The difficulty of dysphagia
Most of us take eating and drinking for granted – after all, both are natural, physiological functions that are essential to the maintenance of life. By eating and drinking on a daily basis we not only nourish the body, but are also giving ourselves a real sensory pleasure which is an important element in our social lives.

A key aspect of enjoying the things we eat and drink is the ability to swallow easily. Unfortunately, this is not always possible. Dysphagia, a condition which is described as difficulty or discomfort when swallowing, commonly occurs among older patients

Dysphagia can have a severe effect on a patient’s health, nutritional status and quality of life. It can affect people in varying degrees: some may experience a mild discomfort, while others might have a complete inability to swallow. These problems can arise anywhere from the mouth to the stomach, and may be due to impaired function of the tongue, palate, pharynx, upper oesophageal sphincter or oesophagus, as they are all involved in the swallowing mechanism.

Management of dysphagia
Ideally a team of should manage dysphagia because providing treatment needs a close interaction between the patient’s speech therapist and other healthcare professionals. As well as medical specialists (such as an otolaryngologist and a radiologist), the team can also include nurses and a dietitian.

A dietitian can give advice on which foods are most suitable for the patient to eat, how they can be prepared to make them more palatable and how to maintain a balanced diet.  They can also give advice on how to fortify meals and recommend appropriate nutritional supplements to ensure patients keep up their energy and nutritional requirements.

The nurse’s role includes weighing patients and assessing for signs and symptoms of nutritional risk and dehydration. When an older patient resides in a nursing home, the nurse can help them practise the exercises set by the speech therapist during meal times. The nurse can also ensure that the patient’s diet corresponds to what was prescribed, record their actual intake and assess them for signs and symptoms of silent aspiration pneumonia.

Treatment
Treating dysphagia depends on the cause of the swallowing difficulties, so each patient needs a thorough investigation.  Since many patients with swallowing difficulties are older and may have problems following instructions, compliance may be an issue. Changing the texture of liquid and food remains the therapy of choice.  This also emphasises the need to involve the patient’s family and carers in the management of dysphagia to ensure suggested methods are implemented and used regularly and appropriately.

Nutritional Support
Over the last few years, there has been an increased concern over the high rates of malnutrition in hospitalised older patients.  This has drawn attention to the important role of nutritional therapy in the management of dysphagia.  People with dysphagic symptoms that limit their food and fluid intake, whether they are hospitalised or cared for in an institution or home, should be considered at high risk of malnutrition and treated accordingly.

The main aims of nutritional therapy are to:

• Assist patients with swallowing to prevent aspiration and choking
• Optimise nutritional status and so prevent dehydration and malnutrition

To minimise the risk of aspiration and choking, dysphagia treatment in adults may involve textural modification of both food and drink.  Liquids will often need to be thickened while solid foods may need to be pureed or softened.  It is often assumed that water and other liquids are easier for patients with dysphagia to swallow, but in reality they present a unique challenge – as they can flow freely through the mouth and into the airways.  This adds to the importance of modifying the texture of liquids to keep patients adequately hydrated.  This can easily be achieved using appropriate thickening agents such as Resource ThickenUp.

Hints for carers of older patients with dysphagia

• Wherever possible, ensure that your patients can choose from a range of appropriate foods.  This not only provides a greater incentive to eat, but also helps them achieve a balanced intake of nutrients
• Patients with dysphagia can quickly become full when served a full meal.  So rather than serving them three large meals a day, try serving smaller portions of foods but more frequently
• Maintaining a patient’s dignity is also vital. If they’re worried about messy eating, coughing and choking, position them appropriately.  Also try to avoid making them feel pressured to eat faster than they find comfortable
• In nursing homes and hospitals, the main meal of the day tends to be served at lunch time.  This is often better for patients with dysphagia as their swallowing difficulties often worsen as they become tired in the evening.  Try to find the optimum mealtime for each of your patients.  This is particularly important for those patients with conditions such as Parkinson’s disease, in which the effect of medications may decline through the day, further impairing patients’ ability to swallow
• Positioning the patient correctly can really help them with swallowing
• Always watch for a worsening of symptoms, and seek advice from other health professionals as soon as it’s needed

Hints on using thickeners for patients with dysphagia

• Take care when adding thickeners to liquids - always start slowly and add little amounts, rather than adding too much at once.  Be sure to follow manufacturers instructions for mixing to gain optimal results from thickeners
• When adding thickeners, you can avoid lumps by putting the liquid and powder in a capped beaker and shaking rather than stirring
• Foods need to be well presented to stimulate the appetite, so when blending a meal, blend the meat and vegetables separately to ensure the food remains colourful.  Food moulds also provide a versatile and attractive way of presenting meals.