Objective: The aim of this study was to clarify the risk factors for impaired swallowing function among patients with schizophrenia suffering from dysphagia by using multiple regression analysis.
Patients: This study was performed retrospectively and included 272 patients with schizophrenia that were referred to the Department of Dentistry and Oral Surgery of our hospital because of swallowing impairment from April 2008 to November 2012. The numbers of male and female cases were 147 and 125, respectively, and the mean age was 68.6 years (standard deviation: 12.7 years). Doses of neuroleptics at the time of assessment of swallowing ability were converted to milligram equivalents of chlorpromazine (CP equivalent dose), and the mean CP equivalent dose at the time of assessment of swallowing ability was 454 mg/day (standard deviation: 603 mg). Swallowing ability of the patients was assessed according to the Functional Oral Intake Scale (FOIS).
Results: Age, independency of daily living, independency of indoor living, sitting ability, CP equivalent dose and presence or absence of orofacial dyskinesia were assessed as explanatory variables and FOIS as a dependent variable for multiple regression analysis. The results indicated that independency of daily living (p＜0.05), independency of indoor living (p＜0.0001) and sitting ability (p＜0.01) were significantly related with FOIS. However, age (p＝0.990), CP equivalent doses at the time of assessment of swallowing ability (p＝0.092), and presence or absence of orofacial dyskinesia (p＝0.056) were not significantly related to FOIS.
Conclusion: Swallowing function was significantly related with activity of daily living (ADL), whereas this function was not significantly related to age, CP equivalent doses or the presence or absence of orofacial dyskinesia among schizophrenic patients suffering from dysphagia.
Objective: Red pepper contains a large amount of capsaicin, which is known to have a swallowing reflex-stimulating effect. Capsaicin is considered to facilitate the release of substance P (SP) by sensory nerves in the pharynx into mucosal membranes, allowing the reflex to occur easily due to elevated SP concentration. Capsaicin-containing film or wafers are now commercially available, and are easily ingested by patients with dysphagia. The swallowing reflex-stimulating effect after ingestion, however, has not been fully investigated. Thus, the effects of capsaicin-containing film on swallowing and cough reflexes, and their influence on SP concentration in saliva were examined in this study.
Methods: A cross-over, double-blind study was performed in 17 male adults aged between 20 and 40 years, using capsaicin-containing (capsaicin content: 1.5 mg/film) and placebo film. The swallowing reflex and the cough reflex were evaluated 6 times every 10 min after ingestion with a baseline value at rest measured 10 min before ingestion of the film. The lag time of swallowing was measured in a simplified swallowing-induction test to evaluate the swallowing reflex. A cough test was conducted using 1% citrate saline solution to evaluate the cough reflex. In addition, the SP concentration in saliva, which was collected 10 min before, 10 and 20 min after ingestion, was measured with an ELISA kit. The control group ingested placebo film. The Freidman test and the Wilcoxon signed-rank test were used for statistical analysis.
Results: Compared with the control group, the lag time of swallowing in the capsaicin group became significantly different at 20 and 40 min after ingestion of capsaicin. By comparing with the baseline of the capsaicin group, swallowing reflex was shortened after 40 min. No significant differences were observed at other measurement points or in other evaluation items.
Conclusion: Ingestion of capsaicin-containing film was demonstrated to have a swallowing reflexstimulating effect at 40 min after ingestion.
Objectives: Some articles on dysphagia have reported that laryngopharyngeal sense influences the occurrence of aspiration pneumonitis. However, propelling of the bolus into the pharynx during Stage II transport is seldom perceived. The purposes of this study were to evaluate epiglottal perception of arrived bolus during Stage II transport using actual food and to determine the effect of differences in food texture on the epiglottal perception.
Methods: Twenty healthy volunteers chewed three food samples cooked to different grades of texture (hard, soft and medium), using enzyme homogeneous permeation. The subjects made a sign when they felt that the bolus had reached the epiglottis during Stage II transport. We evaluated the actual location of the bolus using videoendoscopy when the subject perceived that the food had arrived at their epiglottis.
Results: There were statistically significant differences between soft and hard food textures for both the duration from the beginning of chewing to the sign from the subjects and to arrival of the bolus at the epiglottis. The difference between the duration from the beginning of chewing to the sign from the subjects and to actual arrival of the bolus at the epiglottis did not depend on food texture and no significant difference was observed among the three food textures. Most subjects made a sign when the food arrived at about the posterior part of the tongue and the epiglottis.
Discussion: The healthy subjects could not correctly perceive the arrival of the bolus at the epiglottis during Stage II transport. Additionally, the texture of the test food did not affect epiglottal perception.Therefore, it is speculated that variations in mastication time might make the processed bolus a similar texture before the occurrence of swallowing.
Purpose: To study how food forms physically and mentally affect the elderly from the analysis of the elders' autonomic nervous system reactions (changes to the systolic blood pressure, pulse, and salivary amylase) and subjective evaluation.
Subjects: 18 elderly adults (6 males and 12 females) living at home in Area A, with an average age of 69.11 (with 4.5 years on either side).
Method: In a quasi-experimental cross-over design, two food forms, solid bananas and mashed bananas, were used. The ANOVA procedure was taken for analysis of changes in the autonomic nervous system that occurred before and after the intake of the food in both forms, and the Wilcoxon signed-rank test was used for subjective evaluation.
Results and Discussion: The main effect was seen in the autonomic nervous system reactions that occurred before and after the intake of the food, and the values of the elders’ systolic blood pressure, pulse, and salivary amylase significantly lowered after the intake of the food in both forms (p＜0.01). No interaction by the form of the food or by the order of forms of food to be taken was observed. The decline in autonomic nervous system activities after the intake of food, regardless of its form, can be considered as a result of a sense of comfort given by the action of eating. Subjective evaluation was conducted from the five points of appearance, smell, taste, temperature, and texture (p＜0.05). As a result, the mashed banana was given significantly lower evaluations than the solid bananas on all the five points. The subjects knew they were the same food but still preferred solid bananas to mashed ones. It was therefore concluded that the mental promotion of appetite can be affected by the form of food.
Conclusion: The autonomic nervous system activities of the elderly individuals declined regardless of the form of the food, while in the subjective evaluation, mashed bananas were poorly evaluated as the individuals preferred taking solid bananas. It can be said that the taste and form of food are connected in the memory of individuals, and that the appetite may be lost when the actual taste and form disagree. Due to dysfunction or other disorders, elderly patients are often forced to eat food in a form that they have never experienced before. It is however important to encourage elderly patients to have a healthy appetite for food. This study suggests the importance of keeping the form of the food that promotes the appetite of elderly patients.
Purpose: After physical cleaning in oral care, it is important to eliminate the contaminants in the oral cavity in order to avoid aspiration pneumonia by the contaminants. Rinse and suction is the gold standard, but the risk of aspiration remains with water rinse. Therefore, effective methods of eliminating contaminants are still unknown. This preliminary study aimed to elucidate effective methods of eliminating contaminants after oral care in healthy subjects.
Methods: Twenty healthy volunteers with no history of dysphagia participated in this study. The subjects brushed their teeth more than 4 h after the last brushing. The number of bacteria on the tongue, palate, or gingivobuccal fold was measured by a bacteria detection apparatus (Panasonic Healthcare) before oral care, just after the care, after eliminating contaminants, and 1 h after the care. Three methods of eliminating contaminants were applied: 1. Water rinsing (Rinse), 2. Wiping with wet tissue for oral use (WT), and 3. Wiping with sponge brush (SB). Each procedure was conducted on a different day. The number of bacteria on each location at each timing was compared using the Friedman test.
Results: For the Rinse group, the number of bacteria decreased significantly on the gingivobuccal fold from before the care to after the elimination, but there was no significant difference on the tongue or palate.
For the WT group, the number of bacteria decreased significantly from before the care to after the elimination on all three locations.
For the SB group, the number of bacteria decreased significantly on the gingivobuccal fold from before the care to after the elimination.
Conclusion: The present study demonstrated that wiping with wet tissue is the most effective method to decrease bacteria. The findings suggest that, after oral care, wiping with wet tissue would be a better way of eliminating contaminants than mouth rinse which may increase aspiration of contaminants. Further study is needed to explore effective methods of elimination in individuals with dysphagia.
Introduction: Noninvasive positive pressure ventilation (NPPV) is used as noninvasive ventilatory support without intratracheal intubation for patients with a range of diseases. In our hospital, since 2007, we have performed safe bronchoscopic examinations with ventilatory support employing NPPV in patients with respiratory failure. Herein, we report safe performance of gastrostomy under respiratory management with NPPV in a patient with amyotrophic lateral sclerosis (ALS) complicated by type II respiratory failure.
Case: A 67-year-old woman had suffered from ALS since 2010. She visited our hospital with a chief complaint of dyspnea in December 2011, which led to hospital admission for treatment of type II respiratory failure due to progression of respiratory muscle paralysis.
Clinical course: On the day of hospital admission, respiratory management by NPPV was initiated. Although her respiratory failure improved rapidly, gastrostomy for tube feeding was necessitated by reduced dietary intake due to progression of bulbar paralysis and generalized muscle weakness. Percutaneous endoscopic gastrostomy (PEG) was scheduled but the operation had to be performed under ventilatory support employing NPPV because of concerns about possible worsening of respiratory failure due to intraoperative use of a sedative in addition to respiratory muscle atrophy. As for masks, we used an Endoscopy Mask® with an endoscope insertion hole produced by Smiths Medical Japan. For NPPV, we used the Philips Respironics V60®. After the patient had been sedated with intravenous midazolam 10 mg, PEG was performed with NPPV through the face mask. A gastric fistula could be made without worsening of her respiratory condition.
Discussion: We consider NPPV to be among the most useful methods of respiratory support during gastrostomy in patients with poor respiratory functions. However, in our opinion, this method should be used only after careful consideration because it requires certain skills and a multidisciplinary team approach.
Corticobasal degeneration (CBD) is a rare neurological disease in which parts of the brain deteriorate or degenerate. The initial symptoms of CBD are stiffness, shakiness, and slowness in either upper or lower extremities. Other initial symptoms include dysphagia, dysarthria, and difficulty in controlling the muscles of the face and mouth.
We report the case of a 72-year-old female with CBD and impairment of bilateral vocal cord abduction who had a gastrostomy tube due to a diagnosis of aspiration pneumonia 2 years ago. Her family complained of difficulty in deglutition, therefore we started intervention for evaluating swallowing function in March 2011. We confirmed that she could ingest some jelly without aspiration, so she was followed up every 2 or 3 months. Her dysphagia developed slowly, and the silent aspiration appeared.
In March 2012, her family found that she was frequently holding her breath with the mouth closed during the daytime, and showed cyanosis under care and snoring at night. We evaluated the state of her larynx using an endoscope during the pharyngeal reflex and breathing, and movement was observed. Impairment of the bilateral vocal cord abduction during expiration appeared for 70 seconds. Thus, we decided to stop her oral intake, and prescribed measurement of oxygen saturation during the daytime and at night. It was observed that her oxygen saturation fell rapidly during the early morning and tube feeding. We contacted her family doctor, and informed that the patient might inhale oxygen when her oxygen saturation fell.
Symptoms of impaired vocal cord abduction without atrophy of the cricoarytenoid muscle are seen in Parkinson's disease and progressive supranuclear palsy, however, it is unknown for CBD patients. The potential for vocal cord abduction was preserved, and impairment of the bilateral vocal cord abduction was caused by abnormal constriction of some muscles of the larynx. Episodes of respiration difficulty occurred with the progression of dysphagia. Although the occurrence of vocal cord abduction is rare in CBD, we should pay attention to detect this symptom when evaluating swallowing function.