Introduction

Individuals may need modified consistency diets for chewing and swallowing problems. The prevalence of chewing and swallowing problems is much higher in the population of mentally retarded and developmentally disabled adults as compared to the general population. In addition, as individuals age, the prevalence of these disorders further increases. One study found that 49.4% of institutionalized severely and profoundly mentally retarded people had symptoms of dysphagia. (2)

Reflux esophagitis and gastroesophageal reflux are forms of dysphagia. One study reported that the prevalence of gastroesophageal reflux disease among institutionalized intellectually disabled individuals with an IQ < 50 is high and about 70% of them have reflux esophagitis. Factors that increase the risk of gastroesophageal reflux disease include cerebral palsy, IQ < 35, scoliosis, use of anticonvulsant drugs or benzodiazepines, not being ambulant, and dental erosions. (1)

Food and fluids should be presented to the individual in a form that is easy to swallow without risk of aspiration, contains adequate levels of nutrients, and should be served in an appetizing and appealing manner.

Without treatment, the developmentally disabled client faces the real possibilities of developing aspiration pneumonia or choking. Therefore, it is imperative that such problems are taken seriously and that a course of action is immediately implemented in the proper manner. It is important for the dietitian to be familiar with the possible chewing and swallowing difficulties that might be encountered and what could be done for individuals with these problems. It is of utmost importance that the dietitian and speech therapist work together to train other members of the healthcare team, staff, and family members regarding the appropriate dietary treatment and how to handle possible compliance issues. High functioning adults should also be taught to prepare meals of the appropriate consistency for themselves.

Chewing and Swallowing Disorders that Require Modified Consistency Diets

Missing teeth and poorly fitting dentures can make chewing more difficult. To allow the client to be able to take in adequate amounts of food for proper nutrition, softer consistency foods may be needed. Teeth allow us to be able to chew many different types of foods of different textures. Properly chewed food is swallowed easily as a bolus. Those with missing teeth or poorly fitting dentures likely will have a reduced intake of fresh fruits, vegetables, and meats since these may be more difficult to chew than other items. These foods are major dietary sources of vitamins, minerals, fiber, and protein. If this is not compensated for, nutritional status may be compromised. If not monitored by a Registered Dietitian, many individuals would choose softer more processed foods that are often high in fat and cholesterol and low in vitamin and mineral content. (3)

Many individuals with mental retardation and developmental disabilities (MR/DD) find it difficult to obtain an adequate level of dental care. Such individuals are increasingly living in community settings rather than in institutions. They often rely on Medicaid which provides little, if any, dental coverage. In addition, many dentists do not serve this population. Therefore, many such individuals are not able to obtain the optimal level of dental care. (4)

It is noted that several organizations that serve the MR/DD population have dentists and medical doctors available in their clinics. For example, Cerebral Palsy Associations of New York State, Metropolitan New York Services, offers services at five clinics throughout New York City. Also, Ohio State University offers clinic services for the MR/DD population at its Nisonger Center. The Utah State Developmental Center operates an Outpatient Dental Clinic. Several states have non-profit organizations that run outpatient clinics for these individuals.

Those with cognitive impairment or neurological impairment may need a modified consistency diet despite good dentition. Cerebral palsy, muscular dystrophy, tumors of the brain or esophagus, profound mental retardation, stroke, surviving a severe accident, and a variety of other disorders that affect mental status and cognitive function may lead to chewing and/or swallowing problems. In addition, some medications have side effects that can affect swallowing ability.

It would be helpful to use a screening tool to identify those clients who are at higher choking and aspiration risk. All health professionals could use a screening form during initial and scheduled evaluations. When a client has dysphagia, he has greater difficulty eating and drinking, and also often is not able to consume enough to maintain a healthy weight and meet his nutritional needs through a proper diet. (2)

Malnutrition may not be so evident in those clients who have always appeared thin and have normal laboratory blood work; however, low body weight may signify an underlying chewing or swallowing disorder. Constipation can result from inadequate consumption of fluids and fiber. Those who do not consume adequate amounts of calcium are at increased risk of osteoporosis, especially if they also have mobility impairments. (2)

Swallowing Difficulty

Swallowing can be broken down into two stages. During the oropharyngeal phase, the tongue and striated muscles contract and work together to mix food with saliva. The food is sent from the oral cavity through the oropharynx, where an involuntary swallowing reflex is triggered. This lasts about one second. In the posterior oropharynx, many muscles must contract and relax for swallowing to take place. The soft palate closes the nasopharynx and the pharynx moves up and forward. The epiglottis moves downward to cover the airway while the bolus of food moves into the esophagus. During the esophageal phase, there are involuntary contractions of skeletal muscles in the upper esophagus pushing the bolus of food downwards. The lower esophageal sphincter relaxes, and the food bolus enters the stomach eight to twenty seconds later. Dysphagia may result from either a disorder of the initiation of the swallowing reflex or of the propulsion of the food bolus down the esophagus. (5)

The Speech Therapist may determine from the evaluation or the physician may determine from the modified barium swallow that there is a need for the client to consume thickened liquids or a modified consistency diet. In addition, the Speech Therapist may teach the individual certain techniques to use at meals to make swallowing less difficult. The staff and family members should be made aware of this, as well as all members of the healthcare team.

The possible liquid consistencies are thin (regular, non-thickened), nectar consistency, honey consistency, or pudding consistency. Thin liquids include common items such as water, most juices, milk, and gelatin desserts. Thin liquids can be easily poured and drip off a spoon very easily. Nectar, such as apricot nectar, is naturally nectar consistency. Nectar consistency liquids can be poured, but will not flow off a spoon as easily as thin liquids would. Honey and pudding consistency liquids are not naturally occurring. Honey consistency liquids can be poured with some resistance and will drip off a spoon slowly like honey would. Pudding consistency liquids cannot be easily poured. Instead, they need to be spooned and would fall off a spoon in blobs like pudding would. If commercially pre-thickened liquids are not used, thickening agents, which are commercially available, should be added to thin fluids to thicken them to either nectar consistency, honey consistency, or pudding consistency as needed.

Those who are at high risk can develop aspiration pneumonia or choke. Aspiration pneumonia occurs when food or fluids enter the lungs. The bacteria in the food or fluids leads to a pneumonia infection. The individual needs to be hospitalized for this, and it has the potential to be fatal. A choking episode could also be fatal and measures to prevent such an occurrence such as the proper diet consistency and properly trained staff are needed.

If dysphagia progresses to the point that the individual can no longer swallow safely at all without aspirating, a tube-feeding (enteral feeding) is indicated. The individual, the family, and any living will or health care proxy needs to be consulted before this recommendation is made. Also sometimes a tube-feeding is used for those individuals who are able to take in a small amount of foods and fluids, but not enough to sustain life. In this case, the individual may receive a tube feeding in addition to meals with the hope that oral intake will be able to increase and the individual may be able to be weaned off the tube.

The individual?s treatment plan should reflect the recommendations of the Speech Therapist as well as the physician-approved diet order and diet consistency order. For those clients who are dependent upon staff people to prepare all meals, the staff people need to be trained to prepare foods of the proper texture and consistency. The training could be conducted by a Speech Therapist, Registered Dietitian, or other knowledgeable health professional.

For free living individuals, counseling about how and why to follow the modified consistency diet from the Speech Therapist and Registered Dietitian/Nutritionist is definitely needed.

Identifying High Aspiration/Choking Risk Individuals

Those clients who need to be spoon-fed should be monitored closely for any signs of chewing and/or swallowing difficulties. Staff should allow sufficient time to feed individuals without rushing them to avoid potential choking concerns.

Symptoms of dysphagia to watch for include any mealtime behaviors of coughing, choking, gagging, throat clearing, labored or gurgly breathing, the need to use multiple swallows to get the food down, very slow eating, very rapid eating, pain when swallowing, drooling at meals, throat clearing during meals, labored or gurgly breathing, frequent heartburn/acid reflux, loss of appetite, weight loss or low body weight, more than 25% of the food left over on a regular basis, a sensation of food sticking in the throat, and food remaining in the mouth after chewing and swallowing. Some of these may not necessarily occur due to dysphagia, but a qualified health professional such as a Speech Therapist or Registered Dietitian should make that determination. An isolated occurrence of any of these behaviors does not mean that the individual definitely has dysphagia, but if any of these become a pattern the individual needs to be evaluated. Some additional behaviors associated with dysphagia include altered bite reflexes, poor upper body control, poor head control, inability to feed oneself, pneumonia, tongue thrust, drooling, severe cerebral palsy, severe mental retardation, seizure disorders, and speech disorders. (2)