Second update of a systematic review and evidence-based recommendations on texture modified foods and thickened liquids for adults (above 17 years) with oropharyngeal dysphagia.

BACKGROUND & AIMS: It is well known that oropharyngeal dysphagia (OD) challenges eating, drinking, and swallowing by penetration to the airway. In clinical practice, thickening agents in liquid and texture modified diets are used to reduce pneumonia and secure nutritional status. The scientific evidence on this OD management is, however, limited. In 2016 we updated an original clinical guideline on OD in adults. Based on the strength of the evidence of two randomized control trials (RCTs), we provided a weak clinical recommendation against the use of thickening agents for liquid and none for diet. In the hope of finding new scientific evidence, we aimed to update the clinical guideline by examining the evidence if thickening of liquid and diet 1) improve survival and quality of life, 2) reduce the occurrence of aspiration risk and pneumonia, 3) improve dehydration, nutritional status, and mealtime performance, and 4) relate to patient preferences and intervention adherence. METHODS: We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. We first searched systematic reviews and meta-analyses, and secondly, the primary literature of RCTs. We undertook the search in PubMed, Embase, CINAHL, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from January 1, 2015, to May 19, 2021. The quality of the evidence was evaluated using the revised Cochrane risk-of-bias tool and the GRADE (Grading of Recommendations: Assessment, Development and Evaluation) approach. RESULTS: One new study was included, resulting in a total of three RCTs, of which two were already included in our former guideline. The three studies focused on the thickening of liquid, but no change of the former weak recommendation against the thickening of liquid could be made due to the quality of evidence evaluation. CONCLUSION: There is no convincing evidence that thickened liquid or texture modified diet prevents death or pneumonia nor improves the quality of life, nutritional status, or oral intake in individuals with OD. There is a need for future studies to examine the effect and discuss outcome measures in OD management with thickening agents.

Item analysis of the Eating Assessment Tool (EAT-10) by the Rasch model: a secondary analysis of cross-sectional survey data obtained among community-dwelling elders.

BACKGROUND: The Eating Assessment Tool (EAT-10) is increasingly used to screen for self-perceived oropharyngeal dysphagia (OD) in community-dwelling elders. A summated EAT-10 total score ranges from 0 to 40, with a score ≥ 3 indicative of OD. When using cut-points of a summated score, important requirements for the measurements are specific objectivity, validity, and reliability. Analysis by the Rasch model allows investigation of whether scales like EAT-10 satisfy these requirements. Currently, a few studies have found that EAT-10 responses from clinical populations with OD do not adequately fit the Rasch model. PURPOSE: The aim of this study was to determine whether measurements by EAT-10 fit the Rasch model when applied in screening self-perceived OD in non-clinical populations. METHODS: Secondary analysis was conducted on data from a cross-sectional survey of community-dwelling elders living in a municipal district of Tokyo, Japan, in which 1875 respondents completed the Japanese version of EAT-10 (J-EAT-10). Data were cleaned and recoded for the purpose of the analysis in this study, which resulted in inclusion of J-EAT-10 responses from 1144 respondents. Data were analyzed using RUMM2030 and included overall model fit, reliability, unidimensionality, threshold ordering, individual item and person fits, differential item functioning, local item dependency, and targeting. RESULTS: The analysis identified that the response categories from zero to four were not used as intended and did not display monotonicity, which necessitated reducing the five categories to three. Considerable floor effect was demonstrated and there was an inappropriate match between items' and respondents' estimates. The person separation reliability (PSI = 0.65) was inadequate, indicating that it is not possible to differentiate between different levels of OD. Several items displayed misfit with the Rasch model, and there were local item dependency and several redundant items. CONCLUSIONS: J-EAT-10 performed less than optimally and exhibited substantial floor effect, low reliability, a rating scale not working as intended, and several redundant items. Different improvement strategies failed to resolve the identified problems. Use of J-EAT-10 in population-based surveys cannot therefore be recommended. For such purpose, alternative screening tools of self-perceived OD should be chosen or a new one should be developed and validated.

First-Hand Experience of Severe Dysphagia Following Brainstem Stroke: Two Qualitative Cases.

BACKGROUND: Dysphagia has profound effects on individuals, and living with dysphagia is a complex phenomenon that touches essential areas of life. Dysphagia following a brainstem stroke is often more severe and the chances of spontaneous recovery are less likely as compared with dysphagia following a hemispheric stroke. OBJECTIVE: To explore how two individuals with brainstem stroke experienced severe dysphagia during their inpatient neurorehabilitation and how they experienced their recovery approximately one month following discharge. METHODS: An explorative study was conducted to evaluate the first-hand perspective on severe eating difficulties. A qualitative case study was chosen to collect data during two face-to-face semi-structured interviews. Phenomenological perspectives shaped the interview-process and the processing of data. RESULTS: Analysis of the empirical data generated the following main themes regarding experiences of: (i) the mouth and throat; (ii) shared dining; and (iii) recovery and regression related to swallowing-eating-drinking. CONCLUSION: Participants expressed altered sensations of the mouth and throat, which affected their oral intake and social participation in meals. Good support for managing and adapting their problems of swallowing, eating, and drinking in daily activities is essential. Knowledge and skills of professionals in relation to dysphagia is a significant requirement for recovery progress in settings within the municipality.

Systematic review and evidence based recommendations on texture modified foods and thickened liquids for adults (above 17 years) with oropharyngeal dysphagia - An updated clinical guideline.

BACKGROUND & AIMS: Oropharyngeal dysphagia (OD) has significant consequences for both the person with dysphagia and the society. An often-used treatment for OD is the recommendation of the texture of food and liquids. This recommendation seems to be based more on best practice than on evidence from a systematic review of existing scientific evidence. The aim of this paper was to report the result of an up-date of an original national guideline focussing on whether thickened liquids (review question 1) and modified foods (review question 2) are beneficial for adults above 17 years with OD in relation to three critical outcomes (aspiration, pneumonia and death) and seven important outcomes (dehydration, weight loss, mealtime performance, patient preferences, intervention adherence and quality of life). METHODS: Three steps were used. First: An updated systematic literature search. Second: An assessment of the quality of the evidence for each review question by means of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Third: Development of clinical recommendations based on the evidence, assessment of the risk benefit ratio, and perceived patient preferences. RESULTS: The body of evidence consisted of two RCTs for review question 1 both using nectar thickened liquids or honey-thickened liquids. No evidence was found for two important outcomes, mealtime performance and quality of life. With regard to risk of pneumonia, death, aspiration, dehydration, weight loss and intervention adherence no significant differences were found. The outcome addressing patient preferences, found a non-significant increased dissatisfaction with nectar thickened liquids (RR 1.11; 95% CI 0.95-1.30) and a significant increased dissatisfaction with honey thickened liquids compared to thin liquids/chin down (RR 1.18; 95% CI 1.01-1.37). No evidence was identified for review question 2. CONCLUSIONS: Based on the quality of the evidence, assessment of the risk benefit ratio, and perceived patient preferences a weak recommendation against the use of texture modified liquids and good clinical practice pointing for the use of texture modified foods in patients with OD were made.

Brain Injury and Severe Eating Difficulties at Admission-Patient Perspective Nine to Fifteen Months after Discharge: A Pilot Study.

The purpose of this pilot study was to explore and interpret the way that individuals with acquired brain injury, admitted to inpatient neurorehabilitation with severe eating difficulties, experienced eating nine to fifteen months after discharge. Four individuals with acquired brain injury were interviewed via qualitative semi-structured interviews. An explorative study was conducted to study eating difficulties. Qualitative content analysis was used. Four main themes emerged from the analysis: personal values related to eating, swallowing difficulties, eating and drinking, meals and social life. Three predominating experiences were: fed by tube, "relearning" to eat, and eating meals together. The preliminary results regarding the four participants suggest that the meaning of food and being able to eat and take part in meals may be nearly the same as before the injury; however, having the ability to eat reduced or lost completely, even temporarily, was unexpected and difficult, and caused strong emotional reactions, even 18 months after injury. Time spent using a feeding tube had a negative, but not persistent, impact on quality-of-life. The preliminary findings provide knowledge regarding the patient perspective of adapting to and developing new strategies for activities related to eating, however, further prospective, longitudinal research in a larger scale and with repeated interviews is needed.

A validation study of the Facial-Oral Tract Therapy Swallowing Assessment of Saliva.

OBJECTIVE: To investigate the validity and reliability of the Swallowing Assessment of Saliva in detection of aspiration risk. DESIGN: Validation study. SETTING: Inpatient neurorehabilitation centre. SUBJECTS: Adult patients with acquired brain injury. A total of 43 patients for concurrent validity and 33 other patients for inter-rater reliability. INTERVENTIONS: Concurrent validity was established with blinded Swallowing Assessment of Saliva and endoscopic evaluation within a 24-hour time interval. Inter-rater reliability was established with two blinded Swallowing Assessments of Saliva within a one-hour time interval. MAIN MEASURES: The Swallowing Assessment of Saliva is a seven-item scale with a combination of swallowing and non-swallowing items. It is based on the Facial-Oral Tract Therapy approach. RESULTS: The Swallowing Assessment of Saliva had a sensitivity of 91%, 95% confidence interval (CI) (59; 100), a specificity of 88% %, 95% CI (71; 97) and a kappa coefficient of 0.87 ±0.17 in detection of aspiration risk. Furthermore, analyses showed that experienced and inexperienced occupational therapists performed equally in detection of aspiration risk. CONCLUSION: The Swallowing Assessment of Saliva is a simple, sensitive and reliable assessment for detecting aspiration risk in patients with acquired brain injury.

Factors affecting return to oral intake in inpatient rehabilitation after acquired brain injury.

PRIMARY OBJECTIVE: To extend previous observations by investigating if differences exist in time to initiation or to recovery of total oral intake in patients with acquired brain injury assessed by either Facial-Oral Tract Therapy (F.O.T.T.) or Fibreoptic Endoscopic Evaluation of Swallowing (FEES) and to investigate whether other factors influence these outcomes. RESEARCH DESIGN: Randomized controlled trial. METHODS: One hundred and nineteen patients with dysphagia in inpatient neurorehabilitation were randomized. The main outcome was time to maximum on the Functional Oral Intake Scale. RESULTS: There was no difference in time to initiation or recovery of total oral intake using F.O.T.T. or FEES. Oral intake was initiated for 42% on admission and 92% at discharge; 2.5% of the patients were on total oral intake within 24 hours of admission and 37% at discharge. The likelihood of recovery to total oral intake before discharge was found to depend on age, Functional Independence Measure score, length of stay and number of dysphagia interventions. CONCLUSION: There was no significant difference in time to initiation and recovery of total oral intake before discharge, whether assessed by F.O.T.T. or FEES, indicating that an instrumental assessment is unnecessary for standard evaluation. Age, functional independence and length of stay had a significant influence.

[Neurogenic oropharyngeal dysphagia is a frequent condition in patients admitted to the ICU]. / Neurogen dysfagi ses hyppigt hos patienter på intensivafdelinger.

Neurogenic oropharyngeal dysphagia (NOD) is a frequent condition in neurological patients admitted to the ICU, particularly in patients with brainstem lesions. The CNS damage itself can predispose to dysphagia, but also the treatment and preventive measures may predispose to and exacerbate the condition. Frequent pneumonia in a neurological patient is a warning signal that should cause screening for dysphagia. Complications are serious and can be fatal. Neurological patients should be examined for NOD before decannulation. Treatment is difficult, so prevention and multidisciplinary neurological rehabilitation is important.

Randomized trial of two swallowing assessment approaches in patients with acquired brain injury: Facial-Oral Tract Therapy versus Fibreoptic Endoscopic Evaluation of Swallowing.

OBJECTIVE: To examine whether patients assessed for initiation of oral intake only by Facial-Oral Tract Therapy had a greater risk of developing aspiration pneumonia during neurorehabilitation than patients assessed by Fibreoptic Endoscopic Evaluation of Swallowing. DESIGN: Randomized controlled trial. SETTING: Specialized, national neurorehabilitation centre. SUBJECTS: Adult patients with acquired brain injury. Six hundred and seventy-nine patients were assessed for eligibility and 138 were randomly allocated between June 2009 and April 2011. INTERVENTIONS: Assessment by Facial-Oral Tract Therapy (control group) or Fibreoptic Endoscopic Evaluation of Swallowing (intervention group). MAIN MEASURE: Primary outcome was the number of aspiration pneumonias that developed after initiation of oral intake. RESULTS: One hundred and nineteen patients were included in the analysis of the primary outcome (62 controls/57 interventions). Sixteen patients were clinically diagnosed with pneumonia (4 controls/12 interventions). Nine patients had to be excluded: 6 patients got pneumonia before initiating oral intake; 3 patients with the clinical diagnosis of pneumonia did not show radiological signs. Seven patients were left for analysis, 4 of whom developed aspiration pneumonia within 10 days after initiating oral intake (1 control/3 interventions). CONCLUSION: In the presence of a structured clinical assessment with the Facial-Oral Tract Therapy approach, it is unnecessary to undertake an instrumental investigation of swallowing before initiation of oral intake.

Measuring elderly dysphagic patients' performance in eating--a review.

PURPOSE: This review aims to identify psychometrically robust assessment tools suitable for measuring elderly dysphagic patients' performance in eating for use in clinical practice and research. METHOD: Electronic databases, related citations and references were searched to identify assessment tools integrating the complexity of the eating process. Papers were selected according to criteria defined a priori. Data were extracted regarding characteristics of the assessment tools and the evidence of reliability, validity and responsiveness. Quality appraisal was undertaken using developed criteria concerning the study design, the statistics used for the psychometric evaluation and the reported values. RESULTS: Eight of fourteen identified assessment tools met the inclusion criteria. Three assessment tools were specific to dementia, two were specific to stroke and three targeted a range of neurological and geriatric conditions. The rigor of the assessment tools' psychometric properties varied from no evidence available to excellent evidence. Only two assessment tools were rated adequate to excellent. CONCLUSION: 'The Minimal Eating Observation Form-Version II' to be used for screening and 'The McGill Ingestive Skills Assessment' to be used for treatment planning and monitoring appeared to be psychometrically robust for clinical practice and research. However, further research on their psychometric properties is needed.

[Dysphagia--an overlooked problem in neurorehabilitation]. / Dysfagi--et overset problem i neurorehabiliteringen.

INTRODUCTION: The purpose of this study was to evaluate the management of dysphagia in patients with traumatic brain injury (TBI) and adjoining disorders during multidisciplinary neurorehabilitation in phase I and II in Denmark and abroad. MATERIALS AND METHODS: The study was conducted as structured interviews at six outstanding international neurorehabilitation institutions and as a national questionnaire survey including five phase I neurointensive wards and two phase II neurorehabilitation institutions. RESULTS: Data from the study visits showed that the international clinics received patients with cuffed tracheostomy tubes, had 24-hour medical support, and semiintensive monitoring. Patients were treated by multidisciplinary teams and all were clinically and instrumentally examined for dysphagia. Data from the Danish questionnaire survey showed that the two neurorehabilitation institutions did not receive patients with cuffed tracheostomy tubes. Both institutions had 24-hour medical support, multidisciplinary teams and monitoring of saturation. Clinical and instrumental examinations of dysphagia were not systematic procedures in either phase I or II. CONCLUSION: The study demonstrates the need for clinical guidelines on the examination and treatment of dysphagia in patients with TBI and adjoining disorders within neurorehabilitation in phase I and II in Denmark. There is also a need to clarify the management of dysphagia in patients with cuffed tracheostomy tubes.