Managing Patients with Dysphagia Belfast, 21 st May 2014

Transcription

1 Managing Patients with Dysphagia Belfast, 21 st May 2014

2 Agenda 5.15 pm Registration and Finger Food Served 6.00 pm Welcome Address Nichola Hawes, Nutrition Product Specialist, Nutricia Medical Workshop 1 Nursing Staff and Catering Staff 6.10 pm Understanding Dysphagia Nichola Hawes, Nutrition Product Specialist, Nutricia Medical Workshop 2 Nursing Home Managers 6.10 pm Managing Patients with Dysphagia in the Community Lesley Garrett, Speech & Language Therapist,

3 Agenda Workshop 3 All 6.50 pm Innovations in Thickening Powder: Nutilis Clear a clear breakthrough Susan Mc Fall, Key Account Manager, Nutricia Medical 7.00 pm The Practical Aspects of Preparing Modified Consistency Fluids and Food Neil Palliser Bosomworth, Consultant Diet Chef 7.45 pm Questions & Answers 8.00 pm Close

4 Introduction

5 Nutricia Medical Ireland s Number 1 medical nutrition provider. Part of the Danone Group 350 people employed directly in Ireland, with an additional 350 employed indirectly. 2 manufacturing sites in Ireland, Macroom and Wexford, with 50m investment in Macroom (December 2010). Nutricia s product range used exclusively by the majority of Ireland s hospitals.

6 Introducing the latest innovation Nutilis Clear A clear breakthrough

7 Nutricia Medical Supporting Healthcare Professionals: Sample request service - support.ireland@nutricia.com, Freephone: Dietetic Advice Line - Freephone: Educational events Educational resources MUST training Dedicated medical nutrition website

8 Normal Diet Right product for nutritional requirement and swallowing status Tube Tube or Oral Supplements + Thickeners Oral Suppl. Severe Moderate Mild No Dysphagia Severity of Dysphagia

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10 The supplement in 7 easy spoonfuls Easy to manage 125g portion: Appealing for patients with a reduced appetite Does not interfere with ability to eat normal meals Minimises wastage High energy and protein 200kcals and 12 g protein per serving with all the essential vitamins and minerals: Supporting the maintenance of physical mobility Helping maintain and build weight Easy to swallow and digest Vanilla Forest Fruits Banana Chocolate

11 Workshop 1 Nursing Staff and Catering Staff

12 Nutrition and Dysphagia Nichola Hawes, Nutrition Product Specialist, Nutricia Medical

13 Agenda Phases of swallowing Signs and symptoms of dysphagia Consequences of dysphagia Consistencies of food and fluid and malnutrition

14 Dysphagia Dysphagia is a medical term used to describe a swallowing disorder, characterised by difficulty in oral preparation for the swallow, or in moving material from the mouth to the stomach

15 Normal Swallowing Swallowing is a very complex process. It can be divided into 4 phases: Oral Preparatory Oral Pharyngeal Oesphageal Time: Variable 1 sec sec 10 sec The preparatory phase and (part of) the oral phase are considered to be voluntary; The pharyngeal and oesophageal phases are involuntary

16 Normal Swallow Video Download from dysphagia.ie

17 What happens in patients with dysphagia Weakness of the mouth and throat muscles may result in food or drinks going down the wrong way. This means that the food or drinks will go into the lungs instead of the stomach. This can cause chest infections and pneumonia.

18 Dysphagia Dysphagia is not a medical condition in itself, but results from a common condition in many patient types: Stroke Dementia Parkinson's disease Multiple sclerosis Head & neck resections Tumours Physical / Intellectual disabilities

19 Main conditions contributing to Dysphagia 1) Stroke Loss of brain functions due to lack of blood supply to the brain Can affect ability to understand/formulate speech or swallow Duration of dysphagia in stroke is short (2-6 weeks) Swallow is likely to recover Dysphagia prevalence in Stroke: 13-94% 2 2) Head and neck cancer Tumors of the oral cavity, pharynx and larynx Main causes are tobacco and alcohol use Takes a long time after treatment >1 year before the problems disappear Thrift 2001; Larsson 2005

20 Main conditions contributing to Dysphagia 3) Alzheimer s disease Most common form of dementia Dysphagia is most common in severe Alzheimer s - where patients lose control of nerve functions that coordinate the swallow Dysphagia prevalence in Dementia: 45% 1 4) Parkinson s disease Parkinson s disease, degenerative disorder of central nervous system Parkinson s disease often impairs the patients motor skills, speech, swallowing and other functions Kalia 2003

21 Main conditions contributing to Dysphagia 5) Age-related physiologic changes Loss of dentition Decreased ability to produce saliva Decreased tongue pressure and tongue strength Slower oral and pharyngeal bolus transit movement Delayed initiation of the pharyngeal reflex 6) Physical / Intellectual disabilities Easterling 2008

22 How to diagnose Dysphagia? Speech and Language Therapist Bed Side Assessment Videofluroscopy Live moving image of swallow Clients are given various consistencies, depending on level of severity Food/fluid mixed with barium and so are visible on xray Penetration/aspiration evident

23 Videofluroscopy

24 Symptoms short term Food in the nose Feeling of food stuck in the throat or a feeling of having a lump in the throat Changes in voice, including nasal or wet speech Difficulty chewing or controlling food in the mouth If the person avoids swallowing food ( pockets it) Coughing or choking when swallowing Frequent throat clearing Drooling Odd breathing or attempts to speak while swallowing Changes in eating habits e.g. eating slowly, or avoiding meals altogether

25 Symptoms longer term Significant, unintended weight loss (more than 10% of body weight over six months) Unexplained, rapid rises in body temperature Recurrent chest infections or pneumonia General weakness, a noticeable change in mental status, and the overall effects of losing strength Dehydration

26 Consequences - the patient s point of view Study on 360 dysphagic patients across Europe 50% claimed they were eating less 41% experienced anxiety or panic during mealtime 36% avoided eating with others 55% said that swallowing difficulties made their life less enjoyable 32% reported still being hungry and thirsty after their meal Ekberg et al. 2002

27 Video: What to look out for and symptoms of dysphagia. Knowing the signs and symptoms of dysphagia is extremely important. Download from dysphagia.ie

28 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 swallowing 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

29 Compensation strategies- Positioning at mealtimes Sit upright in erect position Head tilted forward/chin down Support impaired side of body Sit at or below patient s eye level Place food in stronger side of mouth Sit on side which will maximise careful feeding Take account of visual field deficits re seating and food placement

30 Strategies to reduce risk of aspiration The patient should Never talk while eating or drinking Take small amounts at a time, especially of liquids If you hear a gurgly sound to their voice after swallowing, get the patient to cough and swallow again. Avoid beakers with upright mouth pieces as they cause the head to tilt head backwards, making it easier for drinks to go down the wrong way. Never use a straw for taking drinks. Note for family/carers: Do not offer food or fluids to a person with swallowing problems unless he/she is fully alert.

31 How to feed a patient- the wrong way! Video Link SectionDivd05

32 How to feed a patient the right way Video Link SectionDivd06

33 Dietary Adjustments Speech and Language Therapist Assess swallowing status Recommends modified diet / fluid consistencies Recommends other safe feeding strategies Dietitian Assess nutrition status and requirements Assess adequacy of dietary intake Advise on food choices / supplements to best meet the individual s requirements

34 Dietary Adjustments Diet modification - alters the viscosity of foods and liquids to: alters the speed at which food passes through the pharynx assist the patient in swallowing reduce the risk of aspiration Dependent on the nature of the swallowing disorder- some patients have especially problems with consuming thick liquids others experience most difficulties with thin liquids

35 Stages of Fluid NI Stage 1: Syrup Can be drunk through a straw Can be drunk from a cup Leaves a thin coat on the back of a spoon Stage 2: Custard Cannot be drunk through a straw Can be drunk from a cup Leaves a thick coat on the back of a spoon Stage 3: Pudding Cannot be drunk through a straw or from a cup Needs to taken with a spoon

36 Right Dietary Modification

37 What are these descriptors? These descriptors detail the types and textures of foods needed by individuals who have dysphagia The food textures are: B = Thin Purée Dysphagia Diet C = Thick Purée Dysphagia Diet D = Moist Mashed / Pre-Mashed Dysphagia Diet E = Soft/Fork Mashable Dysphagia Diet The speech and language therapist will prescribe the correct texture diet for the patient.

38 Dietary Modification Information in Booklet from Nutricia

39 Contents

40 Texture B

41

42 Texture D

43 Texture E

44 Diet Modification Modified consistency foods may need to be fortified to increase calorie or protein content Encourage patient to take small bites and to eat slowly Little and often eating pattern may be more appropriate Do not mix solid foods and liquids in the same mouthful

45 Pureed / liquidised meals { Only 6% of the pureed meals were eaten Source: Thornton, S, Northampton General Hospital, 2000.

46 Modified meals

47 Piping Piping puréed, thickened mince to make cottage pie

48 Piping Puréed lasagne Puréed Sausage and Mash

49 Thickening puréed foods Puree the food you want to thicken so it is completely smooth and free from any lumps. Ideally sieve the puree, especially for foods with husks (e.g. peas and sweetcorn) Add the necessary number of scoops of Nutilis to the puree and stir it well Allow the food to stand until it reaches the required consistency The food can now be served chilled/frozen for later use

50 Other factors to consider in patients with dysphagia: Avoid high risk foods Stringy, fibrous texture e.g. celery, lettuce Mixed consistency foods e.g cereals which do not blend with milk such as muesli, soup with lumps Crunchy foods e.g. toast, flaky pastry, dry biscuits, crisps Crumbly items e.g. bread crusts, pie crusts, crumble Hard foods e.g. boiled and chewy sweets and toffee Husks e.g. sweetcorn and granary bread

51 Other factors to consider in patients with dysphagia: Dehydration & Constipation 75% of dysphagia patients suffer from dehydration 6 Ensure adequate fluid intake aim for at least 8 cups of fluid per day. If constipation is a problem, try the following: Take cereal fibre sources e.g. Weetabix, porridge etc. Take extra fruit e.g. banana, stewed apple or rhubarb with thickener. Include fruit juice e.g. prune or orange, thickened to the correct consistency. Regular exercise to the best of the patient s ability.

52 Other factors to consider in patients with dysphagia: Malnutrition Texture modified food may not be enough to address malnutrition 1,2 How to deal with malnutrition? Identify early Weight history Diet history MUST Treat Identify safe diet Provide nutritional requirements 48% of dysphagia patients are malnourished 3 1.Wright L et al. J Hum Nutr Dietet 2005; 18: Bannerman E & McDermott K. J Am Med Assoc 2011;12: Felt P. Healthcare Caterer Spring:11-14.

53 Treatment of Malnutrition Present meals attractively so that patients feel like eating them Fortify normal diet Cream, butter, sugar, honey, skimmed milk powder, oil. Use nutritional supplements Enteral/PEG feeding

54 Normal Diet Right product for nutritional requirement and swallowing status Tube Tube or Oral Supplements + Thickeners Oral Suppl. Severe Moderate Mild No Dysphagia Severity of Dysphagia

55 References 1. Easterling, C and Robbins, E. Dementia and dysphagia. Geriatr Nurs. 2008;29(4): Langdon C & Backer D 200. Dysphagia in stroke a new solution. Stroke Research and Treatmen. Article ID Groher ME, Bukatman R. The prevalence of swallowing disorders in two teaching hospitals. Dysphagia Raut VV, McKee GJ, Johnston BT. Effect of bolus consistency on swallowing does altering consistency help? Eur Arch Otorhinolaryngol Jan;258(1): Bisch EM, Logemann JA, Rademaker AW, Kahrilas PJ, Lazarus CL. Pharyngeal effects of bolus volume, viscosity, and temperature in patients with dysphagia resulting from neurologic impairment and in normal subjects. J Speech Hear Res Oct;37(5): Felt P. Nutritional Management of Dysphagia in the Healthcare Setting. Healthcare Caterer. 2006;Spring Leibovitz, A., Baumoehl, Y., Lubart, E., Yaina, A., Platinovitz, N. & Segal, R. Dehydration among long-term care elderly patients with oropharyngeal dysphagia. Gerontology. 2007;53: Day, C. Pell, D. How safe is that thickened drink? Complete Nutrition. 2007;7(2): L. Oudhuis et al., Thickeners for dysphagic patients comparison of a new amylase resistant product with four standard starch-based products - in vitro study. ESPEN 2: e & e Ekberg O, Hamndy S, Woisard V, Wuttge-Hannig A, Ortega P Social and Pysychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia 2002; 17 :

56 Workshop 3 All Group together

57 Innovations in Thickening Powders Susan McFall, Key Account manager, Nutricia Medical

58 Have you ever wondered where innovations come from?

59 Working with customer generating ideas

60 Years of research and many trials

61 To find the ultimate formula

62 Innovations in Thickening Powders

63 Introducing the latest innovation Nutilis Clear A clear breakthrough

64 Simple Practical Convenient

65 Nutilis Clear- the 3 key benefits Transparent results Designed to maintain the original appearance of drinks and liquids, which may improve compliance and improve fluid intake

66 Nutilis Clear- the 3 key benefits Simple to use Just add the powder to a glass and stir. Thickens rapidly and does not continue to thicken* * Oudhuis A, Vallons K. Presented at ESSD Data on File

67 Nutilis Clear- the 3 key benefits Great Taste Does not change the taste, flavour or smell of the drink or liquid

68 How many 200ml-drinks per tin*? Nutricia Nutilis Clear 175g tin Fresenius Thick & Easy 225g tin 58 drinks 25 drinks Cost per drink: 0.15 Cost per drink: 0.20 *MIMS, February 2014, **200ml drinks as per manufacturer dosage instructions, Calculation based on Stage 1

69 Give your patients the benefits of Nutilis Clear Product Tin Size (g) Price per tin * Cost per Stage 1 Drink ** No. of Stage 1 Drinks per Tin ** Nutilis Clear Nutilis Powder Thick & Easy *MIMS, February 2014, **200ml drinks as per manufacturer dosage instructions

70 Nutilis Clear A clear breakthrough

71 Nutilis Clear Specific Support Material Patient Information Pack For patients going home, there is a very useful Nutilis Clear pack with: Patient Safe Swallowing Guide Nutilis Clear Mixing Chart Letter for patient to give to GP NEW For further information, samples or to request materials contact our customer care team Freephone (NI): support.ireland@nutricia.com or visit

72 The Practical Aspects of Preparing Modified Consistency Meals Neil Palliser Bosomworth, Consultant Dysphagia Chef

73 Nutilis Clear just 3 simple steps

74 The Nutilis Clear challenge Demonstration As simple as 1,2,3! Feel free to compare! 1 Mix it Appearance of drink Simplicity of use Taste and mouth-feel 2 3 Compare it Taste it! "This is the biggest thing since sliced bread" "This is an excellent product - we definitely want to use it * * Nutilis Clear feedback from SLTs and dietitians at a recent Dysphagia meeting in Titanic Belfast

75 Hands On Mixing Session Dividing into 7 groups Preparing Stage 1 drink Apple Juice, Mineral Water Compare and Contrast

76 Nutilis Clear in Food Fruit Smoothies New Recipe Book Coming Soon Fruit Fool

77 Nutilis Clear in Food Vegetables: peas and carrots Lasagne

78 Nutilis Clear in Food Soaking Solution

79 Nutilis Clear A clear breakthrough

80 Any Questions?

81 The premier source of information for the management of patients with dysphagia A dedicated website for health care professionals Almost 1000 members registered for the newsletter Speech & language therapists, nursing home staff, dietitians, nurses, catering staff, GPs and pharmacists

82 Practical information about dysphagia: Symptoms & treatment options Educational videos Latest news and event updates Read download and print: Recipe books Patient information Clinical evidence & articles Access FREE Nutilis material Training, shakers, product samples Patient Information Packs Community forum

83 You could be the lucky winner of this Luxury hamper 1 2 Find Competition Entry Form in your packs Please, fill it and bring it to our Stand 3 You may be the lucky one! Log on TODAY

84 Thank You