Dysphagia and Swallowing

Dysphagia is a common condition seen in many long-term care clients.

Although many factors can cause trouble swallowing, it is often seen in post-stroke clients and those who have dementia, where a person’s ability to control muscle movements in their throat and epiglottis has been affected (Health Direct 2018). This makes the person at risk of inhaling both food and liquids causing aspiration, which can lead to fatal pneumonia and choking.

When assisting a person with dysphagia during meals, it is critical you know what types of food and at what consistency they are allowed to consume, therefore making it essential to consult a client’s care plan before beginning.

Liquid Consistency

Depending on a client’s swallow test (usually performed by a speech pathologist), the patient will be prescribed a particular consistency of liquid to match their ability.

Liquid consistency can be anywhere from puree-thick, to runny and thin.

Standards for Texture Modified Fluid Consistency

• Level 0 - Thin
• Level 1 - Slightly Thick
• Level 2 - Mildly Thick
• Level 3 - Moderately Thick
• Level 4 - Extremely Thick

(IDDSI 2019)

Some of these fluids will come pre-prepared to the desired consistency, but others may need to have fluid thickener added to achieve the correct consistency for your client.

Food Consistency

Like liquids, foods should be served at a manageable consistency as well, depending on the ability of the client to chew or swallow.

Standards for Texture Modified Food Consistency

• Level 3 - Liquidised
• Level 4 - Pureed
• Level 5 - Minced and Moist
• Level 6 - Soft and Bite-Sized
• Level 7 - Easy to chew / Regular

(IDDSI 2019)

Some people will be on normal consistency foods and can eat anything that they choose, while others may be at the stage of consuming slightly thickened liquids in addition to normal consistency food.

The next step up is soft, bite-sized foods. This means that the food should not be crunchy, and the servings should be as manageable as possible. You should avoid raw vegetables and corn, and encourage moist and soft foods.

A further step into the consistency paradigm is minced and moist foods. This means that the consistency of the foods should be minced, bite-sized, and require as little chewing as possible to process in the mouth and swallow.

Smooth, pureed food is used for those who require the softest consistency, before moving to fully-liquidised nutrition. Everything must be the same texture and require no chewing.

Tips for Assisting a Person with Dysphagia and Late-Stage Dementia to Eat and Drink

• Clients may not enjoy eating softer foods. In these cases, try to vary foods on the menu.
• Some studies show triggering different taste sensations, such as with sour or cold foods, can aid to stimulate the swallow reflex.
• Be aware of ‘pouching’. This is when the client holds food in their cheek. Some patients can hold an entire meal in this way.
• Another way to assist in swallowing is to have the patient tuck their chin to their chest. This can help with certain types of dysphagia and this method may be recommended by the client’s speech pathologist.
• Some speech pathologists recommend stroking the side of a patient’s cheek to encourage them to swallow, but it depends on the cognitive level of your patient.
• It is important to monitor your patient closely for signs of aspiration, such as coughing, gagging or turning red. This is a medical emergency and should be managed accordingly.
• Dietary supplements may become necessary to ensure your client is receiving sufficient nutrition.

(Loret 2015; Pines of Sarasota 2016; IDDSI 2019)

Additional Resources

• International Dysphagia Diet Standardisation Initiative Framework: http://ftp.iddsi.org/Documents/IDDSI_framework_with_creative_commons_Mar2019.pdf.
• Helping a Person Eat and Drink in Late Stage Dementia: https://www.youtube.com/watch?v=sNPAESrllgQ.
• Speech Pathology Australia Clinical Guidelines for Dysphagia: https://www.speechpathologyaustralia.org.au/.../Clinical_Guidelines/Clinical_Guidelines.

References

• Health Direct 2018, Dysphagia (difficulty swallowing), Health Direct Australia, viewed 16 September 2019, https://www.healthdirect.gov.au/dysphagia.
• International Dysphagia Diet Standardisation Initiative 2016, The Framework and Descriptors, viewed 16 September 2019, http://ftp.iddsi.org/Documents/IDDSI_framework_with_creative_commons_Mar2019.pdf.
• International Dysphagia Diet Standardisation Initiative 2019, What is the IDDSI Framework?, IDDSI, viewed 16 September 2019, https://iddsi.org/framework/.
• Loret, C 2015, ‘Using Sensory Properties of Food to Trigger Swallowing: A Review’, Critical Reviews in Food Science and Nutrition, vol. 55, no. 1, pp. 140-5, viewed 16 September 2019, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151816/.
• Nestle Health Science 2015, Australian Standards for Texture Modified Foods and Fluids, viewed 16 September 2019, https://daa.asn.au/wp-content/uploads/2015/04/A3_Aus-Standards-Food-and-Fluids-Poster-Check-2.pdf.
• Nestle Health Science 2018, Your Complete Guide to Dysphagia, viewed 16 September 2019, https://www.nestlehealthscience.co.uk/hcp-education-hub/dysphagia/documents/your%20complete%20guide%20to%20dysphagia.pdf.
• Pines of Sarasota 2016, Helping a Person Eat and Drink in Late Stage Dementia, online video, viewed 16 September 2019, https://www.youtube.com/watch?v=sNPAESrllgQ.
• Queensland Government, My Nutrition: Thickened Fluids, viewed 16 September 2019, https://www.health.qld.gov.au/__data/assets/pdf_file/0029/146567/txt_mod_tf.pdf.
• Speech Pathology Association of Australia Limited 2012, Dysphagia, viewed 16 September 2019, https://www.speechpathologyaustralia.org.au/SPAweb/Members/Clinical_Guidelines/spaweb/Members/Clinical_Guidelines/Clinical_Guidelines.aspx?hkey=f66634e4-825a-4f1a-910d-644553f59140.