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Dysphagia and the older adult: When eating becomes a challenge - Part 2 (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.

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 caregivers. In our last conversation we talked about dysphagia, how this condition presents, who may be affected, and some of the challenges dysphagia may pose. Today, we’ll continue to explore dysphagia, really focusing on assessment and management considerations for clinicians, or in other words, what we can do about dysphagia in clinical practice. Peter, can you begin by first describing approaches to identifying dysphagia?

Lam: Absolutely. Bethany, dysphagia is one of these conditions that is often under-recognized and under-diagnosed. People consider it to be a natural part of aging, and we really need to be more diligent in the screening and assessment process. As we talked about before, when dysphagia is inadequately managed it can lead to malnutrition, dehydration, negative health consequences that ultimately affects the individual's quality of life. Interestingly enough, there were a couple of studies published internationally that mention reasons for people not seeking treatment, or management or assessment. First one being that people are not aware that treatment options or management options were available. Which sounds really scary. In this study they also identified that 39% of those suffering from dysphagia thought they could not be treated. As I mentioned before, they thought that dysphagia was just a normal part of aging and there was no point doing anything about it.

There was also a large percentage of people that just were not bothered enough by the problem to do something. Travel and access sometimes was difficult, to find the clinicians that have the skills and experience. It also indicated that some people believed that treatment was too time-consuming because they had to go back to multiple treatment sessions or assessment sessions, and then sadly, some people actually thought that the treatment or the management of the treatment was too expensive. So I think as clinicians we need to be aware of these, and help those that are suffering from dysphagia to understand that they do have options. To start, we need to screen more often for dysphagia just because we know that it’s under-recognized. There are some good screening tools out there, and some examples of the screening tools that are currently used by clinicians are things like the 3 ounce water test; the screening tool developed right here in Toronto, Ontario, the TorBest; and the EAT-10 tool. There are also specific screening tools for the head and neck cancer population, and the stroke population. I think clinicians just need to be aware that not every screening tool will apply to all populations, and they need to be mindful of which screening tools are sensitive to identifying people with dysphagia for specific populations. The screening tools also are not comprehensive assessment tools. They really just help us to identify those with dysphagia, do they have the presence of symptoms, or not. And then, when we identify that they have the presence of symptoms, a thorough swallowing evaluation should be something that we do for these individuals.

Hopkins: Thank you for that Peter. You brought up some very interesting points about why people may not be seeking treatment which is interesting for clinicians to consider. And clearly using screening tools that are validated and are for the target population that you’re working with is very important. So screening is currently something you would advise and as you mentioned, that’s all that is, it’s a screen. What comes next then in terms of the assessment part of this picture?

Lam: So the assessment process is something that takes a little longer, which involves looking into the individual's history, their health status, what the reported symptoms are, including a review of the current medications that they’re taking, and to see what the impact of those are on their reported symptoms. It involves a review of their current diet, their management, whether it’s texture modification or any therapeutic-type diet management, taking a very close look at their eating and drinking ability, what compensations they may have taught themselves in terms of how to more safely and efficiently eat and drink, evaluating their mealtime performance in relation to endurance, efficiency, and just to note their ability to be able to get enough nutrition and hydration. Once that’s done, we would do a much more focused exam on the structures that we had talked about earlier, the parts of the mouth, the tongue and the throat that’s involved in the eating and drinking process. This is often referred to as an oral mechanism exam, oral motor exam, or in some cases as a rudimentary oral exam, where we’re looking at the structures involved in eating and swallowing, the strength of the muscles, the range of motion, the coordination. We would look more thoroughly at the persons oral condition, oral hygiene, note how their vocal quality and how it might change with eating and drinking. Look at their respiratory status and their ability to cough and clear, just to make sure that if something happens to go the wrong way that they actually have the ability to expel that, so that we’re not putting somebody in a high-risk of airway obstruction.

Hopkins: So that now that we’ve talked about the screening and the assessment, what comes next, or what are some of the management strategies available in the clinician’s toolbox, once you’ve identified someone, and have gone through the assessment process?

Lam: So often once we have identified someone’s abilities, the goal of the management is to try to see what we can do to best meet the person at their abilities. The most common practice that we know for the management of dysphagia is texture modification of food and thickening of liquids. A systematic review that was recently conducted by the International Dysphagia Diet Standardization Initiative has identified that this is the most prevalent management tool that clinicians are using, and it really showed that thickening of liquids helped to slow down the flow for those that have coordination issues. Those that aspirate thin liquids because of the fast flow, by using a thickening agent, or thicker liquids, it does help them to swallow and minimize the risk of materials entering their airway. Now interestingly enough, there’s also evidence that surfaced in the systematic review, that showed us that we could actually thicken something too much because in the older population of adults that suffer from dysphagia their swallow tends to weaken over time and with age, and if we have something that’s too thick, that requires too much strength to propel, residue can actually be left behind and that presents a risk of the materials being aspirated after the swallow takes place. At this point there is no particular evidence that says to us that one thickness is perfect for this population, or a particular condition. All we really know is the fact that solid foods, foods that are less texture modified, and thicker consistencies require greater effort and greater strength and when it comes to texture modified foods and thickening liquids, clinicians really need to be mindful of the fact that we only modify the food or thicken the liquid to the extent to meet the person’s abilities, and let’s not over do it.

Hopkins: I think that’s such an important comment. Thicker isn’t always better. Certainly from a safety perspective, as you’ve outlined and also from a palatability perspective as well, from the individual who’s eating and drinking those foods. Increasing thickness and helping to control flow is important as long as we don’t go too far. Peter, when it comes to thickening liquids, there are a number of common agents on the market, there are general categories of starch-based thickeners versus gum-based thickeners and there are differences between each of those. What considerations should the clinician be aware of when they’re thinking about using a starch-based product versus a gum-based product?

Lam: When is comes to thickening agents, I think people need to recognize that both starch-based products and gum-based products have a place in the management aspect of dysphagia. Starch-based products tend to be more economical, so for those who are worried about finances and thinking that management and treatment may be too expensive. Starch-based products are often chosen for the cost, but people also need to recognize that with starch-based products it does often alter the taste and sometimes palatability of the liquid that they mix it with. Because it’s a starch it does have an affect on the glycemic response and again, because it’s a starch it does have a caloric content associated with it. Having said all of that, the benefits of that is if somebody actually needs more calories within their diet because they can’t eat enough then the starch-based thickener might actually be beneficial for this individual.

The starch-based product is something that also allows more flexibility when it comes to thickening. Suppose we thicken something and we let it bloom to the desired thickness and we find that it’s still not thick enough, more thickener can be added to allow the product to become thicker. On the contrary, with the xantham gum thickener, we know that the xantham gum thickener is much more taste neutral, it has a better eye appeal because it mixes up clear, rather than the starch thickener that presents the thickened liquid to be more cloudy. It’s more taste neutral. The lovely part of it is it’s resistant to salivary amalyse. The starch will get broken down by the enzymes in our saliva, where as the xantham gum thickener is not affected by that. The limitation for the xantham gum thickener is the fact that once it reaches an optimal thickness, because of the thickening process, you really cannot add any more thickener to thicken the product further. People have often said I like the way the xantham gum thickener behaves because it tends to feel more slippery and easier to swallow. Whereas the starch-based thickeners tend to feel a bit more gummy, and can leave potentially more residue behind. As I said before, there’s a place for both, and clinicians need to be aware of what is of the best benefit for the individual that they’re supporting.

Hopkins: You brought up a good point about preparation and mixing. I think it behooves clinicians to be thinking about that and if they’re working with individuals in the community and people that are preparing these for loved ones or for themselves, there’s some education that goes with this, isn’t there, in terms of best practices and the do’s and the don’ts that we need to be thinking of? Now in terms of foods, we’re thinking about comfort foods, chicken soup, cereal, there are certain foods that we think as being safe, comforting, and for an individual with dysphagia, that may not be the case. Can you comment a little bit on that?

Lam: Sure, this is again, one of those situations where food is medicine, where often we think that if we can help people eat more they’re going to get well. A lot of times we think of these comfort foods or medicinal type foods such as chicken soup is good for the soul, but for those with dysphagia these may present to be the most challenging foods. Just because we need to be able to manage both solid food in our mouth and thin liquids in our mouth at the same time. Think about a bowl of chicken soup. Think about the broth running to the back of someone’s throat before they’re ready to swallow the solids that are in their mouth. Same with a bowl of cereal, we might be thinking we’ll just give someone a bowl of cereal because it’s easy to eat but for those of us with no swallowing concerns, we can coordinate this and be able to time that swallow accordingly, but that excess milk that’s in that bowl of cereal can then be aspirated and cause difficulty. So we need to be mindful of things like mixed consistency foods, and we’re helping to modify foods to make it easier for people to eat. As I mentioned before, we need to be mindful of the fact that we should only be modifying the food to meet that person’s abilities and not over do it because we know people eat food first with their eyes, and we do need to keep foods looking appealing, we need to keep foods enjoyable for people in all senses of eating.

Hopkins: Yes, a great point, and again it comes back to that social aspect, that pleasure of eating that’s so important to people. We’ve been talking a lot about food, which is really important and which we’re really passionate about, are there other things we need to be thinking about when working with individuals who have dysphagia, beyond food and liquid?

Lam: Absolutely, as I mentioned, food and liquid modification is really only 1 aspect, and clinician tend to choose this because they think it is easier to achieve, but sometimes we forget about that fact that we really need to look at the person’s meal time abilities and their meal time functioning. Are they seated in the right position, is the head and neck positioned correctly to allow for the optimal angle for swallowing? Do they actually have the hand-eye coordination to be able to get food from the table, bowls, plates to their mouth? Are they able to see the food? Are there some environmental distractions causing them not to be focusing on the food or drink? Maybe we’ve overloaded the table with a number of food and drink items, which creates chaos and confusion for someone with cognitive abilities to discern between edible and non-edible foods and the multitude of things that are in front of them. There are rehabilitation exercises that can be done for those that are able to be rehabilitated, their positioning, things that we can do for a person’s head and neck, by changing the position we can actually change the mechanism of the swallow, but again, this is something that should be done after a thorough assessment, and again, I mentioned structural issues, and sometime surgical interventions can be done to help with the swallowing management. So really, I’d like to clear up that myth that dysphagia can’t be treated and we need to be aware that there are options out there and it does go beyond food and fluid.

Hopkins: Peter, I almost hesitate to say this, but you’ve given us a lot of food for thought, a lot of great information today. And as you’ve just mentioned, dysphagia is a serious condition for people, however, it is really helpful to know that there are tools to assist clinicians in screening and identification, and then in the management of those individuals to improve nutrition and hydration, as well as the considerations around the pleasure of eating and quality of life, so thank you for that. Before we sign off, I would like to take a minute to ask you one last question so our listeners can get to know you a little bit better. Can you tell us how you first became interested in the field of nutrition?

Lam: Bethany, your listeners are probably going to think this is crazy for him to say this, but I really was not interested in the field of nutrition in my initial career path. I was interested in food. I was interested in helping people enjoy food. I started my work life in a restaurant environment where I just thought it was so pleasurable to see people come and enjoy themselves eating and drinking. I never thought about entering the field of nutrition. Growing up as an Asian child, my parents always intended for me to become either a lawyer, or a doctor or an engineer, so nutrition was not even something of consideration. Believe it or not, as time evolved, I recognized that nutrition is so related to the enjoyment of eating and drinking, which is really my passion, and as a result the stars all just lined up and I somehow became a dietitian and focused in on the field of nutrition and then now even focusing even more of my energy into dysphagia and dysphagia management because I just absolutely love to see people enjoy eating and drinking.

Hopkins: That is an interesting story, I didn’t actually know that about you before Peter. We’re really glad that you found the field of nutrition, and with your passion for food and your experience in the food industry, they lend themselves so nicely to the management of individuals with dysphagia and keeping that pleasure of eating top of mind all the time, and on what we can do to help is fantastic.

CLOSING: On that note, we will conclude this podcast, and I’d like to thank you Peter for joining us, and thank all of our listeners.

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