1 Dysphagia: Nutrition and Hydration Management Funding for the educational program and/or materials...

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Dysphagia:Dysphagia:Nutrition and Hydration ManagementNutrition 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.

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Presentation ObjectivesPresentation Objectives List the three phases of swallowingList the three phases of swallowing Verbalize two of the three indirect therapies for oropharyngeal dysphagiaVerbalize two of the three indirect therapies for oropharyngeal dysphagia Describe the four levels of the National Dysphagia DietDescribe the four levels of the National Dysphagia Diet

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Presentation PreviewPresentation Preview

IntroductionIntroduction Phases of swallowingPhases of swallowing ScreeningScreening Treatment Treatment National Dysphagia Diet and National Dysphagia Diet and

thickened liquidsthickened liquids Post TestPost Test

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Swallowing Fun FactsSwallowing Fun Facts

We swallow more We swallow more than 600 times/daythan 600 times/day

We swallow about We swallow about once every minute once every minute while asleepwhile asleep

The swallow The swallow mechanism is mechanism is innervated by 7 innervated by 7 pairs of nerves pairs of nerves and 26 muscle and 26 muscle groupsgroups

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IntroductionIntroductionDysphagiaDysphagia

Defined as difficulty swallowing or the inability to Defined as difficulty swallowing or the inability to swallow.swallow.

Technically, it is oral-pharyngeal dysphagia or Technically, it is oral-pharyngeal dysphagia or oropharyngealoropharyngeal Pertinent to mouth and pharynx and not esophagusPertinent 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 May be a result of many different medical

conditionsconditions Can be an acute problem or progress slowly Can be an acute problem or progress slowly

over a long period of timeover a long period of time

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Dysphagia: EpidemiologyDysphagia: Epidemiology Estimated to affect 22% of the world’s population >50 years of age Estimated to affect 22% of the world’s population >50 years of age

Up to 30% of patients in hospitalsUp 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.)(Cook, Kawashima et al.)

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People Affected by DysphagiaPeople Affected by Dysphagia

Patients at high risk for dysphagiaPatients at high risk for dysphagia Intermediate-stage Parkinson’s diseaseIntermediate-stage Parkinson’s disease Multiple sclerosis (MS)Multiple sclerosis (MS) Amyotrophic lateral sclerosis (ALS)Amyotrophic lateral sclerosis (ALS) DementiaDementia StrokeStroke Head and Neck CancersHead and Neck Cancers

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ConsequencesConsequences

Dysphagia can increase the risk ofDysphagia can increase the risk of Inadequate intake resulting in weight Inadequate intake resulting in weight

loss and malnutritionloss and malnutrition DehydrationDehydration Aspiration of food and fluids into the Aspiration of food and fluids into the

airwayairway• Acutely causing aspiration pneumonitisAcutely causing aspiration pneumonitis• Chronically causing aspiration pneumoniasChronically causing aspiration pneumonias

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AspirationAspiration Aspiration PneumoniaAspiration 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 pneumoniaSilent 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)(Cook)

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Dysphagia: ConsequencesDysphagia: Consequences

The Vicious CycleThe Vicious Cycle

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

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SwallowingSwallowing

Three phases of Three phases of swallowingswallowing Oral phaseOral phase Pharyngeal phasePharyngeal phase Esophageal phaseEsophageal phase

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Oral PhaseOral Phase Food in the mouth is Food in the mouth is

combined with salivacombined with saliva Chewed if necessaryChewed if necessary Formed into a bolus Formed into a bolus

by the tongueby the tongue Tongue pushes food Tongue pushes food

to the rear of oral to the rear of oral cavitycavity

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Oral PhaseOral Phase

Challenges in this phase with dysphagiaChallenges in this phase with dysphagia Weakened lip muscles may decrease ability to seal the Weakened lip muscles may decrease ability to seal the

lips and drink from a strawlips and drink from a straw Increased intracranial pressure or cranial nerve Increased intracranial pressure or cranial nerve

damage may cause weakened tongue movementsdamage may cause weakened tongue movements Poor tongue strength and motility may cause problems Poor tongue strength and motility may cause problems

with :with :• Food may be pocketed in mouthFood may be pocketed in mouth• Difficulty forming a bolus and moving the food for Difficulty forming a bolus and moving the food for

the involuntary swallow initiation. the involuntary swallow initiation.

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Pharyngeal PhasePharyngeal Phase InvoluntaryInvoluntary Bolus is moved between the Bolus is moved between the

tonsillar pillarstonsillar pillars Soft Palate (posterior nares) are Soft Palate (posterior nares) are

closedclosed Epiglottis and vocal chords close Epiglottis and vocal chords close

off airwayoff airway Respirations ceaseRespirations cease

Upper esophageal sphincter is Upper esophageal sphincter is openedopened Food is directed to esophagusFood is directed to esophagus

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Pharyngeal PhasePharyngeal Phase

Symptoms of difficultySymptoms of difficulty GaggingGagging ChokingChoking Nasopharyngeal regurgitationNasopharyngeal regurgitation

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Esophageal PhaseEsophageal Phase

InvoluntaryInvoluntary Upper esophageal Upper esophageal

sphincter is relaxedsphincter is relaxed Peristaltic wave Peristaltic wave

moves the bolus moves the bolus down the down the esophagusesophagus

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Esophageal PhaseEsophageal Phase

Difficulties in this phase may Difficulties in this phase may

be due to:be due to: Mechanical obstructionMechanical obstruction Impaired peristalsisImpaired peristalsis

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What happens during What happens during chewing and swallowing?chewing and swallowing?

Effects on food during chewing and Effects on food during chewing and swallowingswallowing CompressionCompression AdhesivenessAdhesiveness TensileTensile ShearShear Fracture Fracture (National Dysphagia Diet)(National Dysphagia Diet)

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Screening for DysphagiaScreening for Dysphagia

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Symptoms of DysphagiaSymptoms of Dysphagia DroolingDrooling ChokingChoking Coughing during mealsCoughing during meals Gurgly voice qualityGurgly voice quality Absent gag reflexAbsent gag reflex Food avoidanceFood avoidance Pocketing foods in the Pocketing foods in the

cheekscheeks Lengthy meal timesLengthy meal times

Complaints of multiple, Complaints of multiple, painful swallowspainful swallows

Prolonged eating timeProlonged eating time Weight lossWeight loss DehydrationDehydration Difficulty managing oral Difficulty managing oral

secretionssecretions

LogemanLogeman

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ScreeningScreening

Observation during meals by nurse Observation during meals by nurse and dietitianand dietitian

Treatment team involvementTreatment team involvement Swallowing evaluation by speech Swallowing evaluation by speech

pathologistpathologist

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Dysphagia Screening: Dysphagia Screening: Clinical ExamClinical Exam

Exam Components:Exam Components: Comprehensive swallowing historyComprehensive swallowing history Exam of the oral cavity for oral control, tongue activity and oral residual or pocketing of foodExam 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 excursionObservation with auscultation of a “dry” swallow and with food for initiation of laryngeal elevation and laryngeal excursion Voice quality and cough after swallowVoice quality and cough after swallow

Clinical exam unable to detect 40% of silent aspiratorsClinical exam unable to detect 40% of silent aspirators (Logeman)(Logeman)

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ScreeningScreening

Medications can play a role in pathology, Medications can play a role in pathology, treatment and prevention of dysphagiatreatment and prevention of dysphagia Medication side effectsMedication side effects

• Dry mouthDry mouth• Pharyngeal ulcerationPharyngeal ulceration• Tardive dyskinesiaTardive dyskinesia• Drug-induced confusionDrug-induced confusion

(Logeman)(Logeman)

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Diagnostic ToolsDiagnostic Tools Videofluoroscopic procedureVideofluoroscopic procedure

Most widely used determine physiology of Most widely used determine physiology of swallowswallow

Other evaluation toolsOther evaluation tools• Fiberoptic endoscopic examinationFiberoptic endoscopic examination• UltrasoundUltrasound• ElectromyographyElectromyography• ElectroglottographyElectroglottography

(Logeman)(Logeman)

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DiagnosticsDiagnostics

Videofluoroscopic procedureVideofluoroscopic procedure Also known as modified barium swallowAlso known as modified barium swallow A radiographic study of a person’s A radiographic study of a person’s

swallowing mechanism that is recorded swallowing mechanism that is recorded on videotapeon videotape

(Logeman)(Logeman)

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TreatmentTreatment

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TreatmentTreatment

Use of proper swallowing techniquesUse of proper swallowing techniques Therapy techniquesTherapy techniques

• Indirect therapyIndirect therapy• Direct therapyDirect therapy

Change consistency of foods/ liquidsChange consistency of foods/ liquids National Dysphagia DietNational Dysphagia Diet Thickened liquidsThickened liquids

(Cook)(Cook)

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TreatmentTreatment

Indirect therapyIndirect therapy Oral motor control exercisesOral motor control exercises

• Focuses on the six aspects of tongue control Focuses on the six aspects of tongue control during swallowingduring swallowing

Stimulation of swallowing reflexStimulation of swallowing reflex• Heightens the sensitivityHeightens the sensitivity

Exercises to increase adduction of tissueExercises to increase adduction of tissue• Technique uses lifting, pushing, and vocalizationTechnique uses lifting, pushing, and vocalization

(Cook)(Cook)

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TreatmentTreatment

Direct therapyDirect therapy Giving food or liquid to the patient and Giving food or liquid to the patient and

asking him or her to swallow while asking him or her to swallow while giving instructionsgiving instructions• ExamplesExamples

Positioning of the headPositioning of the head Sequence of instructionsSequence of instructions

(Cook)(Cook)

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National Dysphagia Diet and National Dysphagia Diet and Thickened LiquidsThickened Liquids

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National Dysphagia Diet (NDD)National Dysphagia Diet (NDD)

National Dysphagia Diet (NDD) Task Force National Dysphagia Diet (NDD) Task Force

2002 established guidelines for 3 levels of 2002 established guidelines for 3 levels of altered solid food textures and 3 altered altered solid food textures and 3 altered

viscosity liquid levels viscosity liquid levels

National Dysphagia Diet

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National Dysphagia Diet National Dysphagia Diet

Four levels of the NDDFour levels of the NDD Dysphagia PureedDysphagia Pureed

• Very cohesive, pudding-like, does not require chewingVery cohesive, pudding-like, does not require chewing Dysphagia Mechanically AlteredDysphagia Mechanically Altered

• Semisolid foods, requiring chewing abilitySemisolid foods, requiring chewing ability Dysphagia AdvancedDysphagia Advanced

• Soft-solid foods that require more chewingSoft-solid foods that require more chewing RegularRegular

• All foods allowedAll foods allowed National Dysphagia Diet

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National Dysphagia DietNational Dysphagia Diet

Dysphagia PureedDysphagia Pureed DescriptionDescription

• Pudding-like, no coarse texture, raw fruit or Pudding-like, no coarse texture, raw fruit or vegetables, nuts, cannot use any food that vegetables, nuts, cannot use any food that requires bolus formation, controlled requires bolus formation, controlled manipulation, or masticationmanipulation, or mastication

RationaleRationale• For people who have moderate to severe For people who have moderate to severe

dysphagiadysphagiaNational Dysphagia Diet

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Dysphagia Mechanically AlteredDysphagia Mechanically Altered DescriptionDescription

• Foods that are moist, soft-textured, and Foods that are moist, soft-textured, and easily formed into a bolus.easily formed into a bolus.

RationaleRationale• Chewing ability required, for those with mild Chewing ability required, for those with mild

to moderate dysphagiato moderate dysphagia


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Dysphagia AdvancedDysphagia Advanced DescriptionDescription

• Regular texture food with the exception of Regular texture food with the exception of very hard, sticky or crunchy foodsvery hard, sticky or crunchy foods

RationaleRationale• A transition to a regular dietA transition to a regular diet• For individuals with mild dysphagiaFor individuals with mild dysphagia


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National Dysphagia DietNational Dysphagia DietDiet Examples of Foods to

Avoid

Dysphagia PureedDysphagia Pureed

Level 1Level 1

Beverages with lumps, dry breads and Beverages with lumps, dry breads and cereals, oatmeal, ices, gelatins, cookies, cereals, oatmeal, ices, gelatins, cookies, cakes, fats with chunky additives, whole cakes, fats with chunky additives, whole fruit, whole or ground meat, cheese, fruit, whole or ground meat, cheese, cottage cheese, rice, potatoes, soups cottage cheese, rice, potatoes, soups with chunks, vegetableswith chunks, vegetables

Dysphagia Mechanically Dysphagia Mechanically AlteredAltered

Level 2Level 2

Dry breads, coarse cereals that may Dry breads, coarse cereals that may contain nuts or seeds, dry cakes and contain nuts or seeds, dry cakes and cookies, fresh or frozen fruits, dried cookies, fresh or frozen fruits, dried fruits, dry meat, peanut butter, soups fruits, dry meat, peanut butter, soups with chunks, fibrous vegetables, seeds with chunks, fibrous vegetables, seeds and nutsand nuts

Dysphagia AdvancedDysphagia Advanced

Level 3Level 3

Dry bread, coarse cereals, dry cakes Dry bread, coarse cereals, dry cakes and cookies, difficult to chew fruits, and cookies, difficult to chew fruits, tough meats, chunky peanut butter, tough meats, chunky peanut butter, potato skins, raw vegetables, nuts and potato skins, raw vegetables, nuts and seedsseeds

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Techniques to improve acceptanceTechniques to improve acceptance Provide a pleasant atmosphere for Provide a pleasant atmosphere for

diningdining Add seasoning for stronger flavorsAdd seasoning for stronger flavors Use a variety of foods to improve Use a variety of foods to improve

appearance by adding colorappearance by adding color


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Techniques to improve acceptance Techniques to improve acceptance continued..continued.. Use molds to shape and enhance Use molds to shape and enhance

productproduct Add appropriately textured Add appropriately textured

garnishes to foods garnishes to foods


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

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Thickened LiquidsThickened Liquids LiquidsLiquids

Swallowing of liquids requires coordination Swallowing of liquids requires coordination and controland control

Easily aspirated into the lungsEasily aspirated into the lungs Liquids may need to be thickened for safe Liquids may need to be thickened for safe

swallowswallow

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Thickened LiquidsThickened Liquids

What are the benefits?What are the benefits? Delay the bolus transit through the pharynxDelay the bolus transit through the pharynx Extend the duration of pharyngeal peristalsisExtend the duration of pharyngeal peristalsis Prolong the opening of the cricopharyngeal Prolong the opening of the cricopharyngeal

(upper esophageal) sphincter(upper esophageal) sphincter

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Commercial thickenerCommercial thickener Liquids must be encouraged due to high Liquids must be encouraged due to high

risk of dehydration risk of dehydration Types of thickened liquid Types of thickened liquid

consistenciesconsistencies NectarNectar HoneyHoney PuddingPudding

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Thickened LiquidsThickened Liquids NectarNectar

Easily pourable and similar to thicker Easily pourable and similar to thicker cream soupscream soups

HoneyHoney Less pourable, drizzle from a cup or bowlLess pourable, drizzle from a cup or bowl

PuddingPudding Hold their own shape, not pourable, Hold their own shape, not pourable,

eaten with a spooneaten with a spoon

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Hydration is critical to overall good Hydration is critical to overall good health of people with dysphagia.health of people with dysphagia.

Proper consistency and adequate Proper consistency and adequate consumption are key factors in consumption are key factors in promoting safe hydration for your promoting safe hydration for your patients.patients.

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Improve Safety and Efficacy of Improve Safety and Efficacy of Dysphagia DietsDysphagia Diets

Observe PatientsObserve Patients Watch for the red flagsWatch for the red flags Document and report Document and report

Review MenusReview 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?

TeamworkTeamwork Nursing, dietary, and swallowing therapistsNursing, dietary, and swallowing therapists Identify gaps in foods and liquidsIdentify gaps in foods and liquids create solutions create solutions

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ConclusionConclusion

Dysphagia is a serious condition that Dysphagia is a serious condition that requires clinical screening and treatmentrequires clinical screening and treatment

Treatment involves therapy techniques Treatment involves therapy techniques and/ or diet and liquid modification and/ or diet and liquid modification Team communication is necessaryTeam communication is necessary

The National Dysphagia Diet provides The National Dysphagia Diet provides specific dietary guidelines to reduce risk of specific dietary guidelines to reduce risk of complications from dysphagiacomplications from dysphagia

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Post TestPost TestDysphagiaDysphagia

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Post TestPost Test

1. Which phase of swallowing is 1. Which phase of swallowing is considered voluntary?considered voluntary?

A. Oral phaseA. Oral phase

B. Pharyngeal phaseB. Pharyngeal phase

C. Esophageal phaseC. Esophageal phase

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Post TestPost Test

2. Which of the following diseases does 2. Which of the following diseases does not increase a person’s risk of not increase a person’s risk of dysphagia?dysphagia?

A. StrokeA. Stroke

B. DementiaB. Dementia

C. HypertensionC. Hypertension

D. Multiple sclerosisD. Multiple sclerosis

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Post TestPost Test

3. Which of the following foods would 3. Which of the following foods would be not be allowed on a Dysphagia be not be allowed on a Dysphagia Pureed Diet?Pureed Diet?

A. NutsA. Nuts

B. Pureed meatsB. Pureed meats

C. Mashed potatoesC. Mashed potatoes

D. Pureed breadsD. Pureed breads

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Post Test AnswersPost Test Answers

Question #1 - A. Oral phase is Question #1 - A. Oral phase is considered voluntaryconsidered voluntary

Question #2 - C. Hypertension is not a Question #2 - C. Hypertension is not a risk for dysphagiarisk for dysphagia

Question #3 - A. Nuts are not Question #3 - A. Nuts are not appropriate on a Dysphagia Puree appropriate on a Dysphagia Puree DietDiet

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ReferencesReferences

Mahan LK, Escott-Stump S. Krause’s Food, Nutrition, and Diet Therapy. 11Mahan LK, Escott-Stump S. Krause’s Food, Nutrition, and Diet Therapy. 11 thth ed. Philadelphia, PA:Saunders;2004:1087-1092.ed. Philadelphia, PA:Saunders;2004:1087-1092.

Logemann J. Evaluation and Treatment of Swallowing Disorders. Austin, Logemann J. Evaluation and Treatment of Swallowing Disorders. Austin, Texas:Pro-ed;1983.Texas:Pro-ed;1983.

Sonies BC. Dysphagia. A Continuum of Care. Gaithersburg, MD:Aspen;1997.Sonies BC. Dysphagia. A Continuum of Care. Gaithersburg, MD:Aspen;1997.

National Dysphagia Task Force. American Dietetic Association. National Dysphagia Task Force. American Dietetic Association. National National Dysphagia Diet: Standardization for Optimal Care. Dysphagia Diet: Standardization for Optimal Care. Chicago: American Chicago: American Dietetic Association, 2002.Dietetic Association, 2002.

Cook IJ, Kahrilas PJ. AGA technical review on management of oropharyngeal Cook IJ, Kahrilas PJ. AGA technical review on management of oropharyngeal dysphagia. Gastroenterology 1999; 116:455-478.dysphagia. Gastroenterology 1999; 116:455-478.

Kawashima K, Motohashi Y, Fujishima I. Prevalence of Dysphagia Among Kawashima K, Motohashi Y, Fujishima I. Prevalence of Dysphagia Among Community Dwelling Elderly Individuals as Estimated Using a Community Dwelling Elderly Individuals as Estimated Using a Questionnaire for Dysphagia Screening. Dysphagia 2004; 19:266-271Questionnaire for Dysphagia Screening. Dysphagia 2004; 19:266-271

Logeman J. Evaluation and treatment of swallowing disorders. Pro-ed, Austin, Logeman J. Evaluation and treatment of swallowing disorders. Pro-ed, Austin, TX 1983.TX 1983.

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