NACC South East Christmas Seminar Dysphagia Diet Food Texture Descriptors Caroline Lecko Patient Safety Lead NPSA/RCN

Aims To provide a background to the development of the new descriptors To discuss what’s different To discuss why it’s important To provide an update on the international position

Dysphagia Diet Food Descriptors Launched in April 2011 Developed by: NPSA RCSLT NNNG HCA Supported by: NHS Supply Chain Endorsed by the NACC August 2011 Engagement with industry

Why did we need new descriptors? Original descriptors issued in 2002 by the BDA & RSCLT BDA review document published in 2009 Recognised that there needed for engagement with industry and caterers Compliance with National Descriptors for Texture Modification in Adults was poor Requests from industry and caterers fro detailed guidance on categories of texture

Examples from the National Reporting and Learning System patient requires soft moist diet . however soft options on menu not suitable as contains lumps . patient started to cough and choke . patient was asked to stop eating and rest for 30 minutes . patient recovered and to commence of puree diet Patient was transferred to ward .... on .... , had been seen by colleagues and it was recommended she have a syrup consistency fluids and soft diet due to dysphagia . Went to review patient and found patient drinking normal fluids , with difficulty . Spoke to a nurse who informed that the recommendations had not been handed over , however the recommendations are recorded extensively in notes , including nurses entry immediately prior to transfer . Pt previously assessed by SALT as requiring a Soft Grey Diet / meal arrived with boiled pots, whole peas & sweetcorn, should have been mashed pot, mushy peas & no sweetcorn.  

What new? Endorsement from all of the key professional organisations All care settings are required to have 2 available textures: Texture C (Thick Puree Dysphagia Diet) Texture E (Fork Mashable Dysphagia Diet) Texture D ( Pre-mashed Dysphagia Diet) & Texture B (Thin Puree Dysphagia Diet) may be required in some care settings Have been developed to include children

What does the new document include? Specific standards for each texture B, C, D, & E Audit checklists so that food can be measured can be measured against the standards for each texture

C Thick Puree Dysphagia Diet C C Thick Puree Dysphagia Diet C For example C Thick Puree Dysphagia Diet C C Thick Puree Dysphagia Diet C General description: √ Food has been pureed or has a puree texture. It does not require chewing. √ It is a thick puree* √ It is smooth throughout with no ‘bits’ (no lumps, fibres, bits of shell/skin, bits of husk, particles of gristle/bone etc.) It may need to be sieved to achieve this. Check before serving: × No hard pieces, crust or skin have formed during cooking/heating/standing × Fluid/gravy/sauce/custard in or on the food has not thinned out or separated off. Note – definition of ‘thick’ puree Holds its shape on a plate or when scooped. Can be eaten with a fork because it does not drop through the prongs. Food has been pureed or has puree texture Pass Fail Borderline It does not require chewing It is smooth throughout with no ‘bits’ (no lumps, fibres, bits of shell/skin, bits of husk, particles of gristle/bone, etc) No hard pieces of crust have formed during cooking/heating It has not thinned out and any liquid within the food has not separated off Holds its shape on a plate or when scooped Can be eaten with a fork because it does not drop through the prongs

Who are the descriptors for? Primarily designed for food producers Useful for staff teaching and training

So why is it important?

The risks – potentially life threatening Malnutrition Dehydration Choking Aspiration pneumonia Death Liquidised food and thickened drinks can be particularly unappealing with the potential to result in individual becoming malnourished and dehydrated. An instruction for thickened fluids is viewed as ‘a prescription for dehydration’ Malnutrition is associated with the visual appearance and taste of the food, along with the fact that some texture modified food may also lack nutrient density. Choking is considered the main complication of dysphagia caused by food going down the ‘wrong way’ potentially entering into the lungs causing infection and aspiration pneumonia. All of these risks increase morbidity and mortaility.

Limited social activity Depression Anxiety Loneliness The risks – quality of life Low self-esteem Embarrassment Limited social activity Depression Anxiety Loneliness Loss of taste/smell

The role of food in the management of dysphagia Impacts on both the potential life threatening risks and quality of life issues Food needs to safe e.g. Meets the national guidelines for texture modification Food needs to be nutritious e.g. Meets national guidelines Reducing the risks associated with malnutrition, choking and aspiration pneumonia There needs to be choice Food needs to taste good Foods needs to look good We eat with our eyes and dysphagia does not affect your vision Food needs be socially and culturally acceptable All these things will improve someone’s quality of life.

20 – 30% of patients within acute care Dyphagia affects a lot of people US – Dysphagia occurs in approximately 51% - 71% of patients with stroke and 75% of nursing home More than 60,000 people die annually from complications related to dysphagia, making it the sixth leading cause of death in the US. 22% of the world’s population over 50 years old are affected by oropharyngeal dysphagia 20 – 30% of patients within acute care 59 – 60% of residents in care homes Department of Veterans Affairs – Veterans Health Administration Directive 2006 Cook & Kahrilas 1999

99% of children with severe cerebral palsy have dysphagia > 900,000 people in England are living with the effects of stroke (NICE 2008). Of all those with dysphagia following stroke 76% will remain with severe and 15% profound dysphagia 200/100,000 UK population have dysphagia due to PD. More than 90% of those with MND will have dysphagia RCSLT Resource Manual for Commissioning and Planning Services (2009) There is also increasing recognition that Dysphagia is a symptom of concern in many other condition – head and neck cancer, acquired brain injury, cervical discectomy for example.

68% of those with dementia in homes 27% of those with COPD 68% of those with dementia in homes 5.27% of all adults with LD were referred for advice regarding dysphagia Between 50% - 75% of nursing home residents 10% of acutely hospitalised elderly

The Global Picture The Tango has just began ...... Potential for International Dysphagia Descriptors Potential collaboration with interest from UK, Canada, Australia, Ireland, so far Discussed at the European Society of Swallowing Disorders (ESSD) in September 2011 Watch this space .......