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1 Dysphagia: Nutrition and Hydration Management Funding for the educational program and/or materials is sponsored by Nestlé Nutrition. Copyright 2009 Nestlé

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Presentation on theme: "1 Dysphagia: Nutrition and Hydration Management Funding for the educational program and/or materials is sponsored by Nestlé Nutrition. Copyright 2009 Nestlé"— Presentation transcript:

1 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 2 Presentation Objectives List the three phases of swallowing List the three phases of swallowing Verbalize two of the three indirect therapies for oropharyngeal dysphagia Verbalize two of the three indirect therapies for oropharyngeal dysphagia Describe the four levels of the National Dysphagia Diet Describe the four levels of the National Dysphagia Diet

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

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

5 5 Introduction Dysphagia Defined as difficulty swallowing or the inability to swallow. Defined as difficulty swallowing or the inability to swallow. Technically, it is oral-pharyngeal dysphagia or oropharyngeal Technically, it is oral-pharyngeal dysphagia or oropharyngeal Pertinent to mouth and pharynx and not esophagus Pertinent to mouth and pharynx and not esophagus Can occur in all age groups Can occur in all age groups May be a result of many different medical conditions May be a result of many different medical conditions Can be an acute problem or progress slowly over a long period of time Can be an acute problem or progress slowly over a long period of time

6 6 Dysphagia: Epidemiology Estimated to affect 22% of the worlds population >50 years of age Estimated to affect 22% of the worlds population >50 years of age Up to 30% of patients in hospitals Up to 30% of patients in hospitals ~60% of residents in nursing homes ~60% of residents in nursing homes Probably 14% of people >65 years of age living in the community Probably 14% of people >65 years of age living in the community Children? Children? No incidence or prevalence is noted! No incidence or prevalence is noted! (Cook, Kawashima et al.)

7 7 People Affected by Dysphagia Patients at high risk for dysphagia Patients at high risk for dysphagia Intermediate-stage Parkinsons disease Intermediate-stage Parkinsons disease Multiple sclerosis (MS) Multiple sclerosis (MS) Amyotrophic lateral sclerosis (ALS) Amyotrophic lateral sclerosis (ALS) Dementia Dementia Stroke Stroke Head and Neck Cancers Head and Neck Cancers

8 8 Consequences Dysphagia can increase the risk of Dysphagia can increase the risk of Inadequate intake resulting in weight loss and malnutrition Inadequate intake resulting in weight loss and malnutrition Dehydration Dehydration Aspiration of food and fluids into the airway Aspiration of food and fluids into the airway Acutely causing aspiration pneumonitisAcutely causing aspiration pneumonitis Chronically causing aspiration pneumoniasChronically causing aspiration pneumonias

9 9 Aspiration Aspiration Pneumonia Aspiration Pneumonia 25-30% of patients with dysphagia are silent aspirators 25-30% of patients with dysphagia are silent aspirators Silent aspiration has a 7 fold higher risk for developing aspiration pneumonia 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. In the elderly with dysphagia those who have silent aspiration have a higher mortality rate.(Cook)

10 10 Dysphagia: Consequences The Vicious Cycle

11 11 Many people with dysphagia go unrecognized or undiagnosed until a major event such as aspiration pneumonia occurs. Many people with dysphagia go unrecognized or undiagnosed until a major event such as aspiration pneumonia occurs.

12 12 Swallowing Three phases of swallowing Three phases of swallowing Oral phase Oral phase Pharyngeal phase Pharyngeal phase Esophageal phase Esophageal phase

13 13 Oral Phase Food in the mouth is combined with saliva Food in the mouth is combined with saliva Chewed if necessary Chewed if necessary Formed into a bolus by the tongue Formed into a bolus by the tongue Tongue pushes food to the rear of oral cavity Tongue pushes food to the rear of oral cavity

14 14 Oral Phase Challenges in this phase with dysphagia Challenges in this phase with dysphagia Weakened lip muscles may decrease ability to seal the lips and drink from a straw 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 Increased intracranial pressure or cranial nerve damage may cause weakened tongue movements Poor tongue strength and motility may cause problems with : Poor tongue strength and motility may cause problems with : Food may be pocketed in mouthFood may be pocketed in mouth Difficulty forming a bolus and moving the food for the involuntary swallow initiation.Difficulty forming a bolus and moving the food for the involuntary swallow initiation.

15 15 Pharyngeal Phase Involuntary Involuntary Bolus is moved between the tonsillar pillars Bolus is moved between the tonsillar pillars Soft Palate (posterior nares) are closed Soft Palate (posterior nares) are closed Epiglottis and vocal chords close off airway Epiglottis and vocal chords close off airway Respirations cease Respirations cease Upper esophageal sphincter is opened Upper esophageal sphincter is opened Food is directed to esophagus Food is directed to esophagus

16 16 Pharyngeal Phase Symptoms of difficulty Symptoms of difficulty Gagging Gagging Choking Choking Nasopharyngeal regurgitation Nasopharyngeal regurgitation

17 17 Esophageal Phase Involuntary Involuntary Upper esophageal sphincter is relaxed Upper esophageal sphincter is relaxed Peristaltic wave moves the bolus down the esophagus Peristaltic wave moves the bolus down the esophagus

18 18 Esophageal Phase Difficulties in this phase may Difficulties in this phase may be due to: Mechanical obstruction Mechanical obstruction Impaired peristalsis Impaired peristalsis

19 19 What happens during chewing and swallowing? Effects on food during chewing and swallowing Effects on food during chewing and swallowing Compression Compression Adhesiveness Adhesiveness Tensile Tensile Shear Shear Fracture Fracture (National Dysphagia Diet)

20 20 Screening for Dysphagia

21 21 Symptoms of Dysphagia Drooling Drooling Choking Choking Coughing during meals Coughing during meals Gurgly voice quality Gurgly voice quality Absent gag reflex Absent gag reflex Food avoidance Food avoidance Pocketing foods in the cheeks Pocketing foods in the cheeks Lengthy meal times Lengthy meal times Complaints of multiple, painful swallows Complaints of multiple, painful swallows Prolonged eating time Prolonged eating time Weight loss Weight loss Dehydration Dehydration Difficulty managing oral secretions Difficulty managing oral secretions Logeman

22 22 Screening Observation during meals by nurse and dietitian Observation during meals by nurse and dietitian Treatment team involvement Treatment team involvement Swallowing evaluation by speech pathologist Swallowing evaluation by speech pathologist

23 23 Dysphagia Screening: Clinical Exam Exam Components: Comprehensive swallowing history Comprehensive swallowing history Exam of the oral cavity for oral control, tongue activity and oral residual or pocketing of food 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 Observation with auscultation of a dry swallow and with food for initiation of laryngeal elevation and laryngeal excursion Voice quality and cough after swallow Voice quality and cough after swallow Clinical exam unable to detect 40% of silent aspirators (Logeman)

24 24 Screening Medications can play a role in pathology, treatment and prevention of dysphagia Medications can play a role in pathology, treatment and prevention of dysphagia Medication side effects Medication side effects Dry mouthDry mouth Pharyngeal ulcerationPharyngeal ulceration Tardive dyskinesiaTardive dyskinesia Drug-induced confusionDrug-induced confusion(Logeman)

25 25 Diagnostic Tools Videofluoroscopic procedure Videofluoroscopic procedure Most widely used determine physiology of swallow Most widely used determine physiology of swallow Other evaluation tools Other evaluation tools Fiberoptic endoscopic examinationFiberoptic endoscopic examination UltrasoundUltrasound ElectromyographyElectromyography ElectroglottographyElectroglottography (Logeman)

26 26 Diagnostics Videofluoroscopic procedure Videofluoroscopic procedure Also known as modified barium swallow Also known as modified barium swallow A radiographic study of a persons swallowing mechanism that is recorded on videotape A radiographic study of a persons swallowing mechanism that is recorded on videotape (Logeman)

27 27 Treatment

28 28 Treatment Use of proper swallowing techniques Use of proper swallowing techniques Therapy techniques Therapy techniques Indirect therapyIndirect therapy Direct therapyDirect therapy Change consistency of foods/ liquids Change consistency of foods/ liquids National Dysphagia Diet National Dysphagia Diet Thickened liquids Thickened liquids (Cook)

29 29 Treatment Indirect therapy Indirect therapy Oral motor control exercises Oral motor control exercises Focuses on the six aspects of tongue control during swallowingFocuses on the six aspects of tongue control during swallowing Stimulation of swallowing reflex Stimulation of swallowing reflex Heightens the sensitivityHeightens the sensitivity Exercises to increase adduction of tissue Exercises to increase adduction of tissue Technique uses lifting, pushing, and vocalizationTechnique uses lifting, pushing, and vocalization (Cook)

30 30 Treatment Direct therapy Direct therapy Giving food or liquid to the patient and asking him or her to swallow while giving instructions Giving food or liquid to the patient and asking him or her to swallow while giving instructions ExamplesExamples Positioning of the head Positioning of the head Sequence of instructions Sequence of instructions (Cook)

31 31 National Dysphagia Diet and Thickened Liquids

32 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 33 National Dysphagia Diet Four levels of the NDD Four levels of the NDD Dysphagia Pureed Dysphagia Pureed Very cohesive, pudding-like, does not require chewingVery cohesive, pudding-like, does not require chewing Dysphagia Mechanically Altered Dysphagia Mechanically Altered Semisolid foods, requiring chewing abilitySemisolid foods, requiring chewing ability Dysphagia Advanced Dysphagia Advanced Soft-solid foods that require more chewingSoft-solid foods that require more chewing Regular Regular All foods allowedAll foods allowed National Dysphagia Diet

34 34 National Dysphagia Diet Dysphagia Pureed Dysphagia Pureed Description Description Pudding-like, no coarse texture, raw fruit or vegetables, nuts, cannot use any food that requires bolus formation, controlled manipulation, or masticationPudding-like, no coarse texture, raw fruit or vegetables, nuts, cannot use any food that requires bolus formation, controlled manipulation, or mastication Rationale Rationale For people who have moderate to severe dysphagiaFor people who have moderate to severe dysphagia National Dysphagia Diet

35 35 National Dysphagia Diet Dysphagia Mechanically Altered Dysphagia Mechanically Altered Description Description Foods that are moist, soft-textured, and easily formed into a bolus.Foods that are moist, soft-textured, and easily formed into a bolus. Rationale Rationale Chewing ability required, for those with mild to moderate dysphagiaChewing ability required, for those with mild to moderate dysphagia National Dysphagia Diet

36 36 National Dysphagia Diet Dysphagia Advanced Dysphagia Advanced Description Description Regular texture food with the exception of very hard, sticky or crunchy foodsRegular texture food with the exception of very hard, sticky or crunchy foods Rationale Rationale A transition to a regular dietA transition to a regular diet For individuals with mild dysphagiaFor individuals with mild dysphagia National Dysphagia Diet

37 37 National Dysphagia Diet DietExamples 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 38 National Dysphagia Diet Techniques to improve acceptance Techniques to improve acceptance Provide a pleasant atmosphere for dining Provide a pleasant atmosphere for dining Add seasoning for stronger flavors Add seasoning for stronger flavors Use a variety of foods to improve appearance by adding color Use a variety of foods to improve appearance by adding color National Dysphagia Diet

39 39 National Dysphagia Diet Techniques to improve acceptance continued.. Techniques to improve acceptance continued.. Use molds to shape and enhance product Use molds to shape and enhance product Add appropriately textured Add appropriately textured garnishes to foods garnishes to foods National Dysphagia Diet

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

41 41 Thickened Liquids Liquids Liquids Swallowing of liquids requires coordination and control Swallowing of liquids requires coordination and control Easily aspirated into the lungs Easily aspirated into the lungs Liquids may need to be thickened for safe swallow Liquids may need to be thickened for safe swallow

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

43 43 Thickened Liquids Commercial thickener Commercial thickener Liquids must be encouraged due to high risk of dehydration Liquids must be encouraged due to high risk of dehydration Types of thickened liquid Types of thickened liquidconsistencies Nectar Nectar Honey Honey Pudding Pudding

44 44 Thickened Liquids Nectar Nectar Easily pourable and similar to thicker cream soups Easily pourable and similar to thicker cream soups Honey Honey Less pourable, drizzle from a cup or bowl Less pourable, drizzle from a cup or bowl Pudding Pudding Hold their own shape, not pourable, eaten with a spoon Hold their own shape, not pourable, eaten with a spoon

45 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.

46 46 Improve Safety and Efficacy of Dysphagia Diets Observe Patients Observe Patients Watch for the red flags Watch for the red flags Document and report Document and report Review Menus Review Menus What can you do to provide more appetizing and dysphagia friendly foods? What can you do to provide more appetizing and dysphagia friendly foods? Teamwork Teamwork Nursing, dietary, and swallowing therapists Nursing, dietary, and swallowing therapists Identify gaps in foods and liquids create solutions Identify gaps in foods and liquids create solutions

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

48 48 Post Test Dysphagia

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

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

51 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 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 53 References Mahan LK, Escott-Stump S. Krauses Food, Nutrition, and Diet Therapy. 11 th ed. Philadelphia, PA:Saunders;2004:1087-1092. 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; 116:455-478. Kawashima K, Motohashi Y, Fujishima I. Prevalence of Dysphagia Among Community Dwelling Elderly Individuals as Estimated Using a Questionnaire for Dysphagia Screening. Dysphagia 2004; 19:266-271 Logeman J. Evaluation and treatment of swallowing disorders. Pro-ed, Austin, TX 1983.


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