Helen Crawley, SRD, RPHNutr, Faculty Health and Social Care Sciences, University of Kingston.Achieving adequate calorie, nutrient and fluid intake in people with swallowing problems can be a challenge but preventing malnutrition and dehydration are essential in reducing morbidity and mortality among those with eating difficulties.
Achieving adequate calorie, nutrient and fluid intake in people with swallowing problems can be a challenge but preventing malnutrition and dehydration are essential in reducing morbidity and mortality among those with eating difficulties.
Disorders which cause difficulties with eating are those affecting the ability to bite, chew or swallow food.
This disorder in swallowing may be due to a delayed or absent swallow reflex and difficulties with lip seal, tongue and jaw movements that lead to impairment of both the oral and pharangeal phases of swallowing. It is commonly seen after stroke, where 30% of patients have dysphagia and in dementia, particularly in the later stages. Swallowing difficulties are also associated with carcinomas of the mouth and oesophagus, after surgery on the jaw, in neurological diseases such as Parkinsons disease and Huntingdons disease and in cerebral palsy and multiple sclerosis.
Chewing difficulty and mouth pain
These are commonly caused by dental disease, poor dentition, mouth ulcers or infections such as thrush in the mouth. Sore, painful mouths and tongues are also related to nutrient deficiencies, particularly of iron or vitamins B12 or C.
A number of complications are associated with the above disorders:
- Aspiration of food and fluid into the airways can lead to chest infections and pneumonia;
- Increased length of stay in hospital, morbidity and mortality are associated with dysphagia;
- Malnutrition and dehydration are common wherever food and fluid intake are affected.
Why do eating disorders lead to malnutrition and dehydration?
Difficulties in eating can lead to dehydration and malnutrition for a number of reasons. For example:
- Dehydration commonly occurs as fluid intake is reduced in dysphagia, while change in types of foods eaten may reduce the intake of total food consumed and the intake of some important nutrients;
- Poor dentition and mouth pain often lead to reduced intakes of fruits, vegetables, meat and more fibrous cereal foods, which can lead to lower intakes of vitamins A and C, folates, iron and zinc, nutrients thyat are particularly important for maintaining the immune system;
- Patients with eating or swallowing difficulties are likely to need altered textured diets and fluids, and this is likely to lead to lower energy density meals those on texture-modified diets may only meet 45% of their energy requirements;
- Loss of independence in eating is associated with reduced energy intake eating may be much slower and use of cutlery may be limited, while embarrassment, anxiety or a fear of choking while eating can make both patients and carers nervous and unhappy about mealtimes;
- Reduced appeal of food in terms of taste, temperature, variety and appearance can affect appetite.
Encouraging patients to eat well
A range of interventions can help to ensure patients experiencing difficulty eating achieve adequate nutritional intake:
- The speech and language therapist will assess and monitor patients with eating difficulties, advise on how to prevent aspiration and the most appropriate texture of foods and drinks (Box 1);
- Dental care is essential including the treatment of mouth ulcers and thrush, investigation of mouth and tooth pain and proper fitting of dentures where appropriate;
- Personal preferences in terms of food and drink eaten should always be respected finding out as much as possible about patients' likes and dislikes is essential;
- Allowing people enough time to eat has been shown to be an important factor in increasing energy intake for people with swallowing difficulties eating can be tiring so flexibility in the timing of meals and snacks given has been shown to be essential;
- Portion sizes of meals should be appropriate small, frequent meals are often more acceptable and less daunting to patients;
- Temperature of foods can affect the management of swallowing disorders if patients have decreased oral sensation then chilled or cold foods, or hot foods, may stimulate the swallow reflex more easily than warmed or tepid food;
- Ensuring patients are sitting in a good position preferably upright with feet flat on the ground, the body well supported and the head tipped slightly forward will help eating;
- Ensuring foods are energy and nutrient dense is important where total food intake is likely to be reduced encourage patients to choose foods which provide important nutrients to the diet such as meat, fish, fruits, vegetables, dairy products and cereals, and if more energy dense meals are needed, adding extra cheese, butter or cream will increase the number of calories;
- Supplements should be used with care commercial supplement drinks, puddings and soups can be useful as a short term addition to the diet when there are particular concerns about a persons calorie intake, but fortifying real food with additional nutrients is often more acceptable to patients and encourages a return to more normal eating patterns and improved nutrition in the long term;
- People should be helped to maintain their independence in eating wherever possible encouraging the use of finger foods where the use of cutlery is difficult or consulting with occupational therapists on modified utensils is helpful;
- Prompting and encouragement throughout the meal may be particularly important for people with dementia, who may need to be gently reminded to chew and swallow food.
Helping people to eat
For patients who need assistance with eating (think of it as helping someone to eat' rather than feeding) the care and commitment of staff is essential. Advice on how to help someone to eat can be found in Food, Drink and Dementia (see resources).
Altering the texture of food and drink
The texture modification of foods and fluids have been described with National descriptors for five categories of fluid and six categories of solid textures (BDA/RCSLT, 2002). The aim of changing texture is to provide a steady flow of food or fluid between the tongue and the palate to aid control. Speech and language therapists and dietitians can advise on the appropriate consistency.
Fluids often need to be thickened, but it is important that staff know how to prepare thickened fluids correctly as different brands of thickeners will alter texture differently. Pre-thickened drinks are available and these have been shown to greatly improve fluid intake among patients in non-specialist wards. New research shows that bubbles in carbonated drinks may also be helpful in stimulating the swallow reflex and the use of frozen fluids as ice lollies can offer an alternative, manageable fluid source for some patients.
Foods and meals which will be of a soft or pureed consistency should be made as attractive as possible. Foods should be pureed separately, preferably without water, to ensure each food is still recognisable and nutrient content is not diluted, soaking solutions can be used to improve the visual appearance of modified foods, moulds and piping can make pureed foods into recognisable shapes which increase acceptability.
BDA.RCSLT (2002) National Descriptors for Texture Modification in Adults
Crawley, H. (2002) Food, drink and dementia: how to help people with dementia eat and drink well. Dementia Services Development Centre, University Stirling.www.stir.ac.uk/dsdc
See also www.dysphagia.com