Colodny N, 2005 – Dysphagic independent feeders’ justifications for noncompliance with recommendations by a speech-language pathologist.
Summary: Dysphagic independent feeders’ justifications for noncompliance with recommendations by a speech-language pathologist.
The purpose of this study was to examine the various ways in which independent-feeding patients with dysphagia justified their noncompliance with swallowing recommendations suggested by a speech-language pathologist (SLP).
Sixty-three independent-feeding dysphagia patients between the ages of 65 and 100 years who had been identified by the SLP or staff as noncompliant with SLP recommendations were interviewed about their reasons for noncompliance. Reasons were classified into 8 categories: (a) denial of a swallowing problem, (b) dissatisfaction with the preparations such as thickened liquids or pureed foods, (c) assuming a calculated risk for noncompliant behaviors, (d) rationalizing their noncompliance in the face of contradictory evidence, (e) minimization of the severity of their problem, (f) verbal accommodation while maintaining noncompliance, (g) projection of blame toward the SLP, and (h) deflection of noncompliance by referring to an external authority. Reasons for noncompliance were discussed in light of theory and research on denial, coping mechanisms, and the social-cognitive transition model. Implications were drawn for SLP practice in dealing with noncompliant independent-feeding patients with dysphagia.
Accreditation & date: Am J Speech Lang Pathol, 2005 Feb; 14(1):61-70.
PubMed link: www.ncbi.nlm.nih.gov/pubmed/15962847.
Finestone HM, 1995 – Malnutrition in stroke patients on the rehabilitation service and at follow-up: prevalence and predictors.
Summary: Malnutrition in stroke patients on the rehabilitation service and at follow-up: prevalence and predictors.
This prospective study presents the prevalence and risk factors of malnutrition in 49 consecutive stroke patients on the rehabilitation (Rehab) service and at 2- to 4-month follow-up.
Malnutrition was diagnosed using biochemical and anthropometric data. Stroke patients, on admission to Rehab, have a very high prevalence of malnutrition. Malnutrition, 49% on admission, declined to 34%, 22%, and 19% at 1 month, 2 months, and follow-up, respectively. Dysphagia, 47% on admission, was associated with malnutrition (p = .032) and significantly declined over time. Using logistic regression, predictors of malnutrition on admission involved acute service tube feedings (p = .002) and histories of diabetes (p = .027) and prior stroke (p = .013). Tube feedings, associated with malnutrition on admission (p = .043), were more prevalent in brain stem lesion patients. Patients tube fed > or = 1 month during rehabilitation or at home were not malnourished. Malnutrition was associated with advanced (> 70 years) age at 1 month (p = .002) and weight loss (p = .011) and lack of community care (p = .006) at follow-up. Early and ongoing detection and treatment of malnutrition are recommended during rehabilitation of stroke patients both on the service and at follow-up.
Accreditation & date: Arch Phys Med Rehabil, 1995 Apr;76(4):310-6.
PubMed link: www.ncbi.nlm.nih.gov/pubmed/7717830.
Germain I, 2006 – A novel dysphagia diet improves the nutrient intake of institutionalized elders.
Summary: A novel dysphagia diet improves the nutrient intake of institutionalized elders.
Objectives: Dysphagia affects 35% to 60% of the institutionalized elderly population. This study aimed at evaluating the nutrient intake of frail institutionalized elderly persons with dysphagia and to assess the impact of Sainte-Anne’s Hospital Advanced Nutritional Care program on dietary intake and weight.
Design: A 12-week intervention study.
Subjects/setting: Ninety-three individuals residing in a Montreal, Canada, long-term care facility who were aged at least 65 years were evaluated. Seventeen subjects with a body mass index (BMI; calculated as kg/m(2)) <24 or weight loss >7.5% within 3 months and with dysphagia were included.
Intervention: The treated group (n=8; aged 82.5+/-4.41 years, weight 55.9+/-12.1 kg, BMI 22.4+/-3.93) received Sainte-Anne’s Hospital reshaped minced- or pureed-texture foods with thickened beverages where required. The control group (n=9; aged 84.6+/-3.81 years, weight 54.3+/-7.49 kg, BMI 21.2+/-2.31) maintained traditional nourishment.
Main outcome measures: Macronutrient and micronutrient intake, weight, and BMI were measured at baseline, 6 weeks, and 12 weeks.
Statistics: Student t tests were performed to evaluate change within and between groups.
Results: The treatment and control groups were similar at baseline, having a mean age of 82.5+/-4.41 years vs 84.6+/-3.81 years and BMI of 22.4+/-3.93 vs 21.2+/-2.31, respectively. The average weight in the treated group increased compared to the control group (3.90+/-2.30 vs -0.79+/-4.18 kg; P=0.02). Similarly, the treated group presented an increased intake of energy, proteins, fats, total saturated fats, monounsaturated fats, potassium, magnesium, calcium, phosphorus, zinc, vitamin B-2, and vitamin D compared to control subjects (P < 0.05).
Conclusions: Institutionalized elderly patients with dysphagia can eat better and increase body weight via a diversified, modified in texture, and appealing oral diet that meets their nutrition needs.
Accreditation & date: J Am Diet Assoc, 2006 Oct;106(10):1614-23.
PubMed link: www.ncbi.nlm.nih.gov/pubmed/17000194.
Hudson HM, 2000 – The interdependency of protein-energy malnutrition, aging, and dysphagia.
Summary: The interdependency of protein-energy malnutrition, ageing, and dysphagia.
Advancing age is increasingly associated with confounding chronic and acute ailments, predisposing elderly individuals to conditions such as malnutrition and swallowing dysfunction.
This enhanced susceptibility to malnutrition and dysphagia in this aging demographic lends itself to exacerbating, disabling conditions that may result in increased morbidity and mortality in the event of an aspiration episode. Early identification of substandard nutritional status and subsequent interventiion in the elderly dysphagic population may circumvent the deleterious effects of malnutrition.
Accreditation & date: Dysphagia, 2000 Winter; 15(1):31-8.
PubMed link: www.ncbi.nlm.nih.gov/pubmed/10594256.
Kayser-Jones J, 1999 – Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision.
Summary: Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision.
Objective: To investigate the factors that influenced fluid intake among nursing home residents who were not eating well.
Design: A prospective, descriptive, anthropological study.
Setting: Two proprietary nursing homes with 105 and 138 beds, respectively. PARTICIPANTS: Forty nursing home residents.
Measurements: Participant observation, event analysis, bedside dysphagia screening, mental and functional status evaluation, assessment of level of family/advocate involvement, and chart review were used to collect data. Data were gathered on the amount of liquid served and consumed over a 3- day period. Daily fluid intake was compared with three established standards: Standard 1 (30 mL/kg body weight), Standard 2 (1 mL/kcal/energy consumed), and Standard 3 (100 mL/kg for the first 10 kg, 50 mL/kg for the next 10 kg, 15 mL/kg for the remaining kg).
Results: The residents’ mean fluid intake was inadequate; 39 of the 40 residents consumed less than 1500 mL/day. Using three established standards, we found that the fluid intake was inadequate for nearly all of the residents. The amount of fluid consumed with and between meals was low. Some residents took no fluids for extended periods of time, which resulted in their fluid intake being erratic and inadequate even when it was resumed. Clinical (undiagnosed dysphagia, cognitive and functional impairment, lack of pain management), sociocultural (lack of social support, inability to speak English, and lack of attention to individual beverage preferences), and institutional factors (an inadequate number of knowledgeable staff and lack of supervision of certified nursing assistants by professional staff) contributed to low fluid intake. During the data collection, 25 of the 40 residents had illnesses/conditions that may have been related to dehydration.
Conclusions: When staffing is inadequate and supervision is poor, residents with moderate to severe dysphagia, severe cognitive and functional impairment, aphasia or inability to speak English, and a lack of family or friends to assist them at mealtime are at great risk for dehydration. Adequate fluid intake can be achieved by simple interventions such as offering residents preferred liquids systematically and by having an adequate number of supervised staff help them to drink while properly positioned.
Accreditation & date: J Am Geriatr Soc, 1999 Oct; 47(10):1187-94.
PubMed link: www.ncbi.nlm.nih.gov/pubmed/10522951.
Logemann JA, 2007 – Oropharyngeal dysphagia and nutritional management.
Summary: Oropharyngeal dysphagia and nutritional management.
Purpose of review: This review examines recent studies of the evaluation and treatment of oropharyngeal dysphagia as well as papers investigating oropharyngeal dysphagia and nutritional management.
Recent findings: There continue to be difficulties in accurate diagnosis of some disorders in oropharyngeal swallow, accounting for the patient’s dysphagic symptoms and in identifying optimal treatment strategies for each patient. The efficacy of new techniques for the treatment of oropharyngeal dysphagia have been examined in various populations. Exercise programs have been showing increased efficacy in particular patient groups.
Summary: Articles in this past year have focused largely on identifying new procedures for assessment of oropharyngeal swallowing and defining treatment effects. Relatively little work has examined nutritional management in patients with oropharyngeal dysphagia. Most studies that have investigated nutritional management do not carefully define the patient’s medical diagnosis or specific swallowing disorders. Similarly, those that study oropharyngeal dysphagia do not relate these data to nutritional management of these patients.
Accreditation & date: Curr Opin Clin Nutr Metab Care, 2007 Sep;10(5):611-4.
PubMed link: www.ncbi.nlm.nih.gov/pubmed/17693745.
Low J, 2001 – The effect of compliance on clinical outcomes for patients with dysphagia on videofluoroscopy.
Summary: The effect of compliance on clinical outcomes for patients with dysphagia on videofluoroscopy.
This study investigates clinical outcomes and the degree of compliance in patients who received advice on dysphagia management and the effect of the level of compliance on the incidence of chest infections and aspiration pneumonia, cause of death, and hospital readmission.
We performed a retrospective cohort study of 140 patients who had videofluoroscopic studies at Princess Margaret Hospital, Christchurch, New Zealand, from 1 January 1996 to 30 June 1997. The degree to which recommendations on dysphagia management were followed was correlated with the incidence of chest infections, aspiration pneumonia, and readmissions to the hospital. Cause of death, including the contribution of aspiration pneumonia, was assessed by review of medical records and death certificates. Information was available for 89% of the cohort. Twenty-one percent of the survivors never complied with the advice given. Noncompliant subjects were younger (p < 0.05) and more likely to be living at home rather than receiving institutional care (p = 0.05). Noncompliers had more hospital admissions because of chest infections or aspiration pneumonia (22% vs. 1.5%; p < 0.001). Home-dwelling noncompliant subjects received more courses of antibiotics (p < 0.02), but there was no difference in the number of chest infections. Fifty-four people died during the study period. Aspiration pneumonia was recorded as a definite or probable cause of death in 26 (52%) of the 50 subjects for whom reliable information was available and in 6 of 7 subjects who made a deliberate and documented decision not to comply. We conclude that noncompliance with recommendations about dysphagia management is associated with adverse outcomes. There was a high mortality rate and aspiration pneumonia was a common cause of death.
Accreditation & date: Dysphagia, 2001 Spring;16(2):123-7.
PubMed link: www.ncbi.nlm.nih.gov/pubmed/11305222.
Whelan K, 2001 – The role of probiotics and prebiotics in the management of diarrhoea associated with enteral tube feeding.
Summary: The role of probiotics and prebiotics in the management of diarrhoea associated with enteral tube feeding.
Introduction: Diarrhoea is a common and serious complication of enteral tube feeding, and has a range of aetiologies. Manipulation of the colonic microflora may reduce the incidence of enteral tube feeding diarrhoea via suppression of enteropathogens and production of short-chain fatty acids. Probiotics and prebiotics are commonly used during enteral tube feeding to manipulate the colonic microflora; however, their efficacy is as yet uncertain.
Methods: English-language studies investigating the pathogenesis of enteral tube feeding diarrhoea and the use of probiotics and prebiotics were identified by searching the electronic databases CINAHL, EMBASE and MEDLINE from 1980 to 2001. The bibliographies of articles obtained were searched manually.
Results: Only two prospective, randomized, double-blind, placebo-controlled trials have investigated the effect of a probiotic on enteral tube feeding diarrhoea; however, results are conflicting. No prospective, randomized, double-blind, placebo-controlled studies have specifically addressed the effect of a prebiotic on the incidence of enteral tube feeding diarrhoea.
Conclusions: Theoretically, probiotics and prebiotics may be of benefit in prophylaxis against enteral tube feeding diarrhoea; however, there is currently insufficient evidence to support their routine use. Prospective, randomised, double-blind, placebo-controlled studies investigating their effect on diarrhoea are required. These observations are discussed with reference to the current literature.
Accreditation & date: J Hum Nutr Diet, 2001 Dec;14(6):423-33.
PubMed link: www.ncbi.nlm.nih.gov/pubmed/11906584.
Rodrigue N, 2002 – Meeting the nutritional needs of patients with severe dysphagia following a stroke: an interdisciplinary approach.
Summary: Meeting the nutritional needs of patients with severe dysphagia following a stroke: an interdisciplinary approach.
Dysphagia is a common problem with individuals who have experienced a stroke.
The interdisciplinary stroke team noted delays in clinical decision-making, or in implementing plans for patients with severe dysphagia requiring an alternative method to oral feeding, such as enteral feeding via Dobhoff (naso-jejunum) or PEG (percutaneous endoscopic gastrostomy) tubes, occurred because protocols had not been established. This resulted in undernourishment, which in turn contributed to clinical problems, such as infections and confusion, which delayed rehabilitation and contributed to excess disability. The goal of the project was to improve quality of care and quality of life for stroke patients experiencing swallowing problems by creating a dysphagia management decision-making process. The project began with a retrospective chart review of 91 cases over a period of six months to describe the population characteristics, dysphagia frequency, stroke and dysphagia severity, and delays encountered with decision-making regarding dysphagia management. A literature search was conducted, and experts in the field were consulted to provide current knowledge prior to beginning the project. Using descriptive statistics, dysphagia was present in 44% of the stroke population and 69% had mild to moderate stroke severity deficit. Delays were found in the decision to insert a PEG (mean 10 days) and the time between decision and PEG insertion (mean 12 days). Critical periods were examined in order to speed up the process of decision-making and intervention. This resulted in the creation of a decision-making algorithm based on stroke and dysphagia severity that will be tested during winter 2002.
Accreditation & date: Axone, 2002 Mar; 23(3):31-7.
PubMed link: www.ncbi.nlm.nih.gov/pubmed/14621495.
Wright L, 2005 – Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet.
Summary: Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet.
Background: There are very few studies looking at the energy and protein requirements of patients requiring texture modified diets. Dysphagia is the main indication for people to be recommended texture-modified diets. Older people post-stroke are the key group in the hospital setting who consume this type of diet. The diets can be of several consistencies ranging from pureed to soft textures.
Objective: To compare the 24-hour dietary intake of older people consuming a texture modified diet in a clinical setting to older people consuming a normal hospital diet.
Method: Weighed food intakes and food record charts were used to quantify the patients’ intakes, which were compared to their individual requirements.
Results: The oral intake of 55 patients was measured. Twenty-five of the patients surveyed were eating a normal diet and acted as controls for 30 patients who were prescribed a texture-modified diet. The results showed that the texture-modified group had significantly lower intakes of energy (3877 versus 6115 kJ, P < 0.0001) and protein (40 versus 60 g, P < 0.003) compared to consumption of the normal diet. The energy and protein deficit from estimated requirements was significantly greater in the texture-modified group (2549 versus 357 kJ, P < 0.0001; 6 versus 22 g, P = 0.013; respectively).
Conclusions: These statistically significant results indicate that older people on texture-modified diets have a lower intake of energy and protein than those consuming a normal hospital diet and it is likely that other nutrients will be inadequate. All patients on texture-modified diets should be assessed by the dietitian for nutritional support. Evidence based strategies for improving overall nutrient intake should be identified.
Accreditation & date: J Hum Nutr Diet, 2005 Jun;18(3):213-9.
PubMed link: www.ncbi.nlm.nih.gov/pubmed/15882384.
Valentini L, 2009 – The first nutritionDay in nursing homes: participation may improve malnutrition awareness.
Summary: The first nutritionDay in nursing homes: participation may improve malnutrition awareness.
Background & aims: A modified version of the nutritionDay project was developed for nursing homes (NHs) to increase malnutrition awareness in this area. This report aims to describe the first results from the NH setting.
Methods: On February 22, 2007, 8 Austrian and 30 German NHs with a total of 79 units and 2137 residents (84+/-9 years of age, 79% female) participated in the NH-adapted pilot test. The NHs participated voluntarily using standardized questionnaires. The actual nutritional intake at lunch time was documented for each resident. Six-month follow-up data were received from 1483 residents (69%).
Results: Overall, 9.2% and 16.7% of residents were classified as malnourished subjectively by NH staff and by BMI criteria ( < 20 kg/m(2)), respectively. Independent risk factors for malnutrition included age>90 years, immobility, dementia, and dysphagia (all p < 0.001). In total, 89% of residents ate at least half of the lunch meal, and 46% of residents received eating assistance for an average of 15 min. Six-month mortality was higher in residents with low nutritionDay BMI (<20 kg/m(2): 22%, 20-21.9 kg/m(2): 17%) compared to residents with BMI >or= 22 kg/m(2) (10%, p<0.001). Six-month weight loss >or= 6 kg was less common in residents with nutritionDay BMI < 22 kg/m(2) compared to residents with higher nutritionDay BMI (3.4% vs 12.4%, p < 0.001).
Conclusions: The first nutritionDay in NH provided valuable data on the nutritional status of NH residents and called attention to the remarkable time investment required by NH staff to adequately provide eating assistance to residents. Participation in the nutritionDay project appears to increase malnutrition awareness as reflected in the outcome weight results.
This study showed that dysphagia is an independent risk factor for malnutrition in elderly patients.
Accreditation & date: Clin Nutr, 2009 Apr;28(2):109-16. Epub 2009 Mar 5.
PubMed link: www.ncbi.nlm.nih.gov/pubmed/19264381.
Leibovitz A, 2007 – Dehydration among long-term care elderly patients with oropharyngeal dysphagia.
Summary: Dehydration among long-term care elderly patients with oropharyngeal dysphagia.
Introduction: Long-term care (LTC) residents, especially the orally fed with dysphagia, are prone to dehydration. The clinical consequences of dehydration are critical. The validity of the common laboratory parameters of hydration status is far from being absolute, especially so in the elderly. However, combinations of these indices are more reliable.
Objective: Assessment of hydration status among elderly LTC residents with oropharyngeal dysphagia. METHODS: A total of 28 orally fed patients with grade-2 feeding difficulties on the functional outcome swallowing scale (FOSS) and 67 naso-gastric tube (NGT)-fed LTC residents entered the study. The common laboratory, serum and urinary tests were used as indices of hydration status. The results were considered as indicative of dehydration and used as ‘markers of dehydration’, if they were above the accepted normal values.
Results: The mean number of dehydration markers was significantly higher in the FOSS-2 group (3.8 +/- 1.3 vs. 2 +/- 1.4, p = 0.000). About 75% of these FOSS-2 patients had > or =4 dehydration markers versus 18% of the NGT-fed group (p = 0.000). A low urine output (< 800 ml/day) was significantly more common in the FOSS-2 group (39 vs. 12%, p = 0.002). Above normal values of blood urea nitrogen (BUN), BUN/serum creatinine ratio (BUN/S(Cr)), urine/serum osmolality ratio (U/S(Osm)), and urine osmolality U(Osm), were significantly more frequent in the dehydration-prone FOSS-2 group. This combination of 4 indices was present in 65% of low urine output patients. In contrast, it was present in only 36% of the higher urine output patients (p = 0.01). Patients with a ‘normal’ daily urine output (>800 ml/day) also had a significant number (2 +/- 1.5) of positive indices of dehydration.
Conclusions: Dehydration was found to be common among orally fed FOSS-2 LTC patients. Surprisingly, probable dehydration, although of a mild degree, was not a rarity among NGT-fed patients either. The combination of 4 parameters, BUN, BUN/S(Cr ), U/S(Osm) and U(Osm), offers reasonable reliability to be used as an indication of dehydration status in daily clinical practice.
Accreditation & date: Gerontology, 2007; 53(4):179-83.
PubMed link: www.ncbi.nlm.nih.gov/pubmed/17264513.