Speech pathology & dysphagia Prudence Ellis Speech Pathologist 0433 177 739 prudence.ellis@live.com.au

Dysphagia refresher Swallowing problems Can be due to neurodegenerative conditions, stroke, TBI, disability or ageing http://cargocollective.com/ritamaldonadobranco#Visualising-dementia

Signs of dysphagia Coughing or choking Throat clearing during intake Increased shortness of breath during intake Gurgly or wet sounding voice Drooling of food/drink/saliva Patient complaints Very slow intake http://thehealthybear.com/how-to-safe-a-life-if-choking/choking-first-aid/

Dementia and dysphagia People with dementia often experience swallowing problems (between 45 and 80%!) The type of swallowing problems they experience may differ depending upon their type of dementia. What have you seen for: Vascular dementia Alzheimer’s dementia Fronto-temporal dementia Vascular Dementia show difficulty chewing and coordinating a swallow (Gallagher, 2011). Alzheimer’s Disease may forget to eat, be unable to chew, forget to swallow and show poor pharyngeal clearance (Homer and colleages) Fronto-temporal Dementia may experience an increase in appetite, change in food preferences, have larger bite sizes and eat non-edible items (Easterling).

Dysphagia and behaviour Some neurodenegerative conditions (eg. dementia) carry with them specific behaviours around eating/drinking This does not preclude oropharyngeal dysphagia http://www.docgautham.com/disorders/dementia

Signs of dysphagia in dementia Be aware of other problems associated with dementia and dysphagia These may be within in the scope of practice within a variety of disciplines (eg. Dietetics, OT, SP, RN,) Spitting out bits of food Holding food in their mouth Difficulty chewing Overfilling their mouth Food spilling out of their mouth Food getting stuck in their throat Forgetting to swallow and not sensing food in the mouth Coughing/throat clearing/gurgly voice during or immediately after eating or drinking

Referrals to SP Important These behaviours can place a person at risk of choking and aspiration and are often missed Different clinical areas may offer different services from SP in this area Even more important that we are all aware of the strategies!

Refresher - diets Full (normal/regular) Unmodified Description Full (normal/regular) Unmodified Soft (texture A; some hospitals break this into ward soft and dysphagia soft) Crunchy, hard or dry foods are avoided. Meat cooked until tender and foods are moist. Food could be easily broken up with the back of a fork. Pieces should be no larger than 1.5cm in size. Minced (texture B) Food is moist and soft and diced into small pieces, no larger than 0.5cm in size. Food is textured and can be mashed with the tongue rather than chewed. Puree (texture C) All food should be blended until smooth and be lump free. Foods may be slightly grainy due to their original form but this should be as smooth as possible. Dietitians Association of Australia and The Speech Pathology Association of Australia Limited (2007). Texture-modified food and thickened fluids as used for individuals with dysphagia: Australian standardised labels and definitions. Nutrition & Dietetics 64 (Suppl.2): 553-576.

Refresher - fluids Fluid Description Thin Normal drinks; Mildly thick (nectar, level 150, level 1) These fluids leave a film on a fork and drain through the prongs in a smooth stream Moderately thick (honey, level 400, level 2) These fluids drip through the prongs of a fork in several blobs Extremely thick (pudding, level 900, level 3) These fluids remain on a fork and do not stream through the prongs Dietitians Association of Australia and The Speech Pathology Association of Australia Limited (2007). Texture-modified food and thickened fluids as used for individuals with dysphagia: Australian standardised labels and definitions. Nutrition & Dietetics 64 (Suppl.2): 553-576.

Problems and suggestions Symptom Suggestion Spitting out bits of food Provide a napkin on which to place the food. Holding food in their mouth Offer sips of drink between mouthfuls of food Difficulty chewing Encourage them to swallow again (without any more food) before taking another mouthful. Overfilling their mouth Food spilling out of their mouth Use small cutlery Consider giving food in smaller, more frequent portions. Eat with them, and help them portion their meal by providing verbal prompts, like ‘slow down’ and ‘have a drink.’ Food getting stuck in their throat Forgetting to swallow and not sensing food in the mouth Alternate between food and drinks Alternate between a teaspoon of food and an empty teaspoon Try foods of different tastes, textures and temperatures Coughing/throat clearing/gurgly voice during or immediately after eating or drinking Ensure they are seated fully upright and not tilting to one side or another.

Types of thickener Xantham gum (from red algae) Flavour Creations; Instant thick Nestle thicken-up Clear FC Pre-thickened fluids http://www.thickenupclear.com/about-thickenup-clear http://www.flavourcreations.com.au/en/dysphagia-products

Types of thickener continued Guar gum-based (bean) Supercol-U Precise Thick’N (/Instant) Guarcol Other - combinations Aptamil feed thickener Nutilis (Nutricia) http://www.chipmonk.com.au/index.php/sizes; http://www.precisethickn.com.au/precise-thickn-instant/; http://www.thepharmacy.com.au/product_images/r/330/Guarcol_500g__28361_zoom.jpg

Paediatric & other thickeners Spoken with Aptamil (Karicare), Nutricia (Nutilis) Nestle and FC Considerations Texture Look Taste Smell Recipe Money/location My 2 cents... Nutilis – suitable for over the age of 3. The guideline is from the manufacturer and representatives are not sure what it is based upon. Guideline is slightly different to what is stated on the tin. http://www.aptaclub.com.au/our-products/aptamil-gold-feed-thickener.aspx http://www.nutilis.com/au/home.html

Case example Mr EM 95 year old man with fronto-temporal dementia Consistently tries to eat with his hands, very dehydrated, lips and tongue cracked, oral thrush present ; Staff sit him up against a table (arms under table) so he does not touch the food; feed him 1:1 puree Coughs with thin fluids when drinking quickly (sporadically); unable to chew hardest foods Referred for: ? Puree as he tries to eat with his hands and coughs with fluids

Recommendations Soft diet and thin fluids Spout cup to slow drinking but encourage independence (no OT coverage available) Finger foods encouraged (soft bread, soft cake) Appropriate dining environment to support socially appropriate finger-food behaviours Supervision with eating, no 1:1 feeding Result: Improved independence and dignity, improved hydration, nil signs of aspiration

Case example Mrs JA 65 year old woman with Alzheimer’s disease Forgets to feed herself, coughs with thin fluids, forgets to chew Weight loss of 3kg in 1 month, dehydrated 1:1 feeding give Referred for: ? Puree as she doesn’t feed herself and holds food in her mouth for a long time

Recommendations Minced diet (full diet allowed) and mildly thick fluids Contrasting placemat (no OT coverage) Seat at dining table with residents who model appropriate eating behaviours Finger foods encouraged Calm, positive dining environment Result: Resident loved mildly thick fluids; weight gain of 500g in 2 weeks, no 1:1 feeding, improved social interaction

Discussion What do these cases support?

Modified food/fluids Modified foods and fluids can be delicious and done very well The people we see will echo our reaction It is important that we spruik the positive outcomes and the positives of the products – not dwell on negatives Try them – they aren’t so bad Be creative!

Thickening at home - tips Follow the directions! Add all the powder at once – don’t add a small amount and then add more Don’t add powder and walk away – do it all at once (or it will go lumpy) Mix for as long as the instructions suggest

Thickening at home - tips Carry a measuring cup (for FC, use an empty FC cup as measurement) FC offer lids for their pre-thickened fluids – these are quite cheap and effective for storage Where there is thickener, there should be a recipe! Image courtesy of Flavour Creations, 2014

Encouraging hydration Thickened fluid ideas: Thicken water (or other) and freeze as an ice cube for drinks Freeze pre-thickened creamy products as “ice cream” (these taste amazing) Use ice block moulds to make thickened ice blocks in summer Thickened coffee + thickened ice cubes + pre-thickened/frozen creamy vanilla = delicious iced coffee treat! Foams (see recipe in Don’t Give Me Eggs That Bounce) Cookies and cream ice cream Image courtesy of HammondCare Media http://www.theguardian.com/lifeandstyle/wordofmouth/2011/may/16/best-iced-coffee-frappuccino

Fork test If you are unsure of the thickness of fluids, hold them next to a pre-thickened fluid and judge their similarity ...or try the fork test... Mildly thick fluids should leave a film on a fork and drain through the prongs in a smooth stream Moderately thick fluids should drip through the prongs of a fork in several blobs Extremely thick fluids should remain on a fork and do not stream through the prongs Reminder: 2Cal is not mildly thick

Modifying meals “Not that mushy stuff!”

Modifying meals at home - tips We are not committing people to a lifetime of “mush” and terrible food! Finely cut up foods to create a minced diet – don’t use a blender! Blend foods separately Use moulds http://www.wardipedia.org/29-food-presentation/

References Don’t give me eggs that bounce: 118 cracking recipes for people with Alzheimer’s (2014). Morgan-Jones, P., Colombage, E., McIntosh, D., Ellis, P. HammondCare Media. Dietitians Association of Australia and The Speech Pathology Association of Australia Limited (2007). Texture-modified food and thickened fluids as used for individuals with dysphagia: Australian standardised labels and definitions. Nutrition & Dietetics 64 (Suppl.2): 553-576.

Contact details Prudence Ellis (Prue) prudence.ellis@live.com.au 0433 177 739