Hydration in dysphagia management

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/

Dysphagia…the role of a dietitian

This blog post was written as a guest blog post for Speech Therapy Works (www.speechtherapyworks.co.uk) run by Sandra Robinson.

As the result of swallowing difficulties, it is highly likely that a person’s eating and drinking is affected. The degree to which their eating and drinking is affected will vary on an individual basis. One of the major consequences of dysphagia not being identified and/or not being managed appropriately is malnutrition.  

Malnutrition is the result of an imbalance of the energy, protein and other important nutrients in the body resulting in the following:

  • loss of muscle mass
  • weight loss
  • reduced ability to fight infection
  • increased risk of falls
  • impaired wound healing

Malnutrition is a severe complication of dysphagia and studies suggest up to 50% individual with dysphagia are at risk of malnutrition and 16% are malnourished1.

Why does malnutrition occur in people with dysphagia?

There are numerous reasons why a person with dysphagia becomes malnourished or is at increased risk of malnutrition. These reasons may include:

  • inadequate food and fluid intake following changes to the recommended consistency of food and fluid that is safe to consume as advised by a speech and language therapist
  • inadequate provision of nutritious texture modified food and fluid
  • taking longer to eat a meal therefore a person may lose interest, or the meal goes cold therefore the meal becomes unappetising

What role does a dietitian play in helping people with dysphagia?

Following diagnosis of dysphagia, it is important that a dietitian works closely with speech and language therapists to ensure any nutritional concerns are addressed. As discussed earlier there may be numerous reasons why a person with dysphagia may become nutritionally compromised and identifying these reasons will be key to improving someone’s nutritional intake.

  1. Texture modified diets and fluids

Management strategies for dysphagia can include texture modification of diet and fluids.  The IDDSI framework is a globally developed standardised set of terminology to describe texture modified foods and thickened liquids2.

Depending on the recommendations set out by the speech and language therapist, the degree of nutritional support required will vary. For some individuals they may be able to manage for example 80% of their nutritional intake from texture modified diet but require oral nutritional supplements to provide the deficit. When considering the use of oral nutritional supplements there are several things a dietitian will need to consider:

  • does the person need their drinks thickened?
  • does the person like milk?
  • is the person able to make a drink or do they need a ready to drink version?

Dependent on these factors will determine the type and format of oral nutritional supplement recommended.  It may be appropriate to consider a pre-thickened oral nutritional supplement if the person requires thickened fluids as these products offer a safe solution to ensure that the recommended thickened fluid consistency is received.

Before or alongside the use of oral nutritional supplements, food fortification is usually recommended and is a way of improving the nutritional value of food and can be used in texture modified diets.  For example:

  • Using cream or whole milk instead of water to puree the food
  • Add butter or cheese into food before preparing to the correct consistency e.g. mashed potato
  • Add cream or custard to fruit before it is pureed.

In addition to addressing nutritional concerns, dietitians will also look at the hydration status of an individual.  It is common for people with dysphagia to have inadequate fluid intake which can lead to dehydration.  

The major consequences of dehydration include:

  • Low blood pressure
  • Urinary tract infections
  • Constipation
  • Confusion
  • Dizziness

Maintaining adequate hydration in people with dysphagia can be challenging due to a number of reasons.

Thickened fluids are commonly used as part of texture modification strategies to reduce the risk of aspiration.  However, it is important that the extent to which the fluid is thickened is balanced alongside risk of dehydration, compliance with thickened fluids and the safety aspect for a safe swallow.  This is where collaboration between dietitians and speech and language therapist is essential to ensure the risk of dehydration is minimised whilst also managing the risk of aspiration.

Strategies to reduce the risk of dehydration in people with dysphagia could include the following:

  • Offered flavoured thickened drinks rather than thickened plain water
  • The use of gum-based thickeners over starch-based thickeners may be preferable to improve the visual appeal and palatability of the thickened drink
  • Pre-thickened drinks may play a role particularly if the person also requires nutritional supplementation

2. Provision of safe and nutritious food and drink

Dysphagia management is everyone’s responsibility and once a plan has been outlined about how to manage dysphagia, it is important all key individuals are involved in the plan. Once recommendations are in place for a texture modified diet, it is important that those who prepare and serve the food and drink are aware of these recommendations.. 

Texture modified foods can be self-prepared or ready meals can be purchased.  When preparing homemade texture modified it is important that the preparation of the food is in line with the IDDSI framework descriptors for the recommended level advised by the speech and language therapist.

Summary

Due to the overlap between dysphagia and malnutrition, it is important that speech and language therapists and dietitians work together.  The role of the dietitian in dysphagia management is to ensure adequate nutrition and hydration, particularly when texture modified food and diet recommendations are in place.  This will help to improve a person’s nutritional status, aid recovery and improve quality of life.

References:

  1. Tagliaferri S, Lauretani F, Pelá G, Meschi T, Maggio M. The risk of dysphagia is associated with malnutrition and poor functional outcomes in a large population of outpatient older individuals. Clinical Nutrition [Internet]. 2019;38(6):2684–9. 
  2. Cichero JAY, Lam P, Steele CM, Hanson B, Chen J, Dantas RO, et al. Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework. Dysphagia [Internet]. 2016/12/02. 2017 Apr;32(2):293–314.

Dysphagia management…the role of the speech and language therapist

Guest blog post written by Sandra Robinson, Speech and Language Therapist

This guest blog post was written by independent Speech and Language Therapist Sandra Robinson and owner of Speech Therapy Works. Give her a follow on Twitter @SandraSpeech

Dysphagia is the medical term for a swallow disorder. It’s the medical term for a swallowing problem and is a mixture of Modern Latin and Greek; ‘dys’ means something has gone wrong and ‘phagia’ means ‘to eat’.

It’s a symptom caused in adults by another underlying condition such as a stroke, brain injury, neurodegenerative disease, dementia, head and neck cancer or other cancers, respiratory or gastro problems, mental health difficulties, infection, medications and treatments, and learning disability.

If one or more stages of the swallow are impaired, it can result in choking, chest infections, pneumonia, dehydration, malnutrition and weight loss, psychological deterioration, and ultimately death.

In the UK, speech and language therapists (SLT) play a key role in working with people with dysphagia, to assess the swallow function, and provide therapy in the form of exercises, strategies, manoeuvres, protocols, sensory input, compensatory changes and education.

They work to understand the individual with dysphagia, their medical history and current difficulties, their needs, wishes and preferences. And they work with dietitians to ensure that the person with dysphagia can get the nutrition and hydration they need. All the evidence shows that a multidisciplinary team approach works best, and improves people’s quality of life.

SLTs and dietitians work together in hospitals, in rehab centres, community and clinic services and in private organisations. They often refer people with swallow and/or malnourishment to each other for support.

The SLT’s role is to help assess and manage swallow function, including:

  • advising on the safest consistencies of food and drink using the IDDSI Framework,
  • keep the person with dysphagia and family/carers informed and perhaps provide training on what and how to support safer eating and drinking
  • if the person with dysphagia is at severe risk of choking or pneumonia, they may suggest being nil by mouth and finding other ways to provide nutrition and hydration such as a enteral feeding and/or an intravenous line (IV).

The dietitian will assess for the risk or existence of malnutrition, how to support someone to take enteral feeding, or advise on nutritional support and medically related dietary needs, prevention of skin breakdown or to support healing, education for people with malnutrition and their family/carers, and prevention of weight loss and malnourishment.

Ideally, the SLT and dietitian may see a person with dysphagia together. If this isn’t possible, they will liaise through multidisciplinary team meetings or one to one. This helps to provide more holistic care for the person with dysphagia.  

By working together and with the person with dysphagia and their family/carers, not only can SLTs and dietitians support people to overcome acute episodes of illness but help with rehabilitation, and prevention of possible future issues.

References

Cichero, J.A.Y., Lam, P., Steele, C.M. et al. Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework. Dysphagia 32, 293–314 (2017). https://doi.org/10.1007/s00455-016-9758-y

Cynthia J. Heiss, Lyn Goldberg, Marisa Dzarnoski. Registered Dietitians and Speech-Language Pathologists: An Important Partnership in Dysphagia Management, Journal of the American Dietetic Association, Volume 110, Issue 9, 2010, Pages 1290-1293, ISSN 0002-8223, https://doi.org/10.1016/j.jada.2010.07.014

RCLST. Dysphagia Overview. Available at: https://www.rcslt.org/speech-and-language-therapy/clinical-information/dysphagia#section-1 [Online] Last accessed 29 August 2020

Dysphagia…the basics

This is the first of series of blog posts on the topic of dysphagia and the link with nutrition, specifically malnutrition and the role a dietitian plays in the management of dysphagia. This first blog post will cover the basics of dysphagia. Look out for further blog post in this series including a guest blog post by a speech and language therapist.

What is dysphagia?

Dysphagia is the medical term given to swallowing difficulties and can occur in both children and adults. These swallowing difficulties usually arise due to an associated medical condition. It is estimated that approximately 8% of the world’s population are affected by dysphagia.

Dysphagia may not necessarily be an initial presenting symptom of a medical condition but may occur as the medical condition progresses such as neurological disorders e.g. Parkinson’s disease.

What are the signs and symptoms of dysphagia?

  • Coughing or choking when eating or drinking 
  • A ‘gurgly’ wet sounding voice 
  • A sensation that food is stuck in the throat 
  • Reduced ability to chew 
  • Taking a long time to finish a meal 
  • Persistent drooling of saliva 

What medical conditions are associated with dysphagia?

  • Stroke 
  • Neurological conditions such as Parkinson’s disease, motor neurone disease and Alzheimer’s 
  • Head & neck or oesophageal cancer 
  • Respiratory conditions such as chronic obstructive pulmonary disease  
  • Learning disabilities 
  • Traumatic brain injury 

What are the consequences of dysphagia?

If not identified or appropriately managed, the following consequences may arise:

  • dehydration
  • malnutrition or weight loss
  • chest infections
  • aspiration pneumonia
  • longer hospital stays or admission into hospital

How is dysphagia treated?

Treating dysphagia depends on what underlying condition or conditions a person may have. Some people experience dysphagia for only a short period of time, whereas others might have it for a longer period of time.

A speech and language therapist is the key healthcare professional for management of dysphagia. The role of a speech and language therapist includes:

  • Diagnosis of dysphagia
  • Help people regain their swallowing through exercises, techniques and positioning 
  • Promote patient safety through modifying the texture of food and fluids, reducing the risk of malnutrition, dehydration and choking
  • Promote quality of life, taking into account an individual’s and their families’ preferences and beliefs, and helping them adjust to living with swallowing difficulties
  • Work with other healthcare staff, particularly dietitians, to optimise nutrition and hydration
  • Educate and train others in identifying, assessing and managing dysphagia, including families and the wider health and care workforce

[Source: Royal College of Speech and Language Therapists]

Once an assessment by a speech and language therapist has taken place, advice may be provided on how to promote patient safety through the modification of the texture of food and fluids and swallowing exercises, technique and positioning.

What are texture modified diet and fluids?

Texture modification is common practice in dysphagia management.  The aim of texture modification is to prevent or reduce aspiration and potentially subsequent pneumonia. 

In April 2019 the UK implemented the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. This framework was developed by a global team of experts with the aim of improving patient safety for those individuals with dysphagia by standardising the terminology and definitions for texture-modified foods and liquids applicable to individuals with dysphagia of all ages, in all care settings, and all cultures.

The International Dysphagia Diet Standardisation Initiative 2016 @https://iddsi.org/framework/
Attribution is NOT PERMITTED for derivative works incorporating any alterations to the IDDSI Framework that extend beyond language translation. Supplementary Notice: Modification of the diagrams or descriptors within the IDDSI Framework is DISCOURAGED and NOT RECOMMENDED. Alterations to elements of the IDDSI framework may lead to confusion and errors in diet texture or drink selection for patients with dysphagia. Such errors have previously been associated with adverse events including choking and death.

As mentioned above, dietitians work closely with Speech and Language Therapists once a diagnosis of dysphagia is made. Dietetic input will involve ensuring adequate nutrition and hydration particularly if texture modification of diet and fluids has been recommended.

A later blog post in this mini series about dysphagia, will discuss the role of the dietitian in dysphagia management.