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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.

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.

Are you IDDSI ready? We are!

CLICK HERE TO LEARN MORE This information is intended for healthcare professionals only. Nutilis Clear is a Food for Special Medical Purposes and must be used under medical supervision.

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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.

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 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

Copyright © 2018 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use of CPD activities for personal use. Not for reproduction for publishing purposes without written permission from NH Publishing Ltd.

Are you ready for IDDSI? We are! From April 2018 the scoop and dosage of Nutilis Clear will change in line with IDDSI guidelines. Visit nutriciahcp.com for more information.

This information is intended for healthcare professionals only. Nutilis Clear is a Food for Special Medical Purposes and must be used under medical supervision.

SUPPORTING YOU TO SUPPORT YOUR PATIENTS

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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.

Nutritional feeding at risk is a term often However, it is important to note that in the 8-+46#5#$%&&'%$()*+#,-).$$ used by speech and language therapists when near future, the International Dysphagia Diet an individual with dysphagia may have the Standardisation Initiative (IDDSI) framework &#5*36#0$0#J3/353-/1$ inability to swallow any of the recommended will be released in the UK (Figure 1). The IDDSI modified textures and/or is not suitable for committee was setup in 2013 and includes a group enteral nutrition.5 of experts within dietetics, medicine, speech and Decisions on enteral nutrition and hydra- language, occupational therapy, nursing, patient safety, food science and technology from around the tion are open to conventional ethical analysis !"#$%&&'%$()*+#,-).$*/0$&#12)345-)1$*)#$632#/1#0$7/0#)$5"#$$ and subject to mental capacity law. 8)#*539#8-++-/1$:55)3;753-/<'"*)#*63.#$=>?$%/5#)/*53-/*6$@32#/1#$$ It is world. The group shared a common aim to develop "5541ABB2)#*539#2-++-/1>-)CB632#/1#1B;D<1*B=>?B$ standardised terminology and desbest practice to determine someone’s best international E*)2"$=F$G?HI$ ! interests; which means considering values and criptors for dysphagia diets that would meet the preferences, previous and current wishes, and needs of individuals with dysphagia worldwide.2 Currently, there are various different requires consultation with families and other descriptions available, which essentially use carers.5 different terminology, labels, numbers and levels MODIFIED TEXTURES causing great confusion to carers, researchers Modified diet and fluids can be used as a and healthcare professionals. As modern strategy for managing disordered swallowing. technology allows the movement of both patients Thickening fluids, or providing soft foods, can and health professionals around the world, the make a great difference to an individual’s care use of globally recognised terms for foods and and safety. Tables 1 and 2 show the currently liquids has clear advantages for facilitating the used unified descriptions of modified textures in delivery of safe and quality therapeutic products to individuals with dysphagia.7 Benefits of using the UK.6

Are you IDDSI ready? We are!

CLICK HERE TO LEARN MORE This information is intended for healthcare professionals only. Nutilis Clear is a Food for Special Medical Purposes and must be used under medical supervision.

Copyright © 2017 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use of CPD activities for personal use. Not for reproduction for publishing purposes without written permission from NH Publishing Ltd.

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Volume 8.09 - 24th May 2018

Figure 2: IDDSI timeframe: are you ready?10

the framework not only improve safety risks, but also allow for larger research studies and systematic reviews, which in turn means a more robust evidence base around the care of patients with dysphagia. The Research7 completed within dysphagia, highlighted that a diet consistency formulated by a SLT should consistently meet certain standards for safety. As there is often confusion with the texture modification descriptors, this can lead to the provision of an incorrect consistency provided to the patient, which has shown to result in adverse events such as aspiration and incidences of choking.7 This IDDSI pilot study7 identified an incorrect perception that ‘the thicker the liquid, the safer the swallow’. However, thickened liquids can contribute to incomplete clearance from the pharynx and a higher risk of aspiration from post swallow residue.1 Patients who aspirate very thick liquids tend to have worse health outcomes, including fatal ones.7,8 Other research8 also highlighted that coronial inquests have identified staff confusion regarding food textures and their labels as factors specifically noted to contribute to patient mortality.

The British Dietetic Association (BDA) has announced its support for the IDDSI framework. They have been working in collaboration with NHS England and a range of stakeholders over the past two years to explore whether the UK should adopt the IDDSI framework.9 The BDA also conducted a survey on dietitians in August 2017 regarding the acceptability of IDDSI.9 There is ongoing work on developing a toolkit for the framework within the UK - a challenging task, but clearly an important part of the successful implementation of the IDDSI as supported by the Kempen study7,10 conducted in Germany in 2015. 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 ‘healthcare team to include the food service

NHD CPD eArticle team, showing that, through multi-professional 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

Volume 8.09 - 24th May 2018

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.

References 1 Royal college of Speech and Language Therapy; RCSLT Resource Manual for Commissioning and Planning Services for SLCN. Dysphagia. RCSLT (2009). www. rcslt.org/speech_and_language_therapy/commissioning/dysphagia_manual_072014 2 The International Dysphagia Diet Standardisation Initiative (IDDSI) framework: the Kempen pilot. Peter Lam, soenke Stanschus, Rizeana Zaman. Dec 2016. https:// doi.org/10.12968/bjnn.2017.13.Sup2.S18 3 NICE guidelines CG32. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. www.nice.org.uk/guidance/cg32/ chapter/1-Guidance 4 Royal College of Physicians; National Clinical Guideline for Stroke. Fifth Edition (2016). www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-NationalClinical-Guideline-for-Stroke-5t-(1).aspx) 5 Royal College of Physicians and British Society of Gastroenterology. Oral feeding difficulties and dilemmas. A guide to practical care, particularly towards the end of life. London: Royal College of Physicians (2010). www.rcplondon.ac.uk/sites/default/files/ documents/oral-feeding-difficulties-and-dilemmas.pdf 6 Royal College of Speech and Language Therapy: Dysphagia diet food texture descriptors. April 2011. www.rcslt.org/members/publications/ dysphagia_diet_texture_descriptions 7 Cichero JAY, Steele C, Duivestein J et al. Curr Phys Med Rehabil Rep (2013) 1: 280. The Need for International Terminology and Definitions for Texture-Modified Foods and Thickened Liquids Used in Dysphagia Management: Foundations of a Global Initiative. https://doi.org/10.1007/s40141-013-0024-z 8 Jukes S, Cichero JAY, Haines T, Wilson C, Paul K, O’Rourke M. Evaluation of the uptake of the Australian standardised terminology and definitions for texture modified foods and fluids. Int J Speech Lang Pathol. 2012; 14(3): 214-5. 9 The British Dietetic Association. The BDA announces adoption of the International Dysphagia Diet Standardisation Initiative (IDDSI) Framework. October 2017. www. bda.uk.com/news/view?id=186 10 iddsi.org and www.bda.uk.com/professional/practice/international_dysphagia_diet_standardisation_initiative_framework

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Questions relating to: Dysphagia: an update on current practice Type your answers below, download and save or print for your records, or print and complete by hand. Q.1

Explain the sequence and stages of swallowing.

Q.2

What is a speech and language therapistsâ&#x20AC;&#x2122;s role in supporting a patient with dysphagia?

Q.3

Outline the MDT approach to enteral feeding in dysphagia.

Q.4

Describe the category C modified texture diet descriptor.

Q.5

What are the descriptors for a thin puree diet?

Q.6

Describe the modified fluid descriptors for pudding consistency.

Q.7

Explain the aims of the International Dysphagia Diet Standardisation Initiative (IDDSI).

Q.8

What issues surrounding thickened liquids did the IDDSI pilot study highlight?

Please type additional notes here . . .