The importance of raising awareness of dysphagia

By Dawn Hopkinson, Clinical Specialist Speech and Language Therapist, Priory Highbank Centre.

Earlier this year we celebrated Swallowing Awareness Day, which highlights the impacts of dysphagia – a breakdown in the ‘normal’ swallowing process. Dysphagia leads to eating and drinking difficulties and can be life threatening. 

Dysphagia can be characterised by “an abnormality in the transfer of a bolus from the mouth to the stomach.  Abnormalities may involve the oral, pharyngeal and oesophageal stage in the swallowing sequence” (Groher, 1997).

Causes of dysphagia

Dysphagia can be caused by (according to the NHS website):

• Neurological conditions (e.g. brain injury, including stroke)
• Congenital and development conditions (e.g. cerebral palsy)
• Obstruction (e.g. mouth and throat cancer)
• Muscular conditions (e.g. scleroderma and achalasia)

Recognising dysphagia

Swallowing is a continual process but can be broken down into four stages:

1. Oral preparatory
2. Oral
3. Pharyngeal also referred to as laryngeal
4. Oesophageal

A breakdown can occur either in one or in multiple stages of the swallowing process.

It is important to know the normal sequence of events in each stage of the swallowing process, in order to recognise when something is not working effectively and safely.

Dysphagia-modified diet

Following a dysphagia assessment by a speech and language therapist, a modified dysphagia diet will be recommended (if clinically indicated) for safe and effective eating and drinking.  The current national guidelines for dysphagia management state:

• Grade C dysphagia diet – (pureed diet) consists of food that has been pureed with no bits or lumps
• Grade D dysphagia diet – (pre-mashed soft fork-mashable diet) consists of soft food that has been pre-mashed with a fork
• Grade E dysphagia diet – (soft fork-mashable diet) consists of soft food (as above) but does not require mashing with a fork before presenting beforehand. Food requires a little more chewing than at Grade D

The summary above is a brief overview and full criteria can be found on the National Dysphagia Guidelines website.

Inclusion of high risk category foods into a patient’s diet will be at the discretion of their speech and language therapist, following ongoing dysphagia reviews and assessments.

High risk foods include:

• Stringy, fibrous textures – e.g. pineapple, runner beans, celery, lettuce
• Vegetable and fruit skins including beans – e.g. broad beans, baked beans, soya beans, kidney beans, peas, grapes
• Mixed consistency foods – e.g. cereals which do not blend with milk (e.g. muesli, corn flakes), mince with thin gravy, soup with lumps
• Crunchy foods – e.g. toast, flaky pastry, dry biscuits, crisps
• Crumbly foods – e.g. bread crusts, pie crusts, crumble, dry biscuits
• Hard foods – e.g. boiled and chewy sweets and toffees, nuts and seeds
• Husks – e.g. sweetcorn and granary bread

Patients with a breakdown at the oral or pharyngeal stage of the swallowing process may require drinks to be thickened.  The thickness will depend upon clinical findings during the dysphagia assessment and can be dependent on different variables.  Drinks are currently categorised into the following stages:

• Stage 1 – syrup consistency
• Stage 2 – custard consistency
• Stage 3 – pudding consistency

Dysphagia treatment

Dysphagia can be a life threatening condition that can lead to chest infections, aspirate pneumonia and even death and it is therefore imperative that it is managed effectively by the treating team.

At Priory Highbank Centre, the interdisciplinary team’s treatment includes:

• Speech and language therapy – carry out swallowing assessments and implement guidelines regarding consistency of food and drinks that are appropriate for the level of dysphagia being experienced
• Nursing team – ensure that clients receive the appropriate level of support as required by guidelines and provide information regarding any known allergies. Nursing staff are also vital in providing information regarding any changes that may occur in a patient’s eating and drinking ability and request swallowing assessments when required
• Physiotherapy – provide recommendations and guidance for effective positioning (if a patient is not seated correctly, this can have a compounding effect on a person’s swallowing ability
• Occupational therapy – provide recommendations and adapted cutlery to help someone become more independent in eating and drinking without it placing extra demands on the patient that could compromise swallowing ability
• Psychology – assess and implement behavioural guidelines that improve eating and drinking potential. Behavioural difficulties, particularly following a brain injury, often impact on the ability to eat and drink safely
• Dietitian – ensures that diets of all consistencies are optimal in terms of nutritional and calorific content
• Catering – work mostly in conjunction with speech and language therapists and dietitians to ensure that patients receive the dysphagia modified diet that conforms to speech and language therapists and dietitians’ recommendations

Working as an interdisciplinary team ensures effective dysphagia management.

We should always bear in mind that we do not eat and drink purely for nutritional and hydration reasons.  Eating and drinking is a social experience that usually brings pleasure.  We all enjoy going out for meals or eating that box of chocolates whilst watching a film.  Dysphagia therefore can bring about mixed feelings for both the patient and their family and can often lead to feelings of frustration, low mood, confusion and even anger.  Supporting such feelings is also an important part of dysphagia management.     

Priory’s Brain Injury Service at Highbank is able to offer tailored treatment to those with dysphagia and who have swallowing issues as a result, or require percutaneous endoscopic gastrostomy or jejunostomy (PEG or PEJ) feeding.

References

Groher, M. (1997). Dysphagia. Boston: Butterworth-Heinemann

nhs.uk. (2018). Swallowing Problems Dysphagia - Causes. [online] Available at: https://www.nhs.uk/conditions/swallowing-problems-dysphagia/causes/ [Accessed 17 May 2018]