Dysphagia PDF

Dysphagia 1  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 2  Introduction Dysph...

Dysphagia 1  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 2  Introduction Dysphagia either refers to the difficulty someone may have with initiating a swallow (usually referred to as oropharyngeal dysphagia) or it refers to the sensation that foods and or liquids are somehow hindered in their passage from the mouth to the stomach (usually referred to as esophageal dysphagia). Dysphagia therefore is the “perception” that there is an impediment to the normal passage of swallowed material. 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 3 Physiology of Swallowing 4 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! 5  People Affected by Dysphagia Patients at high risk for dysphagia – Intermediate-stage Parkinson’s disease. – Multiple sclerosis (MS) – Dementia. – Stroke. – Head and Neck Cancers. – Myasthenia gravis. – Cerebral palsy 6  Consequences Impairments in swallowing can have a profound impact on intake and nutritional status, and greatly increase the risk of aspiration and its complications of bacterial pneumonia and bronchial obstruction. Emotionally, dysphagia can affect quality of life; patients with dysphagia may feel panic at mealtime and avoid eating with others. Meeting nutritional needs is a challenge and in som e instanc es, enteral nutrition m ay b e necessary. 7 Dysphagia: Consequences The Vicious Cycle 8  Nutrition Therapy The goal of nutrition therapy for dysphagia is to modify the texture of foods and/or viscosity of liquids to enable the patient to achieve adequate nutrition and hydration while decreasing the risk of aspiration. Solid foods may be minced, mashed, ground, or pureed and thin liquids may be thickened to facilitate swallowing, but these measures often dilute the nutritional value of the d i e t a nd m a ke f o o d a nd b e v e ra g e s l e ss appealing. 9  The Am erican Dietetic Association has published the National Dysphagia Diet, developed by a group of dietitians, speech and language therapists, and a food scientist for the purpose of standardizing dysphagia diets throughout the United States (The National D y s p h a g i a D i e t Ta s k Fo rc e , 2 0 0 2 ). I t i s composed of three levels of solid textures and four liquid consistencies. 10  Three Levels of Solid Textures - Level 1: Dysphagia Pureed Smooth cooked cereals; pureed bread products; milk; smooth desserts such as yogurt, pudding, custard, and apple sauce; pureed fruits, vegetables, meats, scrambled eggs, and soups. 11 - Level 2: Dysphagia Mechanically Altered Cooked cereals may have a little texture; some well-moistened ready-to-eat cereals; well-moistened pancakes with syrup; moist well-cooked potatoes, noodles, and dumplings; soft poached or scrambled egg; soft canned or cooked fruit; 12  Level 3: Dysphagia Advanced All breads are allowed except for those that are crusty; moist cereals; most desserts except those with nuts, seeds, coconut, pineapple, or dried fruit; soft, peeled fruit without seeds; moist tender meats or casseroles with small pieces of meat; moist potatoes, rice, and stuf fin g; all soup s exc ep t those with c hewy m eats or vegetables; most cooked, tender vegetables, except corn; shredded lettuce. 13  Four Liquid Consistencies - Thin: Clear juices, frozen yogurt, ice cream, milk, water, coffee, tea, soda, broth, plain gelatin, liquid fruits such as watermelon. - Nectarlike: Nectars, vegetable juices, chocolate milk, buttermilk, thin milkshakes, cream soups, other properly thickened beverages 14 - Honeylike: Honey, tomato sauce, yogurt -Spoon-Thick: Pudding, custard, hot cereal. 15  The levels o f so lid fo o d and liq uid s are o rd ered separately to allow maximum f le xibility and safety in meeting the patient’s needs. The patient may start at any of the levels. The solid food consistencies include pureed, mechanically altered, and a more advanced consistency of mixed textures. The liquids are described as thin, nectarlike, honeylike, and spoon-thick. Generally a speech or language pathologist (SLP) performs a swallowing evaluation on the patient to determine the appropriate consistency of food and liquids and recommends feeding techniques based on the patient’s individual status. Changes to the diet prescription are made as the patient’s ability to swallow improves or deteriorates 16  Generally, moist, semisolid foods are easiest to swallow, such as pudding, custards, scrambled eggs, and yogurt because they form a cohesive bolus that is more easily controlled. Dry, crumbly, and sticky foods are avoided. Some foods, such as bread, are slurried to create a texture easily swallowed while retaining the appearance of “regular” bread. Commercial thickeners added to pureed foods can allow pureed foods to be molded into the appearance of “normal” food, which is more visually appealing than “baby food.”. In studies comparing molded food to standard pureed food, people with dysphagia found the molded food to be more difficult to eat, instead preferring pureed food. Flavor enhanc ers, c olored plates, and attrac tive garnishes can improve the appearance of pureed food. 17 18  Thickened liquids are more cohesive than thin liquids and are easier to control. Commercial thickening agents provide instructions on how to mix the product with liquids to achieve the desired consistency, yet wide variations in consistency occur depending on the beverage type, thickener brand, temperature of the liquid, and time between thickened f lu id preparation and service to the patient. Commerc ially prepared thic kened beverages are available but viscosity varies among manufacturers and many product labels do not include viscosity. Thickened beverages are often poorly accepted making it dif fic ult to maintain an adequate fluid intake. 19 - Various feeding techniques may facilitate safe swallowing: Serve small, frequent meals to help maximize intake. Encourage patients with dysphagia to rest before mealtime. Postpone meals if the patient is fatigued. Give mouth care immediately before meals to enhance the sense of taste. Instruct the patient to think of a specific food to stimulate salivation. A lemon slice, hard candy, or dill pickles may also help to trigger salivation, as may Moderately flavored foods. Reduce or eliminate distractions at mealtime so that the patient can focus his or her attention on swallowing. Limit disruptions, if possible. Do not rush the patient; allow at least 30 minutes for eating. 20  Place the patient in an upright or high Fowler’s position. If the patient has one-sided facial weakness, place the food on the other side of the mouth. Tilt the head forward to facilitate swallowing. Use adaptive eating devices such as built-up utensils and mugs with spouts, if indicated. Syringes should never be used to force liquids into the patient’s mouth because this can trigger choking or aspiration. Unless otherwise directed, do not allow the patient to use a straw. Encourage small bites and thorough chewing. Discourage the patient from consuming alcohol because it reduces cough and gag reflexes. 21 22