Manual of Clinical Nutrition

Manual of Clinical Nutrition Management B- 6 Copyright © 2013 Compass Group, Inc.

NUTRITION MANAGEMENT OF DYSPHAGIA

Description
Dysphagia is not a disease, but a disruption in swallowing function. Although dysphagia can occur at any age,
it is particularly prevalent in older adults (1). Dysphagia may result from neurological disorders, degenerative
diseases, cancers, or post intubation trauma (1). The nutrition management of dysphagia includes modifying
the consistency and texture of foods and liquids according to the patient’s tolerance, which is determined by a
comprehensive medical, swallowing, and nutrition evaluation by the healthcare team including the physician,
speech-language pathologist, and registered dietitian. Therapeutic goals for nutrition are customized and
often include diet modifications and swallowing retraining. An individualized meal plan will generally
include modifications in the texture and consistency of foods (eg, pureed or textured-modified foods and
thickened liquids) that optimize the quality of nutritional intake while reducing the risk of aspiration or
choking.

Indications
Dysphagia is an impairment in one or all stages of swallowing, resulting in the reduced ability to obtain
adequate nutrition by mouth and a possible reduction of safety during oral feeding (1,2). Patients 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. If dysphagia
is suspected, a swallowing evaluation should be performed by a qualified healthcare provider (1). This
evaluation may include a bedside evaluation, indirect or fiberoptic laryngoscopy, fiberoptic endoscopic
evaluation of swallowing, and a videofluoroscopic swallow study (VFSS), which is also known as a modified
barium swallow study. The VFSS is a definitive test in diagnosing the type of dysphagia (1). Fiberoptic
endoscopic evaluation of swallowing was recently shown to be as reliable as VFSS when using the
Penetration-Aspiration Scale ( 1 ). However, the VFSS remains 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 nutrition care plan for patients with dysphagia is developed based on ( 3 ):

 results of VFSS

 recommendations from the speech-language pathologist

 nutrient requirements of the patient

 food preferences of the patient

 other medical, psychological, or social factors affecting the patient's eating

Nutritional Adequacy
Dysphagia diets can be planned to meet the Dietary Reference Intakes as outlined in Section IA: Statement on
Nutritional Adequacy. Enteral feedings may be necessary to supplement oral intake until a sufficient quantity
of food can be consumed. If enteral nutrition for neurological dysphagia is anticipated to last for longer than
4 weeks, a percutaneous endoscopic gastrostomy (PEG) tube is preferable to a nasogastric tube (4). PEG tubes
are associated with fewer treatment failures and improved nutritional status as compared to nasogastric
tubes, and they allow the patient to receive adequate nutrition while oral intake is stabilized (4). In one study,
more than half of the patients who received a PEG tube due to poor tolerance of thickened food were
eventually able to resume oral feedings (1, 5 ). If a patient can tolerate oral liquids, the medical food
supplements should be in compliance with the consistency prescribed for the patient.

A record of food intake, including fluid intake and enteral feedings, is necessary at all stages of dysphagia
therapy. When oral intake approaches the patient’s energy and protein requirements, the patient should
begin to be weaned from the enteral feedings. A review of seven studies of modified-texture diets in older
adults with dysphagia found that people who consume these diets report an increased need for assistance
with eating, dissatisfaction with foods, and decreased enjoyment in eating, resulting in decreased food intake
and weight loss (Grade I)* (4). Recognition of the social and psychological burden of dysphagia, creation of an
individualized treatment approach, and provision of eating assistance may contribute to increased food
intake and weight maintenance or weight gain in older adults (Grade I) (4).