Dysphagia and dietary levels in skilled nursing facilities

Oropharyngeal swallowing hydrodynamics of thin and mildly thick liquids in an anatomically accurate throat-epiglottis model

Understanding the mechanisms underlying dysphagia is crucial in devising effective, etiology-centered interventions. However, current clinical assessment and treatment of dysphagia are still more symptom-focused due to our limited understanding of the sophisticated symptom-etiology associations causing swallowing disorders. This study aimed to elucidate the mechanisms giving rise to penetration flows into the laryngeal vestibule that results in aspirations with varying symptoms. Methods: Anatomically accurate, transparent throat models were prepared with a 45° down flapped epiglottis to simulate the instant of laryngeal closure during swallowing. Fluid bolus dynamics were visualized with fluorescent dye from lateral, rear, front, and endoscopic directions to capture key hydrodynamic features leading to aspiration. Three influencing factors, fluid consistency, liquid dispensing site, and dispensing speed, were systemically evaluated on their roles in liquid aspirations. Results: Three aspiration mechanisms were identified, with liquid bolus entering the airway through (a) the interarytenoid notch (notch overflow), (b) cuneiform tubercle recesses (recess overflow), and (c) off-edge flow underneath the epiglottis (off-edge capillary flow). Of the three factors considered, liquid viscosity has the most significant impact on aspiration rate, followed by the liquid dispensing site and the dispensing speed. Water had one order of magnitude higher aspiration risks than 1% w/v methyl cellulose solution, a mildly thick liquid. Anterior dispensing had higher chances for aspiration than posterior oropharyngeal dispensing for both liquids and dispensing speeds considered. The effects of dispending speed varied. A lower speed increased aspiration for anterior-dispensed liquids due to increased off-edge capillary flows, while it significantly reduced aspiration for posterior-dispensed liquids due to reduced notch overflows. Visualizing swallowing hydrodynamics from multiple orientations facilitates detailed site-specific inspections of aspiration mechanisms.

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.

A comprehensive assessment of oral health, swallowing difficulty, and nutritional status in older nursing home residents

Declines in oral consumption and swallowing function are common reasons which may elevate the risk of malnutrition in the older adults. This study aimed to provide valuable information and contribute to the existing body of knowledge in this field as well as highlight the importance of a comprehensive assessment of oral health, swallowing function, and nutritional status in long-term care residents. This was a cross-sectional study. Thirty-nine participants were recruited from a nursing home. The comprehensive assessment was evaluated in participants, including oral health (Oral Health Assessment Tool (OHAT)), swallowing function (Functional Oral Intake Scale (FOIS) and Eating Assessment Tool (EAT)-10), and nutritional status (Mini Nutritional Assessment-Short Form (MNA-SF). The average age of participants was 80.4 ± 11.7 years, and 46% of these older adults were found to be at the risk of malnutrition. There was a negative correlation between the OHAT and MNA-SF scores. In addition, subjects with poor oral health (OHAT score = 5~8), oral consumption of a modified diet (FOIS score = 4~6), and reduced swallowing function (EAT-10 score ≥ 3) were more likely to be at risk of malnutrition. A comprehensive evaluation of oral health and swallowing function was closely connected with the nutritional status of older nursing home dwellers.

Informed or misinformed consent and use of modified texture diets in dysphagia

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.

Relationship between oral and nutritional status of older residents with severe dementia in an aged care nursing home

OBJECTIVE

The aim of this study was to investigate the relationships between the oral and nutritional status of older residents with dementia in an aged care nursing home.

BACKGROUND

Insufficient oral evaluation and care due to refusal of treatment in older people with dementia may cause deterioration in oral and nutritional status.

MATERIALS AND METHODS

The subjects were 123 older residents with dementia who had been admitted to an aged care nursing home. Oral condition and body mass index (BMI) as a measure of nutritional status were investigated, and the results for the mild and severe dementia groups were compared. BMI was compared by the food consistency between the mild and severe dementia groups.

RESULTS

In the severe dementia group, fewer older adults had removable dentures and many had no molar occlusion. The rate of subjects who had refused oral care by the caregivers was significantly higher in the severe dementia group than in the mild dementia group. In the severe dementia group, the BMI of those having texture-modified foods was significantly lower than those having a normal diet. The BMI of subjects without molar occlusion and with a history of cerebrovascular disease was significantly lower in the severe dementia group.

CONCLUSIONS

The BMI of subjects in the severe dementia group having texture-modified food was significantly lower than that of those with a normal diet. The BMI of subjects in the severe dementia group without molar occlusion was significantly lower than those with molar occlusion.

Effects of Dining-focused Life Enhancement Program in Welfare Facilities for Seniors in Japan

This study evaluated the effectiveness of a life-enhancement program designed to focus on dining conditions in welfare facilities for seniors living in Japan. Effectiveness was specifically evaluated based on whether improvements were achieved in (1) nutritional status, (2) oral health, (3) frequency of fever, and (4) vitality of appetite across three sites. As part of a comprehensive-care initiative that began with dining support, the program consisted of two main components: (1) a 3-month intensive program comprised of (a) collective experiential learning for residents and staff (including nutritionists, nurses, and physiotherapists) and (b) a tailor-made individual program for residents followed by (2) a 3-month continuation program. Participants included 168 individuals (31 males and 137 females) from a total of three facilities (average age was 85.9 [60-104] years). Results showed that the intensive program significantly improved nutritional status (e.g., BMI, caloric intake, and water intake; P < 0.000-0.005) and tongue movement (P < 0.000) while significantly reducing dental-plaque and tongue-coating indices (P < 0.000). Significant improvements were also achieved for degree of appetite and vitality indices (P < 0.000-0.001). However, incidences of fever were not reduced. These findings indicate that the program effectively improved nutritional status, oral health, vitality, and appetite. However, these effects did not sufficiently remain once the program was finished, thus suggesting the need for a continuous intervention.

Pureed diets containing a gelling agent to reduce the risk of aspiration in elderly patients with moderate to severe dysphagia: A randomized, crossover trial

GOALS

The aim of this study was to evaluate the effectiveness of adding a gelling agent to pureed diets to prevent aspiration pneumonia in elderly patients with moderate to severe dysphagia.

BACKGROUND

Pureed diets are often used to reduce aspiration in patients with dysphagia. However, the ideal texture of a pureed diet to prevent aspiration pneumonia remains unclear.

MATERIALS AND METHODS

We prospectively conducted a randomized, crossover trial of pureed rice with or without a gelling agent in patients with moderate to severe dysphagia (ClincialTrials.gov number, NCT03163355). The primary outcome measure was pharyngeal residuals using an endoscopic scoring system. The secondary outcome was the sense of material remaining in the throat following swallowing.

RESULTS

Sixty two patients (58% men), mean age 83 ± 9 years with moderate to severe dysphagia were included. Residuals in the throat were significantly less likely with pureed rice with than without the gelling agent (median cyclic ingestion score (range); 1 (0-4) vs 2 (0-4); P = .001). Irrespective of the presence or absence of the gelling agent, the sense of material remaining in the throat was significantly less frequent in older patients (87 ± 7.6 vs 75 ± 9.1 years, P < .01; 86 ± 7.3 vs 75 ± 8.6 years, P < .01).

CONCLUSIONS

Pureed diets containing a gelling agent may reduce the risk of aspiration pneumonia possibly by decreasing pharyngeal residues in elderly patients with moderate to severe dysphagia.

Impact of the Consistency of Food Substances on Health and Related Factors of Residents in Welfare Facilities for Seniors in Japan

The aim of this study is to determine the effect of food consistency on health and related factors among residents in welfare facilities for seniors (n = 227; mean age, 86.2 ± 8.0 years; 78.9% female). Residents who ate regular food had a lower incidence of fever during the 3-month period (p < 0.001) and consumed more calories (1325.97 ± 220.2 kcal) than those who ate chopped (1125.0 ± 256.8 kcal), paste (1122.0 ± 288.5 kcal), and gastric tube food (812.5 ± 150.7 kcal) (p < 0.001). Modifying a resident’s food by making it softer and finer did not reduce the incidence of choking. Logistic regression analysis (backward elimination method) revealed four factors related to eating regular food: vitality index, appetite, number of remaining teeth, and choking frequency. Causal relationships were not obtained because this was a cross-sectional study. The findings of this study suggest that a regular consistency of food positively influences the health of older individuals.

Nutrition Care Management Practices for In-Patients with Dysphagia in Korean Clinical Settings

This study aimed to examine nutrition care management for in-patients with dysphagia and to evaluate knowledge on nutrition care related to dysphagia among dietitians in clinical settings. A total of 554 questionnaires were distributed to dietitians at hospitals located in Seoul and Gyeonggi Province in Korea, and 147 responses were used for data analysis after excluding responses with significant missing data. Study participants worked at general hospitals (37.2%), long-term care hospitals (24.3%), hospitals (19.2%), and tertiary hospitals (11.5%). Prior education and training related to dysphagia was received by 69.9% of the respondents. The percentage of hospitals that had diet guidelines for dysphagia was 68.0%. Dysphagia diets of 2 levels and 3 levels were provided in 55.1% and 34.7% of the hospitals, respectively. Overall 74.7% of the dietitians responded that they provided information on dysphagia diets to in-patients and caregivers, but only 45.7% of dietitians did so in the long-term care hospitals. Among the respondents who used commercial thickening agents, 77.2% used only one type of commercial thickening agent. Patients or caregivers (75.7%) or nurses (34.5%) were reported to modify viscosity of liquid. Dietitians showed low levels of knowledge on nutrition care related to dysphagia (a mean of 5.14 based on possible scores from 0 to 10 points). To promote nutritional consumption and prevent malnutrition and aspiration, hospitals need the standardized diet guidelines, and dietitians should improve their expertise in nutritional care for patients with dysphagia.

Texture modified diet in German nursing homes: availability, best practices and association with nursing home characteristics

Background

For nursing home (NH) residents with swallowing or chewing problems, appealing texture-modified-diets (TMD) need to be available in order to support adequate nutrition. The aim of this study was to describe the availability of TMD and best practices for TMD in German NHs and to identify related NH characteristics.

Methods

Information on NH characteristics, available texture-modified (TM)-levels (soft, “minced & moist”, pureed) and implemented best practices for TMD (derived from menu plan, separately visible components, re-shaped components, considering individual capabilities of the resident) was collected in a survey in German NHs. The number of TM-levels as well as the number of best practices for TMD were tested for their association with 4 structural, 16 operational and 3 resident-related NH characteristics.

Results

The response rate was 7.2% (n = 590) and 563 NHs were included. The vast majority of NHs (95.2%) reported offering “minced & moist” texture and 84.2% preparing separately visible meal components. Several operational characteristics were more frequently (p < 0.05) reported from NHs offering three TM-levels (27.7%) or four best practices for TMD (13.0%) compared to NHs offering one TM-level (28.4%) or one best practice for TMD (20.1%): special diets and delivery forms (e.g. fingerfood 71.2% vs 38.8%; 80.8% vs. 44.3%), written recipes (69.9% vs. 53.1%; 68.5% vs. 53.9%), a dietetic counseling service (85.9% vs. 66.3%; 89.0% vs. 65.2%), a quality circle for nutritional care (66.7% vs. 43.8%; 71.2% vs. 50.4%), regular staff training (89.7% vs. 73.1%; 95.9% vs. 74.8%) and process instructions (73.7% vs. 53.1%; 75.3% vs. 47.8%). No associations were found regarding structural and resident-related NH characteristics, except a higher percentage of residents receiving TMD in NHs with three compared to one TM-level (median 16.3% vs. 13.2%, p = 0.037).

Conclusion

All participating NHs offer some form of TMD, but only a small number offers a selection of TMD and pays adequate attention to its preparation. Operational NH characteristics – which might reflect a general nutritional awareness of the NH – seem to be pivotal for provision of TMD, whereas neither structural nor resident-related characteristics seem to play a role in this regard.

Perception Versus Performance of Swallow Function in Residents of Long-Term Care

Purpose The purpose of this study was to determine if older adults residing in long-term care were able to accurately self-report their swallowing status by comparing subjective complaints of dysphagia and objective methods of swallowing screening. Method Data were collected from 397 residents of long-term care (M _age = 86.8 years ± 7.8; 263 female). Cognitive impairment scores were collected, and each resident was asked (a) if they thought they had a swallowing problem, (b) if they coughed/choked when they ate, and (c) if they coughed/choked when they drank. These responses were compared to results of a swallowing screening tool and mealtime observations of coughing and choking. Results Residents who reported swallowing difficulties (10%, n = 41) were 8 times more likely to fail the swallowing screening (p < .001); however, 80% of residents who failed the swallowing screening did not previously report that swallowing was an issue. There was no significant association between self-reports of coughing and choking at meals and observations. There was no difference in level of cognition between residents who accurately reported swallowing status and those who were inaccurate. Conclusions Residents are largely unable to accurately self-report swallowing difficulties and also have difficulty accurately reporting incidences of coughing and choking. These findings suggest that concerted efforts are required to implement regular, formal swallowing screening protocols in long-term care to objectively identify those at risk.

Speech-Language Pathologists’ Views About Aspiration Risk and Comfort Feeding in Advanced Dementia

Background:

Speech-language pathologists (SLPs) are often called upon to assess swallowing function for older adults with advanced dementia at high risk of aspiration and make recommendations about whether the patient can safely continue oral nutrition.

Objective:

To describe the circumstances under which SLPs recommend oral nutritional intake for these patients.

Methods:

A mail survey of a national probability sample of SLPs (n = 731). Speech-language pathologists were asked if there were circumstances in which they would recommend oral feeding for patients with advanced dementia at high risk of aspiration, and if yes, to describe the circumstances under which they do so.

Results:

Six themes emerged: (1) when patient preferences are known; (2) for quality of life near end of life; (3) if aspiration risk mitigation strategies are employed; (4) if physician’s preference; (5) if aspiration risk is clearly documented and acknowledged; and (6) if SLP is knowledgeable about current evidence of lack of benefit of feeding tubes in advanced dementia or that nothing by mouth status will not necessarily prevent aspiration pneumonia.

Conclusions:

Speech-language pathologists have an important role within the interprofessional team in assessing swallowing in patients with advanced dementia, advising family and hospital staff about risks and benefits of oral feeding, and the safest techniques for doing so, to maximize quality of life for these patients near the end of life. Speech-language pathologists are often faced with balancing concerns about aspiration risk and recommending the more palliative approach of oral feeding for pleasure and comfort, potentially creating moral distress for the SLP.

Modifying Food Textures: Practices and Beliefs of Staff Involved in Nutrition Care

PURPOSE

Modifying food texture is an important part of dysphagia management, yet less is known about the day-to-day practices that might impact the nutritional well-being of patients. This study surveyed staff involved in the service delivery of texture-modified foods with the objectives to gain information about roles and responsibilities, instruction and knowledge about modifying foods, and beliefs about the use of texture-modified foods in nutrition care.

METHOD

We created a 21-item survey about texture-modified foods. Recruitment efforts focused on both professional and frontline staff involved in service delivery. Practice groups and organizations provided the means of recruiting professionals from different disciplines. Because frontline staff (e.g., certified nursing assistants, cooks) do not have similar membership groups, we recruited them through direct contacts with health care agencies.

RESULTS

A total of 175 individuals completed the survey. Respondents included 107 professionals (primarily certified dietary managers, registered dietitians, speech-language pathologists) and 68 frontline staff (mostly certified nursing assistants/home health aides). Although the frontline and professional staff showed generally similar patterns of opinions and beliefs about modified food textures, differences emerged in reported experiences, roles, and responsibilities in service delivery.

CONCLUSIONS

Survey respondents conveyed generally positive attitudes and opinions about the use of texture-modified foods, and respondents perceived them to be easy to execute and beneficial to the nutritional well-being of patients. Survey findings clearly highlight the contributions of frontline staff in the service delivery of modified food textures. Consideration must be given to continued reliance on informal, limited instruction about texture-modified foods and possible implications for safe nutrition care. Both professional and frontline staff convey a willingness to customize or alter food textures and the belief that patients should be able to choose the level of texture modification that they want to eat.

Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified?

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.

Texture-modified food and fluids in dementia and residential aged care facilities

INTRODUCTION

Dysphagia is common in people living with dementia and associated with increased risk of aspiration pneumonia, dehydration, malnutrition, and death. Treatment options are limited and the use of texture-modified food and fluids (TMF) is a widespread clinical practice. This review aimed to evaluate the evidence for TMF in dementia.

METHODS

A literature search using terms "dysphagia," "texture-modified food and fluids," "dementia," and "aged care" was performed by using three electronic databases from 1990 to March 2017. Studies were assessed for suitability, then reviewed with data extracted, and grouped by categories of outcome measures.

RESULTS

A total of 3,722 publications were identified, and 22 studies met the inclusion criteria. Studies were heterogeneous in design and methodology. There were no publications examining dementia exclusively; however, many subjects with dementia were included in studies of residential aged care facilities. TMF reduced the risk of aspiration seen on videofluoroscopy but not clinical aspiration and pneumonia. TMF was associated with lower daily energy and fluid intake and variable adherence.

CONCLUSION

There is a lack of evidence for people living with dementia and in residential care facilities that TMF improves clinical outcomes such as aspiration pneumonia, nutrition, hydration, morbidity, and mortality. Adverse effects including poorer energy and fluid intake were identified.

Reinstituting Oral Feeding in Tube-Fed Adult Patients With Dysphagia

Feeding tubes are valuable assets in the rehabilitation of adult patients with dysphagia. Feeding tubes may be placed in response to perceived risks of airway compromise or insufficient nutrient intake. However, not all patients require long-term enteral feeding. With intensive dysphagia therapy, many patients will experience resolving deficits or improvement in swallowing ability. These patients require an appropriate strategy to transition from tube to oral feeding. This article reviews some of the basic characteristics of dysphagia and identifies specific swallowing difficulties in 2 groups of patients who often benefit from temporary enteral feeding: stroke survivors and patients treated for head and neck cancer. Specific suggestions are offered for clinical strategies to reinstitute oral feeding in these groups of tube-fed patients.

Using Spaced Retrieval With External Aids to Improve Use of Compensatory Strategies During Eating for Persons With Dementia

PURPOSE

This study was designed to determine whether spaced retrieval (SR), when paired with an external memory aid, is an effective technique to teach persons with dementia to use compensatory swallowing strategies. A secondary purpose was to learn whether speech-language pathologists naive to the study aims would judge posttraining sessions as improved, or safer, in comparison to baseline sessions, thereby validating the changes in behavior due to SR training to use external aids during meals.

METHOD

A multiple baseline design across behaviors was used to evaluate the effects of teaching compensatory swallowing behaviors (i.e., chin tuck, alternation of liquids and solids, lingual/finger sweep) to 5 nursing home residents diagnosed with dementia and coexisting dysphagia.

RESULTS

SR training with the use of a visual aid was functionally related to improvements in 2-3 compensatory swallowing behaviors for each of the 5 participants.

CONCLUSIONS

Study outcomes paired with social validation ratings demonstrated that persons with dementia could learn compensatory swallowing behaviors for perceived safety during intake. Because participants were eating in a quiet and controlled environment, generalization to the typical dining environment remains unknown, and further research is needed to investigate the long-term impact of this training protocol.

Factors associated with compliance with viscosity-modified diet among dysphagic patients

Objective

To investigate compliance with a viscosity-modified diet among Korean dysphagic patients and to determine which factors are associated with compliance.

Methods

We retrospectively reviewed medical records of patients who had been recommended to use thickeners in the previous videofluoroscopic swallowing study (VFSS). Among 68 patients, 6 were excluded because tube feeding was required due to deterioration in their medical condition. Finally, 62 patients were included in the study. Patient compliance was assessed using their medical records by checking whether he or she had maintained thickener use until the next VFSS. To determine which factors affect compliance, the relationship between thickener use and patient characteristics, such as sex, age, inpatient/outpatient status, severity of dysphagia, aspiration symptoms, follow-up interval of VFSS, and current swallowing therapy status were assessed. For noncompliers, reasons for not using thickeners were investigated by telephone interview.

Results

Among 62 patients, 35 (56.5%) were compliers, and 27 (43.5%) were noncompliers. Eighteen (90%) of 20 inpatients had followed previous recommendations; however, only 17 (40.5%) of 42 outpatients had been using thickeners. Of patient characteristics, only admission status was significantly correlated with compliance. When asked about the reason why they had not used thickeners, noncompliers complained about dissatisfaction with texture and taste, greater difficulty in swallowing, and inconvenience of preparing meals.

Conclusion

Among Korean dysphagic patients, compliance with a viscosity-modified liquid diet was only about 50%. Betterments of texture and taste along with patient education might be necessary to improve compliance with thickener use.

Dysphagia in the elderly: management and nutritional considerations

Dysphagia is a prevalent difficulty among aging adults. Though increasing age facilitates subtle physiologic changes in swallow function, age-related diseases are significant factors in the presence and severity of dysphagia. Among elderly diseases and health complications, stroke and dementia reflect high rates of dysphagia. In both conditions, dysphagia is associated with nutritional deficits and increased risk of pneumonia. Recent efforts have suggested that elderly community dwellers are also at risk for dysphagia and associated deficits in nutritional status and increased pneumonia risk. Swallowing rehabilitation is an effective approach to increase safe oral intake in these populations and recent research has demonstrated extended benefits related to improved nutritional status and reduced pneumonia rates. In this manuscript, we review data describing age related changes in swallowing and discuss the relationship of dysphagia in patients following stroke, those with dementia, and in community dwelling elderly. Subsequently, we review basic approaches to dysphagia intervention including both compensatory and rehabilitative approaches. We conclude with a discussion on the positive impact of swallowing rehabilitation on malnutrition and pneumonia in elderly who either present with dysphagia or are at risk for dysphagia.

Effects of therapy in oropharyngeal dysphagia by speech and language therapists: a systematic review

Medical and paramedical treatments should be evaluated according to current standards of evidence-based medicine. Evaluation of therapy in oropharyngeal dysphagia fits into this growing interest. A systematic review is given of the literature on the effects of therapy in oropharyngeal dysphagia carried out by speech therapists. Thus, the review excludes reports of surgical or pharmacological treatments. The literature search was performed using the electronic databases PubMed and Embase. All available inclusion dates up to November 2008 were used. The search was limited to English, German, French, Spanish, and Dutch publications. MESH terms were supplemented by using free-text words (for the period after January 2005). Fifty-nine studies were included. In general, statistically significant positive therapy effects were found. However, the number of papers was rather small. Moreover, diverse methodological problems were found in many of these studies. For most studies, the conclusions could not be generalized; comparison was hindered by the range of diagnoses, types of therapies, and evaluation techniques. Many questions remain about the effects of therapy in oropharyngeal dysphagia as performed by speech and language therapists. Although some positive significant outcome studies have been published, further research based on randomized controlled trials is needed.

Treatment of oral and pharyngeal dysphagia

Research on treatment of oropharyngeal dysphagia has supported several treatment approaches. Treatment can include postural changes, heightening preswallow sensory input, voluntary swallow maneuvers, and exercises. Evidence to support the efficacy of these procedures is variable. An instrumental study of a patient's oropharyngeal swallow forms the basis for treatment selection.

Overview of Results From the Largest Clinical Trial for Dysphagia Treatment Efficacy

Information presented herein provides an overview of the largest randomized clinical trial ever completed in dysphagia. The two-part sequential randomized clinical trial studied the effect of two common dysphagia interventions (chin tuck and thickened liquids) for immediate prevention of aspiration during videofluorographic assessment and also for the incidence of pneumonia at 3-months for patients with Parkinson's disease and/or dementia. Results indicated that thickened liquids (nectar-thick or honey-thick) prevented aspiration during the radiographic study more frequently than chin-down posture; however, both interventions were equally successful at preventing pneumonia. Adverse events such as urinary tract infection and dehydration were more common with thickened liquids. Median length of hospital stay due to pneumonia was three times longer for patients drinking honey-thick liquids compared to nectar-thick and chin-tuck arms of the study. Several important secondary outcomes are discussed as well as implications for clinical practice. The reader is encouraged to refer to other published works for detailed information that is highlighted in this overview.

Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial

BACKGROUND

Aspiration pneumonia is common among frail elderly persons with dysphagia. Although interventions to prevent aspiration are routinely used in these patients, little is known about the effectiveness of those interventions.

OBJECTIVE

To compare the effectiveness of chin-down posture and 2 consistencies (nectar or honey) of thickened liquids on the 3-month cumulative incidence of pneumonia in patients with dementia or Parkinson disease.

DESIGN

Randomized, controlled, parallel-design trial in which patients were enrolled for 3-month periods from 9 June 1998 to 19 September 2005.

SETTING

47 hospitals and 79 subacute care facilities.

PATIENTS

515 patients age 50 years or older with dementia or Parkinson disease who aspirated thin liquids (demonstrated videofluoroscopically). Of these, 504 were followed until death or for 3 months.

INTERVENTION

Participants were randomly assigned to drink all liquids in a chin-down posture (n = 259) or to drink nectar-thick (n = 133) or honey-thick (n = 123) liquids in a head-neutral position.

MEASUREMENTS

The primary outcome was pneumonia diagnosed by chest radiography or by the presence of 3 respiratory indicators.

RESULTS

52 participants had pneumonia, yielding an overall estimated 3-month cumulative incidence of 11%. The 3-month cumulative incidence of pneumonia was 0.098 and 0.116 in the chin-down posture and thickened-liquid groups, respectively (hazard ratio, 0.84 [95% CI, 0.49 to 1.45]; P = 0.53). The 3-month cumulative incidence of pneumonia was 0.084 in the nectar-thick liquid group compared with 0.150 in the honey-thick liquid group (hazard ratio, 0.50 [CI, 0.23 to 1.09]; P = 0.083). More patients assigned to thickened liquids than those assigned to the chin-down posture intervention had dehydration (6% vs. 2%), urinary tract infection (6% vs. 3%), and fever (4% vs. 2%).

LIMITATIONS

A no-treatment control group was not included. Follow-up was limited to 3 months. Care providers were not blinded, and differences in cumulative pneumonia incidence between interventions had wide CIs.

CONCLUSION

No definitive conclusions about the superiority of any of the tested interventions can be made. The 3-month cumulative incidence of pneumonia was much lower than expected in this frail elderly population. Future investigation of chin-down posture combined with nectar-thick liquid may be warranted to determine whether this combination better prevents pneumonia than either intervention independently.

Challenges in the design and conduct of a randomized study of two interventions for liquid aspiration

BACKGROUND

Liquid aspiration during swallowing has been linked to pneumonia, the most common cause of infectious death in the elderly. This paper examines the key issues in the design and implementation of the first multisite, randomized behavioral trial in dysphagia in an aging population. The study evaluated two commonly used treatments with respect to short-term and long-term management of liquid aspiration and subsequent pneumonia in dysphagic geriatric participants with dementia and/or Parkinson's disease.

METHODS

Discussed are lessons learned during the conduct of this trial and include (1) ethical and methodological design issues, (2) pragmatic implementation of procedures and forms, (3) importance of multiple communication and monitoring strategies, (4) response to funding issues, and (5) changes in staff and facilities.

RESULTS

In order to complete this trial the researchers were required to provide more support than anticipated in tasks such as completion of regulatory requirements by sites, supplementing site staff to identify potential study participants using a 'circuit rider' approach, continued recruitment of new sites and staff throughout the course of the trial, adapting forms and procedures and managing within economic constraints in a changing trial environment.

LIMITATIONS

Many of the challenges faced by the researchers were not anticipated when the study began. Successful strategies are described for these unanticipated difficulties, based on retrospective evaluation.

CONCLUSIONS

Successful conduct of clinical trials in long-term care environments that are heavily impacted by changes extraneous to the trial design and with staff typically new to clinical trials is possible but success depends on logistical flexibility.

A Novel Dysphagia Diet Improves the Nutrient Intake of Institutionalized Elders

OBJECTIVES

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

DESIGN

A 12-week intervention study.

SUBJECTS/SETTING

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

STATISTICS

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

RESULTS

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

CONCLUSION

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

Use of thickened liquids in skilled nursing facilities

OBJECTIVE

Long-term care residents are routinely provided with thickened liquids for the management of dysphagia. The objective of this study was to identify the prevalence of thickened liquid use in skilled nursing facilities.

DESIGN

Facility-wide data were provided by staff at 252 randomly selected skilled nursing facilities owned by 11 multifacility providers. The sample represented 25,470 residents and approximately 20% of all freestanding skilled nursing facilities nationwide.

MAIN OUTCOMES MEASURES

Data regarding prevalence of thickened liquid use and facility characteristics were collected during May 2002. Statistical analysis Descriptive statistics included national and regional averages and national percentile distributions.

RESULTS

A mean of 8.3% (range 0% to 28%) of residents were receiving thickened liquids, with considerable variation between Centers for Medicare and Medicaid Services regions. Of those receiving thickened liquids, on average 60% received "nectar/syrup" thick, 33% received "honey" thick, and 6% received "pudding/spoon" thick, although the frequencies with which each thickness was prescribed varied widely between facilities (range 0% to 100%). Thickened water was provided to residents in 91.6% of facilities. Nationally, registered dietitian staffing levels were lower on average than speech language pathologist staffing levels.

CONCLUSIONS

Thickened liquids are provided to a significant segment of the skilled nursing facility resident population. In the absence of outcomes-based practice standards to guide administrative decisions related to the provision of thickened liquids, dietetics professionals may find regional and national norms helpful for quality assurance processes and to inform resource management decisions in clinical staffing and foodservice.

Prevalence of impaired swallowing in institutionalized older people in taiwan

OBJECTIVES

To investigate the prevalence of impaired swallowing in residents at long-term care facilities (LTCFs) in Taiwan.

DESIGN

A chart review, a structured questionnaire completed at interview, a neurological examination, and a timed swallowing test were used to assess impairment and to gather demographic data.

SETTING

Nine skilled nursing facilities and nine intermediate-care facilities in metropolitan Taipei.

PARTICIPANTS

One thousand two hundred twenty-one conscious and unconscious residents with a mean age of 77.07.

MEASUREMENTS

Impaired swallowing was defined when a subject met two or more of the following criteria: self-report of swallowing difficulty, a score of 2 or more derived from a swallowing questionnaire combined with a neurological examination investigating symptoms and signs of impairment, and coughing/choking during a timed swallowing test or a measured swallowing rate (volume swallowed per second) below the 10th percentile as derived from a gender-based study of an older community in Taipei.

RESULTS

Of the 1,221 subjects, 356 (29.2%) were fed by tube. The prevalence rates for impaired swallowing as estimated were 97.5% and 31.9% for tube-fed and non-tube-fed subjects respectively, whereas the overall prevalence for tube-fed and non-tube-fed subjects altogether was 51.0%.

CONCLUSIONS

The findings may serve to increase awareness of this problem among healthcare professionals in LTCFs. Further research is contemplated to investigate whether early identification makes a difference in treatment choices and outcomes.

Radiographic evaluation of complex dysphagic patients: comparison with videoendoscopic technique

Swallowing is a highly coordinated sequence of physiologic events. Many disease processes affect the patient's ability to have a functional swallow. The traditional videofluoroscopic swallowing study is an effective and established method for evaluating these patients and is the current examination of choice. Videoendoscopic evaluation is a safe and affordable procedure that can be used in an outpatient or office setting. It can also be a complementary technique, allowing direct visualization of pharyngeal structures and aspiration. We discuss the use of both techniques.

Oropharyngeal swallowing and aging: a review

This article provides an overview of normal oropharyngeal swallowing in relation to advanced age, with specific attention to oropharyngeal movement patterns and temporospatial swallowing durations. Swallowing disorders associated with aging are addressed with specific attention to the need for application of normative data to the diagnostic process. Attention is drawn to the need for continued research on swallowing function in the normal adult if efforts to maximize functional independence in eating and swallowing in the institutionalized adult are to be realized.