Texture-modified diets are associated with decreased muscle mass in older adults admitted to a rehabilitation ward

Dysphagia terminology for texture modified fluid and food: a national survey of speech-language pathologists' practice

PURPOSE

To investigate: (a) Swedish Speech-Language Pathologists (SLPs) dysphagia management with TMC, including terminology, inter-professional collaboration, and knowledge of standard TMC guides; and (b) the current TMC terminology/guides used within university hospitals, in Sweden.

METHOD

Part One surveyed SLPs from 19/21 regions. Recruitment occurred via regional SLP/department managers, the national SLP association and email lists. Non-parametric statistics were employed. Part Two explored TMC guides within the seven university hospitals.

RESULT

The initial survey identified 78 Swedish TMC terms. Overlap of both TMC terms and descriptions occurred. Different terms to describe same/similar textures were used by 70% of the SLPs. Knowledge of established guides was high (>90%), though TMC was often (60%) based on locally developed documents. Collaboration with other professions was reported by 97% of SLPs, however almost half perceived collaboration to be inadequate, citing difficulties with transfer of TMC recommendations. Variance in TMC terms/guides within/across the university hospitals occurred.

CONCLUSION

Variable TMC terminology is used in Sweden, impacting optimal dysphagia management. Future research should focus upon implementation of standardised TMC terminology.

Association Between Malnutrition and Food Texture Levels in Integrated Facilities for Medical and Long-Term Care

OBJECTIVES

 This study aims to investigate the association between malnutrition using the global consensus criteria and food texture levels in residents of Integrated Facilities for Medical and Long-Term Care (IFMLCs), which are new long-term care insurance facilities in Japan.

METHODS

This single-center study had a retrospective cross-sectional design. The study was conducted from November 1 to 30, 2021, and the study participants were residents admitted to an IFMLC during the study period. Malnutrition was diagnosed according to the Global Leadership Initiative on Malnutrition (GLIM) criteria. Food texture levels consumed by patients at admission were categorized based on the International Dysphagia Diet Standardization Initiative (IDDSI) framework. Multivariate logistic regression models were used to determine the association between the food texture levels consumed and malnutrition.

RESULTS

A total of 98 older residents were analyzed in this study. The median age of the participants was 88 years, and 68 (69%) female participants were included. The IDDSI framework levels were 24% in levels 7 and 6 and 26% in levels 5 and 4. A significant difference in the prevalence of low BMI, reduced muscle mass, and reduced food intake or assimilation was noted between IDDSI framework levels 4 and 7. Multivariate logistic regression analysis was performed for malnutrition, adjusting simultaneously for potential confounders. IDDSI level 4 (odds ratio, 5.074; 95% confidence interval, 1.059-28.092; p=0.042) consumption was independently associated with malnutrition.

CONCLUSIONS

The consumption of lower food texture levels categorized using the IDDSI framework was associated with a higher malnutrition prevalence in IFMLC residents.

Factors associated with the maintenance in food texture for dependent older people with dysphagia living in nursing home - A retrospective cohort study

OBJECTIVES

Maintaining the texture of the food that nursing home residents eat is critical for maintaining quality of life and preventing malnutrition. The aim of the present study was to identify the conditions necessary for maintaining food texture for this population.

MATERIALS AND METHODS

The study included 143 people for whom reevaluation 1-year post-baseline was possible from among 256 dependent older people who consumed solid food on admission to a nursing home (baseline). The age, sex, primary disease, activities of daily living, nutritional status, oral status, swallowing ability, primitive reflexes, and food texture of the participants were determined. The participants who ate pureed or jelly after 1 year were identified and evaluated to determine factors related to maintenance of a solid diet.

RESULTS

A total of 21 participants (14.7%) changed to a pureed or jelly diet after 1 year. Multivariate analysis showed good activities of daily living (p < .05), good swallowing ability (p < .05), and maintained nutritional status (p < .05) to be correlated with solid food maintenance.

CONCLUSIONS

Maintaining activities of daily living, feeding and swallowing ability, and nutritional status appear to be important factors for the maintenance of a solid diet.

Impaired oral status is associated with sarcopenic obesity in post-stroke patients

PURPOSE

Oral problems and muscle health are indeed significant concerns in ageing populations. However, there is limited evidence concerning the association between these issues. The study's focus was to investigate the association between oral problems and sarcopenic obesity, wherein sarcopenia and obesity coexist concurrently, in post-stroke patients.

METHODS

This retrospective, observational, cross-sectional study included patients hospitalised for post-stroke rehabilitation. Oral problems were assessed using the Revised Oral Assessment Guide (ROAG). Sarcopenic obesity was diagnosed according to the European Society of Clinical Nutrition and Metabolism/European Association for the Study of Obesity criteria. Multiple linear regression analysis was used to examine the association between the ROAG and sarcopenic obesity after adjusting for confounding factors.

RESULTS

A total of 760 patients were included, with a mean (SD) age of 71 (9) years, of whom 408 (54.7%) were male. The median (interquartile range, 25th and 75th percentiles) ROAG was 11 [9, 13]. Sarcopenic obesity was diagnosed in 16 (3.9%) men, 18 (5.1%) women, and 34 (4.5%) patients overall. Multivariate linear analysis showed that ROAG was significantly and positively associated with sarcopenic obesity (β = .091, P = .023), followed by obesity alone (β = .084, P = .044), and sarcopenia alone (β = .081, P = .037).

CONCLUSION

Oral problems were associated with sarcopenic obesity in post-stroke. Oral assessment and intervention may have a positive impact on ADL and QOL in post-stroke patients with sarcopenic obesity.

Impact of pureed and liquidised diets on health-related quality of life scores in older patients during postacute rehabilitation: A pilot study

BACKGROUND

Consuming texture-modified diets was considered to negatively affect health-related quality of life (HR-QoL). However, the precise relationship between the levels of food texture consumed and HR-QoL remains uncertain. The present study aimed to determine the association between levels of food texture consumed and HR-QoL.

METHODS

This cross-sectional study included 122 hospitalised patients aged ≥ 65 years (mean ± SD age 78.9 ± 7.9 years; 48.4% female) who required postacute rehabilitation. Consumed food texture levels were classified using the International Dysphagia Diet Standardization Initiative (IDDSI) framework 2.0. HR-QoL was evaluated using the five-level EuroQoL five-dimension (EQ-5D-5L). The association between food texture levels and HR-QoL was analysed using a multivariate linear regression model.

RESULTS

The lower food texture levels consumed were associated with significantly lower EQ-5D-5L scores. Consumption of pureed (IDDSI Level 4) and liqudised (IDDSI Level 3) diets were associated with lower EQ-5D-5L scores among older patients undergoing postacute rehabilitation (regression coefficient -0.304; 95% confidence interval = -0.472 to -0.137 and regression coefficient, -0.444, 95% confidence interval = -0.676 to -0.213, respectivly).

CONCLUSIONS

The findings suggest a link between the consumption of pureed and liquidised diets and lower HR-QoL scores in older hospitalised patients undergoing rehabilitation. To establish a clearer cause-and-effect relationship, future research should encompass multicentre and longitudinal studies, building upon the insights from the present study.

Measures for Identifying Malnutrition in Geriatric Rehabilitation: A Scoping Review

Malnutrition is a common condition in geriatric rehabilitation settings; however, the accuracy and predictive validity of the measures to identify malnutrition have not been established. The current scoping review followed the Joanna Briggs Institute's evidence synthesis manual and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews checklist. Literature published through September 2023 was searched using MEDLINE and CINAHL. The inclusion criteria selected studies reporting malnutrition measures, which include static body weight and weight loss. Identified tools were classified as nutritional screening tools, nutritional assessment tools, or diagnostic criteria. The domains of each tool/criterion and their accuracy and predictive validity were extracted. Fifty-six articles fulfilled the inclusion criteria, and six nutritional screening tools, three nutritional assessment tools, and three diagnostic criteria for malnutrition were identified. These measures consisted of various phenotypes, e.g., weight loss, causes such as inflammation/disease, and risk factors of malnutrition, e.g., functional impairment. The predictive validity of nutritional screening tools (n = 6) and malnutrition diagnostic criteria (n = 5) were inconsistently reported, whereas those for nutritional assessment tools were scarce (n = 1). These findings highlight the need to distinguish the functional impairment of nutritional origin from that of non-nutritional origin in nutritional assessment procedures, and the need to study the accuracy and the predictive validity of these measures in geriatric rehabilitation patients.

Usefulness of the GLIM criteria to predict recovery of activities of daily living in older adults with post-acute stroke

OBJECTIVES

The usefulness of malnutrition diagnosed using the Global Leadership Initiative on Malnutrition (GLIM) criteria as a predictor of recovery of activities of daily living is unclear. This study aimed to investigate whether baseline malnutrition diagnosed using the GLIM criteria was predictive of recovery of activities of daily living in older patients with post-acute stroke.

MATERIALS AND METHODS

A retrospective cohort study was conducted in patients aged ≥70 years with post-acute stroke. The outcome was activities of daily living measured using the motor domain of the Functional Independence Measure (FIM-motor) score at discharge. Participants were classified as malnourished or non-malnourished according to the GLIM criteria. Multivariate linear regression analyses were performed to determine whether baseline malnutrition diagnosed using the GLIM criteria was predictive of the FIM-motor score at discharge. The analysis was adjusted for clinically relevant covariates associated with rehabilitation outcomes after stroke.

RESULTS

A total of 236 patients (mean age, 80.0 years; female, 54.2%) were included in the analysis. On admission, 83 (35.2%) patients were diagnosed with malnutrition. Multivariate linear regression analyses showed that malnutrition diagnosed using the GLIM criteria was predictive of the FIM-motor score at discharge (β = -0.347, P < 0.001).

CONCLUSIONS

Identifying malnutrition using the GLIM criteria is useful for predicting recovery of activities of daily living in older patients with post-acute stroke.

Rheology, Texture and Swallowing Characteristics of a Texture-Modified Dysphagia Food Prepared Using Common Supplementary Materials

A dysphagia diet is a special eating plan. The development and design of dysphagia foods should consider both swallowing safety and food nutritional qualities. In this study, the effects of four food supplements, namely vitamins, minerals, salt and sugar, on swallowing characteristics, rheological and textural properties were investigated, and a sensory evaluation of dysphagia foods made with rice starch, perilla seed oil and whey isolate protein was carried out. The results showed that all the samples belonged to foods at level 4 (pureed) in The International Dysphagia Diet Standardization Initiative (IDDSI) framework, and exhibited shear thinning behavior, which is favorable for dysphagia patients. Rheological tests showed that the viscosity of a food bolus was increased with salt and sugar (SS), while it decreased with vitamins and minerals (VM) at shear rates of 50 s^-1. Both SS and VM strengthened the elastic gel system, and SS enhanced the storage modulus and loss modulus. VM increased the hardness, gumminess, chewiness and color richness, but left small residues on the spoon. SS provided better water-holding, chewiness and resilience by influencing the way molecules were connected, promoting swallowing safety. SS brought a better taste to the food bolus. Dysphagia foods with both VM and 0.5% SS had the best sensory evaluation score. This study may provide a theoretical foundation for the creation and design of new dysphagia nutritional food products.

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).

RELATIONSHIP BETWEEN NUTRITIONAL STATUS, DYSPHAGIA, AND FUNCTIONAL EATING LEVEL IN ADULT PATIENTS WITH CEREBRAL PALSY IN LONG INSTITUTIONAL STAYS

BACKGROUND

Diets with modified consistencies for patients with dysphagia in long term care health institutions may be associated with malnutrition.

OBJECTIVE

: To assess the nutritional status of adult patients with cerebral palsy and dysphagia hospitalized in a health institution for more than 10 years.

METHODS

: This prospective investigation was performed in 56 patients with cerebral palsy (ages 25 to 71 years, mean: 44±12 years) and no other neurological diagnosis in hospital stay for more than 10 years had their nutritional status, dysphagia, and food ingestion capacity assessed in two moments with a 12-month interval in between them, respectively using the body mass index, the dysphagia risk assessment protocol (PARD), and the functional oral ingestion scale (FOIS).

RESULTS

: There were no differences between December 2015 and December 2016 in the patients' weight, nutritional status, diet consistency classification, PARD, and FOIS. The limits of prescribed diet consistency (IDDSI-FDS) and the assessments of dysphagia and functional eating level influenced the nutritional status. More intense dysphagia and greater eating restrictions were associated with a worse nutritional status.

CONCLUSION

: The nutritional status of adult patients with cerebral palsy hospitalized in a health long term institution who had modified diets according to their swallowing and mastication capacity did not worsen between assessments with a 12-month interval in between them. The severity of dysphagia and diet restrictions interfere with the patients' nutritional status: dysphagia and more intense eating restrictions are associated with a worse nutritional status.

The Relationship between Low Skeletal Muscle Mass and Subsequent Oral Intake Ability among the Aged Population

This study aimed to determine the relationship between skeletal muscle mass in an aged population with limited oral intake upon admission and functional oral intake at the subsequent 3-month follow-up. Methods: This was a retrospective cohort study using the Japanese Sarcopenia Dysphagia Database involving older adults (≥60 years) with limited oral intake (Food Intake Level Scale [FILS] level of ≤8). People without skeletal muscle mass index (SMI) data, unknown methods of SMI evaluation, and SMI evaluation by DXA were excluded. Data for 76 people (47 women, 29 men) were analyzed (mean [standard deviation] age: 80.8 [9.0] years; median SMI: women, 4.80 kg/m²; men, 6.50 kg/m²). There were no significant differences in age, FILS upon admission and methods of nutrition intake between the low (n = 46) and the high skeletal muscle mass groups (n = 30), although the proportion of sex between the two groups was different. The FILS level at the time of follow-up differed significantly between the groups (p < 0.01). The SMI upon admission (odds ratio: 2.99, 95% confidence interval: 1.09-8.16) were significantly associated with the FILS level at the time of follow-up after adjustment for sex, age, and history of stroke and/or dementia (p < 0.05, power = 0.756). Conclusion: A low skeletal muscle mass is a disadvantage for achieving a subsequent fully functional oral intake ability among the aged population with limited oral intake upon admission.

Interaction between malnutrition and physical disability in older adults: is there a malnutrition-disability cycle?

Malnutrition and physical disability are urgent issues in super-aging societies and the 2 phenomena are closely linked in older adults. Both conditions have common underlying causes, including physiological changes due to aging and burdens imposed by disease or injury. Accordingly, a concept of the malnutrition-disability cycle was generated and a comprehensive literature search was performed. There was insufficient evidence to prove an interrelationship between malnutrition and physical disabilities, because of the study design and poor quality, among other factors. However, some evidence exists for the interaction between low body mass index and swallowing disorders, and the effects of some malnutrition and disability components. This review provides the rationale for this interaction, the concept of a malnutrition-disability cycle is proposed, and the available evidence is critically appraise.

Foodservice systems and mealtime models in rehabilitation: Scoping review

AIMS

To describe current foodservice systems and mealtime care utilized in the rehabilitation setting. A secondary aim was to identify commonly used outcome measures in foodservice research in the rehabilitation setting.

DESIGN

A scoping review.

DATA SOURCES

PubMed, CINAHL, Scopus, Embase, PsycINFO and Cochrane were searched until January 2022.

REVIEW METHODS

The review was conducted according to Joanna Briggs Institute's methodology for scoping reviews. Included studies were conducted in the inpatient rehabilitation setting, adult population ≥18 years old and provided a description of at least one element of the foodservice system, food and menu, waste and/or eating environment.

RESULTS

Of 5882 articles screened, 37 articles were included, reporting 31 unique studies. Most rehabilitation units had cook-fresh production methods (50%), used decentralized bulk delivery methods (67%) had a communal dining room (67%) and had a 3-week menu cycle (71%). Mealtime care was predominantly provided by nursing staff, however few studies reported on specific activities. Nutritional intake was a key outcome measure across included studies (43%), with only six papers reporting on rehabilitation outcomes. Of the intervention studies (n = 9), all were aimed at improving nutritional intake through menu or mealtime care modifications; few (n = 3) studied changes in rehabilitation outcomes.

CONCLUSION

This scoping review identified a considerable lack of reporting of foodservice and mealtime care systems used in rehabilitation settings in the available literature. Further investigation is required to understand what models of mealtime care are provided to patients and to understand the impact of changes to foodservice and mealtime systems on patient outcomes.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was necessary for this review.

Nutritional Management in Adult Patients With Dysphagia: Position Paper From Japanese Working Group on Integrated Nutrition for Dysphagic People

This position paper prepared by the Japanese Working Group on Integrated Nutrition for Dysphagic People (JWIND) aims to summarize the need for nutritional management in adult patients with dysphagia, the issues that nutrition professionals should address, and the promising approaches as well as to propose a vision for the future of nutritional care for adult patients with dysphagia. JWIND is a joint certification system recognized by the Japan Dietetic Association and the Japanese Society of Dysphagia Rehabilitation; its members are mostly experts known as "Certified Specialist of Registered Dietitian for Dysphagia Rehabilitation." Malnutrition and dysphagia are associated with each other. Therefore, malnutrition detection and intervention are essential for patients with dysphagia. However, evidence on the usefulness nutritional assessment and intervention to ensure appropriate nutritional care remains insufficient. Here, we present current knowledge of the relationship between primary diseases causing dysphagia and malnutrition, the indicators used for nutritional assessment, and nutritional interventions such as texture-modified diet (TMD) quality improvement, oral nutritional supplementation, and comprehensive intervention. We also discuss the current status and issues in nutritional care for adult patients with dysphagia. Furthermore, we have proposed measures that nutrition professionals should consider based on 3 perspectives: nutritional assessment, TMD, and nutritional intervention. Individualized and specialized nutritional management by registered dietitians (RDs) through appropriate assessment of the nutritional status of adult patients with dysphagia is needed. To maintain and improve swallowing function and nutritional status, RDs should intervene from the state of risk or early dysphagia onset, providing individualized care per their expertise as part of a multidisciplinary team. However, systematic clinical practice and research regarding the association of nutrition with dysphagia are currently insufficient. Therefore, further clinical practice and evidence building, including the verification of the efficacy on nutritional support through intervention research, are needed.

Association between food texture levels consumed and the prevalence of malnutrition and sarcopenia in older patients after stroke

BACKGROUND/OBJECTIVES

Texture-modified diets (TMDs) may affect nutritional status and sarcopenia in patients after stroke. This study aimed to investigate the association of food texture levels consumed by patients after stroke with the prevalence of malnutrition and sarcopenia.

SUBJECTS/METHODS

This was a two-center cross-sectional study. A total of 443 patients aged ≥65 years undergoing post-stroke rehabilitation and with oral intake in rehabilitation wards in Shizuoka prefecture and Okinawa prefecture, Japan, were included in the analysis. Food textures were categorized according to the International Dysphagia Diet Standardization Initiative (IDDSI) framework. Malnutrition was diagnosed according to the Global Leadership Initiative on Malnutrition and sarcopenia was assess by the European Working Group on Sarcopenia in Older People 2 criteria. The Cochran-Armitage trend test was used to examine the prevalence of malnutrition and sarcopenia by consumption of lower food texture levels.

RESULTS

Malnutrition and sarcopenia were diagnosed in 245 (55.3%) and 275 (62.1%) participants, respectively. Consumption of lower food texture levels was associated with a higher prevalence of malnutrition and severe malnutrition (P < 0.001 for both). In addition, consumption of lower food texture levels was associated with a higher prevalence of probable sarcopenia and sarcopenia (P < 0.001 for both). On multivariate analysis, significant associations were observed between IDDSI levels 5 (P < 0.001) and 4 (P = 0.009) and malnutrition, and between IDDSI levels 6 (P = 0.015), 5 (P = 0.033), and 4 (P = 0.015) and sarcopenia.

CONCLUSIONS

In patients with stroke, consumption of lower food texture levels categorized by the IDDSI framework was associated with a higher prevalence of malnutrition and sarcopenia.

Relationship between Food Crushing and Oral Function in Older Adults Requiring Nursing Home Care: A Pilot Study

We investigated how jelly is crushed and examined the relationship between tongue pressure and tongue food crushing ability among older adults requiring nursing home care. Seventy-two participants were instructed to freely crush the test foods soft jelly (SJ) and hard jelly (HJ). We visually evaluated the crushability of the test food and identified the intraoral tissues (active sites) used to crush the test food. The active sites were consistent for all participants for both SJ and HJ, and they included the maxillary and mandibular teeth in 41 participants, teeth and residual ridges in 15 participants, maxillary and mandibular residual ridges in 10 participants, and tongue and palate in six participants. Two participants failed to crush the SJ; the active sites in both participants were the tongue and palate. No participant using the tongue and palate as active sites could crush the HJ. Furthermore, 64 participants could crush the SJ and 23 could crush the HJ using the tongue and palate. The cutoff value of the tongue pressure for crushability of the HJ was 22.0 kPa. Assessing tongue pressure and intraoral active sites involved in food crushing could help determine an appropriate diet for older adults requiring nursing home care.

Effects of Carbonation on Swallowing: Systematic Review and Meta-Analysis

OBJECTIVES

The effectiveness of the use of carbonation in preventing penetration/aspiration or enhancing swallowing function in adults remains unclear. This systematic review aimed to evaluate the effectiveness of carbonation on improving swallowing function in adult subjects.

METHODS

Literature published before March 2021 was inspected using MEDLINE, CINAHL, Web of Science Core Collection, The Cochrane Library, Cochrane Central Register of Controlled Trials, and Ichushi-web databases. We searched for intervention studies or randomized control trials considering the effects of carbonated liquids on swallowing function. The risk of bias was assessed using the Cochrane tool for assessing the risk of bias for randomized controlled trials and the Risk of Bias Assessment Tool for Nonrandomized Studies.

RESULTS

The systematic review identified 19 studies with a total of 586 participants. The effects of carbonation on swallowing function are diverse. Overall, most studies showed that carbonation promotes swallowing function compared to other liquids. Five studies were included in the quantitative synthesis. Meta-analysis showed that carbonated liquids prevent aspiration (risk difference [RD] -0.27%, 95% confidence interval [CI] -0.44 to -0.10; I²  = 0%; number needed to treat 3.8, 95% CI 2.2 to 15.0; moderate quality of evidence) when compared to noncarbonated thin liquids. Carbonated liquids also increased the duration of swallowing apnea than did noncarbonated liquids (standardized mean difference 0.25 (mean difference 0.36 seconds), 95% CI 0.03 to 0.47; I²  = 0%; low quality of evidence).

CONCLUSIONS

Carbonation had favorable effects on swallowing function. Further in-depth studies are needed to clarify the benefits of carbonation.

LEVEL OF EVIDENCE

NA Laryngoscope, 2022.

ESPEN guideline on hospital nutrition

In hospitals through Europe and worldwide, the practices regarding hospital diets are very heterogeneous. Hospital diets are rarely prescribed by physicians, and sometimes the choices of diets are based on arbitrary reasons. Often prescriptions are made independently from the evaluation of nutritional status, and without taking into account the nutritional status. Therapeutic diets (low salt, gluten-free, texture and consistency modified, …) are associated with decreased energy delivery (i.e. underfeeding) and increased risk of malnutrition. The European Society for Clinical Nutrition and Metabolism (ESPEN) proposes here evidence-based recommendations regarding the organization of food catering, the prescriptions and indications of diets, as well as monitoring of food intake at hospital, rehabilitation center, and nursing home, all of these by taking into account the patient perspectives. We propose a systematic approach to adapt the hospital food to the nutritional status and potential food allergy or intolerances. Particular conditions such as patients with dysphagia, older patients, gastrointestinal diseases, abdominal surgery, diabetes, and obesity, are discussed to guide the practitioner toward the best evidence based therapy. The terminology of the different useful diets is defined. The general objectives are to increase the awareness of physicians, dietitians, nurses, kitchen managers, and stakeholders towards the pivotal role of hospital food in hospital care, to contribute to patient safety within nutritional care, to improve coverage of nutritional needs by hospital food, and reduce the risk of malnutrition and its related complications.

Masticatory movements and food textures in older patients with eating difficulties

Objectives

To investigate whether masticatory movements in older patients with eating difficulties were associated with oral motor function, physical function, and appropriate food textures.

Background

There are few reports on the association between masticatory movements and food textures in older patients with eating difficulties.

Materials and Methods

This cross‐sectional study involved outpatients at a clinic that specialised in eating and swallowing rehabilitation. Masticatory movements were evaluated as normal or abnormal masticatory path patterns. Oral and physical functions were assessed in terms of oral and physical status, muscle strength and motor skills. The appropriate food texture was determined based on fibreoptic endoscopic evaluation of swallowing and a video fluoroscopic swallowing study. The associations between food texture and masticatory organ, muscle strength and motor skills were analysed.

Results

A total of 126 outpatients (75 men and 51 women; mean age, 78.2 years; SD, 9.6 years) were included in the analysis. 68 participants (54.0%) showed abnormal masticatory movements. Masticatory movement was associated with masticatory performance (odds ratio [OR] = 0.99, 95% confidence interval [CI] = 0.98‐0.99), oral diadochokinesis (OR = 0.55, CI = 0.35‐0.86) and stepping test (OR = 0.92, CI = 0.86‐0.97). Masticatory movement (OR = 2.94, CI = 1.23‐7.01) and the number of natural teeth (OR = 0.94, CI = 0.89‐0.99) were associated with normal food.

Conclusion

Masticatory movements in older patients with eating difficulties may be associated with appropriate food textures whilst being influenced by individual differences in systemic motor control. Masticatory movements may be as important as teeth to enjoy eating.

Texture-Modified Diets are Associated with Poor Appetite in Older Adults who are Admitted to a Post-Acute Rehabilitation Hospital

OBJECTIVE

This study aimed to clarify the association between texture-modified diets and poor appetite in older adults, as it is not fully understood.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

We included 208 inpatients who were aged ≥65 years (mean age 78.9 ± 7.6 years, 57.7% female) and admitted to a rehabilitation unit with stroke, musculoskeletal disease, or hospital-associated deconditioning covered by the Japanese insurance system, between January 2019 and January 2020.

METHODS

Participants were divided into 2 groups according to their food texture level: International Dysphagia Diet Standardization Initiative (IDDSI) levels 3 to 5 for the texture-modified diet group and levels 6 and 7 for the normal diet group. Appetite was assessed using the Simplified Nutritional Appetite Questionnaire for the Japanese elderly, and a score ≤14 was defined as poor appetite. The relationship between IDDSI levels and poor appetite was analyzed using the Cochrane-Armitage trend test. Logistic regression analysis was used to investigate the relationship between the consumption of texture-modified diets and poor appetite. Statistical significance was set at P < .05.

RESULTS

The numbers of participants on modified diets according to the IDDSI framework were as follows: 4, 11, 41, 76, and 76 in levels 3, 4, 5, 6, and 7, respectively. In total, 152 and 56 patients were classified into the regular diet group and texture-modified diet group, respectively. A significantly higher prevalence of poor appetite was observed with the consumption of texture-modified diets (P < .001 for trend). Logistic regression analysis showed that poor appetite was independently associated with the consumption of texture-modified diets (odds ratio 3.443, P = .011).

CONCLUSIONS AND IMPLICATIONS

These findings indicate that the consumption of texture-modified diets is associated with poor appetite. Further studies are required to verify whether a multimodal approach involving improvement in the appearance, taste, flavor, and nutrients of the food can improve poor appetite.

Safety and Efficacy of Specially Designed Texture-Modified Foods for Patients with Dysphagia Due to Brain Disorders: A Prospective Study

Providing texture-modified food for patients with dysphagia is a cornerstone of dysphagia treatment. This study aimed to evaluate the safety and efficacy of a specially designed texture-modified food that can be easily swallowed while maintaining the unique taste by adjusting hardness and adhesiveness in patients with brain disorders using a videofluoroscopic swallowing study. We included 101 patients with oropharyngeal dysphagia due to brain disorders who were referred to the rehabilitation department. To evaluate the safety and efficacy of a specially designed texture-modified food, rice gruel was compared with a regular instant rice porridge, and bulgogi mousse was compared with ground bulgogi, which normally serves as a texture-modified diet for patients with dysphagia in our hospital during the videofluoroscopic swallowing study. The Penetration–Aspiration Scale score, oropharyngeal transit time, number of swallows required to maximally eliminate food materials from the oropharyngeal space, and vallecular and pyriform sinus residue after swallowing scale score were compared. Rice gruel required a shorter oropharyngeal transit time and fewer number of swallowing per the given amount of food than regular instant rice porridge; however, no statistical difference was found in the vallecular and pyriform sinus residue after swallowing scale scores and the Penetration–Aspiration Scale scores. Bulgogi mousse required more swallowing and had lower Penetration–Aspiration Scale scores than ground bulgogi; however, no significant difference was found in the oropharyngeal transit time and the vallecular and pyriform sinus residue after swallowing scale scores. The study foods were safe and efficacious compared to control foods usually provided for patients with dysphagia from various brain disorders.

Texture-Modified Diets, Nutritional Status and Mealtime Satisfaction: A Systematic Review

While the association between dysphagia and malnutrition is well established, there is a lack of clarity regarding the nutritional status and mealtime satisfaction of those consuming texture-modified diets (TMDs). This systematic review summarises and critically appraises the nutritional status and mealtime satisfaction of adults consuming TMDs. A systematic database search following PICO criteria was conducted using Cochrane Central (via Ovid), MEDLINE, CINAHL, EMBASE and Scopus. Nutritional status, mealtime satisfaction and costs were identified as primary outcomes. Eligible studies were grouped according to outcome measurement. In total, 26 studies met the inclusion criteria. Twenty studies evaluated the nutritional status by weight change or using malnutrition screening tools and found the consumption of TMDs correlated with weight loss or malnutrition. Nine studies evaluated mealtime satisfaction, with two reporting poor satisfaction for people on thickened fluids (TFs). Nutrition intervention through adjusting texture and consistency and nutrition enrichment showed positive effects on weight and mealtime satisfaction. The majority of the studies were rated as 'neutral' quality due to the limited number of experiments. TMD consumers had compromised nutritional status and poor mealtime satisfaction. More research input is required to identify promising strategies for improving the nutritional status and mealtime satisfaction of this population. Food services need to consider texture, consistency and fortification in designing menus for people on TMDs to avoid weight loss and malnutrition, and to enhance mealtime enjoyment.

Nutritional Assessment in Adult Patients with Dysphagia: A Scoping Review

Malnutrition negatively affects the quality of life of patients with dysphagia. Despite the need for nutritional status assessment in patients with dysphagia, standard, effective nutritional assessments are not yet available, and the identification of optimal nutritional assessment items for patients with dysphagia is inadequate. We conducted a scoping review of the use of nutritional assessment items in adult patients with oropharyngeal and esophageal dysphagia. The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched to identify articles published in English within the last 30 years. Twenty-two studies met the inclusion criteria. Seven nutritional assessment categories were identified: body mass index (BMI), nutritional screening tool, anthropometric measurements, body composition, dietary assessment, blood biomarkers, and other. BMI and albumin were more commonly assessed in adults. The Global Leadership Initiative on Malnutrition (GLIM), defining new diagnostic criteria for malnutrition, includes the categories of BMI, nutritional screening tool, anthropometric measurements, body composition, and dietary assessment as its required components, but not the blood biomarkers and the “other” categories. We recommend assessing nutritional status, including GLIM criteria, in adult patients with dysphagia. This would standardize nutritional assessments in patients with dysphagia and allow future global comparisons of the prevalence and outcomes of malnutrition, as well as of appropriate interventions.

Ultrasonographic Measurement of Masseter Muscle Thickness Associates with Oral Phase Dysphagia in Institutionalized Elderly Individuals

BACKGROUND & AIMS

Oral phase dysphagia is dependent on ability to chew. As people age, general muscle atrophy contributes to decreased masseter strength. The main objective of this study was to assess the relationship between the thickness of the masseter muscle measured by ultrasonography and the presence of dysphagia in a group of institutionalized elderly people. As a secondary objective, we aimed to establish cutoff points of masseters muscle thickness (MMT) to identify elderly individuals at risk of oral dysphagia.

METHODS

Cross-sectional study of all residents from 3 nursing homes. All individuals underwent ultrasonographic measurements of left and right MMT and were classified according to the presence of dysphagia assessed by both the EAT-10 screening questionnaire and the volume-viscosity swallow test (V-VST).

RESULTS

469 patients (69% women, mean age 84.7 yrs) were recruited. Dysphagia was present in 41.6% and 26% of individuals according the EAT-10 and V-VST, respectively. Multivariate logistic regression showed that 1 mm increase in MMT reduced the risk of dysphagia by 21% according to the EAT-10 tool and by 30% using the V-VST after adjusting for age, sex, mini-nutritional assessment score, and body mass index. We used receiver operative characteristic (ROC) curves to identify cutoff points of MMT to detect dysphagic individuals according to either EAT-10 or V-VST.

CONCLUSIONS

The MMT measured by ultrasonography is reduced in elderly individuals with dysphagia. Based on MMT, clinicians may be better informed about the patients'´ ability to masticate solid foods and identify potential nutrient deficiencies in geriatric settings.

Impact of Oral and Swallowing Function on the Feeding Status of Older Adults in Nursing Homes

BACKGROUND

To date, there have been few guidelines proposed for adjustment of the food consistency, particularly to match the oral function of older adults, which will guide clinicians and caregivers in appropriately modifying food.

OBJECTIVE

We investigated how oral, swallowing, and cognitive conditions of older adults who required daily nursing care in a nursing home were associated with different dietary food consistencies.

METHODS

Clinical examinations to record dentition status, swallowing, and cognitive functions were performed, and the feeding status, including the food consistencies and need for assistance at lunchtime, was evaluated in 37 older residents in nursing homes. The swallowing function was assessed by performing a modified water-swallowing test, and food swallowing was tested using pudding and rice crackers. The χ2 test was used to determine the relationships among the parameters.

RESULTS

No participants were able to take cooked rice, nor regular and soft side dishes. There was no significant relationship between dentition status and feeding status. Of the participants, 95% ate pudding without any problems and 49% ate rice crackers without any signs of swallowing difficulty such as coughing or stopping chewing. There was a significant relationship between the food test score using a rice cracker and the level of food consistencies, and between the same test score and the level of mealtime assistance, whereby the better the score of the food test using a rice cracker, the better was the level of food consistencies including use of a thickening agent and the better was the level of mealtime assistance.

CONCLUSION

The results strongly suggest that the food test using a rice cracker was associated with the level of food consistency and mealtime assistance for older adults in nursing homes.

The Impact of Diet Type on Weight Loss in Patients with Alzheimer's Disease

OBJECTIVES

To compare differences in weight loss in patients with Alzheimer's disease on normal, diabetic, or texture-modified diets.

METHODS

This prospective interventional study examined the data of patients with Alzheimer's disease who were admitted to a long-term care hospital in Japan from February to April 2013. Dietary elements and weight loss over a 3-month period were examined. Results: Of the 75 patients examined, 6 were on a normal diet, 10 were on a diabetic diet, and 59 were on a texture-modified diet. Weight loss was significantly associated with body weight, Mini Nutritional Assessment®, and diet type. In the non-malnourished patients, there was a significant difference between the three types of diets in terms of eating rate and weight loss.

CONCLUSION

Diet type was independently associated with weight loss in patients with Alzheimer's disease. Research using larger sample sizes is necessary to eliminate the differences between these diet types.

Effectiveness of Swallowing Care on Safe Oral Intake Using Ultrasound-Based Observation of Residues in the Epiglottis Valley: A Pragmatic, Quasi-Experimental Study

The demand for methods to ensure safe oral consumption of food and liquids in order to prevent aspiration pneumonia has increased over the last decade. This study investigated the safety of swallowing care selected by adding ultrasound-based observation, evaluated its efficacy, and determined effective content of selected swallowing care. The study employed a pragmatic quasi-experimental research design. Participants were 12 community-dwelling adult patients (age: 44-91 years) who had experienced choking within 1 month prior to the study. After the control phase, in which conventional swallowing care was provided, trained nurses provided ultrasound observation-based swallowing care for a minimum period of 2 weeks. Outcome measurements were compared across three points, namely T1-beginning of the control phase, T2 and T3-before and end of the intervention phase. The mean durations of intervention were 30.8 days in the control phase and 36.5 days in the intervention phase. Pneumonia and suffocation did not occur in the control phase or the intervention phase. The safe intake food level and the food intake level score significantly improved during the intervention phase (p = 0.032 and 0.017, respectively) by adding eating training based on the ultrasound observation. However, there was no significant improvement in the strength of the muscle related to swallowing by the selected basic training. Our results suggest that swallowing care selected based on the ultrasound observation, especially eating training, safely improved safe oral intake among community-dwelling adults with swallowing dysfunction.

Nutritional status and functionality in geriatric rehabilitation patients: a systematic review and meta-analysis

PURPOSE

Since there is only limited evidence available for geriatric rehabilitation patients, this systematic review and meta-analysis aims to characterize the nutritional status in this population and its relationship with functionality.

METHODS

Eight databases were searched for full-text articles reporting baseline nutritional intake and status of adults ≥ 60 years in rehabilitation settings. Pooled estimates were calculated for prevalence of malnutrition and risk of malnutrition based on the Mini Nutritional Assessment (MNA) and for mean body mass index (BMI). Associations between nutritional status (MNA, MNA short form and BMI) and functional status (Barthel Index and Functional Independence Measure) and prevalence of sarcopenia were reviewed.

RESULTS

62 out of 1717 references were eligible for inclusion. Pooled prevalence [95% confidence interval (CI)] of malnutrition and risk of malnutrition were 13 (5-20) % and 47 (40-54) %. Pooled estimate (95% CI) for BMI was 23.8 (23.2-24.5) kg/m². Existing data suggest a risk for low protein and energy intake and vitamin D deficiency. Functional status differed widely. Seven out of ten studies reported significant associations between reduced nutritional status and reduced functionality, whilst two out of seven studies reported significant associations between higher BMI and functionality. Prevalence of sarcopenia was high with 40-76% in this population.

CONCLUSIONS

Although geriatric rehabilitation populations and settings were heterogeneous, a relevant percentage of geriatric rehabilitation patients were affected by a reduced nutritional status. Nutritional status was associated with decreased functionality. This emphasizes the need for screening for malnutrition and targeted nutritional intervention.

Safety and the effectiveness of a new education program for nurses to assess swallowing function using fiberoptic endoscopic evaluation of swallowing (FEES)

AIM

Nurses have the potential to perform fiberoptic endoscopic evaluation of swallowing (FEES) in Japan, which can aid in their provision of swallowing care appropriate to individual patients' swallowing functions. We aimed to confirm the safety and effectiveness of a new nursing education program on FEES by examining its impact on autonomy in performing FEES and accuracy in observing bolus swallowing.

METHODS

In this prospective descriptive study, we developed a FEES education program comprising three phases: (a) obtaining knowledge and skills through e-leaning and a practical workshop; (b) becoming proficient in skills for assessing healthy adults through self-learning; and (c) obtaining clinical competence through 30 cases of on-the-job training (OJT). The trends in autonomy and in accuracy of FEES were evaluated by the data during OJT.

RESULTS

Of the three certified nurses in dysphagia nursing, a trainee completed 30 cases of OJT and the other two trainees experienced 20 cases and 10 cases, respectively without any adverse event. Autonomy in the four major FEES skills gradually increased over the OJT. The correct answer rate, sensitivity, and specificity of the penetration-aspiration scale and severity of residue in the pyriform sinus and epiglottis valley were above 95% at the first 10 cases of OJT among three trainees and they were 100% after the 11th case of OJT.

CONCLUSIONS

Our results suggest that the developed education program helped nurses with experience being present at FEES obtain sufficient knowledge and skills to appropriately and safely perform FEES with 30 cases of OJT.

Development and Predictors of Sarcopenic Dysphagia during Hospitalization of Older Adults

The study aimed to investigate the impact of sarcopenia and sarcopenia-related conditions on the development of swallowing disorders during hospitalization. Older adult inpatients (n = 8768) without swallowing disorders in the premorbid period were studied. Sarcopenia-related conditions were evaluated in terms of nutritional status, physical status, and ambulatory conditions as well as hand-grip strength and muscle mass assessed by calf circumference. Development of swallowing disorders was defined based on food texture at discharge from the hospital. The patients’ mean age was 76.1 ± 6.9 years. A total of 374 (4.3%) patients developed swallowing disorders during hospitalization. They were older, with poorer nutritional status, and had more decline of physical performance than those without swallowing disorders. Performance Status score (odds ratio (OR) = 1.28 (1.12–1.46) p < 0.001), ambulatory dependency (OR = 1.72 (1.09–2.71), p = 0.020), malnutrition score (OR = 0.92 (0.87–0.97), p = 0.002), insufficient nutritional intake (OR = 2.33 (1.60–3.40), p < 0.001), and length of stay (OR = 1.01 (1.00–1.01), p = 0.001) were independent contributing factors for swallowing disorder development in the multivariate analysis. The presence of possible sarcopenia was also a contributor to swallowing disorder development. In conclusion, swallowing disorders could develop in patients with possible sarcopenia and sarcopenia-related conditions during hospitalization. Clinicians should be aware of this risk and provide appropriate interventions to prevent sarcopenic dysphagia.

Swallowing function in advanced age

PURPOSE OF REVIEW

To present current literature regarding swallowing function in advanced age, including healthy ageing, dysphagia and trends in multidisciplinary team service delivery.

RECENT FINDINGS

Normative studies support swallowing efficiency but greater variability in healthy advanced age, through to 100 years old. Deviations from normative data and symptoms of dysphagia leading to aspiration or nutritional risk, imply swallowing disorder, rather than simply the ageing process. Quantitative and qualitative studies are emerging that promote management of swallow dysfunction for an ageing society, including innovative assessment, home treatment, swallowing exercise and optimized mealtimes.

SUMMARY

Current literature on swallowing function in advanced age provides multidisciplinary perspectives and initiatives, with clear commitment to improving quality of life for older adults. The diversity of the older population and serious consequences of swallowing difficulties calls for routine screening tools for swallowing impairment and malnutrition risk. Representation of 'oldest old' in future normative studies is essential to guide swallowing management in adults over 85 years old.

Burden of Premorbid Consumption of Texture Modified Diets in Daily Life on Nutritional Status and Outcomes of Hospitalization

OBJECTIVES

Due to the water-rich cooking process required to soften texture modified diets (TMDs), TMDs may have poorer nutrition. The aim of this study was to investigate the associations between daily premorbid TMD consumption and nutritional status at the time of hospitalization, and its burden on hospitalization outcomes.

DESIGN

Retrospective observational study.

SETTING

An academic hospital.

PARTICIPANTS

The cohort comprised 3,594 older adult patients aged ≥65 years admitted to the hospital.

MEASUREMENTS

Patients were interviewed on admission using a premorbid daily consumption meal form to determine whether the patient ate a TMD. Nutritional status was examined using nutritional screening tools (Mini-Nutritional Assessment Short Form [MNA-SF], Malnutrition Universal Screening Tool [MUST], Geriatric Nutritional Risk Index [GNRI]) and the European Society of Clinical Nutrition and Metabolism (ESPEN)-defined criteria of malnutrition at admission. Length of hospital stay (LOS) and in-hospital mortality were considered outcomes of hospitalization. Multivariate analyses were performed to detect associations between premorbid TMD consumption and nutritional status and outcomes.

RESULTS

The mean age of the subjects was 75.9±7.0 years, including 58% males. Overall, 110 (3.1%) patients consuming a premorbid TMD were identified. They were older (p<0.001), had poor nutritional status (lower MNA-SF score [p<0.001] and GNRI value [p<0.001], higher MUST score [p<0.001], and more prevalent ESPEN-defined malnutrition [61.8% vs. 14.0%, p<0.001] than did patients without a TMD. The mortality rate and LOS of patients with TMD was higher (7.3% vs. 2.9%, p=0.017) and longer (19 days vs. 8 days, p<0.001) than those without TMD. Multivariate analyses showed that TMD consumption was independently associated with poor nutritional status and prolonged LOS after adjusting confounders.

CONCLUSION

Daily consumption of a TMD during the premorbid period affects nutritional status at the time of hospitalization and outcomes. Further studies are necessary to investigate whether nutritional intervention can improve outcomes for people on a TMD.

Early impacts of modified food consistency on oromotor outcomes in mouse models of Down syndrome

Down syndrome (DS) in humans is associated with differences of the central nervous system and oromotor development. DS also increases risks for pediatric feeding challenges, which sometimes involve the use of altered food consistencies. Therefore, experimental food consistency paradigms are of interest to oromotor investigations in mouse models of Down syndrome (DS). The present work reports impacts of an altered food consistency paradigm on the Ts65Dn and Dp(16)1Yey mouse models of DS, and sibling control mice. At weaning, Ts65Dn, Dp(16)1Yey and respective controls were assigned to receive either a hard food or a soft food (eight experimental groups, n = 8-10 per group). Two weeks later, mice were assessed for mastication speeds and then euthanized for muscle analysis. Soft food conditions were associated with significantly smaller weight gain (p = .003), significantly less volitional water intake through licking (p = .0001), and significant reductions in size of anterior digastric myofibers positive for myosin heavy chain isoform (MyHC) 2b (p = .049). Genotype was associated with significant differences in weight gain (p = .004), significant differences in mastication rate (p = .001), significant differences in a measure of anterior digastric muscle size (p = .03), and significant reductions in size of anterior digastric myofibers positive for MyHC 2a (p = .04). In multiple measures, the Ts65Dn model of DS was more affected than other genotype groups. Findings indicate a soft food consistency condition in mice is associated with significant reductions in weight gain and oromotor activity, and may impact digastric muscle. This suggests extended periods of food consistency modifications may have impacts that extend beyond their immediate roles in facilitating deglutition.