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Dysphagia (difficulty swallowing food, fluids or medication) is increasingly

recognised as a symptom in a number of medical conditions. It can occur in degenerative diseases, such as Parkinson’s disease, motor neurone disease (MND), multiple sclerosis (MS) and dementia, where the signs of dysphagia can be very mild initially, but increase significantly over time as the disease progresses.

Dysphagia can also occur with a sudden onset, such as following stroke or a head injury. Additionally, the elderly are more at risk of developing

Dysphagia in the community: tips and recommendations

dysphagia as a result of changes to the swallowing mechanism that occur with age (Sura et al, 2012). Studies suggest that dysphagia has a prevalence of 13% in the elderly living in the community, approximately 25% of hospitalised individuals, between 50 and 75% of residents in nursing homes, and up to 68% of people in elderly mentally infirm (EMI) care homes (Holland et al, 2011; Kayser-Jones and Pengilly, 1999).

Dysphagia can occur at any point in the swallowing process. During the oral stage of swallowing (which takes place in the mouth), difficulties can occur in chewing and forming a bolus of food in preparation for swallowing, or result in the individual being unable to control fluids as they move through the oral cavity resulting in them spilling out of the mouth or spilling backwards into the throat before the swallow triggers.

Difficulties can also happen in the pharyngeal stage (taking place in the throat), where the swallow itself may be delayed in triggering, or in severe cases, the swallow may be absent resulting in the person being at risk of fluid and/or food entering the lungs (Logemann, 1998).

Dysphagia can be identified by a number of signs and symptoms, including (National Institute for Health and Care Excellence [NICE], 2006; National Patient Safety Agency [NPSA], 2007): Difficulty placing food/drink in

the mouth Inability to control food, drinks,

medication or saliva in the mouth Difficulty in initiating the

swallow itself The feeling of food sticking in the

mouth or throat Frequent chest infections Unexplained weight loss, which

may occur over a short or longer period of time

Regurgitation of food or drinks Coughing and choking,

particularly when eating and drinking, or immediately afterwards

Finding mealtimes distressing The loss of ability to recognise

food and drinks.

Identifying that a person has difficulties swallowing is usually through the process of completion of a ‘swallowing screening’ protocol. This is an evidence based tool where a nurse or other trained person follows a pre-set algorithm to assess a person’s ability to safely swallow fluid and diet. This may start with teaspoons of water, followed by sips of water and then move onto assessing different textures of foods. If the patient fails the protocol at any stage, for example is coughing when

Carolyn Taylor, specialist dietitian; Sue Pownall, speech and language therapist, Sheffield Teaching Hospitals

There are a number of clinical conditions that result in dysphagia (difficulties swallowing food and drink). Sometimes dysphagia can resolve, however, for many it can be long term and also continue to deteriorate over time as the disease progresses. Successful management of dysphagia requires provision of differing levels of texture modification to an individual’s food and fluid consistency. It is important that this is assessed correctly so that the individual receives the appropriate consistency to swallow safely. If an inappropriate consistency is given, this can result in aspiration pneumonia, which can have fatal consequences. If individuals are given a consistency which has been over modified so that it is softer or thicker than required, their pleasure in food and drinks can be reduced unnecessarily, risking malnutrition and dehydration. This article introduces the differing consistencies which are recommended and the consequences that can result from incorrect consistencies being given. It also discusses suitable foods and fluids to meet both the requirements of the differing texture modifications and nutritional components of these consistencies.

KEYWORDS: Dysphagia Malnutrition Hydration Elderly

Carolyn Taylor, Sue Pownall

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▼ Practice point

It can be challenging to provide a nutritious, visually appealing texture-modified diet because altering the consistency makes the food less attractive.

Red Flag

If a patient’s swallowing mechanism is impaired and the bolus enters the lungs, i.e. aspiration, this can result in chest infection, termed ‘aspiration pneumonia’, which can lead to hospitalisation and even death (Thompson, 2016).

taking a drink, the person is referred for a comprehensive assessment of their swallowing. It is commonly the Speech and Language Therapist who will complete this more detailed assessment and who will then make recommendations about the safety of the person’s swallowing mechanism and give any recommendations about diet and fluid modifications required.

CLASSIFICATION OF DIFFERENT TEXTURE MODIFICATIONS (IDDSI)

One of the recognised issues relating to the implementation of appropriate diets is the lack of nationally recognised descriptors for different consistencies. To rectify this problem, the International Dysphagia Diet Standardisation Committee was formed and developed a framework called the International Dysphagia Diet Standardisation Initiative (IDDSI), which was produced in 2016 (IDDSI, 2016). The framework consists of a continuum of 8 levels (0–7), where drinks are measured from levels 0–4, while foods are measured from levels 3–7. Further details on the framework can be found at: https://iddsi.org/framework/. By using this framework, there is now a consistent language for the recommendation of different consistencies.

IMPLICATIONS OF HAVING A TEXTURE-MODIFIED DIET

Providing an inappropriate textured modified diet for someone with dysphagia can be harmful to the individual (Warlow et al, 2008). Warlow also recount a number of incidences where advice to follow a texture-modified diet has not been adhered to with fatal consequences (Warlow et al, 2008). There is also evidence that information given to

those that care for patients is often imprecise and can make it difficult for carers to accurately prepare the correct consistency of fluid (Pownall, 2009). This can lead to carers being more cautious than required and preparing softer diets than necessary, or offering fluids that are thicker than required. While being done for the right intentions, this mismatch can lead to other unintended problems. For example, a diet which has been overly softened could reduce its enjoyment and nutritional intake, while fluids which are thicker than necessary could increase the risk of dehydration due to their not being enjoyable (Pownall and Taylor, 2017).

Eating meals is not just about providing nutrition, as they are also meant to be enjoyable and have a social element. People who require a texture-modified diet can become more isolated around meal times (Hall et al, 2008; Thompson, 2016). They can feel different, requiring different meals, or they may feel that they are ‘messy eaters’ and withdraw from social situations. They may also become slower eaters, as they have to make effortful swallows, so food becomes cold before they have finished and thus they might struggle to complete an adequate meal. Furthermore, a texture-modified diet also has a change in appearance and there is evidence that this affects flavour and ultimate enjoyment of eating (Ullrich and Crichton, 2015).

Texture-modified diets also have a lower nutritional value, as foods requiring softening are cooked for longer and thus nutrients, in particular the water-soluble vitamins (B and C), are destroyed by the prolonged cooking process. Meat can often be difficult to puree and is often avoided, or alternatively, it requires significant amounts of fluid to be added, diluting down the nutrients. This increases the risk of protein and iron deficiency. Pulses, as alternative iron sources, are also difficult to puree due to the thick skins. This means that an increased volume of food needs to be eaten to meet the same nutritional intake (Wright et al, 2005). For patients who are not enjoying their food, or may have a reduced appetite due

to illness, it can be challenging to meet their nutritional needs with diet alone (Keller et al, 2012). Thus, it is important that patients are given support to enjoy food and maintain their nutritional status.

Furthermore, as requiring a texture-modified diet is a risk factor for malnutrition, only those that need such diets should be given them (O’Keefe, 2018), as while providing a softer diet than necessary, may be more reassuring for carers, it can cause other problems for the patient involved.

IMPLICATIONS OF REQUIRING THICKENED FLUIDS

There is evidence that people struggle to maintain adequate fluid intake when recommended to have their drinks thickened. Thickened fluids are known to affect flavour and the ability to quench thirst (Cichero, 2013), which can increase the risk of dehydration. Thus, it is essential that directions on how to thicken fluids are adequately followed. Different thickeners also have different characteristics. They are generally either starch- or gum-based thickeners. Gum-based ones are often more palatable to patients with dysphagia (Penney, 2014).

It is also important to consider how medications are administered and their absorption rates. There is some evidence that absorption rates are changed when taken with thickened fluids. If tablets are crushed, this again might change the bioavailability (Cichero, 2013).

IMPROVING THE NUTRITIONAL CONTENT OF TEXTURE-MODIFIED DIETS

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KEY POINTS Sometimes dysphagia can

resolve, however, for many it can be long term and also continue to deteriorate over time as the disease progresses.

Providing an inappropriate textured modified diet for someone with dysphagia can be harmful to the individual.

Eating meals is not just about providing nutrition, as they are also meant to be enjoyable and have a social element.

Texture-modified diets have a lower nutritional value, as foods requiring softening are cooked for longer and thus nutrients, are destroyed by the prolonged cooking process.

As requiring a texture-modified diet is a risk factor for malnutrition, only those that need such diets should be given them.

If patients are struggling with the volume of food required to meet their nutritional needs, they should be encouraged to take smaller, more frequent meals and snacks.

Food molds have been developed and found to be useful in improving compliance and acceptance of pureed meals (Hall et al, 2008). These work by first pureeing the food and then reshaping it into a similar shape to the pre-pureed food item. During this process, it is possible to increase the nutritional content of the food by: Blending pureed food with

nutritious fluids such as milk, cream, sauces, or creamy soup rather than water

Adding extra butter or margarine when pureeing vegetables

Adding grated cheese or cream to pureed potatoes, or soups

When using milk, add milk powder to the milk to increase the nutritional content of the milk

There are also some companies that will deliver nutritious texture-modified diets to people at home.

If patients are struggling with the volume of food required to meet their nutritional needs, they should be encouraged to take smaller, more frequent meals and snacks. Three smaller, nutritious meals followed by three snacks between meals will improve nutritional intake. Softer nutritious snacks include: Yoghurts, fromage frais or soya

desserts — smooth, without fruit pieces maybe required

Mousse Smooth soups could be used as a

nutritious drink. They may need to be thickened

Smoothies, milkshakes or milky drinks — these may need to be thickened

ADDITIONAL SUPPLEMENTATION

A number of neurological conditions, which are associated with swallowing difficulties, also have increased nutritional requirements associated with them, such as Parkinson’s disease, MND, and MS. Spasm or tremors also increase energy expenditure, which needs to be replaced.

It may be that even with a good dietary intake, weight loss is still evident. In these instances, additional prescribable supplementation may be needed. Most companies that produce oral nutritional supplements (ONS) make ones which are suitable for all the different thicknesses of fluids and include a smooth and puree-type supplement. They also make pre-prepared thickened, nourishing drinks. These supplements are also Advisory Committee on Borderline substances

Milk pudding pots, such as custard, rice pudding, crème caramel

Tinned fruit may be suitable for someone on a soft diet.

MONITORING NUTRITIONAL INTAKE FOR THOSE ON A TEXTURE-MODIFIED DIET

As said above, it is essential to monitor the nutritional and hydration state of patients on texture-modified diets and thickened fluids.

Risk of malnutrition is often monitored using the Malnutrition Universal Screening tool (MUST) (Elia, 2003). This comprises three elements for determining risk of malnutrition. The first is weight and body mass index (BMI). Those with a lower BMI are at heightened risk of malnutrition. The second is unexpected weight loss. If more than 5% of an individual’s weight has been lost, without trying, over a 3–6-month period, this increases the risk of malnutrition. The final element is associated with an acuity score, or if patients are likely to have very little or nothing to eat for more than five days. The acuity score is added to those with an acute illness, such as those who are critically ill, have had a recent head injury, or are undergoing gastrointestinal surgery. The acuity score is less likely for those in the community, although, lack of eating for five days may result in the need to add a score for this element for such patients.

For the first two elements of MUST, a weight is required. It is therefore important that regular weight monitoring is completed. If this is not possible, more subjective measures should be considered, such as whether a person’s clothes are becoming loose, loss of skin integrity, or patients becoming withdrawn (Taylor, 2014).

Hydration states can be monitored by frequency of passing urine and concentration of the urine. Urine should be a clear, straw colour; if darker, this indicates the need for increased fluid intake. Other symptoms of dehydration include confusion, dizziness, and a weak pulse (Thomas et al, 2008).

▼ Remember...

The sooner a swallowing problem is identified, the sooner it can be treated. Community nurses are well placed to recognise any changes in a patient’s swallowing ability.

▼ Practice point

Ensuring adequate nutritional and fluid intake for individuals with dysphagia can be challenging.

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JCN 2019, Vol 33, No 2 49

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Having read this article, reflect on:

What is meant by texture-modified diets

The impact that such diets can have on patient wellbeing

The importance of informing and supporting carers/families of patients with dysphagia.

Then, upload the article to the free JCN revalidation e-portfolio as evidence of your continued learning: www.jcn.co.uk/revalidation

RevalidationAlert

(ACBS) listed for dysphagia. However, for some neurological conditions, swallow is likely to deteriorate further and may result in patients being advised not to take any food or fluids orally (Daniel, 2006). In these instances, people require support from the multidisciplinary team to be able to make informed choice about their dietary intake. This is a complex situation and outside the remit of this article. However, it is worth remembering that a number of patients have capacity to make informed choice, and will choose to eat and drink, accepting the consequences of their decisions. These decisions are normally taken jointly with the patient, carers and all members of the multidisciplinary team, who will consider quality of life against having to refrain from eating and drinking due to an absent swallow. Providing food can be a challenge to those caring for patients who have made these decisions, and it is important that they are adequately supported through these times.

SUMMARY

The process of eating and drinking well has both physiological, psychological and social aspects. Everyone likes to have a choice of what they eat and drink. People eat for enjoyment as well as to meet their nutritional needs. However, as a result of dysphagia, certain consistencies of food or fluid have the potential to be harmful. Understanding the psychological impact of this is important. It is also essential that those caring and supporting the person with their swallowing difficulties are adequately informed of the reasons for the dietary/fluid recommendations, and understand the potential consequences if an inappropriate consistency is taken. Ensuring an adequate nutritional and fluid intake for individuals with dysphagia can be challenging.

REFERENCES

Cichero J (2013) Thickening agents used for dysphagia management: effect on bioavailability of water, medication and feelings of satiety. Nutrition J 12: 54

Daniel S (2006) Neurological disorders affecting oral, pharyngeal swallowing. GI Motility online. Available online: www.nature.com/gimo/contents/pt1/full/gimo34.html (last accessed 26 March, 2019)

Elia M (2003) Screening for Malnutrition: A Multidisciplinary Responsibility. Development and Use of the Malnutrition Universal Screening Tool (‘MUST’) for Adults. BAPEN, Redditch

Hall G, Wendin K (2008) Sensory design of foods for the elderly. Ann Nutr Metab 52(suppl 1): 25–8

Holland G, Jayasersekeran V, Pendleton N, Horan M, Jones M, Hamdy S (2011)Prevalence and symptom profiling of oropharyngeal dysphagia in a community dwelling of an elderly population: Self-reporting questionnaire survey. Dis Esophagus 24(7): 476–80

International Dysphagia Diet Standardisation Initiative (2016). Available online: http://iddsi.org/resources/framework/

Kayser-Jones K, Pengilly K (1999) Dysphagia among nursing home residents. Geriatr Nurs 20: 77–84

Keller HE, Chambers L, Niezgoda H, Duizer L (2012) Issues associated with the use of modified texture foods. J Nutr Health Aging 16(3): 195–200

Logemann JA (1998) Evaluation and treatment of swallowing disorders. 2nd edn. College-Hill Press, Inc, San Diego

National Institute for Health and Care Excellence (2006) Nutrition Support in Adults: oral nutrition support, enteral feeding and parenteral nutrition. Clinical guideline 32. NICE, London

National Patient Safety Agency (2007) Dysphagia Diet Food Texture Descriptors. Available online: www.nrls.npsa.nhs.uk

O’Keeffe S (2018) Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified? BMC Geriatr 18: 167

Penney B (2014) Use of fluid thickener to reduce dysphagia risk. Nurs Times 110(12): 16–18

▼ Practice point

Adding an ONS to a patient’s diet helps to provide nutrients, particularly for those who can only eat small amounts.

Pownall S (2009) Investigations into the management of patients presenting with dysphagia following stroke. Doctoral thesis, University of Sheffield, Sheffield

Pownall S, Taylor C (2017) Use of thickening agent and nutritional supplements for patients with dysphagia following stroke. Br J Neurosci Nurs 13(6): 220

Sura L, Madhaven A, Carnaby G, et al (2012) Dysphagia in the elderly: management and nutritional considerations. Clin Interv Aging 7: 287–98

Taylor C (2014) Practical strategies for treating malnutrition in the community. J Community Nurs 28(3): 43–50

Thomas D, Cote T, Lawhorne L, Levenson S, et al (2008) Understanding clinical dehydration and its treatment . J Am Med Directors Assoc 9(5): 292–301

Thompson R (2016) Identifying and managing dysphagia in the community. J Community Nurs 30(6): 42–7

Ullrich S, Crichton J (2015) Older people with dysphagia: transitioning to texture-modified food. Br J Nurs 24: 686–92

Warlow C, van Gijn J, Dennis M, et al (2008) Stroke Practical Management. 3rd edn.Blackwell Publishing

Wright L, Cotter D, Hickson M, Frost G (2005) Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. J Hum Nutr Diet 18: 213–9JCN

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