Pill swallowing can be daunting. In fact, one survey revealed around 40% of adults who otherwise had no swallowing problems struggled with pills. What if, on the other hand, pills themselves make food and liquid difficult to swallow – otherwise known as dysphagia?
Medication use is widespread in older people. According to a survey published in 2012, more than 80% of Australians over 50 reported taking one or more medicines within the past 24 hours. Over 40% had taken five or more medications – both prescription and complementary.
Medication side effects, particularly in aging, can cause drug-induced dysphagia. Directly or indirectly, this can result from a specific medication, a certain combination of medications or ‘polypharmacy’ – taking more than 5 medications, as is common in older people.
Dry mouth or confusion, central nervous system suppression and muscle relaxation are medication side effects that can interfere with swallowing either temporarily or persistently. Some drugs can directly damage swallowing mechanisms.
Much of this drug-induced dysphagia can be avoided by thoroughly and accurately assessing a patient’s medication use. Patients should be informed and empowered to request this from their practitioners. Where possible, unnecessary or harmful prescriptions can be eliminated or replaced with alternative or liquid medications.
Other strategies to facilitate easy swallowing include taking medications at least 30 minutes before bedtime with plenty of fluid and sitting at a 45-90-degree angle, sipping water regularly throughout the day, using a saliva substitute, and taking one pill at a time.
One study tested two further methods to help pills go down.
The first is a “pop-bottle method.” This involves filling a bottle with water, placing the tablet on your tongue and drinking the fluid and pill with a sucking motion, lips placed firmly around the bottle opening. Study participants reported swallowing large pills was 60% easier doing this than sipping water from a cup.
The next method yielded an 89% perceived improvement. Somewhat counterintuitive, this approach involves putting the pill on your tongue, taking a sip of water without swallowing, then dropping the chin down to your chest to swallow the pill.
Unavoidable dysphagia can be managed by a team including speech pathologists and dietitians to facilitate swallowing and recovery. Most importantly, nutritional needs must be addressed to avoid malnutrition and further complications, where necessary using texture-modified food.
Most of us long ago abandoned our childlike delight of playing with food; watching rapturously as it flowed through our fork, kneading it into a ball, belligerently breaking it up and squishing it through our fingers.
Some lucky adults get to do this for a living. The International Dysphagia Standardisation Initiative (IDDSI) applies such tests to determine if food is safe for people with different stages of dysphagia – including the ‘Fork Drip Test’, ‘Fork Pressure Test’, and the ‘Chopstick Test.’ What fun.
But it’s an important and serious matter for older people who suffer from stroke or other conditions that make swallowing difficult, and may choke or suffocate if food goes down the wrong way.
IDDSI was only recently launched in Australia, with support from Speech Pathology Australia. Proportion Food representatives attended the inaugural IDDSI Australian User and Industry Forum 2018.
Chief support officer for ProPortion Foods, Nikki King, says she was impressed by “the willingness for collaboration between multiple parties – speech therapists, dietitians, food service staff, management and industry.
“There was an overwhelming positivity around the need for standards from a patient safety point of view.”
Following instructions from Peter Lam and Dr Julie Cichero (IDDSI Co-Chairs), delegates and speech pathologists tested a range of foods, including ProPortion Foods’ SmartserveTM which was classified as Level 4 Puree.
Smartserve products are “soft-textured dairy desserts and snacks high in protein.” They come in 10 different flavours and are easy to open.
The IDDSI ‘Level 4 Puree’ classification – designated green – places the food in the ‘pureed’ food and ‘extremely thick’ liquid categories, comparable to the National Dysphagia Diet’s ‘Dysphagia Pureed’ category.
As with level 3 (liquidised/moderately thick), the designation overlaps between food and drink categories. Considering feedback from food service professionals, IDDSI retained separate text labels depending on whether the item is required as a food or drink.
Level 4 is measured using the fork drip test; the amount of food or liquid that flows through the fork’s prongs determines its level of thickness. Level 4 puree will remain on the fork, with some forming a “small tail” underneath.
Australia’s implementation of IDDSI, replacing currently approved Australian standards, has three phases: awareness, preparation, adoption.
Stage one, which started December 2016, was an awareness building venture amongst all relevant sectors.
Stage two, now underway as of January 2018, involves preparing and approving processes, protocols, materials and products, and training clinicians, staff and relevant stakeholders.
The recent forum marked an important step forward for Stage 2. The next step, on track for May 2019, will see the new IDDSI system introduced for commercial use, transition and integration.
Swallowing. Most of us perform this apparently simple act many times every day without a second thought.
Yet eating and swallowing is an extremely complex procedure that recruits over thirty different nerves and muscles to move food and liquid down the correct channels from mouth to stomach.
Malfunction in any aspect of this intricate operation can result in swallowing difficulties, or dysphagia, afflicting up to one in five older community-dwelling adults and around half of those living in aged care facilities.
It’s easy to lose heart when eating and drinking can’t be enjoyed as before, which can result in a vicious cycle of unintentional weight loss, malnutrition, and further despondency.
However, there are ways to keep the nutritional side of things on the bright side to avoid complications like pneumonia, dehydration and infection, and optimise health and recovery.
A team of health professionals helps manage dysphagia and navigate individuals through the act of safe swallowing and recovery, with speech pathologists at the helm and dietitians on board to carefully monitor a patient’s ability, progress and nutrition status.
In some cases, tube feeding through the nose or stomach (enteral nutrition) or directly into the blood (parenteral nutrition) is the best option to deliver or supplement with life-giving nutrients and fluid. But patients should be supported to eat and drink orally wherever possible.
Strategies for eating can include postural adjustments, swallow manoeuvres, trained feeding assistance, adaptive feeding equipment, distraction-free environment, swallow rehabilitation and texture-modified food and liquid.
Mildly to extremely thickened liquid or nectar is most commonly used for dysphagia. Thin fluids are avoided for fear of choking – therefore it is important to maintain good hydration, and watch out for dark-coloured urine, skin turgor and dry membranes.
Texture-modified foods, ranked according to their viscosity, have four levels of consistency depending on the patient’s swallowing and chewing ability.
Smooth pureed food is the easiest option. Much trial and error has been invested in getting this right – which would be obvious, for instance, if you’ve ever tried to puree green beans (hint: they’re stringy…).
The pureed food must have consistent thickness, be free from lumps and require no chewing. Examples include smooth, pureed cereals, meats, mashed potato, avocado, custard, and fruit-free yoghurt.
The next level is moist, semi-solid food that requires some chewing ability but is easily mashed with a fork. These foods can have a little texture and soft, smooth lumps, like cooked cereals, ground or cooked meat, and soft, canned fruit and vegetables.
Soft foods are allowed for more advanced swallowing and chewing ability, including well cooked vegetables, baked beans, soft or canned fruit, moist breads and rice, and tender, thinly sliced meat, fish or chicken.
Level four requires no texture modification – all foods are on the menu.
Some simple tricks can boost food’s nutrition density, like pureeing with milk or cream for extra protein and energy, and adding butter or milk powder.
And for those repelled by colourless, unidentifiable slop, advanced food manufacturing techniques now use thickeners and food moulds to enhance pureed food’s appeal while improving the nutrition profile.
One of the key management techniques for people with dysphagia is the use of texture-modified foods and thickened liquids. However, until recently, there have been different standards around the world for measuring the thickness of specialised texture-modified foods and liquids. Furthermore, the naming, ranking and colour identifiers for texture-modified foods and liquids varied from region to region.
Universal standardisation of measuring viscosity was the key reason for the formation of IDDSI – the International Dysphagia Diet Standardisation Initiative.
IDDSI was founded in 2013, with the aim of developing standardised definitions and terminology for texture-modified foods and liquids which are used for people with dysphagia. The standardisation was designed to suit all cultures and care settings.
IDDSI is run by a group of volunteers from various backgrounds, including nutrition and dietetics, speech pathology, medicine, occupational therapy, nursing, food science, engineering and technology .
IDDSI’s key goal is to develop a standardised method for naming and describing the foods and liquids used in people with dysphagia across the lifespan.
It is important for there to be measurements of food and liquids, as appropriate thickness and textures help to prevent choking for those with dysphagia. However, there was a lack of consistency across countries and cultures that made defining food and liquids difficult. IDDSI worked towards creating globally accessible definitions.
Another important step was to develop a practical measurement technique for foods and liquids that could be used by anyone, including patients, caregivers, food service companies and health practitioners.
IDDSI has two key frameworks: the measurement and definition of texture-modified food, and of thickened liquids . Food and liquids are assessed and ranked according to their viscosity. The chart below shows the rankings and names of each level. There is an overlap of foods and liquids at levels 3 and 4. The colours were chosen by IDDSI to be universally standardised, and took into account people with colour blindness and symbolic colours (e.g. red is a universal medical colour for alarm or danger) .
IDDSI’s method for measuring liquids is also known as the ‘flow test’, with ratings on a scale from 0-4. The liquid is placed in a 10ml syringe, and allowed to flow out of the nozzle for 10 seconds. The nozzle is then covered to stop the flow, and the loss of fluid from the syringe is measured.
Extremely thick liquids, or level 4, will retain 10ml, and so are best measured using the fork drip test. Moderately thick liquids, or level 3, will retain between 8-10ml. Mildly thick liquids, or level 2, will retain between 4-8ml. Finally, slightly thick liquids will retain between 1-4ml, and thin will retain 1ml or less.
In order for this test to be accurate, the correct syringe must be used. The 10ml scale must measure 61.5mm, and the nozzle needs to be a slip tip .
The IDDSI method for testing soft foods and extremely thickened drinks is also known as the ‘fork drip’ test. Texture modified foods are ranked from 3-7, as evident in the chart above.
For this test, the food is placed on a fork, and observed whether it flows through the prongs of the fork. The amount of food which flows through the fork will determine if it is suitable for levels 5, 6 or 7. For liquidised food and moderately thick drinks, or level 3, the food or liquid will drip slowly or in strands through the prongs of the fork. Pureed food and extremely thick drinks, or level 4, the food or liquid will remain in a mound on the fork, with only a small amount forming a small tail under the fork. This test assesses whether a food is sufficiently liquidised, or if a drink is sufficiently thickened .
IDDSI has video tutorials for each of these tests on their website, to guide consumers, practitioners and manufacturers.
In 2016, Speech Pathology Australia (SPA) and the Dietitians Association of Australia (DAA) ran a forum regarding the adoption of the IDDSI framework.
They believed that it has many benefits and would encourage international research efforts in dysphagia. However, there were some concerns about transitions, funding and resources. Therefore, they are continuing to use the current Australian Standards for Texture Modified Foods and Fluids at this time. A committee has been formed to plan and gather resources for implementation of IDDSI in the near future.
Although it may be a number of years away, both the SPA and DAA are working towards implementing IDDSI’s standards for measurement and classification of dysphagia food and beverages .