JCPSLP Vol 20 No 3 November 2018

Nutrition, swallowing, mealtimes: Recipes for success

Viewpoints Nutrition, swallowing, mealtimes: Dietitians’ perspectives on recipes for success Adrienne M Young, Elise Treleaven, and Anna Farrell

Food is our common ground, a universal experience. – James Beard, chef H ow true this is for the professions of dietetics and speech-language pathology (SLP). Malnutrition and dysphagia often present together, for example, as a consequence of ageing (Wirth et al., 2016) and diseases such as head and neck cancer (Brown et al., 2013) and stroke (Foley, Martin, Salter, & Teasell, 2009). Oropharyngeal dysphagia, and associated increased eating time and effort and prescription of texture modified food and fluids often has a negative impact on food and fluid intake and nutritional status (Agarwal et al., 2012; Vivanti, Campbell, Suter, Hannan-Jones, & Hulcombe, 2009; Vucea, Keller, Morrison, Duizer, et al., 2018). In the case of severe dysphagia, a person may no longer be able to eat, requiring placement of nasogastric or gastrostomy tube for feeding. Our common ground is clear: striving to optimise health and quality of life as it relates to their food. Best outcomes for our clients can be achieved by dietitians and SLP working together to identify, assess and treat clients with dysphagia and malnutrition. Screening and identifying at risk clients Given their common coexistence, interdisciplinary risk screening processes may be more efficient in providing timely referral for assessment and intervention. For example, integrated admission processes where nursing or other staff screen for malnutrition and dysphagia, and where dietetics and SLP departments work together to audit, feedback and improve on processes in a coordinated way. Interdisciplinary screening can also be incorporated into routine clinical practice of dietitians and speech pathologists. The Malnutrition Screening Tool (MST) is the most commonly used tool to identify malnutrition in Australian health care facilities, and includes two simple questions about weight loss and reduced oral intake (Ferguson, Capra, Bauer, & Banks, 1999). The MST could be easily used by SLPs to identify where a dietetics referral should be made. In practice, it is common for dietitians to identify signs of dysphagia as part of their nutrition and mealtime assessments (Johnson, Brody, Marcus, & Touger-Decker, 2015), and it has been shown that dietitians can adequately perform dysphagia risk screening (Brody, Touger-Decker, VonHagen, & Maillet, 2000) and refer on to SLP where required (see Box 1). Assessment and intervention for clients with dysphagia and malnutrition While dysphagia and malnutrition assessments need to be completed by the SLP or dietitian respectively, it may be

1. Dysphagia screening by dietitians is completed in outpatient clinics for clients undergoing radio- therapy for certain types of head and neck cancers. Only those identified at risk of dysphagia are referred on to be seen by the SLP, allowing the clinician to prioritise those clients requiring their expertise. 2. Interdisciplinary outpatient clinics provide care for clients with head and neck cancer. This model involves joint assessment, care planning and monitoring by a SLP and dietitian, and is delivered choice in accessing their swallowing, nutrition and communication intervention. Joint facility-based telehealth consultations are also provided between clients and regional and metropolitan dietitians and speech pathologists, which ensures high levels of coordinated care and provides interdisciplinary education and workforce training (Burns et al., 2017). 3. SLP involvement in food services includes having a designated SLP with a food service portfolio who is involved in menu changes and testing new products. Regular meal quality audits are conducted with speech pathology to ensure appropriate texture and quality of our texture modified products (Banks et al., 2017). Recently we have introduced puree moulded meals which have improved patient satisfaction and intake. 4. Standardised enteral feeding protocols for acute inpatients were developed by dietitians (in collaboration with SLPs and other members of the multidisciplinary team) to allow nurse-initiated enteral feeding on our head and neck surgery, neurosurgery and stroke wards. Using these protocols, nursing staff commence enteral feeding immediately after non-oral feeding is recommended or can decrease feed volumes as SLP upgrades the oral diet, without the need for dietitian review. This has resulted in more timely nutrition intervention for clients and improved efficiency for clinicians (Lim et al., 2018). Box 1: Examples of collaborative dietetics and speech-language pathology (SLP) practice at Royal Brisbane and Women’s Hospital useful to conduct these assessments concurrently to reduce repetition when questioning the client, facilitate the development of a cohesive treatment plan, and allow client concerns and questions to be addressed accurately and in a timely manner. Joint education sessions provided by SLPs and dietetics have shown to be well received by either face-to-face or via telehealth, offering metropolitan clients greater convenience and

Adrienne M Young (top), Elise Treleaven

(centre) and Anna Farrell

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JCPSLP Volume 20, Number 3 2018

www.speechpathologyaustralia.org.au