Recently, various thickeners have become commercially available, but the fact that no index (model food) of consistency is indicated on the product label is a serious issue for consumers.
The aim of this study was to establish an index (model food) for thickener solutions when users prepare them.
We reviewed measurements for evaluating the physical properties of thickener solutions and liquid food to examine the correlation with non-oral sensory properties.
To prepare thickened samples, the volumetric amount of each commercial thickener was added to water to make the solution thickness like either a honey or yogurt consistency indicated on the product label.
The difference in sensory properties between the model food (honey or plain yogurt) and the thickened solutions was examined. A sensory evaluation panel compared the viscosities of these samples by tilting the containers, stirring the contents with a spoon, and by pouring the thickened solution from a spoon.
These samples were subjected to physical measurements, including the texture properties of hardness, adhesiveness, cohesiveness, and viscosity at the shear rate of 0.7–50 s-1.
According to the sensory evaluation data, the honey was considered to have a viscosity that was not similar to that of honey-like thickener solutions. This was because the shear viscosity of physical measurements indicated that honey was Newtonian flow, while most thickener solutions were Non-Newtonian flow. This suggested that honey was not an appropriate model food.
The texture properties of hardness–cohesiveness and hardness–adhesiveness on a two-dimensional plot showed that the Newtonian samples including honey and Non-Newtonian samples were located in the same range and could not be distinguished.
Measurements of not only texture properties but also viscosity at different shear rates are necessary to determine the index (model food) for thickener solutions that are prepared by stirring.
Facilities that provide food such as hospitals and facilities for the elderly or physically handicapped, have meals for mastication and/or swallowing disorders. Generally, the solid component of these meals is softer and/or smaller pieces, and the liquid component is thicker. However, although the standardization of diet modifications is extremely important for managing the nutrition and safety of dysphagic patients, there has been no standard.
To standardize diet modifications, we classified meals for dysphagic patients in food service facilities depending on the modification method and the degree of texture and consistency. We then analyzed the correspondence between the classifications and the disorder types of the people receiving the meals.
To collect meal information for dysphagic patients such as the name, modification method, degree of texture and consistency, and disorder type, a questionnaire was sent to dietitians who work in hospitals or in facilities for the elderly or physically handicapped.
In total, 323 dietitians returned the questionnaire, and information on 693 staple food dishes (rice) and 895 dishes other than staple food was collected. The staple foods were classified into seven and dishes into fifteen. By correspondence analysis, the disorder type of the people receiving each classification of food was characterized.
Through all classifications, major disorder types were mastication or swallowing disorders. But most answers did not show any functional decline, only the symptom as a result of functional decline of the related organ. Therefore, we cannot get details of disorder types. However, some of the information may not be based on medical grounds. This suggests that dietitians do not have adequate knowledge of the mechanism of eating, and cannot understand the functional status of their patients. We consider that it is important that all people who work in food service understand the purpose and meaning of diet modifications, and when preparing meals, consider the disorder type of the people receiving them.
[Objective] To obtain basic information on postural adjustment during swallowing by investigating the effects of the height of tables on which the forearms are placed during swallowing on the activity of the suprahyoid muscles.
[Methods] A total of 10 healthy volunteers swallowed porridge (5 g) under the following three conditions: without a table (both arms hanging by side), and with the forearms resting on a table where the distance between the table surface and sitting surface was either one third of the sitting height (Condition A) or one third of the sitting height plus 15 cm (Condition B). During swallowing, surface electromyography of the suprahyoid muscles was performed, difficulty of swallowing was subjectively assessed, and the elevation angle of the shoulder girdle was measured. The duration of muscle activity during swallowing, muscle activity integral, and the time from the start of swallowing to maximum muscle activity were calculated based on the surface electromyography of the suprahyoid muscles. The assessment and measurement items for the conditions with a table were normalized using the condition without a table as a standard, and the rates of change from the condition without a table were calculated (% muscle activity time, % muscle activity integral, % time to maximum muscle activity, and % subjective difficulty of swallowing). Comparisons of assessment and measurement items among the three conditions, the elevation angle of the shoulder girdle between the two conditions with a table, and the rates of change in assessment and measurement items from the condition without a table were performed using the Wilcoxon signed rank sum test.
[Results] Compared to the condition without a table, Condition A had a significantly shorter muscle activity time and time to maximum muscle activity of the suprahyoid muscles and a significantly lower muscle activity integral and subjective difficulty of swallowing, but no significant differences were observed for Condition B. Compared to Condition B, Condition A had a significantly higher elevation angle of the shoulder girdle and a significantly lower % muscle activity time, % muscle activity integral, % time to maximum muscle activity, and % subjective difficulty of swallowing.
[Conclusion] The present findings suggest that the height of the table on which the forearms are placed during swallowing affects the activity of the suprahyoid muscles. Appropriate adjustment of this height, along with postural adjustment of the neck and trunk, may therefore be a useful component of postural adjustment during swallowing.
[Objective] To explore factors related to repetitive aspiration pneumonia in elderly patients with dysphagia.
[Subjects] Sixty-eight patients admitted to the Tarumizu Municipal Medical Center Tarumizu Chuo Hospital, Japan between April 2007 and June 2009 with aspiration pneumonia were enrolled in the study. They were divided into two groups: those who were experiencing aspiration pneumonia once (primary group, n ＝53), and those experiencing a relapse of aspiration pneumonia (of two or more times) (relapse group, n ＝15).
[Method] Age, gender, length of hospital stay, number of stroke episodes, cognitive status, higher brain dysfunction, gait ability, food texture requirements, repetitive saliva swallow test (RSST), and modified water swallow test (MWST) were examined as independent variables.
[Results] The two groups were similar with respect to age, gender, length of hospital stay, and RSST. There were significant differences between the two groups in terms of number of stroke episodes, gait ability, and MWST. In the primary group, approximately 50% of patients were hospitalized from their home, while in the relapse group, approximately 87% were hospitalized from other facilities. In the relapse group, 64% had higher brain dysfunction; intention dysfunction and pacing dysfunction were particularly influenced by aspiration pneumonia.
[Conclusion] These factors may play an important role in predicting the recurrence of aspiration pneumonia. These results also show the importance of initial assessment ratings, and suggest a need for inter-rater reliability of assessment measures within rehabilitation facilities. We propose that knowledge about dysphagia should be given to the patients’ families upon leaving hospital, and that training methods for cognitive dysfunction, higher brain dysfunction and dysphagia should be closely examined.
The management of dysphagia for both outpatients and inpatients has been carried out since the Department of Oral Rehabilitation, School of Dentistry, Showa University was established on June 1, 2004. This paper reports the effectiveness of intensive management of severe dysphagic inpatients aged 65 years or over.
A comparison of inpatients aged 74 years or under with those 75 years or over hospitalized at some time from June 2004 to March 2009 was performed. The subjects were 14 patients, including 7 inpatients aged 74 years or under (average 69.4 y) and 7 inpatients 75 years or over (average 81.3 y). Age, gender, cause of dysphagia, period of hospitalization, time from dysphagia onset to hospitalization in our hospital, number of videofluoroscopic examination of swallowing (VF), method of dysphagia rehabilitation, feeding method, diet modification, daily kilocalories consumed and feeding level were investigated.
Causes of dysphagia were cerebrovascular accidents (CVA) in three patients and post-surgical head and neck cancer (HNC) in four patients in those aged 74 years or under. CVA in two patients, HNC in one patient, dementia in two patients, progressive supranuclear palsy (PSP) in one patient and another disease in one patient were causes of dysphagia in the 75-years-and-over group.
The average period of hospitalization for inpatients aged 74 years or under was 14.0 days and that for inpatients aged 75 years or over was 13.4 days. The shortest period from dysphagia onset to hospitalization in our hospital was 62 days and the longest period was 1,329 days (3 years and 8 months). The average number of attempts at VF examination during hospitalization was 2.4 times. Diet level was improved in 10 subjects (six 74 years or under patients and four 75 years or over patients). The amount of kilocalories consumed in one day increased in nine subjects (three 74 years or under patients and six 75 years or over patients). These results verify the effectiveness of our dysphagia program for intensive management of inpatients with severe dysphagia.
[Purpose] The purpose of this study was to evaluate the nutritional status and eating habits of care-givers for patients with dysphagia at home.
[Subjects] The subjects were ten care-givers (2 males, 8 females), age 71.8±5.6 years, for patients with neuromuscular diseases.
[Methods] We assessed the nutritional status of the care-givers by physical and biochemical examinations. In addition, we investigated the care background and their eating habits using a questionnaire.
[Results] The total serum protein level in three care-givers and the albumin level in five were lower than the normal levels. The prealbumin, retinol binding protein, and transferrin levels were near the lower limits of the normal range. The counts of total lymphocytes in seven care-givers were lower than the normal counts. In five care-givers, the iron and zinc levels in serum were lower than the normal levels.
Regarding their eating habits, they consumed small amounts of green vegetables, fish, eggs, and potatoes, however, they consumed large amounts of beans, meat, and sweets. All the care-givers consumed smaller amounts of nutrients than required except for fat, and they consumed less than half of the required amounts of vitamins. Most of the care-givers did not pay attention to their diet.
[Conclusion] In home care support, it is important to pay attention to the nutritional status of care-givers as well as that of patients.
Oculopharyngodistal myopathy (OPDM) is characterized by ptosis as an initial symptom followed by slow progressive dysphagia and muscle weakness in the hands and lower legs. We report the case of a 60-year-old male with OPDM who had recovered from severe dysfunction of the upper esophageal sphincter (UES) by using a head rotation maneuver. He was admitted to a hospital due to aspiration pneumonia derived from OPDM. Fiberoptic endoscopic evaluation of swallowing 7 days after admission revealed severe dysfunctions of velopharyngeal closure, pharyngeal contraction, UES opening, and laryngeal closure. After this examination, nutrition was altered from oral feeding to tube feeding. Balloon catheter dilatation of the UES was instructed to the patient for the purpose of dilating the UES. At the endoscopic evaluation 28 days after the first examination, no remarkable improvement of UES opening was observed with balloon dilatation. However, distinct opening of the UES was found with head rotation maneuver. The food bolus entered the esophagus through the opposite side of the hypopharynx and UES to the head rotated side. As a result of these findings, it was decided to change his feeding method from tube feeding to oral feeding of normal food with head rotation at discharge from the hospital. Head rotation maneuver is usually used in cases of hemi-paralysis of the pharynx, causing post-swallow residue in the piriform sinus or post-swallow aspiration. The mechanism of the technique is thought to involve blocking the entry of food to the hypopharynx of the affected side and using the unaffected side. In this case, however, the main effect of head rotation was to physically pull one side of the cricopharyngeal muscle but not to block the one side of the food way since there was no laterality of paralysis in this case. The findings suggest that the head rotation maneuver can be applied as a compensatory maneuver in cases of chronic muscle disease with dysfunction of the UES.
The patient was an 86-year-old woman with a medical diagnosis of multiple cerebral infarction. The results of the initial evaluation were: repetitive saliva swallowing test, 0 time/30 s; modified water swallowing test, 1 point; and food test, 1 point, with all of them indicating the severest degree. A videofluoroscopic examination of swallowing (VF) showed severe cricopharyngeal dysfunction and reduced laryngeal elevation, and all of the jelly remained in the bilateral pyriform sinuses. The evaluation of quality of life (QOL) on a 5-grade scale of degree of satisfaction was 5, “dissatisfied,” the lowest grade. Indirect therapy in the form of a training plan was performed initially, but no change was observed, and so gastrostomy was performed. We then tried to perform swallowing training with a feeding tube according to Saigusa et al., but because swallowing by active movement of the tube was completely impossible, we devised a modified version of their method. In our method, we pass a thread via an external naris through the esophagus to the gastrostomy tube with an endoscope, and after connecting the thread at the external naris end to a urethral catheter, pull the thread at the gastrostomy tube end toward us, thereby enabling the patient to swallow by active-assistive movement of the urethral catheter. Although the swallowing movements were mainly due to active-assistive movements in the beginning, as a result of performing training for 8 weeks, swallowing movements by active movement eventually became possible, and VF revealed a marked improvement in the cricopharyngeal dysfunction. Training ended when the patient was transferred to another hospital, and although it never became possible for the patient to obtain her total nutritional requirements orally, a clear improvement in function was observed, and there was a dramatic improvement to a score of 1 “satisfied” in the evaluation of degree of satisfaction, an indicator of QOL. The above findings suggest the usefulness of a method that enables swallowing by active-assistive movement of a tube, when swallowing by means of active movement of the tube is difficult in patients with cricopharyngeal dysfunction complicated by pharyngeal dysphagia. Unlike rehabilitation of the limbs and trunk, it is anatomically difficult to act directly on the affected site, and so there have been very few attempts at rehabilitation of disorders in the pharyngeal stage of deglutition, particularly by passive movement or activeassistive movements. Accordingly, this useful method paves the way for the rehabilitation of pharyngeal dysphagia patients.