Like breathing, swallowing is essential to everyday life. Humans swallow at between 500-700 times a day, around three times an hour during sleep, once per minute while awake and even more during meals.
Around one million Australians have a swallowing difficulty (‘dysphagia’). Swallowing problems can occur at any stage of life. However, the knowledge of dysphagia and its implications remain largely unknown for most Australians. That is why in March each year, we celebrate Swallowing Awareness Day. It is an opportunity to bring attention to swallowing disorders and to supports that are available.
To be diagnosed with dysphagia, a speech pathologist will assess a person’s swallowing skills. Once the dysphagia diagnosis is given, our goal is usually to help that person eat and drink what they want, safely and comfortably. There is often an individual take on this goal (for some, the goal is having a beer with mates, for others the goal is to have a hot cross bun at Easter!). Speech pathologists use their knowledge and skills to help the person achieve that goal. This can involve changes to equipment, posture, swallowing technique, foods or drinks being consumed, or direct swallowing rehabilitation.
Dysphagia in adults with disabilities
For adults with disabilities, the swallowing problem is often lifelong and directly related to the person’s disability. For example there might be structural differences in the face or mouth that impact how well the person can chew food, or there might be sensory challenges around what foods a person can eat. As an adult with a disability gets older, swallowing skills can decline. The mealtime support is often focused on safety and choking risk for an adult with disability who has dysphagia, because their swallowing difficulties can be life-threatening.
Mealtimes are about more than survival!
We recognise that swallowing is essential for survival. Yet, that’s not what mealtimes are about. It is so much more! Mealtimes reflect our quality of life. Food is a way to welcome visitors, relax with friends, express culture, and celebrate. Meals create opportunities for social interactions, emotional support, and a sense of belonging.
Mealtime support for adults with disabilities
Under the NDIS scheme in Australia, speech pathologists are tasked with recommending mealtime supports for adults with disabilities. This is an important responsibility. It requires compassion, knowledge, science, reasoning, teamwork, problem solving, and time. If done well, the person with a disability will have safe and enjoyable mealtimes. Choking risk will be minimised and the person will be supported in a way that promotes their quality of life.
Our approach to mealtime assessment
We think about mealtime support as having three phases. There is the assessment, then supported decision making, followed by implementation and monitoring. Below is an outline of each step.
1. Clinical swallowing evaluation and mealtime assessment
In the first phase, the speech pathologist will complete a clinical swallowing evaluation. This involves:
- Gathering a case history
- Oral musculature assessment
- Oral trials with food and fluid
- Trialling various techniques or interventions to find out what can help
Our speech pathologists use their training in anatomy and physiology of the head and neck, plus knowledge of body structures and functions, to identify the presence of a swallowing impairment. This includes drawing conclusions about the cause and prognosis for the dysphagia.
Going further, the speech pathologist will consider the broader mealtime context. What does a “typical” mealtime look like for the person? What might be working and not working? What are the person’s mealtime-related goals, interests, concerns?
We pull all this information together to form a comprehensive picture of the person’s current mealtimes. This phase would generally be considered the “science” part of the mealtime process!
2. Supported decision making
We respect every Australian’s right to self determination. We applying this to our mealtime service through supported decision making. We bring all the information we gather from a mealtime assessment to the person, their immediate support people, and other important people in the person’s life (e.g., family, friends, other service providers). We talk about what we have seen and diagnosed. We make sure we have the right information, and that we haven’t missed anything. We work together to identify the goals of the mealtime service, and make a plan to achieve those goals. We always aim to include the person in these conversations.
It is critical that the person agrees to the mealtime support that we eventually recommend.
3. Implementation and monitoring
The final phase in our mealtime service is the implementation and monitoring phase. This is when we write up a “Mealtime Management Plan” for the person. This outlines in detail, how to support the person to have safe and enjoyable mealtimes. We ask key personnel to sign and endorse the “MMP”. We then share copies of the MMP with the client and anyone who might support them at mealtimes.
We don’t stop there. It is important that the people providing the mealtime support know what to do and why. We always offer training to paid support staff, regarding an individual’s mealtime management plan. We make sure that our recommendations are practical and realistic for paid staff to implement. We set a date to come and review the MMP, but our training will also cover “signs that things are not working” so that staff know when and how to call for help if it’s needed.
A mealtime service requires compassion, knowledge, science, reasoning, teamwork, problem solving, and time.
What are some examples of mealtime support?
The first level of support focuses on values of respect and inclusion. Recent research described the experience of adults with dysphagia and found a number of factors services as facilitators to swallowing-related quality of life. These included:
Interestingly, these factors also served as barriers to quality of life. E.g., if the person was not involved in designing their mealtimes or experienced discrimination because of their swallowing difficulty, it negatively impacted their quality of life.
The next set of supports focus on the very practical things a person can do during a mealtime, such as:
Where to go for more information:
References
| Title | Publication year |
|---|---|
| Examining the content and outcomes of training in dysphagia and mealtime management: a systematic review informing co-design of new training. | 2022 |
| Self-determination and cooperation in supported mealtimes involving people with severe ID. | 2022 |
| A review of the impact of food design on the mealtimes of people with swallowing disability who require texture-modified food. | 2022 |
| The true cost of dysphagia on quality of life: the views of adults with swallowing disability. | 2022 |
| “No! You can’t have it!” Problematising choice in institutionalised adults with intellectual disability. | 2020 |
| Feasibility and validity of using trained AHA’s to assist in mealtime monitoring dysphagia patients. | 2019 |
| People with intellectual disability and dysphagia. | 2017 |
| Prognostic models for identifying adults with intellectual disability and mealtime support needs who are at greatest risk of respiratory infection and emergency hospitalisation. | 2017 |
| The incidence of healthcare use, ill health, and mortality in adults with intellectual disabilities and mealtime support needs. | 2015 |
