Annexes

Key question

See guideline section

1.

How should stroke patients be assessed for nutritional status in order to identify patients at risk who require nutritional intervention?

2.4

2.

In stroke patients who cannot swallow adequately, what is the evidence for the effectiveness of the following therapies?

1. facilitation exercises with or without biofeedback
2. sensory enhancement.

5.3

3.

Is there evidence that stroke patients, who are nutritionally at risk and/or dysphagic, benefit from nutritional supplementation, food fortification, or dietary advice? Specify setting.

6.1

An example standard protocol for the modified barium swallow assessment using videofluoroscopy (adapted from a published protocol): ¹⁵³

Lateral projection, patient sitting in usual position of comfort
Speech sample
Swallow 5 ml of thick liquid from a spoon
Drink thick liquid from a cup (1 swallow)
Swallow 5 ml of thin liquid from a spoon
Drink thin liquid from a cup (1 swallow)
Modifications and other liquids as appropriate
Masticate and swallow 1 teaspoon (or ¼ biscuit) formable solid food (category A) – patient seated in usual position of comfort with head in neutral position
Masticate and swallow 1 teaspoon particulate solid food (category B)
Modifications and other foods as appropriate
Postero-anterior projection, patient sitting upright with neck slightly extended if possible
Take thin liquid from a cup, hold it in the mouth, and then swallow
Modifications or other foods as appropriate
Additional swallows of thin liquid as needed for imaging the oesophagus

ORAL PHASE

NORMAL

ABNORMAL *NFR

ABNORMAL

LIQUID

PASTE

SOLID

LIP SEAL

CHEWING ACTION

ORAL CONTROL OF BOLUS

LOSS OF BOLUS TO PHARYNX

TONGUE STRIPPING ACTION

PHARYNGEAL PHASE

TRIGGERING OF SWALLOW REFLEX

RESIDUE

CRICOPHARYNGEAL FUNCTION

LARYNGEAL ELEVATION

PHARYNGEAL PHASE (ANTERO-POSTERIOR VIEW)

HEMIPARESIS

LARYNGEAL CLOSURE

RESIDUE ON VOCAL CORDS

ASPIRATION

POTENTIAL/OBSERVED (P/O) : BEFORE SWALLOW

(NORMAL = 1 P = 2 O = 3) : DURING SWALLOW

: AFTER SWALLOW

*NFR = Not Functionally Relevant
SCORING 1= Normal, abnormal/nfr*, 2-5 = abnormal (slight-severe), 6 = not attempted or not observed

Additions to standard procedure:

Further comments:

Signed:

Source: Dunnet & Sellars 1990 unpublished study. It is advised that clear criteria be established for each category of answer in order to provide rating consistency.

TEXTURE MODIFICATION - FOOD

TEXTURE

DESCRIPTION OF FOOD TEXTURE

FOOD EXAMPLES

A

• a smooth, pouring, uniform consistency
• a food that has been pureed and sieved to remove particles
• a thickener may be added to maintain stability
• cannot be eaten with a fork

• tinned tomato soup
• thin custard

B

• a smooth, uniform consistency
• a food that has been pureed and sieved to remove particles
• a thickener may be added to maintain stability
• cannot be eaten with a fork
• drops rather than pours from a spoon but cannot be piped and layered
• thicker than A

• soft whipped cream
• thick custard

C

• a thick, smooth, uniform consistency
• a food that has been pureed and sieved to remove particles
• a thickener may be added to maintain stability
• can be eaten with a fork or spoon
• will hold its own shape on a plate, and can be moulded, layered and piped
• no chewing required

• mousse
• smooth fromage frais

D

• food that is moist, with some variation in texture
• has not been pureed or sieved
• these foods may be served or coated with a thick gravy or sauce
• foods easily mashed with a fork
• meat should be prepared as C
• requires very little chewing

• flaked fish in thick sauce
• stewed apple and thick custard

E

• dishes consisting of soft, moist food
• foods can be broken into pieces with a fork
• dishes can be made up of solids and thick sauces or gravies
• avoid foods which cause choking hazard (see list of High Risk Foods)

• tender meat casseroles (approximately 1.5 cm diced pieces)
• sponge and custard

Normal

Any foods

Include all foods from “High Risk Foods” list

From the British Dietetic Association and the Royal College of Speech and Language Therapists joint document: National Descriptors for Texture Modification in Adults, 2002.¹¹⁵

HIGH RISK FOODS

Stringy, fibrous texture including pineapple, runner beans, celery, lettuce

Vegetable and fruit skins including beans (eg broad, baked, soya, black-eye), peas, grapes

Mixed consistency foods including cereals which do not blend with milk, (eg muesli), mince with thin gravy, soup with lumps

Crunchy foods including toast, flaky pastry, dry biscuits, crisps

Crumbly items including bread crusts, pie crusts, crumble, dry biscuits

Hard foods including boiled and chewy sweets and toffees, nuts and seeds

Husks including sweetcorn and granary bread

TEXTURE MODIFICATION - FLUID

TEXTURE

DESCRIPTION OF FLUID TEXTURE

FLUID EXAMPLES

Thin fluid

still water

water, tea, coffee without milk, diluted squash,spirits, wine

Naturally thick fluid

product leaves a coating on an empty glass

full cream milk, cream liqueurs, Complan, Build Up (made to instructions), Nutriment, commercial sip feeds

Thickened fluid

Stage 1 =

Stage 2 =

Stage 3 =

Fluid to which a commercial thickener has been added to thicken consistency

• can be drunk through a straw
• can be drunk from a cup if advised or preferred
• leaves a thin coat on the back of a spoon

• cannot be drunk through a straw
• can be drunk from a cup
• leaves a thick coat on the back of a spoon

• cannot be drunk through a straw
• cannot be drunk from a cup
• needs to be taken with a spoon

NHS Quality Improvement Scotland, has produced clinical standards on “Food, Fluids and Nutritional Care in Hospitals” (www.nhshealthquality.org).¹¹⁷