CONDITIONS & DISORDERS
DYSPHAGIA: AN UPDATE ON CURRENT PRACTICE Amanda Mostyn Registered Dietitian, University of Chester Amanda is a Band 5 rotational dietitian currently working in Stroke and Neurology. Her work includes acute stroke/stroke rehab. Amanda has had previous experience in general medicine, gastroenterology and orthopaedics.
REFERENCES Please visit the Subscriber zone at NHDmag.com
Dysphagia is the term used to describe a swallowing impairment, which can be transient, deteriorating or persistent, depending on the underlying pathology. It can be a result of acute medical decompensation (e.g. sepsis, UTI, exacerbated COPD), neurological impairment (e.g. CVA, HI, progressive disease), or structural changes (e.g. head and neck cancers and subsequent reconstructions).1 Prevalence is difficult to measure due to the nature of how incidence is recorded it can often be associated with a variety of different health conditions to which an individual is being treated.1 Dysphagia in the acute setting is commonly seen in the ageing population. This could be related to the fact that the mechanism of swallowing is greatly reliant upon the motor and sensory nervous system being intact, and these deteriorate with age.1 Swallowing is a complex physiological sequence which involves over 30 nerves and muscles. These have two main functions: to move food from mouth to stomach and provide airway protection.1 There are four stages of swallowing: oral preparatory phase, oral phase, pharyngeal and oesophageal phase. These each play a role in the prevention of aspiration, chest infections and pneumonia.1 There are various ways in which a person with dysphagia can be supported and this is most commonly overseen by a speech and language therapist (SLT). SLTs play a valuable multidisciplinary team (MDT) role in the assessment, differential diagnosis and subsequent management of dysphagia. This can include environmental modifications, safe swallowing advice, appropriate dietary modification and the application of swallowing strategies, which improve the efficiency of swallow function and reduce the risk of aspiration. SLTs work very closely with dietitians to ensure optimum nutrition and hydration for high risk patients.1
This article will discuss the link between dysphagia and malnutrition, some of the treatment options for dysphagia (particularly in the prevention of malnutrition) and the implementation of the International Dysphagia Diet Standardisation Initiative (IDDSI) framework which is to be officially launched in April 2018.2 This is thought to be an important step forward in standardising dysphagia care worldwide. Dysphagia can affect individual or multiple stages of the swallowing mechanism. This can have adverse effects on the individual, particularly relating to their nutritional intake. As previously highlighted, there are various different management options for dysphagia, but for the purpose of this article, we shall focus on dietary modifications and medical interventions, such as enteral feeding (e.g. nasogastric tube [NGT] and percutaneous endoscopic gastrostomy [PEG]). These treatments are commonly used within dietetic practice to prevent malnutrition and dehydration within dysphagic patients.1 ENTERAL FEEDING IN DYSPHAGIA
Enteral feeding within individuals with disorder swallowing is commonly used in an acute setting as initial reduction of aspiration risk and to improve nutritional status. An MDT approach is required for long-term nutritional plans, such as PEG tubes; each case should be considered individually, recognising the clinical situation, diagnosis, prognosis and ethical issues involved.3 www.NHDmag.com March 2018 - Issue 132
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CONDITIONS & DISORDERS Table 1: The different texture dietary modifications6 Textures
Description
Examples
Category B Thin puree diet
• It does not require chewing. • Smooth throughout (no lumps). • Does not hold its shape on a plate or when scooped. • A light, disposable plastic teaspoon must be able to stand upright when the head is fully covered.
Pureed fruits with custard, cream, mousse, yoghurt. Add extra milk or cream to achieve correct consistency.
Category C Thick puree diet
• Does not require chewing. • Smooth consistency (no lumps). • Holds its shape on a plate or when scooped. • Prongs of a fork make a clear pattern on the surface. • It can be piped, layered or moulded.
The texture of wheat-biscuit breakfast cereal fully softened with milk fully absorbed.
Category D Pre-mashed
• Food is soft, tender and moist and needs very little chewing. • Has been mashed up with a fork before serving. • Meat is finely minced or made to texture C if necessary.
Small soft well cooked pasta with sauce, for example, moist macaroni cheese.
Category E Fork- mash
• Food is soft, tender and moist but needs some chewing. • It can be mashed with a fork.
Soft scrambled egg, poached egg with soft bread/bread rolls (no crusts), butter or margarine.
Table 2: Modified fluids6 Texture fluid
Description
Stage 1 Syrup consistency
• Can be drunk from a cup or straw. • Will leave a thin coating on the fork/spoon/cup.
Stage 2 Custard consistency
• Easiest way to take this drink is from a spoon. • Flows slowly when poured. • Leaves a thick coat on the back of a fork/spoon/cup.
Stage 3 Pudding consistency
• Needs to be taken with a spoon. • Will hold a cohesive shape on a spoon. NB: if a spoon/fork is able to stand upright unsupported in the drink, it is too thick.
It is important to remember that nutritional care plans in palliative care should consider the appropriateness of a nutritional intervention and should not have burdensome restrictions imposed on oral food and/or fluid intake if those restrictions would exacerbate suffering.4
Nutritional feeding at risk is a term often used by speech and language therapists when an individual with dysphagia may have the inability to swallow any of the recommended modified textures and/or is not suitable for enteral nutrition.5 Decisions on enteral nutrition and hydration are open to conventional ethical analysis and subject to mental capacity law. It is best practice to determine someone’s best interests; which means considering values and preferences, previous and current wishes, and requires consultation with families and other carers.5 MODIFIED TEXTURES
Modified diet and fluids can be used as a strategy for managing disordered swallowing. Thickening fluids, or providing soft foods, can make a great difference to an individual’s care and safety. Tables 1 and 2 show the currently used unified descriptions of modified textures in the UK.6 However, it is important to note that in the near future, the International Dysphagia Diet Standardisation Initiative (IDDSI) framework www.NHDmag.com March 2018 - Issue 132
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CONDITIONS & DISORDERS Figure 1: The International Dysphagia Diet Standardisation Initiative (IDDSI) framework.2,10 The framework consists of a continuum of eight levels (0-7) and includes descriptors, testing methods and evidence for both liquid thickness and food texture levels.
will be released in the UK (Figure 1). The IDDSI texture modification descriptors, this can lead committee was setup in 2013 and includes a group to the provision of an incorrect consistency 8-+46#5#$%&&'%$()*+#,-).$$ of experts within dietetics, medicine, speech and provided to the patient, which has shown to language, occupational therapy, nursing, patient result in adverse events such as aspiration and &#5*36#0$0#J3/353-/1$ safety, food science and technology from around incidences of choking.7 This IDDSI pilot study7 the world. The group shared a common aim to identified an incorrect perception that â&#x20AC;&#x2DC;the thicker develop international standardised terminology the liquid, the safer the swallowâ&#x20AC;&#x2122;. However, and descriptors for dysphagia diets that would thickened liquids can contribute to incomplete meet the needs of individuals with dysphagia clearance from the pharynx and a higher risk of !"#$%&&'%$()*+#,-).$*/0$&#12)345-)1$*)#$632#/1#0$7/0#)$5"#$$ 8)#*539#8-++-/1$:55)3;753-/<'"*)#*63.#$=>?$%/5#)/*53-/*6$@32#/1#$$ worldwide.2 aspiration from post swallow residue.1 Patients "5541ABB2)#*539#2-++-/1>-)CB632#/1#1B;D<1*B=>?B$ Currently, there are various different who aspirate very thick liquids tend to have worse E*)2"$=F$G?HI$ ! descriptions available, which essentially use health outcomes, including fatal ones.7,8 Other different terminology, labels, numbers and levels research8 also highlighted that coronial inquests causing great confusion to carers, researchers have identified staff confusion regarding food and healthcare professionals. As modern textures and their labels as factors specifically technology allows the movement of both patients noted to contribute to patient mortality. and health professionals around the world, the The British Dietetic Association (BDA) use of globally recognised terms for foods and has announced its support for the IDDSI liquids has clear advantages for facilitating the framework. They have been working in delivery of safe and quality therapeutic products collaboration with NHS England and a range to individuals with dysphagia.7 Benefits of using of stakeholders over the past two years to the framework not only improve safety risks, explore whether the UK should adopt the but also allow for larger research studies and IDDSI framework.9 The BDA also conducted a systematic reviews, which in turn means a more survey on dietitians in August 2017 regarding robust evidence base around the care of patients the acceptability of IDDSI.9 with dysphagia. There is ongoing work on developing a toolkit The Research7 completed within dysphagia, for the framework within the UK - a challenging highlighted that a diet consistency formulated by task, but clearly an important part of the successful a SLT should consistently meet certain standards implementation of the IDDSI as supported by the for safety. As there is often confusion with the Kempen study7,10 conducted in Germany in 2015. www.NHDmag.com March 2018 - Issue 132
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SUPPORTING YOU TO SUPPORT YOUR PATIENTS
CONDITIONS & DISORDERS Figure 2: IDDSI timeframe: are you ready?10
The Kempen study7,10 was a pilot study identifying the requirements for implementing the IDDSI framework. It also aimed to develop guidelines and/or resources to facilitate and inform future pilots on the framework. The study highlighted that the IDDSI is the first to identify that the multi-professional circle of speech and language therapy and dietetics in dysphagia can be increased outside the â&#x20AC;&#x2DC;healthcare team to include the food service team, showing that, through multiprofessional collaboration, food service staff became more aware of their important role in dysphagia, providing safety from choking. Clinical staff also became more aware of the complexities and time pressures in plating meals in the kitchen.7 This highlights that people can become motivated to change when they experience an issue in practice, which then becomes the catalyst to change. The Kempen study concluded that the appropriate training of entire staff from food service to bedside should be included in implementation of the IDDSI framework to ensure successful implementation.7,10
CONCLUSION
Dysphagia is a disorder of the mechanism of swallowing which has great adverse implications to an individual, including increased mortality and morbidity rates due to the high rate of malnutrition and aspiration pneumonia. Enteral feeding is often indicated post-acute phases of dysphagia; particularly stroke cases, but also can be seen in long-term swallowing disorders as a mechanism of total nutrition support, or supportive feeding. Modified texture diet and fluids are common practice in the treatment of dysphagia, which, as highlighted in this article, are consistencies that are carefully chosen by a speech and language therapist for an individual, based on their swallowing needs. Discrepancy in the provision of appropriate modified consistencies due to confusion is notably prevalent, due to the availability of different texture descriptors from different medical backgrounds. The IDDSI framework, which has support from both the BDA and RCSLT shall commence in April 2018 in the UK to tackle this discrepancy and confusion with modified textures, with an overall aim for patient safety in patients with dysphagia. www.NHDmag.com March 2018 - Issue 132
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*Vanilla, strawberry and banana REFERENCES 1. Data on file. Abbott Laboratories Ltd., 2017 (Sensory research and evaluation: PaediaSure Plus vs. PaediaSure Compact). 2. Data on file. Abbott Laboratories Ltd., 2017 (Sensory research and evaluation: PaediaSure Compact banana flavour and PaediaSure Compact strawberry flavour). Date of preparation: July 2017 ANUKANI170158a
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