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.

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

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

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

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

Screening for Dysphagia

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

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).

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.

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.

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

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)

Treatment

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)

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)

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)

National Dysphagia Diet and Thickened Liquids

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

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.

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

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

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

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

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

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

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

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.

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

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.

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

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

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.

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

Post Test Dysphagia

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

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

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

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

References Mahan LK, Escott-Stump S. Krause’s Food, Nutrition, and Diet Therapy. 11th 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.