Speech Pathology Dysphagia eBook

Wellness & Lifestyles Australia

SWALLOWING & DYSPHAGIA & FOOD/FLUID CONSISTENCIES

E-BOOK

prepared by Sarah Ciccarello

2007,2008,2009

Table of Contents Page No. IMPORTANT NOTICE ..................................................................................................... 1 INTRODUCTION .......................................................................................................... 2 CRANIAL NERVES AND MUSCULATURE INVOLVED IN SWALLOWING............................................... 3

CRANIAL NERVES............................................................................................... 3 ANATOMICAL STRUCTURES FOR SWALLOWING (AND SPEECH) .......................................... 5 THE PHARYNX .................................................................................................. 6

THE NORMAL SWALLOW ................................................................................................ 7 OVERVIEW....................................................................................................... 7 THE ORAL PREPARATORY PHASE ............................................................................ 8 THE ORAL PHASE............................................................................................... 9 STRUCTURES INVOLVED IN THE ORAL PREPARATORY ................................................... 10 AND ORAL PHASES OF SWALLOWING....................................................................... 10 THE PHARYNGEAL PHASE.................................................................................... 11 STRUCTURES INVOLVED IN THE PHARYNGEAL PHASE OF SWALLOWING.............................. 12 THE OESOPHAGEAL PHASE .................................................................................. 13 A NORMAL SWALLOW - SUMMARY .......................................................................... 14

DYSPHAGIA .............................................................................................................. 15 SUMMARY ...................................................................................................... 15 CAUSES OF DYSPHAGIA ...................................................................................... 16 SIGNS AND SYMPTOMS OF DYSPHAGIA ..................................................................... 17 CONTRIBUTING FACTORS OF DYSPHAGIA ................................................................. 18 SAFE SWALLOWING PROCEDURES .......................................................................... 19 SAFE SWALLOWING POSITIONING .......................................................................... 19 SAFE SWALLOWING STRATEGIES............................................................................ 21

TEXTURE-MODIFICATION OF FOODS ................................................................................. 22 AND THICKENED FLUIDS ............................................................................................... 22

INTRODUCTION................................................................................................ 22 Unmodified – Regular Foods Definition ................................................................... 23 Soft Diet Definition........................................................................................... 24 Soft Diet Examples ........................................................................................... 25 Minced & Moist Diet Definition ............................................................................. 26 Minced & Moist Diet Examples.............................................................................. 27 Smooth Pureed Or Vitamised Diet Definition ............................................................ 28 Smooth Pureed Or Vitamised Diet Examples ............................................................. 29 Unmodified Fluids Definition ............................................................................... 32 Mildly Thick Fluid Definitions............................................................................... 33 Moderately Thick Fluid Definitions ........................................................................ 34 Extremely Thick Fluid Definition........................................................................... 35

SUMMARY ................................................................................................................ 36 CONTACT US ............................................................................................................ 37

MANUAL LAST MODIFIED 4/8/2010

http://www.wellnesslifestyles.com.au Ph: +61 8 8331 3000 Fax: +61 8 8331 3002

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IMPORTANT NOTICE The information provided in this document can only assist you in the most general way. This document does not replace any statutory requirements under relevant State and Territory legislation. Wellness & Lifestyles Australia (W&L) accepts no liability arising from the use of, or reliance on, the material contained in this document, which is provided on the basis that the Office of W&L is not thereby engaged in rendering professional advice. Before relying on the material, users should carefully make their own assessment as to its accuracy, currency, completeness and relevance for their purposes, and should obtain any appropriate professional advice relevant to their particular circumstances. To the extent that the material in this document includes views or recommendations of third parties, such views or recommendations do not necessarily reflect the views of the Office of W&L or indicate its commitment to a particular course of action. © Copyright Australia 2009 This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved.


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INTRODUCTION Welcome to the W&L series of eBooks. You have chosen the edition on: Swallowing and dysphagia Swallowing safety Modified foods and thickened fluids

This resource will be beneficial for those who: Want a clear and comprehensive description of the normal swallow Want a clear and comprehensive description of dysphagia, including signs and symptoms and

causes. Want a comprehensive guide to supporting those with a dysphagia, including safe meal assistance

and appropriate food and fluid consistencies Want up to date information about modified food and thickened fluid.

This eBook may provide a comprehensive overview of the normal swallow and dysphagia. Causes of dysphagia, signs and symptoms of dysphagia, contributing factors to dysphagia, safe swallowing procedures and positioning, and the role of texture modified foods and thickened fluid are also included. Anatomy and cranial nerves involved in the swallow are also included for your reference. The information provided is up to date and follows industry standard. W&L recommend that individuals with a dysphagia continue to consult their doctor and speech pathologist to ensure progress can be monitored and strategies put in place to suit individual requirements. This is to ensure maximum safety with meals and drinks, according to an individual’s level of dysphagia.


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CRANIAL NERVES AND MUSCULATURE INVOLVED IN SWALLOWING

CRANIAL NERVES There are six cranial nerves involved in swallowing (and speech). Below is a brief summary, CNV: TRIGEMINAL

Chewing (With IX) raises the larynx and pulls it forward during the pharyngeal stage of the swallow. Taste, except from the front 2/3 of the tongue. Sensation of the face, mouth and mandible (jaw).

CNVII: FACIAL

Controls the muscles of facial expression Taste to the front two-thirds of the tongue Secretions of tears and saliva

CNVIX: GLOSSOPHARYNGEAL

Secretions of saliva Taste back 1/3 of the tongue Involved in elevating the pharynx during swallowing and talking.

CNX: VAGUS

Raises the velum (With IX) innervates/powers pharyngeal constrictor muscles (With XI) innervates/powers musculature of larynx Vocal fold adduction/closure during swallowing Muscles involved in oesophageal stage of swallowing and respiration Sensation in larynx Taste

CNXI THE SPINAL ACCESSORY NERVE

Constricts the pharynx CNXII: HYPOGLOSSAL

Movement of the tongue


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Diagram taken from: Massey, B. T. (2006). Figure 2 - Origin of cranial nerves involved in swallowing, GI Motility online, accessed 27 August 2010 on

http://www.nature.com/gimo/contents/pt1/full/gimo2.html


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ANATOMICAL STRUCTURES FOR SWALLOWING (AND SPEECH) Swallowing is a complex process, which involves many muscles in the face and throat. The following is a brief summary for your reference. The oral cavity The muscles involved in chewing are innervated or powered by the trigeminal nerve. They include:

The temporalis – raises, retracts, and assists in closing the mandible (jaw). The masseter – raises, closes the mandible. The medial pterygoid – raises the mandible, assists in its closure. The lateral pterygoid – depresses (lowers), opens, protrudes (pushes forward), and lateralises (side

to side movement) the mandible. Other muscles involved in chewing include: (Lip muscles)

The obicularis oris – sphincter muscle that encircles the mouth, closes the mouth and puckers the lips when it contracts.

The zygomaticus – assists in movement of the lips, enable lips to show sadness and happiness. (Cheek muscle)

The buccinator – keeps food in contact with teeth. These muscles are innervated/powered by the facial nerve. Muscles involved in movements of the velum:

The palatoglossal – raise velum The levator veli palatini – raise velum

(Both are innervated/powered by the vagus nerve)

The tensor veli palatini – tenses the velum (This is innervated/powered by the trigeminal nerve)

The palatopharyngus – lowers the velum, constricts the pharynx The muscularis uvula – shortens the velum

(Both are innervated/powered by the spinal accessory nerve) Poor velopharyngeal closure may result in food/fluid entering the nasopharynx (and will also impact speech). While this may be unpleasant, it is not life threatening. It is important to be aware of this condition, as patients experiencing this difficulty may feel that it is a very important issue to address.


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THE PHARYNX The pharynx is divided into three parts: the nasopharynx, oropharynx and laryngopharynx.

Diagram taken from: Anatomy of the respiratory system, chapter 36, accessed 27 August 2010 on

http://fau.pearlashes.com/anatomy/Chapter%2036/Chapter%2036.htm

There are three pharyngeal recesses. Food/fluid can lodge in these recesses. They include:

The vallecula - the space or depression between the base of the tongue and the epiglottis. The two pyriform sinuses - located in the pharynx, beside the larynx. They are formed by the

shape of muscle attachments to the pharyngeal walls. The following muscles form the external layer of the pharynx:

The superior, middle, and inferior pharyngeal constrictor muscles – help move food toward the oesophagus by a stripping action. The plunger action of the tongue also plays a major role in this process.

The following make up the internal layer of the pharynx:

The stylopharyngeus muscle - elevates the larynx, elevates and dilates the pharynx The salpingopharyngeus muscle - assists in elevating pharynx

The following muscle separates the pharynx from the oesophagus:

The cricopharyngeus muscle or pharyngeal-oesophageal (P.E) segment - at the end of the pharyngeal phase of the swallow, the P.E segment relaxes, enabling the bolus (ball of food/fluid) to enter the oesophagus. Usually, the P.E segment is closed to prevent reflux of materials and to ensure air does not enter the digestive system. If the P.E. segment does not relax, food will accumulate in the pharynx and may spill over the larynx into the airway. The P.E segment is innervated/powered by the vagus nerve.


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THE NORMAL SWALLOW

OVERVIEW Swallowing is complex process that we are usually not conscious of. There are a number of processes and structures involved in swallowing, some of which are voluntary and some involuntary. As previously highlighted, there are a number of cranial nerves and musculature involved in the swallowing process. The swallowing process is usually broken down into four stages:

The oral preparatory stage (in the mouth)

The oral stage (in the mouth)

The pharyngeal stage (in the throat)

The oesophageal stage (in the oesophagus).


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THE ORAL PREPARATORY PHASE

The first stage is the oral preparation stage, where food or liquid is chewed in preparation for swallowing. Chewed food is mixed with saliva to form a cohesive ball or ‘bolus’. The bolus is kept in the front of the mouth by the tongue. The airway is open and nasal breathing occurs during this phase. Lip seal is maintained to prevent food/fluid from leaking from the mouth. Buccal (cheek) muscles are tense to prevent pocketing of food (or to prevent food getting ‘stuck’ between the cheek and teeth). This phase is voluntary, meaning that we have control of food/fluid in the oral cavity. For example, we may control how long we chew and taste our food (for example, swishing food/fluid around the mouth for a long time, or swallowing straight away). This phase may be by-passed by dropping food/fluid to the back of the throat.

Figure taken from: Dawodu, S. (2008). Swallowing disorders, emedicine, viewed 21 October 2010 on

http://emedicine.medscape.com/article/317667-overview


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THE ORAL PHASE

The second stage is the oral stage, where the tongue pushes the food or liquid to the back of the mouth, starting the swallow response. This phase is also voluntary. In this phase, the tongue moves the bolus backward, the lips are sealed to ensure food/fluid stays in the mouth, the soft palate is raised (to prevent food/fluid from entering the nasal cavity), and the epiglottis (a ‘flap’ that covers the airway during swallowing) tips down to protect the airway. The elderly may demonstrate prolonged chewing (even without a dysphagia), particularly with dentures.

Figure taken from: Dawodu, S. (2008). Swallowing disorders, emedicine, viewed 21 October 2010,



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STRUCTURES INVOLVED IN THE ORAL PREPARATORY

AND ORAL PHASES OF SWALLOWING

Lips

Open and close

Maintain labial or ‘lip’ seal to keep food, fluid and saliva in the oral cavity

Maintain oral pressure

Jaw

Rotary (around, rather than up and down) movement during mastication

Strength is required for tougher foods

Tongue

May protrude (move forward) and move laterally (side to side movement)

Pushes food toward teeth for chewing

Helps to form a cohesive bolus by mixing food and saliva

Helps to remove leftover food from gums and cheeks

Controls and holds food or fluid in preparation for swallowing

Pushes the bolus backward for swallowing

Cheeks

Tension prevents food falling in sides of mouth


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THE PHARYNGEAL PHASE The pharyngeal stage of the swallow is involuntary, which means we no longer have control over the muscles or structures pushing the food/fluid backward. It is the most critical stage of the swallow; airway closure must occur to prevent the bolus from entering the airway. A number of events occur almost simultaneously: In this phase, the soft palate closes off the nasopharynx (to prevent food/fluid from entering the nasal cavity). The hyoid and larynx rise and move forward, the epiglottis lowers and the vocal folds close to protect the airway. The cricopharyngeal sphincter opens to enable food/fluid to pass from the pharynx into the oesophagus. Contraction of the pharyngeal constrictor muscles propel the bolus toward the oesophagus. The gag reflex helps to stop aspiration. However, 40% of the population do not have a gag reflex.

Diagram taken from:

Dawodu, S. (2008). Swallowing disorders, emedicine, viewed 21 October 2010, http://emedicine.medscape.com/article/317667-overview


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STRUCTURES INVOLVED IN THE PHARYNGEAL PHASE OF SWALLOWING Important pharyngeal structures and their function during swallowing are outlined below:

Soft plate

Seals off the nasal cavity (so food/fluid does not come out of the nose).

Pharyngeal (throat) muscles

Helps to push food down toward the oesophagus

Larynx (voice box)

Closure of the larynx during swallowing protects the airway

Cricopharynx

This muscle relaxes to allow food or fluid to pass from the back of the throat (pharynx) into the oesophagus.

Peristalsis (muscle contraction) occurs when food is in the oesophagus to help push

food/fluid down into the stomach.


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THE OESOPHAGEAL PHASE

The oesophageal phase of the swallow begins once the food or fluid bolus has passed through the cricopharynx. It is an involuntary action which propels the food down to the stomach. After food enters the oesophagus, automatic wavelike movements (peristalsis) in the oesophageal muscles push food/fluid down to the stomach. The cricopharyngeal muscle closes to prevent food being regurgitated into the throat. Usually, this phase may last between eight and twenty seconds. However, in elderly individuals peristalsis may be slower. Oesophageal problems can cause the reflux of food back into the pharynx, which may cause aspiration.

Diagram taken from: Dawodu, S. (2008). Swallowing disorders, emedicine, viewed 21 October 2010,



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A NORMAL SWALLOW - SUMMARY

Diagrams taken from: Dawodu, S. (2008). Swallowing disorders, emedicine, viewed 21 October 2010,


2. Food is chewed and prepared by the tongue, jaw and lips. Fluid is also manipulated.

1. Food is chewed and prepared by the tongue, jaw and lips. Fluid is also manipulated.

3. The bolus is propelled toward and into the oesophagus. The epiglottis tips down to protect the airway.

4. Peristalsis (muscle contractions) move food toward the stomach.


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DYSPHAGIA

SUMMARY Dysphagia means swallowing difficulty. A swallowing difficulty may occur within any of the phases of swallowing. Dysphagia may involve difficulty chewing, moving food around the mouth, pushing food/fluid backward with the tongue, initiating the swallow, or pushing food/fluid toward the stomach. Dysphagia may also result in difficulties managing saliva. Dysphagia may lead to choking and can result in food, fluid or saliva passing into the lungs (aspiration) causing aspiration pneumonia. Dysphagia occurs in as many as:

45% of individuals aged over 75 years

33% of residents in acute care

66% of residents requiring long term care

40-75% of stroke residents

It is a Speech Pathologists role to assess, diagnose and manage dysphagia. Speech Pathologists may provide safe swallow strategies, and alter food/fluid consistencies to increase safety when swallowing.


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CAUSES OF DYSPHAGIA

Dysphagia is most often caused by: Stroke/CVA

50% of stroke patients acquire dysphagia at some stage. The severity of dysphagia may or may not

lessen over time. The severity of dysphagia will depend on the location and degree of damage.

Dementia

Individual’s with more advanced dementia may spit food out or forget how to swallow/use

utensils. Individuals typically require increased meal assistance as dementia progresses. Neuromuscular diseases/disorders Including:

Atrophies/dystrophies Huntington’s Chorea Myasthenia gravis Parkinson’s Disease

Dystonia Motor Neurone Disease ALS MS

Local structural defects Including:

Cancers Tumours Fistula

Medications Some medications, such as those for depression, hypertension, cancer, and Parkinson’s disease, may impact swallowing by causing drowsiness, reducing consciousness, or impairing salivation. Oesophageal disorders Including:

Reflux Motility issues Oesophageal sphincter difficulties

Other Including:

Trauma Septic Surgery Depression

Congenital Auto immune disorders Behavioural issues, e.g. hysterical


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SIGNS AND SYMPTOMS OF DYSPHAGIA

Individuals may report increased difficulties with eating

Others (nursing or care staff/family members) may notice the individual experiencing difficulties

eating.

Drooling/dribbling

Coughing/choking before/during/post food/fluid

Gurgly or wet voice post food/fluid

Multiple swallows to clear

Sneezing during or post food/fluid

Pneumonia

Pocketing food (food remaining in mouth post swallowing)

Difficulties chewing food or taking a long time to chew food

Spitting food out

Reduced level of alertness

Poor labial/lip seal

Nil or reduced gag reflex

Dysarthria (slurred speech)

Reduced ability to manipulate bolus in oral cavity/mouth

Nil or weakened cough reflex

Important note: 40% of people are silent aspirators, and therefore demonstrate no symptoms of coughing/choking. It is important to monitor patients with nil or a weakened cough reflex.


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CONTRIBUTING FACTORS OF DYSPHAGIA Level of alertness A reduced level of alertness may impact an individual’s ability to chew and swallow food/fluid safely. Individuals should only eat or drink when they are fully alert. Environment Reduce distractions General Health Reduced general wellbeing may impact an individual’s ability to swallow safely. Poor oral hygiene Poor oral hygiene may allow bacteria to breed, leading to an increased risk of infection. Posture Fully upright, with the head tilted forward offers the safest swallowing position. Use pillows to ensure an upright position if necessary. Ensure patients are not leaning to one side. Do not feed patients if their head is tilted backward – this will increase the risk of aspiration, as the airways will be more open.


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SAFE SWALLOWING PROCEDURES

CORRECT POSITIONING FOR SWALLOWING

Ensure patients are seated comfortably, fully upright, and with a slightly forward head position. This helps to reduce the risk of aspiration.

Ensure impacted sides are positioned appropriately. Use pillows to prop patients if necessary. Pillows are often useful in achieving an upright position. Ensure the head does not tilt backward – this opens the airway and increases the risk of aspiration. If in a hospital bed, request assistance to move the patient/resident upward in the bed before

raising the back. This helps to ensure a fully upright position, as the whole back, not just the neck, are positioned upright.

Remain upright for at least half an hour post food/fluid.

SAFE SWALLOWING POSITIONING The below pictures demonstrate appropriate positions for swallowing in a seated and bed environment.

Ensure residents are seated fully upright, as demonstrated in the picture.

Ensure the affected side is appropriately positioned – pillows may be useful to facilitate an upright position.

The head should be tilted slightly forward – a pillow may be useful to support this position.


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If a resident is unable to be positioned appropriately in a chair, they may require appropriate positioning in bed.

Pillows may be required on either side to ensure an upright position. The head should be tilted slightly forward – a pillow may be useful to support this position.

Residents should NEVER be in a position where the head can extend backward for eating and drinking (as displayed in the picture) – this opens up the airway and may increase the risk of aspiration.


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SAFE SWALLOWING STRATEGIES Before implementing any of the below strategies, be sure to consult a doctor and a speech pathologist. General guidelines

Ensure patient is alert & upright (90˚) with head tilted forwards and chin towards chest (chin

tuck).

Avoid distracters at meal times, concentrate on chewing and swallowing rather than talking,

watching television, etc.

Modified cutlery, crockery & non-slip mats may assist with independence of feeding.

Ensure dentures are clean and fit firmly.

Clear throat whenever voice sounds ‘wet’ or ‘gurgly’.

Resident may require daily special feeding to be undertaken by an RN or EN

Eating and drinking

Encourage patient to eat/drink slowly, take small amounts to prevent build up and rest between

mouthfuls.

Encourage the patient to chew on the stronger side of their mouth if one side is weaker.

Swallow twice after each mouthful to help clear any food that is left behind.

Alternate eating with drinking- to clear leftover food & encourage drinking between mouthfuls.

Ensure the patient has swallowed what is in their mouth before the next mouthful.

Check and clear pocketing in mouth

Cough or clear throat if voice sounds ‘wet’, ‘gurgly’ or food sticking.

Discontinue if patient fatigues, coughs excessively or fails to swallow.

Leave upright for at least thirty minutes at completion of meal/drink.

Mouth toilet at completion of every meal.

Eat with Teaspoon to limit amount taken.

Drink through a straw to help maintain ‘chin down’ position.

Avoid drinking through a straw.

Turn head to the left/right when swallowing, to stop food catching in throat.

Tilt head to the left/right when swallowing, to help food pass through throat.

Provide verbal cues to eat, swallow.


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TEXTURE-MODIFICATION OF FOODS

AND THICKENED FLUIDS

Adapted from: Dieticians Association of Australia and The Speech Pathology Association of Australia Limited (2007). Texture-modified foods and thickened fluids as used for individuals with dysphagia: Australian standardised labels and definitions. Nutrition and dietetics, 64(Suppl. 2): S53-S76.

INTRODUCTION

The ability to swallow normal food and fluid requires strong muscle control and coordination of both respiration and swallowing. Reduced control and coordination can indicate a dysphagia, which impacts an individual’s ability to swallow. As a result of dysphagia, food and fluid may require modification to ensure safety when swallowing. In individuals with dysphagia, unmodified foods may enter the lungs, causing aspiration and aspiration pneumonia. Dysphagia may result in poor nutrition and hydration, reduced well being, aspiration and poor health. Speech Pathologists may implement modified foods or fluid following assessment, forming individualised dysphagia care plans, to ensure swallowing safety. Thickened fluids slow the act of swallowing and by doing so, facilitate safer swallowing. Modified foods prepare food for swallowing and reduce the amount of chewing and effort an individual may have to put in before swallowing. Many people do not enjoy a modified diet; however, unmodified foods may impact safety during swallowing. If recommended diet plans are not completely adhered to, individuals may aspirate, as food or fluid enters the lungs, which can lead to aspiration pneumonia. Aspiration pneumonia can lead to death, and care facilities may be left liable if directives from health care professionals are not met. The following information outlines the current standardised food and fluid consistencies recommended for people with dysphagia.


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Unmodified – Regular Foods Definition

Unmodified – Regular Foods

Description

Everyday foods

Characteristics

There are various textures of regular foods Some are hard and crunchy and some are naturally soft

Food inclusions and exclusions

By definition all food and textures can be included

Unmodified

Regular Foods

Texture A

Soft

Texture B

Minced and Moist

Texture C

Smooth Pureed

Unmodified Most Modified


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Soft Diet Definition

Texture A – Soft

Description

Food may be naturally soft (e.g. ripe bananas), or may be

cooked or cut to alter its texture

Characteristics

Can be chewed but not necessarily bitten Minimal cutting is required, and can be easily broken up with a

fork Food should be moist or served with a sauce or gravy top

increase the moisture content. (NB: Sauces and gravies should be served at the required thickness level)

Refer to special notes (page S72)

Testing Information

Targeted particle size for infants and children = less than half

of that for adults and children over 5 years or equal to 0.8cm (based on tracheal size)28

Targeted particle size for children over 5 years and adults = 1.5cm x 1.5cm 10.27.30

Unmodified

Regular Foods

Texture A

Soft

Texture B

Minced and Moist

Texture C

Smooth Pureed



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Soft Diet Examples Texture A – Soft

Recommended foods and those to avoid (examples only) Foods Recommend Avoid Bread, cereals, rice, pasta, noodles

Soft sandwiches(a) with very moist fillings, for example egg and mayonnaise, hummus (remove crusts and avoid breads with seeds and grains)

Breakfast cereals well moistened with milk(b)

Soft pasta(a) and noodles Rice (well cooked) Soft pastry, for example quiche with a

pastry base Other, soft, cooked grains

Dry or crusty breads, breads with hard seeds or grains, hard pasty, pizza

Sandwiches that are not thoroughly moist Course or hard breakfast cereals that do not

moisten easily, for example toasted muesli, bran cereals

Cereals with nuts, seeds and dried fruit

Vegetables, legumes

Well cooked vegetables(a) served in small pieces or soft enough to be mashed or broken up with a fork

Soft canned vegetables, for example peas Well cooked legumes (the outer skin must

be soft), for example baked beans

All raw vegetables (including chopped and shredded)

Hard, fibrous or stringy vegetables and legumes, for example sweet corn, broccoli stalks

Fruit Fresh fruit pieces that are naturally soft, for example banana, well-ripened pawpaw

Stewed and canned fruits in small pieces Pureed fruit Fruit juice(b)

Large/round fruit pieces that pose a choking risk, for example whole grapes, cherries

Dried fruit, seeds and fruit peel Fibrous fruits, for example pineapple

Milk, yoghurt, cheese

Milk, milkshakes, smoothies(b) Yoghurt (may contain soft fruit)(b) Soft cheeses,(a) for example Camembert,

ricotta

Yoghurt with seeds, nuts, muesli or hard pieces of fruit

Hard cheeses, for example cheddar and hardened/crispy cooked cheese

Meat, fish, poultry, eggs, nuts, legumes

Casseroles with small pieces of tender meat(a)

Moist fish (easily broken up with the edge of a fork)

Eggs(a) (all types except fried) Well cooked legumes (the outer skin must

be soft), for example baked beans Soft tofu, for example small pieces,

crumbled

Dry, tough, chewy, or crispy meats Meat with gristle Fried eggs Hard or fibrous legumes Pizza

Desserts Puddings, dairy desserts,(b) custards,(b)

yoghurt(b) and ice-cream(b) (may have pieces of soft fruit)

Moist cakes (extra moisture, e.g. custard may be required)

Soft fruit-based desserts without hard bases, crumbly or flaky pastry or coconut, for example apple crumble

Creamed rice, moist bread and butter pudding

Dry cakes, pastry, nuts, seeds, coconut, dried fruit, pineapple

Miscellaneous Soup(b)—(may contain small soft lumps, e.g. pasta)

Soft fruit jellies or non-chewy lollies(a) Soft, smooth, chocolate Jams and condiments without seeds or

dried fruit

Soups with large pieces of meats or vegetables, corn, or rice

Sticky or chewy foods, for example toffee Popcorn, chips, biscuits, crackers, nuts,

edible seeds

(a) These foods require case-by-case consideration. (b) These foods may need modification for individuals requiring thickened fluids.


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Minced & Moist Diet Definition

Texture B – Minced and Moist

Description

Food is soft and moist and should easily form into a ball

Characteristics

Individual uses tongue rather than teeth to break the small

lumps in this texture Food is soft and moist and should easily form into a ball Food should be easily mashed with a fork May be presented as a thick puree with obvious lumps in it Lumps are soft and rounded (no hard or sharp lumps) Refer to special notes (page S72)

Testing Information

Recommended particle size for infants and children = 0.2 –

0.5cm (based on tracheal size)28 Recommended particle size fir children over 5 years and

adults = 0.5cm 10.27.30

Unmodified

Regular Foods

Texture A

Soft

Texture B

Minced and Moist

Texture C

Smooth Pureed



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Minced & Moist Diet Examples Texture B – Minced and Moist

Recommended foods and those to avoid (examples only) Foods Recommend Avoid (in addition to the Foods to Avoid

listed for Texture A—Soft) Bread, cereals, rice, pasta, noodles

Breakfast cereal with small moist lumps, for example porridge or wheat flake biscuits soaked in milk

Gelled bread Small, moist pieces of soft pasta, for

example moist macaroni cheese (some pasta dishes may require blending or mashing)

All breads, sandwiches, pastries, crackers, and dry biscuits

Gelled breads that are not soaked through the entire food portion

Rice that does not hold together, for example parboiled, long-grain, basmati

Crispy or dry pasta, for example edges of a pasta bake or lasagne

Vegetables, legumes

Tender cooked vegetables that are easily mashed with a fork

Well cooked legumes (partially mashed or blended)

Vegetable pieces larger than 0.5 cm or too hard to be mashed with a fork

Fibrous vegetables that require chewing, for example peas

Fruit Mashed soft fresh fruits, for example banana, mango

Finely diced soft pieces of canned or stewed fruit

Pureed fruit Fruit juice(a)

Fruit pieces larger than 0.5 cm Fruit that is too hard to be mashed with a

fork


Milk, milkshakes, smoothies(a) Yoghurt(a) (may have small soft fruit

pieces) Very soft cheeses with small lumps, for

example cottage cheese

Soft cheese that is sticky or chewy, for example Camembert


Coarsely minced, tender, meats with a sauce. Casseroles dishes may be blended to reduce the particle size

Coarsely blended or mashed fish with a sauce

Very soft and moist egg dishes, for example scrambled eggs, soft quiches

Well cooked legumes (partially mashed or blended)

Soft tofu, for example small soft pieces or crumbled

Casserole or mince dishes with hard or fibrous particles, for example peas, onion

Dry, tough, chewy, or crispy egg dishes or those that cannot be easily mashed

Desserts Smooth puddings, dairy desserts,(a)

custards,(a) yoghurt(a) and ice-cream(a)

(may have small pieces of soft fruit) Soft moist sponge cake desserts with lots

of custard, cream or ice-cream, for example trifle, tiramisu

Soft fruit-based desserts without hard bases, crumbly or flaky pastry or coconut, for example apple crumble with custard

Creamed rice

Desserts with large, hard or fibrous fruit particles (e.g. sultanas), seeds or coconut

Pastry and hard crumble Bread-based puddings

Miscellaneous Soup(a)—(may contain small soft lumps, e.g. pasta)

Plain biscuits dunked in hot tea or coffee and completely saturated

Salsa’s, sauces and dips with small soft lumps

Very soft, smooth, chocolate Jams and condiments without seeds or

dried fruit

Soups with large pieces of meats or vegetables, corn, or rice

Lollies including fruit jellies and marshmallow

(a) These foods may require modification for individuals requiring thickened fluids.


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Smooth Pureed Or Vitamised Diet Definition

Texture C – Smooth Pureed

Description

Food is smooth and lump free. It is similar to the

consistency of commercial pudding. At times, smooth pureed food may have a grainy quality, but should not contain lumps.

Refer to special notes (page S72)

Characteristics

Smooth and lump free but may have a grainy quality Moist and cohesive enough to hold its shape on a spoon (i.e.

when placed side by side on a plate these consistencies would maintain their position without ‘bleeding’ into one another

Food could be moulded, layered or piped

Testing Information

Cohesive enough to hold its shape on a spoon (i.e. when

placed side by side on a plate these consistencies would maintain their position without ‘bleeding’ into one another)

Special Note

Some individuals may benefit from the use of a runny

pureed texture. This texture would be prescribed on a case by case basis. (Runny pureed textures do not hold their shape; they bleed into one another when placed side by side on a plate

Unmodified

Regular Foods

Texture A

Soft

Texture B

Minced and Moist

Texture C

Smooth Pureed



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Smooth Pureed Or Vitamised Diet Examples Texture C – Smooth Pureed

Recommended foods and those to avoid (examples only) Foods Recommend Avoid (in addition to the Foods to Avoid

listed for Texture B—Minced and Moist) Bread, cereals, rice, pasta, noodles

Smooth lump-free breakfast cereals, for example semolina, pureed porridge

Gelled bread Pureed pasta or noodles Pureed rice

Cereals with course lumps or fibrous particles, for example all dry cereals, porridge

Gelled breads that are not soaked through the entire food portion

Vegetables, legumes

Pureed vegetables Mashed potato Pureed legumes, for example baked

beans (ensuring no husks in final puree) Vegetable soups that have been blended

or strained to remove lumps(a)

Coarsely mashed vegetables Particles of vegetable fibre or hard skin

Fruit Pureed fruits, for example commercial pureed fruits, vitamised fresh fruits

Well mashed banana Fruit Juice(a) without pulp

Pureed fruit with visible lumps


Milk, milkshakes, smoothies(a) Yoghurt(a) (lump-free), for example plain

or vanilla Smooth cheese pastes, for example

smooth ricotta Cheese and milk-based sauces(a)

All solid and semi-solid cheese including cottage cheese


Pureed meat/fish (pureed with sauce/gravy to achieve a thick moist texture)

Soufflés and mousses, for example salmon mousse

Pureed legumes, hummus Soft silken tofu Pureed scrambled eggs

Minced or partially pureed meats Scrambled eggs that have not been pureed Sticky or very cohesive foods, for example

peanut butter

Desserts Smooth puddings, dairy desserts,(a)

custards,(a) yoghurt(a) and ice-cream(a) Gelled cakes or cake slurry, for example

fine sponge cake saturated with jelly Soft meringue Cream(a), syrup dessert toppings(a)

Desserts with fruit pieces, seeds, nuts, crumble, pastry or non-pureed garnishes

Gelled cakes or cake slurries that are not soaked through the entire food portion

Miscellaneous Soup(a)—vitamised or strained to remove lumps

Smooth jams, condiments and sauces

Soup with lumps Jams and condiments with seeds, pulps or

lumps

(a) These foods may require modification for individuals requiring thickened fluids.


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Special Notes Foods and other items requiring special considerations for individuals with dysphagia

The following foods were identified as requiring emphasis

Bread

Requires the ability to both nite and chew. Chewing stress required for

bread is similar to that of a raw apple. The muscle activity required for each chew of bread is similar to that required to chew peanuts.35 For this reason, individuals who fatigue easily may find bread difficult to chew

Bread requires moistening with saliva for effective mastication. Bread does not dissolve when wet; it clumps. It poses a choking risk if it adheres to the roof of the mouth, pockets in the cheeks or if swallowed in a large clump. This is similar to the noted choking effects of ‘chunks’ of peanut butter

Ice – Cream

Is often excluded on diets for individuals who require thickened fluids.

This is because ice-cream melts and becomes like a thin liquid at room temperature or within the oral cavity

Jelly

May be excluded from diets for individuals who require thickened fluids.

this is because jelly particulates in the mouth if not swallowed promptly

Soup

Individuals who require thickened fluids will require their soups

thickened to the same consistency as their fluids unless otherwise advised by a speech pathologist

‘Mixed’ or ‘dual’ consistencies

These textures are difficult for people with poor oral control to safely

contain and manipulate within the mouth These are consistencies where there is a solid as well as a liquid present

in the same mouthful Examples include individual cereal pieces in milk, fruit punch,

minestrone soup, commercial dried fruit in juice, watermelon

Special occasion foods or fluids

These foods (e.g. chocolates, birthday cake etc) should be well planned

to ensure that they are appropriate for individuals requiring texture modified foods and / or thickened fluids

Nutritional supplements

For individuals who also require thickened fluids, nutritional

supplements may require thickening to the same level of thickness

Medication

Individuals on Texture C – Smooth Pureed are unsuitable for oral

administration of whole tablets or capsules. Consult with medical and pharmaceutical staff.

Individuals requiring any form of texture-modified food or fluids may have difficulty swallowing medications. Seek advice if in doubt


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Characteristics of foods that pose a choking risk

Stringy Rhubarb Beans Celery is considered a choking risk until 3 years of age37,38

Crunchy

Popcorn Toast Dry biscuits Chips/crisps39

Crumbly Dry cakes Biscuits39

Hard or Dry Foods

Nuts Raw broccoli Raw cauliflower Apple Crackling Hard crusted rolls / breads Seeds Raw carrots are considered a choking risk until 3 years of age37-41

Floppy Textures

Lettuce Cucumber Uncooked baby spinach leaves (adheres to mucosa when moist –

conforming material)42 Fibrous or ‘tough’ foods

Steak Pineapple39

Skins and Outer Shells

Corn Peas Apple with peel Grapes38,40,41

Round or Long Shaped

Whole grapes Whole cherries Raisins Hot dogs Sausages40,41

Chewy or Sticky

Lollies (adhere to mucosa) Cheese chunks Fruit roll ups Gummy lollies Marshmallows Chewing gum Sticky mashed potato Dried fruits36,41-43

Husks

Corn Bread with grains Shredded wheat Bran38,41

‘Mixed’ or ‘dual’ consistencies

Food that retain solids within a liquid base (e.g. minestrone soup, breakfast cereal)

watermelon


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Unmodified Fluids Definition

Unmodified – Regular Fluids

There are various thickness levels in unmodified fluids. Some are thinner (e.g. water and breast milk) and some are thicker (e.g. fruit

nectar) Unmodified – regular fluids do not have thickening agents added to them

Flow Rate

‘Very fast – fast flow’

Characteristics

Drink through any type of teat, cup or straw as is

appropriate for age and skills

Testing Information

N/A

Unmodified

Regular Fluids

Level 150

Mildly Thick

Level 400

Moderately Thick

Level 900

Extremely Thick



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Mildly Thick Fluid Definitions

Level 150 – Mildly Thick

Is thicker than naturally thick fluids such as fruit nectars, but for example, not as

thick as a thick shake

Flow Rate Steady, fast flow

Characteristics

Pours quickly from a cup but slower than regular, unmodified

fluids May leave a coating film of residue in the cup after being

poured Drink this fluid thickness from a cup Effort required to take this thickness via a standard bore straw

Testing Information

Subjectively, fluids at this thickness run fast through the

prongs of a fork, but leave a mild coating on the prongs Testing scales for viscosity exist but are not formalised or

standardised and therefore are not included

Special Notes

Breast milk or infant formula may be thickened for the

therapeutic treatment of dysphagia in infants. This fluid thickness is thinner than level 150 – Mildly Thick, however it is thicker than unmodified breast milk or infant formula. It is the same thickness as commercially available ‘Anti-regurgitation’ (AR) formula

Consideration should be given to flow through a teat as determined by case-by-case basis

Unmodified

Regular Fluids

Level 150

Mildly Thick

Level 400

Moderately Thick

Level 900

Extremely Thick



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Moderately Thick Fluid Definitions

Unmodified

Regular Fluids

Level 150

Mildly Thick

Level 400

Moderately Thick

Level 900

Extremely Thick

Level 400 – Moderately Thick

Is similar to the thickness of room temperature honey or a thickshake

Flow Rate Slow flow

Characteristics

Cohesive and pours slowly Possible to drink from a cup, although fluid flows very slowly Difficult to drink using a straw, even if using a wide bore

straw Spooning this fluid into the mouth may be the best way of

taking it

Testing Information

Subjectively, fluids at this thickness slowly drip in dollops

through the prongs of a fork Testing scales for viscosity exist but are not formalised and

are therefore not included



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Extremely Thick Fluid Definition

Unmodified

Regular Fluids

Level 150

Mildly Thick

Level 400

Moderately Thick

Level 900

Extremely Thick

Level 900 – Extremely Thick

Is similar to the thickness of pudding or mousse

Flow Rate No flow

Characteristics

Cohesive and holds its shape on a spoon It is not possible to drink this thickness using a straw Spoon is the optimal method for taking this type of fluid This fluid is too thick if the spoon is able to stand upright in

it unsupported

Testing Information

Subjectively, fluids at this thickness sit on and do not flow

through the prongs of a fork Testing scales for viscosity exist but are not formalised or

standardised and therefore are not included



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SUMMARY In summary, dysphagia can occur in any of the four stages of swallowing - chewing, propelling the food/fluid bolus toward the back of the mouth with the tongue, initiating the swallow, and moving food/fluid toward the stomach. It is important to understand that dysphagia will range in severity and impact individuals differently, thus dysphagia will require different management approaches, which will be implemented by a speech pathologist to best suit the individual. An assessment by a speech pathologist is important to ensure dysphasic individuals receive treatment to ensure safe swallowing and appropriate food and fluid consistencies, which can reduce issues, including dehydration, malnutrition, aspiration and aspiration pneumonia. Please use this resource as a guide to expand your knowledge and awareness of dysphagia and its management. W&L recommend that carers of in dividuals with dysphagia and individuals with dysphagia continue to consult their doctor and speech pathologist to ensure appropriate management is implemented, to facilitate maximum safety with meals and drinks, according to an individual's level of dysphagia. All the best for a speedy recovery, The W&L Team


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CONTACT US Wellness & Lifestyles Australia 2/59 Fullarton Road, Kent Town SA 5067 P: +61 8 8331 3000 F: +61 8 8331 3002 E: [email protected] W: www.wellnesslifestyles.com.au www.wleducation.com.au W&L services include: Physiotherapy Aged Care Funding Instrument (ACFI) Consultancy Podiatry Speech Pathology Dietetics Diabetes Education Occupational Therapy Psychology Physiotherapy Aide Diversional Therapy Aromatherapy Natural Therapies Massage Exercise Physiology Educational Training Staff Wellness Program Locum Services Medicare Billing Aged Care Funding Instrument Documentation Online Training W&L products include: Posters E-books E-learning modules Audio/visual Hot tips/articles

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