Presentation on theme: "Dysphagia: Nutrition and Hydration Management"— Presentation transcript:
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 judgmentor the specific advice of a medical professional.
2 Presentation Objectives List the three phases of swallowingVerbalize two of the three indirect therapies for oropharyngeal dysphagiaDescribe the four levels of the National Dysphagia Diet
3 Presentation Preview Introduction Phases of swallowing Screening TreatmentNational Dysphagia Diet and thickened liquidsPost Test
4 Swallowing Fun Facts We swallow more than 600 times/day We swallow about once every minute while asleepThe 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 oropharyngealPertinent to mouth and pharynx and not esophagusCan occur in all age groupsMay be a result of many different medical conditionsCan be an acute problem or progress slowly over a long period of timeDysphagia 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 ageUp to 30% of patients in hospitals~60% of residents in nursing homesProbably 14% of people >65 years of age living in the communityChildren?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 dysphagiaIntermediate-stage Parkinson’s diseaseMultiple sclerosis (MS)Amyotrophic lateral sclerosis (ALS)DementiaStrokeHead and Neck CancersPeople 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 malnutritionDehydrationAspiration of food and fluids into the airwayAcutely causing aspiration pneumonitisChronically causing aspiration pneumoniasChronic respiratory infections due to fluids being aspirated into the lungs.Weight loss due to a decrease in intakeAspiration 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 pneumoniaIn 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 CycleThis 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 phaseProper 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 necessaryFormed into a bolus by the tongueTongue pushes food to the rear of oral cavityThis 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 strawIncreased intracranial pressure or cranial nerve damage may cause weakened tongue movementsPoor tongue strength and motility may cause problems with :Food may be pocketed in mouthDifficulty 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 pillarsSoft Palate (posterior nares) are closedEpiglottis and vocal chords close off airwayRespirations ceaseUpper esophageal sphincter is openedFood is directed to esophagusOnce 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 noseThe 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 regurgitationGagging 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 esophagusDuring 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 obstructionImpaired peristalsisMechanical 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 swallowingCompressionAdhesivenessTensileShearFracture(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 deformsExample-tongue presses a marshmallow against the palateAdhesiveness- food attracted to another surfaceExample-peanut butter against the palateTensile- food is extendedExample- elongated effects of the pharynx muscles on a bolusShear- food cut into piecesExample-shredding foods during chewingFracture- food is broken by two opposing forcesExample- incisors biting through a crisp crackerAdapted from National Dysphagia Task Force. American Dietetic Association. National Dysphagia Diet: Standardization for Optimal Care. Chicago: American Dietetic Association, 2002.
21 Symptoms of Dysphagia Drooling Choking Coughing during meals Gurgly voice qualityAbsent gag reflexFood avoidancePocketing foods in the cheeksLengthy meal timesComplaints of multiple, painful swallowsProlonged eating timeWeight lossDehydrationDifficulty managing oral secretionsSome 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 involvementSwallowing evaluation by speech pathologistTreatment 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 historyExam of the oral cavity for oral control, tongue activity and oral residual or pocketing of foodObservation with auscultation of a “dry” swallow and with food for initiation of laryngeal elevation and laryngeal excursionVoice quality and cough after swallowClinical 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 ScreeningMedications can play a role in pathology, treatment and prevention of dysphagiaMedication side effectsDry mouthPharyngeal ulcerationTardive dyskinesiaDrug-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 swallowOther evaluation toolsFiberoptic endoscopic examinationUltrasoundElectromyographyElectroglottography(Logeman)
26 Diagnostics Videofluoroscopic procedure Also known as modified barium swallowA radiographic study of a person’s swallowing mechanism that is recorded on videotapeAssesses oral and pharyngeal transit times during deglutition and pinpoints the motility problemsAssesses not only whether the patient is aspirating, but also reason for the aspiration(Logeman)
28 Treatment Use of proper swallowing techniques Therapy techniquesIndirect therapyDirect therapyChange consistency of foods/ liquidsNational Dysphagia DietThickened liquidsIndirect therapy includes three types of exercises:Exercises to improve oral motor controlStimulation of swallowing reflexExercises 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 swallowingStimulation of swallowing reflexHeightens the sensitivityExercises to increase adduction of tissueTechnique uses lifting, pushing, and vocalizationExamples of oral motor control exercises are:1. range of tongue motion exercises2. resistance exercises3. bolus control exercises4. bolus propulsion exercisesThe 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 instructionsExamplesPositioning of the headSequence of instructionsIndirect therapy includes three types of exercises:Exercises to improve oral motor controlStimulation of swallowing reflexExercises to increase adduction (movement toward the midline) of tissues(Cook)
32 National Dysphagia Diet (NDD) National Dysphagia Diet (NDD) Task Force2002 established guidelines for 3 levels of altered solid food textures and 3 altered viscosity liquid levelsNational Dysphagia Diet
33 National Dysphagia Diet Four levels of the NDDDysphagia PureedVery cohesive, pudding-like, does not require chewingDysphagia Mechanically AlteredSemisolid foods, requiring chewing abilityDysphagia AdvancedSoft-solid foods that require more chewingRegularAll foods allowedNational Dysphagia DietThese four levels replace terms like- ground, chopped, soft and mechanically soft.
34 National Dysphagia Diet Dysphagia PureedDescriptionPudding-like, no coarse texture, raw fruit or vegetables, nuts, cannot use any food that requires bolus formation, controlled manipulation, or masticationRationaleFor people who have moderate to severe dysphagiaFor 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 dessertsButter, margarine, sour cream and smooth saucesPureed meatsMashed potatoes with gravyPureed soups that are blenderizedPureed vegetables that have no lumps or seedsNational Dysphagia Diet
35 National Dysphagia Diet Dysphagia Mechanically AlteredDescriptionFoods that are moist, soft-textured, and easily formed into a bolus.RationaleChewing ability required, for those with mild to moderate dysphagiaFor the dysphagia mechanically altered recommend:Soft pancakes, pureed bread mixesCooked cereal with little texturePudding or custard, soft fruit pies with bottom crust onlyCanned fruit other than pineapplesoft, moist cakesButter, margarine, cream, gravySoft drained canned or cooked fruit without seeds or skinFruit juice with a small amount of pulpMoistened ground or cooked meat, may be served with gravyMoist mac and cheese, well-cooked pasta, cottage cheeseWell-cooked, moistened, broiled, baked or mashed potatoesSoups with easy to chew meat and vegetablesSoft, well cooked vegetablesNational Dysphagia Diet
36 National Dysphagia Diet Dysphagia AdvancedDescriptionRegular texture food with the exception of very hard, sticky or crunchy foodsRationaleA transition to a regular dietFor individuals with mild dysphagiaFor the dysphagia advanced diet recommend:Well-moistened breads, pancakes, muffins, etc.Well-moistened cerealsAnything without seeds, nuts, dry fruit, coconut or pineappleAll fats allowed except those that are coarse or difficult to chewAll canned and cooked fruits, soft peeled fresh fruitsThin sliced, tender, or ground meat and poultryAll potatoes and starches, except potato skins, crisp-friend potatoes, or dry bread dressingAll soups, except those with tough meats or cornAll cooked tender vegetablesNational Dysphagia Diet
37 National Dysphagia Diet Examples of Foods to AvoidDysphagia PureedLevel 1Beverages 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, vegetablesDysphagia Mechanically AlteredLevel 2Dry 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 nutsDysphagia AdvancedLevel 3Dry 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 acceptanceProvide a pleasant atmosphere for diningAdd seasoning for stronger flavorsUse a variety of foods to improve appearance by adding colorRemember 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 productAdd appropriately texturedgarnishes to foodsRemember 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 controlEasily aspirated into the lungsLiquids may need to be thickened for safe swallowIt 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 pharynxExtend the duration of pharyngeal peristalsisProlong the opening of the cricopharyngeal (upper esophageal) sphincter
43 Thickened Liquids Commercial thickener Liquids must be encouraged due to high risk of dehydrationTypes of thickened liquidconsistenciesNectarHoneyPuddingCommercial 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 soupsHoneyLess pourable, drizzle from a cup or bowlPuddingHold their own shape, not pourable, eaten with a spoonNectar- similar to apricot nectarDo 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 LiquidsHydration 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 nectarDo 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 PatientsWatch for the red flagsDocument and reportReview MenusWhat can you do to provide more appetizing and dysphagia friendly foods?TeamworkNursing, dietary, and swallowing therapistsIdentify gaps in foods and liquids create solutionsWe 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 ConclusionDysphagia is a serious condition that requires clinical screening and treatmentTreatment involves therapy techniques and/ or diet and liquid modificationTeam communication is necessaryThe National Dysphagia Diet provides specific dietary guidelines to reduce risk of complications from dysphagia
49 Post Test 1. Which phase of swallowing is considered voluntary? A. Oral phaseB. Pharyngeal phaseC. Esophageal phase
50 Post Test2. Which of the following diseases does not increase a person’s risk of dysphagia?A. StrokeB. DementiaC. HypertensionD. Multiple sclerosis
51 Post Test3. Which of the following foods would be not be allowed on a Dysphagia Pureed Diet?A. NutsB. Pureed meatsC. Mashed potatoesD. Pureed breads
52 Post Test Answers Question #1 - A. Oral phase is considered voluntary Question #2 - C. Hypertension is not a risk for dysphagiaQuestion #3 - A. Nuts are not appropriate on a Dysphagia Puree Diet
53 ReferencesMahan 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.