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

Methodological and ethical challenges in designing and conducting research at the end of life: A systematic review of qualitative and textual evidence

AIM

This systematic review aims to identify methodological and ethical challenges in designing and conducting research at the end of life from the perspective of researchers and provide a set of recommendations.

BACKGROUND

Conducting research with patients and family carers facing end-of-life issues is ethically and methodologically complex.

DESIGN

A systematic review was conducted.

DATA SOURCES

Four databases (MEDLINE, EMBASE, CINAHL, PsycInfo) were searched from inception until the end of 2021 in February 2022.

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews was followed, and the JBI Approach to qualitative synthesis was used for analysis.

RESULTS

Seventeen of 1983 studies met inclusion criteria. Data were distilled to six main themes. These included (1) the need for flexibility at all stages of the research process; (2) careful attention to timing; (3) sensitivity in approach; (4) the importance of stakeholder collaboration; (5) the need for unique researcher skills; and (6) the need to deal with the issue of missing data.

CONCLUSION

The findings illuminate several considerations that can inform training programmes, ethical review processes and research designs when embarking on research in this field.

Fidelity in Behavioral Interventions for Oropharyngeal Dysphagia in Parkinson's Disease: A Systematic Review

Measuring fidelity of delivery and engagement in the methods of a trial helps us to understand whether planned interventions were effective. Treatment fidelity is critical in proving that change in study outcomes is due to the intervention itself and not to variability in its implementation or measurement. Existing reviews of oropharyngeal dysphagia (OD) interventions for Parkinson's disease (PD) have not systematically scrutinized fidelity within clinical trials. This study aimed to examine treatment fidelity in behavioral interventions for OD in PD and provide information about the reliability of existing study findings on behavioral interventions. All published and unpublished randomized controlled trials (RCTs) regarding behavioral interventions for OD in PD were sought. A comprehensive search of eight electronic databases was performed from inception to January 2019 and updated in April 2020. Gray literature was explored to minimize publication bias. No language or date restrictions were applied. Data were extracted by two independent reviewers with a third mediator. The National Institutes of Health Behavior Change Consortium Treatment Fidelity checklist was used to assess fidelity. From the 4998 references identified, eight studies met the inclusion criteria. Behavioral interventions in the included studies varied. The level of treatment fidelity was rated as low across all studies included in the review. The review concluded that low levels of treatment fidelity adherence in RCTs on dysphagia interventions in PD undermine the interpretation of the validity and reliability of study findings along with successful replication of these interventions in research and clinical practice.

Instrumental Swallowing Assessment in Adults in Residential Aged Care Homes: A Scoping Review

OBJECTIVES

To systematically describe evidence on the use of instrumental swallowing assessment for residents of aged care homes.

DESIGN

Scoping review using the Joanna Briggs Institute methodology for scoping reviews.

SETTING AND PARTICIPANTS

Published peer-reviewed and gray literature written in English between 2000 and 2020 about instrumental swallowing assessment (ISA) in adults in residential aged care homes (RACHs).

MEASURES

A systematic, 3-tiered search of databases including Medline, CINAHL, Embase, Scopus, and Cochrane Database of Systematic Reviews, and gray literature databases was conducted. Content analysis identified common themes.

RESULTS

Forty-two sources, 30 from peer-reviewed journals, 12 gray literature publications, and 66 websites of mobile ISA providers that discussed videofluoroscopic swallowing studies (VFSS) and/or fiberoptic endoscopic evaluation of swallowing (FEES) use in RACHs were included. Most peer-reviewed sources were referenced narratives or surveys of speech pathology practice patterns (53.3%). Researchers in 3 studies used onsite mobile FEES and in 2 studies off-site VFSS, with adults living in RACHs, as part of their research design (16.7%). There were 66 mobile instrumental swallowing assessment provider websites, based within the United States. Three countries (Australia, United States, United Kingdom) had professional guidelines that stipulated minimal requirements for the safe and appropriate provision of ISA services across settings. Themes identified across sources included (1) the approach to swallowing management and clinical indicators for ISA, (2) the role of ISA, (3) service and consumer influences on ISA, and (4) mobile FEES.

CONCLUSIONS AND IMPLICATIONS

There is a paucity of quality research on instrumental swallowing assessment in adults living in RACHs. There are broad regional and international variances in the way that videofluoroscopy and FEES are accessed and used. A more robust evidence base is required to guide health professionals to design tailored ISA care pathways for residents of RACHs, to achieve high-quality health, social, and economic outcomes.

Enteral versus oral feeding in advanced dementia

The global population is aging, and with this demographic shift, the incidence and prevalence of dementia are expected to increase. According to the World Health Organization, an estimated 50 million people are living with dementia worldwide, and this number is expected to triple to 150 million by 2050. Dementia initially affects the brain, eventually affecting the entire body culminating in death, commonly from the complications and comorbidities. People with dementia often experience eating difficulties in addition to a severe decline in cognitive, verbal, and functional abilities secondary to gradual neurodegenerative process, leading to weight loss, malnutrition, and dehydration. When eating difficulties and weight loss occur, health care providers and families often feel obligated to decide to either continue the oral feeding or opt for feeding tube placement. Primary care clinicians, both nurse practitioners and physicians, are presented with challenges when facilitating the decision regarding the feeding options in patients with advanced dementia. This narrative review aims at evaluating the impact of enteral nutrition versus oral feeding by comparing the rates of survival and adverse events in older adults with advanced dementia. It also highlights the best approaches to optimizing nutrition for this frail population.

Modifying the consistency of food and fluids for swallowing difficulties in dementia

BACKGROUND

People with dementia can have feeding and swallowing difficulties (dysphagia). Modification of the consistency of food or fluids, or both, is a common management strategy. However, diet modification can affect quality of life and may lead to dehydration and malnutrition. Evidence on the benefits and risks of modifying food and fluids is mandatory to improve the care of people with dementia and dysphagia.

OBJECTIVES

To determine the effectiveness and adverse effects associated with modifying the consistency of food and fluids in improving oral intake and eliminating aspiration in adults with dysphagia and dementia.

SEARCH METHODS

We searched ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), the Cochrane Library, MEDLINE via Ovid SP, Embase via Ovid SP, PsycINFO via Ovid SP, CINAHL via EBSCOhost, LILACS via BIREME, ClinicalTrials.gov and the World Health Organization (WHO) Portal on 9 May 2018. We also checked the reference lists of relevant articles to identify any additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs and cluster-RCTs published in any language that measured any of the outcomes of interest. We included trials with adults with a clinical diagnosis of dementia with symptoms and signs of dysphagia confirmed on instrumental assessment. We included participants with all types, stages and severities of dementia. Control groups received either no intervention or interventions not involving diet modification or modification to sensory properties of food.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed for inclusion all potential studies identified. Data were extracted independently along with assessment of methodological quality using standard Cochrane methods. We contacted study authors for additional unpublished information.

MAIN RESULTS

No trials on modification of food met the inclusion criteria. We included two studies that examined modification to fluids. Both were part of the same large multicentre trial and included people with dementia and people with or without dementia and Parkinson's disease. Participation in the second trial was determined by results from the first trial. With unpublished data supplied by study authors, we examined data from participants with dementia only. The first study, a cross-over trial, investigated the immediate effects on aspiration of two viscosities of liquids (nectar thick and honey thick) compared to regular liquids in 351 participants with dementia using videofluoroscopy. Regular liquids with a chin down head posture, as well as regular liquids without any intervention were also compared. The sequence of interventions during videofluoroscopy may have influenced response to intervention. The second study, a parallel designed RCT, compared the effect of nectar and honey thick liquids with a chin down head posture over a three-month period in a subgroup of 260 participants with dementia. Outcomes were pneumonia and adverse intervention effects. Honey thick liquids, which are more consistent with descriptors for 'spoon thick' or 'extremely thick' liquids, showed a more positive impact on immediate elimination of aspiration during videofluoroscopy, but this consistency showed more adverse effects in the second follow-up study. During the second three-month follow-up trial, there were a greater number of incidents of pneumonia in participants receiving honey thick liquids than those receiving nectar thick liquids or taking regular liquids with a chin down posture. There were no deaths classified as 'definitely related' to the type of fluids prescribed. Neither trial addressed quality of life. Risk of bias for both studies is high. The overall quality of evidence for outcomes in this review is low.

AUTHORS' CONCLUSIONS

We are uncertain about the immediate and long-term effects of modifying the consistency of fluid for swallowing difficulties in dementia as too few studies have been completed. There may be differences in outcomes depending on the grade of thickness of fluids and the sequence of interventions trialled in videofluoroscopy for people with dementia. Clinicians should be aware that while thickening fluids may have an immediate positive effect on swallowing, the long-term impact of thickened fluids on the health of the person with dementia should be considered. Further high-quality clinical trials are required.

Difficulties in thickened water ingestion in healthy subjects

BACKGROUND

For some patients with dysphagia who have airway aspiration, it is not possible to drink water as a thin liquid, as they need their water to be thickened.

OBJECTIVE

To evaluate in healthy volunteers the difficulties and dynamics of ingestion of thickened water.

METHOD

In 94 healthy volunteers aged 18-67 years, the ingestion of 100 mL of water with consistencies of thin liquid and thickened with 1.2 g (nectar-thick), 2.4 g (honey-thick) and 3.6 g (pudding-thick) of a commercial thickener with maltodextrin, xanthan gum and potassium chloride was evaluated. The volunteers drank in a random sequence 100 mL of each consistency. The duration and the number of swallows to drink the volume were measured. The interval between swallows, the flux of ingestion and the volume of each swallow were calculated. After each test, the individual was asked about the sensation during drinking, with ten as the best sensation and zero as the worst sensation, and about the difficulty to swallow each consistency.

STATISTICAL ANALYSIS

The analysis was done using a linear model with mixed effects.

RESULTS

The time to ingest the volume increased (liquid: 5.8 s; nectar: 7.9 s; honey: 9.5 s; pudding: 12.7 s; p < 0.01), the flux of ingestion decreased (liquid: 20.3 mL/s; nectar: 15.6 mL/s; honey: 13.4 mL/s; pudding: 10.6 mL/s; p < 0.01), the sensation worsened (liquid: 9.7; nectar: 5.7; honey: 4.3; pudding: 2.8), and the difficult of ingestion increase with the increase of the water consistency. Individuals with dental prosthesis (n = 11) had a decrease in the flux of ingestion with 3.6 g of thickener (prosthesis: 11.1 mL/s, no prosthesis: 6.8 mL/s, p = 0.05) and a decrease in the volume in each swallow (prosthesis: 17.6 mL, no prosthesis: 10.5 mL).

CONCLUSIONS

There is some difficulty to drink thickened water. The use of dental prosthesis cause further difficulties.

Effect of Bolus Viscosity on the Safety and Efficacy of Swallowing and the Kinematics of the Swallow Response in Patients with Oropharyngeal Dysphagia: White Paper by the European Society for Swallowing Disorders (ESSD)

BACKGROUND

Fluid thickening is a well-established management strategy for oropharyngeal dysphagia (OD). However, the effects of thickening agents on the physiology of impaired swallow responses are not fully understood, and there is no agreement on the degree of bolus thickening.

AIM

To review the literature and to produce a white paper of the European Society for Swallowing Disorders (ESSD) describing the evidence in the literature on the effect that bolus modification has upon the physiology, efficacy and safety of swallowing in adults with OD.

METHODS

A systematic search was performed using the electronic Pubmed and Embase databases. Articles in English available up to July 2015 were considered. The inclusion criteria swallowing studies on adults over 18 years of age; healthy people or patients with oropharyngeal dysphagia; bolus modification; effects of bolus modification on swallow safety (penetration/aspiration) and efficacy; and/or physiology and original articles written in English. The exclusion criteria consisted of oesophageal dysphagia and conference abstracts or presentations. The quality of the selected papers and the level of research evidence were assessed by standard quality assessments.

RESULTS

At the end of the selection process, 33 articles were considered. The quality of all included studies was assessed using systematic, reproducible, and quantitative tools (Kmet and NHMRC) concluding that all the selected articles reached a valid level of evidence. The literature search gathered data from various sources, ranging from double-blind randomised control trials to systematic reviews focused on changes occurring in swallowing physiology caused by thickened fluids. Main results suggest that increasing bolus viscosity (a) results in increased safety of swallowing, (b) also results in increased amounts of oral and/or pharyngeal residue which may result in post-swallow airway invasion, (c) impacts the physiology with increased lingual pressure patterns, no major changes in impaired airway protection mechanisms, and controversial effects on oral and pharyngeal transit time, hyoid displacements, onset of UOS opening and bolus velocity-with several articles suggesting the therapeutic effect of thickeners is also due to intrinsic bolus properties, (d) reduces palatability of thickened fluids and (e) correlates with increased risk of dehydration and decreased quality of life although the severity of dysphagia may be an confounding factor.

CONCLUSIONS

The ESSD concludes that there is evidence for increasing viscosity to reduce the risk of airway invasion and that it is a valid management strategy for OD. However, new thickening agents should be developed to avoid the negative effects of increasing viscosity on residue, palatability, and treatment compliance. New randomised controlled trials should establish the optimal viscosity level for each phenotype of dysphagic patients and descriptors, terminology and viscosity measurements must be standardised. This white paper is the first step towards the development of a clinical guideline on bolus modification for patients with oropharyngeal dysphagia.

Effectiveness of interventions to directly support food and drink intake in people with dementia: systematic review and meta-analysis

BACKGROUND

Eating and drinking difficulties are recognised sources of ill health in people with dementia. In the EDWINA (Eating and Drinking Well IN dementiA) systematic review we aimed to assess effectiveness of interventions to directly improve, maintain or facilitate oral food and drink intake, nutrition and hydration status, in people with cognitive impairment or dementia (across all settings, levels of care and support, types and degrees of dementia). Interventions included oral nutrition supplementation, food modification, dysphagia management, eating assistance and supporting the social element of eating and drinking.

METHODS

We comprehensively searched 13 databases for relevant intervention studies. The review was conducted with service user input in accordance with Cochrane Collaboration's guidelines. We duplicated assessment of inclusion, data extraction, and validity assessment, tabulating data, carrying out random effects meta-analysis and narrative synthesis.

RESULTS

Forty-three controlled interventions were included, disappointingly none were judged at low risk of bias. Oral nutritional supplementation studies suggested small positive short term but unclear long term effects on nutritional status. Food modification or dysphagia management studies were smaller and of low quality, providing little evidence of an improved nutritional status. Eating assistance studies provided inconsistent evidence, but studies with a strong social element around eating/drinking, although small and of low quality provided consistent suggestion of improvements in aspects of quality of life. There were few data to address stakeholders' questions.

CONCLUSIONS

We found no definitive evidence on effectiveness, or lack of effectiveness, of specific interventions but studies were small and short term. People with cognitive impairment and their carers have to tackle eating problems despite this lack of evidence, so promising interventions are listed. The need remains for high quality trials tailored for people with cognitive impairment assessing robust outcomes.

SYSTEMATIC REVIEW REGISTRATION

The systematic review protocol was registered (CRD42014007611) and is published, with the full MEDLINE search strategy, on Prospero.

A systematic review of strategies used to increase recruitment of people with cancer or organ failure into clinical trials: implications for palliative care research

CONTEXT

The challenges of palliative care clinical trial recruitment are well documented.

OBJECTIVES

The aim of the study was to review tested strategies to improve recruitment to trials of people with a range of conditions who may access palliative care services but are not explicitly stated to be "palliative."

METHODS

This was a systematic review with narrative description. The Cochrane, Embase, PubMed, PsycINFO, and CINAHL electronic databases were searched (English; January 2002 to February 2014) for quasi-experimental and randomized controlled trials (RCTs) testing the effect of recruitment strategies on accrual to clinical trials of people with organ failure and cancer. Titles, abstracts, and retrieved articles were screened by two researchers and categorized by recruitment challenge: 1) patients with reduced cognition, 2) those requiring emergency treatment, and 3) willingness of patients and clinical staff to contribute to trials.

RESULTS

Of 549 articles identified, 15 were included. Thirteen reported RCTs and two papers reported three quasi-experimental studies. Five were cluster RCTs of recruiting sites/institutions. One was a randomized cluster, crossover, feasibility study. Seven studies recruited patients with cancer. Others included patients with dementia, stroke, cardiovascular disease, diabetes, frail elderly, and bereaved carers. Some interventions improved recruitment: memory aid, contact before arrival, cluster consent, "opt out" consent. Others either reduced recruitment (formal mental capacity assessment) or made no difference (advance research directive; a variety of educational, supportive, and advertising interventions).

CONCLUSION

Successful strategies from other disciplines could be considered by palliative care researchers. Tailored, efficient, evidence-based strategies must be developed, acknowledging that strategies with face validity are not necessarily the most effective.

Clinical efficacy and randomized clinical trials in dysphagia

This manuscript reviews the current state of research on treatment efficacy for swallowing disorders in relation to the use of large-scale randomized multi institutional trials. Dose response trials, i.e., how much treatment is needed to achieve the desired result, are not yet available in dysphagia. The financial and medical pressures on clinicians responsible for diagnosing and treating the dysphagic patient are noted as they often impact the timing of patient care in dysphagia. The process of integration of treatment techniques into the diagnostic study (Modified Barium Swallow, videofluoroscopy) to improve the patient's swallow as quickly as possible is described. The availability of a clinical trial group, the Communications Sciences and Disorders Clinical Trials Research Group (CSDRG), is noted to assist clinicians and scientists in the development of all types of clinical trials in dysphagia.

Rehabilitation or compensation: time for a fresh perspective on speech and language therapy for dysphagia and Parkinson's disease?

BACKGROUND

Dysphagia is a common symptom of Parkinson's disease and can have negative consequences for physical health and quality of life. A variety of treatment options are available to clinicians working with people who have dysphagia and Parkinson's disease. These options can be broadly categorized as being compensatory or rehabilitative in nature.

AIMS

To explore the evidence behind treatment options available to clinicians working with dysphagia and Parkinson's disease and to draw conclusions about whether compensatory or rehabilitative approaches are likely to provide the best outcomes for our patients.

METHODS & PROCEDURES

A critical literature review of compensatory and rehabilitative interventions for dysphagia in Parkinson's disease was undertaken. Relevant studies were analysed for their robustness and potential clinical applications. General conclusions were drawn based on the evidence base identified in this review.

MAIN CONTRIBUTION

This review outlines the lack of evidence supporting both compensatory and rehabilitative methods of treating dysphagia in Parkinson's disease. It directs clinicians and researchers towards areas that require further investigation.

CONCLUSIONS & IMPLICATIONS

To date, compensatory methods of treating dysphagia in Parkinson's disease have received more research attention than rehabilitative methods and yet neither approach has a strong evidence base. This review argues that rehabilitative methods could possibly have greater potential to increase swallowing safety and improve quality of life in the long-term than compensatory methods alone. However, at present there is a lack of research in this area.

Assessment of data quality in an international multi-centre randomised trial of coronary artery surgery

Background

ART is a multi-centre randomised trial of cardiac surgery which provided a unique opportunity to evaluate the data from a large number of centres from a variety of countries. We attempted to assess data quality, including recruitment rates, timeliness and completeness of the data obtained from the centres in different socio-economic strata.

Methods

The analysis was based on the 2-page CRF completed at the 6 week follow-up. CRF pages were categorised into "clean" (no edit query) and "dirty" (any incomplete, inconsistent or illegible data). The timelines were assessed on the basis of the time interval from the visit and receipt of complete CRF. Data quality was defined as the number of data queries (in percent) and time delay (in days) between visit and receipt of correct data. Analyses were stratified according to the World Bank definitions into: "Developing" countries (Poland, Brazil and India) and "Developed" (Italy, UK, Austria and Australia).

Results

There were 18 centres in the "Developed" and 10 centres in the "Developing" countries. The rate of enrolment did not differ significantly by economic level ("Developing":4.1 persons/month, "Developed":3.7 persons/month). The time interval for the receipt of data was longer for "Developing" countries (median:37 days) compared to "Developed" ones (median:11 days) (p < 0.001). The median number of data queries was 23% in "Developed" countries compared to 19% in "Developing" ones (p = ns).

Conclusions

In this study we showed that data quality was comparable between centres from "Developed" and "Developing" countries. Data was received in a less timely fashion from Developing countries and appropriate systems should be instigated to minimize any delays. Close attention should be paid to the training of centres and to the central management of data quality.

Trial registration

ISRCTN46552265

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.

Comparison of trained clinician ratings with expert ratings of aspiration on videofluoroscopic images from a randomized clinical trial

Accurate detection and classification of aspiration is a critical component of videofluoroscopic swallowing evaluation, the most commonly utilized instrumental method for dysphagia diagnosis and treatment. Currently published literature indicates that interjudge reliability for the identification of aspiration ranges from poor to fairly good depending on the amount of training provided to clinicians. The majority of extant studies compared judgments among clinicians. No studies included judgments made during the use of a postural compensatory strategy. The purpose of this study was to examine the accuracy of judgments made by speech-language pathologists (SLPs) practicing in hospitals compared with unblinded expert judges when identifying aspiration and using the 8-point Penetration/Aspiration Scale. Clinicians received extensive training for the detection of aspiration and minimal training on use of the Penetration/Aspiration Scale. Videofluoroscopic data were collected from 669 patients as part of a large, randomized clinical trial and include judgments of 10,200 swallows made by 76 clinicians from 44 hospitals in 11 states. Judgments were made on swallows during use of dysphagia compensatory strategies: chin-down posture with thin liquids and head-neutral posture with thickened liquids (nectar-thick and honey-thick consistencies). The subject population included patients with Parkinson's disease and/or dementia. Kappa statistics indicate high accuracy for all interventions by SLPs for identification of aspiration (all kappa > 0.86) and variable accuracy (range = 69-76%) using the Penetration/Aspiration Scale when compared to expert judges. It is concluded that while the accuracy of identifying the presence of aspiration by SLPs is excellent, more extensive training and/or image enhancement is recommended for precise use of the Penetration/Aspiration Scale.

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.

Swallowing and dysphagia rehabilitation: translating principles of neural plasticity into clinically oriented evidence

PURPOSE

This review presents the state of swallowing rehabilitation science as it relates to evidence for neural plastic changes in the brain. The case is made for essential collaboration between clinical and basic scientists to expand the positive influences of dysphagia rehabilitation in synergy with growth in technology and knowledge. The intent is to stimulate thought and propose potential research directions.

METHOD

A working group of experts in swallowing and dysphagia reviews 10 principles of neural plasticity and integrates these advancing neural plastic concepts with swallowing and clinical dysphagia literature for translation into treatment paradigms. In this context, dysphagia refers to disordered swallowing associated with central and peripheral sensorimotor deficits associated with stroke, neurodegenerative disease, tumors of the head and neck, infection, or trauma.

RESULTS AND CONCLUSIONS

The optimal treatment parameters emerging from increased understanding of neural plastic principles and concepts will contribute to evidence-based practice. Integrating these principles will improve dysphagia rehabilitation directions, strategies, and outcomes. A strategic plan is discussed, including several experimental paradigms for the translation of these principles and concepts of neural plasticity into the clinical science of rehabilitation for oropharyngeal swallowing disorders, ultimately providing the evidence to substantiate their translation into clinical practice.

The usefulness of the line spread test as a measure of liquid consistency

Although dietary modification is a common treatment strategy used to manage dysphagic patients who aspirate thin liquids, there are no standard definitions for thickened liquid preparation. This lack of standardization leads to variability in practice and points to the need for a simple tool for clinicians to assess thickened liquid consistency. The current study analyzed the utility of the Line Spread Test (LST) in this regard. Twenty-six liquids (10 powder-thickened "nectar" juices, 10 powder-thickened "honey" juices, and 6 barium mixtures) were assessed using both a viscometer for objective measurement of viscosity and the LST. Whereas the LST was able to separate the juices into nectar and honey categories, it was not able to separate barium mixtures into these categories nor compare barium to juices. Furthermore, the LST was not predictive of viscosity. Thus, the results of the current study suggest that the LST may be useful in the broad categorization of fluids into therapeutically significant groupings but that it cannot be used more specifically to measure fluid viscosity. Further studies of this and other tools are necessary to identify inexpensive practical tools for quantification of thickened liquid consistency.