Dysphagia Passport

Dysphagia Passport

DYSPHAGIA PASSPORT

Eating, Drinking and Swallowing Information

This passport belongs to

Name:____________________________________________

THIS PASSPORT CONTAINS IMPORTANT INFORMATION ABOUT YOUR EATING AND DRINKING. PLEASE HAVE IT ACCESSIBLE AT ALL TIMES. BRING IT WITH YOU IF YOU ARE ADMITTED TO HOSPITAL.

Provided by Worcestershire Acute Hospitals NHS Trust and Worcestershire Health and Care NHS Trust

INTRODUCTION

This booklet gives information about your eating and drinking recommendations. It also provides general advice for safer eating and drinking.

Please present this booklet at relevant hospital admissions, appointments or home visits.

USEFUL CONTACTS

Worcestershire Acute Hospitals NHS Trust

ACUTE SPEECH AND LANGUAGE THERAPY

Tel: 01905 760475.  Email: [email protected]

The below contacts are within Worcestershire  Health and Care NHS Trust

COMMUNITY ADULT SPEECH AND LANGUAGE THERAPY 

Tel: 01905 681049.  Email: [email protected]

INPATIENT STROKE SPEECH AND LANGUAGE THERAPY

Evesham Community Hospital

Tel: 01386 502098. Email: [email protected]

COMMUNITY STROKE SPEECH AND LANGUAGE THERAPY

North Tel: 01527 488188       South Tel: 01386 502355

Email: [email protected]

COMMUNITY LEARNING DISABILITY SPEECH AND LANGUAGE THERAPY

North Tel: 01527 488555       South: 01905 520555

Email: [email protected]

DYSPHAGIA INTERVENTION RECORD – to be completed by your Speech and Language Therapist (SLT)

Date   o  Please select	Recommendations:	Name       Signature Location
Date     o  Assessment   o  Review   o  Final Review   o  Eating and drinking with acknowledged risk *
Date     o  Assessment   o  Review   o  Final Review   o  Eating and drinking with acknowledged risk *

DYSPHAGIA INTERVENTION RECORD – to be completed by your Speech and Language Therapist (SLT)

Date   o  Select one	Recommendations:	Name       Signature Location
Date   o  Assessment   o  Review   o  Final Review o  Eating and drinking with acknowledged risk *
Date   o  Assessment   o  Review   o  Final Review o  Eating and drinking with acknowledged risk *

* Eating and drinking with acknowledged risk (EDAR) replaces the previous term feeding at risk. Information on EDAR will be provided by relevant professionals e.g. doctor, speech and language therapist (SLT).

ADVICE TO ENCOURAGE SAFER EATING AND DRINKING

• You should be alert when eating and drinking. Do not have food or drink when drowsy or less awake.

Positioning

• Preferably sit upright in a chair to eat and drink. Keep sitting upright for at least 30 minutes after a meal to reduce risk of reflux.
• Avoid leaning to the side or being slumped over. Use pillows, if needed, to support you to sit in an upright position.
• Your head and chin should be in a central position, not tipped sideways, backwards or forwards.
• If you cannot achieve or maintain a central upright position, then optimise your best tolerated position.

Mouth Care

• Your mouth should be clean and moist.  If you usually have a dry mouth, discuss this with your Speech and Language Therapist (SLT).
• If you have dentures, they should be worn while eating (provided they fit well).  You may wish to consider dental fixative. 
• Ensure mouth, teeth and/or dentures are cleaned at least twice daily.

Pacing

• Take the time you need, do not rush.
• Swallow each mouthful before taking the next. Don’t overfill your mouth.
• Take a single sip at a time. Don’t gulp the drink.

Utensils

• Use normal cups and beakers unless recommended. Your SLT will advise if it is appropriate to use straws, spouted cups or adapted drinks containers.
• Equipment that makes eating and drinking easier may be helpful (e.g. plate guards, adapted cups and cutlery, non-slip mats). This equipment can be bought online, or you could speak to an occupational therapist.

WHAT ARE SWALLOWING PROBLEMS?

Swallowing problems are known as dysphagia which can affect the ability to eat and drink. 

Changing food and drink consistency

• Modified textures (consistencies) may help you swallow more easily and safely.   Your SLT will assess your swallow and let you know the most beneficial  consistencies  of food and drink for you.  This may change over time and the most recent advice should be recorded in this booklet.

• This reduces the likelihood of food and/or drinks going the ‘wrong way’ and entering the lungs (aspiration), rather than the stomach.  This can result in coughing, choking or chest infections.

• Altered food and drink consistencies are given labels called ‘Levels’ with a number (eg: Level 1). This helps you know what consistency of food and drink is safest.  This labelling system is called the International Dysphagia Diet Standardisation Initiative (IDDSI). You can find out more about IDDSI on this website https://iddsi.org/.

THE IDDSI FRAMEWORK

THICKENED FLUIDS

When you have a drink the liquid moves very quickly in your mouth and can be hard to control.

Imagine how difficult it is to hold water in your hands – it runs everywhere!  Then imagine how much easier it is to hold custard or yoghurt.  Thicker textures move more slowly so you can control them better.

This is the same for when you have a drink in your mouth.  Adding a thickening powder makes the drink move slower, and so is easier and safer to swallow.

How to thicken drinks?

There are different brands of thickener. You need to refer to the instructions on your thickener container to make the consistency recommended by your SLT.

The number of scoops is a guideline. Some drinks will thicken more than others. It is more important to achieve the correct consistency.

IDDSI Level 1: slightly thick drinks Looks like: thin syrup.   Thicker than water Requires a little more effort to drink than thin liquids Flows through a straw or syringe
IDDSI Level 2: mildly thick Looks like: cough syrup.   Flows off a spoon Sippable, pours quickly from a spoon, but slower than thin drinks Mild effort is required to drink this thickness through standard bore straw (standard bore straw = 0.209 inch or 5.3 mm diameter)
IDDSI Level 3: moderately thick Looks like: pouring custard.   Can be drunk from a cup or eaten with a spoon but cannot be eaten with a fork because it drops through the prongs. Will not hold its shape on a spoon , pours slowly off a spoon Cannot be piped, layered or moulded Smooth texture, with no lumps, fibres, bits of shell, skin or husk.  Difficult to suck through a standard bore or wide bore straw (wide bore straw = 0.275 inch or 6.9mm)
IDDSI Level 4: extremely thick  Looks like: mousse.   Holds shape on spoon Flows very slowly under gravity Does not require chewing Could be piped, layered or moulded No lumps Falls off spoon in a single spoonful when tilted and continues to hold a shape on a plate Cannot be sucked through a straw Not sticky Liquid does not separate from solid

TEXTURE MODIFIED FOOD

Food consistency changes may be recommended by your SLT. 

How to modify food textures

Each IDDSI level comes with descriptions for how they should be prepared. Brief descriptions for each level can be found at the top of each page in this booklet. More detailed information can be found in our specific IDDSI level food leaflets or on the IDDSI website:

https://iddsi.org/framework/IDDSI-framework.

IDDSI Level 3: liquidised   Smooth, no bits or lumps. Does not need chewing. Cannot be piped, layered or moulded on a plate. Cannot be eaten with a fork. Can be eaten with a spoon or drunk from a cup.  

IDDSI Level 4: purée   Thick and smooth. Holds its shape and can be eaten with a fork or spoon. A ‘drip’ may fall through the fork and form a ‘tail’. It can be piped, layered or moulded. Should not separate into liquid and solid components. It cannot be poured, cannot be drunk from a cup, cannot be sucked through a straw. No bits or lumps.  

IDDSI Level 5: minced and moist   Soft, moist and tender. Can be eaten with fork or spoon. No liquid should drip from fork or spoon. Finely mashed/minced to approximately 4mm pieces).  Can be mashed with pressure from fork. Does not need biting. Requires very little chewing. Not hard, chewy, dry, or crumbly.  

IDDSI Level 6: soft and bite-sized   No bread. Soft, moist and tender. Max. 1.5cm x 1.5cm pieces. Can be eaten with fork, spoon or chopsticks. Needs some chewing.  Should be soft enough that it can be broken up easily with a fork and does not return to its original shape. Does not require biting. Does not need to be cut with a knife. Liquid should not separate.  

IDDSI Level 7EC: easy to chew   Needs some chewing. May require biting. Can be easily cut with the side of a fork. Is soft and tender. May include mixed consistencies unless otherwise specified. Can include bread unless otherwise specified. Does NOT include high-risk foods unless specified.  

IDDSI Level 4: Pureed food

• Food is of a thick smooth consistency. 
• Holds its shape on a plate or when scooped. Can be eaten with a fork or spoon.
• It should slide easily off the spoon or fork (not stick to the utensil), and hold its shape on a plate.
• When scooped onto the fork, most of the food should sit in a mound or pile on the fork. Chop sticks are not suitable for this texture.
• When pushed with a fork, it should retain the indentation.
• A very small amount ( a ‘drip’) may fall through the fork and form a ‘tail’ below the fork.
• The food should not flow, dollop or drip continuously through the prongs.
• It can be piped, layered or moulded.
• Should not separate into liquid and solid components.
• It cannot be poured, drunk from a cup, or sucked through a straw.
• No bits or lumps – you may need to sieve the food to achieve this.
• It does not need chewing.
• Do not give pre-packaged baby food as the sole source of nutrition as it does not contain the correct nutritional content for an adult.

Food preparation:

• Use a blender, liquidiser or push through a sieve.
• Avoid skins, nuts, pips or seeds, bones, gristle & cartilage as they do not puree well.
• You can add extra moisture to food to help make a smooth puree texture when blending.   (e.g. white sauce, cheese sauce, gravy, tomato based sauce, milk, cream, custard, apple sauce, butter).
• Puree each food separately e.g. potato, meat, vegetables, so that it has a more appealing presentation when served on a plate.
• Puree each food separately to maintain colour and present foods separately on the plate. Moulds can be used to shape pureed food. 
• Add more flavour with ingredients like soft cheese, pesto, curry powder, mustard, soy sauce, Bovril, marmite or lemon juice.

Meal Suggestions
Breakfast	· Ready Brek or smooth porridge. · Thick yoghurt · Pureed fruit. · Milkshakes or smoothies (thickener may need adding). · Pureed scrambled or poached egg. · Pureed smoked haddock – blended with butter, cream or milk. · Halwa (without puri)
Main Meals	· Pureed pasta with sauce e.g. macaroni, Bolognese. · Pureed khichdi. · Pureed curry with a thick sauce. · Pureed casserole/stew with a thick sauce e.g. bigos/gulasz. · Pureed sausages (skins removed) with a thick gravy. · Pureed fish with a thick sauce. · Pureed broccoli/cauliflower with cheese sauce. · Pureed cottage/shepherd’s pie. · Pureed ratatouille. · Pureed chilli con carne. · Pureed dahl (channa or moong) is suitable if lentils cooked until soft. · Smooth potatoes, sweet potatoes & yams – can add cheese, butter, cream, gravy, cream/soft cheese. · Pureed vegetables (skins removed), without husks such as sweetcorn or  peas or pulses. · Pureed meat/broth dishes e.g. nihari.
Snacks/desserts	Yoghurt, mousse, custard, instant whip, pureed fruit (no skins, seeds or pips), smoothie, cheese spread, smooth paté, smooth thick soup, panna cotta, smooth avocado, hummus, pureed tinned spaghetti, pureed egg mayonnaise, pureed kheer, pureed ryz z jabłkami, lassi (without froth).

IDDSI Level 5: Minced and moist food

• Food can be mashed with a fork. It can be eaten with a fork, spoon or chopsticks.
• It must be finely mashed/minced to approximately 4mm pieces.
• It should slide easily off the spoon or fork (not stick to the utensil).
• Can be scooped and shaped on a plate . When pressed with a fork particles should easily be separated.
• Food is soft, moist and tender with no separate thin liquid.

Meal             Suggestions
Breakfast	· Ready Brek or smooth porridge, halwa (without puri). · Weetabix – blended with milk but no excess fluid. · Thick yoghurt, fromage frais. · Mashed or stewed fruit or fruit smoothies. · Scrambled or mashed boiled egg. · Mashed smoked haddock with plenty of butter.
Main Meals	· Mashed pasta with sauce e.g. macaroni cheese, ravioli, Bolognese. · Mashed vegetable or mince curry with a thick sauce (no rice). · Mashed fish (no bones) with plenty of sauce. · Mashed broccoli/cauliflower with cheese sauce. · Smooth thick soups (adding potato can help to thicken it). · Thick, mashed stews e.g. bigos, gulasz or nihari (thick broth). · Dahl (channa or moong) (lentils cooked until soft). · Any meat minced very finely (approximately 4mm pieces) with a thick gravy or sauce. · Khichdi. · Mashed potato, sweet potato  or yams – can add cheese, butter, cream, gravy, cream/soft cheese. · Mashed vegetables e.g. carrot, swede, broccoli, parsnips.
Snacks/desserts	As Level 4 with the addition of; mashed banana, rice pudding, mashed cake with custard or cream, cheese triangles, crème caramel, egg mayonnaise, tuna/salmon mayonnaise, ryz z jabłkami (pureed rice), kheer cooked until soft and rice grains not whole.

IDDSI Level 6: Soft and bite-sized food

• Food is soft, moist and tender.  Can be eaten with a fork, spoon or chopsticks.
• Must be cut no larger than 15mm x 15mm pieces.  Fish must break up into small pieces with a fork.
• Food should be soft enough so that it can be broken up easily with a fork, does not return to its original shape when pushed with a fork.
• Does not include bread products.

Meal            Suggestions
Breakfast	· Ready Brek or porridge, halwa (without puri). · Weetabix (ensure it is well soaked in milk but no excess fluid). · Thick yoghurt, fromage frais, or lassi. · Soft/chopped/stewed fruit. · Eggs: scrambled, boiled, poached. · Smoked haddock with plenty of butter.
Main Meals	· Pasta with sauce e.g. macaroni cheese, ravioli, Bolognese. · Well cooked vegetable or mince curry with sauce. · Shepherd’s/cottage pie. · Fish pie. · Poached fish with sauce. · Well cooked broccoli/cauliflower with cheese sauce. · Chilli con carne. · Dahl. · Rice requires thick smooth sauce to moisten and hold it together. It should not be sticky or gluey or separate into individual grains. · Stew/casserole: any meat or poultry which has been slow. cooked and is very tender, with a thick gravy or sauce e.g. bigos, gulasz or nihari (thick broth). · Potatoes, sweet potatoes & yams: mashed, soft boiled, jacket – (without the skin). · Well cooked/soft vegetables e.g. carrots, swede, broccoli.
Snacks/desserts	As Level  4 and 5 with the addition of; soft cheese, cottage cheese, eggs, banana, chopped cake with custard/ cream, kheer cooked until soft and rice grains not whole.

  IDDSI Level 7: Easy to chew food

• This is a sub-type of regular or ‘normal’ diet  (Level 7) for people who may have difficulty chewing.  It isn’t designed for people with swallowing problems or increased choking risk, although some people with swallowing problems may benefit from it.  If you have swallowing difficulties, your SLT should assess whether this is the right diet for you. 

• Some examples of people who may benefit from this diet level:
  • People with dentures who have difficulty with regular diet.
  • People with temporary mouth discomfort or pain.
  • People with no swallowing difficulties who are easily tired by   chewing a regular diet.

Level 7 Easy to chew food:

• Needs some chewing
• May require biting
• Can be easily cut with the side of a fork
• Is soft and tender
• May include mixed consistencies unless otherwise specified (see page 14)
• Can include  bread unless otherwise specified
• Does NOT include high-risk foods (see page 14) unless specified.

Most foods can be adapted to the appropriate IDDSI level.

Meal            Suggestions
Breakfast	· Cereals softened in milk, · Omelette, eggs of any type · Soft pastries that will be easily cut with a fork and are not crumbly · Halwa puri (puri soft rather than crispy) · Soft fruit (e.g. banana, canned peaches) · Black pudding · Smoked haddock, smoked salmon · Yoghurt with soft fruit, smoothies with pieces of soft fruit in them
Main Meals	· Vegetables without tough/fibrous skins (e.g. tomatoes, cooked cabbage, sauerkraut, cooked peas). · Tender meats e.g. pulled pork. · Egg dishes (e.g. quiche). · Quorn meat substitute, tofu. · Beans: baked beans or canned beans without tough skins. · Pasta (spaghetti etc). · Dhal and curries with tender meats or soft vegetables. · Potatoes:, sweet potatoes, yams baked (inside but not skins), soft (but not crunchy) chips, kluski śląskie. · Rice: in sauces, risottos, biryani etc. · Fish: fishfingers, soft cooked fish. · Soups (e.g. chowder, minestrone) or stews (e.g. bigos, goulash, nihari with tender meats/soft vegetables) · Salad: without hard or fibrous vegetables or tough skins.
Snacks/desserts	· Puddings: steamed, rice, bread and butter, kheer, ryz z jabłkami etc. · Crisps that easily dissolve in the mouth: e.g. Quavers, Skips, Pom Bears, Wotsits etc. · Soft biscuits (dunked), pink wafers. · Soft baked breakfast bars with soft fruit filling. · Soft cheese crackers (not dry/crumbly/hard) e.g. ‘cheese thin melts’ · Cheese: soft cheeses, not pieces of hard cheese such as parmesan · Soft dried fruit (e.g. prunes, soft apricots etc.) · Chocolate that melts in the mouth and does not have hard pieces such as nuts or biscuit in it: e.g. Maltesers, Milky Way.

High risk foods:

High risk foods can cause choking and are more difficult to chew and swallow.  The list below is not exhaustive but gives you an indication of the types of food which may be considered high risk.  Not everyone who is recommended an     regular diet will find all these foods difficult – this can be judged on an individual  basis, with advice from your speech and language therapist.

• Stringy, fibrous textures e.g. pineapple, runner beans, celery, lettuce.
• Mixed consistency foods e.g. cereals which do not blend with milk such as muesli, mince with thin gravy, soup with bits, fruit salad.
• Crunchy dry foods e.g. toast, flaky pastry, dry biscuits, crisps.
• Crumbly dry textures e.g. biscuits, crackers, pie crusts, crumble topping.
• Hard foods e.g. boiled and chewy sweets, nuts and seeds, raw vegetables.
• Vegetable and fruit skins, husks  e.g. grapes, peas, sweetcorn, broad beans, ‘bits’ in granary bread.
• Stodgy, chewy textures  e.g. some meats, white bread, toffee sweets.

More about ‘mixed consistencies’:

• Foods that have more than one texture (eg: cereal in milk, fruit pieces in jelly, salad, cake with dried fruit) are called ‘mixed consistencies’.
• Transitional foods start as one texture (e.g firm solid) and change into another texture specifically when moisture (e.g. water or saliva) is applied, or with a change in temperature (e.g. ice-cream, prawn crackers, wafers, jelly). It’s important to consider transitional foods when people are on thickened fluids.
• Mixed consistencies can be harder to swallow, especially for people with swallowing problems.
• The risk of choking can be increased.
• Mixed consistencies are usually only recommended as part of a regular or easy to chew diet, as near-normal swallowing is needed to  them safely.

Where to find more information about creating modified textured diets:

• The IDDSI website has more information about how to check food is the right consistency, including information for people who are preparing the food. You can find out more at this link: https://iddsi.org/

Some people find it difficult to prepare modified food consistencies. Please see page 20 for a few suppliers of modified texture diets that can be brought in, if this would help you. The list is not exhaustive.

Level 7: Regular Food

• A ‘normal’ diet.
• Includes all bread products (including sandwiches) as these require the ability to bite and chew, and cannot be easily broken down due to their fibrous nature. Bread products can be difficult for people who fatigue quickly while chewing or have a dry mouth. They also become sticky and this can increase choking risk.

USEFUL INFORMATION—some options for food suppliers

Simply Puree	Apetito
Tel: 0191 456 0456	Tel: 01225 234509
https://simplyfoodsolutions.co.uk/simply-puree/	http://www.apetito.co.uk/
NH Case Ltd	Oak House Foods
Tel: 01963 828900	Tel: 0333 370 6700
http://www.nhcase.com/	https://www.oakhousefoods.co.uk/
Wiltshire Farm Foods	Mrs Gills Kitchen
Tel: 0800 077 3100	Tel: 020 8807 6584
https://www.wiltshirefarmfoods.com/	https://mrgills.co.uk/

USEFUL INFORMATION

IDDSI Framework documents translated into other languages are available at:

https://iddsi.org/resources/framework-documents

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