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Davies V, Taylor M. Nutritional and hydration interventions for people with dysphagia. Nurs Stand 2024; 39:77-81. [PMID: 38544435 DOI: 10.7748/ns.2024.e12237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2024] [Indexed: 04/04/2024]
Abstract
Dysphagia (swallowing difficulties) is particularly common in older people and is associated with various health conditions. Dysphagia affects an individual's ability to eat and drink, and can have a significant effect on their clinical outcomes and quality of life. This article explores ways in which nurses can support people with dysphagia to minimise the effects of the condition and enhance their quality of life. The authors examine the role of commonly used strategies such as dietary texture modification and thickened fluids that aim to optimise nutrition and hydration. However, some of the management options for dysphagia do not have a strong evidence base, so nurses should consider whether any dietary restrictions are proportionate and ensure that their benefits outweigh the risks.
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Affiliation(s)
- Vicky Davies
- Faculty of Social and Life Sciences, Wrexham University, Wrexham, Wales
| | - Melanie Taylor
- The Walton Centre NHS Foundation Trust, Liverpool, England
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McCurtin A, Byrne H, Collins L, McInerney M, Lazenby-Paterson T, Leslie P, O'Keeffe S, O'Toole C, Smith A. Alterations and Preservations: Practices and Perspectives of Speech-Language Pathologists Regarding the Intervention of Thickened Liquids for Swallowing Problems. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024; 33:117-134. [PMID: 37889208 DOI: 10.1044/2023_ajslp-23-00226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
PURPOSE The intervention of thickened liquids (TL) is commonly used to reduce aspiration in people with dysphagia. Speech-language pathologists (SLPs) have traditionally believed it is an effective intervention. Recent articles highlight limited evidence, poor acceptance, and a variety of unintended consequences. This study explores if current debates have been reflected in SLP practices and perspectives. METHOD An e-survey was developed. Participants were recruited via professional associations in Australia, New Zealand, Ireland, the United Kingdom, and the United States. Descriptive and inferential statistics were used to explore the data. Principal component analysis was used to summarize SLP practices and perspectives. RESULTS The 370 respondents represented mainly experienced, confident, hospital-based clinicians. While 20% of respondents frequently recommend TL, 61% believe it to be a burdensome treatment. "Best treatment" and "It works" beliefs continue to underpin decision making. Those who recommend TL most often are most influenced by penetration, coughing, and their own clinical experience. They are more likely to believe TL is evidence based and effective, reduces aspiration, and improves hydration. Person-centeredness is important among all respondents, although significant numbers would implement TL against patient wishes. Improvements in aspiration status and quality of life rank highly as reasons to discontinue TL. CONCLUSIONS The results of this study suggest that fewer respondents are regularly using TL. Divergent groups are evident with those frequently employing and believing in the efficacy of TL and those who do not. While current debates are influencing practice, there clearly remains a significant number of SLPs continuing to recommend TL. This study's findings highlight both alterations and preservations in the discipline's approach to TL and calls for SLPs to reframe our thinking regarding this intervention as well as consider alternative options in this treatment space. SUPPLEMENTAL MATERIAL https://doi.org/10.23641/asha.24317110.
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Affiliation(s)
- Arlene McCurtin
- School of Allied Health, University of Limerick, Ireland
- Health Research Institute, Health Implementation Science and Technology Research Cluster, University of Limerick, Ireland
- Swallow Perspectives, Advocacy and Research Collective (SPARC), University of Limerick
| | - Hannah Byrne
- School of Allied Health, University of Limerick, Ireland
| | - Lindsey Collins
- Swallow Perspectives, Advocacy and Research Collective (SPARC), University of Limerick
- Centre for Applied Dementia Studies, Faculty of Health Studies, University of Bradford, United Kingdom
| | - Michelle McInerney
- School of Allied Health, University of Limerick, Ireland
- Swallow Perspectives, Advocacy and Research Collective (SPARC), University of Limerick
- CP-ACHIEVE in Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Tracy Lazenby-Paterson
- Swallow Perspectives, Advocacy and Research Collective (SPARC), University of Limerick
- Intellectual (Learning) Disability Service, NHS Lothian, Edinburgh, United Kingdom
| | - Paula Leslie
- Swallow Perspectives, Advocacy and Research Collective (SPARC), University of Limerick
- Newcastle External Assessment Group, Northern Medical Physics and Clinical Engineering, Newcastle upon Tyne Hospitals NHS Trust, United Kingdom
- Center for Bioethics and Health Law, University of Pittsburgh, PA
| | - Shaun O'Keeffe
- Swallow Perspectives, Advocacy and Research Collective (SPARC), University of Limerick
- Department of Geriatric Medicine, Galway University Hospitals, Ireland
| | - Claire O'Toole
- School of Allied Health, University of Limerick, Ireland
| | - Alison Smith
- Swallow Perspectives, Advocacy and Research Collective (SPARC), University of Limerick
- NHS Hertfordshire and West Essex Integrated Care Board, Hemel Hempstead, United Kingdom
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Werden Abrams S, Gandhi P, Namasivayam-MacDonald A. The Adverse Effects and Events of Thickened Liquid Use in Adults: A Systematic Review. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:2331-2350. [PMID: 37437527 DOI: 10.1044/2023_ajslp-22-00380] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
PURPOSE Practice pattern studies suggest that liquid modification is currently a primary strategy used by speech-language pathologists to manage dysphagia; however, the breadth of negative consequences associated with their use is not well understood. The purpose of this review was to summarize the evidence on adverse events and effects of thickened liquid (TL) use in adults. METHOD Six databases were searched in February 2022: EMBASE, MEDLINE (PubMed), Speechbite, AMED, AgeLine, and CINAHL. Articles were included if they compared adults receiving different TL viscosities and discussed at least one adverse event or effect of consuming TLs. Articles were excluded if they were review articles, rehabilitation studies, rheological analyses, not in English, or not peer reviewed. Screening and data extraction were completed by two independent reviewers. Risk of bias was assessed using Cochrane tools. RESULTS Thirty-three studies (N = 4,990 participants across all studies) were eligible for inclusion (2,405 unique records screened). Reported adverse events included dehydration (n = 5), pneumonia (n = 4), death (n = 2), urinary tract infection (n = 1), and hospitalization (n = 1); adverse effects included reduced quality of life (n = 18), aspiration (n = 12), reduced intake (n = 8), increased residue (n = 4), and reduced medication bioavailability (n = 2). Results were mapped on to codes and domains of the International Classification of Functioning, Disability and Health. CONCLUSIONS A range of adverse outcomes associated with TL use were identified. Adverse outcomes should be monitored and reported in dysphagia research. Given current research evidence, it is vital for clinicians to weigh the risks and benefits of TL use to mitigate potential adverse outcomes.
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Affiliation(s)
- Sophia Werden Abrams
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Pooja Gandhi
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute, University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Ontario, Canada
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Gallegos C, Turcanu M, Assegehegn G, Brito-de la Fuente E. Rheological Issues on Oropharyngeal Dysphagia. Dysphagia 2023; 38:558-585. [PMID: 34216239 DOI: 10.1007/s00455-021-10337-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Abstract
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).
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Affiliation(s)
- Crispulo Gallegos
- Product and Process Engineering Center, Fresenius Kabi Deutschland GmbH, Daimlerstrasse 22, 61352, Bad Homburg, Germany.
| | - Mihaela Turcanu
- Product and Process Engineering Center, Fresenius Kabi Deutschland GmbH, Daimlerstrasse 22, 61352, Bad Homburg, Germany
| | - Getachew Assegehegn
- Product and Process Engineering Center, Fresenius Kabi Deutschland GmbH, Daimlerstrasse 22, 61352, Bad Homburg, Germany
| | - Edmundo Brito-de la Fuente
- Product and Process Engineering Center, Fresenius Kabi Deutschland GmbH, Daimlerstrasse 22, 61352, Bad Homburg, Germany
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O’Keeffe ST, Leslie P, Lazenby-Paterson T, McCurtin A, Collins L, Murray A, Smith A, Mulkerrin S. Informed or misinformed consent and use of modified texture diets in dysphagia. BMC Med Ethics 2023; 24:7. [PMID: 36750907 PMCID: PMC9903443 DOI: 10.1186/s12910-023-00885-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 01/25/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Use of modified texture diets-thickening of liquids and modifying the texture of foods-in the hope of preventing aspiration, pneumonia and choking, has become central to the current management of dysphagia. The effectiveness of this intervention has been questioned. We examine requirements for a valid informed consent process for this approach and whether the need for informed consent for this treatment is always understood or applied by practitioners. MAIN TEXT Valid informed consent requires provision of accurate and balanced information, and that agreement is given freely by someone who knows they have a choice. Current evidence, including surveys of practitioners and patients in different settings, suggests that practice in this area is often inadequate. This may be due to patients' communication difficulties but also poor communication-and no real attempt to obtain consent-by practitioners before people are 'put on' modified texture diets. Even where discussion occurs, recommendations may be influenced by professional misconceptions about the efficacy of this treatment, which in turn may poison the well for the informed consent process. Patients cannot make appropriate decisions for themselves if the information provided is flawed and unbalanced. The voluntariness of patients' decisions is also questionable if they are told 'you must', when 'you might consider' is more appropriate. Where the decision-making capacity of patients is in question, inappropriate judgements and recommendations may be made by substitute decision makers and courts unless based on accurate information. CONCLUSION Research is required to examine the informed consent processes in different settings, but there is ample reason to suggest that current practice in this area is suboptimal. Staff need to reflect on their current practice regarding use of modified texture diets with an awareness of the current evidence and through the 'lens' of informed consent. Education is required for staff to clarify the importance of, and requirements for, valid informed consent and for decision making that reflects people's preferences and values.
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Affiliation(s)
- Shaun T. O’Keeffe
- grid.412440.70000 0004 0617 9371Department of Geriatric Medicine, Galway University Hospitals, Newcastle Rd, Galway, Ireland
| | - Paula Leslie
- grid.420004.20000 0004 0444 2244Northern Medical Physics and Clinical Engineering, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Tracy Lazenby-Paterson
- grid.39489.3f0000 0001 0388 0742NHS Lothian Community Learning Disability Service, Leith Community Treatment Centre, Edinburgh, UK
| | - Arlene McCurtin
- grid.10049.3c0000 0004 1936 9692School of Allied Health, University of Limerick, Limerick, Ireland ,grid.10049.3c0000 0004 1936 9692Health Implementation Science and Technology Research Group, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Lindsey Collins
- grid.6268.a0000 0004 0379 5283Centre for Applied Dementia StudiesFaculty of Health Studies, University of Bradford, Bradford, UK
| | - Aoife Murray
- grid.6142.10000 0004 0488 0789School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Alison Smith
- Pharmacy and Medicines Optimisation Team, Herts Valleys Clinical Commissioning Group, Hemel Hempstead, UK
| | - Siofra Mulkerrin
- grid.120073.70000 0004 0622 5016Department of Speech and Language Therapy, Addenbrooke’s Hospital, Cambridge, England, UK
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Advances in 3D printing of food and nutritional products. ADVANCES IN FOOD AND NUTRITION RESEARCH 2022; 100:173-210. [PMID: 35659352 DOI: 10.1016/bs.afnr.2021.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The main advantage of both 3D printing (3DP) and 3D food printing (3DFP) over other technologies is the enormous capacity of both techniques for customization. Its use makes it possible to obtain products without planning and implementing a complex and costly manufacturing process. This makes 3DFP a technology of choice for the preparation of food products that meet specific needs, such as controlled nutritional or rheological properties. However, further technological developments are still needed before 3DFP can be considered fully useful for innovative and demanding applications. If both preparation and post-processing of materials based on 3D printing are optimized, aiming to reduce production time and/or complication for non-expert users, this would open a whole new range of possibilities. It is in this sense that the development of advanced 3DFP systems becomes a must. This chapter reviews current advances in extrusion-based 3D food printing systems, with in situ gelation and mixing as key aspects to better exploit the potential of 3DFP. On one hand, 3DFP systems based on in situ gelation (G3DFP) provide greater control over the final properties of the printed products, as the selection of adequate printing parameters gives the possibility of influencing the gelation process. On the other hand, mixing is indispensable for true 3DFP automation, so that the formulations do not have to be prepared by the user. Different innovative 3DFP systems based on gelling and/or mixing are presented in this chapter. Finally, the status and future of extrusion-based 3DFP, and its application in the production of customized foods for specific needs, are also overviewed.
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Diañez I, Gallegos C, Brito-de la Fuente E, Martínez I, Valencia C, Sánchez M, Franco J. Implementation of a novel continuous solid/liquid mixing accessory for 3D printing of dysphagia-oriented thickened fluids. Food Hydrocoll 2021. [DOI: 10.1016/j.foodhyd.2021.106900] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Steele SJ, Ennis SL, Dobler CC. Treatment burden associated with the intake of thickened fluids. Breathe (Sheff) 2021; 17:210003. [PMID: 34295407 PMCID: PMC8291955 DOI: 10.1183/20734735.0003-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 04/08/2021] [Indexed: 12/19/2022] Open
Abstract
The implementation of thickened fluids in patients with dysphagia is widely considered an effective strategy for safe and physiologically improved swallow. However, there is limited evidence to suggest that this intervention reduces the risk of dysphagia-related complications including aspiration pneumonia. In addition, there is growing evidence that this approach is associated with adverse clinical effects including dehydration, malnutrition and reduced health-related quality of life. This review summarises the rationale for thickened fluids, the evidence base (or lack thereof) underpinning their use, and current guideline recommendations. Educational aims To review the evidence base for thickened fluids in the management of dysphagia.To examine the evidence that thickened fluids reduce aspiration pneumonia.To provide an overview of the advantages and disadvantages of thickened fluids in the management of dysphagia.
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Affiliation(s)
- Simon J Steele
- Dept of General and Acute Care Medicine, Alfred Hospital, Melbourne, Australia
| | - Samantha L Ennis
- Dept of Respiratory and Sleep Medicine, Liverpool Hospital, Sydney, Australia
| | - Claudia C Dobler
- Dept of Respiratory and Sleep Medicine, Liverpool Hospital, Sydney, Australia.,The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Thickened liquids: do they still have a place in the dysphagia toolkit? Curr Opin Otolaryngol Head Neck Surg 2021; 28:145-154. [PMID: 32332203 DOI: 10.1097/moo.0000000000000622] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW The use of commercially or naturally thickened liquids is a well-established treatment for patients with dysphagia to fluids, the aim of which is to improve swallow safety by minimizing risk of aspiration. Although the most recent systematic reviews conclude that this treatment lacks evidential support and leads to patient-reported worsening health and quality of life, thickened liquids continue to be used with patients with dysphagia across clinical settings. This review briefly summarizes the evidence and considers potential reasons for the apparent mismatch between the evidence and clinical practice. RECENT FINDINGS Continuing practice with thickened liquids is influenced by a range of factors, including gaps in clinical knowledge, inadequate patient involvement, a culture of common practice and a reliance on invalid surrogate studies or research lacking a credible association between thickened liquids and clinically meaningful endpoints. SUMMARY While awaiting further research, clinical decision-making about thickened liquids can be improved by considering the evidence of clinically meaningful endpoints, promoting shared decision-making with patients and underpinning practice with knowledge about the complex relationship between dysphagia, aspiration and pneumonia.
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McCurtin A, Brady R, Coffey K, O'Connor A. Clarity and contradictions: speech and language therapists' insights regarding thickened liquids for post-stroke aspiration. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2020. [DOI: 10.12968/ijtr.2019.0020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background/Aims Oropharyngeal dysphagia is a common condition following stroke, with adverse consequences including aspiration pneumonia. Internationally, aspiration risk is typically managed using thickened liquids, an intervention with limited empirical support and associated treatment adherence issues. This study explores speech and language therapists' perceptions of and reasons for employing this intervention. Methods A total of 22 speech and language therapists working with people with dysphagia post-stroke in hospital settings participated in three focus groups. Participants were recruited through gatekeeper managers and data were analysed using inductive thematic analysis. Results Three themes were identified: primary justifications for treatment use, acute implementation issues, and having doubts. Use of thickened liquids is pivoted on safety-first reasoning, employed as a first step on the treatment ladder and in the context of limited perceived alternatives. Both clarity and contradictions are revealed by therapists, who acknowledge multiple factors that impact treatment effectiveness, including hospital, patient and product issues. Conclusions The findings from this study provide a basis for understanding clinical decision making for a widely-used gateway treatment that requires further empirical support. The data suggest that, similar to other professions, safety-first reasoning is paramount for speech and language therapists. The dominance of thickened liquids in treating aspiration is reflected internationally and warrants ongoing discussion.
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Affiliation(s)
- Arlene McCurtin
- School of Allied Health, University of Limerick, Limerick, Ireland
- Health Research Institute, University of Limerick, Limerick, Ireland
| | - Ronan Brady
- School of Allied Health, University of Limerick, Limerick, Ireland
| | - Katherine Coffey
- School of Allied Health, University of Limerick, Limerick, Ireland
| | - Anne O'Connor
- School of Allied Health, University of Limerick, Limerick, Ireland
- Health Research Institute, University of Limerick, Limerick, Ireland
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Casazza GC, Graham ME, Asfour F, O'Gorman M, Skirko J, Meier JD. Aspiration in the otherwise healthy Infant-Is there a natural course for improvement? Laryngoscope 2019; 130:514-520. [PMID: 30835858 DOI: 10.1002/lary.27888] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES/HYPOTHESIS Timing and indication for surgical intervention is a major challenge in managing pediatric oropharyngeal dysphagia. No study has evaluated a natural course of swallowing dysfunction in otherwise healthy infants. Our objective was to review the outcomes and time to resolution of abnormal swallow in infants with aspiration. STUDY DESIGN Retrospective case series at a tertiary children's hospital. METHODS Fifty patients under 1 year old with aspiration on a modified barium swallow study were included. Patients born <34 weeks, with medical or genetic comorbidities, or who underwent surgical intervention for aspiration were excluded. Patients were followed until aspiration resolved on a swallow study. Kaplan-Meier survival analysis was performed. RESULTS Forty patients (25 patients [50%] by 6 months, 10 [20%] by 1 year, three [6%] by 2 years, and two [4%] at the end of the follow-up interval) were recommended a normal diet, and 10 patients (20%) were still aspirating by the end of the follow-up interval. Median time to resolution was 202 ± 7 days (range, 19-842 days), probability 48% (95% confidence interval [CI]: 0.34-0.62). The probability of resolution at 6 months was 46% (95% CI: 0.4-0.68), at 1 year was 64% (95% CI: 0.51-0.77), at 2 years was 76% (95% CI: 0.64-0.88), and at the end of the follow-up interval 81.3% (95% CI: 0.7-0.92). CONCLUSIONS The majority of infants with aspiration and without any other major comorbidities improved within 1 year. Future research should be directed toward better understanding swallowing dysfunction in neurologically normal infants. LEVEL OF EVIDENCE 4 Laryngoscope, 130:514-520, 2020.
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Affiliation(s)
- Geoffrey C Casazza
- Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, U.S.A.,Primary Children's Hospital, Salt Lake City, Utah, U.S.A
| | - M Elise Graham
- Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, U.S.A.,Primary Children's Hospital, Salt Lake City, Utah, U.S.A
| | - Fadi Asfour
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, U.S.A.,Primary Children's Hospital, Salt Lake City, Utah, U.S.A
| | - Molly O'Gorman
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, U.S.A.,Primary Children's Hospital, Salt Lake City, Utah, U.S.A
| | - Jonathan Skirko
- Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, U.S.A.,Primary Children's Hospital, Salt Lake City, Utah, U.S.A
| | - Jeremy D Meier
- Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, U.S.A.,Primary Children's Hospital, Salt Lake City, Utah, U.S.A
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O'Keeffe ST. Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified? BMC Geriatr 2018; 18:167. [PMID: 30029632 PMCID: PMC6053717 DOI: 10.1186/s12877-018-0839-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 06/19/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Although modifying diets, by thickening liquids and modifying the texture of foods, to reduce the risk of aspiration has become central to the current management of dysphagia, the effectiveness of this intervention has been questioned. This narrative review examines, and discusses possible reasons for, the apparent discrepancy between the widespread use of modified diets in current clinical practice and the limited evidence base regarding the benefits and risks of this approach. DISCUSSION There is no good evidence to date that thickening liquids reduces pneumonia in dysphagia and this intervention may be associated with reduced fluid intake. Texture-modified foods may contribute to undernutrition in those with dysphagia. Modified diets worsen the quality of life of those with dysphagia, and non-compliance is common. There is substantial variability in terminology and standards for modified diets, in the recommendations of individual therapists, and in the consistency of diets prepared by healthcare staff for consumption. Although use of modified diets might appear to have a rational pathophysiological basis in dysphagia, the relationship between aspiration and pneumonia is not clear-cut. Clinical experience may be a more important determinant of everyday practice than research evidence and patient preferences. There are situations in the management of dysphagia where common sense and the necessity of intervention will clearly outweigh any lack of evidence or when application of evidence-based principles can enable good decision making despite the absence of robust evidence. Nevertheless, there is a significant discrepancy between the paucity of the evidence base supporting use of modified diets and the beliefs and practices of practitioners. CONCLUSION The disconnect between the limited evidence base and the widespread use of modified diets suggests the need for more careful consideration as to when modified diets might be recommended to patients. Patients (or their representatives) have a choice whether or not to accept a modified diet and must receive adequate information, about the potential risks and impact on quality of life as well as the possible benefits, to make that choice. There is an urgent need for better quality evidence regarding this intervention.
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Affiliation(s)
- Shaun T O'Keeffe
- Department of Geriatric Medicine, Galway University Hospitals, Galway, Ireland.
- Unit 4, Merlin Park University Hospital, Galway, Ireland.
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ESPEN guideline clinical nutrition in neurology. Clin Nutr 2018; 37:354-396. [DOI: 10.1016/j.clnu.2017.09.003] [Citation(s) in RCA: 193] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 12/12/2022]
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Zanini M, Bagnasco A, Catania G, Aleo G, Sartini M, Cristina ML, Ripamonti S, Monacelli F, Odetti P, Sasso L. A Dedicated Nutritional Care Program (NUTRICARE) to reduce malnutrition in institutionalised dysphagic older people: A quasi-experimental study. J Clin Nurs 2017; 26:4446-4455. [PMID: 28231616 DOI: 10.1111/jocn.13774] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2017] [Indexed: 10/20/2022]
Abstract
AIMS AND OBJECTIVES To assess the effects of a texture-modified food program for dysphagia on the nutritional, biochemical and functional profile in a cohort of institutionalised older people in Italy. BACKGROUND Dysphagic institutionalised older people, often also affected by dementia, are frequently exposed to malnutrition. Malnutrition in older people has negative effects on mortality, days of hospitalisation, infection, wound healing and risk of pressure injuries. Therefore, it is very important to prevent malnutrition in this frail population. DESIGN A pre-post study without a control group. METHODS The study included 479 dysphagic institutionalised older people from 20 nursing homes. Anthropometrical, biochemical, nutritional and functional parameters were collected retrospectively, 6 months before the study intervention, at time zero and, prospectively for 6 months after implementing the NUTRICARE food programme, for a total of nine evaluations. The NUTRICARE programme includes meals without nutritional supplementation, and personalised levels of density, viscosity, texture and particle size. RESULTS The total mean body mass index of our sample passed from 17.88-19.00; body weight averagely improved by 7.19%, as well as their nutritional and biochemical profiles. There was a progressive improvement of total protein and serum albumin values. Nutritional parameters (serum transferrin and lymphocytes) displayed similar changes. Plasma lymphocytes reached normal levels in 98.23% of the sample. Plasma creatinine levels remained steady throughout the study and within the normal range. No side effects were reported. CONCLUSION The NUTRICARE food programme with a adequate proteins, calories, balanced nutritional and bromatological properties, and appropriate texture and palatability significantly improved the nutritional, biochemical and functional profile in a cohort of institutionalised dysphagic older people. RELEVANCE TO CLINICAL PRACTICE The introduction of a balanced nutritional programme, using high-quality natural ingredients, appropriate texture and palatability can significantly improve health and quality of life in dysphagic older people.
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Affiliation(s)
- Milko Zanini
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | | | - Gianluca Catania
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Giuseppe Aleo
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Marina Sartini
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | | | | | - Fiammetta Monacelli
- Department of Internal Medicine & Medical Specialties, University of Genoa, Genoa, Italy
| | - Patrizio Odetti
- Department of Internal Medicine & Medical Specialties, University of Genoa, Genoa, Italy
| | - Loredana Sasso
- Department of Health Sciences, University of Genoa, Genoa, Italy
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