Nutrition In Dysphagia

By James Collier BSc (Hons) - Consultant in Nutrition and Moderator of Dietetics.co.uk

Dysphagia is associated with a wide range of medical and surgical conditions. It frequently goes unrecognised and can occur as a result of damage to the central nervous system or muscles of the head and neck. Dysphagic patients are at high risk of developing serious complications such as undernutrition, dehydration and aspiration. The multi-disciplinary approach is crucial in appropriate patient care.

Dysphagia can be defined as having difficulty or discomfort in swallowing. Patients present with choking and coughing on swallowing, with food sticking and causing pain or discomfort. Because of this, dysphagia sufferers often have a loss of appetite or weight loss. Aspiration and pneumonia is a serious consequence of food passing into the pharynx uncoordinated, entering the airways, acting as a breading ground for infection. Malnutrition and dehydration are very common, resulting from the reduced oral intake due to the increased effort it takes to eat and drink sufficient amounts. Poor nutritional status is associated with serious health risks such as impaired wound healing, higher risk of infection and impaired mental and physical function.

Team Management of Dysphagia
Dysphagia is best managed by the multi-disciplinary team. Team members could consist of:

Speech and language therapist or other dysphagia specialist (like a dysphagia link nurse or appropriately trained doctor) for swallowing assessments
Dietitian to advise on appropriate nutrition
Patient's nurse or nutrition nurse specialist
Medical staff
Representatives from the hospital catering department

In addition to the above, physiotherapists, occupational therapists, pharmacists, carers and relatives may play a role.

The speech and language therapist assesses the swallowing status of an individual, and dysphagia can present to varying degrees, which will require different treatment. With time an individual's swallow may improve, so periodic reviews of swallow ability are important.

The patient may require fluids thickened to an appropriate consistency. Fluids are thickened by commercial thickener powders, which are based on cornstarch and maltodextrin or vegetable gums like pectin or guar gum. Thickeners are produced by a number of nutritional companies and are available on prescription. There are three main consistencies of thickened fluids: runny honey, custard and semi-solid consistencies (note that some hospitals and organisations use different terminology). Thicker fluids will need to be taken by a spoon and are for increasingly dysphagic patients.

Patients may also not be able to manage to swallow normal food safely so also require altered consistency. Depending on the speech and language therapist's advice, normal, soft or puréed food may be requested. Food with mixed textures and irregular lumps are the least safe.

Nutritional Management of Dysphagia
The aim of nutritional management is to provide a suitable nutritious diet which will prevent aspiration and help make eating a pleasant experience. Other than texture modification, crucial elements in effective nutritional management of dysphagia are appropriate food choice, food fortification and the use of dietary supplements. The key player from the multi-disciplinary team here is the dietitian, who will monitor the patient's nutritional status and intake and advise accordingly. If the patient's nutritional intake is insufficient, alternative feeding may need to be considered. In fact, in severe cases of dysphagia or aphagia (complete absence of swallow), the patient may be put nil by mouth but the swallow assessor, and have to be enterally fed via a naso-gastric or gastrostomy tube. Parenteral fluids may also be initiated to ensure adequate hydration.

To make foods and fluids more nutritious there are a number of easy and practical tips. These include:

Rather than puréeing meals with water, use more milk or cream - for protein and energy
Whole milk can be fortified by adding milk powder - 4 tablespoons per pint of milk
Melt butter or margarine into hot savouries
Add sugar to sweet foods
Add fortified milk to potatoes before puréeing
Stewed fruits and other desserts: add cream, custard, natural yoghurt or evaporated milk before puréeing

Modern Puréed meals
Puréed meals are particularly topical at the moment, as part of the Government's Better Hospital Food agenda (see website www.betterhospitalfood.com), where all hospitals must provide appropriate nutrition.

Several years ago a patient who required a puréed meal was unlikely to be served a diet of an appropriate texture and nutrition, let alone one that was appetising. If a nurse requested a 'puréed meal' for his/her patient, what was sent up was merely the meal choice from the hospital menu liquidised with water or milk and served in a bowl, i.e. nothing more than an unappetising, unattractive 'slop'! Not only was this unappetising and insufficient nutritionally, but it was of an inappropriate consistency for safe swallowing.

More forward thinking catering departments blended foods individually and added thickeners to achieve a uniform consistency. Individual puréed foods were served in separate pools on a plate. While this is better, it is still not acceptable for a patient who, with swallowing problems, has low enthusiasm for food, and high nutritional requirements

A number of catering departments and commercial nutrition companies have trialed and developed extremely appetising and nourishing puréed meals. These involve the use of thickeners and food moulds, so the food somewhat resembles its original form. When, for example, a patient orders puréed chicken, what they are served will resemble a chicken breast on their plate, puréed potato will resemble a scoop of mashed potato, and puréed peas will resemble a spoonful of peas. Glucose polymers, milk powders and cream may be added to raise the nutrient density, and some desserts are based on the commercial sip feed supplements. Soups, sandwiches, main courses and desserts are all available in the moulded puréed format.

Not only are the moulded foods more appetising and of an appropriate consistency, but they are also high in calories and protein, aimed to help the nutritional status of a group of patients at risk of undernutrition. In addition, audits have shown that patients enjoy moulded puréed meals more than the previous inappropriate formats, and are thus more likely to eat the whole meal. This means less food wastage, improved nutritional status, and a more favourable clinical outcome.

Progress
Often dysphagia is temporary (as in many stroke patients) and a number of patients do progress to some degree, a few continuing to a completely normal texture of diet and fluids, but the time for this could range from a few weeks to years. Naturally, this means a wider variety of foods and psychological improvement. Unfortunately with some neurological conditions, such as Parkinson's disease and motor neurone disease, deterioration is progressive.

Summary
Dysphagia is a complex condition, resulting from a number of medical and surgical conditions, and it has a profound impact on patient's lives. Treatment of swallowing problems has dramatically improved over the past few years; now it aims at improving quality of life, optimising nutrition and minimising risk of aspiration. The duty of clinicians is to try to maintain a safe texture for a patient's swallow, prevent malnutrition and encourage the patient to continue to enjoy the pleasures of eating; the multidisciplinary approach is crucial

REFERENCES
Banfield S. Dysphagia: one swallow doesn't make a therapy. News Views Talk in Nutrition. 2000
Kemp S. Restoring pleasure: nutritional management of dysphagia. British Journal of Community Nursing. 2001
Novartis Consumer Health. Dysphagia: Facts and Figures in the UK. 2000
Novartis Consumer Health. Hard to Swallow. Nutrition Matters. 2000