1. Speech pathology & dysphagia
Prudence Ellis
Speech Pathologist

2. Dysphagia refresher Swallowing problems
Can be due to neurodegenerative conditions, stroke, TBI, disability or ageing

3. 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

4. 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).

5. Dysphagia and behaviour
Some neurodenegerative conditions (eg. dementia) carry with them specific behaviours around eating/drinking
This does not preclude oropharyngeal dysphagia

6. 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

7. 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!

8. 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):

9. 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):

10. 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.

11. Types of thickener Xantham gum (from red algae)
Flavour Creations; Instant thick
Nestle thicken-up Clear
FC Pre-thickened fluids

12. Types of thickener continued
Guar gum-based (bean)
Supercol-U
Precise Thick’N (/Instant)
Guarcol
Other - combinations
Aptamil feed thickener
Nutilis (Nutricia)

13. 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.

14. 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

15. 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

16. 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

17. 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

18. Discussion
What do these cases support?

19. 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!

20. 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

21. 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

22. 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

23. 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

24. Modifying meals “Not that mushy stuff!”

25. 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

26. 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):

27. Contact details Prudence Ellis (Prue) prudence.ellis@live.com.au