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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
In addition, the use of the vocal folds
for speech is believed to help rehabilitate function of the larynx for swallow.
Speaking valves allow patients to
speak “hands free.” The valve is placed
like a cap over the opening of the tracheostomy tube. The valve allows air
to flow into the trachea through the
tracheostomy tube upon inhalation
but closes to force exhaled air to flow
Figure 12–6. Fenestrated tracheostomy
tube: outer cannula; decannulation plug
(red); 35 mm reusable inner cannula;
insertion obturator; fenestrated reusable
inner cannula with decannulation cap in
place. © 2023 Medtronic. All rights reserved.
Used with the permission of Medtronic.
around the tube and through the vocal
folds for speaking. Speaking valves
must never be used with a cuffed tracheostomy tube! Even with the cuff
deflated, the cuff narrows the airway
significantly and precludes adequate
exhalation around the cuff. Because
the speaking valve prevents exhaled
possibility of invagination of fragile tracheal mucosa into the fenestra, thereby
obstructing the patient’s airway. In
addition, in order to take advantage
of the fenestra, the inner cannula must
be removed, putting the patient at risk
for airway obstruction from mucus in
the tube.
When medically stable, the patient
with a noncuffed tracheostomy should
be taught to cover the tube opening and
talk. The use of finger control speech
or the use of a one-way valve speaking system is predicated upon the ability of patients to successfully use this
technique without compromising their
ability to clear their secretions or to
breathe. The patient and family should
be instructed in the proper method of
speech and breathing, that is, inhale
through the tracheostomy tube, cover
air from passing out the tracheostomy
tube, there is obstruction to exhalation
if a speaking valve is placed on a cuffed
tracheostomy tube.
A patient’s ability to communicate
orally may be of great help in identifying problems, discussing needs, and
maintaining interactions with significant others and their caregivers (Hoit et
al., 2003, 2007). Lack of communication
while intubated or with a tracheostomy
can significantly interfere with quality
of life. Modification of the artificial airway and/or ventilator settings may
enhance the patient’s ability to communicate. Care providers must maximize
the patient’s ability to communicate
and facilitate useful augmentative and
alternative communication tools and
strategies for patients and their families
(Broyles et al., 2012).
the tube at peak inhalation, and speak
on exhalation. It is important to remind
the patient to then release the cover and
CONCLUSION
again breathe in through the tube. Once
the technique is mastered, patients usually quickly become adept at speaking.
Dysphagia team members must have a
complete understanding of normal air-
12. AIRWAY CONSIDERATIONS IN DYSPHAGIA
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285
way protection mechanisms and how
those mechanisms may be altered by
disease or injury. This is essential to the
development of an accurate dysphagia diagnosis and treatment plan. As
the airway is at risk for compromise in
every patient with dysphagia, it is critical that team members are able to identify signs and symptoms of aspiration
and aspiration pneumonia. In addition,
various medical interventions such as
feeding tubes and airway assistance,
both acute and chronic, have further
impact on swallowing function and the
successful implementation of dysphagia treatment.
STUDY QUESTIONS
1. Describe three physiologic mechanisms important for airway protection during swallowing.
2. Which pulmonary lobe is most commonly involved in upright aspiration pneumonia, and why?
3. Does inflation of the cuff of an
endotracheal or tracheostomy tube
prevent aspiration? Give an explanation for the answer.
4. Describe aspiration precautions
and how they vary between inpatient and outpatient settings and
how they vary between oral and
enteral feeding.
5. Explain how various tracheostomy
tubes impact speech production.
REFERENCES
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Neumann, J. O., Poli, S., . . . Steiner, T.
(2013). Stroke-related early tracheostomy
versus prolonged orotracheal intubation
in neurocritical care trial (SETPOINT):
A randomized pilot trial. Stroke, 44(1),
21–28.
Broyles, L. M., Tate, J. A., & Happ, M. B.
(2012). Use of augmentative and alternative communications strategies by
family members in the intensive care
unit. American Journal of Critical Care, 21,
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Coben, R., Weintraub, A., DiMarino, A.,
& Cohen, S. (1994). Gastroesophageal
reflux during gastrostomy feeding. Gas-
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Esper, D. H., & Harb, W. A. (2005). The
cancer cachexia syndrome: A review of
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Nutrition in Clinical Practice, 20, 369–376.
Hoit, J. D., Banzett, R. B., Lohmeier, H. L.,
Hixon, T. J., & Brown, R. (2003). Clinical ventilator adjustments that improve
speech. Chest, 124, 1512–1521.
Hoit, J. D., Lansing, R. W., & Perona, K.
E. (2007). Speaking related dyspnea in
healthy adults. Journal of Speech, Language,
and Hearing Research, 50, 361–374.
Horner, J., & Massey, E. (1988). Silent aspi-
ration following stroke. Neurology, 38,
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Logemann, J. (1986). Treatment for aspira-
tion related to dysphagia: An overview.
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McClave, S. A., Martindale, R. G., Vanek,
V. W., McCarthy, M., Roberts, P., Taylor,
B., . . . Society of Critical Care Medicine.
(2009). Guidelines for the provision and
assessment of nutrition support therapy
I: The adult critically ill patient. Journal
of Parenteral and Enteral Nutrition, 33(3),
277–316.
McGuinnis, G. E., Shively, J. G., Patter-
son, R. L., & Magovern, G. J. (1971). An
engineering analysis of intratracheal
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557–564.
Metheny, N. A. (2002). Risk factors for aspi-
ration. Journal of Parenteral and Enteral
Nutrition, 26(Suppl. 6), S26–S33.
Metheny, N. A. (2007). Preventing aspira-
tion in older adults with dysphagia: Best
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
practices in nursing care to older adults.
ORL-Head and Neck Nursing, 29, 20–21.
Metheny, N. A., Dahms, T. E., Stewart, B.
J., Stone, K. S., Edwards, S. J., Defer, J.
E., & Clouse, R. E. (2002). Efficacy of
dyestained enteral formula in detecting
pulmonary aspiration. Chest, 121, 1–6.
Metheny, N. P., Mills, A. C., & Stewart, B.
J. (2012). Monitoring for intolerance to
gastric tube feedings: A national survey.
American Journal Critical Care, 21, e33–e40.
Minei, J. P., Nathens, A. B., West, M., Har-
brecht, B. G., Moore, E. E., Shapiro, M.
B., & Maier, R. V. (2006). Inflammation
and the host response to injury, a largescale collaborative project: Patient-oriented research core
procedures for clinical care. I. Guidelines for mechanical ventilation of the
trauma patient. Journal of Trauma, 60(5),
1106–1113.
Munro, C. L., & Grap, M. J. (2004). Oral
health and care in the intensive care unit:
State of the science. American Journal of
Critical Care, 13, 65–74.
Niederman, M. S., & Craven, D. E. (2005).
Guidelines for the management of adults
with hospital acquired ventilator associated and healthcare associated pneumonia. American Journal of Respiratory Criti-
cal Care Medicine, 171, 388–416.
Sands, J. (1991). Incidence of pulmonary
aspiration in intubated patients receiving enteral nutrition through wide and
narrow-bore nasogastric feeding tubes.
Heart and Lung, 20, 75–80.
Simons, S. R., & Abdallah, L. M. (2012). Bed-
side assessment of enteral tube place-
— standard operating
ment: Aligning practice with evidence.
American Journal of Nursing, 112, 40–46.
Skoretz, S. A., Anger, N., Wellman, L., Takai,
O., Empey, A. (2020). A systematic review
of tracheostomy modifications and swallowing in adults. Dysphagia, 35, 935–947.
Splaingard, M. B., Hutchins, L., Sulton, G.,
& Chaudhuri, G. (1988). Aspiration in
rehabilitation patients: Videofluoroscopy
vs. bedside clinical assessment. Archives
of Physical Medicine and Rehabilitation, 69,
637–640.
Takahashi, K., Groher, M. E., & Michi, K.
(1994a). Methodology for detecting swallowing sounds. Dysphagia, 9, 54–62.
Takahashi, K., Groher, M. E., & Michi, K.
(1994b). Symmetry and reproducibility of swallowing sounds. Dysphagia, 9,
168–173.
Trieger, N. (2004). Oral care in the intensive
care unit. American Journal of Critical Care,
13, 24–33.
Whited, R. (1984). A prospective study of
laryngotracheal sequelae in long-term
intubation. Laryngoscope, 94(3), 367–377.
Yoshimatsu, Y., Melgaard, D., Westergren,
A., Skrubbeltrang, C., Smithard, D. G.
(2022) The diagnosis of aspiration pneumonia in older persons: A systematic
review. European Geriatric Medicine, 13(5),
1071–1080.
Zheng, Y., Sui, F., Chen, X., Zhang, G.,
Wang, X., Zhao, S., . . . Li, W. (2012). Early
versus late percutaneous dilational tracheostomy in critically ill patients anticipated requiring prolonged mechanical ventilation. Chinese Medical Journal,
125(11), 1925–1930.
Nutritional Considerations
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in Dysphagia
Katherine A. Kendall and Beverly Lorens
The importance of optimal nutrition in
the patient with dysphagia cannot be
overemphasized. Dysphagia immediately puts good nutrition at risk, and
poor nutrition may present an insurmountable obstacle to successful dysphagia rehabilitation. Although every
member of the team involved in the
care of a patient with dysphagia must
be constantly aware of the patient nutrition status, the complex management
of dietary needs in dysphagic patients
likely requires the input of a dietitian to
assess a patient’s nutrition and hydration needs and then to translate these
needs into a diet that meets texture and
consistency restrictions imposed by the
dysphagia team.
In addition to determining the calorie
and macronutrient needs of individual
patients, an important responsibility of
the dietitian is to make the diet prescribed
as appealing and palatable to a patient as
possible. Implicit in this obligation is the
recognition that eating is not an isolated
act of nutrient provision but is associated
with strong social, cultural, religious, and
other influences in patients’ lives. To the
extent possible, these influences must be
considered in evaluating and treating
the dysphagic patient.
DIETARY ASSESSMENT
INDICATIONS
From the perspective of the professionals involved in the management of
dysphagia, all patients with dysphagia
should be considered as “at risk” for
malnutrition and therefore will benefit
from a dietary assessment. Patients at
nutritional risk are more likely to experience prolonged illness and hospitalizations, require more medication, be
susceptible to infection, develop more
severe disease, and experience an increased rate of hospital readmission and
mortality (Beck etal., 2021; Feinberg et
al., 2017; Gomes etal., 2019). The positive
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
impact of an assessment performed
by a registered dietitian in patients at
nutritional risk was demonstrated in
the “Effect of Early Nutritional Support
on Frailty (EFFORT) trial” conducted
in Switzerland between 2014 and 2018.
The EFFORT trial was a randomized
multicenter study in over 2,000 patients
that demonstrated fewer complications,
fewer intensive care unit (ICU) admissions, and improved survival in hospitalized patients at risk for malnutrition
receiving nutritional support to achieve
protein and calorie goals (Schuetz et al.,
2019, 2020).
In addition to the nutritional assessment initiated at the time of dysphagia
diagnosis, a nutrition evaluation should
be implemented whenever a patient’s
means of feeding have been altered,
when such a change is anticipated,
or when there are any new concerns
about the nutrition or hydration value
of a patient’s diet (White et al., 2012).
Although some patients with dysphagia may be relatively stable in terms
of their swallowing ability, others may
experience great variability over time.
Many recent-event stroke patients,
head trauma patients, and head and
neck surgical patients will experience
improvement in swallowing function
during the period of rehabilitation.
Eventually, these patients may achieve
partial or even full recovery of function.
Patients with progressive neurogenic
conditions, such as Parkinson’s syndrome, demyelinating disease, Huntington’s chorea, amyotrophic lateral sclerosis, or multiple sclerosis, may experience
periods of stability but, in general, will
decline over time, consistent with their
disease (Goguen et al., 2006).
In some populations, changes in eating status are anticipated, and dietary
needs can be addressed before changes
in swallowing function occur. One
example of an expected intermittent
interruption of nutrition intake is the
occurrence of treatment-related nausea or mucositis (such as in a head and
neck cancer patient during adjuvant
radiation therapy), where the goal may
be to maximize nutrition or hydration
during nontreatment periods. In other
populations, the need for nutritional
assistance is acute and unanticipated.
Patients who are apparently well and
then experience a sudden insult, such
as a stroke or trauma, are examples of
this kind of population (Ahmed et al.,
2005; Fietkau et al., 1991; Koehler &
Buhl, 1991; Nyswonger & Helmchen,
1992; Raykher et al., 2007; Senft et al.,
1993).
DEFINITION OF MALNUTRITION
Current approaches to the diagnosis
of malnutrition vary widely with regard
to the diagnostic criteria used and the
specificity, sensitivity, and interrater
reliability of any given protocol. Thus,
there is no single, universally accepted
approach to the diagnosis and documentation of adult malnutrition (Jensen
et al., 2012). Many screening tools are
available and make use of a multitude
of different measurable patient parameters (Cederholm et al., 2019).
All of the currently available screening tools agree that reduced food intake
or significant disease burden and
inflammation are common etiologies
for malnutrition and should trigger a
nutritional assessment. In addition,
symptoms of anorexia and weakness also elicit concern about possible
malnutrition (Cederholm et al., 2015;
13. NUTRITIONAL CONSIDERATIONS IN DYSPHAGIA
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Detsky et al., 1987; Kondrup et al., 2003;
Rubenstein et al., 2001; Stratton et al.,
2004; White et al., 2012).
Weight loss is the most widely used
and best validated parameter in the
assessment of nutritional status. Significant changes in weight and hydration
status signal the need for a comprehensive nutritional evaluation. Guidelines
for determining the severity of unintentional weight loss are presented in
Table 13–1. In general, a person inadvertently losing 10% to 20% of their
usual weight demonstrates moderate
nutritional impairment, whereas a loss
of greater than 20% of usual weight
indicates severe nutritional impairment
(Cederholm et al., 2019; White et al.,
2012). The signs and etiologic criteria
required for a diagnosis of malnutrition as recommended by the Global
Leadership Initiative on Malnutrition
(GLIM), 2016, include greater than 5%
weight loss within the past 6 months or
greater than 10% weight loss over more
than 6 months (Cederholm et al., 2019).
In addition to weight loss, low body
mass index and reduced muscle mass
are considered signs of malnutrition.
Signs of suboptimal hydration include
rapid weight loss (a 48-hour weight loss
of 4 pounds can mean a negative fluid
balance of 2 liters), complaint of thirst,
skin turgor changes, decreased urination, change in blood chemistry such as
a rising blood urea nitrogen (BUN) level
in the absence of other renal indicators,
and an increased serum sodium level
(hypernatremia). Patients with thin liquid dysphagia may be at particular risk
for alterations in hydration status. They
will have difficulty augmenting fluid
intake to compensate for increased
fluid losses if they develop secondary
illness and are also more vulnerable
to fluid depleting conditions such as
fever, diarrhea, or increased perspiration related to heat or physical exertion.
ELEMENTS OF THE
NUTRITIONAL ASSESSMENT
Anthropometric Data
Appropriate weight range is impacted
by gender, age, height, and frame. The
patient’s usual weight, any change in
Table 13 –1. Evaluation of Weight Change
Significant
Weight Loss (%
Time
1 week
1 month
3 months
6 months
Source: Blackburn, G. L., Bistrian, B. R., Maini, B. S., Schlamm,
H. T., & Smith, M. F. (1977). Nutritional and metabolic assessment of the hospitalized patient. Journal of Parenteral and
Enteral Nutrition, 1, 15. Reprinted by permission of SAGE Pub-
lications, Inc.
of Change)
1–2
5
7.5
10
Severe Weight
Loss (% of
Change)
>2
>5
>7.5
>10
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
this amount, over what period of time,
and whether any change was intentional
must be determined (see Table 13–1).
Patients with dysphagia should have
weight monitored regularly as an ongoing indicator of nutritional status and
adequacy of dietary intake.
Presented in Table 13–2 are guidelines for interpreting nutritional status
based on percent of ideal body weight
(IBW) and percent of usual body weight
(UBW). Body mass index (BMI) is
another weight parameter that is calculated using the patient’s weight relative
to their height and is now commonly
used to determine current weight status relative to a set of normative values.
A BMI calculator is available from the
Centers for Disease Control and Prevention (CDC) on their website (www.
cdc
.gov) or from the National Institutes
of Health on their website (www.nhibi
.nih.gov). An example of a BMI chart
is shown in Figure 13–1. The National
Institutes of Health–defined weight
status based on BMI is as follows: BMI
<18.5 = underweight, BMI 18.5 to 24.9 =
desirable, BMI 25.0 to 29.9 = overweight,
BMI >30 = obese (www
.nlm.nih.gov/
medlineplus/ency/arti cle/007196.htm).
Laboratory Data
Visceral protein status is frequently
evaluated by obtaining a serum albumin value (from a blood sample, usually
requested as part of a comprehensive
metabolic panel). A value of less than
3.4 g/dL is suggestive of the patient
being at risk for protein deficiency and
is associated with an increased risk of
all-cause mortality (Baumgartner et al.,
1996; Goldwasser & Feldman, 1997;
Touma & Bisharat, 2019; Zhang et al.,
2017). Different laboratories may have
different normal ranges, and some
adjust normal range based on age.
Prealbumin can provide a more sensitive indicator of current protein status.
However, prealbumin may be lowered
in the presence of metabolic stressors,
inflammation, or infection, irrespective of nutritional state. The Academy
of Nutrition and Dietetics Evidence
Analysis Library performed a review of
albumin and prealbumin with weight
loss in a variety of medical conditions
and found that albumin and prealbumin do not always change with weight
loss and may be a better indicator of the
severity of the inflammatory response
Table 13 –2 . Evaluation of Nutritional Status Based on a
Percentage of Weight
Mild malnutrition 80–90% 85–95%
Moderate malnutrition 70–79% 75–84%
Severe malnutrition 0–69% 0–74%
Source: Koehler, J., & Buhl, K. (1991). Percutaneous endoscopic
gastrostomy for postoperative rehabilitation after maxillofacial
tumor surgery. International Journal of Oral and Maxillofacial Sur-
gery, 20, 38–39. Reprinted by permission of Elsevier.
% of Ideal
Body Weight
% of Usual
Body Weight
13. NUTRITIONAL CONSIDERATIONS IN DYSPHAGIA
Source: Adapted from Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults:The Evidence Repor t.
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Body Mass Index Table
Overweight Obese Extreme Obesity
Normal
BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54
Height
(inches) Body Weight (pounds)
58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 172 177 181 186 191 196 201 205 210 215 220 224 229 234 239 244 248 253 258
59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 178 183 188 193 198 203 208 212 217 222 227 232 237 242 247 252 257 262 267
60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 184 189 194 199 204 209 215 220 225 230 235 240 245 250 255 261 266 271 276
61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 190 195 201 206 211 217 222 227 232 238 243 248 254 259 264 269 275 280 285
62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 196 202 207 213 218 224 229 235 240 246 251 256 262 267 273 278 284 289 295
63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 203 208 214 220 225 231 237 242 248 254 259 265 270 278 282 287 293 299 304
64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 209 215 221 227 232 238 244 250 256 262 267 273 279 285 291 296 302 308 314
65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 216 222 228 234 240 246 252 258 264 270 276 282 288 294 300 306 312 318 324
66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 223 229 235 241 247 253 260 266 272 278 284 291 297 303 309 315 322 328 334
67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 230 236 242 249 255 261 268 274 280 287 293 299 306 312 319 325 331 338 344
68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 236 243 249 256 262 269 276 282 289 295 302 308 315 322 328 335 341 348 354
69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 243 250 257 263 270 277 284 291 297 304 311 318 324 331 338 345 351 358 365
70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 250 257 264 271 278 285 292 299 306 313 320 327 334 341 348 355 362 369 376
71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 257 265 272 279 286 293 301 308 315 322 329 338 343 351 358 365 372 379 386
72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 265 272 279 287 294 302 309 316 324 331 338 346 353 361 368 375 383 390 397
73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 272 280 288 295 302 310 318 325 333 340 348 355 363 371 378 386 393 401 408
74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 280 287 295 303 311 319 326 334 342 350 358 365 373 381 389 396 404 412 420
75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 287 295 303 311 319 327 335 343 351 359 367 375 383 391 399 407 415 423 431
76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287 295 304 312 320 328 336 344 353 361 369 377 385 394 402 410 418 426 435 443
Figure 13–1. BMI calculator. Adapted from Clinical Guidelines on the Identification, Evaluation, and Treatment of Over-
weight and Obesity in Adults: The Evidence Report.
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
(www.adaevidencelibrary.com/conclu
sion.cfm?conclusion_statement_id=2
51263&highlight=albumin&home=1).
Therefore, a low prealbumin value
may not, by itself, reflect compromised
protein or nutrition status. However,
inflammation is increasingly identified
as an important factor that is associated
with the risk of malnutrition. To confirm
the role of inflammation, C-reactive
protein (CRP), a positive acute phase
protein, can be measured as an indicator of stress or inflammation. If CRP is
within normal limits, then the prealbumin can be considered to reflect actual
protein status more confidently (White
et al., 2012).
Laboratory blood chemistry values
that are both commonly available and
useful for evaluating hydration status are serum sodium and blood urea
nitrogen. Elevated values are typical in
the dehydrated patient. Additionally,
albumin will be elevated in dehydration. One needs to remain mindful that
hypoalbuminemia may be masked by
mild to moderate dehydration causing hemoconcentration and a falsely
elevated albumin value. In dehydration, low urine output will occur as the
body seeks to conserve fluid. A useful caveat is never look at individual
blood results in isolation; rather, view
them together as in a composite picture
(Jensen et al., 2012; Krystofiak Russel &
Mueller, 2007).
Nutrition History
Between the time of referral and the time
the patient is evaluated by the dietitian,
it is extremely helpful to have obtained
a food diary record (i.e., a 3-day history
and up to a 7-day history of dietary
intake). The patient or caregiver is
instructed to record the time food or
drink is consumed, the amount consumed, and a description of the food and
how it was prepared, that is, steamed,
fried, or broiled (Appendix 13–A).
The amount of food should be described
using standardized measurements. For
example, a “glass” of juice might be 4,
8, 12, or even 16 ounces, depending on
the size of the container and how full it
was filled and if all was consumed. The
patient is also asked to note if this is a
typical meal pattern and, if not, how
it differs from the usual. Any nutrient
label information concerning calories
and protein per serving size should also
be included in the report. It is important to appreciate that merely recording
one’s dietary intake may alter the usual
pattern of intake.
Additional measures obtained by the
dietitian are a recent (last 24 hours) food
intake record as recalled by the patient
(referred to as a 24-hour recall) and a
food frequency list, which describes
how often the patient has had different
types of foods over a recent time period.
The history of food intake provided
by the patient or caregiver and the
translation of this information in terms
of nutrient content are, at best, only
approximate. The patient’s ability to
recall type and quantity of dietary
intake may be flawed. In addition, our
understanding of the nutrient content
of foods and the patient’s individual
nutrient requirements is not absolute.
These limitations notwithstanding,
it is still important to make the best
interpretation possible from the available information. From all measures
considered, the dietitian will compare
the patient’s dietary intake to standard
referents of dietary requirements. For
13. NUTRITIONAL CONSIDERATIONS IN DYSPHAGIA
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example, the U.S. Department of Agriculture (USDA) Center for Nutrition
Policy and Promotion (CNPP) dietary
guidelines can be accessed via their
website (https://www.cnpp.usda.gov/
dietary-guidelines).
Although nutrition recommendations
are reflective of an adequate normal diet,
textural modifications required to manage dysphagia can result in a meal that
is significantly different in character
from the standard plate, cup, and side
dish. More significantly, normal diet
recommendations focus on including
all food groups, when the textures of
some groups may not lend themselves
readily to consumption by dysphagic
patients. It should be underscored that
the establishment of nutritional needs
is an estimate and, as such, simply
provides a place to begin. Subsequent
monitoring of weight, laboratory values, and the patient’s global sense of
well-being will assist in fine-tuning the
nutrition goals.
Medical History and Lifestyle
Concurrent chronic conditions, such
as diabetes, coronary artery disease,
and renal and pulmonary impairment
that may require dietary management,
must be noted. Preexisting diet modifications may be counterproductive to
adequate nutrition or hydration in a
patient with newly developed dysphagia. A cardiac patient’s low-fat diet may
be inappropriate if the patient is unable
to consume adequate calories while
adhering to the low-fat regimen. The
initial priority for patients with dysphagia is to maintain weight. Once this
is achieved, a patient may begin incorporating lower-fat food choices if the
low-fat diet is still indicated. Similarly,
diabetic patients may need guidance
in adjusting their prior “diabetic” diet
within the new constraints of their dysphagia. Additionally, increased reliance
on pharmaceutical intervention may be
indicated if conditions such as hyperlipidemia and hyperglycemia are not
adequately controlled with diet alone.
Chronic medication use, with particular attention to food-drug interactions,
must also be evaluated.
Mental health status, and in particular recent changes in this status, must
be considered. Alterations in cognitive
skills or ability to pay attention or to
speak will affect communication and
social interaction. This can have implications for a patient’s compliance with
treatment objectives. Such changes may
also trigger depression or a diminished
sense of well-being, with resultant
decreased appetite and failure to maintain weight.
The social environment a patient is
in, or will enter upon leaving the hospital or care facility, is screened as a part
of the nutritional evaluation. In particular, a living situation that allows food
preparation is an important factor to
assess. The dysphagic patient will have
a greater diet variety if the means to
acquire appropriate foods and then prepare them to proper texture and viscosity are available. Also important to the
assessment are observations regarding
the patient’s level of isolation, dependence on others for food procurement
or preparation, current or former occupation, cultural background, and other
factors that may influence food choices
or eating.
The patient’s level of physical activity is important to the nutritional
evaluation. If activity is minimal, the
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