Table 3.
Recommendations for the improvement of TMDs†
| Residents recommended by their dysphagia clinician to follow a TMD should be referred to a nutritional professional (23, 24). |
| TMD/thickened liquids and nutrient-dense, or fortified foods are ‘therapeutic diets' (25). Specially-made, nutritionally-enriched texture-modified foods, and thickened liquids should be recommended for older adults with chronic dysphagia for improving nutritional status, promoting hydration, and minimizing the risk of aspiration (17, 31)a. |
| Foods should be enhanced with energy- and protein-dense ingredients to prevent declines in nutritional and functional status (26, 32, 33). Nutritional analysis of TMDs ensures the comparability of products with regular offerings. Consider ingredient adjustments to increase micronutrient levels (34). |
| When food intake is inadequate, consider ONS* to improve energy and protein intake, preferably offered as 50–125 mL with medication rounds, multiple times/day, between meals and with the encouragement of carers (requires 5–10 minutes/person/offer) (26, 35). ONS provides 400+ kcal/day, including 30+ g protein/day for those at risk or malnourished (36). |
| Adjust portion sizes as per the individual's needs and preferences. Offer a variety of options (flavors, optimal texture and thickness ranges based on the individual's abilities) to the greatest extent possible to decrease rate of refusal. |
| To reduce mealtime fatigue and its associated risk of aspiration, volume of sip or spoon size should be adjusted as per personal requirements. |
| Aim to provide adequate food/fluid according to individual needs and preferences, considering their wishes and safety (28). |
| Increase food attractiveness(15) by presenting in a visually-appealing and dignified way (31, 32, 37). Texture-modified food does not necessarily mimic the appearance of unmodified food, as evidence is lacking for molded foods (38)a. |
| Increase diversity and offer a range of alternative meal choices, and protein- and energy-dense in-between meal snacks to provide adequate nutrition, improve resident autonomy and engagement, and encourage consumption (39). |
| Personalize the ambiance and delivery method to promote appetite and food intake (26, 27, 40). |
| Ensure the use of TMDs and the intake of texture-modified foods, and the resident's nutritional status, are closely monitored and evaluated. |
| Encourage eating but do not force food on residents, as this may take away pleasure from a person's mealtime and lead to reduced food intake, and/or quality of life. Proactively address eating challenges and provide tailored support (e.g. more time to eat, quiet environment, finger foods, etc.). |
| Apply the International Dysphagia Diet Standardization Initiative framework in the prescription, preparation, and assessment of TMDs and thickened liquids to facilitate consistent communication between nursing home staff, carers, and professionals, and reduce variability in the preparation, assessment, and prescription of TMDs and thickened liquids (41). |
| Rapidly and thoroughly evaluate the resident when he/she presents anorexia or refusal to eat while treated with a TMD; the use of TMDs should be re-evaluated in the context of end-of-life and palliative care. |
*ONS, oral nutritional supplements; †TMD, texture-modified diet. aAuthors' personal opinion based on expert-reviewed recommendation