1. Following a dysphagia diet Aynsley Brian, M.A. (Family Members/Caregivers of those affected by Dysphagia)

2. Before we begin… Important mechanisms for swallow: Lips, teeth, tongue: for chewing and moving food Pharynx: passageway of food from mouth to esophagus Epiglottis: protects the airway Trachea: airway or “wind pipe” leading to lungs Esophagus: tube for food to travel to stomach

3. What Is Dysphagia? Difficulty or complete inability to swallow food or drink. The affected person may experience pain, discomfort, choking or aspiration. Dysphagia can be caused by aging, stroke, neurodegenerative diseases (i.e. ALS), neuromuscular disease (i.e. cerebral palsy), radiation therapy associated with throat or mouth cancer, or gastro esophageal reflux disease (GERD).

4. Basic signs/symptoms Drooling Choking Gagging Pocketing of food (between gums and cheeks) Taking longer than 10 seconds to swallow Complaints of pain or “sticking” sensation in throat Coughing up food that was just swallowed Throat clearing “Wet” or gurgly voice

5. Dysphagia phases/types There are 4 basic steps in the swallow – Oral preparatory phase (chewing up the food and placing it on tongue for transport) – Oral transit phase (using your tongue to move food/liquid towards the back of the pharynxt) – Pharyngeal phase (food/liquid begins the descent towards esophagus; epiglottis kicks back to cover airway) – Esophageal phase (esophageal sphincters open and close so that food can make its way into the stomach) Patient my have problems in one, some or all of these stages of swallowing!

6. Oral Phases Pharyngeal Phase Esophageal Phase PHASES

7. What is aspiration? Aspiration occurs when a person’s epiglottis does not correctly cover the trachea (airway) allowing food, liquid, or saliva to enter. When materials enter the airway and travel below the patient’s vocal cords, there is a risk that the material will enter the lungs. If the materials enters the airway but remains above the vocal cords, it is easier to cough up material; this is called penetration.

8. Silent Aspiration A normal persons response would be to cough and clear the airway. Dysphagia patients may have impaired coughing abilities. Silent aspiration occurs when there are no outward signs of swallowing difficulty. Secretions, food, or liquid enter into the airway, past the vocal folds, with no coughing, throat clearing, or signs of distress. However, patient may appear to turn blue.

9. Why does aspiration matter? What happens if food, liquid, saliva or secretions enter the airway and/or lungs? – Choking/lack of oxygen – Aspiration pneumonia – Death (play animation  )

10. Aspiration Prevention Some foods, liquids, and consistencies may be easier for the patient to swallow than others. One of the most effective ways to prevent Aspiration is to follow a the diet recommended by your speech-language-pathologist!

11. Diet recommendations may include: Manipulating the food in some way: Thinner liquids Thickened liquids (to the consistency of honey or nectar) Smooth puree (ex: yogurt, pudding) Textured puree (ex: mashed peas) Soft chopped (dicing soft food into smaller bites) Regular (solid food)

12. American Dietetic Association Levels: Food consistencies – Level 4 Regular All foods are acceptable. – Level 3 Dysphagia Advanced A near-regular diet with the exception of very hard, sticky or crunchy foods. Foods should be bite-size. Avoid crusty or dry bread, nuts, apples, dry fruit, coconut, raw vegetables and corn. – Level 2 Dysphagia Advanced Altered Foods are moist, soft and cohesive. Meats are ground or minced. Avoid rice, corn, bread, soups and casseroles that contain large chunks, nuts, and chewy, stringy or dry foods. – Level 1 Dysphagia Pureed Pureed and cohesive foods, no mixed textures, everything is "pudding-like." Nothing that requires chewing is allowed. Resource: http://www.nestlenutritionstore.com/Pages/ConsistencyGuide.aspx

13. Why follow the diet? Patient may aspirate – Choking, lack of oxygen – Risk for aspiration pneumonia Risk for malnutrition and dehydration – Can they swallow enough nutrition and liquids each day to stay healthy? Pain or discomfort when swallowing wrong consistency – May lead to  FEAR of eating Death

14. Tips to modify the diet Know the patient’s recommended diet level Purchase liquid thickeners/add them to drinks (ex. “Thick-it”) Put soft or solid foods into a food processor to puree. If patient can have almost normal diet, cut food into small, chewable bites. Alter temperature of food (hotter or colder) to increase awareness/sensation of food in the mouth. Be sure to make food look appetizing!

15. Tips ( cont. ) If your family member has a progressive disease or disorder… The original recommended diet may become too difficult for them to swallow Watch for the signs/symptoms SLP may recommend changing the diet to better suit the progression If the your family member is regaining their swallow function… SLP may recommend moving back towards solid/regular foods

16. BUT... It is CRUCIAL that you do not make these decisions on your own!! Talk to your SLP if you have questions or concerns!

17. Positioning The seated position of the patient during feeding varies patient to patient. Certain disorders/diseases may require special positioning. Often times, sitting completely upright is the safest eating method. However, you may find that this creates complications. Talk to your SLP about which method is safe for your loved one.

18. Tips to prevent discomfort after eating Even following a strict diet, the patient may experience Gastroesophageal Reflux Disorder (GERD), commonly known as acid reflux. Avoid highly acidic foods, caffeinated drinks or carbonated beverages. Remain sitting upright for at least 1-2 hours after meals Sleep with a bed-wedge to remain propped up at a 45 degree angle, allowing for better digestion Ask your doctor about reflux management medications

19. Artificial feeding NPO=Not By Mouth Patient may have: Nasogastric (NG Tube), Percutaneous Endoscopic Gastronomy (PEG tube), or Gastronomy Tube (G Tube) If your loved one is fed by a feeding tube, you will need proper formulas and diet supplements to maintain adequate nutrition and hydration. Ask your dietician or physician for information on feeding substances and quantities.

20. Let’s taste textures How can you prepare it if you’ve never tasted it! At each table you will find 4 drink/food items – Item 1: Nectar Thick Liquid – Item 2: Honey Thick Liquid – Item 3: Soft chopped food (diced peach) – Item 4: Textured Puree (pureed peas) Take two straws and two spoons; taste each item! (please dispose of a used utensil after one taste)

21. 1. Nectar Thick Water 2. Honey Thick Water 3. Soft Diced Peaches 4. Pureed Peas

22. Thank you! Questions?