Information for Healthcare professionals

About Dysphagia

Dysphagia is the term to describe difficulty in swallowing food and/or drinks. A swallowing problem may arise as a side effect of many conditions, such as:

  • Stroke
  • Cerebral Palsy
  • Head injury
  • Motor neurone disease
  • Multiple sclerosis
  • Parkinson’s disease
  • Surgery to the head and neck

In some cases the swallowing problem may improve as recovery takes place, such as following stroke. However, in other cases, such as with Parkinson’s disease, the condition may deteriorate, e.g. Parkinson’s disease.

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Dysphagia Clinical Papers - Overview articles

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Bakheit AMO, 2001 – Management of neurogenic dysphagia.

Summary: Management of neurogenic dysphagia.

Accreditation & date: Postgrad Med J, 2001 Nov;77(913):694-9.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/11677277

 

Claudell JJ, 2009 – Factors associated with long-term dysphagia after definitive radiotherapy for locally advanced head-and-neck cancer.

Summary: Factors associated with long-term dysphagia after definitive radiotherapy for locally advanced head-and-neck cancer.

Abstract:
Purpose: The use of altered fractionation radiotherapy (RT) regimens, as well as concomitant chemotherapy and RT, to intensify therapy for locally advanced head-and-neck cancer can lead to increased rates of long-term dysphagia.

Methods and materials: We identified 122 patients who had undergone definitive RT for locally advanced head-and-neck cancer, after excluding those who had been treated for a second or recurrent head-and-neck primary, had Stage I-II disease, developed locoregional recurrence, had 12 months of follow-up, or had undergone postoperative RT. The patient, tumor, and treatment factors were correlated with a composite of 3 objective endpoints as a surrogate for severe long-term dysphagia: percutaneous endoscopic gastrostomy tube dependence at the last follow-up visit; aspiration on a modified barium swallow study or a clinical diagnosis of aspiration pneumonia; or the presence of a pharyngoesophageal stricture.

Results: A composite dysphagia outcome occurred in 38.5% of patients. On univariate analysis, the primary site (p = 0.01), use of concurrent chemotherapy (p = 0.01), RT schedule (p = 0.02), and increasing age (p = 0.04) were significantly associated with development of composite long-term dysphagia. The use of concurrent chemotherapy (p = 0.01), primary site (p = 0.02), and increasing age (p = 0.02) remained significant on multivariate analysis.

Conclusions: The addition of concurrent chemotherapy to RT for locally advanced head-and-neck cancer resulted in increased long-term dysphagia. Early intervention using swallowing exercises, avoidance of nothing-by-mouth periods, and the use of intensity-modulated RT to reduce the dose to the uninvolved swallowing structures should be explored further in populations at greater risk of long-term dysphagia.

Accreditation & dates: Int J Radiat Oncol Biol Phys, 2009 Feb 1;73(2):410-5

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18635320.

 

Cook IJ, 1999 – AGA technical review on management of oropharyngeal dysphagia.

Summary: AGA technical review on management of oropharyngeal dysphagia.

Accreditation & date: Gastroenterology, 1999 Feb;116(2):455-78.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/9922328

 

Daniels SK, 1998 – Aspiration in patients with acute stroke.

Summary: Aspiration in patients with acute stroke.

Abstract:
Objectives: To determine the frequency and clinical predictors of aspiration within 5 days of acute stroke. DESIGN: Case series. SETTING: Tertiary care center. PATIENTS: Consecutive stroke patients (n = 55) with new neurologic deficit evaluated within 5 days of acute stroke.

Main outcome measures: Comparison of features identified on clinical swallowing and oromotor examinations and occurrence of aspiration (silent or overt) evident on videofluoroscopic swallow study (VSS).

Results: Aspiration occurred in 21 of 55 patients (38%). Whereas 7 of 21 patients (33%) aspirated overtly, 14 (67%) aspirated silently on VSS. Chi-square analyses revealed that dysphonia, dysarthria, abnormal gag reflex, abnormal volitional cough, cough after swallow, and voice change after swallow were significantly related to aspiration and were predictors of the subset of patients with silent aspiration. Logistic regression revealed that abnormal volitional cough and cough with swallow, in conjunction, predicted aspiration with 78% accuracy.

Conclusions: Silent aspiration appears to be a significant problem in acute stroke patients because silent aspiration occurred in two thirds of the patients who aspirated. The prediction of patients at risk for aspiration was significantly improved by the presence of concurrent findings of abnormal volitional cough and cough with swallow on clinical examination.

Accreditation & date: Arch Phys Med Rehabil, 1998 Jan;79(1):14-9.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/9440410

 

Ekberg O, 2002 – Social and psychological burden of dysphagia: its impact on diagnosis and treatment.

Summary: Social and psychological burden of dysphagia: its impact on diagnosis and treatment.

Abstract:
The social and psychological impact of dysphagia has not been routinely reported in large studies. We sought to determine the effects of dysphagia on broad measures of the quality of life of patients and to explore the relationship between the psychological handicaps of the condition and the frequency of diagnosis and treatment.

A total of 360 patients selected on the basis of known subjective dysphagia complaints, regardless of origin, in nursing homes and clinics in Germany, France, Spain, and the United Kingdom were interviewed using an established questionnaire. Qualitative interviews with a total of 28 health professionals were conducted to improve understanding of the patient data in the context of each country. Over 50% of patients claimed that they were “eating less” with 44% reporting weight loss during the preceding 12 months. Thirty-six percent of patients acknowledged receiving a confirmed diagnosis of dysphagia; only 32% acknowledged receiving professional treatment for it. Most people with dysphagia believe their condition to be untreatable; only 39% of the sufferers believed that their swallowing difficulties could be treated. Eighty-four percent of patients felt that eating should be an enjoyable experience but only 45% actually found it so. Moreover, 41% of patients stated that they experienced anxiety or panic during mealtimes. Over one-third (36%) of patients reported that they avoided eating with others because of their dysphagia. In a largely elderly population that might accept dysphagia as an untreatable part of the aging process, clinicians need to be aware of the adverse effects of dysphagia on self-esteem, socialization, and enjoyment of life. Careful questioning should assess the impact of the condition on each patient’s life, and patients should be educated on their choices for treatment in the context of any coexisting illness. Awareness of the condition, diagnostic procedures, and treatment options must be increased in society and among the medical profession.

Accreditation & date: Dysphagia, 2002 Spring;17(2):139-46.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/11956839

 

Gallagher L, 2009 – Prescription drugs and their effects on swallowing.

Summary: Prescription drugs and their effects on swallowing.

Abstract:
The impact of medications on the physiology of swallowing has received much attention in dysphagia literature. This article reviews the potential effects of medications commonly prescribed in an adult continuing care and rehabilitation facility on swallowing.

An audit of medications prescribed to 153 adults accessing age-related respiratory, neurology, and learning disability services was performed. This was followed by an investigation of relevant sources to identify the potential side effects of these medications. One side effect, namely, xerostomia, which our investigations revealed could be a side effect of 24.8% of the medications used at our institution, was further investigated. The prevalence of xerostomia was then investigated in a randomly selected sample of ten subjects whose dysphagia had been confirmed by videofluoroscopy. It was found that six of the ten dysphagic clients displayed xerostomia. Review of the medications of these ten subjects indicated that all were using from three to nine drugs that could cause xerostomia. This article highlights the need for health-care professionals to consider the potential effects of these medications on swallowing and, indeed, the general presentation of clients.

Accreditation & date: Dysphagia, 2009 Jun;24(2):159-66.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/19085036

 

Langmore SE, 1998 – Predictors of aspiration pneumonia: how important is dysphagia?

Summary: Predictors of aspiration pneumonia: how important is dysphagia?

Abstract:
Aspiration pneumonia is a major cause of morbidity and mortality among the elderly who are hospitalized or in nursing homes.

Multiple risk factors for pneumonia have been identified, but no study has effectively compared the relative risk of factors in several different categories, including dysphagia. In this prospective outcomes study, 189 elderly subjects were recruited from the outpatient clinics, inpatient acute care wards, and the nursing home care center at the VA Medical Center in Ann Arbor, Michigan. They were given a variety of assessments to determine oropharyngeal and esophageal swallowing and feeding status, functional status, medical status, and oral/dental status. The subjects were followed for up to 4 years for an outcome of verified aspiration pneumonia. Bivariate analyses identified several factors as significantly associated with pneumonia. Logistic regression analyses then identified the significant predictors of aspiration pneumonia. The best predictors, in one or more groups of subjects, were dependent for feeding, dependent for oral care, number of decayed teeth, tube feeding, more than one medical diagnosis, number of medications, and smoking. The role that each of the significant predictors might play was described in relation to the pathogenesis of aspiration pneumonia. Dysphagia was concluded to be an important risk for aspiration pneumonia, but generally not sufficient to cause pneumonia unless other risk factors are present as well. A dependency upon others for feeding emerged as the dominant risk factor, with an odds ratio of 19.98 in a logistic regression model that excluded tube-fed patients.

Accreditation & date: Dysphagia, 1998 Spring;13(2):69-81.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/9513300.

 

Marik PE, 2001 – Aspiration pneumonitis and aspiration pneumonia

Summary: Aspiration pneumonitis and aspiration pneumonia.

Accreditation & date: N ENgl J Med, 2001 Mar 1;344(9):665-71.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/11228282.

 

Martino R, et al. 2005 – Dysphagia after stroke: incidence, diagnosis, and pulmonary complications.

Summary: Dysphagia after stroke: incidence, diagnosis, and pulmonary complications.

Abstract:
Objective: 
To determine the incidence of dysphagia and associated pulmonary compromise in stroke patients through a systematic review of the published literature.

Methods: Databases were searched (1966 through May 2005) using terms “cerebrovascular disorders,” “deglutition disorders,” and limited to “humans” for original articles addressing the frequency of dysphagia or pneumonia. Data sources included Medline, Embase, Pascal, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Selected articles were reviewed for quality, diagnostic methods, and patient characteristics. Comparisons were made of reported dysphagia and pneumonia frequencies. The relative risks (RRs) of developing pneumonia were calculated in patients with dysphagia and confirmed aspiration.

Results: Of the 277 sources identified, 104 were original, peer-reviewed articles that focused on adult stroke patients with dysphagia. Of these, 24 articles met inclusion criteria and were evaluated. The reported incidence of dysphagia was lowest using cursory screening techniques (37% to 45%), higher using clinical testing (51% to 55%), and highest using instrumental testing (64% to 78%). Dysphagia tends to be lower after hemispheric stroke and remains prominent in the rehabilitation brain stem stroke. There is increased risk for pneumonia in patients with dysphagia (RR, 3.17; 95% CI, 2.07, 4.87) and an even greater risk in patients with aspiration (RR, 11.56; 95% CI, 3.36, 39.77).

Conclusions: The high incidence for dysphagia and pneumonia is a consistent finding with stroke patients. The pneumonia risk is greatest in stroke patients with aspiration. These findings will be valuable in the design of future dysphagia research.

Accreditation & date: Stroke, 2005 Dec;36(12):2756-63.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/16269630.

 

Palmer JL, 2008 – Preventing aspiration in older adults with dysphagia.

Summary: Preventing aspiration in older adults with dysphagia.

Abstract:
Dysphagia, the impairment of any part of the swallowing process, increases the risk of aspiration. Dysphagia and aspiration are associated with the development of aspiration pneumonia.

While some changes in swallowing may be a natural result of aging, dysphagia is especially prevalent among older adults with neurologic impairment or dementia, leading to an increased risk of aspiration and aspiration pneumonia. This article discusses best practices for assessment and prevention of aspiration among older adults who are being hand-fed or fed by tube.

Accreditation & date: Am J Nurs, 2008 Feb;108(2):40-8; quiz 49.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18227668.

 

Murphy BA, 2009 – Dysphagia in head and neck cancer patients treated with radiation: assessment, sequelae, and rehabilitation.

Summary: Dysphagia in head and neck cancer patients treated with radiation: assessment, sequelae, and rehabilitation.

Abstract:
Dysphagia is commonly seen in patients undergoing radiation-based therapy for locally advanced squamous carcinoma of the head and neck. Within 4 to 5 weeks of starting therapy, patients develop mucositis, radiation dermatitis, and edema of the soft tissues.

Resulting pain, copious mucous production, xerostomia, and tissue swelling contribute to acute dysphagia. As the acute effects resolve, late effects including fibrosis, lymphedema, and damage to neural structures become manifest. Both acute and late effects result in adverse sequelae including aspiration, feeding tube dependence, and nutritional deficiencies. Early referral for evaluation by speech-language pathologists is critical to (1) ensure adequate assessment of swallow function, (2) determine whether further testing is needed to diagnose or treat the swallowing disorder, (3) generate a treatment plan that includes patient education and swallow therapy, (4) work with dieticians to ensure adequate and safe nutrition, and (5) identify patients with clinically significant aspiration.

Accreditation & date: Semin Radiat Oncol, 2009 Jan;19(1):35-42.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/19028344.

 

Schindler A, 2008 – What we don’t know about dysphagia complications?

Summary: What we don’t know about dysphagia complications?

Abstract:
Prevention of complications is the primary goal in patients with dysphagia. The most common complications of dysphagia are aspiration pneumonia, malnutrition and dehydration; other possible complications, such as intellectual and body development deficit in children with dysphagia, or emotional impairment and social restriction have not been studied thoroughly.

Pulmonary complications of dysphagia should be viewed as an impaired balance between defence mechanisms (cough and mucociliary action, lymphatic clearance and cellular immune defences) and food and secretions aspiration. The main pulmonary complications are aspiration pneumonia, toxic aspiration syndromes, bacterial infections and pulmonary fibrosis. The risk of aspiration pneumonia is increased by poor oral status and health status, dependency for oral care and oral feeding; nonetheless, compliance with feeding recommendations of the dysphagia team, may reduce the risk of pulmonary complications. Malnutrition and dehydration are common in patients with dysphagia; however, enteral nutrition may significantly impact on both. Even though a relationship between malnutrition, dehydration and dysphagia exists, the real impact of one on the others is not known.

Accreditation & date: Rev Laryngol Otol Rhinol (Bord), 2008;129(2):75-8.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18767323.

 

Schmidt J, 1994 – Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke.

Summary: Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke.

Abstract:
In order to assess the risk of pneumonia, dehydration, and death associated with videofluoroscopic evidence of aspiration following stroke, the clinical records of 26 patients with aspiration and 33 randomly selected, case-matched dysphagic controls without videofluoroscopic evidence of aspiration were reviewed. The videofluoroscopic modified barium swallow technique included 5 ml-thin and thick liquid barium, 5 ml barium pudding, and 1/4 cookie coated with barium, plus additional 20 and 30 ml of thin liquid barium. Patients were assessed a mean of 2 +/- 1 SD months poststroke and were followed for a mean of 16 +/- 8 SD months poststroke. The odds ratio for developing pneumonia was 7.6 times greater for those who aspirated any amount of barium irrespective of its consistency (p = 0.05). The odds ratio for developing pneumonia was 5.6 times greater for those who aspirated thickened liquids or more solid consistencies compared with those who did not aspirate, or who aspirated thin liquids only (p = 0.06). Dehydration was unrelated to the presence or absence of aspiration. The odds ratio for death was 9.2 times greater for those aspirating thickened liquids or more solid consistencies compared with those who did not aspirate or who aspirated thin liquids only (p = 0.01). Aspiration documented by modified videofluoroscopic barium swallow technique is associated with a significant increase in risk of pneumonia and death but not dehydration following stroke.

Accreditation & date: Dysphagia, 1994 Winter;9(1):7-11.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/8131429.

Dysphagia Clinical Papers - Assessment & diagnosis

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Clavé P, 2004 – Approaching oropharyngeal dysphagia.

Summary: Approaching oropharyngeal dysphagia.

Accreditation & date: Rev Esp Enferm Dig, 2004 Feb, 96(2):119-31.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/15255021

 

Clavé P , 2008 – Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration.

Summary: Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration.

Abstract:
Aims: To determine the accuracy of the bedside volume-viscosity swallow test (V-VST) for clinical screening of impaired safety and efficacy of deglutition.

Methods: We studied 85 patients with dysphagia and 12 healthy subjects. Series of 5-20 mL nectar (295.02 mPa.s), liquid (21.61 mPa.s) and pudding (3682.21 mPa.s) bolus were administered during the V-VST and videofluoroscopy. Cough, fall in oxygen saturation > or =3%, and voice changes were considered signs of impaired safety, and piecemeal deglutition and oropharyngeal residue, signs of impaired efficacy.

Results: Videofluoroscopy showed patients had prolonged swallow response (> or =1064 ms); 52.1% had safe swallow at nectar, 32.9%, at liquid (p < 0.05), and 80.6% at pudding viscosity (p < 0.05); 29.4% had aspirations, and 45.8% oropharyngeal residue. The V-VST showed 83.7% sensitivity and 64.7% specificity for bolus penetration into the larynx and 100% sensitivity and 28.8% specificity for aspiration. Sensitivity of V-VST was 69.2% for residue, 88.4% for piecemeal deglutition, and 84.6% for identifying patients whose deglutition improved by enhancing bolus viscosity. Specificity was 80.6%, 87.5%, and 73.7%, respectively.

Conclusions: The V-VST is a sensitive clinical method to identify patients with dysphagia at risk for respiratory and nutritional complications, and patients whose deglutition could be improved by enhancing bolus viscosity. Patients with a positive test should undergo videofluoroscopy.

Accreditation & date: Clinical Nutrition,2008, 27(6): 806-15.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18789561

 

Cook I, 2008 – Diagnostic evaluation of dysphagia.

Summary: Diagnostic evaluation of dysphagia.

Abstract:
Taking a careful history is vital for the evaluation of dysphagia. The history will yield the likely underlying pathophysiologic process and anatomic site of the problem in most patients and is crucial for determining whether subsequently detected radiographic or endoscopic ‘anomalies’ are relevant or incidental. Although the symptoms of pharyngeal dysphagia can be multiple and varied, the typical features of neurogenic pharyngeal dysphagia are highly specific, and can accurately distinguish pharyngeal from esophageal disorders. The history will also dictate whether the next diagnostic procedure should be endoscopy, a barium swallow or esophageal manometry. In some difficult cases, all three diagnostic techniques may need to be performed to establish an accurate diagnosis. Stroke is the most common cause of pharyngeal dysphagia. A videoradiographic swallow study is vital in such cases to determine the extent and timing of aspiration and the severity and mechanics of dysfunction as a prelude to therapy.

Accreditation & date: Nat Clin Pract Gastroenterol Hepatol, 2008, 5(7):393-403.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18542115

 

Suiter DM, 2009 – The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia.

Summary: The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia.

Abstract:
Objectives: To investigate the clinical utility of the 3-ounce (90-cc) water swallow challenge alone to determine both aspiration status and oral feeding recommendations in children.

Design: Cross-sectional evaluation of a diagnostic test with a consecutive, referral-based sample.

Setting: Urban, tertiary care, teaching hospital.

Participants: Fifty-six children (age range 2-18 years; mean 13 years) referred for swallowing evaluations.

Outcome measures: Aspiration status during fiberoptic endoscopic evaluation of swallowing (FEES) was the objective criterion standard with which results from the 3-ounce water swallow challenge were compared.

Results: Twenty-two (39.3%) participants passed and 34 (60.7%) failed the 3-ounce challenge. Sensitivity for predicting aspiration status during FEES = 100.0 percent, specificity = 51.2 percent, and false-positive rate = 48.4 percent. Sensitivity for identifying individuals who were deemed safe for oral intake based on FEES results = 100.0 percent, specificity = 44.0 percent, and false-positive rate = 56.0 percent.

Conclusions: If the 3-ounce water swallow challenge is passed, not only thin liquids but diet recommendations with puree and solid food consistencies can be made without the need for further instrumental dysphagia assessment.

Significance: The 3-ounce water swallow challenge has been shown to be a clinically useful screening test for oropharyngeal dysphagia in children.

Accreditation & date: Otolaryngol Head Neck Surg, 2009, 140(2):187-90.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/19201286

 

Wakasugi Y, 2008 – Screening test for silent aspiration at the bedside.

Summary: Screening test for silent aspiration at the bedside.

Abstract:
Many screening tests for dysphagia can be given at bedside. However, they cannot accurately screen for silent aspiration (SA). We studied the usefulness of a cough test to screen for SA and combined it with the modified water swallowing test (MWST) to make an accurate screening system.

Patients suspected of dysphagia (N = 204) were administered a cough test and underwent videofluorography (VF) or videoendoscopy (VE). Sensitivity of the cough test for detection of SA was 0.87 with specificity of 0.89. Of these 204 patients, 107 were also administered the MWST. Fifty-five were evaluated as normal by the screening system, 49 of whom were evaluated as normal by VF or VE. Sixteen were evaluated as “SA suspected” by the screening system; seven of them were normal, and seven were evaluated as having SA by VF or VE. Nineteen were evaluated as aspirating with cough, 14 of whom had aspiration with cough as shown by VF or VE. Seventeen were evaluated as having SA, 15 of whom had SA shown by VF or VE. The cough test was useful in screening for SA. Moreover, a screening system that included MWST and a cough test could accurately distinguish between the healthy who were safe in swallowing and SA patients who were unsafe.

Accreditation & date: Dysphagia, 2008, 23(4):364-70.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18594914

Dysphagia Clinical Papers - Malnutrition & nutritional therapy

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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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Dysphagia Clinical Papers - Texture modification/ Stages (nectar/ honey/ pudding)

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Clavé P, 2006 – The effect of bolus viscosity on swallowing function in neurogenic dysphagia.

Summary: The effect of bolus viscosity on swallowing function in neurogenic dysphagia.

Abstract:
Aim:
To assess the pathophysiology and treatment of neurogenic dysphagia. METHODS: 46 patients with brain damage, 46 with neurodegenerative diseases and eight healthy volunteers were studied by videofluoroscopy while swallowing 3-20 mL liquid (20.4 mPa s), nectar (274.4 mPa s) and pudding (3931.2 mPa s) boluses.

Results: Volunteers presented a safe and efficacious swallow, short swallow response (< or =740 ms), fast laryngeal closure (< or =160 ms) and strong bolus propulsion (> or =0.33 mJ). Brain damage patients presented: (i) 21.6% aspiration of liquids, reduced by nectar (10.5%) and pudding (5.3%) viscosity (P < 0.05) and (ii) 39.5% oropharyngeal residue. Neurodegenerative patients presented: (i) 16.2% aspiration of liquids, reduced by nectar (8.3%) and pudding (2.9%) viscosity (P < 0.05) and (ii) 44.4% oropharyngeal residue. Both group of patients presented prolonged swallow response (> or =806 ms) with a delay in laryngeal closure (> or =245 ms), and weak bolus propulsion forces (< or =0.20 mJ). Increasing viscosity did not affect timing of swallow response or bolus kinetic energy.

Conclusions: Patients with neurogenic dysphagia presented high prevalence of videofluoroscopic signs of impaired safety and efficacy of swallow, and were at high risk of respiratory and nutritional complications. Impaired safety is associated with slow oropharyngeal reconfiguration and impaired efficacy with low bolus propulsion. Increasing bolus viscosity greatly improves swallowing function in neurological patients.

Accreditation & date: Aliment Pharmacol Ther, 2006 Nov 1;24(9):1385-94.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/17059520.

 

Kuhlemeier KV, 2001 – Effect of liquid bolus consistency and delivery method on aspiration and pharyngeal retention in dysphagia patients.

Summary: Effect of liquid bolus consistency and delivery method on aspiration and pharyngeal retention in dysphagia patients.

Abstract:
There is no empirically derived consensus as to what food consistency types and method of food delivery (spoon, cup, straw) should be included in the videofluoroscopic swallowing (VFSS) studies. In the present study, we examine the rates of aspiration and pharyngeal retention in 190 dysphagic patients given thin (apple juice) and thick (apricot nectar) liquids delivered by teaspoon and cup and ultrathick (pudding-like) liquid delivered by teaspoon. Each patient was tested with each of the bolus/delivery method combinations. The fractions of patients exhibiting aspiration for each bolus/method of delivery combination were (1) thick liquids (cup), 13.2%; (2) thick liquids (spoon), 8.9%; (3) thin liquids (cup), 23.7%; (4) thin liquids (spoon), 15.8%, (5) ultrathick liquids (spoon), 5.8%. In each comparison [thick liquid (cup) vs. thick liquid (spoon), thin liquid (cup) vs. thin liquid (spoon), thick liquid (cup) vs. thin liquid (cup), thick liquid (spoon) vs. thin liquid (spoon), and thick liquid (spoon) vs. ultrathick liquid (spoon)], the p value for chi 2 was < 0.001. These results suggest that utilizing thin, thick, and ultrathick liquids and delivery by cup and spoon during a VFSS of a patient with mild or moderate dysphagia can increase the chances of identifying a consistency that the patient can swallow without aspirating and without pharyngeal retention after swallowing.

Accreditation & date: Dysphagia, 2001 Spring;16(2):119-22.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/11305221.

 

Logemann JA, 2008 – A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease.

Summary: A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease.

Abstract:
Purpose: This study was designed to identify which of 3 treatments for aspiration on thin liquids-chin-down posture, nectar-thickened liquids, or honey-thickened liquids-results in the most successful immediate elimination of aspiration on thin liquids during the videofluorographic swallow study in patients with dementia and/or Parkinson’s disease.

Method: This randomized clinical trial included 711 patients ages 50 to 95 years who aspirated on thin liquids as assessed videofluorographically. All patients received all 3 interventions in a randomly assigned order during the videofluorographic swallow study.

Results: Immediate elimination of aspiration on thin liquids occurred most often with honey-thickened liquids for patients in each diagnostic category, followed by nectar-thickened liquids and chin-down posture. Patients with most severe dementia exhibited least effectiveness on all interventions. Patient preference was best for chin-down posture followed closely by nectar-thickened liquids.

Conclusion: To identify best short-term intervention to prevent aspiration of thin liquid in patients with dementia and/or Parkinson’s disease, a videofluorographic swallow assessment is needed. Evidence-based practice requires taking patient preference into account when designing a dysphagic patient’s management plan. The longer-term impact of short-term prevention of aspiration requires further study.

Accreditation & date: J Speech Lang Hear Res, 2008 Feb;51(1):173-83.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18230864.

 

McHorney C, 2002 – The SWAL-QOL and SWAL-CARE outcomes tool for oropharyngeal dysphagia in adults: III, documentation of reliability and validity.

Summary: The SWAL-QOL and SWAL-CARE outcomes tool for oropharyngeal dysphagia in adults: III, documentation of reliability and validity.

Abstract:
Advances in the measurement of swallowing physiologic parameters have been clinician-driven, as has the development of intervention techniques to modify swallowing pathophysiology. However, a critical element to determining the success of such efforts will be established by the patients themselves. We conceptualized, developed, and validated the SWAL-QOL, a 93-item quality-of-life and quality-of-care outcomes tool for dysphagia researchers and clinicians. With 93 items, the SWAL-QOL was too long for practical and routine use in clinical research and practice. We used an array of psychometric techniques to reduce the 93-item instrument into two patient-centered outcomes tools: (1) the SWAL-QOL, a 44-item tool that assesses ten quality-of-life concepts, and (2) the SWAL-CARE, a 15-item tool that assesses quality of care and patient satisfaction. All scales exhibit excellent internal-consistency reliability and short-term reproducibility. The scales differentiate normal swallowers from patients with oropharyngeal dysphagia and are sensitive to differences in the severity of dysphagia as clinically defined. It is intended that the standardization and publication of the SWAL-QOL and the SWAL-CARE will facilitate their use in clinical research and clinical practice to better understand treatment effectiveness as a critical step toward improving patients’ quality of life and quality of care.

Accreditation & date: Dysphagia, 2002 Spring;17(2):97-114.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/11956835.

 

Mills RH, 1999 – Rheology Overview: Control of liquid viscosities in dysphagia management.

Summary: Rheology Overview: Control of liquid viscosities in dysphagia management.

Accreditation & date: Nutrition in clinical practise, 1999, 14(5): 52-56.

PubMed link: cat.inist.fr/?aModele=afficheN&cpsidt=10251705.

 

Raut VV, 2001 – Effect of bolus consistency on swallowing – does altering consistency help?

Summary: Effect of bolus consistency on swallowing – does altering consistency help?

Abstract: 
The influence of food bolus consistency on the pharyngeal wave during swallowing was investigated using a four-sensor manometry probe in 22 healthy volunteers. Pharyngeal pressures were recorded for 5 ml boluses of water, pudding and buttered bread via a manometry probe placed transnasally. The distal sensor was sited within the upper oesophageal sphincter (UOS); the three proximal sensors were then located 2, 4 and 6 cm above the UOS. The amplitude and timing of the swallow waveforms for pudding and buttered bread were recorded and compared with those for water. Increased bolus viscosity led to increased amplitude of the bolus wave and clearing contraction within the pharynx. In the UOS, increased bolus viscosity was associated with a larger pressure nadir (sub-atmospheric pressure) on opening and intra bolus pressure during transit. Bolus consistency also influenced the coordination of the swallow response with delayed pharyngeal clearance. The putative relevance of these findings to dietary modification for patients with neurological and neuromuscular dysphagia is discussed.

Accreditation & date: Eur Arch Otorhinolaryngol, 2001 Jan;258(1):49-53.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/11271436.

 

Troche MS, 2008 – Effects of bolus consistency on timing and safety of swallow in patients with Parkinson’s disease.

Summary: Effects of bolus consistency on timing and safety of swallow in patients with Parkinson’s disease.

Abstract:
Aspiration pneumonia is the leading cause of death in Parkinson’s disease (PD) patients. In clinical practice, the videofluoroscopic examination (VFE) is the most common method for evaluation of swallowing disorders. One of the variables manipulated during the VFE is consistency of the bolus. The results of this examination greatly influence the recommendations made by speech-language pathologists regarding swallow therapy and/or intervention. The primary aim of this study was to investigate the effects of bolus consistency on penetration-aspiration (P-A) score and timing of swallow of persons with PD. The videoradiographic images of ten participants with PD swallowing six thin and six pudding-thick boluses were analyzed. Swallow timing and P-A were measured. (i.e., oral transit time, pharyngeal transit time, number of tongue pumps, and P-A score). The results demonstrated various significant differences and relationships among the dependent variables. Implications for further research and clinical practice are discussed.

Accreditation & date: Dysphagia, 2008 Mar;23(1):26-32. Epub 2007 Jun 6.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/17551793.

 

Robbins J, 2008 – Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial.

Summary: Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial.

Abstract:
Background:
Aspiration pneumonia is common among frail elderly persons with dysphagia. Although interventions to prevent aspiration are routinely used in these patients, little is known about the effectiveness of those interventions.

Objective: To compare the effectiveness of chin-down posture and 2 consistencies (nectar or honey) of thickened liquids on the 3-month cumulative incidence of pneumonia in patients with dementia or Parkinson disease.

Design: Randomized, controlled, parallel-design trial in which patients were enrolled for 3-month periods from 9 June 1998 to 19 September 2005.

Setting: 47 hospitals and 79 subacute care facilities. PATIENTS: 515 patients age 50 years or older with dementia or Parkinson disease who aspirated thin liquids (demonstrated videofluoroscopically). Of these, 504 were followed until death or for 3 months.

Intervention: Participants were randomly assigned to drink all liquids in a chin-down posture (n = 259) or to drink nectar-thick (n = 133) or honey-thick (n = 123) liquids in a head-neutral position.

Measurements: The primary outcome was pneumonia diagnosed by chest radiography or by the presence of 3 respiratory indicators.

Results: 52 participants had pneumonia, yielding an overall estimated 3-month cumulative incidence of 11%. The 3-month cumulative incidence of pneumonia was 0.098 and 0.116 in the chin-down posture and thickened-liquid groups, respectively (hazard ratio, 0.84 [95% CI, 0.49 to 1.45]; P = 0.53). The 3-month cumulative incidence of pneumonia was 0.084 in the nectar-thick liquid group compared with 0.150 in the honey-thick liquid group (hazard ratio, 0.50 [CI, 0.23 to 1.09]; P = 0.083). More patients assigned to thickened liquids than those assigned to the chin-down posture intervention had dehydration (6% vs. 2%), urinary tract infection (6% vs. 3%), and fever (4% vs. 2%). LIMITATIONS: A no-treatment control group was not included. Follow-up was limited to 3 months. Care providers were not blinded, and differences in cumulative pneumonia incidence between interventions had wide CIs.

Conclusions: No definitive conclusions about the superiority of any of the tested interventions can be made. The 3-month cumulative incidence of pneumonia was much lower than expected in this frail elderly population. Future investigation of chin-down posture combined with nectar-thick liquid may be warranted to determine whether this combination better prevents pneumonia than either intervention independently.

Accreditation & date: Ann Intern Med, 2008 Apr 1;148(7):509-18.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18378947.

Dysphagia Clinical Papers - Practice patterns

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Castellanos VH, 2004 – Use of thickened liquids in skilled nursing facilities.

Summary: Use of thickened liquids in skilled nursing facilities.

Abstract:
Objective:
Long-term care residents are routinely provided with thickened liquids for the management of dysphagia. The objective of this study was to identify the prevalence of thickened liquid use in skilled nursing facilities

Design: Facility-wide data were provided by staff at 252 randomly selected skilled nursing facilities owned by 11 multifacility providers. The sample represented 25,470 residents and approximately 20% of all freestanding skilled nursing facilities nationwide.

Main outcome measures: Data regarding prevalence of thickened liquid use and facility characteristics were collected during May 2002. Statistical analysis Descriptive statistics included national and regional averages and national percentile distributions.

Results: A mean of 8.3% (range 0% to 28%) of residents were receiving thickened liquids, with considerable variation between Centers for Medicare and Medicaid Services regions. Of those receiving thickened liquids, on average 60% received “nectar/syrup” thick, 33% received “honey” thick, and 6% received “pudding/spoon” thick, although the frequencies with which each thickness was prescribed varied widely between facilities (range 0% to 100%). Thickened water was provided to residents in 91.6% of facilities. Nationally, registered dietitian staffing levels were lower on average than speech language pathologist staffing levels.

Conclusions: Thickened liquids are provided to a significant segment of the skilled nursing facility resident population. In the absence of outcomes-based practice standards to guide administrative decisions related to the provision of thickened liquids, dietetics professionals may find regional and national norms helpful for quality assurance processes and to inform resource management decisions in clinical staffing and foodservice.

Accreditation & date: J Am Diet Assoc, 2004 Aug;104(8):1222-6.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/1528103.

 

Garcia JM, 2005 – Thickened liquids: practice patterns of speech-language pathologists.

Summary: Thickened liquids: practice patterns of speech-language pathologists.

Abstract:
This study surveyed the practice patterns of speech-language pathologists in their use of thickened liquids for patients with swallowing difficulties.

A 25-item Internet survey about thickened liquids was posted via an e-mail list to members of the American Speech-Language-Hearing Association Division 13, Swallowing and Swallowing Disorders (Dysphagia). Responses of 145 professionals who primarily manage adult dysphagia are reported. Although the majority affirmed that thickening thin liquids was an effective intervention strategy, opinions about effectiveness were more favorable for nectar-thick versus honey-like and spoon-thick consistencies. Respondents also acknowledged that their patients had little liking for thickened liquids. Results highlight issues related to products and staff training, as well as perceptions concerning the factors that might affect patients’ acceptance of and compliance with use of the products.

Accreditation & date: Am J Speech Lang Pathol, 2005 Feb;14(1):4-13.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/15962843.

 

Logemann JM, 2008 – What information do clinicians use in recommending oral versus nonoral feeding in oropharyngeal dysphagic patients?

Summary: What information do clinicians use in recommending oral versus nonoral feeding in oropharyngeal dysphagic patients?

Abstract:
There is little evidence regarding the type(s) of information clinicians use to make the recommendation for oral or nonoral feeding in patients with oropharyngeal dysphagia.

This study represents a first step toward identifying data used by clinicians to make this recommendation and how clinical experience may affect the recommendation. Thirteen variables were considered critical in making the oral vs. nonoral decision by the 23 clinicians working in dysphagia. These variables were then used by the clinicians to independently recommend oral vs. nonoral feeding or partial oral with nonoral feeding for the 20 anonymous patients whose modified barium swallows were sent on a videotape to each clinician. Clinicians also received data on the 13 variables for each patient. Results of clinician agreement on the recommendation of full oral and nonoral only were quite high, as measured by Kappa statistics. In an analysis of which of the 13 criteria clinicians used in making their recommendations, amount of aspiration was the criterion with the highest frequency. Recommendations for use of postures and maneuvers and the effect of clinician experience on these choices were also analyzed.

Accreditation & date: Dysphagia, 2008 Dec;23(4):378-84.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18670808.

 

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.

Abstract:
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.

Dysphagia Clinical Papers - Tube feeding

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Crary MA, 2006 – Reinstituting oral feeding in tube-fed adult patients with dysphagia.

Summary: Reinstituting oral feeding in tube-fed adult patients with dysphagia.

Abstract:
Feeding tubes are valuable assets in the rehabilitation of adult patients with dysphagia. Feeding tubes may be placed in response to perceived risks of airway compromise or insufficient nutrient intake. However, not all patients require long-term enteral feeding.

With intensive dysphagia therapy, many patients will experience resolving deficits or improvement in swallowing ability. These patients require an appropriate strategy to transition from tube to oral feeding. This article reviews some of the basic characteristics of dysphagia and identifies specific swallowing difficulties in 2 groups of patients who often benefit from temporary enteral feeding: stroke survivors and patients treated for head and neck cancer. Specific suggestions are offered for clinical strategies to reinstitute oral feeding in these groups of tube-fed patients. 

Accreditation & date: Nutr Clin Pract, 2006 Dec;21(6):576-86.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/17119164.

 

Dziewas R, 2008 – Do nasogastric tubes worsen dysphagia in patients with acute stroke?

Summary: Do nasogastric tubes worsen dysphagia in patients with acute stroke?

Abstract:
Background:
Early feeding via a nasogastric tube (NGT) is recommended as safe way of supplying nutrition in patients with acute dysphagic stroke. However, preliminary evidence suggests that NGTs themselves may interfere with swallowing physiology. In the present study we therefore investigated the impact of NGTs on swallowing function in acute stroke patients.

Methods: In the first part of the study the incidence and consequences of pharyngeal misplacement of NGTs were examined in 100 stroke patients by fiberoptic endoscopic evaluation of swallowing (FEES). In the second part, the effect of correctly placed NGTs on swallowing function was evaluated by serially examining 25 individual patients with and without a NGT in place.

Results: A correctly placed NGT did not cause a worsening of stroke-related dysphagia. Except for two cases, in which swallowing material got stuck to the NGT and penetrated into the laryngeal vestibule after the swallow, no changes of the amount of penetration and aspiration were noted with the NGT in place as compared to the no-tube condition. Pharyngeal misplacement of the NGT was identified in 5 of 100 patients. All these patients showed worsening of dysphagia caused by the malpositioned NGT with an increase of pre-, intra-, and postdeglutitive penetration.

Conclusions: Based on these findings, there are no principle obstacles to start limited and supervised oral feeding in stroke patients with a NGT in place.

Accreditation & date: BMC Neurol, 2008 Jul 23;8:28.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18651972.

 

Dennis M, 2006 – FOOD: a multicentre randomised trial evaluating feeding policies in patients admitted to hospital with a recent stroke.

Summary:
Food:
a multicentre randomised trial evaluating feeding policies in patients admitted to hospital with a recent stroke.

Abstract:
Objectives
: To determine whether routine oral nutritional supplementation of a normal hospital diet improves outcome after stroke (Trial 1); whether early tube feeding improves the outcomes of dysphagic stroke patients (Trial 2); and if tube feeding via a percutaneous endoscopic gastrostomy (PEG) results in better outcomes than that via a nasogastric tube (NG) (Trial 3).

Design: The Feed Or Ordinary Diet (FOOD) trial was a family of three pragmatic, randomised controlled trials (RCTs). They shared facilities for randomisation, data collection, follow-up and coordination. Patients could be co-enrolled in more than one of these trials.

Setting: Patients were enrolled in 131 hospitals in 18 countries.

Participants: A total of 5033 patients who had been admitted to hospital with a recent stroke were enrolled in the trials between November 1996 and July 2003.

Interventions: In Trial 1, patients who could swallow within the first 30 days of admission were allocated to normal hospital diet versus normal hospital diet plus oral nutritional supplements (equivalent to 360 ml of 1.5 kcal/ml, 20 g of protein per day) until hospital discharge. In Trial 2, dysphagic patients enrolled within 7 days of admission were allocated to early enteral tube feeding versus avoid any enteral tube feeding for at least 1 week. In Trial 3, dysphagic patients were allocated within 30 days of admission to receive enteral tube feeding via PEG versus NG.

Main outcome measures: Survival and the modified Rankin scale (MRS), a measure of functional outcome (grade 0 indicating no symptoms and grade 5 indicating severe disability, requiring help day and night). The primary outcomes were measured 6 months after enrollment, blind to treatment allocation, by the patient or their proxy completing a postal or telephone questionnaire.

Results: In Trial 1, 4023 patients were enrolled by 125 hospitals in 15 countries. Only 314 (7.8%) patients were judged undernourished at baseline. Vital status and MRS at the end of the trial were known for 4012 (99.7%) and 4004 (99.5%), respectively. Of the 2007 allocated normal hospital diet, 253 (12.6%) died, 918 (45.7%) were alive with poor outcome (MRS 3-5) and 823 (41.1%) had a good outcome (MRS 0-2). Of the 2016 allocated oral supplements, 241 (12.0%) died, 953 (47.3%) were alive with poor outcome and 813 (40.4%) had a good outcome. The supplemented diet was associated with an absolute reduction in risk of death of 0.7% (95% CI -1.4 to 2.7; p = 0.5) and a 0.7% (95% CI -2.3 to 3.8, p = 0.6) increased risk of death or poor outcome. In Trial 2, a total of 859 patients were enrolled by 83 hospitals in 15 countries. MRS at the end of the trial was known for 858 (99.9%). At follow-up, of 429 allocated early tube feeding, 182 (42.4%) died, 157 (36.6%) were alive with poor outcome (MRS 4-5) and 90 (21.0%) had a good outcome (MRS 0-3). Of 430 allocated avoid tube feeding 207 (48.1%) died, 137 (31.9%) were alive with poor outcome and 85 (19.8%) had a good outcome. Early tube feeding was associated with an absolute reduction in risk of death of 5.8% (95% CI -0.8 to 12.5; p = 0.09) and a reduction in death or poor outcome of 1.2% (95% CI -4.2 to 6.6; p = 0.7). In Trial 3, 321 patients were enrolled by 47 hospitals in 11 countries. Of 162 allocated PEG, 79 (48.8%) died, 65 (40.1%) were alive with poor outcome and 18 (11.1%) had good outcome. Of 159 allocated NG, 76 (47.8%) died, 53 (33.3%) were alive with poor outcome and 30 (18.9%) had good outcome. PEG was associated with an increase in absolute risk of death of 1.0% (95% CI -10.0 to 11.9; p = 0.9) and an increased risk of death or poor outcome of 7.8% (95% CI 0.0 to 15.5; p = 0.05).

Conclusions: The results of Trial 1 would be compatible with oral supplementation being associated with a 1-2% absolute benefit or harm, but do not support routine supplementation of hospital diet for unselected stroke patients who are predominantly well nourished on admission. In Trial 2, the data suggest that a policy of early tube feeding may substantially reduce the risk of dying after stroke and it is very unlikely that the alternative policy of avoiding early tube feeding would significantly improve survival. Improved survival may be at the expense of increasing the proportion surviving with poor outcome. These data might usefully inform the difficult discussions about whether or not to feed a patient with a severe stroke. In Trial 3, the data suggest that in the first 2-3 weeks after acute stroke, better functional outcomes result from feeding via NG tube than PEG tube, although there was no major difference in survival. These data do not support a policy of early initiation of PEG feeding in dysphagic stroke patients. Future research might be focused on making NG tube feeding safer and more effective, also studies need to confirm the increased risk of gastrointestinal haemorrhage associated with tube feeding and, if confirmed, establish whether any interventions might reduce this risk. Future work might also aim to establish why worse functional outcomes occurred in PEG-fed patients because patients with prolonged dysphagia or intolerance of an NG tube are inevitably fed via a PEG tube.

Accreditation & date: Health Technol Assess, 2006 Jan;10(2):iii-iv, ix-x, 1-120.

 

PubMed link: www.ncbi.nlm.nih.gov/pubmed/16409880.

Dysphagia Clinical Papers - Miscellaneous

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McCormick SE, 2008 – The efficacy of pre-thickened fluids on total fluid and nutrient consumption among extended care residents requiring thickened fluids due to risk of aspiration.

Summary: The efficacy of pre-thickened fluids on total fluid and nutrient consumption among extended care residents requiring thickened fluids due to risk of aspiration.

Accreditation & date: Age Ageing, 2008 Nov;37(6):714-5.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/19004963.

 

Nguyen NP, 2005 – Impact of dysphagia on quality of life after treatment of head-and-neck cancer.

Summary: Impact of dysphagia on quality of life after treatment of head-and-neck cancer.

Abstract:
Purpose: To evaluate the quality of life (QOL) associated with dysphagia after head-and-neck cancer treatment.

Methods and materials: Of a total population of 104, a retrospective analysis of 73 patients who complained of dysphagia after primary radiotherapy (RT), chemoradiotherapy, and postoperative RT for head-and-neck malignancies were evaluated. All patients underwent a modified barium swallow examination to assess the severity of dysphagia, graded on a scale of 1-7. QOL was evaluated by the University of Washington (UW) and Hospital Anxiety and Depression questionnaires. The QOL scores obtained were compared with those from the 31 patients who were free of dysphagia after treatment. The QOL scores were also graded according to the dysphagia severity.

Results: The UW and Hospital Anxiety and Depression scores were reduced and elevated, respectively, in the dysphagia group compared with the no dysphagia group (p = 0.0005). The UW scores were also substantially lower among patients with moderate-to-severe (Grade 4-7) compared with no or mild (Grade 2-3) dysphagia (p = 0.0005). The corresponding Hospital Anxiety (p = 0.005) and Depression (p = 0.0001) scores were also greater for the moderate-to-severe group. The UW QOL subscale scores showed a statistically significant decrease for swallowing (p = 0.00005), speech (p = 0.0005), recreation/entertainment (p = 0.0005), disfigurement (p = 0.0006), activity (p = 0.005), eating (p = 0.002), shoulder disability (p = 0.006), and pain (p = 0.004).

Conclusions: Dysphagia is a significant morbidity of head-and-neck cancer treatment, and the severity of dysphagia correlated with a compromised QOL, anxiety, and depression. Patients with moderate-to-severe dysphagia require a team approach involving nutritional support, physical therapy, speech rehabilitation, pain management, and psychological counseling.

Accreditation & date: Int J Radait Oncol Biol Phys, 2005 Mar 1;61(3):772-8.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/15708256.

 

Smithard DC, 1996 – Complications and outcome after acute stroke. Does dysphagia matter?

Summary: Complications and outcome after acute stroke. Does dysphagia matter?

Abstract:
Background and purpose:
The published data on the relationship between dysphagia and both outcome and complications after acute stroke have been inconclusive. We examined the relationship between these, using bedside assessment and videofluoroscopic examination.

Methods: We prospectively studied 121 consecutive patients admitted with acute stroke. A standardized bedside assessment was performed by a physician. We performed videofluoroscopy blinded to this assessment within 3 days of stroke onset and within a median time of 24 hours of the bedside evaluations. The presence of aspiration was recorded. Mortality, functional outcome, lengthy of stay, place of discharge, occurrence of chest infection, nutritional status, and hydration were the main outcome measures.

Results: Patients with an abnormal swallow (dysphagia) on bedside assessment had a higher risk of chest infection (P=.05) and a poor nutritional state (P=.001). The presence of dysphagia was associated with an increased risk of death (P=.001), disability (P=.02), length of hospital stay (P < .001), and institutional care (P < .05). When other factors were taken into account, dysphagia remained as an independent predictor of outcome only with regard to mortality. The use of videofluoroscopy in detecting aspiration did not add to the value of bedside assessment.

Conclusions: Bedside assessment of swallowing is of use in identifying patients at risk of developing complications. The value of routine screening with videofluoroscopy to detect aspiration is questioned.

Accreditation & date: Stroke, 1996 Jul;27(7):1200-4.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/8685928.

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Dysphagia Clinical Papers - Overview articles

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Bakheit AMO, 2001 – Management of neurogenic dysphagia.

Summary: Management of neurogenic dysphagia.

Accreditation & date: Postgrad Med J, 2001 Nov;77(913):694-9.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/11677277

 

Claudell JJ, 2009 – Factors associated with long-term dysphagia after definitive radiotherapy for locally advanced head-and-neck cancer.

Summary: Factors associated with long-term dysphagia after definitive radiotherapy for locally advanced head-and-neck cancer.

Abstract:
Purpose: The use of altered fractionation radiotherapy (RT) regimens, as well as concomitant chemotherapy and RT, to intensify therapy for locally advanced head-and-neck cancer can lead to increased rates of long-term dysphagia.

Methods and materials: We identified 122 patients who had undergone definitive RT for locally advanced head-and-neck cancer, after excluding those who had been treated for a second or recurrent head-and-neck primary, had Stage I-II disease, developed locoregional recurrence, had 12 months of follow-up, or had undergone postoperative RT. The patient, tumor, and treatment factors were correlated with a composite of 3 objective endpoints as a surrogate for severe long-term dysphagia: percutaneous endoscopic gastrostomy tube dependence at the last follow-up visit; aspiration on a modified barium swallow study or a clinical diagnosis of aspiration pneumonia; or the presence of a pharyngoesophageal stricture.

Results: A composite dysphagia outcome occurred in 38.5% of patients. On univariate analysis, the primary site (p = 0.01), use of concurrent chemotherapy (p = 0.01), RT schedule (p = 0.02), and increasing age (p = 0.04) were significantly associated with development of composite long-term dysphagia. The use of concurrent chemotherapy (p = 0.01), primary site (p = 0.02), and increasing age (p = 0.02) remained significant on multivariate analysis.

Conclusions: The addition of concurrent chemotherapy to RT for locally advanced head-and-neck cancer resulted in increased long-term dysphagia. Early intervention using swallowing exercises, avoidance of nothing-by-mouth periods, and the use of intensity-modulated RT to reduce the dose to the uninvolved swallowing structures should be explored further in populations at greater risk of long-term dysphagia.

Accreditation & dates: Int J Radiat Oncol Biol Phys, 2009 Feb 1;73(2):410-5

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18635320.

 

Cook IJ, 1999 – AGA technical review on management of oropharyngeal dysphagia.

Summary: AGA technical review on management of oropharyngeal dysphagia.

Accreditation & date: Gastroenterology, 1999 Feb;116(2):455-78.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/9922328

 

Daniels SK, 1998 – Aspiration in patients with acute stroke.

Summary: Aspiration in patients with acute stroke.

Abstract:
Objectives: To determine the frequency and clinical predictors of aspiration within 5 days of acute stroke. DESIGN: Case series. SETTING: Tertiary care center. PATIENTS: Consecutive stroke patients (n = 55) with new neurologic deficit evaluated within 5 days of acute stroke.

Main outcome measures: Comparison of features identified on clinical swallowing and oromotor examinations and occurrence of aspiration (silent or overt) evident on videofluoroscopic swallow study (VSS).

Results: Aspiration occurred in 21 of 55 patients (38%). Whereas 7 of 21 patients (33%) aspirated overtly, 14 (67%) aspirated silently on VSS. Chi-square analyses revealed that dysphonia, dysarthria, abnormal gag reflex, abnormal volitional cough, cough after swallow, and voice change after swallow were significantly related to aspiration and were predictors of the subset of patients with silent aspiration. Logistic regression revealed that abnormal volitional cough and cough with swallow, in conjunction, predicted aspiration with 78% accuracy.

Conclusions: Silent aspiration appears to be a significant problem in acute stroke patients because silent aspiration occurred in two thirds of the patients who aspirated. The prediction of patients at risk for aspiration was significantly improved by the presence of concurrent findings of abnormal volitional cough and cough with swallow on clinical examination.

Accreditation & date: Arch Phys Med Rehabil, 1998 Jan;79(1):14-9.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/9440410

 

Ekberg O, 2002 – Social and psychological burden of dysphagia: its impact on diagnosis and treatment.

Summary: Social and psychological burden of dysphagia: its impact on diagnosis and treatment.

Abstract:
The social and psychological impact of dysphagia has not been routinely reported in large studies. We sought to determine the effects of dysphagia on broad measures of the quality of life of patients and to explore the relationship between the psychological handicaps of the condition and the frequency of diagnosis and treatment.

A total of 360 patients selected on the basis of known subjective dysphagia complaints, regardless of origin, in nursing homes and clinics in Germany, France, Spain, and the United Kingdom were interviewed using an established questionnaire. Qualitative interviews with a total of 28 health professionals were conducted to improve understanding of the patient data in the context of each country. Over 50% of patients claimed that they were “eating less” with 44% reporting weight loss during the preceding 12 months. Thirty-six percent of patients acknowledged receiving a confirmed diagnosis of dysphagia; only 32% acknowledged receiving professional treatment for it. Most people with dysphagia believe their condition to be untreatable; only 39% of the sufferers believed that their swallowing difficulties could be treated. Eighty-four percent of patients felt that eating should be an enjoyable experience but only 45% actually found it so. Moreover, 41% of patients stated that they experienced anxiety or panic during mealtimes. Over one-third (36%) of patients reported that they avoided eating with others because of their dysphagia. In a largely elderly population that might accept dysphagia as an untreatable part of the aging process, clinicians need to be aware of the adverse effects of dysphagia on self-esteem, socialization, and enjoyment of life. Careful questioning should assess the impact of the condition on each patient’s life, and patients should be educated on their choices for treatment in the context of any coexisting illness. Awareness of the condition, diagnostic procedures, and treatment options must be increased in society and among the medical profession.

Accreditation & date: Dysphagia, 2002 Spring;17(2):139-46.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/11956839

 

Gallagher L, 2009 – Prescription drugs and their effects on swallowing.

Summary: Prescription drugs and their effects on swallowing.

Abstract:
The impact of medications on the physiology of swallowing has received much attention in dysphagia literature. This article reviews the potential effects of medications commonly prescribed in an adult continuing care and rehabilitation facility on swallowing.

An audit of medications prescribed to 153 adults accessing age-related respiratory, neurology, and learning disability services was performed. This was followed by an investigation of relevant sources to identify the potential side effects of these medications. One side effect, namely, xerostomia, which our investigations revealed could be a side effect of 24.8% of the medications used at our institution, was further investigated. The prevalence of xerostomia was then investigated in a randomly selected sample of ten subjects whose dysphagia had been confirmed by videofluoroscopy. It was found that six of the ten dysphagic clients displayed xerostomia. Review of the medications of these ten subjects indicated that all were using from three to nine drugs that could cause xerostomia. This article highlights the need for health-care professionals to consider the potential effects of these medications on swallowing and, indeed, the general presentation of clients.

Accreditation & date: Dysphagia, 2009 Jun;24(2):159-66.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/19085036

 

Langmore SE, 1998 – Predictors of aspiration pneumonia: how important is dysphagia?

Summary: Predictors of aspiration pneumonia: how important is dysphagia?

Abstract:
Aspiration pneumonia is a major cause of morbidity and mortality among the elderly who are hospitalized or in nursing homes.

Multiple risk factors for pneumonia have been identified, but no study has effectively compared the relative risk of factors in several different categories, including dysphagia. In this prospective outcomes study, 189 elderly subjects were recruited from the outpatient clinics, inpatient acute care wards, and the nursing home care center at the VA Medical Center in Ann Arbor, Michigan. They were given a variety of assessments to determine oropharyngeal and esophageal swallowing and feeding status, functional status, medical status, and oral/dental status. The subjects were followed for up to 4 years for an outcome of verified aspiration pneumonia. Bivariate analyses identified several factors as significantly associated with pneumonia. Logistic regression analyses then identified the significant predictors of aspiration pneumonia. The best predictors, in one or more groups of subjects, were dependent for feeding, dependent for oral care, number of decayed teeth, tube feeding, more than one medical diagnosis, number of medications, and smoking. The role that each of the significant predictors might play was described in relation to the pathogenesis of aspiration pneumonia. Dysphagia was concluded to be an important risk for aspiration pneumonia, but generally not sufficient to cause pneumonia unless other risk factors are present as well. A dependency upon others for feeding emerged as the dominant risk factor, with an odds ratio of 19.98 in a logistic regression model that excluded tube-fed patients.

Accreditation & date: Dysphagia, 1998 Spring;13(2):69-81.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/9513300.

 

Marik PE, 2001 – Aspiration pneumonitis and aspiration pneumonia

Summary: Aspiration pneumonitis and aspiration pneumonia.

Accreditation & date: N ENgl J Med, 2001 Mar 1;344(9):665-71.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/11228282.

 

Martino R, et al. 2005 – Dysphagia after stroke: incidence, diagnosis, and pulmonary complications.

Summary: Dysphagia after stroke: incidence, diagnosis, and pulmonary complications.

Abstract:
Objective: 
To determine the incidence of dysphagia and associated pulmonary compromise in stroke patients through a systematic review of the published literature.

Methods: Databases were searched (1966 through May 2005) using terms “cerebrovascular disorders,” “deglutition disorders,” and limited to “humans” for original articles addressing the frequency of dysphagia or pneumonia. Data sources included Medline, Embase, Pascal, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Selected articles were reviewed for quality, diagnostic methods, and patient characteristics. Comparisons were made of reported dysphagia and pneumonia frequencies. The relative risks (RRs) of developing pneumonia were calculated in patients with dysphagia and confirmed aspiration.

Results: Of the 277 sources identified, 104 were original, peer-reviewed articles that focused on adult stroke patients with dysphagia. Of these, 24 articles met inclusion criteria and were evaluated. The reported incidence of dysphagia was lowest using cursory screening techniques (37% to 45%), higher using clinical testing (51% to 55%), and highest using instrumental testing (64% to 78%). Dysphagia tends to be lower after hemispheric stroke and remains prominent in the rehabilitation brain stem stroke. There is increased risk for pneumonia in patients with dysphagia (RR, 3.17; 95% CI, 2.07, 4.87) and an even greater risk in patients with aspiration (RR, 11.56; 95% CI, 3.36, 39.77).

Conclusions: The high incidence for dysphagia and pneumonia is a consistent finding with stroke patients. The pneumonia risk is greatest in stroke patients with aspiration. These findings will be valuable in the design of future dysphagia research.

Accreditation & date: Stroke, 2005 Dec;36(12):2756-63.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/16269630.

 

Palmer JL, 2008 – Preventing aspiration in older adults with dysphagia.

Summary: Preventing aspiration in older adults with dysphagia.

Abstract:
Dysphagia, the impairment of any part of the swallowing process, increases the risk of aspiration. Dysphagia and aspiration are associated with the development of aspiration pneumonia.

While some changes in swallowing may be a natural result of aging, dysphagia is especially prevalent among older adults with neurologic impairment or dementia, leading to an increased risk of aspiration and aspiration pneumonia. This article discusses best practices for assessment and prevention of aspiration among older adults who are being hand-fed or fed by tube.

Accreditation & date: Am J Nurs, 2008 Feb;108(2):40-8; quiz 49.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18227668.

 

Murphy BA, 2009 – Dysphagia in head and neck cancer patients treated with radiation: assessment, sequelae, and rehabilitation.

Summary: Dysphagia in head and neck cancer patients treated with radiation: assessment, sequelae, and rehabilitation.

Abstract:
Dysphagia is commonly seen in patients undergoing radiation-based therapy for locally advanced squamous carcinoma of the head and neck. Within 4 to 5 weeks of starting therapy, patients develop mucositis, radiation dermatitis, and edema of the soft tissues.

Resulting pain, copious mucous production, xerostomia, and tissue swelling contribute to acute dysphagia. As the acute effects resolve, late effects including fibrosis, lymphedema, and damage to neural structures become manifest. Both acute and late effects result in adverse sequelae including aspiration, feeding tube dependence, and nutritional deficiencies. Early referral for evaluation by speech-language pathologists is critical to (1) ensure adequate assessment of swallow function, (2) determine whether further testing is needed to diagnose or treat the swallowing disorder, (3) generate a treatment plan that includes patient education and swallow therapy, (4) work with dieticians to ensure adequate and safe nutrition, and (5) identify patients with clinically significant aspiration.

Accreditation & date: Semin Radiat Oncol, 2009 Jan;19(1):35-42.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/19028344.

 

Schindler A, 2008 – What we don’t know about dysphagia complications?

Summary: What we don’t know about dysphagia complications?

Abstract:
Prevention of complications is the primary goal in patients with dysphagia. The most common complications of dysphagia are aspiration pneumonia, malnutrition and dehydration; other possible complications, such as intellectual and body development deficit in children with dysphagia, or emotional impairment and social restriction have not been studied thoroughly.

Pulmonary complications of dysphagia should be viewed as an impaired balance between defence mechanisms (cough and mucociliary action, lymphatic clearance and cellular immune defences) and food and secretions aspiration. The main pulmonary complications are aspiration pneumonia, toxic aspiration syndromes, bacterial infections and pulmonary fibrosis. The risk of aspiration pneumonia is increased by poor oral status and health status, dependency for oral care and oral feeding; nonetheless, compliance with feeding recommendations of the dysphagia team, may reduce the risk of pulmonary complications. Malnutrition and dehydration are common in patients with dysphagia; however, enteral nutrition may significantly impact on both. Even though a relationship between malnutrition, dehydration and dysphagia exists, the real impact of one on the others is not known.

Accreditation & date: Rev Laryngol Otol Rhinol (Bord), 2008;129(2):75-8.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18767323.

 

Schmidt J, 1994 – Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke.

Summary: Videofluoroscopic evidence of aspiration predicts pneumonia and death but not dehydration following stroke.

Abstract:
In order to assess the risk of pneumonia, dehydration, and death associated with videofluoroscopic evidence of aspiration following stroke, the clinical records of 26 patients with aspiration and 33 randomly selected, case-matched dysphagic controls without videofluoroscopic evidence of aspiration were reviewed. The videofluoroscopic modified barium swallow technique included 5 ml-thin and thick liquid barium, 5 ml barium pudding, and 1/4 cookie coated with barium, plus additional 20 and 30 ml of thin liquid barium. Patients were assessed a mean of 2 +/- 1 SD months poststroke and were followed for a mean of 16 +/- 8 SD months poststroke. The odds ratio for developing pneumonia was 7.6 times greater for those who aspirated any amount of barium irrespective of its consistency (p = 0.05). The odds ratio for developing pneumonia was 5.6 times greater for those who aspirated thickened liquids or more solid consistencies compared with those who did not aspirate, or who aspirated thin liquids only (p = 0.06). Dehydration was unrelated to the presence or absence of aspiration. The odds ratio for death was 9.2 times greater for those aspirating thickened liquids or more solid consistencies compared with those who did not aspirate or who aspirated thin liquids only (p = 0.01). Aspiration documented by modified videofluoroscopic barium swallow technique is associated with a significant increase in risk of pneumonia and death but not dehydration following stroke.

Accreditation & date: Dysphagia, 1994 Winter;9(1):7-11.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/8131429.

Dysphagia Clinical Papers - Assessment & diagnosis

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Clavé P, 2004 – Approaching oropharyngeal dysphagia.

Summary: Approaching oropharyngeal dysphagia.

Accreditation & date: Rev Esp Enferm Dig, 2004 Feb, 96(2):119-31.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/15255021

 

Clavé P , 2008 – Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration.

Summary: Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration.

Abstract:
Aims: To determine the accuracy of the bedside volume-viscosity swallow test (V-VST) for clinical screening of impaired safety and efficacy of deglutition.

Methods: We studied 85 patients with dysphagia and 12 healthy subjects. Series of 5-20 mL nectar (295.02 mPa.s), liquid (21.61 mPa.s) and pudding (3682.21 mPa.s) bolus were administered during the V-VST and videofluoroscopy. Cough, fall in oxygen saturation > or =3%, and voice changes were considered signs of impaired safety, and piecemeal deglutition and oropharyngeal residue, signs of impaired efficacy.

Results: Videofluoroscopy showed patients had prolonged swallow response (> or =1064 ms); 52.1% had safe swallow at nectar, 32.9%, at liquid (p < 0.05), and 80.6% at pudding viscosity (p < 0.05); 29.4% had aspirations, and 45.8% oropharyngeal residue. The V-VST showed 83.7% sensitivity and 64.7% specificity for bolus penetration into the larynx and 100% sensitivity and 28.8% specificity for aspiration. Sensitivity of V-VST was 69.2% for residue, 88.4% for piecemeal deglutition, and 84.6% for identifying patients whose deglutition improved by enhancing bolus viscosity. Specificity was 80.6%, 87.5%, and 73.7%, respectively.

Conclusions: The V-VST is a sensitive clinical method to identify patients with dysphagia at risk for respiratory and nutritional complications, and patients whose deglutition could be improved by enhancing bolus viscosity. Patients with a positive test should undergo videofluoroscopy.

Accreditation & date: Clinical Nutrition,2008, 27(6): 806-15.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18789561

 

Cook I, 2008 – Diagnostic evaluation of dysphagia.

Summary: Diagnostic evaluation of dysphagia.

Abstract:
Taking a careful history is vital for the evaluation of dysphagia. The history will yield the likely underlying pathophysiologic process and anatomic site of the problem in most patients and is crucial for determining whether subsequently detected radiographic or endoscopic ‘anomalies’ are relevant or incidental. Although the symptoms of pharyngeal dysphagia can be multiple and varied, the typical features of neurogenic pharyngeal dysphagia are highly specific, and can accurately distinguish pharyngeal from esophageal disorders. The history will also dictate whether the next diagnostic procedure should be endoscopy, a barium swallow or esophageal manometry. In some difficult cases, all three diagnostic techniques may need to be performed to establish an accurate diagnosis. Stroke is the most common cause of pharyngeal dysphagia. A videoradiographic swallow study is vital in such cases to determine the extent and timing of aspiration and the severity and mechanics of dysfunction as a prelude to therapy.

Accreditation & date: Nat Clin Pract Gastroenterol Hepatol, 2008, 5(7):393-403.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18542115

 

Suiter DM, 2009 – The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia.

Summary: The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia.

Abstract:
Objectives: To investigate the clinical utility of the 3-ounce (90-cc) water swallow challenge alone to determine both aspiration status and oral feeding recommendations in children.

Design: Cross-sectional evaluation of a diagnostic test with a consecutive, referral-based sample.

Setting: Urban, tertiary care, teaching hospital.

Participants: Fifty-six children (age range 2-18 years; mean 13 years) referred for swallowing evaluations.

Outcome measures: Aspiration status during fiberoptic endoscopic evaluation of swallowing (FEES) was the objective criterion standard with which results from the 3-ounce water swallow challenge were compared.

Results: Twenty-two (39.3%) participants passed and 34 (60.7%) failed the 3-ounce challenge. Sensitivity for predicting aspiration status during FEES = 100.0 percent, specificity = 51.2 percent, and false-positive rate = 48.4 percent. Sensitivity for identifying individuals who were deemed safe for oral intake based on FEES results = 100.0 percent, specificity = 44.0 percent, and false-positive rate = 56.0 percent.

Conclusions: If the 3-ounce water swallow challenge is passed, not only thin liquids but diet recommendations with puree and solid food consistencies can be made without the need for further instrumental dysphagia assessment.

Significance: The 3-ounce water swallow challenge has been shown to be a clinically useful screening test for oropharyngeal dysphagia in children.

Accreditation & date: Otolaryngol Head Neck Surg, 2009, 140(2):187-90.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/19201286

 

Wakasugi Y, 2008 – Screening test for silent aspiration at the bedside.

Summary: Screening test for silent aspiration at the bedside.

Abstract:
Many screening tests for dysphagia can be given at bedside. However, they cannot accurately screen for silent aspiration (SA). We studied the usefulness of a cough test to screen for SA and combined it with the modified water swallowing test (MWST) to make an accurate screening system.

Patients suspected of dysphagia (N = 204) were administered a cough test and underwent videofluorography (VF) or videoendoscopy (VE). Sensitivity of the cough test for detection of SA was 0.87 with specificity of 0.89. Of these 204 patients, 107 were also administered the MWST. Fifty-five were evaluated as normal by the screening system, 49 of whom were evaluated as normal by VF or VE. Sixteen were evaluated as “SA suspected” by the screening system; seven of them were normal, and seven were evaluated as having SA by VF or VE. Nineteen were evaluated as aspirating with cough, 14 of whom had aspiration with cough as shown by VF or VE. Seventeen were evaluated as having SA, 15 of whom had SA shown by VF or VE. The cough test was useful in screening for SA. Moreover, a screening system that included MWST and a cough test could accurately distinguish between the healthy who were safe in swallowing and SA patients who were unsafe.

Accreditation & date: Dysphagia, 2008, 23(4):364-70.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18594914

Dysphagia Clinical Papers - Malnutrition & nutritional therapy

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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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Abstract:
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.

Dysphagia Clinical Papers - Texture modification/ Stages (nectar/ honey/ pudding)

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Clavé P, 2006 – The effect of bolus viscosity on swallowing function in neurogenic dysphagia.

Summary: The effect of bolus viscosity on swallowing function in neurogenic dysphagia.

Abstract:
Aim:
To assess the pathophysiology and treatment of neurogenic dysphagia. METHODS: 46 patients with brain damage, 46 with neurodegenerative diseases and eight healthy volunteers were studied by videofluoroscopy while swallowing 3-20 mL liquid (20.4 mPa s), nectar (274.4 mPa s) and pudding (3931.2 mPa s) boluses.

Results: Volunteers presented a safe and efficacious swallow, short swallow response (< or =740 ms), fast laryngeal closure (< or =160 ms) and strong bolus propulsion (> or =0.33 mJ). Brain damage patients presented: (i) 21.6% aspiration of liquids, reduced by nectar (10.5%) and pudding (5.3%) viscosity (P < 0.05) and (ii) 39.5% oropharyngeal residue. Neurodegenerative patients presented: (i) 16.2% aspiration of liquids, reduced by nectar (8.3%) and pudding (2.9%) viscosity (P < 0.05) and (ii) 44.4% oropharyngeal residue. Both group of patients presented prolonged swallow response (> or =806 ms) with a delay in laryngeal closure (> or =245 ms), and weak bolus propulsion forces (< or =0.20 mJ). Increasing viscosity did not affect timing of swallow response or bolus kinetic energy.

Conclusions: Patients with neurogenic dysphagia presented high prevalence of videofluoroscopic signs of impaired safety and efficacy of swallow, and were at high risk of respiratory and nutritional complications. Impaired safety is associated with slow oropharyngeal reconfiguration and impaired efficacy with low bolus propulsion. Increasing bolus viscosity greatly improves swallowing function in neurological patients.

Accreditation & date: Aliment Pharmacol Ther, 2006 Nov 1;24(9):1385-94.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/17059520.

 

Kuhlemeier KV, 2001 – Effect of liquid bolus consistency and delivery method on aspiration and pharyngeal retention in dysphagia patients.

Summary: Effect of liquid bolus consistency and delivery method on aspiration and pharyngeal retention in dysphagia patients.

Abstract:
There is no empirically derived consensus as to what food consistency types and method of food delivery (spoon, cup, straw) should be included in the videofluoroscopic swallowing (VFSS) studies. In the present study, we examine the rates of aspiration and pharyngeal retention in 190 dysphagic patients given thin (apple juice) and thick (apricot nectar) liquids delivered by teaspoon and cup and ultrathick (pudding-like) liquid delivered by teaspoon. Each patient was tested with each of the bolus/delivery method combinations. The fractions of patients exhibiting aspiration for each bolus/method of delivery combination were (1) thick liquids (cup), 13.2%; (2) thick liquids (spoon), 8.9%; (3) thin liquids (cup), 23.7%; (4) thin liquids (spoon), 15.8%, (5) ultrathick liquids (spoon), 5.8%. In each comparison [thick liquid (cup) vs. thick liquid (spoon), thin liquid (cup) vs. thin liquid (spoon), thick liquid (cup) vs. thin liquid (cup), thick liquid (spoon) vs. thin liquid (spoon), and thick liquid (spoon) vs. ultrathick liquid (spoon)], the p value for chi 2 was < 0.001. These results suggest that utilizing thin, thick, and ultrathick liquids and delivery by cup and spoon during a VFSS of a patient with mild or moderate dysphagia can increase the chances of identifying a consistency that the patient can swallow without aspirating and without pharyngeal retention after swallowing.

Accreditation & date: Dysphagia, 2001 Spring;16(2):119-22.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/11305221.

 

Logemann JA, 2008 – A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease.

Summary: A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease.

Abstract:
Purpose: This study was designed to identify which of 3 treatments for aspiration on thin liquids-chin-down posture, nectar-thickened liquids, or honey-thickened liquids-results in the most successful immediate elimination of aspiration on thin liquids during the videofluorographic swallow study in patients with dementia and/or Parkinson’s disease.

Method: This randomized clinical trial included 711 patients ages 50 to 95 years who aspirated on thin liquids as assessed videofluorographically. All patients received all 3 interventions in a randomly assigned order during the videofluorographic swallow study.

Results: Immediate elimination of aspiration on thin liquids occurred most often with honey-thickened liquids for patients in each diagnostic category, followed by nectar-thickened liquids and chin-down posture. Patients with most severe dementia exhibited least effectiveness on all interventions. Patient preference was best for chin-down posture followed closely by nectar-thickened liquids.

Conclusion: To identify best short-term intervention to prevent aspiration of thin liquid in patients with dementia and/or Parkinson’s disease, a videofluorographic swallow assessment is needed. Evidence-based practice requires taking patient preference into account when designing a dysphagic patient’s management plan. The longer-term impact of short-term prevention of aspiration requires further study.

Accreditation & date: J Speech Lang Hear Res, 2008 Feb;51(1):173-83.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18230864.

 

McHorney C, 2002 – The SWAL-QOL and SWAL-CARE outcomes tool for oropharyngeal dysphagia in adults: III, documentation of reliability and validity.

Summary: The SWAL-QOL and SWAL-CARE outcomes tool for oropharyngeal dysphagia in adults: III, documentation of reliability and validity.

Abstract:
Advances in the measurement of swallowing physiologic parameters have been clinician-driven, as has the development of intervention techniques to modify swallowing pathophysiology. However, a critical element to determining the success of such efforts will be established by the patients themselves. We conceptualized, developed, and validated the SWAL-QOL, a 93-item quality-of-life and quality-of-care outcomes tool for dysphagia researchers and clinicians. With 93 items, the SWAL-QOL was too long for practical and routine use in clinical research and practice. We used an array of psychometric techniques to reduce the 93-item instrument into two patient-centered outcomes tools: (1) the SWAL-QOL, a 44-item tool that assesses ten quality-of-life concepts, and (2) the SWAL-CARE, a 15-item tool that assesses quality of care and patient satisfaction. All scales exhibit excellent internal-consistency reliability and short-term reproducibility. The scales differentiate normal swallowers from patients with oropharyngeal dysphagia and are sensitive to differences in the severity of dysphagia as clinically defined. It is intended that the standardization and publication of the SWAL-QOL and the SWAL-CARE will facilitate their use in clinical research and clinical practice to better understand treatment effectiveness as a critical step toward improving patients’ quality of life and quality of care.

Accreditation & date: Dysphagia, 2002 Spring;17(2):97-114.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/11956835.

 

Mills RH, 1999 – Rheology Overview: Control of liquid viscosities in dysphagia management.

Summary: Rheology Overview: Control of liquid viscosities in dysphagia management.

Accreditation & date: Nutrition in clinical practise, 1999, 14(5): 52-56.

PubMed link: cat.inist.fr/?aModele=afficheN&cpsidt=10251705.

 

Raut VV, 2001 – Effect of bolus consistency on swallowing – does altering consistency help?

Summary: Effect of bolus consistency on swallowing – does altering consistency help?

Abstract: 
The influence of food bolus consistency on the pharyngeal wave during swallowing was investigated using a four-sensor manometry probe in 22 healthy volunteers. Pharyngeal pressures were recorded for 5 ml boluses of water, pudding and buttered bread via a manometry probe placed transnasally. The distal sensor was sited within the upper oesophageal sphincter (UOS); the three proximal sensors were then located 2, 4 and 6 cm above the UOS. The amplitude and timing of the swallow waveforms for pudding and buttered bread were recorded and compared with those for water. Increased bolus viscosity led to increased amplitude of the bolus wave and clearing contraction within the pharynx. In the UOS, increased bolus viscosity was associated with a larger pressure nadir (sub-atmospheric pressure) on opening and intra bolus pressure during transit. Bolus consistency also influenced the coordination of the swallow response with delayed pharyngeal clearance. The putative relevance of these findings to dietary modification for patients with neurological and neuromuscular dysphagia is discussed.

Accreditation & date: Eur Arch Otorhinolaryngol, 2001 Jan;258(1):49-53.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/11271436.

 

Troche MS, 2008 – Effects of bolus consistency on timing and safety of swallow in patients with Parkinson’s disease.

Summary: Effects of bolus consistency on timing and safety of swallow in patients with Parkinson’s disease.

Abstract:
Aspiration pneumonia is the leading cause of death in Parkinson’s disease (PD) patients. In clinical practice, the videofluoroscopic examination (VFE) is the most common method for evaluation of swallowing disorders. One of the variables manipulated during the VFE is consistency of the bolus. The results of this examination greatly influence the recommendations made by speech-language pathologists regarding swallow therapy and/or intervention. The primary aim of this study was to investigate the effects of bolus consistency on penetration-aspiration (P-A) score and timing of swallow of persons with PD. The videoradiographic images of ten participants with PD swallowing six thin and six pudding-thick boluses were analyzed. Swallow timing and P-A were measured. (i.e., oral transit time, pharyngeal transit time, number of tongue pumps, and P-A score). The results demonstrated various significant differences and relationships among the dependent variables. Implications for further research and clinical practice are discussed.

Accreditation & date: Dysphagia, 2008 Mar;23(1):26-32. Epub 2007 Jun 6.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/17551793.

 

Robbins J, 2008 – Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial.

Summary: Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial.

Abstract:
Background:
Aspiration pneumonia is common among frail elderly persons with dysphagia. Although interventions to prevent aspiration are routinely used in these patients, little is known about the effectiveness of those interventions.

Objective: To compare the effectiveness of chin-down posture and 2 consistencies (nectar or honey) of thickened liquids on the 3-month cumulative incidence of pneumonia in patients with dementia or Parkinson disease.

Design: Randomized, controlled, parallel-design trial in which patients were enrolled for 3-month periods from 9 June 1998 to 19 September 2005.

Setting: 47 hospitals and 79 subacute care facilities. PATIENTS: 515 patients age 50 years or older with dementia or Parkinson disease who aspirated thin liquids (demonstrated videofluoroscopically). Of these, 504 were followed until death or for 3 months.

Intervention: Participants were randomly assigned to drink all liquids in a chin-down posture (n = 259) or to drink nectar-thick (n = 133) or honey-thick (n = 123) liquids in a head-neutral position.

Measurements: The primary outcome was pneumonia diagnosed by chest radiography or by the presence of 3 respiratory indicators.

Results: 52 participants had pneumonia, yielding an overall estimated 3-month cumulative incidence of 11%. The 3-month cumulative incidence of pneumonia was 0.098 and 0.116 in the chin-down posture and thickened-liquid groups, respectively (hazard ratio, 0.84 [95% CI, 0.49 to 1.45]; P = 0.53). The 3-month cumulative incidence of pneumonia was 0.084 in the nectar-thick liquid group compared with 0.150 in the honey-thick liquid group (hazard ratio, 0.50 [CI, 0.23 to 1.09]; P = 0.083). More patients assigned to thickened liquids than those assigned to the chin-down posture intervention had dehydration (6% vs. 2%), urinary tract infection (6% vs. 3%), and fever (4% vs. 2%). LIMITATIONS: A no-treatment control group was not included. Follow-up was limited to 3 months. Care providers were not blinded, and differences in cumulative pneumonia incidence between interventions had wide CIs.

Conclusions: No definitive conclusions about the superiority of any of the tested interventions can be made. The 3-month cumulative incidence of pneumonia was much lower than expected in this frail elderly population. Future investigation of chin-down posture combined with nectar-thick liquid may be warranted to determine whether this combination better prevents pneumonia than either intervention independently.

Accreditation & date: Ann Intern Med, 2008 Apr 1;148(7):509-18.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18378947.

Dysphagia Clinical Papers - Practice patterns

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Castellanos VH, 2004 – Use of thickened liquids in skilled nursing facilities.

Summary: Use of thickened liquids in skilled nursing facilities.

Abstract:
Objective:
Long-term care residents are routinely provided with thickened liquids for the management of dysphagia. The objective of this study was to identify the prevalence of thickened liquid use in skilled nursing facilities

Design: Facility-wide data were provided by staff at 252 randomly selected skilled nursing facilities owned by 11 multifacility providers. The sample represented 25,470 residents and approximately 20% of all freestanding skilled nursing facilities nationwide.

Main outcome measures: Data regarding prevalence of thickened liquid use and facility characteristics were collected during May 2002. Statistical analysis Descriptive statistics included national and regional averages and national percentile distributions.

Results: A mean of 8.3% (range 0% to 28%) of residents were receiving thickened liquids, with considerable variation between Centers for Medicare and Medicaid Services regions. Of those receiving thickened liquids, on average 60% received “nectar/syrup” thick, 33% received “honey” thick, and 6% received “pudding/spoon” thick, although the frequencies with which each thickness was prescribed varied widely between facilities (range 0% to 100%). Thickened water was provided to residents in 91.6% of facilities. Nationally, registered dietitian staffing levels were lower on average than speech language pathologist staffing levels.

Conclusions: Thickened liquids are provided to a significant segment of the skilled nursing facility resident population. In the absence of outcomes-based practice standards to guide administrative decisions related to the provision of thickened liquids, dietetics professionals may find regional and national norms helpful for quality assurance processes and to inform resource management decisions in clinical staffing and foodservice.

Accreditation & date: J Am Diet Assoc, 2004 Aug;104(8):1222-6.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/1528103.

 

Garcia JM, 2005 – Thickened liquids: practice patterns of speech-language pathologists.

Summary: Thickened liquids: practice patterns of speech-language pathologists.

Abstract:
This study surveyed the practice patterns of speech-language pathologists in their use of thickened liquids for patients with swallowing difficulties.

A 25-item Internet survey about thickened liquids was posted via an e-mail list to members of the American Speech-Language-Hearing Association Division 13, Swallowing and Swallowing Disorders (Dysphagia). Responses of 145 professionals who primarily manage adult dysphagia are reported. Although the majority affirmed that thickening thin liquids was an effective intervention strategy, opinions about effectiveness were more favorable for nectar-thick versus honey-like and spoon-thick consistencies. Respondents also acknowledged that their patients had little liking for thickened liquids. Results highlight issues related to products and staff training, as well as perceptions concerning the factors that might affect patients’ acceptance of and compliance with use of the products.

Accreditation & date: Am J Speech Lang Pathol, 2005 Feb;14(1):4-13.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/15962843.

 

Logemann JM, 2008 – What information do clinicians use in recommending oral versus nonoral feeding in oropharyngeal dysphagic patients?

Summary: What information do clinicians use in recommending oral versus nonoral feeding in oropharyngeal dysphagic patients?

Abstract:
There is little evidence regarding the type(s) of information clinicians use to make the recommendation for oral or nonoral feeding in patients with oropharyngeal dysphagia.

This study represents a first step toward identifying data used by clinicians to make this recommendation and how clinical experience may affect the recommendation. Thirteen variables were considered critical in making the oral vs. nonoral decision by the 23 clinicians working in dysphagia. These variables were then used by the clinicians to independently recommend oral vs. nonoral feeding or partial oral with nonoral feeding for the 20 anonymous patients whose modified barium swallows were sent on a videotape to each clinician. Clinicians also received data on the 13 variables for each patient. Results of clinician agreement on the recommendation of full oral and nonoral only were quite high, as measured by Kappa statistics. In an analysis of which of the 13 criteria clinicians used in making their recommendations, amount of aspiration was the criterion with the highest frequency. Recommendations for use of postures and maneuvers and the effect of clinician experience on these choices were also analyzed.

Accreditation & date: Dysphagia, 2008 Dec;23(4):378-84.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18670808.

 

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.

Abstract:
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.

Dysphagia Clinical Papers - Tube feeding

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Crary MA, 2006 – Reinstituting oral feeding in tube-fed adult patients with dysphagia.

Summary: Reinstituting oral feeding in tube-fed adult patients with dysphagia.

Abstract:
Feeding tubes are valuable assets in the rehabilitation of adult patients with dysphagia. Feeding tubes may be placed in response to perceived risks of airway compromise or insufficient nutrient intake. However, not all patients require long-term enteral feeding.

With intensive dysphagia therapy, many patients will experience resolving deficits or improvement in swallowing ability. These patients require an appropriate strategy to transition from tube to oral feeding. This article reviews some of the basic characteristics of dysphagia and identifies specific swallowing difficulties in 2 groups of patients who often benefit from temporary enteral feeding: stroke survivors and patients treated for head and neck cancer. Specific suggestions are offered for clinical strategies to reinstitute oral feeding in these groups of tube-fed patients. 

Accreditation & date: Nutr Clin Pract, 2006 Dec;21(6):576-86.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/17119164.

 

Dziewas R, 2008 – Do nasogastric tubes worsen dysphagia in patients with acute stroke?

Summary: Do nasogastric tubes worsen dysphagia in patients with acute stroke?

Abstract:
Background:
Early feeding via a nasogastric tube (NGT) is recommended as safe way of supplying nutrition in patients with acute dysphagic stroke. However, preliminary evidence suggests that NGTs themselves may interfere with swallowing physiology. In the present study we therefore investigated the impact of NGTs on swallowing function in acute stroke patients.

Methods: In the first part of the study the incidence and consequences of pharyngeal misplacement of NGTs were examined in 100 stroke patients by fiberoptic endoscopic evaluation of swallowing (FEES). In the second part, the effect of correctly placed NGTs on swallowing function was evaluated by serially examining 25 individual patients with and without a NGT in place.

Results: A correctly placed NGT did not cause a worsening of stroke-related dysphagia. Except for two cases, in which swallowing material got stuck to the NGT and penetrated into the laryngeal vestibule after the swallow, no changes of the amount of penetration and aspiration were noted with the NGT in place as compared to the no-tube condition. Pharyngeal misplacement of the NGT was identified in 5 of 100 patients. All these patients showed worsening of dysphagia caused by the malpositioned NGT with an increase of pre-, intra-, and postdeglutitive penetration.

Conclusions: Based on these findings, there are no principle obstacles to start limited and supervised oral feeding in stroke patients with a NGT in place.

Accreditation & date: BMC Neurol, 2008 Jul 23;8:28.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/18651972.

 

Dennis M, 2006 – FOOD: a multicentre randomised trial evaluating feeding policies in patients admitted to hospital with a recent stroke.

Summary:
Food:
a multicentre randomised trial evaluating feeding policies in patients admitted to hospital with a recent stroke.

Abstract:
Objectives
: To determine whether routine oral nutritional supplementation of a normal hospital diet improves outcome after stroke (Trial 1); whether early tube feeding improves the outcomes of dysphagic stroke patients (Trial 2); and if tube feeding via a percutaneous endoscopic gastrostomy (PEG) results in better outcomes than that via a nasogastric tube (NG) (Trial 3).

Design: The Feed Or Ordinary Diet (FOOD) trial was a family of three pragmatic, randomised controlled trials (RCTs). They shared facilities for randomisation, data collection, follow-up and coordination. Patients could be co-enrolled in more than one of these trials.

Setting: Patients were enrolled in 131 hospitals in 18 countries.

Participants: A total of 5033 patients who had been admitted to hospital with a recent stroke were enrolled in the trials between November 1996 and July 2003.

Interventions: In Trial 1, patients who could swallow within the first 30 days of admission were allocated to normal hospital diet versus normal hospital diet plus oral nutritional supplements (equivalent to 360 ml of 1.5 kcal/ml, 20 g of protein per day) until hospital discharge. In Trial 2, dysphagic patients enrolled within 7 days of admission were allocated to early enteral tube feeding versus avoid any enteral tube feeding for at least 1 week. In Trial 3, dysphagic patients were allocated within 30 days of admission to receive enteral tube feeding via PEG versus NG.

Main outcome measures: Survival and the modified Rankin scale (MRS), a measure of functional outcome (grade 0 indicating no symptoms and grade 5 indicating severe disability, requiring help day and night). The primary outcomes were measured 6 months after enrollment, blind to treatment allocation, by the patient or their proxy completing a postal or telephone questionnaire.

Results: In Trial 1, 4023 patients were enrolled by 125 hospitals in 15 countries. Only 314 (7.8%) patients were judged undernourished at baseline. Vital status and MRS at the end of the trial were known for 4012 (99.7%) and 4004 (99.5%), respectively. Of the 2007 allocated normal hospital diet, 253 (12.6%) died, 918 (45.7%) were alive with poor outcome (MRS 3-5) and 823 (41.1%) had a good outcome (MRS 0-2). Of the 2016 allocated oral supplements, 241 (12.0%) died, 953 (47.3%) were alive with poor outcome and 813 (40.4%) had a good outcome. The supplemented diet was associated with an absolute reduction in risk of death of 0.7% (95% CI -1.4 to 2.7; p = 0.5) and a 0.7% (95% CI -2.3 to 3.8, p = 0.6) increased risk of death or poor outcome. In Trial 2, a total of 859 patients were enrolled by 83 hospitals in 15 countries. MRS at the end of the trial was known for 858 (99.9%). At follow-up, of 429 allocated early tube feeding, 182 (42.4%) died, 157 (36.6%) were alive with poor outcome (MRS 4-5) and 90 (21.0%) had a good outcome (MRS 0-3). Of 430 allocated avoid tube feeding 207 (48.1%) died, 137 (31.9%) were alive with poor outcome and 85 (19.8%) had a good outcome. Early tube feeding was associated with an absolute reduction in risk of death of 5.8% (95% CI -0.8 to 12.5; p = 0.09) and a reduction in death or poor outcome of 1.2% (95% CI -4.2 to 6.6; p = 0.7). In Trial 3, 321 patients were enrolled by 47 hospitals in 11 countries. Of 162 allocated PEG, 79 (48.8%) died, 65 (40.1%) were alive with poor outcome and 18 (11.1%) had good outcome. Of 159 allocated NG, 76 (47.8%) died, 53 (33.3%) were alive with poor outcome and 30 (18.9%) had good outcome. PEG was associated with an increase in absolute risk of death of 1.0% (95% CI -10.0 to 11.9; p = 0.9) and an increased risk of death or poor outcome of 7.8% (95% CI 0.0 to 15.5; p = 0.05).

Conclusions: The results of Trial 1 would be compatible with oral supplementation being associated with a 1-2% absolute benefit or harm, but do not support routine supplementation of hospital diet for unselected stroke patients who are predominantly well nourished on admission. In Trial 2, the data suggest that a policy of early tube feeding may substantially reduce the risk of dying after stroke and it is very unlikely that the alternative policy of avoiding early tube feeding would significantly improve survival. Improved survival may be at the expense of increasing the proportion surviving with poor outcome. These data might usefully inform the difficult discussions about whether or not to feed a patient with a severe stroke. In Trial 3, the data suggest that in the first 2-3 weeks after acute stroke, better functional outcomes result from feeding via NG tube than PEG tube, although there was no major difference in survival. These data do not support a policy of early initiation of PEG feeding in dysphagic stroke patients. Future research might be focused on making NG tube feeding safer and more effective, also studies need to confirm the increased risk of gastrointestinal haemorrhage associated with tube feeding and, if confirmed, establish whether any interventions might reduce this risk. Future work might also aim to establish why worse functional outcomes occurred in PEG-fed patients because patients with prolonged dysphagia or intolerance of an NG tube are inevitably fed via a PEG tube.

Accreditation & date: Health Technol Assess, 2006 Jan;10(2):iii-iv, ix-x, 1-120.

 

PubMed link: www.ncbi.nlm.nih.gov/pubmed/16409880.

Dysphagia Clinical Papers - Miscellaneous

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McCormick SE, 2008 – The efficacy of pre-thickened fluids on total fluid and nutrient consumption among extended care residents requiring thickened fluids due to risk of aspiration.

Summary: The efficacy of pre-thickened fluids on total fluid and nutrient consumption among extended care residents requiring thickened fluids due to risk of aspiration.

Accreditation & date: Age Ageing, 2008 Nov;37(6):714-5.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/19004963.

 

Nguyen NP, 2005 – Impact of dysphagia on quality of life after treatment of head-and-neck cancer.

Summary: Impact of dysphagia on quality of life after treatment of head-and-neck cancer.

Abstract:
Purpose: To evaluate the quality of life (QOL) associated with dysphagia after head-and-neck cancer treatment.

Methods and materials: Of a total population of 104, a retrospective analysis of 73 patients who complained of dysphagia after primary radiotherapy (RT), chemoradiotherapy, and postoperative RT for head-and-neck malignancies were evaluated. All patients underwent a modified barium swallow examination to assess the severity of dysphagia, graded on a scale of 1-7. QOL was evaluated by the University of Washington (UW) and Hospital Anxiety and Depression questionnaires. The QOL scores obtained were compared with those from the 31 patients who were free of dysphagia after treatment. The QOL scores were also graded according to the dysphagia severity.

Results: The UW and Hospital Anxiety and Depression scores were reduced and elevated, respectively, in the dysphagia group compared with the no dysphagia group (p = 0.0005). The UW scores were also substantially lower among patients with moderate-to-severe (Grade 4-7) compared with no or mild (Grade 2-3) dysphagia (p = 0.0005). The corresponding Hospital Anxiety (p = 0.005) and Depression (p = 0.0001) scores were also greater for the moderate-to-severe group. The UW QOL subscale scores showed a statistically significant decrease for swallowing (p = 0.00005), speech (p = 0.0005), recreation/entertainment (p = 0.0005), disfigurement (p = 0.0006), activity (p = 0.005), eating (p = 0.002), shoulder disability (p = 0.006), and pain (p = 0.004).

Conclusions: Dysphagia is a significant morbidity of head-and-neck cancer treatment, and the severity of dysphagia correlated with a compromised QOL, anxiety, and depression. Patients with moderate-to-severe dysphagia require a team approach involving nutritional support, physical therapy, speech rehabilitation, pain management, and psychological counseling.

Accreditation & date: Int J Radait Oncol Biol Phys, 2005 Mar 1;61(3):772-8.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/15708256.

 

Smithard DC, 1996 – Complications and outcome after acute stroke. Does dysphagia matter?

Summary: Complications and outcome after acute stroke. Does dysphagia matter?

Abstract:
Background and purpose:
The published data on the relationship between dysphagia and both outcome and complications after acute stroke have been inconclusive. We examined the relationship between these, using bedside assessment and videofluoroscopic examination.

Methods: We prospectively studied 121 consecutive patients admitted with acute stroke. A standardized bedside assessment was performed by a physician. We performed videofluoroscopy blinded to this assessment within 3 days of stroke onset and within a median time of 24 hours of the bedside evaluations. The presence of aspiration was recorded. Mortality, functional outcome, lengthy of stay, place of discharge, occurrence of chest infection, nutritional status, and hydration were the main outcome measures.

Results: Patients with an abnormal swallow (dysphagia) on bedside assessment had a higher risk of chest infection (P=.05) and a poor nutritional state (P=.001). The presence of dysphagia was associated with an increased risk of death (P=.001), disability (P=.02), length of hospital stay (P < .001), and institutional care (P < .05). When other factors were taken into account, dysphagia remained as an independent predictor of outcome only with regard to mortality. The use of videofluoroscopy in detecting aspiration did not add to the value of bedside assessment.

Conclusions: Bedside assessment of swallowing is of use in identifying patients at risk of developing complications. The value of routine screening with videofluoroscopy to detect aspiration is questioned.

Accreditation & date: Stroke, 1996 Jul;27(7):1200-4.

PubMed link: www.ncbi.nlm.nih.gov/pubmed/8685928.

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