CONDITIONS & DISORDERS
TEXTURE MODIFICATION IN DYSPHAGIA PATIENTS Jenni Woolrich Highly Specialist Speech and Language Therapist, Betsi Cadwaladr University Health Board (NHS) Jenni has worked as a Paediatric Speech and Language Therapist for eight years. She currently works with children with complex needs, assessing and providing intervention to develop both communication and feeding skills.
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T h e R o y a l C o l l e g e of S p e e c h a n d L a n g u a g e T h e r a p ists d e fi n e s d y s p h a g i a a s ‘ a s w a l l o w i n g d i s o r d e r u s u a l l y resulting from a neurological or physical impairment of the oral, pharyngeal or oesophageal mechanisms’. D y s p h a g i a i s a s s o c i a t e d w i t h i n c r e a s e d m o r b i d i t y, mortality and reduced quality of life.1 Swallowing difficulties can lead to an increased risk of aspiration, when food or drink goes the ‘wrong’ way into the windpipe and enters the lungs, instead of going into the oesophagus and into the stomach; this in turn can lead to chest infections and pneumonia. So why does this happen? The normal swallow requires a combination of many things to work in harmony, ensuring that the food or drink entering our mouths is moved safely from the lips to the stomach. It relies on many anatomical structures working together alongside the motor and nervous systems. When one of the areas becomes less effective, or signals become less clear, it can have a huge impact on the process. Swallowing difficulties can be a result of physical changes such as a trauma to head or neck, neurological complications, or injury to the nervous system, respiratory disease, or due to psychological or behavioural factors. In both children and adults, dysphagia can be present as acute or chronic and within these categories, static or progressive in presentation.1 WHAT CAN WE DO TO HELP THIS?
There are a range of interventions that can be advised from education and training to feeding strategies to swallowing techniques to texture modification. Texture modification will be the focus of this article. The Francis report states that patients should have food and drink that is, as far as possible,
palatable to patients and this must be made available and delivered to them at a time and in a form that they are able to consume.2 WHAT IS TEXTURE MODIFICATION?
Texture modification is an intervention that may be advised by a speech and language therapist (SLT) for a client who has difficulties with their swallow. Following assessment, it may be recommended that changing the texture of the person’s drinks or food may increase the effectiveness of their swallow, but also and more importantly increase the safety of their swallow. For example, a person may find thin fluids such as water difficult because of the speed the water travels from the front to the back of the mouth and into the throat; their difficulty may mean that they are unable to control the liquid sufficiently to swallow and simultaneously protect their airway. By thickening the liquid to a different consistency, the liquid will move more slowly and, therefore, the patient may have more control over the liquid and have more time to coordinate their swallow more effectively and safely. With regard to food, different textures may have different impacts on the swallow. We often take the process of swallowing for granted, but it requires a lot of skill. Infants are taught over time how to move from a pureed diet to one that requires chewing and a lot more oral control. Once an area of the swallow is impacted, this may mean that some textures are more www.NHDmag.com October 2017 - Issue 128
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CONDITIONS & DISORDERS Table 1: Fluid Texture Descriptors4 Stage 1
Syrup
Should pour like single cream.
Stage 2
Custard
Should easily drop off, not pour from a teaspoon.
Stage 3
Pudding
Should stay on the spoon like whipped cream.
Table 2: Food Texture Descriptors5 Descriptor Code
Descriptor Name
What does it look like?
B
Thin Puree
Smooth consistency, no bits/lumps. It may need to be sieved to achieve consistency. It does not require chewing. There are no loose fluids that have separated off. Does not hold its shape on a plate. Cannot be eaten with a fork because it slowly drops through the prongs. Can be poured.
C
Thick Puree
Smooth consistency, no bits/lumps. It may need to be sieved to achieve consistency. It does not require chewing. There are no loose fluids that have separated off. Holds its shape on a plate or when scooped. Can be eaten with a fork as it does not drop through the prongs. Cannot be poured.
D
Pre-mashed
Food is soft, tender and moist. Needs very little chewing. It has been mashed up with a fork before serving. No mixed textures (thick and thin). Any fluid, gravy, sauce or custard in or on the food is very thick. No loose fluids.
E
Fork-mashed
Food is soft, tender and moist but needs some chewing. It can be mashed with a fork. No mixed textures (thick and thin). Any fluid, gravy, sauce or custard in or on the food is thick. No loose fluids.
difficult for them. As you would expect, and similarly to the typical feeding development pattern, the less textured a food is the easier it is to control and move around the mouth and swallow. So, when people are diagnosed with a swallowing problem it may be recommended that the texture of their food is modified. HOW DO WE MODIFY TEXTURE?
We can use thickening agents to change the consistency of both fluids and food: the more thickener that is added, the thicker the fluid or food gets. Thickeners are approved by the Advisory Committee on Borderline substances for the treatment of dysphagia.3 20
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There are two types of thickener: • Starch based products - these have been available for longer and generally are cheaper. The downside of these is that studies have concluded that patients have experienced a ‘starchy’ flavour and these can cause lumps when mixed with some fluids. The thickener is also not stable and will continue to thicken over time; however, when mixed with saliva, the thickener can be broken down by amylase in saliva, leading to a potential safety risk.3 • Gum based products - have been found to be more stable and not change consistency. They have also been found to be more palatable and less grainy.
Figure 1: IDDSI definitions of texture modified foods and thickened liquids
Thickener can be recommended for a patient by an appropriate trained healthcare professional, e.g. an SLT, and is then usually prescribed by their GP or consultant, or prescribing dietitian. We can also change the texture of food by using a blender to produce a puree, or a fork to mash down the food into a smoother but lumpy consistency. HOW DO WE CATEGORISE THE VARIOUS TEXTURES?
Textures are defined by different terms to ensure consistency. With fluids, the varying consistencies are categorised into three stages (see Table 1). These are not currently included in the national descriptors, but are guidelines which are readily adopted across departments. Although used to describe fluids, thickener can also be added to food stuffs to increase the consistency, e.g. a runny yoghurt or sauce could have thickener added to increase its viscosity. With regards to food, there are national descriptors. These are the Dysphagia Diet Food Texture Descriptors published in March 2012 by the National Patient Safety Agency. The descriptors were developed in response to concerns relating to patient safety and a request
from industry and in-house caterers for detailed guidance on categories of texture.5 Table 2 summarises the descriptors. Although the descriptors in Table 2 are national, there is ongoing rally for international terminology and definitions for texture modified food and thickened liquids. Terminology does vary from country to country. Cichero et al comment that the use of globally recognised terms for food and liquids has clear advantages for facilitating the delivery of safe and quality therapeutic products to individuals with dysphagia.6 Since Cichero et al’s paper, the International Dysphagia Diet Standardisation Initiative (IDDSI) has been launched. It is a global standard with terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia for all ages, in all care settings and for all cultures7 (see Figure 1). It claims that the standardised descriptors and testing methods will allow for consistent production and easy testing of thickened liquids and texture modified foods.7 According to the IDDSI website, the UK is reviewing the framework in relation to current national standards and implementation discussions are underway. www.NHDmag.com October 2017 - Issue 128
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CONDITIONS & DISORDERS
The majority of thickeners are intended for children over three years of age . . . For under threes, carob bean-based products can be used to thicken fluids. WHAT DO WE NEED TO CONSIDER WHEN MODIFYING A DIET?
Although thickener is prescribed to increase safety and reduce harm to the patient, as with many things, there are some considerations. The majority of thickeners are intended for children over three years of age, this is due to the sodium content. There have been a small number of reports of gum-based thickened fluids causing infant death4 due to tissues in the intestine becoming inflamed and its contents leaking into the abdomen. For under threes, carob bean-based products can be used to thicken fluids. Another concern is that a high proportion of people with dysphagia are considered to be dehydrated. Research has concluded that water is made bioavailable from all thickeners to even extreme levels of thickness.8 So, if this isn’t the reason for the dehydration, it could be suggested that the dehydration may be due to physiological expectations that thick fluids make [patients] feel full.8 In addition, thickener can suppress the flavour of the fluid and can leave the mouth feeling ‘sticky rather than wet’,8 resulting in the patient having reduced motivation to drink. Often, recommendations from medical staff would be for small amounts to be taken; this, in conjunction with the lack of motivation to drink, may mean that fluids are taken little but perhaps not often. Cichero et al recommend that clinicians should strive to prescribe only the least thickened liquid required for swallowing safety and aggressively pursue treatments to improve functional return to normal, unthickened liquids.8 Similarly to fluids, research has also raised concerns with modified textured foods that although it should be easier for patients to consume, a pureed diet has been implicated in the high prevalence of undernutrition in longterm care residents.9 It is suggested that this population may resist consuming modified textured food because it is often unappealing in appearance, texture and taste.9 22
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To ensure that food and drink is consumed to the level that ensures hydration and appropriate nutrition, dysphagia patients, adults and children alike, need a support system in place to assist and encourage them. Staff in hospitals and school settings, family and others involved in their daily care would require training in the correct use of the thickener to ensure safety.4 Texture modified training should also be offered to catering staff in hospitals, care homes and schools to develop their knowledge of texture modified food and their awareness of dysphagia. Dysphagia is poorly understood by many frontline health professionals and this exposes people to avoidable discomfort, pain or even death. Practical education will help increase staff awareness and ensure thickeners are used consistently, thereby helping to improve safety.4 Patient’s recommendations also need to be reviewed and potentially updated; the timing and frequency of this will be dependent on a patient’s individual needs and circumstances. For example, a person with a progressive illness may be reviewed and their recommendations altered more frequently than a person with a more stable diagnosis. The recommendations should always meet the needs of the patient to ensure safety. SUMMARY
Texture modification is a recognised treatment for both children and adults with swallowing difficulties. It works by reducing the transit of food to allow the patient to coordinate their swallow more effectively and safely. This helps prevent food going the ‘wrong way’ into the lungs which could lead to complications such as choking or pneumonia. The recommendations for this intervention should be based on the needs of the patient, e.g. the degree of the dysphagia, the texture required and the palatability of the products. The competency and confidence of significant others, carers and other professionals in regard to texture modification also need to be considered to ensure the needs of the patient is met and their safety is maintained.