I was reminded of the problems people can experience when they have swallowing difficulties when visiting a relative in hospital a few weeks ago.
Another patient in the four bedded cubicle, Tom, reported to his nurse that he was unable to swallow pills unless they were crushed. An ensuing conversation went on for some time before the patient managed to convince his nurse that he was not delirious, nor demented, but actually the true expert on his own swallowing problems!
It became clear that for some time, Tom’s swallowing impairment had prevented him from taking medication, unless in liquid or crushed form. Visiting the hospital regularly, I got to know Tom quite well and he shared with me the harsh reality of how his quality of life had been affected by his swallowing problem. And not only this, to make matters worse, as a clinical dietitian, it was clear to me that Tom’s admission was prolonged because of his swallowing problem. In this circumstance, it meant he was unable to eat the range of protein-rich foods he so desperately needed to support the healing of his complex wounds.
For the normal healthy person, the enjoyment of eating and drinking is something that is experienced every day, many times a day. The process of swallowing is not given a second thought. However, when it comes to those with a swallowing problem, it can be all they think about.
Our bodies have been designed to transport food and fluid through the body. This process begins with the ability to safely swallow.
Swallowing involves the movement of food or fluid from the mouth, to the stomach. This movement is controlled by a number of muscles, starting with the tongue and moving down through the oesophagus and the stomach. It is all assisted with the aid of many co-contractions of complex muscle groups within the head, neck and throat.
For many New Zealanders, especially older adults, the process of moving food through their gastrointestinal system can be affected by a physiological process associated with advanced ageing. Reductions in muscle mass, muscle strength and tissue elasticity leads to slower transit of food and fluid . Ageing, along with neurological disorders, tumours, post-surgical complications and radiotherapy damage all increase the risk of swallowing difficulties. This can lead to retention of food in the mouth, an inability to chew and swallow food, tiredness, choking, coughing and aspiration, and thus, will have a major affect on a person’s nutritional status.
But what does the research tell us?
Research hot off the press published in 2017, showed over two thirds of older adults aged at least 85 years newly admitted to a New Zealand hospital were malnourished or at risk of malnutrition, and a third were at risk of dysphagia . In this study, those who were malnourished were significantly more likely to be at risk of dysphagia.
Malnutrition in older adults was prominent in further New Zealand research, where nearly half (47%) of those recently admitted to residential care were malnourished, 43% were at risk of malnutrition and 32% were at risk of dysphagia [1, 3]. Unsurprisingly, this study, along with a population-based prevalence study in independent living older people ; showed an association between malnutrition or risk of malnutrition with an impaired swallow.
The challenge for people with swallowing difficulties to meet their nutritional requirements is a constant battle.
This can be particularly difficult when thinking about protein, as while there are many non-animal based sources, for many people, a large portion of their protein intake comes in the form of meat, poultry and fish. When cooked, these foods can be dry, stringy and tough. I’m sure you can imagine the difficulty this would pose for those with swallowing problems.
Protein is particularly important for older adults.
Adequate intake, taken throughout the day, supports the maintenance of muscle mass and activities of daily living, helps the body to fight infections, and supports the body in rehabilitation. And as we mentioned earlier, the physiological processes that occur with ageing, such as difficulty chewing and swallowing, can make digesting some animal-based proteins a real struggle.
In essence, there is no nutrition in food not eaten.
Without effective fortification of foods and close monitoring, the risk of not meeting nutritional requirements for those living with a swallowing problem is high, and the link between malnutrition and swallowing difficulty is clear.
The need for effective nutrition and dysphagia screening and subsequent individualised care plans to manage this is clearly required. These should be actioned for all residents on their arrival to acute or residential care. The Pure Food Co Blogs in the next 2 months will explore malnutrition risk and dysphagia screening along with the development of care plans to treat and prevent malnutrition in older people.
Finally, in case you were wondering, despite Tom’s initial difficulties, he did finally get the support he needed for his swallowing and he was able to get back home. But, it is worth thinking about what might have happened should Tom had not been so clear and clued-in to his swallowing problem. What if Tom had a cognitive impairment or couldn’t express his concerns? His outcome may have been very different indeed.
By Kaye Dennison (NZRD) and Rebecca Watkin (NZRD)
- Wham, C., et al., Malnutrition risk of older people across district health board community, hospital and residential care settings in New Zealand. Australasian Journal on Ageing, 2017: p. 1-7.
- Popman, A., et al., High nutrition risk is associated with higher risk of dysphagia in advanced age adults newly admitted to hospital. Nutrition and Dietetics, 2017.
- Watkin, R.S., et al., Screening for nutrition risk and dysphagia among older adults recently admitted to age related residential care within the Waitemata DHB region, in Annual New Zealand Nutrition Society Conference 2016: Christchurch, New Zealand.
- Serra-Prat, M., et al., Oropharyngeal dysphagia as a risk factor for malnutrition and lower respiratory tract infection in independently living older persons: a population-based prospective study. Age & Ageing, 2012. 41(3): p. 376-381.