1. Dysphagia: Nutrition and Hydration Management
Funding for the educational program and/or materials is sponsored by Nestlé Nutrition.
Copyright 2009 Nestlé HealthCare Nutrition, Inc.
This program is for educational purposes and is not a substitute for clinical judgment
or the specific advice of a medical professional.

2. Presentation Objectives
List the three phases of swallowing
Verbalize two of the three indirect therapies for oropharyngeal dysphagia
Describe the four levels of the National Dysphagia Diet

3. Presentation Preview Introduction Phases of swallowing Screening
Treatment
National Dysphagia Diet and thickened liquids
Post Test

4. Swallowing Fun Facts We swallow more than 600 times/day
We swallow about once every minute while asleep
The swallow mechanism is innervated by 7 pairs of nerves and 26 muscle groups

5. Introduction Dysphagia
Defined as difficulty swallowing or the inability to swallow.
Technically, it is oral-pharyngeal dysphagia or oropharyngeal
Pertinent to mouth and pharynx and not esophagus
Can occur in all age groups
May be a result of many different medical conditions
Can be an acute problem or progress slowly over a long period of time
Dysphagia is defined as difficulty swallowing or the inability to swallow. For this presentation we will discuss oral-pharyngeal or oropharyngeal dysphagia which pertain to the mouth and the throat or pharynx. Esophageal dysphagia is typically treated and spoken to differently and carries its own set of treatment and management techniques.

6. Dysphagia: Epidemiology
Estimated to affect 22% of the world’s population >50 years of age
Up to 30% of patients in hospitals
~60% of residents in nursing homes
Probably 14% of people >65 years of age living in the community
Children?
No incidence or prevalence is noted!
(Cook, Kawashima et al.)
Even though we don’t have good data on children, it is estimated that approximately 10 million children in the US have a swallowing disorder that may be related to reflux, may be short term or may be long term.

7. People Affected by Dysphagia
Patients at high risk for dysphagia
Intermediate-stage Parkinson’s disease
Multiple sclerosis (MS)
Amyotrophic lateral sclerosis (ALS)
Dementia
Stroke
Head and Neck Cancers
People with progressive neurologic diseases such as Parkinsons, MS, ALS will most likely develop dysphagia as their disease states progress. Where as in situations such as stroke an acute dysphagia is likely to improve with resolution of the stroke and rehabilitation of the muscles of the pharynx.

8. Consequences Dysphagia can increase the risk of
Inadequate intake resulting in weight loss and malnutrition
Dehydration
Aspiration of food and fluids into the airway
Acutely causing aspiration pneumonitis
Chronically causing aspiration pneumonias
Chronic respiratory infections due to fluids being aspirated into the lungs.
Weight loss due to a decrease in intake
Aspiration is the inhalation of food particles or fluids into the lungs.

9. Aspiration Aspiration Pneumonia
25-30% of patients with dysphagia are “silent aspirators”
Silent aspiration has a 7 fold higher risk for developing aspiration pneumonia
In the elderly with dysphagia those who have silent aspiration have a higher mortality rate.
(Cook)
Not every dysphagia patient aspirates but the possibility is always there. What makes this a concern it that it is not easily identified as a problem sometimes until it has actually happened, nor is it caught on a clinical exam. Aspiration can only be diagnosed on an instrumental exam such as a video swallow study, in which the transit of food and liquids can be visualized on fluoroscopic xray exam. Something that all clinicians need to remember is that that exam is but one moment in time. Swallowing problems can worsen when people are fatigued or ill. If people with dysphagia don’t receive adequate nutrition, the muscles needed to swallow efficiently can weaken and predispose that patient to aspiration as well.
For the elderly, aspiration pneumonia often leads to death.

10. Dysphagia: Consequences
The Vicious Cycle
This slide nicely summarizes the problem.

11. Many people with dysphagia go unrecognized or undiagnosed until a major event such as aspiration pneumonia occurs.
Dysphagia is not a top of mind issue – even for the health care professional.

12. Swallowing Three phases of swallowing Oral phase Pharyngeal phase
Esophageal phase
Proper positioning is necessary for safe swallowing.
Patients (if able to) should be paying close attention to the swallowing process for safety.

13. Oral Phase Food in the mouth is combined with saliva
Chewed if necessary
Formed into a bolus by the tongue
Tongue pushes food to the rear of oral cavity
This is the only voluntary phase of the process – meaning we control how long something is in our mouth. Even before the oral phase of the swallow begins the oral preparatory phase has been recognized as being important. In this phase that the mouth prepares itself for receiving food; saliva is stimulated by aromas and as the hand brings food to the mouth, the lips open. Some researchers feel that if this phase is eliminated by someone else feeding the resident or patient the swallow won’t be as efficient.

14. Oral Phase Challenges in this phase with dysphagia
Weakened lip muscles may decrease ability to seal the lips and drink from a straw
Increased intracranial pressure or cranial nerve damage may cause weakened tongue movements
Poor tongue strength and motility may cause problems with :
Food may be pocketed in mouth
Difficulty forming a bolus and moving the food for the involuntary swallow initiation.
Even though this is the voluntary phase of the swallow it is very important to preparing the food bolus for the involuntary phase of the swallow. When the lips and tongue are not functioning well it may cause food to inadvertantly spill into the airway.

15. Pharyngeal Phase Involuntary
Bolus is moved between the tonsillar pillars
Soft Palate (posterior nares) are closed
Epiglottis and vocal chords close off airway
Respirations cease
Upper esophageal sphincter is opened
Food is directed to esophagus
Once a bolus of food gets to the back of the tongue, the tongue acts as a “piston” to propel the bolus into the pharynx. Breathing resumes at the end of the phase.
At this point several complex and very coordinated steps take place:
The soft palate closes so that food won’t come out the nose
The epiglottis and vocal chords close off the airway and the upper esophageal or cricopharyngeal sphincter opens and food is directed into the esophagus.
When there is neurologic or surgical damage to the swallowing process these involuntary movements become uncoordinated and the muscles become weak and the potential exists for food to be spilled into the airway. This can happen in a healthy individual as well. We’ve all experience food going down the wrong way…we cough and sputter to try to get the food out of our airway and swallowed. This protective cough keeps the food from going further down into the lungs.
People who are at risk for aspiration usually can’t feel the food going the “wrong way” therefore, don’t produce a protective cough like we can.

16. Pharyngeal Phase Symptoms of difficulty Gagging Choking
Nasopharyngeal regurgitation
Gagging and choking are good, we know that the patient/resident can feel it. Silent aspirators do not feel the food penetration as we spoke to in the last slide.
There is a clinical difference between aspiration and choking. Aspiration typically is liquids in the airway. Unless a significant quantity of liquid goes into the lung in a short period of time it takes a while to manifest a pneumonia.
Choking is solid food obstructing the airway. This is much more immediate and the solid food needs to be removed immediately. Measurers should be taken. Do not leave people who are choking alone. People who die from choking often have been left alone or leave the table and go to the bathroom alone.

17. Esophageal Phase Involuntary Upper esophageal sphincter is relaxed
Peristaltic wave moves the bolus down the esophagus
During the esophageal phase food enters the esophagus and transits about 10 inches through the lower esophageal sphincter and into the stomach. This is a very active process with the muscles of the esophagus propelling the food bolus downward.

18. Esophageal Phase Difficulties in this phase may be due to:
Mechanical obstruction
Impaired peristalsis
Mechanical obstructions can impair transit through the esophagus as can uncoordinated or inadequate muscle control.

19. What happens during chewing and swallowing?
Effects on food during chewing and swallowing
Compression
Adhesiveness
Tensile
Shear
Fracture
(National Dysphagia Diet)
During the process of chewing and swallowing food and liquids a number of mechanical processes are happening either voluntarily or involuntarily. Scientists have terminology that can measure and describe these mechanical processes. Those that we are most concerned with include:
Compression- food deforms
Example-tongue presses a marshmallow against the palate
Adhesiveness- food attracted to another surface
Example-peanut butter against the palate
Tensile- food is extended
Example- elongated effects of the pharynx muscles on a bolus
Shear- food cut into pieces
Example-shredding foods during chewing
Fracture- food is broken by two opposing forces
Example- incisors biting through a crisp cracker
Adapted from National Dysphagia Task Force. American Dietetic Association. National Dysphagia Diet: Standardization for Optimal Care. Chicago: American Dietetic Association, 2002.

20. Screening for Dysphagia

21. Symptoms of Dysphagia Drooling Choking Coughing during meals
Gurgly voice quality
Absent gag reflex
Food avoidance
Pocketing foods in the cheeks
Lengthy meal times
Complaints of multiple, painful swallows
Prolonged eating time
Weight loss
Dehydration
Difficulty managing oral secretions
Some of these signs and symptoms may be indications that people may be at risk for dysphagia. If these are noted during meal or snack times a health care professional should be notified.
Logeman

22. Screening Observation during meals by nurse and dietitian
Treatment team involvement
Swallowing evaluation by speech pathologist
Treatment team or dysphagia team may include the patient’s physician, nursing staff, dietitian, radiologist and swallowing therapist (speech pathologist).

23. Dysphagia Screening: Clinical Exam
Exam Components:
Comprehensive swallowing history
Exam of the oral cavity for oral control, tongue activity and oral residual or pocketing of food
Observation with auscultation of a “dry” swallow and with food for initiation of laryngeal elevation and laryngeal excursion
Voice quality and cough after swallow
Clinical exam unable to detect 40% of silent aspirators (Logeman)
There are a number of steps in a clinical exam but the key point here is that in spite of a rigorous exam process the silent aspirators can still be missed.

24. Screening
Medications can play a role in pathology, treatment and prevention of dysphagia
Medication side effects
Dry mouth
Pharyngeal ulceration
Tardive dyskinesia
Drug-induced confusion
(Logeman)
Tardive dyskinesia is a neurological disorder characterized with repetitive, involuntary, purposeless movements. Caused by long term or high dose use of dopamine antagonists, usually antipsychotics.

25. Diagnostic Tools Videofluoroscopic procedure Other evaluation tools
Most widely used determine physiology of swallow
Other evaluation tools
Fiberoptic endoscopic examination
Ultrasound
Electromyography
Electroglottography
(Logeman)

26. Diagnostics Videofluoroscopic procedure
Also known as modified barium swallow
A radiographic study of a person’s swallowing mechanism that is recorded on videotape
Assesses oral and pharyngeal transit times during deglutition and pinpoints the motility problems
Assesses not only whether the patient is aspirating, but also reason for the aspiration
(Logeman)

27. Treatment

28. Treatment Use of proper swallowing techniques
Therapy techniques
Indirect therapy
Direct therapy
Change consistency of foods/ liquids
National Dysphagia Diet
Thickened liquids
Indirect therapy includes three types of exercises:
Exercises to improve oral motor control
Stimulation of swallowing reflex
Exercises to increase adduction (movement toward the midline) of tissues
(Cook)

29. Treatment Indirect therapy Oral motor control exercises
Focuses on the six aspects of tongue control during swallowing
Stimulation of swallowing reflex
Heightens the sensitivity
Exercises to increase adduction of tissue
Technique uses lifting, pushing, and vocalization
Examples of oral motor control exercises are:
1. range of tongue motion exercises
2. resistance exercises
3. bolus control exercises
4. bolus propulsion exercises
The purpose of stimulation of swallowing reflex is to heighten the sensitivity of the reflex so that when food or liquids are presented and the patient attempts to voluntarily swallow, the reflex will be triggered.
(Cook)

30. Treatment Direct therapy
Giving food or liquid to the patient and asking him or her to swallow while giving instructions
Examples
Positioning of the head
Sequence of instructions
Indirect therapy includes three types of exercises:
Exercises to improve oral motor control
Stimulation of swallowing reflex
Exercises to increase adduction (movement toward the midline) of tissues
(Cook)

31. National Dysphagia Diet and Thickened Liquids

32. National Dysphagia Diet (NDD)
National Dysphagia Diet (NDD) Task Force
2002 established guidelines for 3 levels of altered solid food textures and 3 altered viscosity liquid levels
National Dysphagia Diet

33. National Dysphagia Diet
Four levels of the NDD
Dysphagia Pureed
Very cohesive, pudding-like, does not require chewing
Dysphagia Mechanically Altered
Semisolid foods, requiring chewing ability
Dysphagia Advanced
Soft-solid foods that require more chewing
Regular
All foods allowed
National Dysphagia Diet
These four levels replace terms like- ground, chopped, soft and mechanically soft.

34. National Dysphagia Diet
Dysphagia Pureed
Description
Pudding-like, no coarse texture, raw fruit or vegetables, nuts, cannot use any food that requires bolus formation, controlled manipulation, or mastication
Rationale
For people who have moderate to severe dysphagia
For the dysphagia pureed diet recommend:
Pureed breads, pancakes, french toast etc.
Smooth cereals that are “pudding-like”
Desserts that are smooth like pudding or custard, pureed desserts
Butter, margarine, sour cream and smooth sauces
Pureed meats
Mashed potatoes with gravy
Pureed soups that are blenderized
Pureed vegetables that have no lumps or seeds
National Dysphagia Diet

35. National Dysphagia Diet
Dysphagia Mechanically Altered
Description
Foods that are moist, soft-textured, and easily formed into a bolus.
Rationale
Chewing ability required, for those with mild to moderate dysphagia
For the dysphagia mechanically altered recommend:
Soft pancakes, pureed bread mixes
Cooked cereal with little texture
Pudding or custard, soft fruit pies with bottom crust only
Canned fruit other than pineapple
soft, moist cakes
Butter, margarine, cream, gravy
Soft drained canned or cooked fruit without seeds or skin
Fruit juice with a small amount of pulp
Moistened ground or cooked meat, may be served with gravy
Moist mac and cheese, well-cooked pasta, cottage cheese
Well-cooked, moistened, broiled, baked or mashed potatoes
Soups with easy to chew meat and vegetables
Soft, well cooked vegetables
National Dysphagia Diet

36. National Dysphagia Diet
Dysphagia Advanced
Description
Regular texture food with the exception of very hard, sticky or crunchy foods
Rationale
A transition to a regular diet
For individuals with mild dysphagia
For the dysphagia advanced diet recommend:
Well-moistened breads, pancakes, muffins, etc.
Well-moistened cereals
Anything without seeds, nuts, dry fruit, coconut or pineapple
All fats allowed except those that are coarse or difficult to chew
All canned and cooked fruits, soft peeled fresh fruits
Thin sliced, tender, or ground meat and poultry
All potatoes and starches, except potato skins, crisp-friend potatoes, or dry bread dressing
All soups, except those with tough meats or corn
All cooked tender vegetables
National Dysphagia Diet

37. National Dysphagia Diet
Examples of Foods to Avoid
Dysphagia Pureed
Level 1
Beverages with lumps, dry breads and cereals, oatmeal, ices, gelatins, cookies, cakes, fats with chunky additives, whole fruit, whole or ground meat, cheese, cottage cheese, rice, potatoes, soups with chunks, vegetables
Dysphagia Mechanically Altered
Level 2
Dry breads, coarse cereals that may contain nuts or seeds, dry cakes and cookies, fresh or frozen fruits, dried fruits, dry meat, peanut butter, soups with chunks, fibrous vegetables, seeds and nuts
Dysphagia Advanced
Level 3
Dry bread, coarse cereals, dry cakes and cookies, difficult to chew fruits, tough meats, chunky peanut butter, potato skins, raw vegetables, nuts and seeds

38. National Dysphagia Diet
Techniques to improve acceptance
Provide a pleasant atmosphere for dining
Add seasoning for stronger flavors
Use a variety of foods to improve appearance by adding color
Remember that meals are to be enjoyed by all the senses. It is important to encourage good intake by making sure meals taste good, look good and smell good. It may take a little more time for meal preparation, but improvements to alternate texture diets will improve compliance.
National Dysphagia Diet

39. National Dysphagia Diet
Techniques to improve acceptance continued..
Use molds to shape and enhance product
Add appropriately textured
garnishes to foods
Remember that meals are to be enjoyed by all the senses. It is important to encourage good intake by making sure meals taste good, look good and smell good. It may take a little more time for meal preparation, but improvements to alternate texture diets will improve compliance.
National Dysphagia Diet

40. National Dysphagia Diet
Example: Dysphagia Puree using molds, variety of foods for color and seasonings

41. Thickened Liquids Liquids
Swallowing of liquids requires coordination and control
Easily aspirated into the lungs
Liquids may need to be thickened for safe swallow
It can be life-threatening if liquids are aspirated into the lungs.- aspiration pneumonia may occur.
All liquids must be thickened including supplements and liquids given with medications.

42. Thickened Liquids What are the benefits?
Delay the bolus transit through the pharynx
Extend the duration of pharyngeal peristalsis
Prolong the opening of the cricopharyngeal (upper esophageal) sphincter

43. Thickened Liquids Commercial thickener
Liquids must be encouraged due to high risk of dehydration
Types of thickened liquid
consistencies
Nectar
Honey
Pudding
Commercial liquid thickeners are available in drug stores and from companies that make them. Pre-thickened beverages are also available.
People who have challenges with liquids, often do not get enough fluids. Continue to encourage 6 to 8 cups of fluid each day.
If urinary urgency, frequency or incontinence occur, distribute fluids evenly throughout the day and limit before bedtime.

44. Thickened Liquids Nectar Honey Pudding
Easily pourable and similar to thicker cream soups
Honey
Less pourable, drizzle from a cup or bowl
Pudding
Hold their own shape, not pourable, eaten with a spoon
Nectar- similar to apricot nectar
Do not add anything that melts, such as ice cream or ice cubes. These can turn into thin liquids.
Be sure to stay upright 15 to 30 minutes after meals

45. Thickened Liquids
Hydration is critical to overall good health of people with dysphagia.
Proper consistency and adequate consumption are key factors in promoting safe hydration for your patients.
Nectar- similar to apricot nectar
Do not add anything that melts, such as ice cream or ice cubes. These can turn into thin liquids.
Be sure to stay upright 15 to 30 minutes after meals

46. Improve Safety and Efficacy of Dysphagia Diets
Observe Patients
Watch for the red flags
Document and report
Review Menus
What can you do to provide more appetizing and dysphagia friendly foods?
Teamwork
Nursing, dietary, and swallowing therapists
Identify gaps in foods and liquids create solutions
We need to do all we can to improve what we serve people with dysphagia. It is a real problem that has real needs attached and significant complications associated with failure.

47. Conclusion
Dysphagia is a serious condition that requires clinical screening and treatment
Treatment involves therapy techniques and/ or diet and liquid modification
Team communication is necessary
The National Dysphagia Diet provides specific dietary guidelines to reduce risk of complications from dysphagia

48. Post Test
Dysphagia

49. Post Test 1. Which phase of swallowing is considered voluntary?
A. Oral phase
B. Pharyngeal phase
C. Esophageal phase

50. Post Test
2. Which of the following diseases does not increase a person’s risk of dysphagia?
A. Stroke
B. Dementia
C. Hypertension
D. Multiple sclerosis

51. Post Test
3. Which of the following foods would be not be allowed on a Dysphagia Pureed Diet?
A. Nuts
B. Pureed meats
C. Mashed potatoes
D. Pureed breads

52. Post Test Answers Question #1 - A. Oral phase is considered voluntary
Question #2 - C. Hypertension is not a risk for dysphagia
Question #3 - A. Nuts are not appropriate on a Dysphagia Puree Diet

53. References
Mahan LK, Escott-Stump S. Krause’s Food, Nutrition, and Diet Therapy. 11th ed. Philadelphia, PA:Saunders;2004:
Logemann J. Evaluation and Treatment of Swallowing Disorders. Austin, Texas:Pro-ed;1983.
Sonies BC. Dysphagia. A Continuum of Care. Gaithersburg, MD:Aspen;1997.
National Dysphagia Task Force. American Dietetic Association. National Dysphagia Diet: Standardization for Optimal Care. Chicago: American Dietetic Association, 2002.
Cook IJ, Kahrilas PJ. AGA technical review on management of oropharyngeal dysphagia. Gastroenterology 1999; 116:
Kawashima K, Motohashi Y, Fujishima I. Prevalence of Dysphagia Among Community Dwelling Elderly Individuals as Estimated Using a Questionnaire for Dysphagia Screening. Dysphagia 2004; 19:
Logeman J. Evaluation and treatment of swallowing disorders. Pro-ed, Austin, TX 1983.