Dysphagia: Nutrition and Hydration Management

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

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.)

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

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

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)

10. Dysphagia: Consequences The Vicious Cycle

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

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

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

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.

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

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

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

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

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

20. Screening for Dysphagia

21. 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 Symptoms of Dysphagia Logeman

22. Screening • Observation during meals by nurse and dietitian • Treatment team involvement • Swallowing evaluation by 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)

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)

25. Diagnostic Tools • Videofluoroscopic procedure • 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 (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 (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 (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 (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

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 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 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 National Dysphagia Diet

37. National Dysphagia Diet

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 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 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

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

44. Thickened Liquids • Nectar • 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

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. 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

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