Document Sample
Dysphagia Powered By Docstoc

Cooperative Education

    Kelsey Bratlie

      Fall 2008
      Dysphagia is a very serious symptom of many different diseases and

neurological problems such as stroke, Parkinson’s disease and Alzheimer’s

disease to name a few. Dysphagia is a difficulty in swallowing and many

complications can arise if proper precautions are not met. Therefore, it is

important to understand what dysphagia is and how it may occur. It is also

important to understand how dysphagia can be treated on a nutritional level

with a modified diet.

      Dysphagia is defined as a difficulty in swallowing or the inability to move

foods or liquids easily down the throat to the esophagus. It is a symptom that is

caused by many different disorders some of which include Parkinson’s disease,

Alzheimer’s disease, and stroke. People who have dysphagia experience pain

while swallowing and in some cases they may not be able to swallow foods or

liquids. To be able to better understand what dysphagia is and how it affects a

person, the swallowing process must be understood. In order to move food from

the mouth to the stomach, 50 muscles are used (NIDCD, 1998). The swallowing

process involves three stages. During the first stage of the swallowing process,

the “tongue moves the food around in the mouth for chewing” (NIDCD, 1998).

According to the NIDCD (1998), “Chewing makes the food the right size to

swallow and helps mix the food with saliva. Saliva softens and moistens the

food to make swallowing easy”. Once the food is prepared, swallowing is the
next stage. This is when the “tongue pushes the food or liquid to the back of the

mouth, which triggers a swallowing reflex that passes the food through the

pharynx” (NIDCD, 1998). Also, during this stage, the larynx closes tightly and

breathing stops to prevent food or liquid from entering the lungs. Once the food

passes from the mouth through the pharynx, the third stage begins. During the

third stage the food or liquid enters the esophagus. It takes only about three

seconds for the food to pass through the esophagus (NIDCD, 1998). If there is

any implication in the swallowing process, this is when dysphagia may occur.

      Dysphagia can be classified into two different classes, oropharyngeal and

esophageal. How dysphagia is classified depends on where it occurs. In

oropharyngeal dysphagia, difficulty in “emptying material from the oropharynx

into the esophagus” (Merck, 2007) occurs. Oropharyngeal dysphagia can occur

from muscular disorders or neurologic conditions such as stroke, Parkinson’s

disease or muscular dystrophy among many others. In this condition, “patients

complain of difficulty initiating swallowing, nasal regurgitation, and tracheal

aspiration followed by coughing” according to Merck (2007). Many conditions

can result from oropharyngealdysphagia that is serious. Coughing or choking

can result from the food entering the wrong pipe which can result in “poor

nutrition or dehydration, aspiration or embarrassment” (Mayoclinic, 2008).

Aspiration is very serious and results from food entering the airway instead of
the esophagus. Choking and coughing can result from aspiration and the risk for

pneumonia or other lung problems developing is great (Mayoclinic, 2008).

Symptoms of oropharyngeal dysphagia include: coughing during or after eating

or drinking, extra effort needed for chewing, food or liquid leaking from the

mouth or getting stuck in the mouth, recurring pneumonia or chest congestion

after eating, weight loss, dehydration and weakness and a voice that sounds

gurgled or wet during or after eating or drinking (Mayoclinic, 2008).

       The second classification of dysphagia is esophageal dysphagia. This can

occur from a motility disorder or mechanical obstructions. In this condition, it is

difficult to pass food down the esophagus. According to Mayoclinic (2008),

“foods or liquids “stick” in the chest or throat and sometimes come back up”.

Some conditions which lead to esophageal dysphagia include gastroesophageal

reflux disease (GERD), esophageal tumors or cancer or esophageal strictures

(Merck, 2007).

       There are many healthcare professionals involved in the diagnosis and

treatment of dysphagia. In order to diagnose dysphagia a speech language

therapist uses a bedside swallowing assessment. Other tests are also used such

as the fiber optic laryngoscopy. In this test, the healthcare professional will look

down the patients’ throat with a lighted tube (NIDCD, 1998). A video

fluoroscopy test can also be performed in which a video is taken of a patient
swallowing to view the different stages of swallowing (NIDCD, 1998). An

endoscopy test can also be used in which barium is added to different foods with

different textures. The patient will consume the food and will be monitored on

their ability to swallow the different foods (Mayo Clinic, 2008). A treatment plan

is created after the outcomes of the different tests are evaluated. Treatment can

involve changing the way in which the patient swallows or their diet. Exercises

which help strengthen the muscles involved in swallowing can also be used to

treat dysphagia.

       Altering the diet is important for people with dysphagia. The National

Dysphagia Diet (NDD) was founded to help establish a “standard terminology

and practice applications of dietary texture modification in dysphagia

management” (McCullough, Pelletier & Steele, 2003). The NDD classifies foods

according to eight different textures. There are three levels in the NDD in which

different consistencies of foods are used at the different stages. The first level,

NDD-1, is also called “Dysphagia Pureed”. The foods that are allowed in this

diet consist of “foods of “pudding-like”” consistency that are smooth or pureed

with no lumps” (Nelms, Sucher& Long, 2007, p. 439). NDD-1 requires very little

chewing for people with limited chewing ability. Foods that would not be

allowed in the NDD level one diet include foods such as “gelatin, fruited yogurt,

peanut butter, unblenderized cottage cheese, scrambled, fried or hard cooked
eggs (Nelms, p. 439). An example of a meal on this diet could consist of pureed

pork chop, mashed potatoes, pureed green beans and pureed cake.

       The next level in the National Dysphagia Diet is called “Dysphagia

Mechanically Altered” or NDD-2. This diet consists of foods that are “moist and

soft textured such as tender ground or finely diced meats, soft cooked vegetables,

soft ripe or canned fruit, and some moistened cereals” (Nelms, p. 439). This diet

includes some chewing for people who can tolerate moderate chewing. Foods

that are not recommended for this diet includes “bread, dry cake, rice, cheese

cubes, corn, and peas” (Nelms, p. 439). A sample menu for this diet could consist

of diced chicken, cooked carrots, mashed potatoes and a banana.

       The third stage of the National Dysphagia Diet (NDD-3) is called

“Dysphagia Advanced”. This diet includes “regular foods except very hard,

sticky or crunchy items. Bread, rice, cake shredded lettuce, and tender, moist

meats are allowed” (Nelms). This diet is for patients with more chewing ability.

Foods that would not be allowed in NDD-3 include “hard fruit and vegetables,

corn skins, nuts and seeds” (Nelms). An example of a menu for a Dysphagia

Advanced diet could consist of a chicken breast, baked potato, squash and a

frosted sugar cookie.

       In the National Dysphagia Diet, different levels for liquids are also used.

There are four classifications for liquids. The first level is thin, in this level all
liquids are allowed such as “water, ice, milk, milk shakes, juice, coffee, tea,

carbonated beverages, frozen desserts and gelatin” (Nelms, p 439). The next

levels are nectar-like, honey-like and spoon-thick or pudding-like. Thickening

agents are used to reach the desired consistency of the liquid. There are many

different products such as Thicken Up, Thick Set and Thick-it. The labels on

these packages contain instructions on how much thickener should be used to

reach the desired consistency.

       In order to properly treat dysphagia it is important to understand what

dysphagia is and how it can occur. Difficulty in swallowing can cause

malnutrition and other problems such as aspiration, if the proper diet is not

followed. Therefore, the National Dysphagia Diet is used and the level that will

be used will be based on the level of swallowing ability. From a nutritional

perspective, it is very important that a proper modified diet is used.

Dysphagia. (2007, October).Merck. Retrieved from the Merck website:

Dysphagia. (1998). National Institute on Deafness and Other Communication

       Disorders.Retrieved from the NIDCD website:

McCullough, G., Pelletier, C., Steele. (2003, November 4). National Dysphagia

       Diet: What to Swallow? American Speech-Language-Hearing

       Association.Retrieved from:


Nelms, S., Sucher, K., Long, S. (2007). Nutrition Therapy and Pathophysiology.

       Thomson Brooks/ Cole

Swallowing Problems. (2008). Mayo Clinic. Retrieved from the Mayo Clinic


Shared By: