A freedom that bites
In the second of our two-part series on dysphagia, Bella Talwar advises how GPs can manage the nutritional side-effects
The social opprtunities and pleasures mealtimes present can be destroyed by dysphagia. This can affect the quality of relationships and undermine the patient's confidence and dignity, resulting in feelings of isolation and being excluded by others1. This will lead to an inadequate calorie, nutrient and fluid intake and can have a severe adverse effect on their health, nutritional status and quality of life.
A survey2 carried out in four countries involving 360 patients in nursing homes and hospitals, identified the UK as having the highest incidence of negative responses on eating patterns, mealtime behaviour and enjoyment of eating and life in general. Findings included:
·44 per cent experienced weight loss over the previous 12 months
·62 per cent avoided certain foods and 60 per cent ate less than normal
·59 per cent still felt hungry or thirsty after meals
·73 per cent suggested life in general was less enjoyable
·79 per cent were bothered by dysphagia at mealtimes, 68 per cent felt embarrassed and 47 per cent experienced anxiety or panic attacks during meals
·36 per cent avoided eating with others
·55 per cent had been diagnosed with dysphagia, and 33 per cent got professional treatment.
Dysphagia has severe nutritional implications. If unrecognised over a prolonged period, it can place the patient at risk of malnutrition and its side-effects (see box 1 above).
An overlooked consequence is the patient's ability to drink sufficient fluids. Staff often view the use of fluid-thickening powders for undiagnosed patients experiencing swallowing problems as 'a prescription for dehydration'4. This may be due to restricted palatability and lack of monitoring.
Consequences of dehydration include3:
·Decreased salivary flow resulting in altered colonisation of the oropharynx
·Impaired bolus preparation due to lack of saliva and increased thickness of sputum
·Increased risk of aspiration due to lethargy and mental confusion.
Dysphagia management requires a multidisciplinary approach. Early identification and treatment will have positive outcomes for patient care.
Nutritional screening of all patients should be an integral part of clinical practice5. For GPs this means a rapid, initial evaluation to detect significant risk of malnutrition and to implement a clear plan of action, such as simple dietary advice or referral to a state registered dietitian for expert advice6. Box 2 outlines some useful questions.
The role of the dietitian is to assess and monitor the patient's nutritional status and estimate that nutritional intake meets nutritional needs. They individualise advice by recommending appropriate provision of texture-modified diets, food fortification and supplementation with sip feeds and alternative feeding where indicated.
Although complex, GPs can provide first-line dietary advice by discussing the following aspects with patient and carers.
·Consider food preferences and encourage a balanced diet
·Establish the timing of the patient's main meal of the day
·Encourage small and frequent meals
·Fortify foods with protein and energy-dense sources at each meal
·Use protein and energy sources to adapt the consistency of food for soft/ moist/pureed/liquidised diets
·Calculate daily fluid requirements and advise how to record fluid intake
·Suggest ways to make meals appealing.
·Consider patient's preference for savoury or sweet products
·Determine the type, flavour and consistency required (milk, fruit, yoghurt, mousse or custard)
·Recommend the quantity to be taken on a daily basis as a supplement (not a meal replacement)
·Consider a variety of options from different neutraceutical companies.
Preventing the nutritional consequences of dysphagia requires timely nutritional screening, comprehensive assessment and appropriate nutritional intervention to overcome the physical, social and psychological challenges.
Effective communication between members of the multidisciplinary team is essential in providing high-quality care.
Bella Talwar is specialist head and neck oncology dietitian, Royal National Throat, Nose and Ear Hospital, London
1 Consequences of malnutrition3
·Swallowing impairment and increased risk of infection due to decreased muscle, respiratory and immune functions
·Increased risk of aspiration due to lethargy, weakness and reduced alertness
·Reduced strength of the cough and mechanical clearance in the lungs
·Higher risk of admission to hospital and greater length and cost of hospital stay
·Poor functional status and quality of life due to lethargy and decreased ability to mobilise, work and socialise
·Increased morbidity and mortality
2 Useful case history questions
·How much weight has the patient lost in the past six months?
·How many cups of fluid is the patient drinking during the day?
·Is the patient having their normal portion sizes at meal times?
·How long is the patient taking to eat/drink during a meal?
·Is the patient feeling hungry or thirsty after a meal?
·Which types of food is the patient finding easy/difficult to manage?
·Is the patient chewing food for longer before swallowing?
·Does drinking sips of liquids in between bites of food make it easier?
·Has the patient adapted their eating habits to make it easier to swallow?
·Is it taking more time and effort to eat and drink throughout the day?
·Are there any problems with the patient's dentition?
1 Ekberg O et al (2002). Social dysphagia: its impact on diagnosis and treatment. Dysphagia Spring; 17(2):139-46
2 Ekberg O et al (1999). A European survey assessing the impact of dysphagia. European Study Group for Diagnosis and Therapy of Dysphagia and Globus
3 Langmore SE (1999). Risk factors for aspiration pneumonia. Nutrition in Clinical Practice
4 Whealan K (2001). Inadequate fluid intakes in acute stroke. Clinical Nutrition; 20(5):423 -8
5 Royal College of Physicians Working Party, Nutrition and Patients: A doctor's responsibility. Royal College of Physicians of London (2002)
6 Elia M. Screening for malnutrition: a multidisciplinary responsibility. Development and use of the
'Malnutrition Universal Screening Tool' (MUST) for adults. MAG, a Standing Committee of BAPEN
(ISBN 1 8994670 X) 2003
www.dysphagiaonline.com (dysphagia online)
www.bapen.org.uk (British Association of Parenteral and Enteral Nutrition)
www.espen.org (European Society of Parenteral and Enteral Nutrition)
www.patient.co.uk (Patient Society)
www.bda.uk.com (British Dietetic Association)
www.rcslt.org/ (Royal College of Speech and Language Therapists)