Aims: The hyoid bone of patients with severe motor and intellectual disabilities (SMID) does not often appear clearly in videofluoroscopic examination of swallowing (VF). In this study, the bolus position at the time of contact between the tongue base and the posterior pharyngeal wall during the pharyngeal stage of swallowing between patients with SMID and healthy adults was compared. Subjects and Method: The subjects of this study were 19 healthy adults (healthy group) and 41 patients with SMID (disability group). We used the VF to video-record the subjects at 30 frames/s as they swallowed 3 to 5 mL of paste food. We identified the onset of elevation of the hyoid bone and the time of contact between the tongue base and the posterior pharyngeal wall, measured the time interval between these two movements during swallowing by a person in whom the onset of elevation of the hyoid bone could be identified, and evaluated aspiration. In addition, we evaluated the bolus position at the onset of elevation of the hyoid bone, and at the time of contact between the tongue base and the posterior pharyngeal wall in three stages: before, reaching or after the bolus reached the vallecula of the epiglottis. The results were compared by one-way analysis of variance or Fisher’s exact test. Results and Discussion: There was no difference between the time intervals from the onset of elevation of the hyoid bone to the time of contact between the tongue base and the posterior pharyngeal wall. The average value of each group was 0.105 to 0.231 s, and the position of the bolus head at both time points was consistent in 92.8% of the subjects. The bolus position at the time of contact between the tongue base and the posterior pharyngeal wall based on the position of the vallecula in the healthy group was: before: 7 (36.8%), reaching: 12 (58.3%), after: 0; and in the disability group was: before: 2 (4.9%), reaching: 18 (43.9%), after: 21 (51.2%). There was a difference in the proportion of the number of people regarding the bolus position at the time of contact between the tongue base and the posterior pharyngeal wall between the healthy group and the disorder group. Conclusion: When swallowing the paste foods, the bolus position at the onset of the swallowing movement of patients with SMID tended to pass through the vallecula compared with healthy adults.
Aims: Human ingestion of foods of different textures can be directly quantified using bioinstrumentation (e.g. tongue pressure sensor and throat microphone). This research aimed to investigate the relationship between textural properties and bioinstrumentation measurements for various foods used in nursing care. Methods: Tongue pressure during ingestion of 10 g of food specimens was measured by an ultra-thin sensor sheet with five measuring points attached to the hard palate. Swallowing sound was recorded using an IC recorder with a throat microphone. For in vivo measurements, 28 different food products used in nursing care that can be broken up (crushed) only by tongue pressure were used. Eight healthy dentate subjects were instructed to eat each sample freely while tongue pressure was measured and to then swallow the whole amount at once while swallowing sound was recorded. Tongue pressure signals were divided into squeezing and swallowing parts for analysis. Nine out of the 28 food products were evaluated using the visual analog scale (VAS). The correlation between the parameters obtained from in vivo measurements and the VAS value of sensory evaluations were then tested using cluster analysis and main component analysis. Results and Discussion: Three parameters (obtained from swallowing sound, tongue pressure during squeezing and tongue pressure during swallowing) correlated with the VAS value of sensory evaluation. When the first and second principal components calculated from three parameters in bioinstrumentation for the 28 food products were graphed, each plot could be roughly classified according to“The classification of modified diet for dysphagic persons in 2013 of the Japanese Society of Dysphagia Rehabilitation”. We suggest that these methods may facilitate the objective profiling of food textures on the basis of human’s squeezing and swallowing tongue pressurization.
Aims: This study aimed to clarify the characteristics of pharyngeal swallowing in patients with severe motor and intellectual disabilities (SMID) by comparing hyoid bone movements during swallowing in patients with SMID and healthy adults. Subjects and Method: This study included 24 healthy adults and 24 patients with SMID. We recorded videofluoroscopic images of swallowing (VF) at 30 frames/s as subjects swallowed 3 to 5 mL of food paste. A coordinate plane with the second and fourth cervical vertebrae as the reference line was set and VF animation was analyzed for each frame. For the period from the start of hyoid bone elevation to the maximum elevation, we measured the anterior/superior/total moving distance, movement trajectory, and distance between mandible and hyoid bone. The hyoid bone movement time was linearly transformed for each subject to common time units. Hyoid bone movement was divided into a superior phase and an anterior phase, using the mean lower limit of the 95% confidence interval for healthy adults as the reference value. Those who were below the reference value in the superior phase were classified as the superior phase recession group (SR), and those below the reference value in the anterior phase were classified as the anterior phase stagnation group (AS). The results were compared using one-way analysis of variance (ANOVA). Results and Discussion: The SR group included 12 subjects, with 7 in the AS group. ANOVA with multiple comparisons showed that the anterior movement distance of the hyoid bone was significantly greater in healthy adults than in the SR (p＜0.01) and AS (p＜0.01) groups. The superior movement distance of the hyoid bone was significantly greater in the SR group than in healthy adults (p＜0.01). The distance between the mandible and the hyoid bone was significantly greater in the SR group than in healthy adults (p＜0.01) and the AS group (p＜0.05). It was thought that muscle contraction power decreased due to extension of the ventral suprahyoid muscles in the SR group, and that muscle contraction power decreased due to a decrease in extensibility or to hypotonicity of the infrahyoid muscles in the AS group. Conclusion: Among patients with SMID, the hyoid bone pulled backward in one group when it should have moved upward, and moved an insufficient distance in the other group when it should have moved forward.
Objective: This study’s objective was to identify the factors causing the deterioration of the nutritional status of elderly people with schizophrenia hospitalized in a psychiatric hospital. Method: Sixty-six schizophrenia patients hospitalized in a psychiatric hospital, aged over 65 years and able to orally ingest three full meals a day, were selected for the study. The nutritional status of the participants was evaluated using the Geriatric Nutritional Risk Index (GNRI). The following factors that may influence the deterioration of nutritional status were examined: basic attributes; assessment of independence level in activities of daily living (ADL) (criteria established by the Ministry of Health, Labour and Welfare of Japan); dysphagia function (current number of teeth, repetitive saliva swallowing test [RSST] frequency); ability to function socially using the Rehabilitation Evaluation Hall and Baker scale (Rehab); and cognitive function using the Mini-Mental State Examination (MMSE). Association with the GNRI was analyzed using multivariate analysis, including both univariate analysis and stepwise regression analysis. Results: The items in which a significant association with the GNRI was observed in the univariate analysis were duration of the disorder, length of hospitalization, and self-care and social life skills, the last two of which were subcomponents of Rehab. There was no significant association with ADL, current number of teeth, RSST, MMSE. The items in which a significant association with the GNRI was observed in the stepwise regression analysis, where the GNRI was set as the independent variable, were length of hospitalization and social life skills. In order of strength of influence on the GNRI were length of hospitalization (β＝-0.40, p＝ .001) and social life skills (β＝-0.23, p＝ .045). Conclusion: Factors causing the nutritional status of elderly people suffering from schizophrenia to deteriorate were the protracted length of hospitalization and low social life skills. For the deteriorating nutritional status of elderly schizophrenia patients, not only is the supplementation of deficient energy and nutrients required but they must be provided with a space that helps to rejuvenate the way they spend their days, social life skills to independently enjoy their day-to-day lives, and a recovery of self-confidence.
Objective: Our hospital constructed a pneumonia-prevention system in which ward nurses, dental staff and rehabilitation staff participate in acute wards. We aimed to examine the effect of a multidisciplinary approach for the management of acute stroke on the incidence of pneumonia and the inability to eat. Methods: The pneumonia-prevention system for all inpatients consists of oral assessment, oral care, dental request procedure, and sharing the status of swallowing assessment by the rehabilitation department. A total of 234 patients (127 men, 107 women, mean age 72±13 years) were selected from those who were hospitalized for a clinical presentation of stroke between April 2012 and March 2013 before the system was introduced, and 203 patients (107 men, 96 women, mean age 74±11 years) were selected from those hospitalized between April 2014 and March 2015 after the system was established. Their attributes during hospital admission and later (outcome) were assessed retrospectively by reviewing the medical records, a diagnosis procedure combination (DPC) database, and a patient clinical database operated by the rehabilitation and dental departments. These were then analyzed before the introduction and after the establishment of the system. Results: Subjects after establishment of the system could be interpreted as more severe than those before intervention. The incidence of pneumonia was 15% before introduction and 8% after establishment. The odds ratio for pneumonia onset comparing those before introduction with those after establishment was 2.70 (95% CI 1.17―6.21, p＝0.020). In addition, the Japan Coma Scale grade and initial dysphagia severity scale score were significantly associated with pneumonia onset. There was no change in the rate of oral intake at discharge, but it was considered significant that it did not reduce the proportion in the more severe group. Conclusions: Our system is effective in the prevention of pneumonia and continuation of oral intake. This is thought to be the result of cooperation among ward nurses, dental staff and rehabilitation staff.
The purpose of this study was to develop and investigate the use of a new mouthpiece for dysphagia rehabilitation. The concept was designed to effectively improve the swallowing function of patients with dysphagia performing a lingual exercise. The mouthpiece is made up of a hard medical silicone elastomer (MED-6019, NuSil Technology, USA) that has a slope part to properly press on the palate when the tongue lifts up in the oral cavity. The three prototypes with slope parts of 20°, 30°, and 40° angles were created to fit the form of the palate. The effects of using a mouthpiece in a lingual exercise on the swallowing function were investigated. A single-arm study design was performed on 20 ambulatory patients within a period of 3 months. The measurement points were pre-post exercise on the first day, 1 month, and 3 months later. The subjects wore the mouthpiece for 15 min per day at home and performed the lingual exercise for 3 min. The parameters measured included the tongue and lip strength using a tongue pressure measurement device (Orarize®, JMS), oral moisture degree using an oral moisture-checking device (Mucus®, Life), masticatory performance using a gum test, and swallowing frequency using a repetitive saliva swallowing test (RSST). Statistical analysis was carried out using a two-way ANOVA to compare the parameters during the intervention period and the training. Patients under 60 years and dropouts were excluded from the analysis. The data on thirteen elderly patients with mild dysphagia (73.5±6.4 years, 5 males and 8 females) were analyzed and showed that the main effect of the intervention period in the tongue pressure was significant (p＜0.05). The tongue pressure significantly increased 1 month later compared with that at the first day (p＜0.05) of intervention. In addition, an increase in the lip pressure and RSST score were noted after the intervention and after the exercise, respectively. The continuous lingual exercise with the mouthpiece increased the tongue pressure of elderly patients, which showed the potential of improving their swallowing function.
Objective: The aims of this study were to identify the constituent elements of training for positioning during eating and to develop a training program. Methods: The study participants were six certified dysphagia nurses. The study was carried out between by means of focus group interviews. The interview questions concerned the state of patients with dysphagia and positioning training. Analysis was performed by extracting important categories. The study period was between February and December, 2014. Results and Discussion: Many patients suffer from bad posture, and must be positioned correctly to prevent aspiration. There were positive and negative factors in patient positioning by nurses, as follows: a caring mind, team care, risk management, lack of observation, inappropriate skills, and a busy work environment. Feasible education methods were: learning from the basics, experiential learning, coaching, and skill assessment. The benefits of positioning from a nurse’s perspective were: skill improvement, operational improvement, offer hope in nursing care, and mutual growth. The benefits of positioning from the patient’s perspective were: Pleasure of eating, aspiration prevention, and self-feeding. The extracted categories were consolidated into an education that conveys the pleasure of eating through positioning. In this result, the category related to positioning training was chosen to construct a conceptual diagram. The deepening of positioning technology thinks that nurses and patients can share‘Pleasure of eating’.
Aspiration pneumonia in elderly patients has become a serious problem in recuperation hospitals. Typical symptoms of aspiration pneumonia are fever or inflammation responses. If patients receiving oral feeding develop fever or increased inflammation responses, oral feeding is often restricted. However, restriction of oral feeding has not been confirmed to prevent fever or inflammation responses. Therefore, the present study retrospectively examined the frequency of fever and inflammation responses in patients receiving oral feeding compared with those receiving enteral feeding in a recuperation hospital. Eighty-one patients admitted to a recuperation hospital participated as subjects. Twenty-three subjects were assigned to the oral nutrition (ON) group and 58 to the enteral nutrition (EN) group by method of receiving feeding. Physiological (body temperature and number of fever episodes) and biochemical (WBC and CRP) data were measured in each group. The body temperature, number of fever episodes, WBC, and CRP in the EN group were significantly (p＜0.05) higher than those in the ON group. Therefore, long-term enteral feeding is not effective for improving fever and inflammation responses.
Abstract National Sanatorium Amami-Wakouen is one of the sanatoriums for patients with Hansen’s disease. The average age of the patients is 85.7 years old, and there are some who have complicated dysphagia for sequelae of Hansen’s disease and presbyphagia. An additional characteristic of Hansen’s disease sanatoriums is that family relationships are often weak because of the influence of a policy of prolonged isolation. The present case was a 99-year-old man. We followed the patient from 2011 to 2017 and found that support for oral intake led to a change in the family’s concern. Based on our experience, the important points for end-of-life care for people with dementia are: 1) to understand that dementia includes various symptoms, and is a progressive disease with poor prognosis, 2) to encourage families to grasp changes of patients over time, 3) to cherish opportunities for both patients and their families to spend time together, 4) to continue ingenuity and efforts to support oral intake, and 5) to improve the environment for consultation.