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Dysphagia and the older adult: When eating becomes a challenge - Part 1 (2019)

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Bethany Hopkins: Hello, and welcome to Clinical Nutrition Notes, a podcast where we will speak with guest experts and opinion leaders about the art and science of clinical nutrition.

Brought to you by Nestlé Health Science Canada. This podcast is intended for healthcare professionals for education purposes. I’m your host Bethany Hopkins, medical affairs manager with Nestlé Health Science. Today, we’ll be talking with Peter Lam about dysphagia in the older adult. Peter Lam is a registered dietitian and credentialed food service executive in Vancouver, British Columbia. Over the past 25 years, he has focused his practice in dysphagia and meal-time management. Peter provides consultation to healthcare, food service and the hospitality industry, and is currently co-chair of the International Dysphagia Diet Standardization Initiative, or IDDSI, but when asked, Peter simply refers to himself as an eating enthusiast.

Hopkins: Thank you for joining us Peter. In your nutrition practice, you’re involved in the management of many individuals with dysphagia, their families and care givers. Today we’ll be talking about dysphagia, a condition that may have an impact on quality of life, nutrition, hydration and may have serious health implications for some. To begin, I’d like to have you start by having you define the term dysphagia.

Lam: Thanks Bethany. Dysphagia, in the simplest terms means difficulty swallowing. We look back at the greek routes of the word, “dys” means difficulty, “phagia” simply means eating or swallowing. I think we need to start by thinking about swallowing as a complex process that involves voluntary and involuntary components. When we put food or liquid into our mouth, this is a conscious thing that we’re doing, because we want to taste the food, we want to savour the food, we want to note its’ flavour, and at the same time, we’re chewing the food to the appropriate size, mixing it with saliva, preparing it so that it can be safe to swallow. Now when this food is in a ready to swallow state, it is then propelled by our tongue into the pharynx, and the process then becomes involuntary, where a series of actions occur to actually allow that bolus of food to bypass our airway and safely and efficiently go into our esophagus, and is then propelled with peristaltic contractions of the esophagus towards our stomach. This process involves coordination of a number of muscles and nerves. It is often something we take for granted when we don’t have any difficulty swallowing. However, when a part of this process goes wrong, it can result in dysphagia, and this may involve issues with retaining or retrieving food or liquid, the chewing component where we’re breaking the food down into the appropriate size, the mixing of the food, having enough saliva even in our mouth to make sure that the food actually becomes the optimal consistency, where it’s moist, cohesive and slippery, coordinating the food or drink in our mouth so that the materials don’t spill into our airway before we’re ready to swallow. It can also be difficulty initiating the swallow.

Sometimes it’s inappropriate or mistimed closure of our airway, it could even be insufficient strength to propel that bolus and then leaving some residue behind in our throat which has a risk of being aspirated after the swallow. Occasionally, it’s also structural issues, whether it’s in the mouth or throat, that actually prevent the proper passage of the food or drink; or inappropriate/insufficient opening of the upper esophageal sphincter, it could even be the movement or the motility because of structural issues or because of muscle action in the esophagus, not allowing for the passage of food or drink into the stomach. And another example I can think of is actually poor coordination of the esophagus, such as when we’re experiencing gastro-esophageal reflux, where we actually regurgitate food from our stomach back into our throat, and then the materials enter into our airway. Now these are only some of the examples, but to really identify these, we do need to do a thorough swallowing assessment and evaluation in order to figure out what are the challenges for the individual.

Hopkins: You know it’s interesting to think that something that we do hundreds of times a day and we normally take for granted, is really complex, and there’s a number of things can go wrong along the way. So Peter, thinking about all that and what you just talked about, how does dysphagia usually present, and what should clinicians be looking for?

Lam: Well the first symptom often is individuals refusing to eat or drink. Dysphagia is often quite an embarrassing thing to encounter. Not anybody would easily identify or proclaim themselves to have difficulty eating and drinking. Sometimes the embarrassment is actually associated with coughing, or throat clearing during a meal, when they’re drinking something. It could also result in changes in voice or gurgliness in the voice when eating and drinking. Sometimes it presents itself just as the person is eating very slowly because they don’t want people to notice that they’re actually having any trouble with eating and they’re being extremely careful not to choke, not to cough, not to throat clear, and it results in prolonged mealtimes. When it may have taken them 10-15 minutes to eat in the past, it’s now taking them 45 minutes to an hour to eat a meal. It can present itself as somebody pocketing food, where there’s food actually stuck in their cheeks, in their lips. Sometimes people are so embarrassed that they actually just swallow the food without chewing it, which presents a risk of choking. There could be an exaggerated swallow because it’s painful for them to swallow, or they’re needing to exert that extra force to swallow the more difficult to swallow foods. It can present itself in excessive chewing or the person drooling, or the most embarrassing one of all, losing food or liquid out of their mouth, when they’re eating or drinking.

Hopkins: Peter, thinking of those symptoms, and the way dysphagia presents, who are the individuals that are most affected by dysphagia?

Lam: The most recent publication by the International Dysphagia Diet Standardization Initiative, when we were investigating the need for standardized international terminology and definitions for texture modified foods and thickened liquids, suggested that conservative estimates show that approximately 8% of the world’s population is affected by dysphagia in some form. If we’re looking specifically at the older adult, in nursing homes, studies have shown anywhere from 55-68% prevalence. In the community setting, data that comes out of Japan, the Netherlands, the United Kingdom, suggests anywhere from 11-13% prevalence. When we’re looking at older adults in the acute care hospital setting, it can range anywhere from 25-71% in different parts of the world. There were a couple of interesting studies that showed us, with regards to older adults with dysphagia presenting to acute care, there were certain characteristics. Most of them tend to be over the age of 80, they were typically nursing home residents, suffer from some form of depression, suffer from functional capacity issues, having multiple diagnoses; and often taking a large number of medications that could affect their level of consciousness, their swallow response, the condition of their mouth, such as xerostomia, and some even affecting their respiratory condition. When we’re talking about who it’s most likely to affect, that’s what the studies are telling us so far.

Hopkins: Yes, it’s interesting, and it really is a relatively prevalent condition. Peter, what are some of the common challenges associated with dysphagia that you’d be thinking about as a clinician?

Lam: I think the first thing to really consider is the safety and the efficiency of the persons’ swallowing and what that affects. When we have challenges eating, often we’re not eating enough and we know the appetite is often affected when people get older, but when you compound that with the issues that are present with dysphagia, often you start to see sudden or significant weight change, or sudden or significant change to somebody’s eating pattern that then can lead to malnutrition and dehydration issues. When it’s difficult to drink, you’re not going to drink enough. Often what we see are things like chronic urinary tract infections, constipation issues requiring more and more laxative use, malnutrition symptoms, muscle wasting, reduced functional capacity as a result of the muscle wasting, then in the worst case scenarios, we’re seeing recurrent bouts of chest infection, pneumonia, and in the worst case, when we have issues where it’s actually dangerous for people to be eating food that are not texture modified and there’s the risk for airway obstruction of solid foods, it could even lead to death.

Hopkins: Peter, the consequences can be quite serious. You mention about difficulty with eating, malnutrition, and dehydration. Are there specific types of foods, or specific nutrients that have been observed to be a particular challenge in individuals with dysphagia?

Lam: So often what we tend to see are people avoiding those foods that are difficult to chew if the oral processing and chewing becomes an issue, and these tend to be the protein containing foods. There are a lot of studies that have identified protein malnutrition being one of the key things that we do need to watch for with people that suffer from dysphagia. In order to help these individuals we may actually need to think about elevating or providing them with much more protein and calorie dense foods particularly associated with the animal protein foods. We’ve seen that vitamin B12 and iron, tends to be affected because of the lower intake of the animal protein items. We know that vitamin D can often be deficient for those who have issues with swallowing and then ultimately as I’ve mentioned hydration. With drinking challenges and the potential use of commercial thickeners sometimes we’re not able to achieve those hydration goals for the individuals that have swallowing concerns and so they tend to be at higher risk of dehydration.

Hopkins: We’ve been talking about these challenges, and we’ve been thinking about them from a clinician’s perspective - nutrition, hydration, safety and efficiency, and you alluded to this a little early on, about some of the personal challenges that individuals face, and their families and caregivers. Can you talk a little bit about that?

Lam: Sure. We often forget as clinicians, as we think so much about the technical issues of the dysphagia and the swallowing challenges, that we forget about the mealtime experience for individuals. Chronically coughing, having choking incidents, having things spill out of your mouth at a mealtime or social setting, as I mentioned before is rather embarrassing, and so often what we find with individuals that suffer from dysphagia is they tend to isolate themselves away from those social dining environments or social activities which involve food or drink. It really affects the dynamic of family dining or social interactions for them. It really does take away from the enjoyment and quality of life when you have issues with swallowing, because so much of our life actually does involve food, drink and interactions, to enjoy the food and drink.

Hopkins: Food is such a social part of our lives, isn’t it? A really important part, not just for sustenance, and to get the protein and nutrition we need, but a really important part of who we are, and our interactions with other people. Peter, I want to thank you for sharing your experience today related to dysphagia, which as you mentioned, is a real concern for a number of older adults and their families.

CLOSING: We’ll continue this conversation on our next podcast where we’ll have you address assessment and management considerations for the clinician. Thank you Peter for joining us, and thank you to all of our listeners.

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For the Nestlé Health Science podcast team, I'm Bethany Hopkins.