Filling the Nutritional Gap in Dysphagia

Transcription

1 Filling the Nutritional Gap in Dysphagia Krystel Ouaijan, RDN, MSc Nutrition Support Dietitian in Saint George Hospital UMC PhD in University of Geneva Krystel Ouaijan - Dubai

2 Patient Profiles Hemiplegic patient post stroke Older patient with Parkinson disease Young patient with oropharyngeal cancer Immunocompromised patient with thrush Patient after a tongue surgery Older patient complaining of achalasia Young patient with multiple sclerosis Patient with severe GERD Neurogenic Obstruction Muscular Muscular Krystel Ouaijan - Dubai

3 Dysphagia and Malnutrition Dysphagia impairs swallowing Higher risk of aspiration Increased risk of aspiration pneumonia Healthcare professional puts patient NPO Patient avoids eating Patient loses weight and becomes cachectic Malnutrition Sura et al. Clinical Interventions in Aging 2012; 7: Krystel Ouaijan - Dubai

4 Dysphagia and Malnutrition 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 72% Prevalence of malnutrition 32% 18% 9% 81% Stroke Dementia Head & Neck Cancer Dysphagia present 69% Dysphagia absent Dysphagia is a predictor of malnutrition: Head and neck cancer patients: OR = 1.96 Stroke: OR = 2.45 The odds of malnutrition were significantly increased during the rehabilitation stage but not during the first 7 days of hospital admission Traumatic Brain Injury 3.61 Dysphagia improved Albumin 3.33 Dysphagia worsened Martineau et al. Clinical Nutrition 2005; 24: Tannen et al. International Journal of Nursing Studies 2012; 49 (4): Manon et al. Head & Neck 2014; 36 (1): Silander et al. Laryngoscope 2013; 123: Norine et al. Journal of Rehabilitation Medicine 2009; 41: Kim et al. 2018; 27: Krystel Ouaijan - Dubai

5 And malnutrition matters Impaired immune function More Infections Delayed wound healing Longer recovery from surgeries More risk for developing pressure ulcers Functional impairment Decreased muscle function Longer ventilation duration Krystel Ouaijan - Dubai Norman et al. Clinical Nutrition 2008; 27: 5-15.

6 Implications of Malnutrition All these taken together, malnutrition is associated with: Increased Morbidity Increased LOS Increased Mortality Increased cost and economic burden on healthcare Norman et al. Clinical Nutrition 2008; 27: Krystel Ouaijan - Dubai

7 We can fight malnutrition by addressing dysphagia Break the vicious cycle! Dysphagia contributes to malnutrition How? Pneumonia and other infections Higher risk of aspiration Malnutrition contributes to decreased functional capacity Rofes et al. Gastroenterology Research in Practice 2011; doi: /2011/ Serra-Prat et al. Age Ageing 2012; 41: Nutritional deficits and decreased immunity Frailty and lower muscle coordination Krystel Ouaijan - Dubai

8 hospital Krystel Ouaijan _ 2018

9 Role of the Clinical Dietitian Multidisciplinary approach: In some cases, dietitians are the first health professionals to recognize ENT surgeons swallowing or other difficulties physicians because detect they perform dysphagia, routine diagnose nutritional it and consult screening the dietitians. through mealtime observations and regular monitoring of body weight and food intake. The dietitian follows on a swallowing assessment in collaboration with speech language pathologists and the physicians. She then assesses and develop care plans relevant to their clients unique needs and personal care choices. A statement of Dietitians of Canada. March Krystel Ouaijan - Dubai

10 Screening Tool Specific for Dysphagia The EAT-10 indicates potential problems swallowing by providing an easy quick screening tool. It takes less than 4 minutes. High specificity and sensitivity. The EAT-10 is not a diagnostic tool, its purpose is to screen for those at risk patients as early as possible, assess symptom severity and also evaluate the effectiveness of ongoing treatment. It will direct for assessment and diagnosis of dysphagia with ENT and SLP. Krystel Ouaijan - Dubai Belafsky PC et al. Annals of Otology Rhinology Laryngology 2008; 117 (12):

11 EAT-10 Screening Tool Krystel Ouaijan - Dubai Belafsky PC et al. Annals of Otology Rhinology Laryngology 2008; 117 (12):

12 What studies have reported? Retrospective study on head and neck cancer patients: 40% 35% 30% 35.60% The majority of our patients presented dysphagia to solids. Hydration was not a problem in our patients. When dysphagia to liquids was present, it was necessary to increase the viscosity of the diet (pudding and nectar). 25% 20% 15% 10% 5% 0% 15% 6% 200 patients with dementia Slice of apple Apple puree Water Garcia-Peris et al. Clinical Nutrition 2007; 26: Rosler et al. Journal of the American Medical Directors Association 2015; 16: Krystel Ouaijan - Dubai

13 What studies have reported? Dementia Post-stroke patients 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 32.5% 19.0% 22.9% 6.7% 7.6% 4.8% 1.9% 12.4% 7.6% 10cc liquid 10cc paste 10cm3 bread Mild PA Moderate PA Severe PA Leder et al. Dysphagia 2013; 28: Bingie et al. Neurology India 2010; 58 (1): Krystel Ouaijan - Dubai

14 What studies have reported? Systematic review: 36 articles containing specific information comparing oral processing or swallowing behaviors for at least two liquid consistencies or food textures 1. Thicker liquids reduce the risk of penetration aspiration 2. No sufficient literature on specific viscosity boundaries 3. Properties of hardness, cohesiveness, and slipperiness in food texture are relevant both for physiological behaviors and bolus flow patterns 4. Specific terms used: Hard solid, opaque, thin, nectar-like, honey-like Krystel Ouaijan - Dubai Steele et al. Dysphagia 2015; 30 (1):

15 There is a need for a standardized diet National Dysphagia Diet (NDD): Published in 2002 by the Academy of Nutrition and Dietetic Association Three levels Multi-disciplinary task force of mainly dietitians and SLPs First time to establish standard terminology and practice applications of dietary texture modification in dysphagia management Krystel Ouaijan - Dubai

16 Updated version was established in 2015 International Dysphagia Diet Standardization Initiative: Global initiative since 2013 Group of volunteers from diverse professions: Nutrition & dietetics, medicine, speech pathology, occupational therapy, nursing, patient safety, engineering, food science & technology International standardized terminology and definitions for texture modified foods and thickened liquids for persons with dysphagia: Common language that can be used for technical, cultural, professional and nonprofessional uses Process is intended to be person-focused, rather than profession focused Cichero et al. The IDDSI Framework. Dysphagia 2017; 32 (2): Krystel Ouaijan - Dubai

17 Studies have shown strong consensual validity, criterion validity, and interrater reliability. 8 levels (0-7): Drinks are measured from Levels 0 4 Foods are measured from Levels 3 7 Krystel Ouaijan - Dubai Steele et alarchives of Physical Medicine and Rehabilitation 2018;m99:

18 Fluid Levels Level/Color Description Physiological Rationale 0 Thin/White Flows like water Can drink through of cup or straw 1 Slightly thick/grey Thicker than water, requires a little more effort to drink than thin liquids Flows through a straw 2 Mildly thick/purple Flows off a spoon but not a regular straw Sippable, pours quickly from a spoon 3 Moderately thick/yellow Ex: fruit syrup Can be drunk from a cup Cannot be eaten with a fork because it drips Can be eaten with a spoon Gravity flow test using a 10ml syringe 4 Extremely thick/green Eaten with a spoon and fork Cannot be drunk from a cup Doesn't fall from spoon when tilted Functional ability to safely manage liquids at all types Predominantly used to reduce speed of flow Flowing at a slightly slower rate May be suitable if tongue control is slightly reduced Pain on swallowing Tongue control is insufficient Allows more time for oral control Tongue control is significantly reduced Requires less propulsion efforts Krystel Ouaijan - Dubai

19 Fluid Levels and Testing Krystel Ouaijan - Dubai

20 Gravity flow test using a 10ml syringe Krystel Ouaijan - Dubai

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22 Food Levels Level/Color Description Physiological Rationale 3 Liquidized/Yellow Can be eaten with spoon but not fork No oral processing or chewing required Smooth texture with no bits or lumps 4 Extremely thick/green 5 Minced & Moist/Orange 6 Soft & Bite sized/blue Doesn't t require chewing Falls off a spoon but continues to hold shape on a plate Not sticky Can be eaten with a fork Can be scooped and shaped on a plate Small lumps Can be mashed with pressure from fork Bite-sized pieces 7 Regular/Black Normal food at various textures Naturally soft, minimal crunchiness Pain on swallowing Needs some tongue propulsion effort No biting or chewing required Missing teeth or poorly fitting dentures Tongue control is significantly reduced Biting is not required but minimal chewing Tongue force is required to move the bolus Chewing is required but no biting Tongue control is required to move food for chewing Ability to bite hard or soft food and chew them without tiring Krystel Ouaijan - Dubai

23 Food Levels and Testing Krystel Ouaijan - Dubai

24 Wrap-up for Testing Krystel Ouaijan - Dubai

25 Determine the Level! Krystel Ouaijan - Dubai Steele et alarchives of Physical Medicine and Rehabilitation 2018;m99:

26 Case Study A 60-year-old woman comes to you describing a 2-year history of solid foods getting stuck in her throat once or twice per week. She is currently eating regular solids at home and is drinking thin liquids without any reported difficulty. Food prescription: level 5 (minced and moist) During an instrumental Drink swallowing prescription: assessment, level you 0 determine (thin) that thin liquids are traveling through the oropharynx safely and efficiently, but regular solids are causing large amounts IDDSI of residue, Functional and require Diet Scale 3 to 4 score: swallows 6 per bolus to get everything down. Soft and bite-sized foods also cause a fair amount of pyriform sinus residue, but minced and moist solids appear to go down safely and efficiently. You decide to temporarily recommend a diet of minced and moist solids with thin liquids, while additional workup in search of a causal factor is found. Krystel Ouaijan - Dubai

27 Determine the Level! Krystel Ouaijan - Dubai Steele et alarchives of Physical Medicine and Rehabilitation 2018;m99:

28 Translate the levels into diet orders on trays Krystel Ouaijan - Dubai

29 Do your own checklist! Krystel Ouaijan - Dubai

30 Don t be restrictive! Modified texture diets may result in reduced food intake and therefore increasing the risk of malnutrition Normal Diet 930 Modified texture diet Kcal Normal Diet 40 Modified texture diet Protein (g) Krystel Ouaijan - Dubai Wright et al, Journal of Human Nutrition and Diet2005; 18:

31 Be creative! Study on modified diet with greater food choices (12 w intervention): Reshaped minced- or pureed-texture foods with thickened beverages Oral nutrition supplements in form of puddings Modified texture diet 1947 Expanded modified diet Modified texture diet 83.1 Expanded modified diet Modified texture diet 14.6 Expanded modified diet Kcal Protein (g) Zinc (mg) Germain et al. Journal of the American Dietetic Association 2006;106: Krystel Ouaijan - Dubai

32 Food molds can be very helpful to improve the tray s appearance Krystel Ouaijan - Dubai

33 Other helpful tips Thickening agent is crucial to change the levels of water, common liquids and juices. Edible substance which can increase the viscosity of a liquid without substantially changing its other properties. Oral nutrition supplements provide extra source of calories and proteins but should be used to the right consistency! Krystel Ouaijan - Dubai

34 Another Case Study You have been working with a 27-year-old woman who is recovering Food prescription: not applicable. No food level is safe. from a traumatic brain injury. Drink prescription: not applicable. No food level is safe. She has IDDSI been Functional NPO for Diet 1 month Scale and score: fed 0+ by gastrostomy tube, but medically she is now doing well and the team is keen for her to begin Comment: the primary source of nutrition is by transitioning back to an oral diet. gastrostomy tube. The þ+ diacritic reflects the Your recommendation clinical assessment for suggests trial oral that intake she of may ice not chips be in fully a ready to begin oral intake, but is ready to begin practicing swallows with a therapeutic context. safe, starter item (eg, ice chips [or in Japan, dysphagia jelly]). Krystel Ouaijan - Dubai

35 What do we learn? When swallowing is severely impaired, enteral feeding is considered as primary source of nutrition. The earlier the more efficiency is achieved. Rehabilitation with SLP should be started the soonest. Trials of oral feeding should be done in coordination with ENT and SLP. Patient can start some modified texture (level 4) when ready even when still on gastrostomy tube feeding. Krystel Ouaijan - Dubai

36 Let s see some evidence! Meta-analysis of 11 randomized controlled studies with 735 participants to evaluate PEG versus NG tube: c c Gomes et al. The Cochrane Database of Systematic Reviews 2015; Issue 5. Art. No.: CD Krystel Ouaijan - Dubai

37 PEG vs NGT: Meta-analysis c c Gomes et al. The Cochrane Database of Systematic Reviews 2015; Issue 5. Art. No.: CD Krystel Ouaijan - Dubai

38 Retrospective study on Nutrition Support Two groups: PEG feeding: n = 117 Exclusively oral feeding: n = 105 Both groups received functional training (oral motor skills/sensation, compensatory swallowing techniques) from SLPs. A highly significant negative correlation exists between timing of PEG and functional improvement of nutrient intake. Becker et al. Dysphagia 2011; 26: Krystel Ouaijan - Dubai

39 Take-Away Messages Dysphagia management is a team event. It requires extensive assessment and follow-up. Dysphagia diet should be standardized and well-coded in all institutions. It should be patient-centered. Health care professionals should always be opened for changes. More research is needed in this field. A national task force in Lebanon has been established this year in order to provide regionally adapted protocol for dysphagia. Krystel Ouaijan - Dubai

40 Fighting Dysphagia is Like Running a Marathon! Long way Huge efforts Team work Valuable reward Krystel Ouaijan _ 2018

41 Krystel Ouaijan - Dubai

42 References Sura et al. Dysphagia in the elderly: management and nutritional considerations. Clinical Interventions in Aging 2012; 7: Martineau et al. Malnutrition determined by the patient-generated subjective global assessment is associated with poor outcomes in acute stroke patients. Clinical Nutrition 2005; 24: Tannen et al. Care problems and nursing interventions related to oral intake in German nursing homes and hospitals: a descriptive mulitcentre study. International Journal of Nursing Studies 2012; 49 (4): Manon et al. Nutritional status, food intake, and dysphagia in long-term survivors with head and neck cancer treated with chemoradiotherapy: A cross-sectional study. Head & Neck 2014; 36 (1): Silander et al. An exploration of factors predicting malnutrition in patients with advanced Head and Neck Cancer. Laryngoscope 2013; 123: Norine et al. A review of the relationship between dysphagia and malnutrition following stroke. Journal of Rehabilitation Medicine 2009; 41: Kim et al. Changes in the dysphagia and nutritional status of patients with brain injury. Journal of Clinical Nursing 2018; 27: Norman et al. Prognostic impact of disease-related malnutrition. Clinical Nutrition 2008; 27: Becker et al. Functional dysphagia therapy and PEG treatment in a clinical geriatric setting. Dysphagia 2011; 26: Krystel Ouaijan - Dubai

43 References Rofes et al. Diagnosis and management of oropharyngeal Dysphagia and its nutritional and respiratory complications in the elderly. Gastroenterology Research in Practice 2011; doi: /2011/ Serra-Prat et al. Oropharyngeal dysphagia as a risk factor for malnutrition and lower respiratory tract infection in independently living older persons: a population-based prospective study. Age Ageing 2012; 41: Garcia-Peris et al. Long-term prevalence of oropharyngeal dysphagia in head and neck cancer patients: Impact on quality of life. Clinical Nutrition 2007; 26: Rosler et al. Dysphagia in dementia: influence of dementia severity and food texture on the prevalence of aspiration and latency to swallow in hospitalized geriatric patients. Journal of the American Medical Directors Association 2015; 16: Cichero et al. Development of international terminology and definitions for texture-modified foods and thickened fluids used in dysphagia management: The IDDSI Framework. Dysphagia 2017; 32 (2): Dietitians of Canada. Defining the role of the dietitian in dysphagia assessment and and management. A statement of Dietitians of Canada. March Steele et al. The influence of food texture and liquid consistency modification on swallowing physiology and function: a systematic review. Dysphagia 2015; 30 (1): Krystel Ouaijan - Dubai

44 References Leder et al. Promoting safe swallowing when puree is swallowed without aspiration but thin liquid is aspirated: nectar is enough. Dysphagia 2013; 28: Bingie et al. Quantitative videofluoroscopic analysis of penetration-aspiration in post-stroke patients. Neurology India 2010; 58 (1): Steele et al. Creation and initial validation of the international dysphagia diet standardisation initiative functional diet scale. Archives of Physical Medicine and Rehabilitation 2018; 99: Wright et al. Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. Journal of Human Nutrition and Diet 2005; 18: Germain et al. A novel dysphagia diet improves the nutrient intake of institutionalized elders. Journal of the American Dietetic Association 2006;106: Belafsky PC et al.validity and reliability of the Eating Assessment Tool (EAT-10).Annals of Otology Rhinology Laryngology 2008; 117 (12): Gomes et al. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. The Cochrane Database of Systematic Reviews 2015; Issue 5. Art. No.: CD Krystel Ouaijan - Dubai