Dysphagia can can affect the ability to eat and drink and inability to maintain nutrition and hydration which can impact on health and quality of life. The role of the dietitian in dysphagia management is to ensure adequate nutrition and hydration.

Among those with dysphagia, the prevalence of dehydration ranges from 44% to 75% depending on the patient population, setting, and criteria used to define dehydration¹

The importance of fluid

Fluid is important for our bodies as it plays many roles and is essential for life.

Fluid has many vital functions including:

• regulation of body temperature
• removal of waste materials from the body such as salts and urea
• transports water soluble vitamins such as B vitamins

What is dehydration?

Dehydration occurs due to your body losing more fluid than you are taking in. It can result in the following:

• constipation
• kidney stones
• falls
• urinary tract infections
• pressure sores
• confusion
• drowsiness

What are the signs of dehydration²?

• feeling thirsty
• dark yellow and strong-smelling pee
• feeling dizzy or lightheaded
• feeling tired
• a dry mouth, lips and eyes
• peeing little, and fewer than 4 times a day

Why is dehydration a complication of dysphagia?

Dehydration is commonly a problem in people with dysphagia for a number of reasons but is usually due to inadequate fluid intake. Thickened fluids which are usually recommended for people with dysphagia can play a role. Depending on the severity of the swallowing problems, there may be other reasons alongside using thickened fluids that may be contributing to a reduced fluid intake such as pain on swallowing fluids or requiring assistance from others with their drinks. Other factors independent of dysphagia may also be a feature, including:

• loss of thirst sensation
• unable to communicate needs
• fear of incontinence
• memory issues e.g. forgetting to drink

How can dehydration be managed in people with dysphagia?

1. Choice of thickener
2. Cognitive challenges
3. Physical barriers

Choice of thickener

Thickened drinks are used to alter the flow rate of a liquid allowing more time for the person with dysphagia to swallow the drink safely. The level of thickened fluid required will be determined following a speech and language therapy assessment. Not only may the thickness of the drink change but the amount recommended may also be limited. As a dietitian both these factors are particularly important, especially if oral nutritional supplements are being considered.

It is important that the thickener chosen to alter the consistency of the drink to improve the safety of the drink for the person with dysphagia has the following features:

• does not alter the taste of the drink to be thickened
• does not alter the appearance of the drink to be thickened i.e. no change in colour or clarity of the drink
• can be safely used across a variety of different drinks to increase patient choice

All of these features will aid improve compliance with thickened fluids. It is important to work with the person with dysphagia to implement a care plan that is person centred, whilst balancing risk of aspiration with quality of life.

Cognitive challenges

Communication difficulties that arise due to medical conditions that are common among people with dysphagia include stroke, dementia and brain injury. These communication challenges may make it difficult for the person with dysphagia to express the need for help with a drink, give a preference over drink choice or indicate they are thirsty.

Physical barriers

Dysphagia that has been diagnosed due to conditions such as stroke, brain injury and head and neck cancers, may also pose physical challenges. These include requiring assistance to drink, unable to prepare and serve their own drinks and changes to fluid thickness and volume. These factors may limit a persons overall fluid intake resulting in dehydration.

Overcoming all of these factors in dysphagia management to prevent dehydration are extremely important. Not only is it the responsibility of the dietitian and speech and language therapist to work together to address these challenges, the wider multidisciplinary team are essential. For example, in a care home environment, this responsibility will extend to all care home staff. Education is key alongside clear communication of care plans.

Summary

Management and treatment of dysphagia is multidisciplinary with both the speech therapist and dietitian working closely to reduce the complications of dysphagia such as malnutrition and dehydration. It is important that dehydration is detected early to minimise the risk of complications.

References

1. Reber E, Gomes F, Dähn IA, Vasiloglou MF, Stanga Z. Management of Dehydration in Patients Suffering Swallowing Difficulties. J Clin Med. 2019;8(11):1923. Published 2019 Nov 8. doi:10.3390/jcm8111923
2. https://www.nhs.uk/conditions/dehydration/