Dietary management of swallowing disorders

Simple Advanced Preparation Method for Improving the Thickness Stability of Powder Thickening Agents in Dysphagia Management

Texture modification of foods by using thickening agents is a routine practice for assessing and treating dysphagic patients. However, a powder-thickened fluid's viscosity might change over time, and little has been proposed to overcome this inconsistency. This study aimed to evaluate variations in the thickness of a fluid thickened with a common xanthan gum-based powder and to explore the feasibility of a simple advanced preparation method for thickened liquids to improve thickness stability. Thickened fluids with concentrations of 1.0 g/100 mL, 0.7 g/100 mL, and 0.5 g/100 mL were prepared from both freshly opened and previously opened thickening powders. Fluid thickness was measured every 10 min in a series of International Dysphagia Diet Standardization Initiative flow tests. A significant time-dependent decline in thickness was observed for all three concentrations in both groups, namely those prepared with freshly opened and previously opened thickening powders, and the shortest periods to achieve a stable viscosity after liquid preparation for the two groups were 80 and 70 min, respectively. On diluting the thickened liquids from the base liquid, which was prepared at a concentration of 1.0 g/100 mL and stored at room temperature for 90 min, no significant time-dependent thickness changes were observed over the following 60 min. The simple protocol of preparing the thickest "base" liquid in advance and then diluting it to the desired thickness resulted in a consistent liquid thickness, with the prepared liquids ready to be clinically applied and consumed, with high stability within 60 min.

European white paper: oropharyngeal dysphagia in head and neck cancer

PURPOSE

To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe.

METHODS

Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion.

RESULTS

Twenty-four sections on HNC-specific OD topics.

CONCLUSION

This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

A favorable effect on nutritional status of 12-week tailored texture-modified sous-vide cooking meals in institutionalized elderly women with oropharyngeal dysphagia: an intervention study

BACKGROUND

Dysphagic patients are not always able to meet their energy, micro and macronutrients needs for various causes and therefore are at high risk of malnutrition. The aim of the present study was to evaluate the effectiveness on satisfaction of the meal (by a 10-cm visuo-analogical scale), food intake (by visual estimation of food waste), nutritional status (anthropometric measures, mini nutritional assessment [MNA], vitamin D, B12, folic acid), functional (handgrip) and blood chemistry metabolic parameters of a tailored texture-modified sous-vide cooking meals (TTMSVC), well balanced in macro and micronutrients, in elderly women suffering from oropharyngeal dysphagia at long-term care facilities.

METHODS

A 12-week intervention study was conducted on female elderly subjects affected by oropharyngeal dysphagia of level 3-5. The treated group received TTMSVC with the consistencies standardized using viscosimeter (5000-10000 mP/s). The control group maintained pureed hospital diet.

RESULTS

50 subjects, 25 in treatment group and 25 in control group, with mean±SD age 89.12±4.18 and mini mental state examination (MMSE) 20.58±1.63 were enrolled. The treatment and control groups were similar at baseline. The changes over time between the two groups showed significant differences for food intake, meal appreciation, Body Mass Index (BMI), calf circumference, arm circumference, MNA, prealbumin, albumin, folic acid, vitamin D, ionized calcium, C-Reactive Protein (CRP), Tumor Necrosis Factor (TNF-α), handgrip. Significant positive correlations were observed in the treatment group between the meal appreciation and prealbumin and vitamin D.

CONCLUSIONS

This study demonstrated that elderly dysphagic women at long-term care facilities can eat better and increase nutritional status by eating 12-week tailored appealing TTMSVC.

Changes in nutritional state and dysphagia in stroke patients monitored during a 14-d period in a Burkina Faso hospital setting

INTRODUCTION

Dysphagia and undernourishment are common in cerebrovascular accident (stroke) patients in developed countries. Despite the dietary transition, there is little information available in Africa on this topic. This study aims to assess the prevalence of undernourishment and dysphagia in stroke patients in two Burkina Faso teaching hospitals at a starting point (D0), on the eighth day, and on the 14th (D14) and to specify factors related to undernourishment at day 14.

METHODOLOGY

The nutritional state of the patients was assessed using body mass index, triceps skinfold thickness, and mid-upper arm circumference. Dysphagia was identified using the Practical Aspiration Screening Schema.

RESULTS

A total of 222 patients were included in the study. From D0 to D14, the prevalence of undernourishment increased from 25.2% to 31.0% and the prevalence of dysphagia decreased from 37.4% to 15.8%. All nutritional criteria worsened. In a multivariate analysis, undernourishment was more present at D14 for women (odds ratio [OR] = 7.01; 95% confidence interval [CI]: 1.51-32.56, P = 0.01) and was less present if weight (OR = 0.69; 95% CI: 0.60-0.79, P = 0.0001) or triceps skinfold thickness (OR = 0.85; 95% CI: 0.74-0.99, P = 0.03) were high at D0.

CONCLUSION

The prevalence of undernourishment was high at D0 and increased during the monitoring period. It would be advisable to monitor patients' weight and triceps skinfold thickness, to optimize care for women and patients with low weight or triceps skinfold thickness at D0, to monitor dysphagia, and to inform patients, families, and relevant staff of nutritional concerns after a cerebrovascular accident.

Texture-dependent effects of pseudo-chewing sound on perceived food texture and evoked feelings in response to nursing care foods

Because chewing sounds influence perceived food textures, unpleasant textures of texture-modified diets might be improved by chewing sound modulation. Additionally, since inhomogeneous food properties increase perceived sensory intensity, the effects of chewing sound modulation might depend on inhomogeneity. This study examined the influences of texture inhomogeneity on the effects of chewing sound modulation. Three kinds of nursing care foods in two food process types (minced-/puréed-like foods for inhomogeneous/homogeneous texture respectively) were used as sample foods. A pseudo-chewing sound presentation system, using electromyogram signals, was used to modulate chewing sounds. Thirty healthy elderly participants participated in the experiment. In two conditions with and without the pseudo-chewing sound, participants rated the taste, texture, and evoked feelings in response to sample foods. The results showed that inhomogeneity strongly influenced the perception of food texture. Regarding the effects of the pseudo-chewing sound, taste was less influenced, the perceived food texture tended to change in the minced-like foods, and evoked feelings changed in both food process types. Though there were some food-dependent differences in the effects of the pseudo-chewing sound, the presentation of the pseudo-chewing sounds was more effective in foods with an inhomogeneous texture. In addition, it was shown that the pseudo-chewing sound might have positively influenced feelings.

An Attempt to Improve Food/Sound Congruity Using an Electromyogram Pseudo-Chewing Sound Presentation System

Improving the texture of foods provided during nursing care is necessary to improve the appetite of elderly individuals. We developed a system to vary perceived food texture using pseudo-chewing sounds generated from electromyogram (EMG) signals. However, this previous system could not provide chewing sounds that were sufficiently congruous with foods. Because food/sound combinations that seem unnatural cause individuals to feel uncomfortable with pseudo-chewing sounds, food/sound congruity is important. This research aims to improve the derivation and presentation of pseudo-chewing sounds so as to be able to provide various kinds of chewing sounds. The developed system adjusts the volume of pseudo-chewing sounds that are stored in a digital audio player based on the amplitude of the EMG signal envelope. Using this system, food/sound congruity was examined with two kinds of softened Japanese pickles. Six kinds of pseudo-chewing sounds were tested (noisy chewing sound, EMG chewing sound, and four kinds of actual chewing sounds: rice cracker, cookie, and two kinds of Japanese pickles). Participants reported that food/sound combinations were unnatural with the noisy and EMG chewing sounds, whereas the combinations felt more natural with the pseudo-chewing sounds of Japanese pickles. We concluded that the newly developed system could effectively reduce the unnatural feeling of food/sound incongruity.

The effect of a crunchy pseudo-chewing sound on perceived texture of softened foods

Elderly individuals whose ability to chew and swallow has declined are often restricted to unpleasant diets of very soft food, leading to a poor appetite. To address this problem, we aimed to investigate the influence of altered auditory input of chewing sounds on the perception of food texture. The modified chewing sound was reported to influence the perception of food texture in normal foods. We investigated whether the perceived sensations of nursing care foods could be altered by providing altered auditory feedback of chewing sounds, even if the actual food texture is dull. Chewing sounds were generated using electromyogram (EMG) of the masseter. When the frequency properties of the EMG signal are modified and it is heard as a sound, it resembles a "crunchy" sound, much like that emitted by chewing, for example, root vegetables (EMG chewing sound). Thirty healthy adults took part in the experiment. In two conditions (with/without the EMG chewing sound), participants rated the taste, texture and evoked feelings of five kinds of nursing care foods using two questionnaires. When the "crunchy" EMG chewing sound was present, participants were more likely to evaluate food as having the property of stiffness. Moreover, foods were perceived as rougher and to have a greater number of ingredients in the condition with the EMG chewing sound, and satisfaction and pleasantness were also greater. In conclusion, the "crunchy" pseudo-chewing sound could influence the perception of food texture, even if the actual "crunchy" oral sensation is lacking. Considering the effect of altered auditory feedback while chewing, we can suppose that such a tool would be a useful technique to help people on texture-modified diets to enjoy their food.

Knowledge and practice concerning swallowing disorders in hemiplegic patients among nurses of Bobo-Dioulasso urban primary health care centers in Burkina Faso

Introduction

The quality of management of swallowing disorders (SD) from admission onwards influences the patients' nutritional status and their prognosis. Neurological diseases are the main causes of SD, affecting one in three patients with hemiplegia (Hp). In Burkina Faso (BF), primary health care center (PHCC) nurses are the first to manage these patients, but there are no data related to their management of SD. The study aimed to assess knowledge and practices regarding SD in Hp among PHCC nurses in Bobo–Dioulasso, a main center for care of Hp in BF.

Methods

This cross-sectional study was performed August 1–September 15 2014. Subjects underwent a standardized survey to determine their knowledge and practices concerning SD in Hp.

Results

Of 125 nurses surveyed (83.3% of the targeted workers), 82.4% had experience of caring for Hp. The role of the central nervous system in cases of Hp and SD was recognized by 56.8% of nurses; 42.3% knew that SD can cause aspiration, and 36.0% were aware of rescue techniques to use when aspiration occurs; 39.2% correctly assessed the impact on nutritional status of SD. Knowledge in this area was better among respondents who recently completed training school. 65.6% and 1.6% respectively knew about the impact of posture and the texture of food on the ability to swallow. Among the 103 nurses with experience of treating Hp, 68.0% considered clinical interview the best way to detect SD, and 30.1% did not give the patient advice in this area. In multivariate analysis, detection of SD was associated with good knowledge of the value of voice disorders (OR = 3.5, 95% CI = 1.4–8.1; p = 0.005).

Conclusion

Few nurses had been warned of the connection between Hp and SD, which are classic issues and potential complications. Practices varied, but most were not in accord with what are recognized as good strategies for SD screening and management. In order to improve care of Hp, neurological and nutritional training should be accompanied by specific training in SD, emphasizing screening and simple management.

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US means “United States of America” (USA) has been clarified.

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Details about western countries and developed countries, with two new references: reference number five and number six.

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We have given more explanations about the background to justify why our study targeted only the nurses, with more data concerning the physicians, nurses, and others practitioners per inhabitants in Burkina Faso.

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We have precised that the type of data collection is face-to-face interview.

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The statistical paragraph has been re-written and enriched.

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We replaced the lack of the study in the discussion section firstly.

Interventions for dysphagia in long-term, progressive muscle disease

BACKGROUND

Normal swallowing function is divided into oral, pharyngeal, and oesophageal phases. The anatomy and physiology of the oral cavity facilitates an oral preparatory phase of swallowing, in which food and liquid are pushed towards the pharynx by the tongue. During pharyngeal and oesophageal phases of swallowing, food and liquid are moved from the pharynx to the stomach via the oesophagus. Our understanding of swallowing function in health and disease has informed our understanding of how muscle weakness can disrupt swallowing in people with muscle disease. As a common complication of long-term, progressive muscle disease, there is a clear need to evaluate the current interventions for managing swallowing difficulties (dysphagia). This is an update of a review first published in 2004.

OBJECTIVES

To assess the effects of interventions for dysphagia in people with long-term, progressive muscle disease.

SEARCH METHODS

On 11 January 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, LILACS, and CINAHL. We checked references in the identified trials for additional randomised and quasi-randomised controlled trials. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform on 12 January 2016 for ongoing or completed but unpublished clinical trials.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that assessed the effect of interventions for managing dysphagia in adults and children with long-term, progressive muscle disease, compared to other interventions, placebo, no intervention, or standard care. Quasi-randomised controlled trials are trials that used a quasi-random method of allocation, such as date of birth, alternation, or case record number. Review authors previously excluded trials involving people with muscle conditions of a known inflammatory or toxic aetiology. In this review update, we decided to include trials of people with sporadic inclusion body myositis (IBM) on the basis that it presents as a long-term, progressive muscle disease with uncertain degenerative and inflammatory aetiology and is typically refractory to treatment.

DATA COLLECTION AND ANALYSIS

We applied standard Cochrane methodological procedures.

MAIN RESULTS

There were no randomised controlled trials (RCTs) that reported results in terms of the review's primary outcome of interest, weight gain or maintenance. However, we identified one RCT that assessed the effect of intravenous immunoglobulin on swallowing function in people with IBM. The trial authors did not specify the number of study participants who had dysphagia. There was also incomplete reporting of findings from videofluoroscopic investigations, which was one of the review's secondary outcome measures. The study did report reductions in the time taken to swallow, as measured using ultrasound. No serious adverse events occurred during the study, although data for the follow-up period were lacking. It was also unclear whether the non-serious adverse events reported occurred in the treatment group or the placebo group. We assessed this study as having a high risk of bias and uncertain confidence intervals for the review outcomes, which limited the overall quality of the evidence. Using GRADE criteria, we downgraded the quality of the evidence from this RCT to 'low' for efficacy in treating dysphagia, due to limitations in study design and implementation, and indirectness in terms of the population and outcome measures. Similarly, we assessed the quality of the evidence for adverse events as 'low'. From our search for RCTs, we identified two other non-randomised studies, which reported the effects of long-term intravenous immunoglobulin therapy in adults with IBM and lip-strengthening exercises in children with myotonic dystrophy type 1. Headaches affected two participants treated with long-term intravenous immunoglobulin therapy, who received a tailored dose reduction; there were no adverse events associated with lip-strengthening exercises. Both non-randomised studies identified improved outcomes for some participants following the intervention, but neither study specified the number of participants with dysphagia or demonstrated any group-level treatment effect for swallowing function using the outcomes prespecified in this review.

AUTHORS' CONCLUSIONS

There is insufficient and low-quality RCT evidence to determine the effect of interventions for dysphagia in long-term, progressive muscle disease. Clinically relevant effects of intravenous immunoglobulin for dysphagia in inclusion body myositis can neither be confirmed or excluded using the evidence presented in this review. Standardised, validated, and reliable outcome measures are needed to assess dysphagia and any possible treatment effect. Clinically meaningful outcomes for dysphagia may require a shift in focus from measures of impairment to disability associated with oral feeding difficulties.

Nutritional Care Needs in Elderly Residents of Long-Term Care Institutions: Potential Implications for Policies

OBJECTIVES

To collect information on actual nutritional intervention requirements in long-term care institutions and on the role of institutional factors in nutritional care.

DESIGN

A cross-sectional analysis of baseline data (collected between September 2011 and September 2013) within the context of a multicenter prospective cohort study.

SETTING

Nineteen long-term care institutions.

PARTICIPANTS

Thirteen hundred and ninety-four resident elderly (age ≥60 years).

MEASUREMENTS

The prevalence of nutritional derangements (MNA-Short Form) and the need to introduce nutritional interventions on the residents.

RESULTS

Prevalence of malnutrition and risk of malnutrition were 35.2% [95%CI, 32.8-37.8] and 52.6% [95%CI, 50.0-55.2], respectively. Malnutrition was more frequent upon admission and in larger institutions (≥50 beds). Overall, 50% of the residents requiring an individualized nutritional care plan (any type) were not receiving it. Oral diet, the use of fluid thickeners and oral nutritional supplements had to be introduced in 306 (22.5%), 201 (15%) and 175 (13%) residents, respectively. The need to implement the oral diet was mainly due to inadequacy of texture according to chewing and swallowing capabilities. In gender and age-adjusted multivariable logistic regression models, nutritional interventions were associated with worse nutritional status (P<0.001 for all). Moreover, while the duration of stay was unrelated to the need for nutritional interventions, we observed that residents living in larger long-term care institutions (≥50 beds) were more likely to require improvement in nutrition care.

CONCLUSIONS

In long-term care elderly residents nutritional derangements are very common, underdiagnosed and undertreated. Nutritional screening should be part of routine care. However, also the systematic involvement of a nutritional care specialist appears to be an urgent need, particularly in larger institutions where the standards of care are likely to be lower.

Living with oropharyngeal dysphagia: effects of bolus modification on health-related quality of life--a systematic review

PURPOSE

Difficulty swallowing, oropharyngeal dysphagia, is widespread among many patient populations (such as stroke and cancer groups) and aged community-dwelling individuals. It is commonly managed with bolus modification: altering food (usually cutting, mashing or puréeing) or fluids (typically thickening) to make them easier or safer to swallow. Although this treatment is ubiquitous, anecdotal evidence suggests patients dislike this management, and this may affect compliance and well-being. This review aimed to examine the impact of bolus modification on health-related quality of life.

METHODS

A systematic review of the literature was conducted by speech pathologists with experience in oropharyngeal dysphagia. The literature search was completed with electronic databases, PubMed and Embase, and all available exclusion dates up to September 2012 were used. The search was limited to English-language publications which were full text and appeared in peer-reviewed journals.

RESULTS

Eight studies met the inclusion criteria. Generally, bolus modification was typically associated with worse quality of life. Modifications to foods appeared to be more detrimental than modifications to fluids, but this may be due to the increased severity of dysfunction that is implied by the necessity for significant alterations to foods. The number of studies retrieved was quite small. The diverse nature of methodologies, terminologies and assessment procedures found in the studies makes the results difficult to generalise.

CONCLUSION

Overall, even though the severity of dysphagia may have been a confounding factor, the impact of bolus modification on health-related quality of life in patients with oropharyngeal dysphagia appears to be negative, with increased modification of food and fluids often correlating to a decreased quality of life. Further, associated disease factors, such as decreased life expectancy, may also have affected health-related quality of life. More research is needed.

What do consumers think of pureed food? Making the most of the indistinguishable food

This qualitative study is based on in-depth interviews with 15 consumers (+4 family members) of pureed food. Transcripts were thematically analyzed to summarize and interpret these data. Although no consumer enjoyed eating pureed food, some were grateful to be able to be nourished orally. Food was described as being poor in terms of sensory appeal, and products were often indistinguishable from each other. Consistency in production, delivery, and approach to presentation was identified to be a challenge that affected the acceptance of products, and variety was often lacking. However, consumers saw the necessity of the texture and provided several suggestions that are practicable and feasible for improving their experience and "making the best of it." This is the first in-depth study on consumer perception of pureed food. It not only provides insights into their experience and the impacts on their quality of life but also provides information about ways providers can improve upon these products.

Keeping consumers safe: food providers' perspectives on pureed food

Twelve focus groups were conducted in five sites with 80 allied health providers to identify their perspectives on providing pureed food to consumers. Thematic care analysis was completed to summarize and interpret these data. Providers' greatest concern was keeping consumers safe, and the right texture was prioritized over sensory appeal and acceptance. Providers recognized that these foods impacted the quality of life of consumers and worked to rationalize these diets with residents/patients and their families. In addition, offering foods they knew to be poorly accepted affected their self-concept as providers. As a result of these challenges, they did whatever they could in the kitchen and tableside to promote intake of pureed foods. Those in the "food chain" of pureed food provision suggested several ways to further improve these products. Greater communication between those who assist consumers with eating and those who produce the pureed food they consume is needed to promote acceptable pureed products.

Comparison of different gum-based thickeners using a viscometer and line spread test: a preliminary study

Objective

To compare fluid thickeners composed of starch polysaccharide (STA), guar gum-based polysaccharide (GUA), and xanthan gum-based polysaccharide (XAN) with the use of a viscometer and a line spread test (LST) under various measurement conditions.

Methods

The viscosity of thickened fluid with various concentrations (range, GUA 1%-4%, XAN 1%-6%, STA 1%-7%, at intervals of 1%) was measured with a rotational viscometer with various shear rates (1.29 s^-1, 5.16 s^-1, 51.6 s^-1, and 103 s^-1) at a temperature of 35℃, representing body temperature. The viscosity of STA showed time dependent alteration. So STA was excluded. Viscosities of GUA and XAN (range of concentration, GUA 1%-3%, XAN 1%-6%, at intervals of 1%) were measured at a room temperature of 20℃. LST was conducted to compare GUA and XAN (concentration, 1.5%, 2.0%, and 3.0%) at temperatures of 20℃ and 35℃.

Results

The viscosities of 1% GUA and XAN were similar. However, viscosity differences between GUA and XAN were gradually larger as concentration increased. The shear thinning effect, the inverse relationship between the viscosity and the shear rate, was more predominant in XAN than in GUA. The results of LST were not substantially different from GUA and XAN, in spite of the difference in viscosity. However manufacturers' instructions do not demonstrate the rheological properties of thickeners.

Conclusion

The viscosities of thickened fluid were different when the measurement conditions changed. Any single measurement might not be sufficient to determine comparable viscosity with different thickeners. Clinical decision for the use of a specific thickener seems to necessitate cautious consideration of results from a viscometer, LST, and an expert's opinion.

In-house pureed food production in long-term care: perspectives of dietary staff and implications for improvement

Texture modification of foods to a pureed consistency is a common management approach for older adults with dysphagia. Long-term care (LTC) facilities commonly produce some pureed food in-house. This study investigated challenges and preferred practices associated with the production of pureed food in LTC facilities. Nutrition Managers (n = 27) and cooks (n = 26) from 25 Ontario LTC facilities were recruited for one-on-one, semistructured interviews. Interviews were digitally recorded, transcribed, and analyzed using inductive thematic analysis. Four themes arose from the data to exemplify challenges in production, including (a) difficulty in using standardized recipes, (b) varied interpretation of governmental guidelines, (c) lack of consistency in terminology and texture, and (d) wanting to improve the visual appeal. These challenges were reported to reduce the quality of in-house produced pureed food. Preferred practices to overcome these challenges were also provided by participants, such as involving cooks in pureed recipe improvements and tailoring to the specific needs of residents. Incorporation of these practices into pureed food production may help to shape and improve future practice and pureed food products.

A Novel Dysphagia Diet Improves the Nutrient Intake of Institutionalized Elders

OBJECTIVES

Dysphagia affects 35% to 60% of the institutionalized elderly population. This study aimed at evaluating the nutrient intake of frail institutionalized elderly persons with dysphagia and to assess the impact of Sainte-Anne's Hospital Advanced Nutritional Care program on dietary intake and weight.

DESIGN

A 12-week intervention study.

SUBJECTS/SETTING

Ninety-three individuals residing in a Montreal, Canada, long-term care facility who were aged at least 65 years were evaluated. Seventeen subjects with a body mass index (BMI; calculated as kg/m(2)) <24 or weight loss >7.5% within 3 months and with dysphagia were included.

INTERVENTION

The treated group (n=8; aged 82.5+/-4.41 years, weight 55.9+/-12.1 kg, BMI 22.4+/-3.93) received Sainte-Anne's Hospital reshaped minced- or pureed-texture foods with thickened beverages where required. The control group (n=9; aged 84.6+/-3.81 years, weight 54.3+/-7.49 kg, BMI 21.2+/-2.31) maintained traditional nourishment.

MAIN OUTCOME MEASURES

Macronutrient and micronutrient intake, weight, and BMI were measured at baseline, 6 weeks, and 12 weeks.

STATISTICS

Student t tests were performed to evaluate change within and between groups.

RESULTS

The treatment and control groups were similar at baseline, having a mean age of 82.5+/-4.41 years vs 84.6+/-3.81 years and BMI of 22.4+/-3.93 vs 21.2+/-2.31, respectively. The average weight in the treated group increased compared to the control group (3.90+/-2.30 vs -0.79+/-4.18 kg; P=0.02). Similarly, the treated group presented an increased intake of energy, proteins, fats, total saturated fats, monounsaturated fats, potassium, magnesium, calcium, phosphorus, zinc, vitamin B-2, and vitamin D compared to control subjects (P<0.05).

CONCLUSION

Institutionalized elderly patients with dysphagia can eat better and increase body weight via a diversified, modified in texture, and appealing oral diet that meets their nutrition needs.

Provision of Small, Frequent Meals Does Not Improve Energy Intake of Elderly Residents with Dysphagia Who Live in an Extended-Care Facility

Malnutrition and dehydration are potential consequences of dysphagia, a common swallowing disorder among elderly individuals. Providing smaller, more frequent meals has been suggested (but not demonstrated) to improve energy intake among this group. Accordingly, this study was designed to assess whether the same energy content in five vs three daily meals would improve energy intake. Thirty-seven residents of an extended-care facility, aged older than 65 years, previously evaluated for dysphagia, and receiving a texture-modified diet, agreed to participate in a crossover study with random assignment to three or five meals during an initial 4-day study period, followed by the opposite meal pattern in a second period. Six were excluded from analysis, as their medical condition deteriorated before or during the study. Food and fluids consumed by participants during each study period were weighed before and after each meal. Average energy intakes were similar between the three- and five-meal patterns (1,325+/-207 kcal/day vs 1,342+/-177 kcal/day, respectively; P=0.565); fluid intake was higher with five meals (698+/-156 mL/day) vs three (612+/-176 mL/day; P=0.003). Because offering five daily feedings did not improve energy intakes when compared with three, dietitians caring for this vulnerable group might need to consider other nutrition intervention strategies.

Taste Preference and Rating of Commercial and Natural Thickeners

Dysphagia can negatively affect quality of life, nutritional status, and pulmonary status of individuals. The most common intervention for dysphagia is the use of thickening agents for liquids. This group study (n = 43) investigated the taste preference, taste ratings, and ranking for nectar-thick hot and cold beverages using three types of thickeners: SimplyThick, Thick-It, and noncommercially prepared natural thickeners. Results demonstrated a significant difference between the taste ratings of two commercial thickeners and between one commercial and the natural thickener for the ranking of taste with hot beverages. Every participant rated at least one of the thickener beverages as having an acceptable taste for the hot chocolate and fruit juice beverages. Exploring individual preferences is critical to selecting a beverage that increases compliance to clinical recommendations.

Categorization of dysphagia diets with the line spread test11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the author(s) or on any organization with which the author(s) is/are associated

OBJECTIVE

To categorize dysphagic diets according to the food's viscosity, as determined by an objective method.

DESIGN

Description of dysphagic diet in terms of viscosity.

SETTING

Food science laboratory at a university hospital.

SPECIMENS

Twenty kinds of foods: 10 commercially available and 10 formulated for a dysphagic diet in a tertiary university hospital, representing a wide range of food viscosities.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Viscosity, measured with a viscometer, and a line spread test (LST).

RESULTS

Logarithmic viscosity (centiPoise [cP]) values measured using a viscometer were inversely correlated with the extent of spread (centimeters) on an LST. (Pearson r=-.95, P=.0001). Viscosities and the LST results were 0.9+/-0.1cP and 5.5+/-0.5cm for water, 63.1+/-4.8cP and 3.4+/-0.1cm for the barium solution, 671.0+/-76.9cP and 2.4+/-0.1cm for yogurt, and 10,031+/-728cP and 1cm for pudding.

CONCLUSIONS

Dysphagic diets can be categorized according to their viscosities by objective measurements. The LST correlated well with viscometer measurement and is a practical method with which to measure viscosity.

The risk of aspiration of pureed food as determined by flexible endoscopic evaluation of swallowing with sensory testing

OBJECTIVE

This study evaluates the risk of aspiration of pureed foods in patients with dysphagia with increasing sensory deficits of the hypopharynx with intact versus impaired pharyngeal muscular tone (pharyngeal squeeze).

STUDY DESIGN

Two hundred four dysphagic patients underwent flexible endoscopic evaluation of swallowing with sensory testing and were prospectively divided into 3 groups, with normal, moderate, and severe sensory deficits. Each group was divided into those with normal and those with impaired pharyngeal squeeze. Subjects were given pureed food boluses and were evaluated for aspiration.

RESULTS

There was a significant difference in the incidence of aspiration of pureed foods for normal and moderate sensory loss when comparing normal and impaired pharyngeal squeeze (P < 0.001, Fisher exact test). There was no significant difference in the severe sensory loss group. In both the normal and impaired pharyngeal squeeze groups, there was no significant difference in aspiration as the sensory deficit increases.

CONCLUSIONS

Patients with impaired pharyngeal squeeze at different levels of sensory deficits are at significantly greater risk for aspiration of pureed foods compared with those with normal squeeze. However, as sensory deficits increased, the patients did not show a significant increase in aspiration. The aspiration of pureed foods may depend more on muscle tone of the hypopharynx than on sensation. Dysphagic patients who are given a pureed diet to prevent aspiration may still be at risk for aspiration. This may be easily predicted by the use of flexible endoscopic evaluation of swallowing with sensory testing in conjunction with evaluation of pharyngeal muscle tone.

Treatment for swallowing difficulties (dysphagia) in chronic muscle disease

BACKGROUND

The management of dysphagia (difficulty in swallowing), a common complication of long-term progressive muscle disease in children and adults, is currently unclear.

OBJECTIVES

Our objective was to determine the most appropriate intervention for dysphagia in people with chronic, untreatable, non-inflammatory muscle disease.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group trials register, Cochrane Central Register of Controlled Trials (Cochrane Library Issue 2, 2003), MEDLINE (from January 1966 to Week 2 June 2003), EMBASE (from January 1980 to Week 2 June 2003), AMED (from January 1985 to Week 2 June 2003), LILACS (from January 1982 to June 21 2003) and CINAHL (from January 1982 to Week 2 June 2003) and contacted authors of published studies and other experts.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials of adults and children with chronic untreatable non-inflammatory muscle disease. The interventions under review included dietary modification, swallowing manoeuvres, a range of surgical interventions and enteral feeding. Our primary outcome was stabilisation of previously documented progressive weight loss not attributable to any other cause or weight gain of at least 5 kg in adults or increase in weight to at least the 10th centile in children, maintained for at least six months following the intervention. Secondary outcomes were: reduction in laryngeal penetration of bolus and/or aspiration observed on videofluoroscopy (modified barium swallow), reduction in chest infections attributable to aspiration over a six-month period, improvement in quality of life using a validated rating scale, the proportion of subjects who refused the intervention, the proportion of carers who refused the intervention, and serious adverse events related to the intervention within the first twelve months after intervention.

DATA COLLECTION AND ANALYSIS

We identified no randomised controlled trials. We identified seven case series reporting the results of surgical intervention for moderate to severe dysphagia, and one reporting on the outcome of feeding advice and enteral feeding in children with a congenital myopathy.

MAIN RESULTS

No studies were found that fulfilled the inclusion criteria. Therefore it was not possible to determine the benefit or otherwise of surgical intervention (cricopharyngeal myotomy or upper oesophageal dilatation) for oculopharyngeal muscular dystrophy or other chronic progressive muscle diseases, and dietary advice or enteral feeding for children with congenital myopathy, compared with no intervention or an alternative intervention.

REVIEWERS' CONCLUSIONS

There are no trials that have adequately evaluated treatments in the management of dysphagia for chronic muscle disease. It is therefore not possible to decide on the most appropriate treatment for a given individual based on current evidence.

The rheology of liquids: a comparison of clinicians' subjective impressions and objective measurement

Texture-modified diets are commonly prescribed for patients with dysphagia; it is therefore important to demonstrate that clinicians form accurate impressions of the rheological (flow) properties of the items that they recommend for their clients. We explored the correlation between objective rheological measurement and clinicians' subjective impressions of liquid consistency, rated on the bases of product labeling and sampling. Ten liquids, ranging from thin through nectar-thick and honey-thick to spoon-thick consistencies, were selected for study. Rheological analysis was conducted using a CarriMed CSL Controlled Stress Rheometer. Fifty speech-language pathologists ranked the liquids in order of perceived viscosity, based on their interpretation of the product packaging and label. Product nomenclature proved insufficient to accurately represent the consistency class to which each liquid belonged. A second group of 16 speech-language pathologists rated the perceived relative viscosity and density of nectar-thick and honey-thick juice items in blinded two-point discrimination tests of stirring-resistance, oral manipulation, and vessel weight. Physical sampling of these two products enabled clinicians to reliably perceive relative viscosity and density differences between the nectar- and honey-thick items.

Evaluation of the benefits of monitoring fluid thickness in the dietary management of dysphagic stroke patients

OBJECTIVE

Safe swallowing may be achieved in most patients with neurogenic dysphagia by manipulating the viscosity of ingested fluids. However, in clinical practice fluids are thickened using subjective judgement. This may lead to errors in the preparation of drinks to the prescribed viscosity. The aim of the present study is to examine whether the use of a viscometer improves the dietary management of dysphagic stroke patients.

STUDY DESIGN

A randomized controlled study design was used. The speech and language therapist determined the optimal fluid thickness for each patient. The prescribed fluid viscosity for the study group was obtained using a viscometer. Patients in the control group received fluids prepared according to current practice, i.e. the amount of thickener required to produce the prescribed viscosity was judged subjectively by the nursing staff. The two methods of fluid thickening were used for seven consecutive days. Assessment was made blind to randomization.

MAIN OUTCOME MEASURE

Pulmonary aspiration, assessed clinically and with pulse oximetry. If the patient did not drink all the fluid that was offered the residue was measured.

RESULTS

Ten patients in the study group (n = 23) and nine in the control group (n = 23) aspirated. The mean viscosity of fluids offered to patients in the control group was significantly higher than that of the study patients. There was a statistically significant correlation between the viscosity and the residual volume of fluid (Pearson's test: r = 0.7, p <0.02). The findings of the study suggest that fluids prepared by subjectively assessing the amount of thickener required to produce a given consistency tend to have a higher viscosity than those prepared using the viscometer. However, the higher viscosity does not appear to protect against pulmonary aspiration and may lead to a reduced fluid intake.

CONCLUSION

Manipulation of fluid thickness using objective measurements with a viscometer may improve the dietary management of dysphagic stroke patients.

Pediatric feeding disorders

Pediatric feeding disorders are common: 25% of children are reported to present with some form of feeding disorder. This number increases to 80% in developmentally delayed children. Consequences of feeding disorders can be severe, including growth failure, susceptibility to chronic illness, and even death. Feeding disorders occur in children who are healthy, who have gastrointestinal disorders, and in those with special needs. Most feeding disorders have underlying organic causes. However, overwhelming evidence indicates that abnormal feeding patterns are not solely due to organic impairment. As such, feeding disorders should be conceptualized on a continuum between psycho-social and organic factors. Disordered feeding in a child is seldom limited to the child alone; it also is a family problem. Assessment and treatment are best conducted by an interdisciplinary team of professionals. At minimum, the team should include a gastroenterologist, nutritionist, behavioral psychologist, and occupational and/or speech therapist. Intervention should be comprehensive and include treatment of the medical condition, behavioral modification to alter the child's inappropriate learned feeding patterns, and parent education and training in appropriate parenting and feeding skills. A majority of feeding problems can be resolved or greatly improved through medical, oromotor, and behavioral therapy. Behavioral feeding strategies have been applied successfully even in organically mediated feeding disorders. To avoid iatrogenic feeding problems, initial attempts to achieve nutritional goals in malnourished children should be via the oral route. The need for exclusive tube feedings should be minimized.

Predictive value of clinical indices in detecting aspiration in patients with neurological disorders

OBJECTIVES

(1) To evaluate the predictive value of a detailed clinical screening of aspiration in patients with neurological diseases, both with and without symptoms of dysphagia taking videofluoroscopy as the gold standard; (2) to assess the existence of risk factors for silent aspiration, measuring the cost-benefit ratio of radiological examination.

METHODS

93 consecutive patients meeting the diagnostic criteria for a neurological disease with a risk of swallowing dysfunctions (cerebrovascular accidents, brain injury, Parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis, myotonic dystrophy, and abiotrophic diseases) underwent a detailed clinical assessment using a 25 item form to check for symptoms of dysphagia and impairment of the oropharyngeal swallowing mechanism. The 3 oz water swallow test was also performed to assess the aspiration risk. Sensitivity, specificity, positive predictive, and negative predictive values (NPV) of dysphagia, history of cough on swallowing, and 3 oz test positivity, versus videofluoroscopy documented aspiration, taken as the gold standard, were measured in all the patients and in subgroups with different neurological disorders.

RESULTS

Non-specific complaints of dysphagia showed a very poor predictive value, whereas the symptom "cough on swallowing" proved to be the most reliable in predicting the risk of aspiration, with 74% sensitivity and specificity, 71% positive predictive, and 77% negative predictive value. The standardised 3-oz test had a higher predictive potential than the clinical signs, but had low sensitivity. The association of cough on swallowing with the 3 oz test gave a positive predictive of 84%, and an negative predictive value of 78%. In cases where the clinical tests failed to detect any impairment, videofluoroscopy documented only a low risk (20%) for mild aspiration.

CONCLUSIONS

The association of two clinical items (such as history of cough on swallowing and 3 oz test positivity) provides a useful screening tool, the cost:benefit ratio of which seems very competitive in comparison with videofluoroscopy in aspiration risk evaluation.

Outcomes of individualized interventions in patients with severe eating difficulties

The aim of this case study is to describe the outcomes of individualized interventions for patients with severe eating difficulties. The participants were 15 patients who had severe eating difficulties following a stroke or brain tumor and were receiving oral feeding or tube feeding. Interventions focused on training functions needed for eating, activities in eating, and discussions with the patient. Improvements were especially noted in eating activities, and some improvements were noted in oral movements and nutritional status. Before the interventions, none of the patients ate regular food; afterward, six did, and in four patients, the feeding tube was removed. The patients said eating was easier, and they could eat in a safe way. Furthermore, they appreciated the attention to their experience during meals. Although the impairments were not always alleviated, the patients found means to cope with their eating difficulties.

Development of an objective method for assessing viscosity of formulated foods and beverages for the dysphagic diet

OBJECTIVE

To develop and validate a practical, economical, and objective viscosity assessment tool, the line-spread test, for foods and beverages formulated for the dysphagic diet. The line-spread test is based on the measure of product dispersion over a flat surface.

DESIGN

Viscosity-altering formulations for a selection of soups and beverages commonly served to patients with dysphagia at a local hospital were developed under controlled conditions. The samples were presented to a trained sensory panel for evaluation by quantitative descriptive analysis and were measured by the line-spread test. Numeric results of the two tests were compared.

SETTING

The Food Research Laboratory with private sensory booths at Mount Saint Vincent University.

MAIN OUTCOME MEASURES

Results of the sensory evaluation and the line-spread test would strongly correlate, indicating predictive validity, but the line-spread test would be more reliable and show variability in measurement.

STATISTICAL ANALYSES PERFORMED

Correlation, analysis of variance (ANOVA), and standard deviations (calculated from the within-group mean square error of the ANOVAs).

RESULTS

ANOVA showed that both the sensory panel results and the line-spread test values indicated significant differences among the samples. Standard deviations indicated less variability in line-spread values. There was a strong positive correlation (r = .90 to .97) between the two types of results, which indicated strong predictive validity for the line-spread test.

APPLICATIONS

The line-spread test is a reliable and valid tool to assess viscosity of formulated foods and beverages for the dysphagic diet and can be readily and economically adapted to any dietary department for product development and quality control.

The effects of cold, touch, and chemical stimulation of the anterior faucial pillar on human swallowing

Cold stimulation of the oropharyngeal mucosa, including the faucial pillar region, is used a specific technique for the treatment of swallowing disorders. The physiological mechanisms underpinning this clinical technique are unclear. Thermal (cold), chemical (saline, glucose and water), mechanical (light touch) and feigned stimulation of the faucial pillar were assessed for their effects on the latency to swallow and the repetitive frequency of swallowing. There was no significant difference between these variables following light stimulation of the faucial pillar with a metal probe warmed to body temperature compared with feigned stimulation. However, cold touch stimulation evoked a significant increase in swallowing latency and repetitive frequency compared to feigned stimulation. The results suggest the existence of thermo-sensitive receptors in the faucial pillars that evoke swallowing when stimulated by cold touch. The clinical and physiological importance of these findings are discussed.

Behavioral treatment for adults with oropharyngeal dysphagia

Oropharyngeal dysphagia has been treated by various professionals for many years, with increasingly more attention paid to this disorder by speech-language pathologists in the past decade. There has been a gradual change in emphasis in the literature, from early anecdotal accounts to more scientific, controlled studies that have tested the outcomes and effectiveness of certain techniques or programs. This article reviews the literature in the area of behavioral treatment for oropharyngeal dysphagia, with a critical look at the current state of knowledge. General treatment programs and techniques developed to facilitate or compensate for specific swallowing disorders are summarized.

A review of dysphagia in four cases of motor neurone disease

Dysphagia is a common and distressing problem in motor neurone disease. This paper examines some of the strategies available for managing patients with dysphagia, and illustrates these with four contrasting case histories. The factors which influence the decision making process in patients with dysphagia are also discussed.