Dysphagia. Objectives. Dysphagia and Nutritional Management. Function of Swallowing 12/3/2012. Nutrition Diagnosis: Swallowing difficulty

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1 Objectives Dysphagia and Nutritional Management Sylvia Escott-Stump, MA, RD, LDN East Carolina University Participants will be able to recognize the nutritional risks of dysphagia. Participants will be able to identify aspects of dysphagia that can be managed by dietary changes. Participants will be able to address hydration challenges associated with dysphagia. S. Escott-Stump 2 Function of Swallowing Swallowing Phase1 Oral Transit of Food and Liquid to Pharynx Transfer of Food and Liquid through Pharynx to Esophagus for: Nutrition Hydration Airway Protection to Avoid: Aspiration Related Disease Choking S. Escott-Stump 3 Swallowing Phases 2 and 3 Dysphagia Difficulty in swallowing as a symptom of disease or dysfunction resulting from a neurological, mechanical/structural, or behavioral disorder or condition in any or all of the phases of swallowing. Nutrition Diagnosis: Swallowing difficulty S. Escott-Stump 6 1

2 Dysphagia Facts Dysphagia can occur at any level of the swallow: oral, pharyngeal or esophageal Dysphagia affects an estimated 16-22% of people over age 50 70% of patients are not getting the correct consistency when prescribed thickened liquids About 10% of nursing home residents are on thickened liquids Complications of Dysphagia Poor nutrition Dehydration Aspiration Pneumonia Chronic lung disease Psychological/ Psychosocial issues Less enjoyment of eating Embarrassment/ isolation S. Escott-Stump 7 S. Escott-Stump 8 Costs WARNING SIGNS OF SWALLOWING PROBLEMS Poor Nutrition Dehydration Aspiration Psychological/ Psychosocial Unintentional weight loss Risk of decubs, Unintentional weight loss Pneumonia, Chronic lung disease Unintentional weight loss, Depression Medications, Supplements, Special diets, IV fluids, Intubation, Medical tests, Doctor s visits, Rehab Increased length of stay Increased medical costs Coughing, choking or strangling before, during or after the swallow Holding or pocketing of food between the cheek and gum Slow eating Poor oral consumption of food or fluid Complaints of food sticking in the throat Drooling/leakage of liquids or food from mouth or nose while eating or drinking S. Escott-Stump 9 S. Escott-Stump 10 Food remains at the front of the mouth following swallow MORE WARNING SIGNS OF SWALLOWING PROBLEMS Facial grimaces or reddening of the face Labored or difficult swallowing Gurgling voice or wet cough Impulsive eating behaviors Pneumonia Risk 5-15% of Community Acquired Pneumonias are Aspiration Related Can occur at any age Neurogenic Dysphagia Stroke-45-75% Traumatic Brain Injury-10-35% Neurodegenerative Diseases-ALS, multiple sclerosis, Parkinson s, myasthenia gravis Dementia, Institutionalized Patients Iatrogenic causes, caused by treatment of other conditions S. Escott-Stump 11 S. Escott-Stump 12 2

3 Risk After Stroke Dysphagia guidelines are focused on screening and management, particularly in the early stages after hospital admission, before any food or drink are given. Guidelines should give detailed recommendations for specialist referral. Flexible and non-prescriptive An approach which can be followed by all members of the multi-disciplinary team. Evaluation By Speech Therapy Dysphagia evaluation, treatment and management are the specialty of many speech-language pathologists. Evaluation process: three steps that provide the foundation for making a proper diagnosis and developing a treatment plan. S. Escott-Stump 13 S. Escott-Stump 14 Evaluation By Speech Therapy Evaluation By Speech Therapy Step I: Screening: Thorough patient history; review of the medical chart Interviews with the medical staff, patient and/or family History of the swallowing disorder; onset, duration, and symptoms of the disorder. Respiratory status, cognitive abilities and overall general health. Step 2: Bedside evaluation Structured examination of how effectively the patient manages and manipulates a bolus of food or liquid during the separate stages of swallowing. Assess the oral cavity, pharynx and larynx for structural anomalies and any obvious physical impairments. The therapist presents liquids and morsels of food varying in consistency and bolus size. Step 3: Recommendations The SLP analyzes the information taken from the patient's history and results of the bedside evaluation to decide what recommendations to make for intake by mouth medical referral further instrumental evaluation. Videofluoroscopic Diagnosis Solid Food, Liquid Video, Digital Recording S. Escott-Stump 15 S. Escott-Stump 16 Food Rheology There are five basic forces involved with eating. 1. Compression - The deforming of a food using force, such as between the tongue and palate. 2. Adhesiveness - The attraction between the food and an external surface, such as food sticking to the palate 3. Tensile - The extending of foods under force, such as the effects of the muscles on the bolus as it travels through the pharynx 4. Shear - The cutting of a food into pieces by forces that are not directly opposing, such as the lateral movement of the molars during chewing. 5. Fracture - The breaking of the food by two directly opposing forces, such as the incisors biting through a cookie. S. Escott-Stump 17 Key Terms of Texture Chewability - force required to compress a solid food. Example: Oatmeal Cookie Cohesiveness - degree to which the product deforms rather than shears. Example: Yogurt/Cottage Cheese S. Escott-Stump 18 3

4 Viscosity - force required to draw food between lips/spoon. Example: Water versus condensed milk Adhesiveness - work required to overcome the attraction force between food and the teeth or palate. Example: Peanut butter vs. whipped cream S. Escott-Stump 19 Firmness - the force required to compress a semi-solid food, such as between the tongue and palate. Example: ice cream and banana Springness - the degree or rate that food returns to its original shape when compressed. Example: frankfurters vs. cream cheese Biteability - the force with which a solid food breaks between the incisor teeth. Example: bagels vs. canned pears S. Escott-Stump 20 Other Factors Affecting Swallowing/Chewing Flavor - sweet, spicy, sour Temperature - hot/cold Moistness Consistency of texture Medications may cause dry mouth Prevention of Aspiration Correct consistency of foods & fluids & Eating / feeding techniques positioning environment S. Escott-Stump 21 S. Escott-Stump 22 General Safe Swallowing Guide Maintain an upright position (as near 90 degrees as possible) whenever eating or drinking. Take small bites -- only 1/2 to 1 teaspoon at a time. Eat slowly. l Eat only one food at a time. Avoid talking while eating. When one side of the mouth is weak, place food into the stronger side of the mouth. At the end of the meal, check the inside of the cheek for any food that may have been pocketed. S. Escott-Stump 23 General Safe Swallowing Guide Try turning the head down, tucking the chin to the chest, and bending the body forward when swallowing. This often provides greater swallowing ease and helps prevent food from entering the airway. Do not mix solid foods and liquids in the same mouthful. Do not "wash foods down" with liquids, unless instructed to do so by the therapist. Eat in a relaxed atmosphere, with no distractions. Following each meal, sit in an upright position (90 degree angle) for 30 to 45 minutes. S. Escott-Stump 24 4

5 Evidence-Based Practice Medical Nutrition Therapy Dysphagia Management S. Escott-Stump 26 Medical Nutrition Therapy Cognitive and swallowing dysfunction usually affect nutritional management Neurologic patients are at risk for malnutrition and dehydration Nutrition assessment should evaluate patterns of normal chewing, swallowing, and ingestion as well as total fluid intake Hydration Dehydration occurs in a dysphagic patient t if inadequate amounts of fluid are consumed S. Escott-Stump 27 S. Escott-Stump 28 Nutritional Support Enteral nutrition support preferred modality for nutrition support in patients who cannot swallow because of deteriorating neurologic disease Dysphagia diets when tolerated S. Escott-Stump 29 Management of Dysphagia Goal: Meet nutrition and hydration needs by mouth while reducing the risks of aspiration Three primary methods: 1. Swallowing therapy 2. Swallowing compensations/maneuvers 3. Texture modification/thickened liquids S. Escott-Stump 30 5

6 National Dysphagia Diet The NDD was developed through consensus by a panel of dietitians, SLPs, and a food scientist. Classifies foods according to eight textural properties Anchor foods represent points along continuum for each property. A hierarchy of diet levels includes and excludes items at each level based on subjective comparison with these anchor foods. S. Escott-Stump 31 National Dysphagia Diet Food Textures: Level 1: Dysphagia Pureed Level 2: Dysphagia Mechanically Altered Level 3: Dysphagia yp Advanced Level 4: Regular Liquid Viscosities: Thin: 1-50 cp Nectar-Like: cp Honey-Like: cp S. Escott-Stump 32 Level 1 - Dysphagia Pureed - Purpose This diet is designed for people who have moderate to severe dysphagia, with poor oral phase abilities and reduced ability to protect their airway. Close or complete supervision and alternate feeding methods may be required. S. Escott-Stump 33 Dysphagia 1-Pureed Texture This diet consists of pureed, homogenous, and cohesive foods. Food should be pudding-like consistency; no chunks. Any foods that require bolus formation, controlled manipulation, or chewing are excluded. d No coarse textures, raw fruits or vegetables, nuts, are allowed. Soups are pureed to match the liquids allowed. Bread, biscuits, cakes, and plain cookies are pureed. No oatmeal or unprocessed wheat bran stirred into cereals. S. Escott-Stump 34 Description Homemade Purees Foods pureed with blender or food processor Pureed Food Options Baby Food Frozen Purees Canned Purees Baby food in jars Foods that have been pureed and frozen by manufacturer Foods that have been pureed and canned by manufacturer Cost $ $$ $$ $$ Pros Know how food for was prepared No additives Control ingredients Matches menu Ready-to-use Thaw, heat and serve Looks appealing Variety home and emergency stock Ready-to-use Shelf-stable Concerns Challenges with quality and consistency Nutritional considerations Time consuming Nutritional concerns Loss of dignity Not designed May weep Single portions more costly Limited varieties for S. adult Escott-Stump palate 35 Level 2 - Dysphagia Mechanically Altered - Purpose The textures on this level are appropriate for individuals with mild to moderate oral and/or pharyngeal dysphagia. This diet is a transition from the pureed textures to more solid textures. Some chewing ability is required. Patients should be assessed for tolerance to mixed textures; some mixed textures are tolerated on this diet. S. Escott-Stump 36 6

7 Dysphagia 2- Mechanically Altered Texture Consists of foods that are moist, soft-textured, and easily formed into a bolus. All foods from NDD Level 1 are acceptable at this level. Food may be swallowed with one to two chews. Moisture is added if not present. Meats are ground or are minced no larger than one-quarter-inch pieces; they are still moist, with some cohesion. Gravy or sauces should be used. Diced well-cooked or canned tender fruits and vegetables. Those with strings or membranes such as pineapple, broccoli or asparagus are pureed. Bread, biscuits, cakes, or plain cookies are pureed Avoid rice, bacon, hard cooked eggs, potato chips/french fries, and fibrous cooked vegetables. S. Escott-Stump 37 Level 3 - Dysphagia Advanced - Purpose This diet is a transition to a regular diet. Adequate dentition and mastication are required. The textures t of this diet are appropriate for individuals with mild oral and/or pharyngeal phase dysphagia. Patients should be assessed for tolerance of mixed textures. It is expected that mixed textures are tolerated on this diet. S. Escott-Stump 38 Dysphagia 3 Advanced Texture Consists of food of nearly regular textures with the exception of very had, sticky, or crunchy foods. Foods still need to be moist and should be in bite-size pieces at the oral phase of the swallow. Food may be swallowed with three to four chews. Moisture is added if not present. Remember Mixed consistencies or double consistencies foods may increase the risk of aspiration or choking. Minced meats, casseroles, and meat salads are served without celery or crusts. Well cooked, tender, or canned fruits and vegetables. Bananas are fresh. Soft buttered breads without hard crusts are acceptable. Avoid French bread, crackers, sandwiches, fresh apples, pears or grapes, and cooked corn. S. Escott-Stump 39 S. Escott-Stump 40 Preparation & Presentation Dysphagia Diets Modify texture without compromise of flavor and appearance S. Escott-Stump 41 Pocket Card Pureed or Dysphagia 1 Dysphagia 3 Food may be swallowed with no chewing Food may be swallowed with three to four required. All foods are completely pureed chews. Moisture is added if not present. or pudding consistency without chunks. Minced meats, casseroles, and meat All meats, fruits, and vegetables are salads are served without celery or pureed. crusts. Soups are pureed to match the Well cooked, tender, or canned liquids allowed. fruits and vegetab les. Bananas Bread, biscuits, cake s, and plain fresh. are cookies are pureed. Soft buttered breads without hard crusts are acceptable. Crackers and sandwiches are avoided. Dysphagia 2 Mechanical Soft Food may be swallowed with one to two Soft foods with no hard lumps. chews. Moisture is added if not present. Chopped, grou nd, or minced meats unless All meats are pureed with gravy or extremely soft such as fish or meatloaf. sauce. Well cooked vegetables. Diced well -cooked or canned tender Any soft whole items, easy to chew. fruits and vegetables. Those with Thickened Liquids strings or membranes such as Stage 1 Liquids Pudding Thick Liquids pineapple, broccoli or asparagus are Stage 2 Liquids Honey Thick Liquids pureed. Stage 3 Liquids Nect ar Thick Liquids Bread, biscuits, cakes, or plain Stage 4 Liquids Normal Thin Liquids cookies are pureed S. Escott-Stump 42 7

8 Liquids in Dysphagia Diets Pudding or Spoon thick such as yogurt Honey-like such as honey at room temperature Nectar-like such as pancake syrup LIQUIDS Thin or Thickened??? Regular (Thin) - water, tea, coffee, soda, ice cream, frozen yogurt, gelatin, supplements, watermelon, squash, tomato juices, etc. S. Escott-Stump 43 S. Escott-Stump 44 Thickening Agents How to Thicken Liquids & Foods baby cereal banana flakes bread crumbs cornstarch cooked cereals (cream of wheat or rice) custard mix graham cracker crumbs gravy instant potato flakes mashed potatoes plain unflavored gelatin powder plain sauces (white, cheese, tomato) puréed fruits (baby food) puréed meats (baby food) puréed vegetables (baby food) saltine cracker crumbs Add baby rice or commercial thickener to hot milk-based liquids. Add potato flakes, mashed potatoes, or flaked baby cereal to other hot liquids (soups, sauces, gravies). Add plain unflavored gelatin, puréed fruits, banana flakes, or a commercial thickener to cold liquids. Add potato flakes, mashed potatoes, thick sauces or gravies, canned puréed or strained meat (baby food), or a commercial thickener to puréed soups. Add flaked baby cereal, flavored gelatin, cooked cream of rice or wheat cereal, or a commercial thickener to puréed fruits. Add mashed white or sweet potatoes, potato flakes, sauces, or commercial thickener to puréed vegetables. S. Escott-Stump 45 S. Escott-Stump 46 Thickened Liquids - Properties Some liquids will thicken more than others, even when using the same amount of thickener The ph and acidity of liquids and the percentage of soluble solids affect the degree of thickness At higher temperatures, more thickener may be required to achieve the desired consistency Thickened liquids continue to thicken over time During the digestion process in the month, stomach and small intestine, acids & enzymes break down the starch reversing the thickening action S. Escott-Stump 47 Thickener Options Starch-based Gum-based Description Starch-based thickeners that can be added to beverages or foods Gum-based thickeners that can be added to beverages Cost $ $$ Pros Affordable No added calories and Easily accessible through retail and foodservice channels and online carbohydrates Not affected by time or temperature Clear appearance Concerns Requires mixing If not mixed correctly, may over thicken Adds additional calories and carbohydrates More expensive Requires mixing Limited retail distribution S. Escott-Stump 48 8

9 Commercial Products Pre-Thickened Options Starch-based Gum-based Description Ready-to-use beverages thickened with starch by the manufacturer Ready-to-use beverages thickened with xanthan gum by the manufacturer Cost $$ $$ Pros Ready-to-use, no mixing Ready-to-use, no mixing Readily available through foodservice distributors Reliable consistency No added calories, carbohydrates and sugar Versatile Clear appearance Concerns May thicken over time Added calories, carbohydrates and sugar Limited availability through foodservice distributors S. Escott-Stump 49 S. Escott-Stump 50 Adaptive Feeding Equipment A cup that is cut out around the nose allows drinking without tilting the head back, and a spoon with a shallow bowl is useful if the patient has reduced control over tongue movements. Recipes High Protein Smoothies In a blender, mix 1 cup fruit-flavored yogurt and 1 cup fortified milk with soft, fresh, peeled fruit or soft, canned fruit, and 1 cup of cottage cheese. Mix until smooth. Cottage Cheese Pudding Mix together 1/4 cup cottage cheese and 3 T baby fruit. Chill. Creamed Vegetable Soup In a blender, add 1/2 cup strained or very soft cooked vegetable; 1/2 cup fortified milk, cream, or plain yogurt, 1 tsp margarine; salt, onion powder, and crushed dried parsley flakes to taste. Mix to desired consistency. S. Escott-Stump 51 S. Escott-Stump 52 How to Thin Liquids Communication and Education Add hot milk-based liquids (hot milk or cream) to puréed soups, puréed vegetables, or cooked cereal. Add other hot liquids id (broth, gravy, sauces) to mashed potatoes, puréed or ground meats, and puréed or chopped vegetables. Add cold milk-based liquids to cream, yogurt, cold soups, puréed fruits, or puddings and custards. broth or bouillon gravy juice liquid flavored gelatin melted hot butter/margarine milk (hot or cold) plain yogurt strained puréed soups Dysphagia Policies Update Diet Manual Internal Task Force Registered Dietitians Speech Therapists Nursing Physician Food Service Management S. Escott-Stump 53 S. Escott-Stump 54 9

10 Who educates the patient and family? Nursing on admission Dietitian educates patient and/or family about the diet protocol. Why Manage Dysphagia? Independent predictor of poor outcome, worsening morbidity, increased risk of hospital readmissions, higher health care costs and greater mortality. Ochoa, 2012 S. Escott-Stump 55 S. Escott-Stump 56 In short Dysphagia Management Goal: Modify food textures and viscosity of fluids for the individual to maintain or achieve optimal nutrition and hydration, minimizing risks of aspiration and reducing costs. Thank you, Cyprus! Questions? S. Escott-Stump 57 S. Escott-Stump 58 References Dining Skills Manual, Academy of Nutrition and Dietetics Dysphagia Severity Rating Scale (adapted from Waxman et al, 1990.) Available at Gee AC et al. Nutrition Support and Therapy in Patients with Head and Neck Squamous Cell Carcinomas. Curr Gastroenterol Rep Jun 29. National Dysphagia Diet: Standardization for Optimal Care, Academy of Nutrition and Dietetics, 2003 Ochoa JB. Nutritional assessment and intervention for the patient with dysphagia: challenges for quality improvement. Nestle Nutrition Inst Workshop 72:77, S. Escott-Stump 59 10