Dysphagia Diet Levels Determine Medication Formulations and Guide Patient Counseling
Beverages reach the stomach within 10 seconds; solid foods make the trip in about 21 seconds. In that brief moment, sensory information shoots from the mouth to the brain and back, sending about 50 pairs of muscles into coordinated actions that enable swallowing. The pharyngeal phase of swallowing—which lasts just 1 second—has been called the most complex reflex elicited by the central nervous system.
The amazing feat of swallowing is taken for granted—until something goes wrong—and then those with dysphagia must follow special diets so they can swallow without aspirating. These patients also depend on pharmacists to find solutions so they can take the medications needed to stay healthy.
What Pharmacists Should Know About Dysphagia
Dysphagia affects more people than you might realize and the number is likely to increase because age is a significant risk factor. When researchers from Harvard reviewed information from the 2012 National Health Interview Survey, they found that 1 in 25 adults experienced swallowing problems.1 They also noted that:
- 60 percent are women.
- Average age was 52, although prevalence increases with age.
- One-third said their dysphagia was moderate; one-quarter called it a big problem.
- Stroke was the most commonly reported etiology, followed by neurologic causes.
A multitude of central nervous system, muscular, neuropathic and endocrine disorders can affect a person’s ability to swallow. However, the Mayo Foundation for Medical Education and Research lists the following primary causes of dysphagia:2
Esophageal dysphagia: Marked by food getting stuck in the base of the throat and esophagus—caused by:
- Gastroesophageal reflux disease (GERD): Damage to esophageal tissue from stomach acid causes scarring and narrowing of the lower esophagus.
- Achalasia: The lower esophageal sphincter doesn’t relax so food can’t enter the stomach.
- Diffuse spasm: Poorly coordinated muscle contractions in the esophagus inhibit motility.
- Foreign bodies: Food or other objects become lodged in the throat or esophagus.
- Esophageal ring: Thin area of narrowing in lower esophagus causes a blockage.
- Eosinophilic esophagitis: Eosinophils build up in the esophagus in reaction to allergens or reflux, resulting in blockage.
- Esophageal tumors: This type of cancer accounts for about 1 percent of all cancers in the United States.3 Radiation therapy also causes inflammation and scarring that interferes with swallowing.
Oropharyngeal dysphagia: In this type of dysphagia, weak muscles make it difficult to move food from the mouth into the throat and esophagus, often leading to aspiration and pneumonia. It’s caused by:
- Neurological damage: From a stroke or brain injury.
- Neurological disorders: Muscular dystrophy, Parkinson’s disease, multiple sclerosis and Alzheimer’s disease are a few of the neurological disorders that cause dysphagia.
- Cancer: Treatment for cancers of the head and neck cause oropharyngeal dysphagia.
Dietary Modifications for Dysphagia
Treatment for patients with dysphagia focuses on maintaining nutritional intake and preventing aspiration and subsequent pneumonia. Therapy usually takes a two-pronged approach—dietary modification and training in swallowing techniques—although pharmacologic options are available for specific patients. For example, diltiazem may improve esophageal contraction in patients with motility disorders and nitrates are recommended for achalasia.
In November 2015, the International Dysphagia Diet Standardisation Committee finalized a dysphagia diet framework that defines eight levels of food and drink according to viscosity and texture.4 Levels zero through four represent fluids, while levels three through seven are for food. They overlap at levels three and four, where moderately thick fluids and extremely thick fluids are the same as liquidized foods and pureed foods respectively. Don’t worry if it sounds complex because the three levels used prior to 2015 show how you may need to adjust medications:
- Level 1 – Pureed Diet: Alters food texture so that chewing isn’t necessary. Think of the texture of hummus or pudding, which are allowed on the diet. All foods are cooked and pureed, including meat, pasta, fruits and vegetables.5
- Level 2 – Mechanically Altered Diet: Foods are moist, soft, in small bites and easy to chew. For example, soft meats like fish, pancakes moistened with syrup, scrambled eggs, canned vegetables, canned fruits and hot cereal.6
- Level 3 – Advanced Mechanically Altered Diet: Comes close to a normal diet, adding foods such as soft meat that can be cut with a fork, eggs cooked any way, shredded cheese and fresh fruits that are soft and peeled like peaches or kiwi. Hard, sticky and crunchy foods such should be avoided.7
Formulating Medications Suitable for Dysphagia
At all three levels, the recommended beverage thickness may be thin, nectar-like, honey-like, or thick, depending on each patient’s needs. Don’t assume that medications must be liquefied because some patients need thicker fluids to avoid coughing and aspiration. When tablets are crushed or capsules opened and mixed with foods or liquids, you’ll need to determine whether absorption and potency are altered. You may also need to add flavor to the medication to ensure compliance. Patients on a level 3 diet may be able to mix small tablets with yogurt, pudding or pureed foods. Here are a few tips for counseling patients with dysphagia:
- Ask patients if they have difficulty swallowing: Only 23 percent of patients with dysphagia seek help from a health care professional and at least 10 percent simply stop taking their medications, so don’t hesitate to ask whether they have trouble swallowing their medication.8 Don’t forget that this problem isn’t limited to people with dysphagia
- Patients with dysphagia diagnosis: Ask which diet they follow and their recommended beverage viscosity—use that to guide decisions about medication formulations.
- Consider other forms: Effervescent tablets, chewable tablets, lozenges and disintegrating granules can be considered for patients with dysphagia.
- Develop single-pill solutions: Combining several APIs into a single product that can be swallowed or mixed with food improves compliance.
- Keep tablet crushers in stock: Advise patients to use tablet crushers and splitters to ensure they get the appropriate dose.
- Schedule regular medication reviews: This is especially important for older patients who are more likely to have dysphagia and often take multiple medications. As you ask about swallowing problems, you also gain information about potential adherence issues.
Patient Counseling is the Key to Medication Adherence
You already know that lack of adherence is a widespread concern even in patients who can easily swallow their medications. Add the frustration that comes with dysphagia—the risk of foods getting stuck or being forced to eat only pureed foods—and the chance of non-adherence skyrockets. People at the highest risk for dysphagia include the elderly and those who have had a stroke, but it is crucial to keep swallowing difficulties on the radar for all patients to help find solutions that work for them and you’ll significantly boost medication adherence.
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- “The Prevalence of Dysphagia Among Adults in the United States,” November 2014, http://www.ncbi.nlm.nih.gov/pubmed/25193514 ↩
- “Dysphagia,” October 2014, http://www.mayoclinic.org/diseases-conditions/dysphagia/basics/definition/CON-20033444?p=1 ↩
- “What Are the Key Statistics About Cancer of the Esophagus?” February 2016, http://www.cancer.org/cancer/esophaguscancer/detailedguide/esophagus-cancer-key-statistics ↩
- “What is the IDDSI Framework?” November 2015, http://iddsi.org/framework/ ↩
- “Dysphagia Pureed Diet – Level 1,” accessed August 2016, https://patienteducation.osumc.edu/documents/dys-1.pdf ↩
- “Dysphagia Mechanically Altered Diet – Level 2,” accessed August 2016, https://patienteducation.osumc.edu/documents/dys-2.pdf ↩
- “Dysphagia Mechanically Advanced Diet – Level 3,” accessed August 2016, https://patienteducation.osumc.edu/documents/dys-3.pdf ↩
- “Optimizing Dosage Forms for Improved Therapeutic Compliance,” March 2016, http://www.contractpharma.com/issues/2016-03-01/view_features/optimizing-dosage-forms-for-improved-therapeutic-compliance/ ↩