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Kimberly Jones Dysphagia Diets presentation
- 1. Dysphagia Diets: Kitchen and Nursing Staff are part of the Dysphagia Team Kimberly Jones Nova Southeastern University SLP 6057 11/12/11
- 4. Normal Swallow Phases (Terrado, Russell, & Bowman, 2001)
- 11. National Dysphagia Diet – Level 1 Pictured example taken from: (Dieticians Association of Australia, 2007)
- 13. National Dysphagia Diet – Level 2 Pictured example taken from: (Dieticians Association of Australia, 2007)
- 15. National Dysphagia Diet – Level 3 Pictured example taken from: (Dieticians Association of Australia, 2007)
Editor's Notes
- Patients may decreas their intake of foods and fluids due to a variety of reasons including but not limited to: (Sheperd, 2010) Fatigue with eating Pain with eating Sensation of fullness with small amounts of intake Sensation that food is stuck Fear of choking Increased coughing Dis-satisfaction with diet textures Decreased alertness Decreased mental status
- Texture modification can be temporary or permanent depending on the patient’s diagnoses, condition, and recovery (Terrado, Russell, & Bowman, 2001) Environmental adjustments could include reducing distractions such as television, excess noise, reducing the number of people, turning lights on or off, seating and positioning, specialized eating utinsels or equipment such as silverware with larger handles for gripping, etc… (Terrado, Russell, & Bowman, 2001) Patients can be trained to use techniques to increase their ability to swallow safely such as chin tuck, head tilt, special manuevers, alternating bites and sips, reducing bite and sip sizes, using hard swallows or multiple swallows, etc… (Terrado, Russell, & Bowman, 2001)
- Depending on the thickener base the liquid may continue to thicken as it sits and may change depending on temperature exposure (McCullough, et.al., 2003) Thicker is not necessarily better. Thicken according to recommendations by SLP because: Too thick may be more difficult for some patients to swallow safely Too thick may be less appealing to patients and may decrease compliance or intake leading to aspiration or dehydration The keys are to: Practice thickening Serve thickened liquids promptly Re-check thickness levels after time has passed and adjust or replace as needed
- Peer reviewed research support for the Frazer Water Protocol is limited: There is one controlled randomized study for the adult population(Garon, Engle, & Ormiston, 1997), and there are no studies for the pediatric population. The study by Garon, et. al. (1997) is limited in its clinical implications due to the limited number and diagnoses of it’s participants. Usually implemented based on the assumption that aspirated water can be safely absorbed by the lungs for the purposes of increasing patient compliance with diet modification and/or decreasing the incidence of dehydration (Panther, 2005), but studies are limited here as well: Safe Aspiration of Water: An extensive search for evidence that small amounts of water can be safely absorbed by the lungs yielded only one study by Olson (1970) which evaluated amounts of damage to the lungs of rabbits when small amounts of water were aspirated compared to a 5% glucose liquid and milk. Results indicated that significantly less damage was found in the lungs of those who aspirated water compared to the other two liquids. Results of the Garon, et.al. (1997) study support the safe aspiration of water because neither the control group nor the study group developed aspiration pneumonia or other complications during the study or within 30 days after the study. (Clinical implications remain limited due to the limitations of the study: length of study, characteristics of participants) Hydration: Results of the Garon, et.al. (1997) study do not support use of Frazier Water Protocol as compared to typical dysphagia protocol in an effort to maintain hydration because neither the control group(on thickened liquids only) nor the study group (given access to water between meals) became dehydrated Study by Vivanti, Campbell, Suter, Hannan-Jones, & Hulcombe (2009) found that the greatest contribution to oral fluid intake was from food (over 2/3 of the total daily oral fluid intake) as opposed to thickened fluids in patients who were not reported to be on a water protocol. This study also cited other research that indicated a greater increase in fluid intake with more frequent meals as opposed to increasing the amount of thickened fluids on meal trays. Water absorption rates: (Sharpe, Ward, Cichero, Sopade, & Halley, 2007): Study examining the absorption rates of thickened liquids versus water in rats and humans. (only 6 human participants) Researchers found no significant differences in the absorption rates of thickened liquids (regardless of type of thickener) and water in either rats or humans. Other Possible Factors in hydration: (Batchelor, Neilsen & Sexten, 1996) Dehydration may be a result of many factors including: decreased thirst decreased ability to recognize and/or satiate ones own thirst due to age and/or medical conditions Increased patient and family compliance: There is weak evidence that the FWP may increase patient compliance from the study by Garon, et.al. (1997): Patients filled out a satisfaction survey after the study. All study group participants reported great satisfaction with the allowance of water with most of the comments relating to thirst satiation and reduction in dry mouth. All study participants also reported that thickened liquids were not thirst quenching and did not taste good. ninety percent of control group participants reported they were displeased with thickened liquids and desired ice chips or water for thirst. Results indicate increased patient satisfaction when they are allowed water which MAY increase patient compliance to other diet restrictions.
- 1. When in doubt about a food texture contact an SLP 2. Sometimes families may want to bring in food as a way of caring for their loved one so if nursing is able to provide a few safe options this can help to increase compliance with the diet modifications 3. Some studies indicate that using food-shaped molds for pureed textures can increase the patient’s compliance with the diet texture modifications 4. Thickened liquids may continue to thicken over time or may need to be thoroughly mixed to avoid a mixed consistency depending on the base of the thickener used (startch versus gum based thickeners). Temperature may also interact to change the thickness level. Thicker is not necessarily better for all patients: sometimes patients may have more difficulty swallowing thicker liquids, thicker liquids may be less appealing and may decrease the patient’s consumption leading to dehydration or may decrease compliance leading to consumption of thinner liquids which may be unsafe and lead to aspiration. It is VITAL to present liquids at the appropriate consistencies to avoid these problems… practice, practice, practice, thickening and re-check consistencies if they have been sitting for long periods of time and/or have been refrigerated or heated.