Objective: This study surveyed the situation of evaluation of and rehabilitation for dysphagic patients at hospitals and the distribution of hospitals that can accept dysphagic patients in Niigata Prefecture and presents the problems involved in establishing a medical system for dysphagia. Methods: We conducted a questionnaire survey by mail of all hospitals in Niigata Prefecture from July 1, 2014 to August 30, 2014. The questionnaire contained items related to the following: presence or absence of evaluation of and rehabilitation for dysphagic patients; type of medical staff involved in evaluation and rehabilitation for dysphagic patients; examinations used in evaluating dysphagia; presence or absence and details of special foods for dysphagic patients; acceptance or non-acceptance of dysphagic inpatients and outpatients; and reasons for non-acceptance. Based on the responses, we made a distribution map of the hospitals which accepted dysphagic patients and performed detailed examinations (videofluoroscopic (VF) and/or videoendoscopic examination of swallowing (VE)). Results: Among the 130 hospitals, we received responses from 120 hospitals (92.3%). Evaluation of and rehabilitation for dysphagic patients were performed in 93 hospitals (77.5% of the 120 hospitals that answered the questionnaire) and 83 hospitals (69.2%), respectively. The medical staff involved in evaluation and rehabilitation included speech-language-hearing therapists (in 71 hospitals, 75.5% of the 94 hospitals that performed evaluation and/or rehabilitation), physicians (in 70 hospitals, 74.5%), and nurses (in 65 hospitals, 69.1%). VF and VE were performed in 41 hospitals (44.1% of the 93 hospitals that performed evaluation), and 29 hospitals (31.2%), respectively. Special foods for dysphagic patients were provided at 94 hospitals (78.3% of the 120 hospitals). Among the 120 hospitals, 47 hospitals (39.2%) and 60 hospitals (50.0%), respectively, accepted dysphagic outpatients and inpatients. The reasons for declining patients were lack of medical specialists and related staff, lack of experience or knowledge, and inadequate equipment. VF and/or VE was performed at 33 hospitals (27.5% of the 120 hospitals) that accepted outpatients and at 37 hospitals (30.8%) that received inpatients. Every secondary medical zone has hospitals which could accept dysphagic adult patients but two zones had no hospitals which could accept dysphagic children. Conclusions: Evaluation of and rehabilitation for dysphagic patients are conducted in over 70% of hospitals in Niigata Prefecture. Among those hospitals, about 30% can accept dysphagic patients from other medical institutions. We should support the two secondary medical zones in which there are no hospitals that can accept dysphagic children.
It is difficult for older adults to attain exercise goals by performing head-raising exercises for strengthening the suprahyoid muscles because of sternocleidomastoid muscle fatigue. Although it was reported that tongue-to-palate pressure generation is superior to head-raising exercise to strengthen the suprahyoid muscles, the data is unclear for healthy older adults. The purpose of this study was to determine whether tongue-to-palate pressure generation can be used for laryngeal elevation training. Fifteen healthy younger adults (age, 27.1±2.6 years) and 12 healthy older adults (age, 76.0±3.0 years) participated in this study. We determined the electromyographic activity of the suprahyoid muscles, infrahyoid muscles, and sternocleidomastoid muscle when the participants performed tongue-to-palate pressure generation, head-raising exercise, and Mendelsohn maneuver. All parameters were compared using two-way analysis of variance. In terms of comparing the electromyographic activity of the suprahyoid muscles determined in this study, tongue-to-palate pressure generation significantly outperformed head-raising exercise and Mendelsohn maneuver (p＜ 0.01). In terms of comparing the electromyographic activity of the infrahyoid muscles and sternocleidomastoid muscle, head-raising exercise and Mendelsohn maneuver significantly outperformed tongue-to-palate pressure generation (p＜ 0.01). In healthy older adults, tongue-to-palate pressure generation may effectively improve electromyographic activity of suprahyoid muscles and may be used for laryngeal elevation training.
Objective: The objective of this study was to determine how nurses at advanced treatment hospitals understand dysphagia diets, as well as the difficulty and anxiety associated with food type assessment. Methods: A survey form was distributed to 540 ward nurses at advanced treatment hospital A. The 367 nurses from whom responses were obtained were treated as experimental subjects. In addition, for patients who had used dysphagia diets within the past year, data such as their age and the ward to which they belonged when they started the diet were collected from medical records. Results: A total of 53.2% of the patients who had used a dysphagia diet were aged 60 years or older. Patients belonged to all wards except for the intensive care unit. In the nurses’ survey, the percentage of nurses who had studied the “Japanese Dysphagia Diet 2013 by the Japanese Society of Dysphagia Rehabilitation dysphagia diet committee” was significantly higher among ward nurses with many patients using dysphagia diets (p＝ 0.017). Understanding of aspects, such as the definition of “dysphagia diet,” and the difference between codes 3 and 4 was also significantly higher among ward nurses with many patients using dysphagia diets (p＜ 0.001). Moreover, among the 132 nurses with experience in caring for patients using dysphagia diets, approximately 70% had difficulty or anxiety regarding food type assessment; no significant difference was observed between ward nurses with many patients using dysphagia diets and ward nurses with few such patients. Discussion: As the aging rate has increased, many hospital wards demand practical nursing skills for elderly individuals with dysphagia. The difficulty and anxiety among nurses regarding food type assessment may be due to insufficient knowledge regarding dysphagia diets and other aspects of ingestion and swallowing, as well as insufficient practical nursing skills tailored to individual patients; these issues suggest that it is necessary to provide learning opportunities regarding dysphagia. Conclusions: Ward nurses with many patients using dysphagia diets had a greater understanding of the diet compared to ward nurses with few such patients. However, regardless of the degree of involvement with patients using dysphagia diets, nurses had difficulty and anxiety regarding food type assessment.
Objective: This study aimed to elucidate and evaluate the dynamics of swallowing when using a palatal augmentation prosthesis. We observed changes in pharyngeal pressure during the swallowing process according to the wearing of a palatal augmentation prosthesis (PAP) in healthy individuals using high-reso-lution manometry (HRM). Materials and Methods: Ten healthy subjects (average age 34.2±9.5 years) wearing a PAP of one of three thicknesses ingested water jelly and thin rice porridge. Pressure and timing events were recorded with a 20-sensor HRM catheter. We analyzed the maximum swallowing pressure, duration of contraction, and time of contraction to peak, at the level of the velopharynx, tongue base, and lower pharynx. We analyzed the duration of relaxation of the upper esophageal sphincter (UES), maximum pre-opening UES pressure, and maximum post-closure UES pressure. Results: Healthy individuals that wore the PAP of 10 mm and swallowed jelly and thin rice porridge showed significantly increased peak pressure at the tongue base. Healthy individuals that wore the PAP of 10 mm and swallowed jelly and thin rice porridge showed significantly decreased peak pressure at the lower pharynx. No differences were found among duration of contraction, or time of contraction to peak, at the level of the velopharynx, tongue base, or lower pharynx, and duration of relaxation of UES when comparing those with PAP and those without PAP. Maximum pre-opening UES pressure was higher with PAP than without, and maximum post-closure UES pressure was lower with PAP than without, but neither was statistically significantly different. Conclusion: The thickness of PAP enhanced the anchor of the tongue, and increased the peak pressure at the base of the tongue. Conversely, the pressure of the lower pharynx reduced to compensate. PAP did not affect contraction duration or UES. We collected data for clarifying the dynamics of swallowing in healthy individuals using PAP with HRM. The results of this study demonstrated that HRM can be used to evaluate the dynamics of swallowing with PAP.
Purpose: Dysphagia is common in elderly patients and it can cause aspiration pneumonia. A videofluoroscopic examination (VF) or videoendoscopic evaluation (VE) is the best modality for diagnosing dysphagia. However, these methods are often difficult to use in elderly pneumonia patients with comorbidities such as dementia or physical deterioration. In 2002, the Mann Assessment of Swallowing Ability (MASA) was introduced to evaluate the eating and swallowing ability in first-time stroke patients. The purpose of this study was to investigate the accuracy of the MASA for clinical screening of dysphagia in elderly patients with pneumonia. Subjects and Methods: This study was prospectively performed between December 2014 and June 2015, and 153 pneumonia patients with a mean age of 85.4±9.9 years old were enrolled. The patients were administered the MASA within 3 days of admission. The outcome measures were the oral intake and a recurrence of pneumonia within 30 days. Results: Significant differences were observed in the mean MASA score between the patients with and without oral intake (p＜ 0.001), and between the patients with and without a recurrence of pneumonia (p＜ 0.001). The ROC curves between the MASA scores and the outcome measures were shown. The AUCs were 0.87 (oral intake), and 0.76 (a recurrence of pneumonia). The MASA cut-off values for the oral intake and recurrence of pneumonia were 113 points and 139 points. A multivariate analysis revealed an abnormal MASA score to be an independent risk factor for the recurrence of pneumonia. Conclusion: The MASA is therefore considered to be a useful screening tool for evaluating the eating and swallowing ability in elderly pneumonia patients.
There are various individual problems of clinical ethics in swallowing treatment, and so medical teams face difficulties in management. We report the use of a clinical ethics conference in our hospital with the four-box method to make a decision for a case with severe dysphagia. The patient was an 87-year-old man who had been suffering from repeated aspiration pneumonia. He was unable to eat each meal orally due to poor general condition and severe dysphagia. However, he refused any type of tube feeding. With swallowing therapy, he became able to eat orally once a day, and accept intermittent oro-esophageal tube feeding. Nevertheless, it was still difficult to provide him with meals three times a day due to lack of caregiving manpower with sufficient skills in meal assistance. Alternative tube feeding was indispensable to save him, but he complained that he wanted to eat without restriction. Therefore, we held a clinical ethics conference using the four-box method, which made our team staff realize many unnoticed ethics problems. Furthermore, he could eat orally once a day with respect and autonomy. As a result, his thinking gradually changed, and he received a CV port implantation. Finally, he was transferred to a long-term care hospital. We were able to proceed with decision-making with utmost respect for this patient’s will. Clinical ethics conferences may lead to better clinical decision-making and patients’ consensus.
Introduction: We used interferential current stimulation (IFCS) in combination with direct therapy to treat a patient with dysphagia due to delayed swallowing reflex and weakness of the suprahyoid and pharyngeal muscle groups, with good results. Case Report: A 78-year-old woman suffering from Parkinson’s syndrome underwent videofluoroscopic examination of swallowing (VF) and was found to exhibit aspiration before swallowing when swallowing liquids and pharyngeal retention of solids. Maximum lingual pressure was also low. Course: Therapy consisted of an 8-week course of a combination of tongue-strengthening exercises and thermal-tactile stimulation with direct therapy (conventional therapy). This therapy improved maximum lingual pressure to within normal limits. However, VF did not show any improvement in aspiration before swallowing when swallowing liquids or in pharyngeal retention of solids. After a 2-week break in therapy, direct therapy was resumed with the addition of IFCS (interferential current therapy) for 2 weeks. A Gentle-Stim (Careido Co., Ltd., Sagamihara, Japan) was used to administer IFCS. Aspiration before swallowing when swallowing liquids and pharyngeal retention of solids both improved on VF as a result. Quantitative analysis of liquid swallowing on VF images showed that there was no change in stage transition duration (STD) and laryngeal elevation delay time (LEDT), which are indicators of the swallowing reflex, after conventional therapy but that these had shortened after IFCS. Forward movement of the hyoid bone increased after both conventional therapy and IFCS. The speed of elevation of the hyoid bone did not change after conventional therapy, but increased after IFCS. Discussion: A combination of direct therapy and IFCS improved dysphagia by improving the motor function of the hyoid bone and reducing delay in the swallowing reflex. This combination of direct therapy and IFCS may be useful for dysphagia patients with delayed swallowing reflex.