How to maintain nutritional levels in those with dysphagia…
…use safe-to- swallow, palatable foods and drinks or nutritional supplements.
Of all patient groups, those with dysphagia are at the highest risk of malnutrition. Diagnosis is often referred to as a prescription for dehydration and malnutrition.
This is due to patient’s inability to eat and drink normal foods and because of how they eat and drink?
Consequently, we think modern practice should be turned on its head?
When a patient is malnourished the 2nd step should be to assess the patient for dysphagia and if diagnosed that should be the filter through which all interventions are decided.
The reason is dysphagia has such a massive detrimental impact on patients ability eat and drink – normal patient nutrition rules don’t apply?
The 1st line intervention for patients with a normal swallow is prescribe milk and or juice based oral nutritional supplements (ONS). These are effective but need to be used with caution with dysphagia patients?
With the exception of our Slõ Milkshakes+ they all need to be thickened to the right consistency. This is difficult – to impossible to achieve with gum and starch based thickeners because the fats in ONS prevent these thickeners working.
That puts the patient at risk of aspiration every time a carer tries to change an ONS into a thickened drink.
Healthy and nutritious foods are perfect to help those with normal swallowing ability but dysphagia patients will need their foods changing to a puree, a pre-mashed meal or a fork mashable consistency.
These meals will need their nutritional content increasing using full fat milk, butter, eggs, cheese etc..
However, making meals which are high calorie to the right consistency is difficult. Dysphagia patients also take an incredibly long time to eat and it is tiring. Consequently, there is no guarantee they are consuming enough calories to sustain themselves let alone recover.
Vitamin Supplements would be a huge help to dysphagia patients who are typically deficient in a huge range of micronutrients including: iron, folate, cobalamin (B12) and Vitamin D, Thiamine (B1), zinc, copper and manganese.
But these are only available in tablet form and so until a way is found to make them safer-to-swallow they cannot be included in a dysphagia patients’ management plan.
Enteral and parenteral solutions are a final option and used if a patient continues to lose weight or show other signs of signs poor nutritional intake.
There are several formulas available which are effectively highly processed foods. At a base level they all usually contain water, corn syrup, starches, oils, soy protein and caseins. Special formulations are then created for specific clinical conditions e.g. Semi-elemental tube feeds; diabetic feeds, renal insufficiency and so on. These will be delivered by NG tube, Jejunostomy Tube or PEG.
All of these have well documented infectious risks* associated with using them; point of entry, correct usage and the dramatic detrimental effect on the condition of the mouth.
So what is the answer? There is no definitive one. A holistic approach seems best.
We are “hard wired” to eat and drink and it is a big part of us feeling socially acceptable. Dysphagia imposes such problems on this normal every day function and makes patients feel self-conscious and embarrassed about eating and drinking in company-other interventions to improve nutritional intake are sometimes required.
But whichever intervention is selected, the question that has to be asked before deciding which intervention is most appropriate is… “Does this patient have dysphagia?”
*For this blog I’m not talking about patients that are severely malnourished or at risk of refeeding syndrome. (Patients develop fluid and electrolyte disorders, especially hypophosphatemia, neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications).
Dysphagia is still relevant but requires a specialist intervention strategy.
**Its interesting to note that despite the impact dysphagia has on a patient, very little research exists which is dysphagia focused compared to all other research. Below is all we have found.