehl Y, Lubart E, et al. Dehydration among long term care elderly patients with oropharyngeal dysphagia. Gerontology. 2007;53: Mann G, Hankey GJ, Cameron D. Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke. 1999;30: Martino R, Foley N, Bhogal S, et al. Dysphagia after stroke: incidence, diagnosis and pulmonary complications. Stroke. 2005;36:

31 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 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 Accessed via 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; 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 Data on File. Smithard DG, O Neill PA Park C, et al. Complications and outcomes after acute stroke: does dysphagia matter? Stroke. 1996;27: Stroke Association. Swallowing problems after stroke, Thomas B, Bishop J, Eds. Manual of dietetic practice. 4 th ed. Oxford: Blackwell Scientific Publications Whelan K. Inadequate fluids intakes in dysphagic acute stroke. Clin Nutr. 2001;20: 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.

32 Thank you