Beruflich Dokumente
Kultur Dokumente
2007,2008,2009
Table of Contents
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IMPORTANT NOTICE
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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 individuals level of dysphagia.
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
CNVIX: GLOSSOPHARYNGEAL
Secretions of saliva
Taste back 1/3 of the tongue
Involved in elevating the pharynx during swallowing and talking.
CNX: VAGUS
CNXII: HYPOGLOSSAL
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)
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.
THE PHARYNX
The pharynx is divided into three parts: the nasopharynx, oropharynx and laryngopharynx.
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.
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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Soft plate
Seals off the nasal cavity (so food/fluid does not come out of the nose).
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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13
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:
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
Individuals 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
Huntingtons Chorea
Myasthenia gravis
Parkinsons Disease
Dystonia
Motor Neurone Disease
ALS
MS
Cancers
Tumours
Fistula
Medications
Some medications, such as those for depression, hypertension, cancer, and Parkinsons 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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Others (nursing or care staff/family members) may notice the individual experiencing difficulties
eating.
Drooling/dribbling
Pneumonia
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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Level of alertness
A reduced level of alertness may impact an individuals 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 individuals ability to swallow safely.
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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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.
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.
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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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.
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.
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.
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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
individuals 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
Most Modified
Unmodified
Texture A
Texture B
Texture C
Regular Foods
Soft
Smooth Pureed
Everyday foods
Characteristics
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Unmodified
Most Modified
Unmodified
Texture A
Texture B
Texture C
Regular Foods
Soft
Smooth Pureed
Texture A Soft
Description
Characteristics
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
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Foods
Bread, cereals,
rice, pasta,
noodles
Vegetables,
legumes
Fruit
Milk, yoghurt,
cheese
Meat, fish,
poultry, eggs,
nuts, legumes
Desserts
Miscellaneous
(a)
(b)
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Unmodified
Most Modified
Unmodified
Texture A
Texture B
Texture C
Regular Foods
Soft
Smooth Pureed
Characteristics
Food is soft and moist and should easily form into a ball
Testing Information
26
Foods
Bread, cereals,
rice, pasta,
noodles
Vegetables,
legumes
Miscellaneous
(a)
Desserts
Meat, fish,
poultry, eggs,
nuts, legumes
Milk, yoghurt,
cheese
Fruit
stewed fruit
Pureed fruit
Fruit juice(a)
Milk, milkshakes, smoothies(a)
Yoghurt(a) (may have small soft fruit
pieces)
Very soft cheeses with small lumps, for
example cottage cheese
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
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
Soup(a)(may contain small soft lumps,
e.g. pasta)
Plain biscuits dunked in hot tea or coffee
and completely saturated
Salsas, sauces and dips with small soft
lumps
Very soft, smooth, chocolate
Jams and condiments without seeds or
dried fruit
fork
These foods may require modification for individuals requiring thickened fluids.
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Unmodified
Most Modified
Unmodified
Texture A
Texture B
Texture C
Regular Foods
Soft
Smooth Pureed
Description
Characteristics
Testing Information
Special Note
28
Foods
Bread, cereals,
rice, pasta,
noodles
Vegetables,
legumes
Fruit
Milk, yoghurt,
cheese
Meat, fish,
poultry, eggs,
nuts, legumes
Desserts
Miscellaneous
(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
Bread
May be excluded from diets for individuals who require thickened fluids.
this is because jelly particulates in the mouth if not swallowed promptly
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
Ice Cream
Jelly
Soup
Mixed or dual
consistencies
Special occasion
foods or fluids
Nutritional
supplements
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
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
Medication
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Crunchy
Crumbly
Floppy Textures
Fibrous or tough
foods
Skins and Outer
Shells
Round or Long
Shaped
Chewy or Sticky
Husks
Mixed or dual
consistencies
Rhubarb
Beans
Celery is considered a choking risk until 3 years of age37,38
Popcorn
Toast
Dry biscuits
Chips/crisps39
Dry cakes
Biscuits39
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
Lettuce
Cucumber
Uncooked baby spinach leaves (adheres to mucosa when moist
conforming material)42
Steak
Pineapple39
Corn
Peas
Apple with peel
Grapes38,40,41
Whole grapes
Whole cherries
Raisins
Hot dogs
Sausages40,41
Lollies (adhere to mucosa)
Cheese chunks
Fruit roll ups
Gummy lollies
Marshmallows
Chewing gum
Sticky mashed potato
Dried fruits36,41-43
Corn
Bread with grains
Shredded wheat
Bran38,41
Food that retain solids within a liquid base (e.g. minestrone soup,
breakfast cereal)
watermelon
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Unmodified
Most Modified
Unmodified
Level 150
Level 400
Level 900
Regular Fluids
Mildly Thick
Moderately Thick
Extremely Thick
Flow Rate
Characteristics
Testing Information
N/A
32
Unmodified
Most Modified
Unmodified
Level 150
Level 400
Level 900
Regular Fluids
Mildly Thick
Moderately Thick
Extremely Thick
Is thicker than naturally thick fluids such as fruit nectars, but for example, not as
thick as a thick shake
Flow Rate
Characteristics
Testing Information
Special Notes
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Unmodified
Most Modified
Unmodified
Level 150
Level 400
Level 900
Regular Fluids
Mildly Thick
Moderately Thick
Extremely Thick
Flow Rate
Characteristics
Slow flow
Testing Information
34
Unmodified
Most Modified
Unmodified
Level 150
Level 400
Level 900
Regular Fluids
Mildly Thick
Moderately Thick
Extremely Thick
Flow Rate
Characteristics
Testing Information
No flow
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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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