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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.
22
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
33
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
44
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
55
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)
1010
Dysphagia: ConsequencesDysphagia: Consequences
The Vicious CycleThe Vicious Cycle
1111
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.
1212
SwallowingSwallowing
Three phases of Three phases of swallowingswallowing Oral phaseOral phase Pharyngeal phasePharyngeal phase Esophageal phaseEsophageal phase
1313
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
1414
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.
1515
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
1616
Pharyngeal PhasePharyngeal Phase
Symptoms of difficultySymptoms of difficulty GaggingGagging ChokingChoking Nasopharyngeal regurgitationNasopharyngeal regurgitation
1717
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
1818
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
1919
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)
2020
Screening for DysphagiaScreening for Dysphagia
2121
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
2222
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
2323
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)
2424
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)
2525
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)
2626
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)
2727
TreatmentTreatment
2828
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)
2929
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)
3030
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)
3131
National Dysphagia Diet and National Dysphagia Diet and Thickened LiquidsThickened Liquids
3232
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
3333
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
3535
National Dysphagia DietNational Dysphagia Diet
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
National Dysphagia Diet
3636
National Dysphagia DietNational Dysphagia Diet
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
National Dysphagia Diet
3737
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
3838
National Dysphagia DietNational Dysphagia Diet
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
National Dysphagia Diet
3939
National Dysphagia DietNational Dysphagia Diet
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
National Dysphagia Diet
4040
National Dysphagia DietNational Dysphagia Diet
Example: Dysphagia Puree using molds, Example: Dysphagia Puree using molds, variety of foods for color and seasonings variety of foods for color and seasonings
4141
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
4242
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
4343
Thickened LiquidsThickened Liquids
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
4444
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
4545
Thickened LiquidsThickened Liquids
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.
4646
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
4747
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
4848
Post TestPost TestDysphagiaDysphagia
4949
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
5050
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
5151
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
5252
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
5353
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.