The Criteria of Thickened Liquid for Dysphagia Management in Japan

Effect of bolus property on swallowing dynamics in patients with dysphagia

BACKGROUND

Modification of foods or liquids is commonly administered as part of dysphagia treatment. However, no consensus exists on the parameters for defining texture-modified food for patients with dysphagia.

OBJECTIVES

The aim of this study was to evaluate the effect of food/liquid material on swallowing physiology in patients with dysphagia and to discuss the optimal food choice for direct swallowing therapy.

MATERIALS AND METHODS

A total of 140 patients underwent a videofluoroscopic swallowing study using three test foods/liquids: 3 mL of mildly thick liquid (Thick liquid), jelly made of agar and polysaccharide (Jelly) and jelly made of pectin (Reset gel). Outcome measures of videofluoroscopic images, bolus transit time and hyoid movements were compared.

RESULTS

The frequency of chewing movements was highest for Jelly, followed by Reset gel and Thick liquid. While the probability of oral residue was the highest for Reset gel, pharyngeal residue after swallowing was high for Thick liquid as compared to Jelly and Reset gel. Oral transit time and pharyngeal transit time for Thick liquid were significantly smaller than that for Jelly and Reset gel. Pharyngeal delay time was significantly smaller for Thick liquid than that for Jelly and Reset gel. There was no difference in hyoid elevation time and hyoid movement time among the conditions.

CONCLUSION

Mildly thick liquid material may be optimal for patients with primarily oral motor function impairment and jelly, such as Reset gel, may be more suitable for patients with primarily pharyngeal motor function impairment or oral and pharyngeal coordinative motor function decline.

Relationship between rheological properties, sensory perception, and overall acceptability of thickened liquids for dysphagia in young and old healthy individuals

This study investigated the relationship between rheological properties, sensory perception, and overall acceptability in healthy young and old groups for dysphagia thickened liquids. Unflavored (UTL) and flavored (FTLP) thickened liquids were prepared using tap water or pomegranate juice at 10 different viscosity levels. The rheological properties were then evaluated via syringe flow test and line spread test (LST). When the apparent viscosity levels of UTL and FTLP were similar, the syringe test and LST results were also similar, indicating consistent flow behavior. Sensory perception evaluations showed that the young group better distinguished viscosity differences between stages compared to the old group. Regarding overall acceptability, the old group preferred samples with higher apparent viscosity than the young group. Principal component analysis and k-means cluster analysis were used to explore correlations between variables and classify thickened liquids into four groups. This can serve the foundation for standardized texture grades of dysphagia thickened liquids, considering rheological characteristics and sensory profiles.

Longitudinal Analysis of Dysphagia and Factors Related to Postoperative Pneumonia in Patients Undergoing Esophagectomy for Esophageal Cancer

Few studies have quantified longitudinal changes in swallowing in patients undergoing esophagectomy for esophageal cancer. This study longitudinally analyzed the changes in the Modified Barium Swallow Study Impairment Profile (MBSImP™) scores, swallowing kinematic measurements, and swallowing-related symptoms in patients undergoing esophagectomy. We also examined the association between identified swallowing impairment and aspiration pneumonia after surgery. We included consecutive patients who underwent esophagectomy and completed laryngoscopy and videofluoroscopy before, two weeks, and three months after surgery. We analyzed physiological impairments using the MBSImP. We also assessed the swallowing kinematics on a 5 mL thickened liquid bolus at three time points. Vocal fold mobility was assessed using a laryngoscope. Repeated measures were statistically examined for longitudinal changes in swallowing function. The association between the significant changes identified after esophagectomy and aspiration pneumonia was tested. Twenty-nine patients were included in this study. Preoperative swallowing function was intact in all participants. The timing of swallowing initiation and opening of the pharyngoesophageal segment remained unchanged after surgery. Tongue base retraction and pharyngeal constriction ratio worsened two weeks after surgery but returned to baseline levels three months after surgery. Three months after surgery, hyoid displacement and vocal fold immobility did not fully recover. Aspiration pneumonia occurred in nine patients after surgery and was associated with postoperative MBSImP pharyngeal residue scores. Decreased hyoid displacement and vocal fold immobility were observed postoperatively and persisted for a long time. The postoperative pharyngeal residue was associated with pneumonia and thus should be appropriately managed after surgery.

Effects of Calcium and pH on Rheological Thermal Resistance of Composite Xanthan Gum and High-Methoxyl Apple Pectin Matrices Featuring Dysphagia-Friendly Consistency

High-methoxyl apple pectin (AP) derived from apple was employed as the main ingredient facilitating rheological modification features in developing dysphagia-friendly fluidized alimentary matrices. Xanthan gum (XG) was also included as a composite counterpart to modify the viscoelastic properties of the thickened system under different thermal processes. The results indicate that AP is extremely sensitive to thermal processing, and the viscosity is greatly depleted under a neutral pH level. Moreover, the inclusion of calcium ions echoed the modification effect on the rheological properties of AP, and both the elastic property and viscosity value were promoted after thermal processing. The modification effect of viscoelastic properties (G' and G″) was observed whne XG was incorporated into the composite formula. Increasing the XG ratio from 7:3 to 6:4 (AP:XG) triggers the rheological transformation from a liquid-like form to a solid-like state, and the viscosity value shows that the AP-XG composite system exhibits better thermal stability after thermal processing. The ambient modifiers of pH (pH < 4) and calcium chloride concentration (7.5%) with an optimal AP-XG ratio of 7:3 led to weak-gel-like behavior (G″ < G'), helping to maintain the texture properties of dysphagia-friendly features similar to those prior to the thermal processing.

A Thickening Agent Using Dioscorea japonica Powder Exhibits Suitable Properties for People with Dysphagia

In an aging society, the novel concept of added food functionality in a dysphagia diet is necessary for preventing diseases and maintain nutrition intake. The present study evaluated the utilization of Dioscorea japonica as a thickened liquid for people with dysphagia due to its unique physical properties and beneficial effects on chronic inflammation. The viscosity of the prepared thickened liquid using freeze-dried Dioscorea japonica powder was compared with those of xanthan gum and commercially available thickened liquids in selected conditions resembling to cooking. Dioscorea japonica powder showed high versatility, because the viscosity of its thickened liquid could be easily adjusted by modifying its blending amount and temperature. The thickened liquid of Dioscorea japonica had the most stable viscosity among the thickened liquids when NaCl was added and exhibited excellent resistance to α-amylase, similar to that of the other thickened liquids. The viscosity of the thickened liquid of Dioscorea japonica was relatively stable on changing the pH, but it was slightly unstable when the temperature changed. Overall, the thickened liquid of Dioscorea japonica powder has excellent viscosity stability, comparable to or better than commercially available thickened liquids, and is expected to be used as a new thickened liquid with added food functionality.

Shear-Viscosity-Dependent Effect of a Gum-Based Thickening Product on the Safety of Swallowing in Older Patients with Severe Oropharyngeal Dysphagia

Fluid thickening is a valid therapeutic strategy for patients with oropharyngeal dysphagia (OD). The main aim of this study was to determine the therapeutic effect of the xanthan-gum-based thickener Tsururinko Quickly (TQ, Morinaga Milk Co., Tokyo, Japan) in older patients with severe OD. A total of 85 patients (83.32 ± 6.75 y) with OD and a penetration-aspiration score (PAS) of n ≥ 3 were studied by videofluoroscopy while swallowing duplicate 10 mL boluses at <50 mPa·s, 100, 200, 400, 800, and 1600 mPa·s, to assess the safety and efficacy of swallowing and the biomechanics of a swallowing response at each viscosity level. At <50 mPa·s, only 16.25% patients swallowed safely, 45% had penetrations (PAS 3-5), and 38.75% had aspirations (PAS 6-8). Fluid thickening with TQ greatly increased the prevalence of patients with safe swallowing from 62.90% at 100 mPa·s to 95.24% at 1600 mPa·s in a shear-viscosity-dependent manner. The penetrations and aspirations were significantly reduced to 3.60% and 1.19%, respectively, at 1600 mPa·s. The threshold viscosity was 100 mPa·s and the increasing viscosity above 800 mPa·s did not further improve the therapeutic effect significantly. Increasing the shear viscosity significantly reduced the time to laryngeal vestibule closure (-16.70%), increased the time to upper oesophageal sphincter opening (+26.88%), and reduced the pharyngeal bolus velocity (-31.62%) without affecting the pharyngeal residue. TQ has a strong shear-viscosity-dependent effect on the safety of swallowing in older patients with severe OD without increasing the pharyngeal residue. The therapeutic range for TQ is 100-800 mPa·s, with 200 and 800 mPa·s being the optimal doses to cover the needs of older patients with OD.

Rheological Issues on Oropharyngeal Dysphagia

There is an increasing proof of the relevance of rheology on the design of fluids for the diagnosis and management of dysphagia. In this sense, different authors have reported clinical evidence that support the conclusion that an increase in bolus viscosity reduces the risks of airway penetration during swallowing. However, this clinical evidence has not been associated yet to the definition of objective viscosity levels that may help to predict a safe swallowing process. In addition, more recent reports highlight the potential contribution of bolus extensional viscosity, as elongational flows also develops during the swallowing process. Based on this background, the aim of this review paper is to introduce the lecturer (experts in Dysphagia) into the relevance of Rheology for the diagnosis and management of oropharyngeal dysphagia (OD). In this sense, this paper starts with the definition of some basic concepts on Rheology, complemented by a more extended vision on the concepts of shear viscosity and elongational viscosity. This is followed by a short overview of shear and elongational rheometrical techniques relevant for the characterization of dysphagia-oriented fluids, and, finally, an in-depth analysis of the current knowledge concerning the role of shear and elongational viscosities in the diagnosis and management of OD (shear and elongational behaviors of different categories of dysphagia-oriented products and contrast fluids for dysphagia assessment, as well as the relevance of saliva influence on bolus rheological behavior during the swallowing process).

Effects of thickened carbonated cola in older patients with dysphagia

Carbonated beverages initiate the swallowing reflex earlier than water and have a shorter pharyngeal transit time. However, the effects of carbonation in thickened beverages of the same flavor on swallowing dynamics have not been reported. Therefore, we investigated the effects of thickened carbonated beverages on swallowing in patients with dysphagia by comparing the swallowing dynamics between thickened carbonated and thickened non-carbonated beverages. We enrolled 38 patients with dysphagia and divided them into two groups. Thickened carbonated and thickened non-carbonated beverages were used. Videoendoscopic swallowing evaluations were performed. Aspiration, penetration, pharyngeal residue, and initiation position of the swallowing reflex were evaluated. The reduction in the amount of residue in both the vallecula (p = 0.007) and pyriform sinus (p = 0.004) was greater after ingestion of thickened carbonated cola than thickened non-carbonated cola. The onset of the swallowing reflex was significantly earlier after ingestion of thickened carbonated cola than thickened non-carbonated cola (p = 0.007). There were no significant differences in the extent of penetration. Thickened carbonated beverages positively affected swallowing compared with thickened non-carbonated beverages. Thus, the use of thickened carbonated beverages may be helpful for patients with dysphagia.

Factors Associated with Food Form in Long-Term Care Insurance Facilities

We examined factors related to dietary intake status (food form) of long-term care facility (LTCF) residents to identify factors related to proper food form choice for older individuals requiring nursing care. We surveyed 888 residents from 37 LTCFs in Japan. We evaluated basic information (age, sex, body mass index [BMI]), food form (swallowing-adjusted diet class), Barthel Index (BI), Clinical Dementia Rating (CDR), simply evaluated eating and swallowing functions, the number of present/functional teeth, oral diadochokinesis, repetitive saliva swallowing test (RSST), and modified water swallowing test. To clarify factors associated with food form, participants who had good nutrition by oral intake were categorized into the dysphagic diet (DD) and normal diet (ND) groups. Multi-level analyses were used to detect oral functions associated with food form status. Among objective assessments, BMI (odds ratio [OR] 0.979, 95% confidence interval [CI] - 0.022- to 0.006, p = 0.001), BI (OR 0.993, 95% CI - 0.007 to - 0.004, p < 0.001), CDR 3.0 (OR 1.002, 95% CI 0.002‒0.236, p = 0.046), present teeth (OR 0.993, 95% CI - 0.007 to - 0.001, p = 0.011), functional teeth (OR 0.989, 95% CI - 0.011 to - 0.005, p < 0.001), and RSST (OR 0.960, 95% CI - 0.041 to - 0.007, p = 0.006) were significantly associated with DD vs ND discrimination. Simple evaluations of coughing (OR 1.056, 0.054‒0.198, p = 0.001) and rinsing (OR 1.010, 0.010‒0.174, p = 0.029) could also discriminate food form status. These simple evaluations provide insight into the discrepancies between food form status and eating abilities of LTCF residents. Periodic evaluations by the nursing caregiver may help to prevent aspiration by older individuals with dysphagia.

Neuromuscular electrical stimulation improves swallowing initiation in patients with post-stroke dysphagia

Objective

More than half of post-stroke patients develop dysphagia, which manifests as delayed swallowing and is associated with a high risk of aspiration. In this study, we aimed to investigate the immediate effect of neuromuscular electrical stimulation (NMES) on swallowing initiation in post-stroke patients using videofluoroscopic swallowing study (VFSS) data.

Materials and methods

This randomized, self-controlled crossover study included 35 patients with post-stroke dysphagia. All selected patients received real and sham NMES while swallowing 5 ml of thin liquid. Participants completed the conditions in random order, with a 10-min interval between conditions. The primary evaluation indicators included the Modified Barium Swallow Impairment Profile-6 (MBSImp-6) and Penetration-Aspiration Scale (PAS). Secondary indicators included oral transit time (OTT), pharyngeal transit time (PTT), and laryngeal closure duration (LCD).

Results

Modified Barium Swallow Impairment Profile-6 (P = 0.008) and PAS (P &lt; 0.001) scores were significantly lower in the Real-NMES condition than in the Sham-NMES condition. OTT (P &lt; 0.001) was also significantly shorter during Real-NMES than during Sham-NMES. However, LCD (P = 0.225) and PTT (P = 0.161) did not significantly differ between the two conditions.

Conclusion

Neuromuscular electrical stimulation may represent a supplementary approach for promoting early feeding training in patients with post-stroke dysphagia.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [ChiCTR2100052464].

The sensitivity and specificity of the modified volume-viscosity swallow test for dysphagia screening among neurological patients

Oropharyngeal dysphagia (OD) is a highly prevalent condition after stroke and other neurological diseases. The volume-viscosity swallow test (V-VST) is a screening tool for OD. Considering that the recommendations of volume and thickeners in the original V-VST limited the popularization and application of the test in the Chinese population, we provide the modified V-VST to detect OD among neurological patients. In addition, the accuracy of the modified V-VST to screen OD needs to be verified. We included 101 patients with neurological diseases. OD was evaluated by a modified V-VST and a videofluoroscopy swallowing study (VFSS) using 3 volumes (i.e., 3, 5, and 10 ml) and 4 viscosities (i.e., water, mildly thick, moderately thick, and extremely thick). In this study, to compare with the original V-VST results, a volume of 20 ml was also included. The discriminating ability of modified V-VST in detecting OD was assessed by the sensitivity and specificity values of clinical signs of impaired efficiency (impaired labial seal, piecemeal deglutition, and residue) and impaired safety of swallowing (cough, voice changes, and oxygen desaturation ≥3%) in comparison to the results of VFSS. The modified V-VST showed 96.6% sensitivity and 83.3% specificity for OD, 85.2% sensitivity and 70% specificity for impaired safety, and 90.9% sensitivity and 76.9% specificity for impaired efficacy. Our study suggests that the modified V-VST offers a high discriminating ability in detecting OD among neurological patients.

Observational Variables for Considering a Switch from a Normal to a Dysphagia Diet among Older Adults Requiring Long-Term Care: A One-Year Multicenter Longitudinal Study

This one-year multicenter longitudinal study aimed to assess whether older adult residents of long-term care facilities should switch from a normal to a dysphagia diet. Using the results of our previous cross-sectional study as baseline, older adults were subdivided into those who maintained a normal diet and those who switched to a dysphagia diet. The explanatory variables were age, sex, body mass index (BMI), Barthel Index, clinical dementia rating (CDR), and 13 simple and 5 objective oral assessments (remaining teeth, functional teeth, oral diadochokinesis, modified water swallowing test, and repetitive saliva swallowing test), which were used in binomial logistic regression analysis. Between-group comparison showed a significantly different BMI, Barthel Index, and CDR. Significant differences were also observed in simple assessments for language, drooling, tongue movement, perioral muscle function, and rinsing and in objective assessments. In multi-level analysis, switching from a normal to a dysphagia diet was significantly associated with simple assessments of tongue movement, perioral muscle function, and rinsing and with the objective assessment of the number of functional teeth. The results suggest that simple assessments can be performed regularly to screen for early signs of discrepancies between food form and eating/swallowing functions, which could lead to the provision of more appropriate food forms.

Effects of the internal syringe shape on the International Dysphagia Diet Standardization Initiative flow test

The International Dysphagia Diet Standardization Initiative (IDDSI) proposed the flow test (FT) as a simple method for measuring the viscosity of thickened liquids. However, the FT specifies the use of a particular syringe type (BD-Slip), which is unfortunately not easily available in Japan. Therefore, the current study primarily aimed to investigate the effects of the internal syringe shape on IDDSI FT and identify the most suitable syringe available in Japan for xanthan gum-based thickened liquids. Accordingly, four syringes, namely, Luer slip tip, Luer-Lok tip, TERUMO, and NIPRO syringes, were used to examine FT value with water and nine different water viscosity levels. The correlation and systematic errors on residual FT values between the BD-Slip syringe and the other three syringes were analyzed. The two-dimensional internal shapes of the four syringes were measured using industrial computed tomography (CT) scanning. Based on the results of our FT, TERUMO had the smallest error range among the three syringes, without systematic errors. On a CT scan, three of five tip-shape parameters showed the smallest difference between BD-Slip and TERUMO syringe. Therefore, TERUMO had the smallest FT error range compared with that in BD-Slip tip syringe, indicating that TERUMO could be used as a substitute for BD-Slip when performing IDDSI FT with xanthan gum-based thickened water in Japan.

Risk Factors for Aspiration Pneumonia After Receiving Liquid-Thickening Recommendations

Objective

We examined the influence of liquid thickness levels on the frequency of liquid penetration-aspiration in patients with dysphagia and evaluated the clinical risk factors for penetration-aspiration and aspiration pneumonia development.

Study Design

A case series.

Setting

Single-institution academic center.

Methods

We reviewed medical charts from 2018 to 2019. First, we evaluated whether liquid thickness levels influence the frequency of liquid penetration-aspiration in patients with dysphagia. Penetration-aspiration occurrence in a videofluoroscopic swallowing study was defined as Penetration-Aspiration Scale (PAS) scores ≥3. Second, the association between liquid thickness level and penetration-aspiration was analyzed, and clinical risk factors were identified. Moreover, clinical risk factors for aspiration pneumonia development within 6 months were investigated.

Results

Of 483 patients, 159 showed penetration-aspiration. The thickening of liquids significantly decreased the incidence of penetration-aspiration (P < .001). Clinical risk factors for penetration-aspiration were vocal fold paralysis (odds ratio [OR], 1.99), impaired laryngeal sensation (OR, 5.01), and a history of pneumonia (OR, 2.90). Twenty-three patients developed aspiration pneumonia while undertaking advised dietary changes, including liquid thickening. Significant risk factors for aspiration pneumonia development were poor performance status (OR, 1.85), PAS score ≥3 (OR, 4.03), and a history of aspiration pneumonia (OR, 7.00).

Conclusion

Thickening of liquids can reduce the incidence of penetration-aspiration. Vocal fold paralysis, impaired laryngeal sensation, and history of aspiration pneumonia are significant risk factors of penetration-aspiration. Poor performance status, PAS score ≥3, and history of aspiration pneumonia are significantly associated with aspiration pneumonia development following recommendations on thickening liquids.

Level of Evidence

3.

Tongue muscle strength affects posterior pharyngeal wall advancement during swallowing: A cross-sectional study of outpatients with dysphagia

Background

Tongue muscle strength is important for swallowing but decreases with age, in association with reduced skeletal muscle mass. However, the relationships between pharyngeal dynamics and both skeletal muscle mass and tongue muscle strength are unknown.

Objective

To investigate the effect of reductions in tongue muscle strength on pharyngeal movement during swallowing in patients with dysphagia.

Methods

Subjects were selected from male outpatients ≥65 years old who were examined for the main complaint of dysphagia. Patients with history of neurodegenerative disease affecting tongue movement, cerebrovascular disease or oral cancer were excluded. As a result, 82 men (mean age, 80.6 ± 6.8 years) participated. Skeletal muscle mass index (SMI) as physical parameters and maximum tongue pressure (MTP) as tongue muscles strength were measured. Status and dynamics of the pharyngeal organs, including change in posterior pharyngeal wall advancement (PPWA) when swallowing 3.0 mL of moderately thick liquid, were measured by analysing videofluoroscopic images. Simple bivariate correlation and multiple regression analysis were used to statistically analyse correlations between parameters.

Results

MTP showed a significant positive correlation with SMI (r = .43, P < .01). PPWA showed a significant negative correlation with MTP (r = −0.30, P < .01), but no association with SMI.

Conclusions

While tongue muscle strength is affected by skeletal muscle mass, posterior pharyngeal wall advancement is not readily affected by decreases in skeletal muscle mass. Posterior pharyngeal wall advancement may increase to compensate for swallowing function among individuals with reduced tongue muscle strength.

Ingredients of Jelly Products Affect Aspiration-Related Pulmonary Inflammation; in an Animal Study

Diet modification is an important intervention in the management of patients with dysphagia. Food entering the airway, same as oral bacterium, causes pulmonary inflammation; therefore, the elucidation of inflammatory responses to different foods is important. This study aimed to investigate the differences in the severity of inflammatory response induced by intratrachial injection of foods with different nutritional components. Two jelly products, the one containing only carbohydrates (KURIN jelly: Isocal Jelly KURIN^®) and the other containing carbohydrates, proteins, and lipids (HC jelly: Isocal Jelly HC^®), were prepared. These jelly products (dilution with saline, 50% volume/volume) and saline, as control, were intratracheally administered to Sprague-Dawley rats at a dose of 1 ml/kg (KURIN group (n = 15), HC group (n = 15), Saline group (n = 15)). At 1, 2 and 7 days after administration, lungs were harvested and histological analysis was performed. The severity of induced inflammation was evaluated using the Acute Lung Injury (ALI) score with hematoxylin-eosin staining, and the expression of IL-1β, IL-6 and TNF-α, markers of airway inflammation, were observed with immunostaining. The ALI score in the HC jelly group was significantly higher than the KURIN jelly group and the Saline group (P < 0.01) at 1 and 2 days after administration, while the ALI score in the KURIN jelly group was higher than Saline group only at 2 day after administration. Numerous positive cells for IL-1β, IL-6 and TNF-α were observed only in the HC jelly group at 1 and 2 days after administration. There were no significant histological differences between the three groups at 7 days after administration. Our data suggests that the severity of inflammation caused by aspiration differs depending on the ingredients of the foods, and the nutrients contained in foods might be considered in dietary management for the patients with dysphagia.

Textural Changes by Mastication and Proper Food Texture for Patients with Oropharyngeal Dysphagia

Bolus texture is a key factor for safe swallowing in patients with dysphagia since an improper texture may result in aspiration and/or pharyngeal residue. This article discusses swallowing bolus texture from two key aspects: the textural change of solid food by mastication and the current standardized definition of food texture in Japan. When swallowing a liquid bolus, the texture is mostly maintained from ingestion to swallow onset. For solid food, however, the food is crushed by chewing and mixed with saliva before swallowing; the texture of the ingested food is modified to an easily swallowable form at swallow onset by mastication. Understanding the mechanism of mastication and its assessment are therefore important in deciding the proper diet for dysphagic patients. As standardized criteria for classifying the texture of food and liquid are essential as well, this report also describes the Japanese Dysphagia Diet 2013 that is commonly used as the standardized index for dysphagic diets in Japan.

Triple Adaptation of the Mediterranean Diet: Design of A Meal Plan for Older People with Oropharyngeal Dysphagia Based on Home Cooking

Background: Oropharyngeal dysphagia (OD) and malnutrition are highly prevalent in older patients that are discharged from general hospitals (47% and 30%, respectively). Aims: To develop a nutritional plan for these patients involving a triple adaptation of their traditional diet: (a) rheological adaptation (texture and viscosity) for safe deglutition, (b) nutritional adaptation (water, calories, and proteins), and (c) organoleptic adaptation to improve compliance. Methods: Two fluid viscosities (250 and 800 mPa·s) were selected according to previous studies on optimal viscosities in older patients. The British Dietetic Association food texture classification based on common clinical practice selected two food textures (thick purée and fork-mashable. Two levels of calorie protein enrichment were selected according to previous studies using the Mini Nutritional Assessment (MNA^®). Results: The daily caloric-protein and hydric needs were established at 1750 kcal, 70 g protein, and 1750 mL water in patients with MNA^® ≥ 17; and, 2037 kcal, 90 g protein, and 2000 mL water/day in malnourished patients. Sixteen weekly menus (296 recipes) were developed while using two textures, two levels of viscosity, two nutritional phenotypes (normal/at-risk vs. malnourished), and two seasons of the year (spring/summer-autumn/winter) based on Mediterranean cuisine. Conclusion: This concept paper demonstrates that traditional Mediterranean cooking can be adapted to meet the rheological, nutritional, and hydration needs of older patients with OD. The recipes that we have developed meet the needs of patients with varying degrees of OD and malnutrition are reproducible in patient’s homes and they could have a major impact on the clinical outcomes of these patients.

Thickened Liquids for Dysphagia Management: a Current Review of the Measurement of Liquid Flow

PURPOSE OF REVIEW

The use of thickened liquids has become one of the most common management strategies for individuals with dysphagia. The purpose of this paper is to review methods that can be used to measure the flow characteristics of liquids used in dysphagia management. We describe the measurement of apparent viscosity, measures of extensional flow, slump tests (specifically the line-spread test and Bostwick consistometry), gravity flow tests, and subjective methods.

RECENT FINDINGS

We discuss the relationship between different approaches to measuring flow, the 2002 American National Dysphagia Diet and the 2017 International Dysphagia Diet Standardisation Initiative (IDDSI) framework. A comparison of test results across four methods is provided.

SUMMARY

A consistent approach is needed for the measurement of flow for thickened liquids used in dysphagia management. This review highlights differences that can be expected across different flow testing methodologies. Adherence to a common method and measurement definitions will promote patient safety and facilitate future research regarding the effectiveness of texture modification as an intervention for dysphagia.