Dysphagia is not a disease, but a symptom caused by the alteration of one or more phases of swallowing, with resulting difficulties in making food and drinks travel from the mouth to the stomach

It can cause:
• reduced eating, with resulting malnutrition and dehydration
• reduced confidence when swallowing, with risks of aspiration pneumonia (lung infection caused by the inhalation of food, oral secretions and refluxed gastric material)

There are three types of dysphagia: oral, pharyngeal and oesophageal
 

Oral dysphagia
It can be recognised from: 
• drooling or dropping food from the mouth 
• difficulty or excessive slowness in chewing 
• food residues on the tongue and in the space between teeth, lips and cheeks

Pharyngeal dysphagia
It can be recognised from:
• leaking of fluids or solid foods from the nose 
• coughing, sneezing, altered voice during or after swallowing
• frequent clearing of the throat 
• choking signs
• trouble breathing while eating
• tiredness
• delay and pain in swallowing

Oesophageal dysphagia 
It can be recognised from:
• regurgitation 
• vomiting 
• breastbone pain

Dysphagia can result in social isolation for the patient. The sense of discomfort experienced by a patient with dysphagia while eating can lead them to hide the problem, especially in the initial phase. An anxious state during meals can also occur, leading the patient to refuse both solid and liquid foods
A significant risk for patients suffering with dysphagia is represented by aspiration, i.e. when a small quantity of food and fluids goes into the bronchi; this can be evidently manifested with a choking sensation, persistent cough, appearance of facial redness of cyanosis immediately after or within two to three minutes after swallowing, but sometimes it is silent, which means that patients do not notice anything
Without an intervention in the initial phases, reduced eating causes malnutrition (weight loss or deficiency of nutrients, vitamins and mineral salts deficiency) and dehydration with electrolyte imbalance, impaired renal function and confusional status

To prevent complications there are adaptive measures (they include modifications in the diet texture and the adoption of special nutritional aids), corrective manoeuvres and postures (body posture is corrected and the swallowing process is modified) and re-education techniques (exercises to facilitate or stimulate swallowing)
 

Ensure that the patient eats calmly and without rushing, in a peaceful and comfortable setting
• Make sure that the patient is sitting up straight by helping them lean their head forward and lower their chin towards the chest while swallowing. If the patient is bedridden, it is better to position them with the torso lifted as much as possible, even using more than one pillow to bolster the back 
• The plate and drinks have to be close at hand so that they can be easily reached
• The patient has to eat slowly, adhere to the recommended volume for each bite and not introduce a second bite before completely swallowing the previous one (it is necessary to pay attention to food residues left in the mouth)
• Make them cough from time to time to check whether there is any food in the pharynx
• The patient must not talk while eating, nor watch television or be distracted in any way
• Drugs which can be crushed have to be added to a small quantity of pureed fruits or water gel to facilitate swallowing 
• The patient has to remain seated for at least 15-20 minutes after the meal
• Ensure oral hygiene after meals. In place of toothpastes and mouthwashes, use a sterile gauze or a children’s toothbrush with soft bristles soaked with a small quantity of sodium bicarbonate
• Never use fluids to eliminate food residues if the patient does not have adequate airway protection
• Any fluid must be administered with a spoon (to better dose its quantity) and has to be preceded by the removal of any food residues from the mouth

With regards to diet, to increase daily calorie intake, it is recommended to:
• Increase the portion or divide the diet over multiple meals
• Increase the energy density of the meal by adding oil, butter, whipping cream, mayonnaise or white sauce
• Offer tasty food while respecting the patient’s taste, like ice creams, whipped cream, Tiramisu, puddings and custards

To increase daily protein intake it is recommended to:
• Add homogenised meat, fish or other cold cuts to sauces and creamy pasta dishes
• Use milk to replace water or stock to cook semolina, cereal creams and polenta
• Add eggs to vegetable purees, pâtés, creamy cheeses, etc

To increase daily fluid intake, it is recommended to: 
• Use water gel (neutral or differently flavoured ready-to-use jars) or water thickened by instant flours
• Add syrups (like mint, barley water or raspberry) to thickened water to improve the drink’s taste
• In addition to water, thicken other drinks liked by the patients, like coffee, tea, infusions, wine or orange juice

When the patient’s calorie and protein needs cannot be met with dietary modifications only, it is possible to use oral creamy or thickened food supplements or, in more severe cases, use artificial nutrition (enteral and parenteral) techniques
 

Artificial nutrition, often a life-saver, is a therapy that has to be prescribed by specialists to patients with neurologic or cancer conditions who experience impaired oral nutrition for more than 5 days or permanently; in the latter circumstance, the patients can also receive home artificial nutrition (HAN) under the supervision of a specialised and certified centre to effectively prevent and treat potential complications

In light of the recent law issued in Italy in December 2017 on living wills, artificial nutrition requires the patient’s or their legal representative’s informed consent and it can be interrupted, like any other therapy, when the so-called “therapeutic obstinacy” is recognised. Family members and patients are instructed on how to manage home artificial nutrition and the Operational Unit is available to verify the therapeutic progress and for any changes during the therapy

ASSOCIATIONS
The associations that patients can contact are those related to the disease causing the symptom. For instance, in case of dysphagia in patients with Parkinson’s disease, they should contact the relevant associations, which can give accurate information on diagnostic, therapeutic and care regimens (PDTA) in the community

For further details about this topic, we recommend Reliability and Validity of the Italian Eating Assessment Tool by Antonio Schindler, Francesco Mozzanica, Anna Monzani, Eleonora Ceriani, Murat Atac, Nikolina Jukic-Peladic, Claudia Venturini, Paolo Orlandoni
Research evaluates a self-assessment for dysphagia in Italian. This test (I-EAT 10) includes 10 questions about dysphagia to which the patient or a family member has to answer with a score between 0 and 4; if the total score of the 10 questions exceeds 3, the patient should go to a specialised centre for further diagnostic tests (water swallowing test, FEES, videofluoroscopy)

REFERENCES 
- Gaita A, Barba L, Calcagno P, Cuccaro A, Grasso MG, Pascale O, Martinelli S, Rossini A, Scognamiglio U, Simonelli M, Valenzi A, Salvia A, Donelli G. Il paziente disfagico: manuale per familiari e caregiver. Roma: Istituto Superiore di Sanità; 2008. (Rapporti ISTISAN 08/38)
- Schindler O, Ruoppolo G, Schindler A (Ed.). Deglutology II Edizione. Torino: Omega edizioni; 2011.
- Franco P, Fabriani S, Pasturenzi D, Bonuglia F. La Disfagia: consigli pratici per il paziente disfagico e per i familiari. Roma: Servizio di logopedia Casa di Cura Villa Fulvia
- G. Bartolone, M. Prosiegel H. Schröter-Morasch da Diener HC. Linee Guida diagnostiche e terapeutiche in neurologia. Thieme, 2005, 746- 756 - Traduzione italiana di O. Schindler
- A. Accornero, A. Cattaneo, G.Ciccone , D. Farneti, S. Raimondo, A. Schindler, I. Vernero, P. Visentin. Linee guida sulla gestione del paziente disfagico adulto
in foniatria e logoterapia. Consensus Conference. Torino, 29 Gennaio 2007
- Antonio Schindler, MD, Francesco Mozzanica, MD, Anna Monzani, SLP, Eleonora Ceriani, SLP, Murat Atac, MD, Nikolina Jukic Peladic, MD, Claudia Venturini, MD, Paolo Orlandoni , MD. Annals of otology rhinology & laryngology Reliability and validity of the italian eating assessment tool (I-EAT-10)