Nutrition and Oral Medicine (Nutrition and Health)

Chapter 5 / Bidirectional Impact 77Other screening methods for dysphagia include the Burke Dysphagia Screening Test,which incorporates the individual consuming 3 oz of water, the Standardized SwallowingAssessment; the Hinds and Wiles timed test; and the Smithard et al. Bedside SwallowingAssessment (132). All of these tools look at the following similar clinical features andcontain a component with or without the administration of water. These features includeadministration of water to assess for holding, leakage, coughing, choking, breathlessness,and quality of voice (141,142). The literature reviewed indicates that a registerednurse, registered dietitian, physician, or speech–language pathologist (SLP) can performthese screenings in patients (132,133,137–140,143–148).6.4. Diagnosis of DysphagiaBedside dysphagia evaluations are performed by the SLP and help to identify patientsat risk for dysphagia and increase timely and appropriate diet and dysphagia therapy(130). The evaluation includes observation of a range of textures and consistencies,resulting in a detailed description of the clinical function of component phases of swallowing,usually accompanied by judgment of degree of dysfunction and aspiration risk(132). It must be performed by a certified SLP. Clinical assessment focuses on oral–motor and oral–sensory function, protective reflexes, and respiratory status. Observationsare made on level of arousal, cognitive–linguistic status, and perception (149).Treatment including alteration in the consistencies of foods and the use of swallowingtherapies improves swallowing function in these patients. This leads to improvements innutritional status and overall health (131).6.5. Dysphagia TreatmentOnce the presence of dysphagia is identified, treatment should commence. Goals fortreatment may include the promotion of good nutrition status, weight maintenance, diminutionof the risk of aspiration, promotion of eating independence, and enjoyment ofmealtime (150). The treatment of dysphagia typically includes oral motor exercises,swallowing techniques, positioning during feeding, and diet modification. Elmstahl et al.found in 1999 that the combination of these techniques reduced the degree of oral andpharyngeal dysfunction in acute stroke patients. This in turn led to improved nutritionstatus, as indicated by increases in albumin and total iron-binding capacity (131).6.6. Diet ManagementEating and drinking have important social, cultural, and emotional meaning in allsocieties (151,152). Initiating safe oral nutrition and hydration is a priority for patientswith dysphagia (140). A diet order is recommended once the degree of dysphagia isassessed. Modifications in diet can include changes in food consistencies and/or liquidconsistencies, or even elimination of intake by mouth and initiation of tube feeding.Liquid or pureed foods are sometimes the only consistency tolerated by patients withmechanical disorders that cause dysphagia but may not be the most appropriate choicefor individuals with oropharyngeal dysphagia. Semisolid consistencies that are easy tochew are more often the best choices in this population (153). Cohesive foods that aremoist are easier to manage for most individuals with dysphagia (150). Liquids often haveto be thickened to decrease transit time and allow for protection of the airway (150,153).The patient should take nothing by mouth if aspiration is present. Withholding oral intake