Dysphagia - Hard to swallow?

Dysphagia from the Greek words dys (difficulty) and phagia (to eat) is the term for swallowing difficulties. It is usually caused by a condition that affects the nervous system, such as a stroke, Parkinson’s disease or dementia, or by cancers and their treatment that affect the head, neck and throat. The risk of living with one or more of such conditions increases with age, and in an increasingly ageing population, this means an increased number living with dysphagia. Age and frailty are also associated with physiological changes in swallowing making the older person more susceptible.

Dysphagia can markedly impact health and quality of life. Serious complications include pulmonary aspiration (food and fluid going into the lungs) which may lead to chest infections, and increased risk of choking. Early identification and treatment is important in reducing adverse outcomes. For example, guidelines recommend that stroke patients should be screened within 24 hours and before oral intake to reduce dysphagia related complications. Staff should have sufficient training to be aware of the symptoms of dysphagia (e.g. identification of overt symptoms like coughing after food and drink, pocketing of food and wet gurgly voice), and to make appropriate referrals for detailed assessment and evaluation.

Communication within a multidisciplinary team (heath care professionals including dietitians and speech and language therapists, care staff, management, catering and family members) can facilitate more effective implementation of person-centred care plans and management strategies aimed at minimising dysphagic risks and optimising safety, nutrient intake and quality of life.

Such strategies may involve a range of therapies offered regularly including environmental modifications, postural advice, exercises, safe swallowing advice and appropriate dietary modification. Any approach should consider the client/patient and their carers wherever possible as part of the team involved in decision making processes.

An impaired swallow has many nutritional implications and dysphagia is associated with higher risk of malnutrition. An individual with dysphagia may be unable to eat sufficient food to maintain weight or unable to drink sufficient fluid to maintain hydration. As dysphagia can make eating slow, difficult and tiring, it can reduce both the quantity and variety of foods consumed. In addition to hydration and nutrition needs, consideration should be given to the impact on quality of life. Dysphagia can be associated with emotional and psychological problems and these should not be underestimated, although they are often not recognised. Fear of choking can cause food aversions or anxiety around meal times. Embarrassment (e.g. about drooling) and loss of enjoyment of food as a social function may encourage isolation.

Key to safe swallowing, reduced choking risk and adequate nutrition and hydration is the appropriate texture of food and fluids. Texture modification (e.g. the use of thickeners to help achieve the desired consistency of pureed foods, thickened fluids) is thus the mainstay of oral nutrition management in dysphagia. To improve patient safety and to enable consistent communication, efforts have been made to standardise food and liquid texture modifications. The most recent notable example is the International Dysphagia Diet Standardisation Initiative, IDDSI, a standard framework consisting of 8 texture levels with distinct coloured and number label (https://iddsi.org/). Simple tests have been developed by IDDSI to allow patients, professionals and caregivers to assess the appropriate consistency of liquids and foods. Manufacturers and health care settings were set to be fully IDDSI compliant by April 2019.

Whilst it is clearly important that the texture is safe, meals offered should be varied, balanced and acceptable in taste. Unfortunately, texture modified foods and drinks are commonly associated with unpleasant changes in appearance, flavour and mouthfeel, and with decreased food intake and food refusal. Using liquids in preparation to achieve modified textures can also dilute calorie and nutrient content. Although the focus is often on texture modified foods, the importance of hydration should not be overlooked. A lack of willingness to drink thickened fluids is common, increasing the risk of dehydration.

There has though been strikingly limited clinical, nutritional and sensory research in care homes, in part perhaps because performing such studies with a vulnerable older frail group is challenging. However, this type of research is important to understand best practices and to help improve intake and quality of life. There has been some movement towards addressing some of these issues, with examples of good practice from care catering chefs and commercial companies providing more interesting, varied and appealing foods. The use of moulds and food technology processes have been important in improving sensory appeal, making pureed foods resemble their natural shape, so that instead of a pool of baby food, the pureed food is made to look like a meal. This has been reported to have positive benefits increasing acceptance and consumption. Measures can also be taken to increase the nutrient content of texture-modified meals, for example by adding nutrient rich ingredients. Looking into the future, 3D printing has been noted as an exciting area for advancing texture modification. 3D printing could enable the automated production of design precision foods (printed into edible shapes) and liquids with standardised textures to promote safety, and with a nutrient content that can be personalised. It could also give residents with dysphagia some control by allowing them to be part of the food design and creation. At the moment it remains a venture for the future, but this technology is starting to be tested, albeit on a very small scale in German and Swedish care homes. Crucially we have as yet no real evidence on the experiences of people with dysphagia eating 3D printed foods, and there would need to be assurance of acceptability and safety before this could be considered as a technology of benefit.

As well as advances in food technology, exciting areas of clinical practice lie within restorative and rehabilitative skill and strength techniques aimed at improving swallowing function. There may also be a focus on further individualising treatment. The advance in wearable technology may become increasingly potentially useful, but barriers particularly with regards costs will need to be addressed. Research though should not only be reactive i.e. in patients already with dysphagia, but also focus on prevention. Another area for improvement is in increasing the knowledge of professionals involved in the care of people living with dysphagia. As mentioned, dysphagia benefits from a multidisciplinary approach not only for care, but by allowing a wider range of professionals to serve as important advocates of a condition that affects millions worldwide who may struggle to get their voices heard.

The challenge of adequate hydration in the care of people with dysphagia

Adequate hydration is necessary for survival. Every cell, tissue and organ requires water to function. Dehydration increases the risk of renal failure, falls, impaired mental status, constipation, urinary tract infection, respiratory infection, decreased muscle strength and pressure sores. However ensuring adequate hydration can be particularly challenging area in the care of people with dysphagia, those with swallowing difficulties that require thickened fluids. Thickened liquids are a necessity rather than a choice for swallowing safety. The importance of fluid texture has been noted in the International Dysphagia Diet Standardisation Initiative (IDDSI) framework with standardised descriptors for fluids as well as foods.

People drinking thickened fluids may drink less compared to those drinking regular fluids. The drinks that we consume daily without much thought, such as water, tea, coffee, juice or milk, are all fast-flowing liquids. Yet these can pose a risk to safe swallowing. Thickened liquids (e.g. fluids thickened with powder or bought pre-thickened) are typically prescribed for people with dysphagia. However, dissatisfaction with, and inaccessibility to, thickened liquids can result in poor compliance. Studies have shown that individuals required to drink thickened fluids are less likely to meet their daily fluid requirements and are more likely to be dehydrated than those receiving regular fluids. It may well be that a combination of acceptability, taste and satiety factors affect sufficiency of intake, and further efforts are required to improve intake. So how do we try to ensure that individuals with dysphagia are adequately hydrated without exposing them to the risks of choking and aspiration (liquids entering the airway)? Some steps that could be useful include:

• Early identification programmes - screening programmes and early referrals to appropriate staff like speech and language therapists (SLTs) and dietitians.
• A multidisciplinary team approach to care including care staff and caterers, as well as pharmacists, nurses, dietitians, occupational therapists and SLTs. For example, pharmacists can give advice with regards the optimal administration of medication, occupational therapists can provide valuable support to help users with positioning and feeding strategies and dietitians can provide valuable information on methods of increasing intake.
• Keeping an eye on the next generation thickeners that may improve compliance and safety, although these may have a higher cost implication. The next generation clear gel thickeners typically result in better appearance and flavour, and more reproducible consistency and stability.
• Oral moisture protocols can improve comfort. Mouth wetting is an important requirement to satisfy the feeling of ‘thirst’. This is thought to be a combination of increased oral moisture provided by the liquid and increase in saliva as stimulated by the liquid. Thickened liquids, however, do not provide this ‘mouth wetting’ quality. One way to combat this is to use a water atomizer to mist the oral cavity.
• Liquids can also be provided though foods such as soups, pureed fruit and yogurts.
• Look for novel ways to increase fluid intake like always providing fluids with oral medications, using signs and reminders and pairing fluid intakes with a regular activity (e.g. after bathing or after physiotherapy). Use of symbols, such as a water droplet logo where fluid intake needs to be maximized, can help staff identify those most in need of assistance to meet their daily fluid requirements.

Meeting the hydration needs of patients with dysphagia requiring thickened fluids remains challenging. While early identification and intervention are imperative in dysphagia management, more emphasis must be placed on improving patient compliance through continued efforts to make thickened liquids more palatable and accessible for individuals with dysphagia.