Purpose: The Japanese Dysphagia Diet 2013 (Thickened Liquid) was introduced by the dysphagia diet committee of the Japanese Society of Dysphagia Rehabilitation as a common description of the degree of thickness of thickened liquids for dysphagic persons. This classification showed an objective range of values (viscosity and line spread test [LST]), but these range of values were determined by performing a sensory evaluation of thickened liquid by using mainly thickened liquids made from xanthan gums. In this study, we aimed to examine the effect of the different types of liquid thickeners on the viscosity and LST score.
Methods: Six samples (3 thickeners of xanthan gums, 1 thickener of guar gums, and 2 thickened liquid nutrition products) were used in this study. The samples were ranked based on the low of viscosity by 161 healthy volunteers in a sensory evaluation to measure the viscosity and LST score. The degrees of thickness levels according to the Japanese Dysphagia Diet 2013 (Thickened Liquid) by each method were compared.
Results and Discussion: The thickened liquid nutrition products were evaluated as “moderately thick” or “extremely thick” through sensory evaluation but evaluated as “extremely thick” or “more than extremely thick” through viscosity measurement, and “less than mildly thick” through the LST. Thickened liquid made from guar gums was evaluated as “moderately thick” in the sensory evaluation but evaluated as “mildly thick” in the LST. This means that the viscosity and LST score evaluated according to the Japanese Dysphagia Diet 2013 (Thickened Liquid) differs between different types of thickened liquids made from xanthan gums from the human sense of viscosity. Therefore, this classification should be used even for samples of different types of thickened liquids made from xanthan gums that are deemed unsuitable for evaluation.
Purpose: The purpose of this study was to investigate the distribution of dysphagic patients with disturbance of consciousness and the relationship between level of consciousness and resumption of full oral intake in an acute care hospital.
Subjects and Methods: We retrospectively analyzed 498 dysphagic patients with an average age of 68 (SD 15) years who received swallowing training in our acute care hospital for 4 years. We investigated the number of patients who returned to full oral intake from the viewpoint of their recovery of level of consciousness, examining changes in Dysphagia Severity Scale (DSS) and the Food Intake Level Scale, the Japan Coma Scale (JCS) between at the beginning and the end of intervention.
Results: At the beginning of intervention, alert consciousness (JCS0) was seen in only 86 patients (17%), whereas 412 (83%) were with disturbance of consciousness: 334 patients at JCS1–3, 76 at JCS10–30, and 2 at JCS100–300. Disturbance of consciousness was also found in 71% at the end of intervention.
There was a negative correlation between JCS and DSS: the coefficient of correlation was －0.28 (p＜0.001) at the beginning and was －0.47 (p＜0.001) at the end. More than 95% of patients at JCS0–2 at Occasional Aspiration Level in DSS returned to full oral feeding at the end of intervention, whereas 67% of patients at JCS3 at the same DSS level did. The results of patients at Water Aspiration Level were similar to those at Occasional Aspiration Level. Forty-five percent of all patients at Food Aspiration Level and 34% of all patients at Saliva Aspiration Level returned to full oral intake, whereas more than 70% of patients at JCS0 at both DSS levels did, and about 50% of patients at JCS1 or JCS2 did, and at JCS3 19% of patients at Food Aspiration Level and 5% at Saliva Aspiration Level did. Seventy-one percent of patients who were at Food Aspiration Level or Saliva Aspiration Level at the beginning and with disturbance of consciousness above JCS1 at the end could not achieve full oral intake.
Conclusion: Patients with dysphagia showed severe complication with disturbance of consciousness during acute phase hospitalization. The results suggest that deglutition function is correlated with level of consciousness and the outcome of dietary status is affected by the degree of improvement of consciousness during an intervention according to the initial severity of the patient’ s deglutition function. Continuous JCS assessment of consciousness might be important when considering the prognosis of dysphagia treatment efficacy.
Purpose: The purpose of this study was to clarify the attitudes of nurses towards feeding elderly patients with severe dysphagia.
Subjects and Methods: We explored the attitudes of 129 nurses working at a hospital towards feeding elderly people with severe dysphagia. After reading a detailed case study of a fictitious 83-year-old patient, with a strong desire to continue oral ingestion despite severe dysphagia, participants were asked to complete a questionnaire.
Results: When nurses were asked to take the perspective of a family member they were more positive about oral feeding than when they saw themselves in the role of a nurse (p＜0.01). Nurses who were positive about oral feeding from the perspective of a family member also tended to be positive about this when they viewed the case study from a nurse’s perspective (r＝0.731, p＜0.01). Considered from the viewpoint of a family member, the nurses who had experienced similar examples in their own lives were more positive about oral ingestion than those who did not have this experience (p＜0.01).
Consideration: The different attitudes among nurses might arise from their dilemma of two hopes: giving patients a pleasure of savoring food and avoiding their agony and mortal danger posed by aspiration.
Conclusion: These results suggested that nurses have to share their views, be aware of different attitudes, and reach agreement on how to care for patients with dysphagia by developing their facilitation skills.
We carried out systematic oral care for stroke patients from the acute stage, and found that their ADL and prognosis improved. We standardized the oral care to include many occupational descriptions. Seventy patients in 2010 before the standardization were classified as a control group, and 127 persons in 2012 who received the standardized care were classified as the interposition group.
We compared seven items in the two groups: aspiration pneumonia, pyrexia, intubation or tracheotomy, gastrostomy, grade of swallowing performance, status of daily activity, and rate of discharge to home care. The occurrence of pyrexia fell significantly by this intervention and aspiration pneumonia also decreased. Although there was no improvement of swallowing grade by our intervention, we reduced significantly the number of gastrostomies and increased the performance status of daily activity at the time of discharge, and also the discharge rate. It is suggested that the potential of oral care to maintain oral hygiene and increase the probability of eating leads to modification of the QOL-oriented behavior of patients, family members and medical staff.
This study investigates the effects of oral care for dialysis patients, who often present particular issues in oral health, when conducted in collaboration between dental hygienists and nurses/care workers.
Participants: Twelve hospitalized patients who were undergoing hemodialysis treatment; all of them underwent professional oral care for 3 months.
Method: First, dentists or dental hygienists assessed the participants’ mouth. After the assessment, they held workshops for nurses and care workers in order to standardize the oral care carried out in the hospital. Four types of oral care were performed in a day, one of which was professional care by dental hygienists.
Results: All 12 patients were diagnosed with plaque deposition, tongue coating, xerostomia, and periodontitis. The first two were removed from the mouth by professional oral care. In addition, after the standardization, the nurses and care workers became able to include other methods than mouth cleaning, such as massaging their salivary glands, which somewhat improved xerostomia. After 3 months of treatment, improvements in inflammation and nutritional status could be observed in all 12 patients.
Consideration: Even dialysis patients can improve their oral health if dental hygienists collaborate with nurses and care workers. In the future such professional oral care should be conducted in other areas that involve patients with oral disorders. In order to perform professional oral care safely and effectively, it is important for dental hygienists to cooperate with people in other occupations, who support such patients. This study suggests that professional oral care, which is expected to become more widespread in the future, should be promoted.
We used an existing suction catheter inducer to carry out tube swallowing training easily and safely in a patient with both bite reflex and tongue thrust reflex. The patient was a 57-year-old male who had suffered subarachnoid hemorrhage and subsequently developed hydrocephalus and cerebral infarction. Consciousness disturbance, dysphagia and motor disturbance in the trunk and limbs were prolonged in spite of ventriculo-peritoneal shunt operation. Tube swallowing training in this patient did not proceed successfully, because he had a strong bite reflex and a tongue thrust reflex. We used the existing suction catheter inducer in the mouth to protect the tube from bite and to depress the tongue, in combination with the K-point stimulation technique to open the jaw. This allowed us to perform tube swallowing training easily and safely.
We consider that applying the existing suction catheter inducer made it easy to introduce tube swallowing training, even in this patient with strong bite reflex and tongue thrust reflex.
Purpose: The aim of this study was to determine the factors influencing the childcare burden of mothers with dysphagic children.
Subjects and Methods: The subjects were 34 mothers aged in their 20s to 40s who had disabled children. The children were 19 males and 15 females, aged 15 months to 12 years. We investigated the needs of the parents with a questionnaire for feeding and Nakajima's childcare burden scale. The scale had 8 items, with a maximum total score of 40. We divided the 8 items into two categories: Q1 to 4 concerned social restrictions on the caregiver, while Q5 to 8 concerned the caregiver's negative feelings toward the child. The total score of each category was used for the analysis. Correlations among the items were determined by the χ2 test. The correlations were statistically analyzed by the correlation coefficient, Mann Whitney U-test and Wilcoxon test using Windows PASW Ver. 20. Statistical significance was set at p＜0.05.
Before starting the measurements, the purpose and protocol were explained to the subjects to obtain their consent.
Results: A significant correlation between children's age in months and the category of caregiver's social restriction (r＝0.385, p＝0.025) was found. There was a significant relationship between birth order and the category of caregiver's negative feelings toward the child (p＜0.05). The caregiver's social restriction rate of mothers without a counselor was significantly higher than those with a counselor (p＜0.01).
Conclusion: These results show that extra consideration should be given to the caregiver's burden, especially children's birth order and solitary state of mothers, when designing dysphagia therapy.
In this study, we investigated the relationship between gross motor development and timing for starting weaning in children with down syndrome (hereinafter: DS children), together with the effects of the timing for starting functional therapy for eating on subsequent acquisition of eating function, with the aim of examining support systems at regional care and guidance centers.
Subjects comprised 62 DS children of 3 years or younger at the initial examination who were examined at the outpatient clinic for dysphagia at a regional care and guidance center. The course of gross motor development was acquired from the medical records of the subjects, whereas age at initial exam, eating and swallowing function at initial exam and information regarding timing for starting weaning were acquired from their dysphagia clinic records. Subjects were divided into four groups according to age at initial exam, as 19 subjects were boys aged ≤ 18 months (EB), 24 subjects were girls aged ≤ 18 months (EG), 10 subjects were boys aged ≥ 19 months and ＜36 months (LB), and 9 subjects were girls aged ≥ 19 months and ＜36 months (LG). Because no difference was noted between boys and girls for eating and swallowing function at the initial exam, the relationship with eating and swallowing function at initial exam and with the period of acquisition of eating and swallowing function were investigated in the EB/EG group and LB/LG group.
Gross motor development delay was observed in DS children but weaning was started at the same time as typically-developed children. As a result, weaning was started for many DS children before they could sit stably, so coordination with physiotherapy appears necessary for oral ingestion in a stable posture.
There was no difference in the number of months required to acquire eating and swallowing function due to age at initial exam, suggesting that starting instruction from the early stage could speed up function acquisition. Furthermore, as the function acquisition rate was high for some items in the EB/EG group, early intervention also appears effective from the standpoint of reliably acquiring functions that are learnt early. It appears best to give advice on function acquisition in accordance with weaning period development, and our results indicated that information regarding eating should be given directly after examination at the center and a system for providing continuous support should be refined.
It is important for dysphagia children to promote their interest in eating and enjoying their mealtimes. When tube-feeding children start oral intake, the safety of their swallowing must be confirmed. In this case report, we describe a tube-feeding child who could swallow safely and start oral intake.
A 1.5-year-old boy with severe dysphagia presented to our outpatient clinic for an evaluation of swallowing function. He had severe psychomotor retardation, respiratory disturbance and gastroesophageal reflux disease. He depended on tube-feeding exclusively for taking nutrition because of previous recurrent aspiration pneumonia. He underwent tracheotomy and gastrostomy at 0.9 years and 1.3 years, respectively. Thereafter his respiratory disturbance and gastroesophageal reflux disease improved, however, he was prohibited from oral intake. At the initial examination, he presented drooling and stridor. Frequent endotracheal tube suction was necessary to clear secretions. The findings of endoscopic evaluation of swallowing indicated a little retained secretion in the laryngopharynx and no swallowing reflex during examination. The findings of videofluoroscopic examination of swallowing indicated aspiration and no swallowing reflex. The result of the initial evaluation was that he had no swallowing reflex and could not feed orally at all. We continued consultations every 1 to 2 months at his mother’s request. His mother said that he did not present stridor very often and she sometimes heard his swallowing sound at home. For the first 3 months, he always presented stridor at the consultation room, but thereafter did not always present stridor. However, even if he did not present stridor at the start of the consultation, he always began to do so whenever we performed any examination. Considering his mother’s information and his state in the consultation room, we speculated that he could swallow at home, but that he could not swallow and presented stridor in a different environment from home. After 8 months from the first consultation, we confirmed his swallowing without aspiration by videofluoroscopic examination when he did not present stridor. In contrast to the initial evaluation, our final evaluation was that he could start a little oral feeding when he did not present stridor. For 1 year since starting oral intake, he has had no aspiration pneumonia.