Dysphagia, simply put, is when someone has difficulty eating. They are unable to chew or swallow food or liquids from their mouth to their stomach. Dysphagia itself is not a disease, but rather a condition that occurs from a range of illnesses, diseases, accidents or treatments such as stroke, cancer treatments, head and neck injuries, cerebral palsy, Parkinson’s and dementia to name a few. These diseases and treatments can cause the nerves and muscles in the mouth and throat to weaken or become paralyzed, making it difficult for someone to chew, move the food in their mouth and swallow effectively.
Dysphagia can also occur in the elderly who are otherwise healthy and have no illnesses or diseases. For example, many elderly people experience tooth and muscle loss (in the cheeks and tongue) and that can affect chewing. They can also have reduced saliva flow. Many medications can cause side effects such as dry mouth or reduced cognition. Finally, when someone ages, they can also have reduced nerve function in their mouth which can affect their ability to taste, feel the texture or temperature of the food in their mouth. All these factors can contribute to improper chewing and swallowing response which would normally help push the food down from mouth to their stomach safely.
Consequences of Dysphagia
According to the American Stroke Association, up to 65 percent of stroke patients may experience dysphagia. In long-term care settings such as assisted living residences or nursing homes, more than 60 percent of residents have dysphagia. We tend to take swallowing for granted, but swallowing is a complicated process that uses lots of nerves and muscles. Chewing and swallowing are automatic processes for us and unless something goes wrong, we don’t tend to pay attention to it. However, if we were to cough and choke during mealtimes, this can cause quite an alarm and we have to stop whatever we are doing and concentrate on recovering before continuing our meal. For those with dysphagia, they may not even know that their food or drink is going down the wrong way into their throat and lungs and they be silently aspirating. The effects from untreated dysphagia can be damaging;
Weight loss and Malnutrition
Because of these outcomes, your loved one can be at further risk of other complications like constipation, poor wound healing, increased susceptibility to more infections and weakened muscles. They are not only at risk of having caloric, vitamin and mineral deficiencies because of their irregular and decreased intake of food and fluids, but they can also have psychological issues as well due to their dependence on their others for food and different meal types than they are used to. All this can add to increased anxiety and low mood which can affect their intake, leading to weight loss and malnutrition.
By getting a referral to see a Speech Therapist and Dietitian early and paying attention to their diet and swallow function, your loved one will feel better, prevent nutrition-related problems, and prevent hospitalisation. As we all are aware, hospital stays can be costly, traumatic for both the patient and their families. By following good nutrition practices, your loved one can stay independent for as long as possible. And as a carer, you will be more able to support him/her in living out a meaningful life for their remaining days.
Nutrition Goals in Dysphagia
To ensure your loved one has an adequate nutrition and hydration status
To ensure your loved one is having the correct and safe texture modified diet as advised by their Speech Therapist
To maximise their nutritional intake while maintaining safe eating, i.e. to prevent aspiration and choking
To ensure that your loved one is supported in eating and drinking as independently as possible
What You Can Do
When difficulty in swallowing becomes a problem due to an illness or disability, then your loved one has to concentrate when they are eating or drinking and anyone helping them also needs to give their full attention.
Make sure that the correct texture is always being offered to your loved one.
Ensure that your loved one is positioned properly for feeding.
Make sure their mouth is clean and clear before meals.
Offer small bites of food and sips of fluids.
Make sure the feeding process is not rushed, allow them time to chew and swallow at their own pace.
Use a thickener to thicken up liquids to a safe consistency for them. 1
Avoid talking throughout the meal, have a slow and relaxed eating experience, avoid distractions.
If one side of the mouth is weak, place the spoonful of food in the stronger side.
Ensure the food remains at a suitable temperature throughout the meal, reheat if necessary so it stays palatable.
If possible, allow them to hold the utensil themselves, or place your hand over their hand. This is to help them eat with dignity and maintain independence as much as they are able to.
Do not offer drinks through a straw unless approved by their Speech Therapist.
Help them stay upright for at least 30 minutes after eating. This can help reduce the risk for aspiration
Consider home-delivered texture modified meals. This takes away the hassle of cooking and texture-modification. With professionally-prepared meals, you can be assured that it complies with the Dysphagia diet guidelines and will be attractive enough to enhance the appeal texture modified foods. 2
Be careful with these foods and only use if their Speech Therapist says it’s safe.
Stringy/fibrous foods such as celery, pineapple, melted cheese.
Food with husks such as sweetcorn.
Crunchy and crumbly foods such as toast, chips, biscuits, flaky pastry.
Hard foods such as tough meat, chewy and boiled sweets, nuts, seeds.
Vegetable and fruit skins such as beans, peas, potatoes, orange peels, vegetable stalks, grapes.
Mixed consistency foods such as cereals that do not blend with milk, soups with lumps, chunky peanut butter, yoghurt with added fruit pieces.
Ice-cream, jelly and whipped cream – melt into thick liquid only.
Additional Considerations for:
This serious condition occurs when your loved one suffers from a low appetite and food intake with weight loss as their caloric needs cannot be met when they have dysphagia. It’s important to ensure that we identify and act early by getting a referral to a Dietitian. Dietitians can assess the problem and recommend a meal plan that will help your loved one recover from malnutrition.
Some people with dysphagia and more so, the elderly, have a weaker sense of smell and taste. Therefore, seasoning can help to stimulate appetite. Use flavourful oils, vinegar, soy sauce, curry, chilli to make it tasty if they are able to tolerate them.
Promote protein at every meal (e.g. pork, lamb, mutton, beef, chicken, turkey, quail, fish, cheese, yoghurt, nuts, and legumes such as baked beans, soybean curd, soy milk, red/green beans, eggs and tofu). 2
Promote dairy products such as milk, cheese and yoghurt which are high in calcium and have protein.
Avoid low-calorie, low-fat and low-sugar foods as these are “empty calories”. For a person with poor appetite, the goal is to prevent them from losing weight.
If they are eating poorly, make sure that water is given between meals rather than before a meal, so that they do not feel too full to eat.
Offer high-energy snacks throughout the day which consist of the appropriate and safe texture for your loved one. (E.g. puddings, jellies, thickened custard, stewed pureed fruit, local desserts like red and green bean soups pureed, pulut hitam, soybean curd.)* 3
Add butter, jam, honey, or chocolate sauce to their morning porridge to bulk up the calories.*
Add margarine, butter, oils, mayonnaise, cream, sour cream ,full cream dairy products, honey or jam to their meals.*
It may be easier to start a meal support service that reduces their risk of malnutrition and allow them to remain happily living in their home. 2
Consider nutrition supplements if they are losing weight (thickened if necessary).
*Be careful with the consistency of the foods and only use if their Speech Therapist says it’s safe.
Many people with dysphagia don’t feel the thirst sensation, by then, they may already be dehydrated, so it’s important to keep offering them fluids at the appropriate thickness for them ( especially so if they are unable to communicate) regularly to prevent complications.
Provide them moist foods, such as stews and foods with sauces. (Thickened if necessary).
Provide at least 8 to 10 cups of thickened fluids daily. These can include water, milk, juices, soups and other beverages (Try to cut down caffeinated drinks e.g. coffee and cola drinks as they tend to dehydrate the body).
Offer hydrating jellies as a form of fluid. These tend to be better tolerated taste wise. 3
Keep their mouth and lips moist by helping them with their mouth care.
It is common for people with dysphagia to end up constipated due to the limited amounts of fibrous foods and fluids they have in a day. Ensure they receive plenty of hydrating snacks, fluids and consider a natural fibre supplement if they are having irregular or infrequent bowel movements. 3,4
Your loved one can aspirate if the food, saliva or stomach acids is inhaled into their lungs instead of being swallowed into their esophagus and stomach. As a result, it can cause swelling or infection of the lungs. Therefore, it is important for anyone who is caring for your loved one to keep a lookout for signs of aspiration. Call their doctor right away if you observe:
Their swallowing getting worse
Unintended weight loss
Shortness of breath
Food comes back up into their mouth
A wet-sounding voice after eating or drinking
Myths and Facts
My mother has dysphagia but doesn’t cough when she eats, so she must ok.
People with dysphagia can be silently aspirating. We are not able to hear when it happens. Keep a look out for the other signs of aspiration and ensure your mother is being regularly followed up by a Speech Therapist. They can help to assess if your mother is taking food and liquids into her lungs.
My grandmother has a feeding tube because she cannot swallow well, so she will never be able to eat again.
A feeding tube is a way for someone to get the nutrition they need if they are not eating enough by mouth or if they have dysphagia, however, it is not true that they can never eat again. A feeding tube is reversible and can be a good way to get the nutrition your grandmother needs while her swallowing improves. Regular assessments with her Speech Therapist can determine whether the tube can be removed and she can eat orally again.
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