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Dysphagia, which is any disruption in the swallowing process, is estimated to be present in 15% of the elderly population (Sura et al, 2012).  Aging effects swallowing due to physiological changes to muscle mass, tissue elasticity, and flow of swallowed material.  Preparation of the food prior to swallowing requires more time, and there is a decrease in the amount of oral moisture to transport material through the primary digestive process.  Dysphagia can result from stroke and other diseases such as multiple sclerosis or cancer (Hegg, 2019).  The Peterborough Palliative Care Dementia Group (PPCDG), a team of physicians, dieticians, and pharmacists interested in a standard of expertise in palliative care, published a booklet entitled Compromised Swallowing:  A Practical Guide to Nutrition, Hydration, and Medication in Advanced Dementia.  (Compromised swallowing:  A practical guide to nutrition, hydration, and medication in advanced dementia.  Peterborough Palliative Care in Dementia Group.  Retrieved on June 26, 2018 from www.dementia.jennerhealthcentre.co.uk).  The PPCDG originally concerned itself with nursing and residential homes, but many aspects of their work pertain to in-home and hospital settings as well. According to this publication, 

        “Swallowing and feeding difficulties are known to affect approximately 65% of people with dementia with approximately 30% of                             individuals found to be aspirating (food or fluid ‘going down the wrong way’)” (p. 6). 

 

A referral to a Speech and Language Pathologist (commonly called a therapist) might assist in planning meals with texture and consistency that also provide necessary moisture to the diet.    No tubes or unnecessary tests need be involved in an initial presentation to the SALT or pathologist as issues with swallowing can be diagnosed medically through a swallow test.  The patient drinks several liquids of different consistencies (all containing a contrast solution) while a series of x-rays is taken.  Other tests may include an examination or muscle test of the esophagus and/or an endoscopy of the swallowing process.  All tests investigate physical reasons for swallowing difficulties and aspiration, which is medically defined as the entrance of food or liquid into the area below the level of the true vocal cords (Sura et al, 2012).

 

Treatment or management of dysphagia has many facets, most of undetermined effectiveness in clinical studies.  The most successful treatments appear to occur when individual needs and preferences are taken into consideration.  These interventions include compensations or adjustments to the patient, food/liquid, and/or environment.  Patient adjustments include body or head posture (tucking or raising chin, reducing impact of gravity by lying on side, etc.).  Posture can be a factor in swallowing, and cuing the patient to swallow, take smaller bites, etc. can be instructed.  Swallow maneuvers (hard or forceful swallow) and breath holding just prior to swallowing are other methods utilized but compliance may be short term and not able to be continued in some dementia clients.  According to Suri et al (2012), “No existing data confirm this potential benefit of postural adjustments and some data suggest that these strategies are inferior to more active rehabilitation efforts” (p. 291). Swallow rehabilitation, in contrast to swallow maneuvers, is an exercise regimen prescribed “to improve strength and timing of swallowing, increase tongue strength, or improve timing of swallow” (Suri et al 2012, p. 294). This method relies on the compliance of the client which could be a difficult task in apathetic or cognitively impaired clients.  However, results of these techniques have included reduced aspiration, advances in oral diet, and decreased dependence on tube feeding.  For further reference, the swallowing rehabilitation techniques mentioned in the study are, in no particular order, lingual resistance, EMST (expiratory muscle strength training), Shaker/head-lift, and MDTP (McNeill dysphagia therapy program). 

 

Modification of the consistency of food and liquids is another compensation used for dysphagia.  Thickened liquids continue to be the most common treatment in facilities even with the lack of overall evidence supporting its use.  Of primary concern with the overuse of thickened liquids is the risk for dehydration and dislike (and subsequent reduction in fluid intake) by clients.  This can lead to decreased fluid consumption.  One approach called the ‘Frazier water protocol’ allows water consumption in patients between meals and has had some impressive results in lowering rates of dehydration.  Additional objective assessments need to be conducted on the effectiveness of this method. 

 

The National Dysphagia Diet is comprised of four levels of consistency of foods with recommendations at each level (Suri et al, 2012 and Ohio State University Wexler Medical Center website). (Thickened liquids for safer swallowing. The Ohio State University Wexler Medical Center. Retrieved on May 12, 2018 from https://patienteducation.osumc.edu/documents/dys-2.pdf).

It was developed by the American Dietetic Association in 2002 to standardize recommendations from SLP and dieticians. A summary of each level of the National Dysphasia Diet (NDD) follows.

 

Level 1   Dysphagia Pureed

                          No chewing required, only bolus (small mass) control

                          Smooth sauces without lumps

                          Blended or pureed foods

                          Adding gravy or sauces to enhance flavor and increase moisture

                          Liquid thickness in 3 levels:

• Thin, mildly thick (nectar like)

• Moderately thick (honey like)

• Extremely thick (spoon or pudding thick)

 

Level 2   Dysphagia Mechanically Altered

                          Requires chewing ability

                          Moist, semi –solid, fork tender foods

                          Small pieces that fit between tines of fork

                        

Level 3   Dysphagia Advanced

                          Requires more chewing ability

                          Soft solids and well-moistened foods

                          Bite sized pieces about the size of your thumb

                          Avoid hard-to-chew fresh fruits such as apples, pears, grapes, raisins, pineapple,      

     oranges, coconut

 

Level 4   Regular Diet

                          No modifications or restrictions.

 

One excellent source for levels of dysphagia and corresponding diets and examples is available from Ohio State University Wexner Medical Center website at https://patienteducation.osumc.edu.   The information discusses both recommended and inappropriate foods for each level of a dysphagia diet recommended by a physician and/or speech language pathologist.   Suri et al (2012) reports that to date, no studies have compared the National Dysphagia Diet to other facility/institution strategies for modifying food consistency, but it continues to be widely utilized by professionals and lay people alike. 

 

Other Tips and Strategies

 

According to the Peterborough Palliative Care Dementia Group booklet,

           

“Encourage food and fluids little and often.  Many elderly people (with and without dementia) do not have a large appetite, and nutritional needs are more likely to be met via 5-6 small meals and snacks a day rather than 3 larger meals.” (p. 5).

 

Compromised swallowing is common in later stage dementia—the reflex to swallow appears to become diminished and the patient may need additional cues to swallow.  Again, liquids should be either cold or warm to provide sensation in the mouth that prompts swallowing.   

Milkshakes, creamy soups, etc. make great additions to your repertoire of consumable fluids.  Encourage high caloric drinks and foods to avoid the risk of malnutrition.  Another strategy would be to add extra nutrients such as dried milk powder to fortify milk for cereal, puddings, yogurt, and soups.  Other fortifiers include mayonnaise, butter, evaporated milk, cream, full-fat Greek yogurt, coconut products (oil, cream, or milk), avocado, nut butters (including Nutella), and cheese.  These food fortifiers increase fat and caloric intake and add nutrients.  Solid food can also be moistened with water.   Salads are excellent for fluids, as are water-laden fruits and vegetables such as watermelon, cucumbers, tomatoes, and the like.  Bland food should be avoided.  Sweet, spicy, and sharp flavors should be offered.  Temperature of foods should be alternated within a meal.  Prior to a meal, “offer teaspoons or sips of ice-cold fluid (thickened if appropriate) … and during a meal to stimulate stronger swallows and help to clear remaining oral residue.” (Peterborough Palliative Care Dementia Group, 2018). 

 

Many medications can be in pill or liquid form.  Obviously, a patient should use the preferred form when available.  Many drugs cannot be crushed or capsules opened without changing the effects of the medication.  A physician and pharmacist should be consulted in these cases.  Some medication can also be taken in thickened liquids or a food with pudding consistency.  Speech and language therapists or pathologists can advise in this situation.  Unnecessary medications could be discontinued unless for essential symptom relief but only at the advice of a physician. 

 

Hand feeding can ensure socialization and is the method of choice for those with advanced dementia (Dennehy, 2006).  Most patients respond best to feeders that are personal, interested, calm, flexible, and willing to allow the client to have control (White, 2005).  Hand feeding can be time intensive but allows for human interaction, social presence, and mealtime enjoyability.  This assistance can help provide an atmosphere that allows adequate time to eat and a social setting that accentuates the desire to increase intake. 

 

Sources:

Dennehy C.  Analysis of patients’ rights:  dementia and PEG insertion.  British Journal of Nursing 2006;15(1):18-20.

 

Hegg J.  Seven helpful tips for seniors and caregivers managing dysphasia, 2017. Retrieved on January 15, 2019 at www.dailycaring.com.

 

Sura L, Madhavan A, Carnaby G, Crary M.  Dysphagia in the elderly: management and nutritional considerations.  Clinical Interventions in Aging 2012; 7:287-298.

 

White, H.  Nutrition in advanced Alzheimer’s disease.  NC Med J 2005; 66:307-312.