Dealing with Dysphagia

Sysco Corporation Inservice Program

Outline

• Learning Objectives• Key Concepts

1. Common signs and symptoms of dysphagia include:• Difficulty or pain when swallowing• Excessive swallows for each bite• Coughing or choking while eating or drinking• Food or fluids leaking from the mouth or nose

2. The NDD defines 4 levels of liquid viscosities and 4 levels of semi-solid/solid food textures.

• Liquids: thin, nectar-like, honey-like, spoon-thick• Semi-solid/solid foods: pureed, mechanically

altered, advanced, regular3. When thickening liquids, it is important to measure, mix,

and wait to ensure the liquid achieves the proper consistency.

• Questions

Learning Objectives

After completing this program, participants willbe able to:

• Recognize common signs and symptoms of dysphagia

• Explain the risk of aspiration with dysphagic residents

• Classify liquids according to NDD guidelines for liquid viscosity

• Demonstrate the 3 rules when using food thickener

• Classify semi-solid and solid foods according to NDD guidelines for food texture

What is Dysphagia?

A condition affecting and impairing one of thephases of swallowing.

• Swallowing involves 7 pairs of nerves and 26 muscle groups.

• It is not generally considered a diagnosis, but a symptomcaused by a variety of disorders.

Trachea

Esophagus Stomach Lungs

Common Causes of Dysphagia

Dysphagia has multiple possible causes andoccurs most frequently in older adults.

Any condition that weakens or damages the muscles and nerves used in swallowing

may cause dysphagia, such as:

• Stroke• Cancer of the head, neck, or esophagus• Multiple sclerosis• Parkinson’s disease• Head injury or trauma• Alzheimer’s disease, dementia• Loss of muscle tissue during the aging process can also

contribute to a weaker swallow

Signs and Symptoms ofDysphagia

• Difficulty swallowing• Drooling• Complaints of painful

swallowing• Excessive swallows

foreach bite

• Coughing or choking before, during, or after swallowing

• Wet-sounding/gargled cough or voice afterswallowing

• Oral or nasal regurgitation

• Slow eating• Requiring more than 45

minutes to finish meals• Pocketing food in cheeks• Frequent throat clearing• Excessive hiccupping,

burping, or indigestion• Recurrent chest

infections• Unexplained weight loss• Dehydration

What is aspiration?

Aspiration is the entry of food, fluid, or foreignmaterials into the trachea and lungs.

• Normally, food enters the mouth and travels down the esophagus into the stomach.

• Aspiration occurs when food or fluids inadvertently travel down the trachea into the lungs, which are only meant to be exposed to air.

• Most people cough to prevent foreign substances from being inhaled into the lungs; however, thosewith difficulty swallowing may be more likely toinadvertently inhale foreign substances.

Why is a dysphagic resident atrisk for pneumonia?

Aspiration is a primary complication of dysphagia and may lead to life threatening conditions.

• Any foreign substances that enter the lungs may cause an infection. Bacteria can thrive and multiply when the lungs harbor these substances, and this can lead to the development of aspiration pneumonia.

• Aspiration pneumonia is a major cause of morbidity and mortality among the elderly who are hospitalized or in nursing homes.

How does dysphagia affect aresident’s nutritional status?

It is important that all residents eat anutritionally adequate diet.

• However, dysphagia can make it difficult for those residents to consume enough food and fluids to remain adequately nourished. They are at risk for dehydration, weight loss, nutritional deficiencies, and malnutrition.

• In severe cases of dysphagia, you may notice that some residents can no longer consume food and fluids by mouth. They must use alternative nutrition support, such as the use of a feeding tube, to meet their nutritional needs.

National Dysphagia Diet (NDD)

to standard comparison foods.

The NDD was published in 2002 to establish uniform, standardized terminology and practices for dysphagia management. It classifies food and fluids along a spectrum and defines levels of nutrition intervention.

• A dysphagia diet is one that incorporates modified textures of foods and/or consistencies of liquids.It is important to follow all guidelines accordingly.

• The NDD outlines 4 levels of liquid viscosity and 4 levels of food texture, to ensure consistency when prescribing diets. It includes or excludes items at each level relative

National Dysphagia Diet (NDD)

if and when it is safe for the resident.

Reviewing the results of swallowingevaluations and diagnostic tests allows the healthcare team to determine how a

resident handles various textures and consistencies of food and liquids.

• This assessment is necessary in order to assign the appropriate NDD levels.

• However, a resident’s diet may still need to beindividualized based on their needs and preferences.

• Prescribed NDD levels may be modified as their degree of impairment changes or improves. Diets may be upgraded

NDD Semi-Solid or Solid Foods

Foods are classified into one of the following 4 levels, depending on their method of

preparation and texture:

1) NDD Level 1 Dysphagia Pureed: Includes food of a “pudding-like” consistency; smooth, pureed, or well mashed; homogenous (with no lumps); cohesive; requires no chewing

2) NDD Level 2 Dysphagia Mechanically Altered: Foods should be moist, cohesive, and soft textured; includes tender ground or finely diced meats, soft cooked vegetables, soft, ripe or canned fruit, and some moistened cereals

3) NDD Level 3 Dysphagia Advanced: Includes mostregular foods, except very hard, sticky, or crunchy items

4) NDD Level 4 Regular: All foods are allowed

NDD Liquids

Liquids are classified into one of thefollowing 4 levels, based on their viscosity

or thickness:1) Thin: examples include water, milk, juice, coffee, tea,

carbonated drinks, gelatin, ice cream, sherbet, sorbet, and broth-based soups

2) Nectar-like: coats a spoon and falls in small droplets; examples include fruit nectars, maple syrup, Ensure Plus (Chilled), eggnog, tomato juice, and cream-based soups

3) Honey-like: drips from a spoon in small clumps;examples include commercially prepared pre-thickened liquids; thin liquids are to be thickened by trained staff members using instant food thickener

4) Spoon-thick: falls from a spoon in large clumps; thin liquids are to be thickened to pudding consistency by trained staff members using instant food thickener

Why are liquids thickened forsome dysphagic residents?

Modification of liquid consistencies fordysphagia management is a common practice.

• Beverages may need to be specially prepared for residents with this condition, since swallowing of liquids requires a great deal of coordination and control.

• Because the muscles involved in swallowing are weakened or impaired with dysphagia, thickened liquids may facilitate the swallowing reflex and decrease the risk for aspiration.

• Liquids must be thickened to the appropriate consistency, so as to reflect the physician’s order for the resident.

Pre-Thickened Liquids andFood Thickeners

Pre-Thickened Liquids Food Thickeners

• Commercially prepared pre- thickened liquids are available and provide an option to ensure product consistency.

• Most pre-thickened liquids are color-coded to easily distinguish between nectar- like or honey-like.

• To increase liquid viscosity, commercial starch thickeners are stirred into hot or cold beverages and other liquid foods, such as soup broth.

• Food thickeners allow for the flexibility to prepare only the amount necessary to thicken the liquid.

Rules to remember when usingpowdered food thickeners

1) Measure the thickener.

2) Mix well.

3) Wait to allow the liquid to thicken to the proper consistency before using or serving.

NOTE: The steps and measurements to thicken liquids will differ based on the brand and type of thickener used. Always follow the manufacturer’s instructions.

Types of Food and Liquids to beAvoided with Dysphagia

• Fibrous, gristly meats• Dry, crumbly, crispy food, with hard edges• Sticky foods• Small pieces

Examples: nuts, seeds, popcorn, or coconut

• Raw, crunchy fruits and vegetables Especially with skins or seeds, or which produce a lot of

pulp

• Tough, chewy, crusty breads• Spicy, acidic, or tart foods• Extremely hot liquids and beverages

General Menu vs.Texture Modified MenusLUNCH Regular

DietNDD Level 3 Dysphagia Advanced

(Mechanical Soft diet in IMPAC)

NDD Level 2 Dysphagia

Mechanically Altered (Dysphagia

dietin IMPAC)

NDD Level 1 Dysphagia

Pureed (Pureed diet

in IMPAC)

BBQ Chicken 3 oz BBQ Chicken GR BBQ Chicken GR #8 ScoopBBQ Chicken PU

BBQ Sauce No 2 oz 4 oz 2 oz

Ranch Beans ½ cup X #10 Scoop Ranch Beans PU

#10 Scoop Ranch Beans PU

Cole Slaw ½ cup Steamed Cabbage #8 ScoopSteamed Cabbage PU

#8 ScoopSteamed Cabbage PU

Bread 1 slice Bread/Margarine #16 Scoop Bread PU

#16 Scoop Bread PU

Lemon Bar 2”x3”square

X #10 Scoop Lemon Bar PU

#10 Scoop Lemon Bar PU

Garnish Parsley Sprig

1 each No No No

Eye Appeal of Pureed orMechanically Altered Foods

Ideas to improve the visual presentation:

• Use attractive plates and silverware to improve the visual appeal of a meal.

• Plate food with appropriate and colorful garnishes.

• Shape pureed and ground foods to resemble traditional dishes.

Use small scoops so that pureed meat resemblesmeatballs

Use food molds to restore pureed meats to their traditional shape

Use a pastry bag to pipe pureed pasta into a swirly design

Eye Appeal of Pureed orMechanically Altered Foods

Condiments and Garnishes• Gelatin: cubed, sliced, or

stamped out with a cutter• Condiments: ketchup,

mustard, pureed pickle, mayonnaise, jelly, gravy, and salad dressing

• Sauces: chocolate, butterscotch, cheese, or fruit

• Cheeses: grated or shredded cheeses sprinkled on hot food

• Herbs or spices• Graham cracker, or

fine bread, crumbs• Whipped cream

Pureed Pork Dinner

Taste Appeal of Pureed Foods

Appealing plate presentations and quality tasting foods will help support the resident in maintaining adequate intake and, ultimately,

proper nutritional status. All foods served should be well seasoned and have a

distinctive flavor.

The following ingredients can enhance food flavors:

• Garlic• Ground herbs or spices• Flavored extracts• Lemon zest• Butter

• Meat base• Fruit puree• Cheese• Gravy• Sauces

Meal Time Tips

Serving and feeding residents with dysphagia requires extra care and consideration. Some tips to properly feed residents, and items to check on at the end of the meal, include:

• Minimize distractions: Turn off televisions and seat the resident in a quiet area.

• Properly seat the resident at a 90° angle.• If feeding assistance is provided, make sure reasonably

sized bites are given and feeding is not forced or rushed.• Make sure the resident maintains an upright position for

at least 30 minutes after a meal.• Check to see that no leftover food remains in the

resident’s mouth.• Support independence in eating whenever possible to

enhance quality of life.• Make sure residents follow meals by brushing their teeth

to reduce dental caries. Encourage optimal mouth care.

For More Information

Take advantage of the following videos provided by our partner:

Videos are available in English and Spanish at the address below:http://www.800-45-sysco.com

• About Thickened Liquids• The Puréed Diet Made Easy• The Mechanically Altered Diet Made Easy• Pleasing Plate Presentations for the Dysphagia Diet

Med-Diet is also your source for dysphagia products: thickeners, purees, pre-thickened liquids,

supplements, adaptive equipment, puree molds, and much more!

Med-Diet Videos

Access at http://www.800-45-sysco.com

Questions?Thank you for your participation!

References

• Russell, Carlene. “Dining with Dysphagia.” Dietary Manager. June 2002:11-16.

• National Institute of Deafness and other Communication Disorders. NIDCD Fact Sheet Dysphagia. Available from: http://www.nidcd.nih.gov/health/voice/dysph

• Escott-Stump, S. (2008). Dysphagia. In D. B. Troy (Ed.), Nutrition and Diagnosis-Related Care (6ted., pp. 363-365). Baltimore, MD: Lippincott Williams and Wilkins.

• Nelms, M., Sucher, K., & Long, S. (2007). Diseases of the Upper Gastrointestinal Tract. In P. Marshall (Ed.), Nutrition Therapy and Pathophysiology (pp. 421-455). Belmont, CA: Thomson Brooks/Cole.

• Garcia, JM., Chambers IV, E., Molander, M., “Thickened Liquids: Practice Patterns of Speech-Language Pathologists.” AJ Speech- Lang Path. February 2005:4-13.

• New National Dysphagia Diet Videos. (2011). Retrieved April 18, 2011, from Med-Diet Laboratories website: http://www.dysphagia-diet.com/video.htm

• Sysco Design Center