Dysphagia

Description
The consistency of the diet is modified according to the resident’s tolerance (as determined by the clinical examination), therapeutic goals for nutrition, and the resident’s retraining in swallowing. Pureed food and liquids are thickened to the consistency that the resident can safely swallow.

Characteristics of foods, such as their uniform consistency and their capacity to form a bolus in the mouth, influence the ease with which the food can be chewed and swallowed.

Indications
Residents with dysphagia have difficulty moving food from the front to the back of the mouth, channeling the food into the esophagus, or both processes. Dysphagia may be caused by weak or uncoordinated muscles of the mouth and/or throat; motor and sensory defects impeding chewing or swallowing; or both conditions.

Nutritional Adequacy
Dysphagia diets can be planned to meet the Dietary Reference Intakes as outlined in the Statement on Nutritional Adequacy. However, enteral feedings may be necessary to supplement oral intake until a sufficient quantity of food can be consumed. A record of food intake, including fluid intake and enteral feedings, is necessary at all stages of dysphagia therapy. When oral intake approaches the resident’s energy and protein requirements, weaning from the enteral feeding should begin.

The feeding method should be evaluated for residents who receive enteral nutrition as the primary source of nutrition. One study of residents who had hemiplegic strokes documented better outcomes with percutaneous endoscopic gastrostomy tube feeding than with traditional nasogastric feeding (1). Problems associated with nasogastric feeding include aspiration pneumonia following tube displacement or removal of the tube. Residents in the study who received percutaneous endoscopic gastrostomy feedings gained weight, had minimum time on tube feedings, and had shorter hospitalizations (1). In contrast, residents who had nasogastric feedings lost weight, missed an average of 22% of their prescribed feedings, and had longer hospitalizations.

How to Order the Diet
If dysphagia is suspected, a swallowing evaluation should be performed. This evaluation may include any of the following components: a bedside evaluation, indirect or fiberoptic laryngoscopy, fiberoptic endoscopic evaluation of swallowing, and a videofluoroscopic swallow study (also known as a modified barium swallow). The latter technique is the preferred diagnostic tool for dysphagia because it determines any structural and functional problems that may occur with varied food and liquid consistencies and rules out inappropriate diet consistencies. The dietitian and the speech pathologist should use the results from both the evaluation and a chewing-swallowing challenge to choose appropriate foods and beverages for the resident (2). The National Dysphagia Task Force found that the Dysphagia Outcome and Severity Scale provided the best scale to determine the level at which the National Dysphagia Diet (NDD) should be recommended (3).

Before a resident is fed orally, a diet order specifying that the resident can eat must be obtained from the physician. The dietitian and the speech pathologist must coordinate efforts to determine the appropriate consistency of foods and liquids for the resident both before feedings begin and with subsequent feedings. The consistency of foods and liquids should be altered as the resident progresses.

The severity of dysphagia determines the level of the diet required. Diet orders should include the level of diet per the NDD guidelines (3). The NDD levels 1, 2, and 3 are described below. Also, the liquid consistency desired (eg, thin, nectar-like, honey-like, or spoon-thick) should be indicated. With each progression of the diet, both the level of diet and the liquid consistency need to be specified in the nutrition prescription. The three NDD levels include (3):

General considerations:Dietary considerations vary with each resident. The importance of individual food consistencies cannot be overemphasized. For example, dysphagic residents with an obstruction may be able to take liquids safely, while other residents may aspirate liquids and require thickened liquids and a puree consistency. If a resident cannot tolerate thin liquids, foods that become thin liquid at either room (70°F) or body temperature (98°F), such as gelatin, ice cream, and sherbet, should also be avoided.

Liquids: Residents who have dysphagia frequently have difficulty drinking thin liquids, which are not easily channeled to the back of the mouth. It is necessary to introduce thickened liquids initially and progress to thinner liquids as swallowing proficiency is gained. A thickening agent, such as Thick & Easy, is frequently required for thin liquids so that the resident can swallow without choking or drooling. Most thickeners require 1 tbsp of thickening product per 4 fl oz to bring liquids to a nectar-like thickness, 1½ tbsp per 4 fl oz for a honey-like thickness, and 2 tbsp per 4 fl oz for a spoon-thick consistency. Prepackaged thickened beverages are a good choice to ensure the proper consistency.

Thin liquids include coffee, tea, soda, milk, eggnog, fruit or vegetable juice, juice from canned fruit, broth, ice cream, sherbet, malts, nutritional supplements, frozen yogurt, and gelatin. To ensure hydration from water, use a digestible thickening agent, such as a commercial starch thickener (eg, Thick & Easy). Gum-based thickeners should not be used because they may compromise fluid availability, leading to dehydration.

FOOD GUIDE – DYSPHAGIA DIETS
NDD Level 1: Dysphagia Pureed
FOOD GROUP	FOODS ALLOWED	FOODS EXCLUDED
Beverages and Milk	Smooth beverages	Milk, coffee, tea, sodas, nutritional supplements (may be given if thin liquids are allowed)
Cereals and Grains Cereals should have a pudding-like consistency and may have enough milk to moisten.	Farina-type cooked cereals; cooked cereal should have a pudding-like texture Pregelled or slurried through the entire thickness: doughnuts, pancakes, waffles, French toast, bread Pasta, rice, and dressing that are pureed to a smooth consistency	Coarse cooked or dry cereals Cereals with seeds or nuts All other breads Crackers Regular rice
Vegetables and Potatoes/Soups	Pureed or strained vegetables without chunks or seeds; mashed white potatoes Smooth cream soups or broth-type soups with pureed and strained ingredients	Regular cooked or raw vegetables Potato skins and chips Fried or french-fried potatoes or vegetables Regular soups with rice, corn, peas, or large chunks of meat and vegetables
Fruits and Juices	Applesauce, pureed fruits, well-mashed bananas Fruit juices without pulp	Regular canned, fresh, or frozen fruits Fruit juice with pulp (may be given if thin liquids are allowed)
Meats, Meat Substitutes, Entrees	Pureed or strained meats, poultry, or fish Pureed scrambled eggs Soufflés that are smooth and homogenous	Regular or chopped meats or casseroles Cottage cheese Cheese slices or cubes Scrambled or hard cooked egg Peanut butter Sandwiches Pizza
Desserts	Smooth custard and pudding Plain or custard-style yogurt Desserts pureed to a smooth and moist consistency	Ice cream, sherbet, frozen yogurt, other ices (may be given if thin liquids are allowed) Regular cake, pie, cookies Bread and rice pudding Fruited yogurt
Fats	Butter, margarine, smooth gravy, cream sauces, mayonnaise, salad dressings, cream cheese, sour cream, whipped toppings	All fats with coarse or chunky additives
Miscellaneous	Sugar, jelly, honey, syrup Ketchup, mustard, smooth sauces	Jams and preserves Coarsely ground pepper and spices

NDD Level 2: Dysphagia Mechanically Altered
FOOD GROUP	FOODS ALLOWED	FOODS EXCLUDED
Beverages and Milk	Beverages with minimal amounts of texture or pulp (any texture should be suspended in the liquid and should not precipitate out)	Milk, coffee, tea, sodas, nutritional supplements (may be given if thin liquids are allowed)
Cereals and Grains Cereals may have ¼ cup milk or just enough milk to moisten if thin liquids are restricted. The moisture should be well blended.	Soft pancakes, well moistened with syrup Cooked cereal with little texture, including oatmeal; slightly moistened cold cereals with little structure, such as corn flakes Unprocessed wheat bran stirred into cereals for bulk Pregelled or slurried breads that are gelled through the entire thickness Well-cooked pasta in sauce	Coarse cooked or whole grain dry cereals; cereals with seeds or nuts All other breads Crackers Rice
Vegetables and Potatoes/Soups Vegetables should be < ½ inch and easily mashed with a fork.	Soft cooked or mashed vegetables, including cooked vegetables without hull or stringy fibers Well-cooked shredded hash brown potatoes that are not crisp Soups with easy-to-chew or easy-to-swallow meats or vegetables	Cooked peas or corn; raw vegetables Potato skins and chips Fried or french-fried potatoes or vegetables Broccoli, cabbage, brussels sprouts, asparagus, or other fibrous, non-tender, or rubbery cooked vegetables Soups with rice, corn, peas, or large chunks of meat and vegetables
Fruits and Juices	Soft drained canned or cooked fruits without seeds or skin; fresh soft/ripe banana, jelled cranberry sauce Fruit juices with small amounts of pulp	Fruit cocktail, grapes, cherries, or apricots with skin; fresh, canned, or cooked pineapple; fresh fruits except ripe banana; dried fruits; frozen fruits Watermelon without seeds (may be given if thin liquids are allowed)
Meats, Meat Substitutes, Entrees Meat pieces should not exceed ¼- inch cube and should be tender.	Moist ground meat; casseroles (without rice); melted cheese in casseroles Protein salads, such as tuna or egg, without large chunks, celery, or onion Cottage cheese, smooth quiche without large chunks Scrambled eggs, soufflés Well-cooked, slightly mashed, moist legumes such as baked beans	Dry or tough meats (such as bacon, sausage, hot dogs, bratwurst) Dry casseroles or casseroles with rice or large chunks Cheese slices or cubes Hard-cooked egg Peanut butter Sandwiches Pizza

Desserts	Custard, pudding Soft fruit pies with bottom crust only Crisps and cobblers without seeds, coconut, or nuts and with soft breading or crumb mixture Soft, moist cakes with icing or slurried cakes Pregelled cookies or soft, moist cookies that have been dunked in milk, coffee, or other liquid Soft, smooth chocolate bars that are easily chewed	Ice cream, sherbet, frozen yogurt, other ices (may be given if thin liquids are allowed) Dry cookies or cake Bread and rice pudding
Fats	Butter, margarine, gravy, cream sauces, mayonnaise, salad dressings, cream cheese, sour cream, whipped toppings	All fats with coarse or chunky additives
Miscellaneous	Jams and preserves without seeds; jelly Sauces and salsas with small tender chunks < ½ inch	Seeds, coconut, nuts Sticky or hard foods

SAMPLE MENU
Breakfast	Noon	Evening
Orange Juice Cream of Wheat Scrambled Egg Biscuit with Slurry Margarine Jelly Milk Coffee Sugar Creamer	Honey Glazed Chicken, Ground Buttered Potatoes Soft Cooked Carrots Margarine Frosted Banana Cake Milk Tea Sugar	Braised Beef with Gravy, Ground Soft Cooked Noodles with Gravy Soft Cooked Green Beans Peach Slices, Drained Margarine Pudding Iced Tea Sugar
Beverages thickened to appropriate viscosity, per diet order

NDD Level 3: Dysphagia Advanced
FOOD GROUP	FOODS ALLOWED	FOODS EXCLUDED
Beverages and Milk	All beverages	None
Cereals and Grains All items must be well moistened. Moisten cereals with ¼ cup milk or enough milk to moisten if thin liquids are restricted.	Cooked cereals Well-moistened dry cereals Pasta, noodles, rice Moist bread dressing Well-moistened soft breads, rolls, pancakes, plain muffins, biscuits (Use margarine, butter, jelly, or syrup to moisten.)	Cereals or breads with raisins or nuts Granola-type, coarse, or dry cereals Thick-crust breads Crackers
Vegetables and Potatoes/ Soups	Tender soft-cooked vegetables Vegetable juices Most soups Shredded lettuce	Raw or cooked vegetables with tough skins or seeds; fried or raw vegetables; cooked corn Soups with tough meats or vegetables; clam chowder
Fruits and Juices	Ripe banana, melon, peeled peaches, pears, strawberries Cooked or frozen fruit Canned peaches, pears, apricots Fruit juices	Fruit cocktail, grapes, cherries, or apricots with skin; fresh fruit except ripe banana and those listed as allowed; dried fruits Watermelon without seeds (may be given if thin liquids are allowed)
Meats, Meat Substitutes, Entrees All meats must be well moistened. Add extra gravy or sauces as needed.	Tender meat, fish, or poultry Soft cheese Chopped or ground meats, poultry Soft casseroles Meat, fish, or egg salads Eggs (prepared any way) Smooth peanut butter; liverwurst Yogurt without nuts or coconut	Dry or tough meats (such as bacon, sausage, hot dogs, bratwurst) Chunky peanut butter
Fats	All except those to avoid	Fats with coarse, difficult-to-chew, or chunky additives
Desserts	Cake, tender cookies Custard, pudding Ice cream, sherbet, frozen yogurt, other ices (may be given if thin liquids are allowed) Pies: cream, custard, pumpkin, soft fruit with bottom crust only	Desserts containing nuts, coarse dried fruit, or tough fruit Desserts baked to a hard consistency
Miscellaneous	Soft candy Jelly, smooth jams All sauces	Candy containing tough fruits, coconut, or nuts; hard candy Chewy caramel or taffy-type candies

SAMPLE MENU
Breakfast	Noon	Evening
Orange Juice Cream of Wheat Scrambled Egg Biscuit Margarine Jelly Milk Coffee Sugar Creamer	Honey Glazed Chicken, Ground Buttered Potatoes Soft Cooked Carrots Dinner Roll Margarine Frosted Banana Cake Milk Tea Sugar	Braised Beef with Gravy, Ground Noodles with Gravy Soft Cooked Green Beans Peach Slices Dinner Roll Margarine Soft Cookie Iced Tea Sugar
Beverages thickened to appropriate viscosity, per diet order

SAMPLE MENU

Breakfast

Noon

Evening

SAMPLE MENU

Breakfast

Noon

Evening

SAMPLE MENU

Breakfast

Noon

Evening