Dysphagia & Food Thickeners

Dysphagia means difficulty swallowing. It affects 16–70% of people in residential aged care (pooled prevalence 56%) and is significantly more prevalent in people with dementia (up to 84% in advanced stages). It can affect any phase of swallowing: • Oral phase: difficulty chewing or moving food/fluid to the back of the throat • Pharyngeal phase: delayed or incomplete swallowing reflex • Oesophageal phase: difficulty with food passing down the oesophagus Dysphagia is a serious clinical condition — unmanaged swallowing difficulties can lead to aspiration pneumonia, malnutrition, dehydration, choking, and death. It must be assessed by a Speech Pathologist.

🚨 Report these signs immediately to the nurse or Speech Pathologist: • Coughing or choking during or after eating/drinking • Wet, gurgly or hoarse voice during or after meals • Food or liquid coming out of the nose • Taking a very long time to eat (>30 minutes) • Refusing food or drink • Unexplained weight loss or dehydration • Recurrent chest infections or pneumonia (may indicate silent aspiration) • Drooling or food pocketing in cheeks • Complaint of food sticking in throat or chest • Facial grimacing or distress during swallowing

The International Dysphagia Diet Standardisation Initiative (IDDSI) provides a global framework for texture-modified foods and thickened fluids: FLUID LEVELS (0–4): • Level 0 — Thin: water, juice, tea, coffee (normal fluids) • Level 1 — Slightly Thick: slightly thickened — flows slower than water • Level 2 — Mildly Thick: pourable like fruit nectar, clears spoon quickly • Level 3 — Moderately Thick: pourable but slowly, like a smoothie • Level 4 — Extremely Thick: can be scooped, does not pour, falls off spoon in a mound FOOD LEVELS (3–7): • Level 3 — Liquidised: smooth with no lumps, completely pureed • Level 4 — Puréed: smooth, moist, cohesive — no chewing required • Level 5 — Minced & Moist: small, moist pieces ≤4mm wide (up to 15mm long), requires minimal chewing • Level 6 — Soft & Bite-Sized: tender, easily mashed with tongue, pieces ≤15mm • Level 7 — Regular: normal everyday foods of any texture Each person's prescribed level must be documented and followed consistently by all care staff.

Commercial thickeners are added to fluids and foods to create safe swallowing consistencies. Always follow the manufacturer's instructions and the person's prescribed level. STARCH-BASED THICKENERS: • Examples: Thick & Easy (Hormel Health Labs), Resource ThickenUp (Nestlé) • How they work: Swell in liquid over time — consistency can change as it sits • Consideration: May alter taste slightly; continue thickening if left to sit GUM-BASED THICKENERS (Xanthan gum): • Examples: Precise (Flavour Creations), Thick & Easy Clear, Resource ThickenUp Clear • How they work: Achieve and maintain target consistency rapidly, are more stable over time • Consideration: Preferred for temperature-stable and clear fluids; clearer appearance • Note: Xanthan gum thickeners should NOT be used for infants or those with galactosaemia KEY PREPARATION TIPS: ✅ Use exact measured amounts per manufacturer instructions ✅ Stir thoroughly — lumps can cause choking ✅ Allow correct resting/thickening time before serving ✅ Never add more thickener if consistency seems wrong without re-measuring ✅ Check consistency before each serve (IDDSI flow test using a fork/syringe) ✅ Discard and remake if too thick or too thin ✅ All staff preparing meals/fluids must be trained in the correct method

Safe mealtime practices for people with dysphagia: POSITIONING: • Ensure upright positioning (90°) during all meals and for 30 minutes after • Support head in midline, slightly flexed forward (chin tuck if prescribed) • Never feed a person who is drowsy, unresponsive, or poorly positioned PACE & PORTION: • Offer small amounts at a time (one teaspoon portions for high-risk residents) • Allow adequate time between swallows — never rush • Watch for coughing, wet voice, or signs of fatigue • Stop the meal if signs of aspiration occur ORAL HYGIENE: • Poor oral hygiene increases aspiration pneumonia risk — brush teeth/dentures twice daily • Oral care before and after meals reduces bacterial load in oral cavity STAFF RESPONSIBILITIES: • Follow the prescribed texture/fluid level at every meal and snack • Document meal percentage, any coughing/choking episodes, and fluid intake • Report any change in swallowing behaviour immediately • Never alter the prescribed texture level without Speech Pathologist review

Dementia affects swallowing through multiple pathways: • Loss of recognition of food or the eating process • Apraxia of swallowing — the brain cannot coordinate the complex motor sequence • Reduced oral sensitivity and chewing ability • Inattention or distractibility during meals leading to bolus accumulation • Refusal to open the mouth (food refusal) • Holding food in the mouth without swallowing (pocketing) • Increased prevalence of aspiration pneumonia — a common complication and cause of death in advanced dementia (Mitchell, 2015) As dementia progresses, decisions around artificial nutrition and hydration (e.g., PEG tubes) require sensitive family conversations guided by Advance Care Plans and the person's previously expressed wishes. Research shows PEG tubes do not improve survival or quality of life in advanced dementia. Person-centred mealtime approaches include: familiar foods, familiar crockery, eating with others, soft music, reducing distractions, and offering comfort foods.