A Review of Factors Contributing to Adults' Adherence to Dysphagia Dietary Recommendations Through an Ecological Lens.

PURPOSE: The purpose of this review was to identify the factors affecting adherence to dysphagia dietary recommendations, a necessary contributor to the effectiveness of this compensatory strategy. METHOD: A rapid review of two electronic databases was conducted in April 2021. Studies were included based on the following criteria: (a) were empirical studies published in English, (b) included data from the adult population, and (c) measured adherence to dietary recommendations. The ecological model and the health belief model were used as frameworks during the analysis process. RESULTS: The literature search resulted in 930 unique abstracts, of which 14 articles were included based on the final criteria. Across the literature, multiple factors were identified as having an influence on adherence, classified according to three unique levels: the individual (e.g., dissatisfaction), the caregiver (e.g., knowledge), and the environment (e.g., institutional policies and values). CONCLUSIONS: Improving adherence to dysphagia dietary recommendations is crucial for the effectiveness of those recommendations. As suggested by the current review, increased adherence will require careful attention to the multiple levels of factors that likely play a role, acknowledging the multifaceted nature of this complex behavior. Furthermore, characterizing the multilevel factors that influence adherence can contribute to future theoretical models, which could help guide speech-language pathologists in their clinical practices.

A Biopsychosocial Model of Mealtime Management in Persons with Dementia, an Asset-Based Approach to Patient-Centered Care.

Considering the rapid increase in the population over the age of 65, there is increasing need to consider models of care for persons with dementia (PWD). One common deficit associated with dementia progression is difficulty with successful participation in mealtimes. Difficulty participating in mealtimes in PWD is not the result of one factor, but rather a confluence of biological, psychological, and social characteristics common in dementia. Factors leading to mealtime difficulties for PWD may include changes in cognitive status, altered sensorimotor functioning, and increased reliance on caregiver support. The complex nature of biological, psychological, and social factors leading to mealtime difficulty highlights the need for a pragmatic model that caregivers can utilize to successfully support PWD during mealtimes. Existing models of dementia and mealtime management were reviewed and collated to create a model of mealtime management that considers this complex interplay. The Biopsychosocial Model of Mealtime Management builds on past research around patient-centered care and introduces an asset-based approach to capitalize on a PWD's retained capabilities as opposed to compensating for disabilities associated with dementia. We hope this model will provide a framework for caregivers to understand what factors impact mealtime participation in PWD and provide appropriate means on intervention.

Understanding the Independent Predictors of Dysphagia-Related Quality of Life in Stroke Survivors.

PURPOSE: It is important to pinpoint modifiable factors contributing to reduced dysphagia-related quality of life (QoL) in order to improve treatment outcomes and patient health given that a large proportion of stroke survivors experience dysphagia. The purpose of this exploratory study was to identify the independent predictors of dysphagia-related QoL in community-dwelling stroke survivors. METHOD: A sample of 31 adult stroke survivors with dysphagia (M age = 62 years; 23 males) and their partners (M age = 57 years; seven males) participated in the study. Survivors were > 3 months poststroke and living with their partner. Backward regression analysis methods were employed to determine independent predictors of dysphagia-related QoL using scores from the Swallowing-Related Quality of Life questionnaire. Independent variables tested included age, employment status, receiving dysphagia treatment, number of medical conditions, level of diet modification, Stroke Impact Scale (SIS) scores, relationship with partner, partner age, partner employment status, partner burden, and partner depression. RESULTS: Results indicated that number of survivor medical conditions, degree of diet modification, SIS emotional subscale score, and partner employment status significantly predicted dysphagia-related QoL (p < .001). More specifically, stroke survivors with more medical conditions or a partner who worked outside of the home had worse dysphagia-related QoL, and those with better mental health or a less modified diet had better dysphagia-related QoL. CONCLUSION: Factors related to dysphagia-related QoL are multifactorial and include both survivor and spousal variables. The results of this exploratory study highlight the need for clinicians and researchers to consider patient function and needs more wholistically to maximize perceived QoL.

Sensory-Enhanced, Fortified Snacks for Improved Nutritional Intake Among Nursing Home Residents.

The present study aimed to determine if providing sensory-enhanced, fortified snacks changed nutrient consumption among nursing home residents. Nursing home residents were provided typical facility snacks or sensory-enhanced, fortified snacks across two separate 8-week time blocks. The enhanced snack supplements included quick-dissolving (transitional-state) crisps, puree dips, and dry soup blends that are intended to be accessible for individuals with a wide range of masticatory and swallowing abilities (e.g., oral frailty). Snacks were weighed before and after sessions using a food scale. Calories, fat, carbohydrates, protein, sodium, sugar, and fiber consumed were calculated daily. Despite consuming a smaller percentage of snack weight, participants consumed increased protein and fat, and fewer carbohydrates and sugar in the enhanced snack condition, with no significant difference in caloric intake. Sensory-enhanced, fortified snacks may be viable options for increasing the quality of nutritional intake among nursing home residents, particularly in light of decreased quantity of intake.

Understanding Burden in Caregivers of Adults With Dysphagia: A Systematic Review.

INTRODUCTION: A previous review suggested that dysphagia is negatively associated with burden in caregivers of community-dwelling older adults. Other literature suggests similar patterns of burden may be found across adult patient populations. The current study, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, was conducted to determine the impact of dysphagia on caregivers of adults, regardless of etiology. METHOD: Five electronic databases were searched using terms based on a review by Namasivayam-MacDonald and Shune (2018) but included all adults rather than only older adults. Searches were limited to English-language empirical studies discussing caregiver burden, included caregivers of adult care recipients, had some care recipients with dysphagia, did not include palliative care, and published in a peer-reviewed journal. RESULTS: The search yielded 1,112 unique abstracts, of which 17 were accepted. Across studies, caregiver burden was found to increase due to dysphagia in care recipients. Commonly reported dysphagia-related causes of burden included changes in meal preparation, disruption in lifestyle, effects on social life, lack of support, insertion of feeding tubes, and fear of aspiration. In general, dysphagia-related caregiver burden was a common experience across caregivers, regardless of patient population, caregiver age, and relationship between caregiver and care recipient. Meta-analyses suggest 71% of caregivers of adults with dysphagia experience some degree of burden. CONCLUSIONS: These findings support that dysphagia negatively impacts caregiver burden and suggests sources of burden that clinicians can address within dysphagia management to support caregivers. However, more research is needed to better delineate sources of burden, especially those specific to various dysphagia etiologies, to better meet the needs of our patients.

Visual Modeling: A Socialization-Based Intervention to Improve Nutritional Intake Among Nursing Home Residents.

Purpose Malnutrition is a widespread, dangerous, and costly condition among institutionalized older adults and can be both a contributor to and consequence of dysphagia for individuals with cognitive impairment. However, interventions to maximize intake in individuals with dementia are limited and frequently problematic, with negative implications for independence and quality of life. The goal of this study was to examine a novel, socialization-grounded intervention based on visual modeling, utilizing the theoretical underpinnings of motor resonance and mimicry. Method To examine the impact of environment on intake, data were collected from four nursing home residents (M age = 83.5 years, SD = 4.2; three women) with dementia. Weight of food and liquid intake was measured across 15 meals and three different mealtime conditions: the "baseline condition" in which the individual ate alone, the "watch condition" in which the individual ate in the company of a "mealtime buddy," and the "eat" condition in which the individual consumed a meal while the "mealtime buddy" did the same. Results Data visualization supported a weak functional relation between eating environment and amount of intake consumed across participants. Log response ratio estimates suggested a trend for increased weight of food consumed during the eat condition as compared to baseline and the eat condition as compared to the watch condition for some participants. Conclusions These results preliminarily support the benefit of a visual model for increased consumption in some individuals with dementia. The presence and magnitude of the effect across conditions varied based on individual-level factors, such as cognitive status, which has implications for implementation. Overall, this study provides initial proof of concept regarding the use of visual modeling as an intervention approach, laying the foundation for larger scale future studies.

Contributors to Poststroke Dysphagia-Related Caregiver Burden.

Purpose Caregiver burden negatively impacts both stroke survivor and caregiver well-being. Thus, it is important to better understand the individual- and dyadic-level variables that may contribute to dysphagia-related caregiver burden. The aim of this preliminary study was to identify survivor-, caregiver-, and dyadic-specific factors associated with burden in couples experiencing poststroke dysphagia. Method Twenty-eight stroke survivors ("care recipients") with dysphagia and their spouses ("caregivers") participated. Care recipients and caregivers completed a survey from which scores for the following variables were derived: dysphagia-related caregiver burden, survivor- and spouse-perceived impact of dysphagia on mealtimes (social, mealtime logistics), dyadic congruence on perceived impact, International Dysphagia Diet Standardisation Initiative Functional Diet Scale, Swallowing-Related Quality of Life Scale, and Stroke Impact Scale (cognitive, emotional, physical, and social domains). Spearman's rho and point biserial correlation coefficients were calculated to determine the factors related to caregiver burden. Results Increased burden was significantly associated with greater care recipient- and spouse-perceived impact of dysphagia on mealtime logistics; however, burden was not associated with measures of dyadic congruence of perceived impact. Notably, increased burden was also associated with increased diet restrictiveness and decreased swallow-specific quality of life. Dysphagia-related caregiver burden was not associated with measures of stroke impact/severity across any domain. Conclusions Factors related to dysphagia-related caregiver burden are multifactorial and include both care recipient (e.g., International Dysphagia Diet Standardisation Initiative Functional Diet Scale, Swallowing-Related Quality of Life Scale, perceived impact of dysphagia on mealtime logistics) and caregiver (e.g., perceived impact of dysphagia on mealtime logistics) variables. The results of this preliminary investigation support the need to incorporate aspects of counseling and family-centered care into our management practices, a growing area of interest for speech-language pathologists.

Creation and Initial Validation of the Caregiver Analysis of Reported Experiences with Swallowing Disorders (CARES) Screening Tool.

Purpose Dysphagia is a debilitating condition with widespread consequences. Previous research has revealed dysphagia to be an independent predictor of caregiver burden. However, there is currently no systematic method of screening for or identifying dysphagia-related caregiver burden. The aim of this study was to develop a set of questions for a dysphagia-related caregiver burden screening tool, the Caregiver Analysis of Reported Experiences with Swallowing Disorders (CARES), and pilot the tool to establish preliminary validity and reliability. Method The questionnaire was developed through an iterative process by a team of clinical researchers with expertise in dysphagia, dysphagia-related and general caregiver burden, and questionnaire design. A heterogenous group of 26 family caregivers of people with dysphagia completed the CARES, along with the Eating Assessment Tool (EAT-10), the International Dysphagia Diet Standardisation Initiative Functional Diet Scale (IDDSI-FDS), and the Zarit Burden Interview (ZBI). Information on construct validity, item fit, convergent validity, internal consistency, and reliability was determined via Rasch analysis model testing, Cronbach's alpha, and Spearman's rho calculations. Results The final CARES questionnaire contained 26 items divided across two subscales. The majority of the questionnaire items fit the model, there was evidence of internal consistency across both subscales, and there were significant relationships between dysphagia-specific burden (CARES) and perceived swallowing impairment (EAT-10), general caregiver burden (ZBI), and diet restrictiveness (IDDSI-FDS). Conclusions Results from the current study provide initial support for the validity and reliability of the CARES as a screening tool for dysphagia-related burden, particularly among caregivers of adults with swallowing difficulties. While continued testing is needed across larger groups of specific patient populations, it is clear that the CARES can initiate structured conversations about dysphagia-related caregiver burden by identifying potential sources of stress and/or contention. This will allow clinicians to then identify concrete methods of reducing burden and make appropriate referrals, ultimately improving patient care.

Behavioral Mimicry as a Strategy to Increase Drinking Behaviors in Older Adults.

Purpose Individuals with dysphagia, particularly in the presence of dementia, are at high risk for decreased nutrition and hydration. Unfortunately, current treatment options are not without limitations and often ignore the crucial social aspects of mealtimes. The aim of this exploratory, proof-of-concept study was to examine whether the social phenomenon of nonconscious behavioral mimicry can increase drinking behaviors in healthy older adults. Method Forty-two older adults (M age = 68.26 years, SD = 6.49) participated. Participants and a member of the research team posing as another participant (a confederate) took turns describing two series of pictures, while, unbeknownst to the participants, the confederate either frequently drank from a cup of water or touched the cup. The primary outcome measures (number of drinks per minute, number of cup touches per minute, percentage of time spent drinking, and percentage of time spent touching the cup) were coded and analyzed across both the confederate drinking and cup-touching conditions. Results Participants drank more frequently and spent more task time drinking during the confederate drinking condition as compared to the cup-touching condition. There was significant variability in drinking patterns across participants, with some only drinking when they were not engaged in the picture description task. Conclusions Behavioral mimicry may increase drinking behaviors in healthy older adults, although the effect may not be as robust among certain subsets of individuals. Clinically, mimicry may hold potential as a powerful, noninvasive supplemental mealtime strategy for increasing intake in those who are most at risk for malnutrition.

The influence of swallowing impairments as an independent risk factor for burden among caregivers of aging parents: A cross-sectional study.

Informal caregivers can experience high levels of burden, negatively impacting both the caregiver and care recipient. The presence of dysphagia (swallowing impairments) in care recipients is suggested to contribute to increased caregiver burden. The purpose of this study was to describe the type and severity of caregiver burden experienced by adults caring for community-dwelling older parents reporting symptoms of dysphagia. Using surveys from the National Health and Aging Trends Study and the National Study of Caregiving, data from 895 adults providing care for an aging parent were analyzed. Binary logistic regression analyses revealed that swallowing difficulties reported by a parent is a significant independent predictor of increased physical and emotional burden in their caregivers. Forty percent or more of these caregivers reported moderate to severe physical and/or emotional burden. Suggestions are provided to identify dysphagia early on and to provide supports for caregivers.

Swallowing Impairments Increase Emotional Burden in Spousal Caregivers of Older Adults.

Objective: The aim of this study was to determine the type and extent of caregiver burden uniquely experienced by spousal caregivers of older adults with dysphagia. Method: Using the Round 1 surveys from the National Health and Aging Trends Study and the National Study of Caregiving, we analyzed data on 422 community-dwelling older adults and their spousal caregivers. Results: Approximately 17% of care recipients reported swallowing difficulties. Logistic regression analysis revealed that caregivers of spouses with dysphagia were significantly more likely to experience emotional burden, p = .038; odds ratio (OR) = 2.06; 95% confidence interval (CI): [1.04, 4.09]. Of those spouses caring for partners with dysphagia who reported emotional burden, nearly 70% rated the burden moderate to severe. Discussion: Dysphagia in community-dwelling older adults is associated with increased emotional burden among spousal caregivers. Given the intricate relationship between the health and well-being of both members of the caregiving dyad, these findings support the need for interventions that prioritize dyadic health.

An Altered Eating Experience: Attitudes Toward Feeding Assistance Among Younger and Older Adults.

PURPOSE: Feeding assistance is commonly used to alleviate mealtime difficulties and decrease risk. It is unclear how to best support the transition from independence to assisted feeding across the lifespan. The purpose of this exploratory study was to examine attitudes toward feeding assistance among healthy younger and older adults. DESIGN: Qualitative study. METHODS: A total of 17 younger and 19 older adults were interviewed following a simulated feeding (assisted and self-feeding) experience. Comments were coded for sensation (physical/emotional) and sentiment (positive/negative/neutral) and analyzed for common themes. FINDINGS: All participants commented primarily on the physical aspects of feeding assistance. Younger adults were more likely than older adults to make negative comments, particularly as related to the loss of independence. All participants indicated difficulties/differences with the feeding process stemming from their own preferences not being realized. CONCLUSIONS/CLINICAL RELEVANCE: Although all adults value independence in the aging process, younger adults may more negatively view receiving feeding assistance as a loss of independence. This suggests the need to redefine autonomy in the presence of increased dependence. It is also necessary to individualize the feeding process in order to incorporate individual identity into eating. Promoting interdependence as the consequence of feeding assistance, rather than dependence, can help support this time of transition and promote patient well-being.

Understanding the dining experience of individuals with dysphagia living in care facilities: A grounded theory analysis.

BACKGROUND AND OBJECTIVES: Person-directed care in nursing homes, also known as the 'culture-change movement', aims to enhance dining-related quality of life. However, for residents with dysphagia, it is unclear how to best support this enhancement while balancing eating-related safety/risks. Thus, the purpose of this study was to explore the experience of and to define successful, person-centered dining for residents with dysphagia. RESEARCH DESIGN AND METHODS: Grounded theory methodology guided twenty-one 60-90 minute semi-structured interviews with participants across 7 stakeholder groups including residents, family members, and nursing, dietary, and therapy staff. We used a systematic and iterative approach for all data collection, analysis, and generation of theory. RESULTS, DISCUSSION, AND IMPLICATIONS: A theory emerged from the data that highlighted how individualization and socialization are the central tenants for improving residents' dining experiences and success, or 'focusing on the person: individualization and socialization during mealtimes'. We identified multiple facilitators and barriers to successful dining for residents with dysphagia such as the importance of positive social connections and invested, knowledgeable, and aware care team members. The focus of care was a salient theme suggesting that individualization of care that promotes residents' quality of life is a key facilitator of successful dining experiences. A social-ecological model for successful dining with dysphagia is ultimately proposed: optimizing health and well-being for these residents through successful dining experiences requires collaborative and coordinated care to address a variety of interrelated individual-, interpersonal-, and organizational-level facilitators and barriers.

The Burden of Dysphagia on Family Caregivers of the Elderly: A Systematic Review.

With the rapid increase in the elderly population, there is a simultaneous increased need for care provided by family caregivers. Research in the field of head and neck cancer has indicated that caring for patients with dysphagia can impact a caregiver's quality of life. Given that many older adults present with dysphagia, one can assume that their caregivers are equally, if not more greatly, affected. The purpose of this systematic review was to examine all relevant literature regarding the caregiver burden in caregivers of community-dwelling older adults with dysphagia. A review of relevant studies published through April 2018 was conducted using search terms related to dysphagia, caregiver burden, and older adults. The search yielded 2331 unique abstracts. Of the 176 abstracts that underwent full review, four were accepted. All reported an increase in caregiver burden due to presence of dysphagia in care recipients. Worsening feeding-related behaviors were associated with burden, and the use of feeding tubes was more frequently associated with "heavy burden". The presence of dysphagia in community-dwelling older adults is a factor leading to an increased burden among caregivers. Although aspects of dysphagia play a role in the caregiver burden, the specific reasons for the increased burden are unknown. Clinicians should be aware of dysphagia as a source of the burden, and future studies should further define the relationship between dysphagia and the caregiver burden in order to develop comprehensive approaches to care.

Goal-Directed Drinking Behaviors Can Be Modified Through Behavioral Mimicry.

Purpose: This study tested whether behavioral mimicry can alter drinking behavior. It was hypothesized that participants would increase drinking behaviors given increased confederate drinking but not cup touching. Methods: Nineteen healthy adults (Mage = 20.32 years) completed 2 picture description tasks; during 1 task, a confederate frequently sipped water (complete drinking gesture), and during the other, the confederate touched her cup but did not drink (partial gesture). Outcome measures included number of drinks per minute, number of cup touches per minute, percentage of time spent drinking, and percentage of time spent touching the cup. Results: Participants spent more time drinking and had an increased drinking rate during the drinking condition versus the cup-touching condition. For a majority of participants, drinking rate increased during the drinking condition versus baseline. Drinking, but not cup touching, rate also increased given increased confederate cup touching for many. Conclusions: Mimicry likely contributes to social modeling of drinking behaviors. This effect appears more robust given a complete target gesture (full drink); however, a partial goal-directed drinking gesture may also yield a mimicked response. Beyond the theoretical implications, these results provide directions for research investigating more naturalistic mechanisms for increasing dietary intake in various patient populations (e.g., individuals with dysphagia).

The Effects of Age and Preoral Sensorimotor Cues on Anticipatory Mouth Movement During Swallowing.

PURPOSE: The aim of this study was to investigate the effects of preoral sensorimotor cues on anticipatory swallowing/eating-related mouth movements in older and younger adults. It was hypothesized that these cues are essential to timing anticipatory oral motor patterns, and these movements are delayed in older as compared with younger adults. METHOD: Using a 2 × 2 repeated-measures design, eating-related lip, jaw, and hand movements were recorded from 24 healthy older (ages 70-85 years) and 24 healthy younger (ages 18-30 years) adults under 4 conditions: typical self-feeding, typical assisted feeding (proprioceptive loss), sensory-loss self-feeding (auditory and visual loss/degradation), and sensory-loss assisted feeding (loss/degradation of all cues). RESULTS: All participants demonstrated anticipatory mouth opening. The absence of proprioception delayed lip-lowering onset, and sensory loss more negatively affected offset. Given at least 1 preoral sensorimotor cue, older adults initiated movement earlier than younger adults. CONCLUSIONS: Preoral sensorimotor information influences anticipatory swallowing/eating-related mouth movements, highlighting the importance of these cues. Earlier movement in older adults may be a compensation, facilitating safe swallowing given other age-related declines. Further research is needed to determine if the negative impact of cue removal may be further exacerbated in a nonhealthy system (e.g., presence of dysphagia or disease), potentially increasing swallowing- and eating-related risks.

Association between severity of dysphagia and survival in patients with head and neck cancer.

BACKGROUND: This study examined risk factors for dysphagia, a common and serious condition in patients with head and neck cancer, and the association between severity of dysphagia and survival. METHODS: Chart reviews were performed on patients diagnosed with head and neck cancer between January 2001 and April 2003, who had dysphagia diagnoses or swallowing evaluations. Regression analyses determined factors associated with dysphagia and the association between observed survival and severity of dysphagia. RESULTS: Almost 50% of the 407 patients had dysphagia. Risk factors included advanced stage, older age, female sex, and hypopharyngeal tumors. The most severe dysphagia ([L.] nil per os or "nothing by mouth" status), which was associated with lower survival rates, was the strongest independent predictor of survival. CONCLUSIONS: Swallowing problems should be considered when determining appropriate cancer-directed treatment and posttreatment care. Because of dysphagia's high incidence rate and association with survival, a speech-language pathologist should be involved to ensure routine diagnostic and therapeutic swallowing interventions.