1. An introduction to Dysphagia and Texture Modification
Joanna Naylon – Clinical Lead Speech and Language Therapist
Alice Mitch – Speech and Language Therapist
Early Supported Discharge Team for Stroke
26th January 2016

2. Our bodies produce over 2 litres of saliva per day
Facts and Figures
A normal person swallows approximately
Per day:
590
Eating:
146
Awake (not eating):
394
Sleeping: 50
Our bodies produce over 2 litres of saliva per day

3. Stages of Swallowing
Oral Preparatory Oral Pharyngeal Oesophageal

4. The Normal Swallow
The Pre-Oral stage: seeing food, smelling food, getting food to mouth.
Oral preparatory stage: food is chewed (masticated), mixed with saliva, and formed into a cohesive ball (bolus).
The Oral Stage: food is moved back through the mouth with a front-to-back squeezing action, performed primarily by the tongue.
The Pharyngeal Stage: food enters the upper throat area (pharynx), the soft palate elevates , the epiglottis closes off the larynx, the base of tongue moves backwards and the posterior pharyngeal wall moves forward . These actions help force the food downward to the oesophagus.
Oesophageal stage: food enters the oesophagus (the tube that transports food directly to the stomach). The bolus is moved to the stomach by a squeezing action of the throat muscles.

5. Anatomy of the head and neck

6. ‘Dysphagia is the disorder of swallowing’

7. Prevalence of Dysphagia in the Elderly
Nursing home:
Between 50-75% Nursing Home residents have Dysphagia
Stroke:
42% of Stroke survivors in community settings have Dysphagia
Dementia:
68% of elderly nursing home residents with diagnosed Dementia have Dysphagia
Progressive conditions:
More than 90% of residents suffering from MND, MS or Parkinson’s Disease will develop Dysphagia with the progression of their symptoms

8. Risk factors… Residents who are/have: Poor Oral Hygiene
Dependent with feeding
Not alert
Unable to identify food due to acquired Agnosia
Unable to see food due to hemianopia / visual neglect
Reduced attention / orientation / understanding
Difficulty maintaining an upright position
Fatigues easily
Tube fed
Poor Oral Hygiene
Drooling / Weakness of lips or tongue

9. Warning signs… Coughing or choking when eating or drinking
Recurrent chest infections
Bringing food back up
Food or drink coming down through your nose
A sensation that food is stuck in your throat or chest
Food or drink “going down the wrong way”
Persistent drooling of saliva
Voice sounding wet after eating or drinking
Eyes or nose running during meals
Discomfort when swallowing
Residue of food in the mouth or throat after eating
Pouching of food in cheeks
Unexplained weight loss

10. The results of untreated Dysphagia
Coughing or choking – if food or fluid obstructs the airway
Aspiration pneumonia – Food/fluid/saliva entering the lungs – leading to infection, hospital admission, death
Malnutrition – oral calorific intake can be significantly reduced due to difficulties swallowing
Dehydration – fluid intake can also be significantly reduced due to difficulties swallowing
Reduced quality of life – many people gain enjoyment and associated psychosocial aspects from eating and drinking. Therefore swallowing difficulties can lead to depression and can impact on relationships and social gatherings.

11. So what do you need to do?
Contact the registered GP and request a referral to Speech and Language Therapy stating the concerns you have.
If triaged as appropriate a SALT will contact the home and arrange a mealtime visit to assess the resident’s swallow.
Depending on the outcome the SALT could advise active therapy, fluid/texture modification or referral for further investigation.

12. Texture Modification C DIET: THICK PUREE D DIET: PRE-MASHED
Food is pureed to a thick consistency or is naturally a thick, even texture. It does not need chewing. It will hold its shape on the plate. Food must be an even consistency with no lumps
D DIET: PRE-MASHED
Food is soft and tender and has been well mashed using a fork. It needs some chewing. It usually needs a thick sauce or gravy to moisten
E DIET: FORK MASHABLE
Food is soft and tender and well cooked. If food is suitable for this diet it will break down easily when pressed with a fork, but it does not need to be served mashed. It usually needs a thick sauce or gravy .

13. Which would you prefer?
Sandwich?
Chicken, veg and mash? OR

14. Modifying food
Ask your chefs to get creative, after all we eat with our eyes!
Cook the food as normal
Puree the food in a food processor / blender; sieving where necessary to ensure a completely smooth consistency
Add a food thickening agent
Spatula food into moulds and freeze for 2hrs minimum
Remove food from the mould and heat as normal

15. Why do we modify fluids?
Thicker fluids hold together better in the mouth making them easier to swallow
Thicker fluids pass through the throat more slowly, which allows your body more time to seal off the airway and makes it less likely that fluids will go down the wrong way into your lungs.
Thicker fluids hold together better in the throat which makes it less likely that small amounts will trickle down the wrong way and make you cough.

16. Fluid Modification options

17. The Stages of thickening
Stage 1 – Often called syrup or honey thick
Stage 2 – Yoghurt thick
Stage 3 – Texture of thick custard or soft “pudding”
Different thickening products require different preparation techniques – always check the label.

18. Make up a 100mls of stage 1 juice
Practical!
Make up a 100mls of stage 1 juice
You will need:
A cup
A spoon
A sachet of thickener
Have a taste!!

19. Q&A

20. References
Ellul.J & Barer.D. 1993, Detection and Management of Dysphagia in Stroke Patients with Acute Stroke. Age & Ageing,22;(Suppl 2) 17.
Steele, C., Greenwood, C., Ens, I., Robertson, C. and Seidman-Carlson, C Mealtime Difficulties in a Home for the Aged: Not Just Dysphagia. Dysphagia, 12:43-50.
O'Loughlin, G. and Shanley, C Swallowing Problems in the nursing home: a novel training response. Dysphagia, 13:
Hartelius, L. and Svensson, P Speech and swallowing symptoms associated with Parkinson's disease and multiple sclerosis: a survey. Folia Phoniatrica, 46 (1):9-17.