Manage Swallowing Difficulties to Ensure Good Nutrition and Hydration

It is estimated that between 50–80% of people with Parkinson’s disease will develop swallowing difficulties (dysphagia) at some point. This means that over half of the people with Parkinson’s in your care are at increased risk of malnutrition, dehydration and aspiration. Problems with swallowing can also mean that the person has difficulties in taking medication which, particularly when essential to the management of other symptoms, can lead to more widespread problems and a spiral of decline.

The likelihood of developing swallowing problems increases as the disease progresses but is important to identify the signs early, so that preventative action can be taken. Any delay in identification can mean an increased risk or choking and aspiration, both of which can be potentially life threatening.

Indicators of swallowing problems/dysphagia

  • Drooling – caused by an inability to manage secretions.
  • Weight loss – due to reduced food intake as swallow deteriorates.
  • A ‘bubbly’ or ‘gurgly’ voice – due to secretions accumulating in the throat.
  • Coughing during or after swallowing – suggestive of an impaired swallow.
  • Anxiety about swallowing – based on previous difficulties.
  • Decreased ability to take medications – often an early sign as the person experiences greater difficulty taking tablets or capsules.
  • Recurrent chest infections – suggestive of aspiration.

 

Speech and Language Therapy Input

In common with communication problems, early referral to speech and language therapy is essential. For this reason it is important that all of your team understand how to identify symptoms that may indicate a difficulty with swallowing and that any concerns are shared with the person’s GP or Parkinson’s Nurse Specialist as a matter of urgency. A Speech and Language Therapist will be able to carry out a full assessment of the person’s swallowing mechanism and, if necessary, request more detailed investigations such as a barium swallow or fibre optic endoscopic evaluation of swallowing safety (FEESS) that can provide further information on the nature of the problem.

Any advice or management strategies provided by the Speech and Language Therapist should be recorded by your team in the person’s care plan and incorporated into their daily care. For example, in the case of a person prone to drooling, it is important to know that this is likely to be due to a failure to swallow regularly rather than any excess saliva production. By then reminding the person to swallow regularly, the build-up of saliva can be reduced and the drooling minimised.

The Speech and Language Therapist will be able to advise whether or not the person would benefit from a modified consistency diet to enable them to swallow more safely and easily. In order to prevent confusion about the type of diet provided, it is important that your service uses the standard descriptors used by all health professionals and approved by the NHS National Patient Safety Agency, Royal College of Speech and Language Therapists and the British Dietetic Association when discussing or recording details of a texture modified diet. The terms you should refer to are:

Category B = Thin Purée Dysphagia Diet.
Category C = Thick Purée Dysphagia Diet.
Category D = Pre-mashed Dysphagia Diet.
Category E = Fork Mashable Dysphagia Diet.

The Role of the Dietician

 In cases where the person’s swallow is so poor that maintaining their nutritional status becomes difficult, and particularly where there is already evidence of weight loss, the involvement of the Dietician is essential. A Dietician will be able to suggest strategies such as eating small, nutritionally dense meals regularly, recommending suitable snacks to be eaten between meals and advising on supplements or methods of fortifying food and drinks.

If swallowing safely becomes impossible, the use of a PEG tube may be considered. Although this is usually a last resort and may not be indicated in late-stage Parkinson’s where it is not felt to enhance the person’s quality of life, the Dietician would be responsible for planning any feeding regime and reviewing its effectiveness.

Tip: Ensure that family, friends and visitors are made aware of any swallowing problems and how this affects the type of food and drink the person may safely consume. Well-meaning visitors may bring gifts of food which could cause serious harm to the person in your care, particularly if the person has limited insight into the risks to themselves.

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