Management of dysphagia

Ideally, a multidisciplinary team should manage patients with dysphagia, as providing treatment needs a close interaction between the patient’s speech and language therapist and other healthcare professionals.  As well as medical specialists (such as an otolaryngologist and a radiologist), the multidisciplinary dysphagia team will usually also include nurses and a dietitian.

Speech and language therapists (SLT)
The role of the speech and language therapist is to carry out a detailed and systematic assessment to determine the cause of the dysphagia) and to manage that with changes of position, manoeuvres, or diet and liquid modifications (Pettigrew & O’Toole, 2007).  It may be necessary to move to instrumental investigations such as video fluoroscopy or Fibre optic Endoscopic Evaluation of swallowing (FEES).  The SLT can then inform the rest of the team of a possible reason for the dysphagia and  devise a management plan.  This may include exercises that will strengthen those muscles needed to improve swallowing. 

Dietitians
A dietitian can give advice on which foods are most suitable for the patient to eat, how they can be prepared to make them more palatable and how to maintain a balanced diet.  They can also give advice on how to fortify meals and recommend appropriate nutritional supplements to ensure patients keep up their energy and nutritional requirements.

Nurses
The nurse’s role includes weighing patients and assessing for signs and symptoms of nutritional deficiencies and dehydration.  When an older patient resides in a nursing home, the nurse can help them practise the exercises set by the speech and language therapist during meal times.  The nurse can also ensure that your patient’s diet corresponds to what was prescribed, record their actual intake and assess your patient for signs and symptoms of silent aspiration pneumonia.

Treatment

Treating dysphagia depends on the cause of the swallowing difficulties, so each patient needs a thorough investigation.  Table 1 lists a variety of swallowing problems and possible therapy options. 

Table 1: SWALLOWING THERAPY
JA Logemann (1998)

Swallowing disturbance	Therapy
Reduction in lip closure	Lip exercises
Reduction in cheek tension	Posture (tilt towards stronger side)   Pressure on weaker side
Reduction in range of tongue movements	Tongue exercises   Position food posteriorly   Posture (tilt head backwards)
Delayed swallowing initiation	Chin tuck   Supraglottic swallow
Reduced pharyngeal contraction	Double swallow Alternate liquids/solid swallows Effortful swallow Masako manoeuvre (tongue holding exercise)
Pharyngeal hemiparesis	Posture (tilt head towards stronger side, turn towards weaker side)
Reduced laryngeal elevation	Mendelssohn manoeuvre   Shaker Head Tilt exercise   Supraglottic swallow
Reduced laryngeal closure	Adduction exercises   Supraglottic swallow

Although these methods can be highly effective, they rely on the consistent co-operation of the patient each time they swallow.  Since many patients with swallowing difficulties are older and may be cognitively impaired, full compliance with voluntary corrections can’t be guaranteed.  Therefore, modification of the texture of liquid and food remains the therapy of choice for many of these patients.  This also emphasises the need to involve the patient’s direct environment (family and carers) in the management of dysphagia to ensure suggested methods are implemented and used regularly and appropriately.

Nutritional Support
Over the last few years, there has been an increased concern over the high rates of malnutrition in hospitalised older patient.  This has drawn attention to the important role of nutritional therapy in the management of dysphagia.  Patients with dysphagic symptoms that limit their food and fluid intake, whether they are hospitalised or cared for in an institution or home, should be considered at high risk of malnutrition and treated accordingly.
 
The main aims of nutritional therapy are to:

• Assist patients with swallowing to prevent aspiration and choking
• Optimise nutritional status and so prevent dehydration and malnutrition

To minimise the risk of aspiration and choking, dysphagia treatment in adults may involve textural modification of both food and drink.  Liquids will often need to be thickened while solid foods may need to be pureed or softened.  It is often assumed that water and other liquids are easier for patients with dysphagia to swallow, but in reality they present a unique challenge – as they can flow freely through the mouth and into the airways.  This adds to the importance of modifying the texture of liquids to keep patients adequately hydrated.  This can easily be achieved using appropriate thickening agents such as Resource ThickenUp.

The following sections provide further practical advice on caring for patients with dysphagia.

Hints for carers of older patients with dysphagia

• Wherever possible, ensure that your patients can choose from a range of appropriate foods.  This not only provides a greater incentive to eat, but also helps them achieve a balanced intake of nutrients
• Patients with dysphagia can quickly become full when served a full meal.  So rather than serving them three large meals a day, try serving smaller portions of foods but more frequently
• Maintaining a patient’s dignity is also vital. If they’re worried about messy eating, coughing and choking, position them appropriately.  Also try to avoid making them feel pressured to eat faster than they find comfortable
• In nursing homes and hospitals, the main meal of the day tends to be served at lunch time.  This is often better  for patients with dysphagia as their swallowing difficulties often worsen as they become tired in the evening.  Try to find the optimum mealtime for each of your patients.  This is particularly important for those patients with conditions such as Parkinson’s disease, in which the effect of medications may decline through the day, further impairing patients’ ability to swallow
• Positioning the patient correctly can really help them with swallowing
• Always watch for a worsening of symptoms, and seek advice from other health professionals as soon as it’s needed

Hints on feeding older patients with dysphagia 

• Check your patient’s swallowing is functioning and that they are alert
• Where appropriate check their glasses, hearing aid, dentures and posture
• Choose foods which have a suitable consistency
• Where possible, let your patient see and smell the food to encourage appetite and the production of saliva
• Don’t rush your patient - leave enough time for them to chew and swallow
• When spoon-feeding aim to:
• have a small amount on the spoon and
• place the food in the middle of the mouth, pushing the tongue down, as this avoids the tongue falling back in the mouth
• Avoid contact with their teeth to stop them biting on the spoon
• Ensure your patient’s mouth is empty before offering them their next portion
• When the patient has  finished eating it is important to clean their mouth to avoid food sticking around the oral cavity.
• Any problems they have experienced during feeding should be documented for future reference
• If your patient starts to lose their appetite or starts to lose weight, consult the dietitian

Hints on using thickeners for patients with dysphagia 

• Take care when adding thickeners to liquids - always start slowly and add little amounts, rather than adding too much at once.  Be sure to follow manufacturers instructions for mixing to gain optimal results from thickeners
• When adding thickeners, you can avoid lumps by putting the liquid and powder  in a capped beaker and shaking rather than stirring 
• Ensure patients take sufficient drinks to keep them well hydrated.  A pint of fruit jelly, for instance, will effectively provide the patient with a pint of water
• Foods need to be well presented  to stimulate the appetite, so when blending a meal, blend the meat and vegetables separately to ensure the food remains colourful.  Food moulds also provide a versatile and attractive way of presenting meals.

Hydration

Many dysphagic patients are known to drink less, so it is important to ensure adequate amounts of fluid to keep your patient well hydrated.  This is particularly true of patients who rely on thickened fluids.  This can pose a problem for healthcare professionals and it is essential that hydration is addressed proactively by all members of the MDT.  It is not enough simply to leave a jug of water and a tumbler by your patient’s bedside.  Carers should monitor patients for symptoms of dehydration, ideally keeping a record of their daily fluid intake.  Fluid requirements are usually calculated as 30ml per kg body weight or 6-8 cups of fluid a day.

Hydration is essential to patient care, and as vital as medication and other types of treatment.  It is the responsibility of the members of the multidisciplinary team to ensure their patients have the right hydration at the right time.

Hints on keeping patients hydrated

• Communicate hydration as a priority to everyone in the team.  Inform families too – hydration is everyone’s job
• Encourage and gently remind your elderly patients to drink
• Tea and coffee both count as fluid
• Replace fluids your patient’s dislike with others of a similar nutritional value
• Remember fluids are more than just water – milkshakes, soups, ice cubes, lollies, sorbet, ice cream, jellies, custard and fizzy drinks all count.  Don’t forget sip feeds either!
• Offer them fruit and vegetables, especially those with a high water content like watermelons and tomatoes, which  are 90% water
• Encourage your patient’s to have a full cup of fluid with medication
• In summer adopt ‘happy hour’ where thirst-quenching cocktails are served daily
• Closely monitor all episodes of diarrhoea and vomiting

Enteral tube feeding

Dysphagic states in neurological dysphagia are the most common and established indications for artificial enteral nutrition support via PEG.  Assessing safe swallowing and adequate nutrition are crucial when determining which patients with neurological dysphagia should be referred for PEG.  Early feeding via PEG is helpful and highly effective in stroke patients with dysphagia and inadequate oral intake.  It is also essential that any dysphagic patients are regularly assessed to continually monitor their ability to swallow and thus adjust PEG feeding regimen accordingly until the ability to swallow safely is restored. (Löser, C. et al 2005)