DYSPHAGIA
ALAS HEALTHCARE
Scope
Policy Statement
The Policy
Monitoring service users
Feeding Safety Routines
Treating Dysphagia
Medication management of adults with swallowing difficulties
Complications of dysphagia
Consent and capacity
Related Policies
Related Guidance
Training Statement
Appendix 1 Flow chart
Appendix 2 Swallowing Assessment Tool
Dysphagia is the medical term for swallowing difficulties. Some people with dysphagia have problems swallowing certain foods or liquids, while others cannot swallow at all.
Other signs of dysphagia include:
Coughing or choking when eating or drinking.
Bringing food back up, sometimes through the nose.
A sensation that food is stuck in the throat or chest.
Persistent drooling of saliva.
Over time, dysphagia can also cause symptoms such as weight loss and repeated chest infections. Other consequences of dysphagia include malnutrition, dehydration, medication management difficulties and reduced quality of life.
Causes of dysphagia
Dysphagia is usually caused by another health condition, such as:
A condition that affects the nervous system, such as a stroke, head injury, or dementia
Cancer – such as mouth cancer or oesophageal cancer
Gastro-oesophageal reflux disease (GORD) – where stomach acid leaks back up into the oesophagus
Speech and Language Therapists (SALT) can provide specialist assessment and advice on the management of dysphagia, including reducing the risk of aspiration pneumonia and choking.
Dysphagia management needs a multidisciplinary approach and must include the relevant medical practitioner, nurses and therapists involved and responsible for the care and support of the service user.
The Policy
All staff should be aware of the possibility that any service user especially those with the conditions specified above may develop a swallowing problem. Being alert to identifying whether an individual has eating, drinking or swallowing problems is the responsibility of all those involved in their care and support.
We work with and take advice from a speech and language therapist and healthcare professionals with specific training in dysphagia identification/screening to identify the signs and symptoms of dysphagia in an individual. This is done by observation from the staff as well as by using specific screening tools.
Staff will be trained to identify and support people living with dysphagia. Trained staff will carry our swallow assessments and where required, ensure that service users receive the correct modified diets. SALT plans will be followed and reviewed regularly. [AMEND AS NECESSARY]
Monitoring Service users
This starts at the initial assessment and in the planning of care and support.
Service user’s needs may change over time and monitoring and reviews are required on an ongoing basis.
Particular attention should be given to those:
Who have a history of repeated chest infections.
Cough when eating or drinking.
Have a hoarse, gurgle like or wet voice.
Do not clear food residue from their mouth.
Poor chewing ability.
Are losing weight for no other reason.
Have reduced urine output.
Are unable to sit upright.
Drooling, saliva.
Dry mouth
Have a low level of awareness or consciousness.
If swallowing difficulties are observed staff must report them immediately to their manager and record them in the service user’s care notes.
It is important to discuss what has been observed with the service user and family/carer.
A swallowing assessment should be carried out with the service users consent.
A management plan will be put in place following the “Feeding Safely Routines”.
The GP will be informed who may refer the service user for further evaluation and a detailed assessment should be made as indicated.
Feeding Safely Routines
Conscious Level – no one should be given food or drink if unconscious or semiconscious. Alternative nutritional and hydration options should be discussed with the responsible clinician.
Distraction – reduce distractions at mealtimes to facilitate concentration and awareness. This should include reducing chat and the service user should not be encouraged to talk/respond when eating or drinking. The reason for this should be explained.
Time – allow adequate time to support the individual to eat and drink. Consider the use of insulated containers to maintain the temperature of food for those people whose mealtimes may be prolonged.
Positioning – people should sit upright for all snacks, meals and drinks. People should be advised to remain sitting upright for at least 30 minutes after a meal to avoid reflux.
Oral Hygiene – it is of key importance to note that people with eating and drinking difficulty often have poor oral hygiene which can lead to a greater incidence of chest infections. Encourage a ‘clearing swallow’ or ‘saliva swallow’ to assist in clearing residue from the mouth. Cleaning teeth and the mouth at intervals during the day is advocated.
Position – Staff should position themselves at eye level to observe signs of aspiration as well as being able to provide verbal prompts and encouragement. Sitting above eye level or sitting at the side of individuals to assist with eating and drinking may have a negative impact on the individual’s ability to swallow safely as they may change their posture.
Utensils – To facilitate a safer swallow and to improve sensory awareness adapted utensils may be required.
Spectacles and hearing aids – Swallowing requires multisensory stimulation. Food should be visually appetising in its presentation and smell appealing to stimulate the appetite (and thus salivary flow) as well as increasing the amount taken. Ensuring that the individual can hear the guidance and advice being given e.g. when prompted to slow down. Similarly, an individual’s swallowing will be affected by hearing the crackle and crunch of different food consistencies. Therefore, hearing aids and spectacles need to be available and fit comfortably.
Dentition – dentures, if worn, should fit well. Be aware that some individuals prefer to eat without their dentures and softening the diet may help.
Independence – Individuals should be encouraged to feed and drink themselves to encourage and maintain functional independence. Vary the amount of assistance according to individual need (e.g. verbal prompts, loading spoon, hand over hand feeding etc).
Size of a mouthful – experimenting with the preferred size of a mouthful is important. It should be sufficient to stimulate chewing and swallowing but it is important to avoid overlarge mouthfuls.
Documentation –The amount of food and drink that has been consumed should be noted to monitor adequate nutrition and hydration. Advice on adequate nutrition and hydration can be sought from the dietician.
Portion size – people who are frail or lack stamina should be given small portions which require less energy to eat (e.g. softer and/or more moist foods). These small portions of food or drink should be given at more frequent intervals in the day
Treating dysphagia
Treatment usually depends on the cause and type of dysphagia. The type of dysphagia can usually be diagnosed after testing swallowing ability and examination of the oesophagus.
Many cases of dysphagia can be improved with treatment, but a cure is not always possible. Treatments for dysphagia include:
Speech and language therapy to learn new swallowing techniques
Changing the consistency of food and liquids to make them safer to swallow (Modified diet)
Alternative forms of feeding, such as tube feeding through the nose or stomach
Surgery to widen the narrowing of the oesophagus by stretching it or inserting a plastic or metal tube (known as a stent)
Modifying Diet
The Speech and Language team after carrying out an assessment may recommend a modified diet.
The International Dysphagia Diet Standardisation Initiative (IDDSI) has been adopted by the Royal College of Speech and Language Therapists. It recommends a hierarchy of eight textures according to need. These are defined by colour, number and name. Snacks, as well as meals, should be available in the appropriate consistency to assist in the provision of nutrition and hydration outside of mealtimes.
Modifying the diet makes chewing easier for those who are frail or with reduced masticatory skills. Modifying taste and temperature have been found to improve swallowing with some older people who may have a reduced sense of taste. Increasing the intensity of taste (e.g. with spice) can stimulate a more effective swallowing reflex. Some individuals have been found to swallow more effectively when a hot meal is interspersed with a very cold drink and vice versa.
Using thickeners to fluids can cause more difficulty with some individuals and therefore should be used with caution and only following recommendation by a dysphagia trained health care professional.
The impact of modifying diet needs to be reviewed frequently.
Resources and information on the implementation of IDDSI are available from the RCSLD website and the IDDSI website.
Medication management of adults with swallowing difficulties
Improved communication – Staff should always ask the service user whether they have difficulty swallowing medication and ask them the reason why.
GP’s should always be informed of any known swallowing difficulties and that they are taken into consideration when prescribing medication.
Medication reviews should include asking the service user if they have any problems with swallowing medication.
Community pharmacists should assess the suitability of medication formulations for individual service users and report swallowing difficulties to the prescriber
Any problems in swallowing medication must be recorded in the medication plan of care.
Staff administering medication should be aware of people who have problems swallowing their medication.
Risk assessments and GP or pharmacist guidance in the medication plan of care and MAR must be followed.
Medication Policy procedures will always be followed to ensure the safe administration of medication.
Complications of dysphagia
The main complication of dysphagia is coughing and choking, which can lead to pneumonia.
In a choking situation, the service user is reassured and encouraged to clear the blockage themselves by sitting or standing, drinking water and coughing. If the situation continues all staff have basic life support training and can respond to a choking incident. Please refer to Basic Life Support Policy.
After any choking incident, the GP should be informed or medical advice obtained in case of swelling in the nasopharyngeal tract.
Aspiration pneumonia
Aspiration pneumonia is a chest infection that can develop after accidentally inhaling something, such as a small piece of food. It causes irritation or damage to the lungs. Older people are particularly at risk of developing aspiration pneumonia.
The symptoms of aspiration pneumonia include:
A cough – this may be a dry cough or may produce phlegm that’s yellow, green, brown, or bloodstained.
A high temperature of 38C (100.4F) or over.
Chest pain.
Difficulty breathing – breathing may be rapid and shallow and the person may feel breathless, even at rest.
Symptoms of aspiration pneumonia can range from mild to severe, and it is usually treated with antibiotics. Severe cases will require hospital admission and treatment with intravenous antibiotics.
Any of the above symptoms require immediate medical intervention.
Consent and capacity
Consent must be sought before any investigation or treatment. The Mental Capacity Act 2005 applies to individuals aged 16 and over and sets out the law regarding capacity and consent. It is underpinned by 5 major principles which must be considered when assessing capacity:
A person must be assumed to have capacity unless it has been clearly established that they lack capacity regarding the specific decision under consideration at that point in time.
A person is not to be treated as unable to make a decision unless all practicable steps to help them to do so have been taken without success.
A person is not to be treated as unable to make a decision merely because they make what is considered to be an unwise decision.
An act was done, or decision made, under the Mental Capacity Act for or on behalf of a person who lacks capacity must be done, or made, in their best interests.
Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action.
It is important to remember that capacity can fluctuate with time and an individual may lack the capacity for a decision at one point in time but be able to make the same decision at a later time. If an individual is judged to lack the capacity to make a decision, then the decision should be made for them in their best interests. The Mental Capacity Act Code of Practice contains guidance on this process and emphasises the need to encourage participation. The individual should be supported to be as involved as possible in the decision and their feelings and beliefs should be taken into consideration.
Related Policies
Basic Life Support
Nutrition, Hydration and Food Safety
Oral Health
Medication
Training Statement
All staff, during induction, are made aware of the organisation’s policies and procedures, all of which are used for training updates. All policies and procedures are reviewed and amended where necessary, and staff are made aware of any changes. Observations are undertaken to check skills and competencies. Various methods of training are used, including one to one, online, workbook, group meetings, and individual supervisions. External courses are sourced as required.
Date Reviewed: October 2022
Person responsible for updating this policy:
Next Review Date: October 2023
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Appendix 1 Flow Chart
