Dysphagia Webinar, May, 2013[2]

Report
Dysphagia and Diet for People
with Traumatic Brain Injury
Robert Trombley, Registered Dietitian
Barbara Goodman, Speech/Language Pathologist
It can happen on any given day
From this:
To this:
Objective
 Define basic dysphagia terms and diagnostic
tests
 Understand dysphagia recommendations and
diet modifications
 Identify best-practices
 Recognize potential pitfalls
 Strategies for compliance
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Unique and Lifelong Experience
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How often does dysphagia occur and who
does it affect?
 Statistics in the incidence of dysphagia in
the traumatic brain injury individual vary
widely; one study reporting 80% effected
and 16% needing assistance with eating
one year post injury (Duong, Englaneder,
Wright, Cifi, Greenwald and Brown, 2004)
 Dysphagia prevalence increases with age,
therefore, people with a TBI may acquire
dysphagia as they age.
 61% of adults admitted to acute trauma
centers
 41% of individuals in rehab settings
 30% - 75% of patients in nursing homes
 10 million Americans (adults and
children) are evaluated each year with
swallowing difficulties
ASHA, Communication Facts: Special Populations: Dysphagia- 2008 Edition,
compiled by Andrea Castrogiovannirder
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Definition:
Dysphagia is defined as a difficulty in
swallowing. This includes any difficulty in the
process of: biting, chewing, handling and/or
swallowing of food and/or liquid.
One example of a swallowing problem that we
can all relate to is when food or drink “goes
down the wrong way”, which we all have
experienced at one time or another. For
people with dysphagia, this problem is
occurring more frequently.
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Swallowing: The Delicate Ballet
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The Normal Swallow
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http://www.radionz.co.nz/national/programm
es/ourchangingworld
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People with traumatic brain injury may have
damaged the cranial nerves and/or have
structural abnormalities (to their jaw, neck,
throat) affecting swallowing.
Symptoms:
 Coughing
 Throat clearing
 Hunching of shoulders
 Sensation of food getting caught
 Reddening in the face and/or facial grimacing
 Pain with swallowing
 Vomiting
 Wet voice
 Slow eating - fatigue
 Holding food in mouth
 Refusal to eat
 Weight loss, dehydration
 Heartburn or Reflux
 Upper respiratory infections and/or pneumonia
 Choking
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Stages of Swallowing:
Stage One: Oral Phase
 Includes oral preparatory phase
 Mastication (chewing) of the food
 Forms a bolus (mass of soft chewed food)
 Bolus moves to the back of the oral cavity into the
oropharynx (throat)
 Takes approx. one second
 Common problems: difficulty in chewing, forming a
bolus, controlling the bolus, propelling the bolus to
pharynx
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Stage Two: Pharyngeal
 Tongue pushes food to pharynx, which
triggers swallowing response.
 Larynx and epiglottis move to close off
the airway for protection, breathing stops.
 Reflexive, lasting one second or less.
 Common problems: delayed swallow,
nasal regurgitation, inadequate protection
of the airway, pharyngeal stasis
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Stage Three: Esophageal
 The bolus enters the esophagus and
travels to the stomach
 Reflexive, takes approx. 3 seconds,
may take longer for pill (medication)
 Common problems: poor peristalsis,
obstructions
Diagnostic Tools
Flexible Endoscopic Evaluation of
Swallowing (FEES)
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Modified Barium Swallow Study (MBS)
or Videofluoroscopic Swallow Study
(VDSS)
Modified Barium Swallow (MBS)
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Recommendations:
 Diet modifications
 Compensatory and/or Facilitation
Strategies
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1. Prepare for the MBS (if possible attend)- how is the person eating and drinking nowWhat is working for them and what seems to be causing problems:
 Symptoms
 Types of food or drink that work best or worse
 Positioning
 Pace of eating and drinking
 Bring to the MBS small sample of a simple favorite food (sandwich, pizza)
2.
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After the speech pathologist makes the diet recommendations:
Ask, ask, ask questions
What is a thickened liquid? Where do I get these thickening agents?
What is a soft mechanical food?
What is the best position for the person to eat? To drink?
What does a chin tuck look like?
How much food is a normal bite? A normal sip of a drink?
How do I give medications?
Will direct speech therapy help?
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A Modified and Thickened WHAT????
Published 2002
NDDTF
‒ Academy of Nutrition and
Dietetics
‒ American Speech-Language
and Hearing Association
Thickened liquids
Dietary textures
Standard of treatment
Great guide for general
recommendations for food at
the different levels
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Primary Food Consistencies
Regular – Level 4
Chopped – Level 3
Mechanical Soft – Level 2
Puree – Level 1
Primary Liquid Consistencies
Thin
Nectar
Honey
Pudding
Nectar Thick
Honey Thick
Denial and Confusion
“There is no problem.”
“Who says I have trouble eating
and drinking?”
“Why am I eating this?”
 Provide clear, simple and
consistent language
 Make sure that everyone is
on the same page
 Do not argue, accept that this
is their perspective, but do
follow diet recommendations
 Provide praise for any
positive action
 Be patient
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Judgement and Memory
 Taking excessively
large bites or sips
 Eating very quickly
 Unable to remember strategies
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Precut food
Pre-teach
Verbal reminders
Visual/auditory
reminders- pictures,
clock
 Special cups,
silverware, plates
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Adverse health outcomes
Weight loss
Dehydration
Malnutrition
Respiratory illness
Pneumonia
Upper respiratory infection
Bronchitis
The yuck factor or
Lost passion for food
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Gaining Acceptance
Increasing Compliance
What was
that!
RIGHT ON!
Gaining Acceptance
Increasing Compliance
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Aroma
Seasoning
Layering/Swirling
Piping
Molds
TASTE IT
Kitchen Essentials
Appliances and small wares
Kitchen Essentials
Food thickeners
Kitchen Essentials
Liquid thickeners
Powders
Gells
Preparation Tips
Proteins
Marinating
Acid-based marinades
Braised
Stewed
Easier to prepare cold
Proteins molecules tighten
when heated
Braising and stewing
tenderizes the connective
tissue
Never use water
Stocks, Gravies
Fats/oils, Mayonnaise
Milk/Cream
Preparation Tips
Starches
Rice
Pasta, Noodles, Macaroni
Potatoes
Beans
Preparation Tips
Fruits & Vegetables
Skins
Stringy
Woody
Seeds
Dried fruits
Apples
Grapes
Pineapple
Asparagus
Broccoli stalks
Carrots
Celery
Raisins
Go from fear and confusion….
To confidence and success
Successful Functional Outcomes:
 Compliance
 Satisfaction
 Limited level of distress-both the caregiver
and the TBI individual
 Good health
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