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TOLERABILITY, COMPLIANCE, AND PRODUCT EVALUATION OF A PRE-THICKENED ORAL NUTRITIONAL SUPPLEMENT FOR DISEASE RELATED MALNUTRITION IN PATIENTS WITH DYSPHAGIA

T. Dennehy1, F. Veldkamp2, M. Lansink3, R.J. Schulz4

1. Bank House Surgery, Cork, Ireland; 2. TOPAZ Overduin, Katwijk, The Netherlands; 3. Danone Nutricia Research, Utrecht, The Netherlands;
4. Department of Geriatric Medicine, St Marien Hospital, Cologne

Corresponding Author: M. Lansink, Nutricia Research, Uppsalalaan 12, 3584 CT Utrecht, The Netherlands T: +31 30 2095000, M: +31 6 27847940, E-mail address: mirian.lansink@nutricia.com

J Aging Res Clin Practice 2019;8:85-90
Published online January 15, 2020, http://dx.doi.org/10.14283/jarcp.2019.15

Abstract

Background: Oropharyngeal dysphagia is a prevalent risk factor for malnutrition in older patients and both conditions are related to poor outcome. For the management of (risk of) malnutrition in patients with oropharyngeal dysphagia pre-thickened oral nutritional supplements are available. Objective: The objective of the study is to describe tolerance parameters (stool frequency and incidence and intensity of gastrointestinal symptoms), study product intake (compliance), product appreciation and product properties of a pre-thickened oral nutritional supplement compared to a manually-thickened standard oral nutritional supplement.
Design: A randomized, open label, controlled, parallel group study. Setting: participants were recruited through nine general practices in Ireland, one nursing home in The Netherlands, and one hospital in Germany. Participants: Fifty patients requiring oral nutritional support (twenty-four of fifty cases (48%) with dysphagia) were divided into two groups: test group (N = 27) and control group (N = 23). Intervention: During four weeks the test group received a ready-to-use, low volume (125 mL), and energy dense pre-thickened oral nutritional supplement, and the control group a manually-thickened iso-caloric oral nutritional supplement (200 mL) with a similar viscosity. Measurements: Compliance and stool frequency were recorded daily, evaluation of the product appreciation and properties and gastrointestinal tolerability were assessed with questionnaires. Results: Incidence and intensity of gastrointestinal symptoms was not statistically different between groups. Pre-thickened oral nutritional supplement scored significantly better on compliance in week 4 (p = 0.019), on thickness appreciation by patients (day 14, p = 0.035) and on product properties evaluation by carers (appearance, preparation time, ease of preparation and change in thickness, all p < 0.001) compared to the manually-thickened ONS. Conclusion: These results substantiate the use of pre-thickened oral nutritional supplement for the dietary management of patients in need of nutritional support and with oropharyngeal dysphagia.

Key words: Pre-thickened ONS, dysphagia, gastro-intestinal (GI) tolerability, compliance, product properties.

Introduction

Oropharyngeal dysphagia (OD) is a clinical symptom, defined by a difficulty or inability to form or to move the alimentary bolus safely from the mouth to the oesophagus. OD may cause choking, aspiration, aspiration pneumonia, malnutrition, dehydration, and death due to complications (1-3).  Swallowing disorders are prevalent in different conditions/diseases e.g. aging, stroke, head and neck cancer, and Alzheimer’s and other neurological disorders. OD can considerably affect the patient’s quality of life (4).
Modifying the texture of foods and the viscosity of fluids by thickeners is considered to be one of the basic compensatory interventions in the management of OD by practitioners in the field of speech and language therapy (SLT), nurses and dietitians (5). The terminology used to describe the consistency of thickened liquids and the number of levels/stages varies widely between countries. For instance until last year,  in the UK the British Dietetic Association (BDA) system was used to describe the viscosity levels: stage 1, 2, 3 (6). The terminology has recently been evaluated by the International Dysphagia Diet Standardization Initiative (IDDSI) and European Society for Swallowing Disorders (ESSD). IDDSI published a framework for a global standardised terminology and definitions to describe texture modified foods and thickened liquids, consisting of a continuum of 8 levels (0-7) (7). ESSD concluded that there is evidence for increasing viscosity to reduce the risk of airway invasion in a viscosity-dependent manner and this is a valid management strategy for OD (8). In addition, to improve the safety of patients the ESSD is developing a labelling system of viscosity levels for fluid thickening (based on SI units of viscosity (mPa.s) at 50s-1 and 25ºC, effect of salivary amylase and shear thinning on viscosity).
Patients with dysphagia on a texture modified diet usually do not reach their dietary requirements (9). Inferior sensory and/or nutritional qualities of texture modified diets may play a role in this and use of modified texture foods is highly associated with undernutrition (10, 11).  Therefore, nutritional intake should be facilitated and increased by enriching meals and/or using ONS (12, 13). It is important for OD patients that ONS have the right thickness; however, the intra and inter subject variation and lack of proper training of carers and users in the preparation of thickened drinks and/or pureed meals may lead to variation in the viscosity of fluids provided to dysphagia patients (14, 15). This may negatively influence food and fluid intake, but also safety of swallowing (16). For dysphagia patients, pre-thickened, ready to use ONS are available, but also standard ONS manually thickened to the prescribed viscosity stage are used in clinical practice. The success of nutritional support depends not only on the supplied energy and nutrients, but also on compliance by the users, which might be positively affected by the ONS energy-density (17).
In the present study four weeks use of a pre-thickened, high energy dense, low volume ONS (125 mL, test product) in patients in need of nutritional support was compared to that of a manually thickened, isocaloric ONS (200 mL, control product) with respect to GI tolerability, compliance, subjective evaluation of product appreciation and product properties.

Methods

Subjects

Patients in need of nutritional support, as prescribed by a health-care professional, were included in the study over a period of 1 year. Inclusion criteria were age of ≥ 18 years, a prescription for oral nutritional support of ≥ 300 kcal/day of energy enriched sip feed or, in case of new users, a Malnutrition Universal Screening Tool (MUST) score of 1 or higher (malnutrition risk for score 0, 1, and ≥ 2 is low, medium and high, respectively), a requirement for oral nutritional support for at least four weeks and written informed consent. Half of the patients should have been diagnosed with dysphagia and require thickened drinks with a stage 1 consistency according to the BDA classification. Exclusion criteria were participation in any other study involving investigational or marketed products concomitantly or within two weeks prior to entry into the study, requirement of oral nutritional support other than energy enriched ONS (e.g. high protein sip feeds, disease specific sip feeds), known lactose intolerance or galactosaemia, major hepatic or renal dysfunction, known inflammatory bowel diseases, having an ileostomy or colostomy, strong dislike of the flavours to be tested (strawberry and vanilla) and investigator’s uncertainty about the willingness or ability of the subject to comply with the study protocol.

Study design

This randomized, prospective, open label, controlled, parallel-group multi-centre study (Netherlands Trial Register: NTR1643) was performed with nine general practices in Ireland, one nursing home in The Netherlands, and one hospital in Germany.  The study is compliant with the ethical guidelines of the Declaration of Helsinki and approved by the ethics committees of the local sites.
At baseline, subjects were randomly assigned to either of the study groups, using minimization for ONS prescription (2 options: 1 serving/day, 2 servings/day) and requiring thickened drinks (2 options: yes, no). A hybrid minimization procedure was chosen (18).
Allocation to study groups started randomly and continued as long as balanced distribution was maintained for ONS prescription and requirement of thickened drinks. Since the control product was different in volume from the test product and, unlike the test product, the control product required thickening, it was not possible to blind the subjects, carers and physicians.
Test product was a pre-thickened, low volume (125 mL) energy-dense, fibre-enriched ONS with amylase-resistance features (Nutilis Complete Stage 1, Nutricia N.V. Zoetermeer, The Netherlands) and the control product an isocaloric standard volume (200 mL) fibre-enriched ONS (Fortisip Multi-fibre, Nutricia N.V. Zoetermeer, The Netherlands) manually thickened with commercially available thickeners. The product compositions are shown in table 1. The pre-thickened product had a targeted viscosity of 450 mPa.s determined at a shear rate of 50s-1 and a temperature of 20°C, and it corresponds to IDDSI level 3 and to stage 1 of the former BDA (6, 7). Viscosities of the control was thickened at stage 1 BDA consistency with the available thickener used in each location.

Table 1 Product composition

Table 1
Product composition

*The control product is thickened with the thickening powder to a stage 1 consistency (BDA classification).

Study endpoints were stool frequency and incidence and intensity of each GI symptom per time point, study product compliance, patients’ evaluation on product appreciation and carer’s evaluation on the properties of products. Stool frequency was assessed daily, and incidence and intensity of GI symptoms were assessed during the baseline period and at day 14 and day 28 of the study.  Compliance was assessed daily, and it was defined as having a mean intake of at least 75% of the recommended volume during the intervention period. Patients’ evaluation on product appreciation was assessed at day 14 and 28 after consuming the product, and carer’s evaluation on product properties was collected at the end of the study. Occurrence of adverse events and medication use was recorded throughout the study period. Information on incidence and intensity of GI symptoms in the past 2 days was collected using a 4-point scale (absent (0), mild (1), moderate (2), severe (3)). This questionnaire was completed by the subject or carer and GI symptoms scored were: nausea, vomiting, diarrhoea, constipation, abdominal distension (bloating), belching, and flatulence. Product appreciation scored by the subjects able to complete the questionnaire were: taste, sweetness, mouth feel, thickness, aftertaste, and mouth feel after swallowing using a hedonic 7-point scale (ranging from “I like it very much” to “I dislike it very much”). Product properties scored by carers were: appearance, preparation time, ease of preparation, and change in thickness using a hedonic 5-point scale. Safety was determined by evaluating adverse events (AEs) and serious adverse events (SAEs).

Statistics

Subject characteristics at initial assessment were summarised per group. Group comparisons for stool frequency, incidence and intensity of GI symptoms, number of subjects who were compliant and number of subjects with AEs, product appreciation (clustered as negative (1-3), neutral (4) or positive (5-7)) and carer’s evaluation of product properties were analysed using Fisher’s exact test. A p-value of <0.05 (two-sided) were considered statistically significant. In the event of missing data, these data points were treated as ‘missing’ and not included as valid data points in the analyses. No correction for multiplicity has been applied. For statistical analysis the results of the intention to treat (ITT) population (N=50) were used. Statistical analysis was performed using SPSS version 15.0 for Windows.

Results

Patients

Fifty patients were included in the study, 27 in the test group and 23 in the control group. Twelve patients did not complete the study: 6 in the test group and 6 in the control group. Reasons for early termination included dislike of the study product, AEs and discharge of patients. Table 2 summarizes the demographics and patient characteristics. Thirteen of  twenty-seven subjects in the test group and eleven of twenty-three subjects in the control group (48% of the patients in both groups) had swallowing problems and required thickened drinks with a BDA stage 1 consistency  (table 2).

Table 2 Demographics and characteristics of randomised patients

Table 2
Demographics and characteristics of randomised patients

Data are given in n (%) unless otherwise indicated;  * BMI (Body Mass Index): < 18.5 (underweight), 18.5-24.9 (normal weight), 25-29.9 (overweight), >30 (obesity). BMI at baseline was available for 48 subjects: test (n=26) and control (n=22); † MUST score: 0 (low risk of malnutrition), 1 (medium risk of malnutrition), ≥ 2 (high risk of malnutrition)

Stool frequency and incidence and intensity of GI symptoms

There were no significant differences in stool frequency between test and control group (table 3) nor for the dysphagia subgroup (data not shown), and the majority of subjects had 0-1 stools per day. The majority of GI symptoms were absent or mild for both groups. No GI symptoms were reported as severe in the test group. In the control group there was one incidence of severe constipation and one incidence of severe diarrhoea at baseline. At day 14, one incidence of severe belching and two incidences of severe flatulence were reported. However, no significant differences in incidence and intensity per GI symptom were observed between the groups either at baseline, day 14 or day 28; neither for the total group nor for the dysphagia subgroup (data not shown).

Table 3 Comparison of outcome parameters

Table 3
Comparison of outcome parameters

*Data of drop-out subjects were included until moment of drop out. Due to missing values, data not always count up to 27 for the active and 23 for the control group. Stool frequency at baseline is based on data of one day. For the other time points, stool frequency was only calculated if a minimum of 3 days was recorded. †Fisher’s Exact test

Study product compliance

Twenty of twenty-seven subjects in the test group and sixteen of twenty-three subjects in the control group (about 70% of the subjects in both groups) were prescribed 1 bottle per day, the remaining patients being on a prescription of 2 or more bottles per day. No significant differences in the number of subjects who were compliant with study product intake were shown for the total intervention period between groups, twenty-one of twenty-five (84%) subjects for the test product and sixteen of twenty-one (76.2%) subjects for the control product, p = 0.711 (table 3), nor for the dysphagia subgroup. For week 4 a significantly higher percentage of subjects in the test group was compliant as compared to the control group, all the subjects in the test group (n=21) vs ten of fourteen (71.4%) subjects in the control group p = 0.019 (table 3). No differences of body weight between test and control group were found at different time points (baseline, day 14, and day 28) (p > 0.05).

Patients’ evaluation on product appreciation and carer’s evaluation on product properties

The questionnaire used to evaluate the product appreciation was filled in by 23 patients in the test group and 22 patients in the control group at day 14 and by 21 and 16 patients respectively at day 28. No significant difference in five aspects (taste, sweetness, mouth feel, aftertaste, and mouth feel after swallowing) was found between groups. Thickness appreciation of the test product scored significantly higher compared to the control product at day 14 (p = 0.035).
The questionnaire used to evaluate the product properties was filled in by 13-22 carers for the test product (appearance: n = 22, preparation time: n = 13, ease of preparation: n = 15 and change in thickness: n = 18) and 17 carers for the control product. For all four aspects significant differences were found between test and control product: carers indicated that product appearance (p = 0.049), preparation time (p < 0.001), ease of preparation (p < 0.001) and stability of consistency (p < 0.001) were significantly better for the pre-thickened ONS compared with manually-thickened ONS (figure 1).

Figure 1 Carer’s evaluation of appearance, preparation time, ease of preparation, and change in thickness

Figure 1
Carer’s evaluation of appearance, preparation time, ease of preparation, and change in thickness

Carers were asked: (A) What is your view on the appearance of the thickened sip feed? (B) How much time did you approximately need to prepare the thickened sip feed? (C) What is your view on the ease of preparation of the thickened sip feed? (D) Did you notice any thickness change during consumption of the thickened sip feed?

(Serious) adverse events (S(AE)s)

No significant differences were shown in the number of subjects with one, two or more adverse events between groups. In the test group 22 AEs occurred in 11 patients and none of these was reported as related to the study product. In the control group 18 AEs were reported in 11 patients. One AE (vomiting) was possibly related to the control product and 3 AEs in one person (diarrhoea, abdominal cramps, nausea) were classified by the investigator as definitely related to the control product. During the study 5 SAEs (femur fracture, cholecystitis, hospital admission (due to vomiting and diarrhoea), pneumonia and cardiac arrest) were reported in the test group. All were classified as not related to the study product according to the investigator. In the control group, no SAEs were described.

Discussion

Current study results showed that no significant differences in stool frequency and incidence and intensity of GI symptoms were observed between the test and control group. There was no significant difference in product compliance between groups for the overall period, but in week 4 the pre-thickened ONS had a significantly better compliance. Product appreciation evaluated by the patients was not significantly different between groups except for the thickness appreciation which scored significantly better for the test group. Product properties evaluated by the carers were significantly better for the test product compared to the control product. Together these data substantiate the use of a pre-thickened ONS in patients with dysphagia.
For the total intervention period compliance was twenty-one of twenty-five (84%) subjects in the test group and sixteen of twenty-one (76.2%) subjects in the control group. These numbers are in line with the mean overall compliance to ONS of 78% previously reported in a systematic review (17). In this review, mean compliance to ONS in community studies was 80.9%, whereas in the hospital setting an average 67.2% of the patients was compliant. In the current study, patients from both settings were included. Interestingly, in week 4 the compliance became significantly higher in the group consuming the energy dense pre-thickened test product as compared with the control group. This is in line with previous observations of significantly greater compliance and energy intakes with small volume, energy dense ONS compared with standard sip feeds (17, 19). Besides the low volume of the test product, pre-thickening of the ONS rather than manually thickening may also have an effect on compliance, as suggested by studies that found increased intake with pre-thickened drinks. In a small cross-over pilot study with 11 patients requiring thickened fluids it was suggested that the use of pre-thickened drinks (including milk, fruit juices, orange juice and tea) as compared to manually thickened drinks increases nutrients intake derived from drinks (20). And in a study with acute stroke patients with dysphagia, it was also shown that patients who received pre-thickened fluids drank almost 100% more than those on powder thickened fluids (21). It is not likely that in the current study a difference in appreciation of the products has played a role in the improved compliance in the test group in week 4, since the appreciation of the two ONS was not significantly different between groups except for thickness appreciation in favour of the pre-thickened ONS at day 14.
Body weight did not differ between test and control group at different time points (baseline, day 14, and day 28). Comparable nutritional value of test and control product and number of patients who were prescribed one bottle/day (about 70%) or ≥ 2 bottles/day (about 30%) in the test and control group had probably contributed to this result.
The ready-to-use ONS was considered by the carers to have a better appearance, a shorter preparation time, was easier to prepare, and had a more stable consistency. Comparably, Kotecki and Schmidt reported that due to variability in the skill of the preparer and alteration in the viscosity of the product over time, commercially thickened liquids showed a more consistent viscosity than manually prepared thickened liquids (22). Based on their findings they conclude that the benefit of commercially thickened liquids is the potential for an improved quality of life for the patient with dysphagia. Other studies also reported that many patients are served manually thickened liquids that are too thick or too thin with respect to the target level of thickness (14, 23). In a study by MacLeod et al. 24 subjects with learning disabilities who required a modified texture diet with thickened fluids and did not meet their nutritional requirements, received pre-thickened ONS in a 4 week, open, non-controlled, prospective observational pilot study. Results indicated that the pre-thickened ONS had advantages over existing treatment options as assessed by: ease of use (71%), guaranteed a safer consistency (71%), meets nutritional requirements (58%) and compliance (50%) (24). Together the findings above suggest that consistent viscosities and convenience of use appear to be important advantages of ready to use products as compared to manually thickened products.
Current study results indicate that GI tolerability of the pre-thickened ONS is similar to the manually-thickened ONS in patients in need of nutritional support. The GI symptoms recorded during this study were absent or mild during use of either test or control product. Both the test and control product of the current study contained a fibre blend consisting of a mixture of soluble and insoluble fibres (soy polysaccharides, cellulose, resistant starch, gum arabic, oligofructose and inulin). Previous studies in elderly patients and nursing home residents have shown that dietary fibres have positive effects on bowel movements and constipation (25, 26), which was also concluded in a systematic review (27).
In summary, the pre-thickened, small volume, energy-dense, fibre-enriched, ready-to-use ONS with amylase-resistant features was better appreciated by patients and/or carers for its consistent viscosity and convenience of use, had a higher compliance in week 4, and had a similar and good GI tolerability as compared to the manually-thickened, standard, isocaloric, fibre-enriched ONS.  No safety issues based on AEs were reported. Therefore, these results substantiate the use of a pre-thickened ONS for the dietary management of patients in need of nutritional support with OD.

Funding: Sources of funding: this study was supported by Danone Nutricia Research. Danone Nutricia Research was responsible for  the study: design and conduct, statistical analysis and interpretation of the results,  preparation and approval of the manuscript.

Acknowledgements: All authors made substantial contributions to the conception and design of the study, or acquisition of data, or analysis and interpretation of data, in drafting the article, revising it critically, and have approved the final version submitted. We would like to thank Sonia Guida and Nick van Wijk for their contribution in revising the manuscript.

Conflict of interest disclosure: Declaration of interest: Mirian Lansink is an employee of Danone Nutricia Research and Tom Dennehy, Fleur Veldkamp, and Ralf-Joachim Schulz declare no conflict of interest.

 

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PREDICTORS OF ORAL INTAKE DIFFICULTY IN OLDER PATIENTS WITH DYSPHAGIA

 

Y. Kuroda

 

Department of Rehabilitation, St. Francis Hospital, 9-20 Komine-machi, Nagasaki City, 852-8125 Japan

Corresponding Author: Yoshitoshi Kuroda, Department of Rehabilitation, St. Francis Hospital, Nagasaki, Japan, 9-20 Komine-machi, Nagasaki City, 852-8125 Japan, Telephone: +81-95-846-1888, Fax: +81-95-845-7600, Email: kuroda@athena.ocn.ne.jp

 

Abstract

The aim of this study was to identify the predictors of oral intake difficulty in older patients with dysphagia. The subjects were 133 hospitalized older individuals with dysphagia. They were divided into two groups according to the oral intake ability: the oral intake and non-oral intake groups. Swallowing function was measured with a graded water swallowing test and a food intake level scale. Functional status was evaluated with a physical dependency scale and a comprehension scale. Nutritional status was measured with anthropometric measures and serum albumin levels. The non-oral intake group was significantly impaired in the swallowing measures, physical dependency, and mid-upper arm circumference. Multivariate analysis revealed that impairment in mid-upper arm circumference and graded water swallowing test were independently associated with oral intake difficulty. In conclusion, swallowing impairment, advanced body mass reduction, and physical dependency were the significant predictors of oral intake difficulty in older patients with dysphagia.

Key words: Dysphagia, elderly, malnutrition, oral intake, physical dependency.

 

Introduction

Dysphagia is a highly prevalent condition in hospitalized older adults. Recent studies have reported a prevalence of 27% in independently-living elderly (1) and 47% in hospitalized elderly (2). One major consequence of dysphagia is reduced oral intake due to swallowing difficulty. A recent large-scale study demonstrated that 41% of older patients admitted with aspiration pneumonia could not achieve sufficient oral intake within 30 days (3). This is a serious issue in current geriatric medicine, because older patients with poor oral intake often become candidates to receive long-term artificial nutrition, which may lead to diminished quality of life. Therefore, it is important to identify the predictors of oral intake difficulty in this clinical population. Given that previous studies demonstrated that dysphagia in the elderly was associated with older age, dementia, impaired activity of daily living, and malnutrition (2, 4, 5), those factors may affect the oral intake. The aim of this study was to identify the predictive factors for poor oral intake in older patients with dysphagia.

 

Methods

The subjects of this study were older individuals admitted to St. Francis Hospital for acute care between April 2012 and February 2014. The study inclusion criteria were aged 65 and older and referral to the Speech Pathology Service for assessment of dysphagia. Six patients with malignancy, four patients already being tube-fed, and one patient who had cerebral hemorrhage during the hospitalization were excluded to avoid their influence on the results. A total of 133 patients were enrolled for this study.
Swallowing measures consisted of a graded water swallowing test (GWST) (6) and a food intake level scale (FILS) (7). The GWST uses 2, 3, and 5 ml of plain and thickened water in a graded manner, ranging from 0 (fails in 2 ml thickened water trial) to 6 (passes in 5 ml plain water trial). The FILS is an observer-rating scale for assessing the severity of dysphagia, examining to what degree patients take food orally on a daily basis, ranging from 0 (no oral intake, and no swallowing training) to 10 (normal oral food intake). Functional measures included a physical dependency scale and comprehension scale that are described elsewhere (6). Nutritional measures included mid-upper arm circumference (MUAC), calf circumference (CC), and serum albumin levels. MUAC was measured at the midpoint between the tip of the acromion process and the tip of the olecranon process of the left arm. CC was measured at the point of maximal circumference of the left leg. In principle, the evaluations were performed in the early days of hospitalization.
The subjects were divided into two groups according to the oral intake ability. The oral intake group (n = 91) were those who achieved sufficient oral intake (FILS of 7 or above) until the end of hospitalization. The non-oral intake group (n = 42) were those who continued to require artificial nutrition (FILS of 6 or below) during the hospitalization. In this study, patients of the non-oral intake group were defined as those with oral intake difficulty. To make the data more readily comparable and to accommodate the logistic regression analysis, ordinal and cardinal variables were converted into the categorical measures using cutoff points. The cutoff points were applied for age (85 years or older), GWST (score <4), FILS (score <5), physical dependency scale (score <1), comprehension scale (score <2), MUAC (<22.5 cm for men and <20.8 cm for women), CC (<31.3 cm for men and <29.9 cm for women), and albumin levels (<2.8 g/dL). The cutoff points of MUAC and CC were 2 standard deviations below the means for a normal population aged 40-44 years for each sex (8), and the other cutoff points were arbitrary chosen close to the mean.
Comparative analyses between the two groups were performed using the Student’s t-test, Mann-Whitney test, and chi square test. Multivariate logistic regression analysis was performed using the oral intake difficulty represented by the non-oral intake group as the dependent variable and other dichotomous variables as independent variables. A p-value <0.05 was considered statistically significant. This study was approved by the ethics committee of our hospital.

 

Results

The basic results are shown in Table 1. The subjects were 53 men and 80 women, with a mean ± SD age of 85.8 ± 6.2 years. Primary diseases on admission were respiratory disease (n = 88), digestive disease (n = 12), urinary infection (n = 6), cardiac disease (n = 5), orthopedic disease (n = 4), cerebrovascular accident (n = 3), and others (n = 15). Of the 133 patients, 88 had dementia, and 58 had a history of other neurological disease (cerebrovascular disease or Parkinson’s disease) according to the medical records.

Table 1 Basic results

Table 1
Basic results

 

A comparison of the variables between the oral intake and non-oral intake groups is shown in Table 2. There were no significant differences between the two groups in age, sex, or disease conditions. Regarding the swallowing measures, the non-oral intake group showed significantly higher rates of impaired GWST (p < 0.001) and impaired FILS (p < 0.001) compared with the oral intake group. The non-oral intake group also showed significantly higher rates of physical dependency (p = 0.005), but not impaired comprehension (p = 0.593). Regarding nutritional status, the non-oral intake group showed significantly higher rates of decreased MUAC (p < 0.001), but not decreased CC (p = 0.231) or low serum albumin levels (p = 0.139).
The result of multivariate regression analysis showed that the significant and independent predictors of oral intake difficulty were decreased MUAC (odds ratio = 4.67; 95% confidence interval: 1.49, 14.70; p = 0.008) and impaired GWST (odds ratio = 3.62; 95% confidence interval: 1.63, 8.07; p = 0.002).

Table 2 Comparison between the oral intake and non-oral intake groups

Table 2
Comparison between the oral intake and non-oral intake groups

*GWST: graded water swallowing test (impaired: <4, failure with the 3 mL plain water trial); **FILS: food intake level scale (impaired: <5, difficulty in consuming a meal, even with the use of easy-to-swallow foods); ***MUAC: mid-upper arm circumference (decreased: men <22.5 cm, women <20.8 cm); ****CC: calf circumference (decreased: men <31.3 cm, women <29 .9 cm)

 

Discussion

Of the 113 patients, 91 achieved sufficient oral intake until the end of hospitalization whereas 42 did not. No significant differences were observed in demographic variables (age and sex) or disease conditions between the oral intake and non-oral intake groups. Considering that the prevalence of dementia and other neurological conditions was not significantly different between the two groups, it was unlikely that the oral intake difficulty in the present subjects was related to such neurological conditions.
The results showed that impaired GWST, impaired FILS, physical dependency, and decreased MUAC were the significant predictors of poor oral intake. The independent association between decreased MUAC and poor oral intake suggests a non-negligible influence of significant body mass loss on oral intake behavior in older patients with dysphagia. Considering that some authors have suggested that MUAC, more so than CC, reflects end-stage decline (9) and that CC is seemingly affected by ambulatory status, a significant reduction in MUAC may be a better indicator of profound changes in body mass compared with that in CC. Therefore we postulated here that advanced body mass reduction was associated with oral intake difficulty. One hypothesis is that general and profound reduction of muscle mass and function extends into the head and neck region, which leads to the disruption of the swallowing mechanism, resulting in impaired efficiency and safety of swallowing. This hypothesis can be explained based on the concept of sarcopenic dysphagia (10). Another hypothesis is that profound malnutrition represented by decreased MUAC may be associated with adverse conditions including delay in recovery from illness, susceptibility to infections, and increased comorbidity, fatigue, and psychological distress such as apathy and depression (11, 12), all of which may affect oral intake. We consider that these two hypotheses are not mutually exclusive, and further data are needed to support each hypothesis.
The major limitations of the present study are as follows. First, instrumental assessment of muscle mass and function was not conducted, which may limit the discussion. Second, this was a single-institution study, which may limit generalization from the results.
In conclusion, swallowing impairment, advanced body mass reduction, and physical dependency were the significant predictors of poor oral intake in older patients with dysphagia. Further investigations on the underlying mechanism of the condition are required.

 

Conflicts of interest: The author has no conflict of interest to disclosure, and do not receive any funding for this study

 

References

1.    Serra-Prat M, Hinojosa G, López D et al. Prevalence of oropharyngeal dysphagia and impaired safety and efficacy of swallow in independently living older persons. J Am Geriatr Soc 2011; 59: 186-187.
2.     Carrión S, Cabré M, Monteis R et al. Oropharyngeal dysphagia is a prevalent risk factor for malnutrition in a cohort of older patients admitted with an acute disease to a general hospital. Clin Nutr 2015; 34: 436-442.
3.     Momosaki R, Yasunaga H, Matsui H, Horiguchi H, Fushimi K, Abo M. Predictive factors for oral intake after aspiration pneumonia in older adults. Geriatr Gerontol Int (Epub ahead of print).
4.     Cabré M, Serra Prat M. Force L, Almirall J, Palomera E, Clavé P. Oropharyngeal dysphagia is a risk factor for readmission for pneumonia in the very elderly persons: observational prospective study. J Gerontol A Biol Sci Med Sci 2014; 69: 330-337.
5.     Kuroda Y. Clinical characteristics associated with dysphagia in the hospitalized elderly. J Aging Res Clin Pract 2015; 4: 133-136.
6.     Kuroda Y. Relationship between swallowing function, functional and nutritional status in hospitalized elderly individuals. Int J Speech Lang Pathol Aud 2014; 2: 20-26.
7.     Kunieda K, Ohno T, Fujishima I, Hojo K, Morita T. Reliability and validity of a tool to measure the severity of dysphagia: the food intake level scale. J Pain Symptom Manage 2013; 46: 201-206.
8.     Hosoya N, Okada T, Muto Y et al. Japanese anthropometric reference data 2001 (JARD2001). Jpn J Nutr Assess 2002;19(Suppl): 1-81. (Japanese)
9.     Dent E, Chapman I, Piantadosi C, Visvanathan R. Nutritional screening tool and anthropometric measures associate with hospital discharge outcomes in older people. Austral J Ageing 2015; 34:E1-6.
10.     Wakabayashi H. Presbyphagia and sarcopenic dysphagia: association between aging, sarcopenia, and deglutition disorders. J Frail Aging 2014; 3: 97-103.
11.     Norman K. Richard C, Losch H, Pirlich M. Prognostic impact of disease-related malnutrition. Clin Nutr 2008; 27: 5-15.
12.     Saunders J, Smith T. Malnutrition: causes and consequences. Clinical Medicine 2010; 10: 624-627.

CLINICAL CHARACTERISTICS ASSOCIATED WITH DYSPHAGIA IN THE HOSPITALIZED ELDERLY

Department of Rehabilitation, St. Francis Hospital, Nagasaki City, Japan

Corresponding Author: Yoshitoshi Kuroda, Department of Rehabilitation, St. Francis Hospital, 9-20 Komine-machi, Nagasaki City, 852-8125 Japan, Telephone: +81-95-846-1888, Fax: +81-95-845-7600, Email: kuroda@athena.ocn.ne.jp

Abstract

The aim of this study was to determine the factors associated with dysphagia in the hospitalized older adults. The dysphagia group consisted of 46 patients (23 men and 23 women) while the non-dysphagia group consisted of 40 patients (10 men and 30 women). The measurements included Mini Nutritional Assessment Short-Form (MNA-SF) scores, serum albumin levels, anthropometrics, and a mobility index. The dysphagia group was older and had significantly higher rates of male sex, respiratory disease on admission, dementia, other neurological disease, and impaired mobility than the non-dysphagia group. The dysphagia group also showed significantly lower values in nutritional measurements including MNA-SF scores, serum albumin levels. Logistic regression analysis showed that the factors significantly and independently associated with dysphagia were impaired mobility, dementia, and male gender. The results of present study showed that hospitalized elderly with dysphagia are likely to present with problems including physical and mental disabilities and malnutrition.

Key words: Dysphagia, elderly, hospitalization, disability, malnutrition.

Introduction

Dysphagia is a common condition among the elderly. Recent studies have reported the prevalence of oropharyngeal dysphagia as 27.2% in independently living elderly (1) and 47.4 % in hospitalized elderly (2). Studies have also reported that dysphagia in the older population is associated with malnutrition (2-4), impaired activities of daily living (1, 4), increased rates of lower respiratory tract infection (3, 5), and higher mortality rates (5). These findings clearly indicate that dysphagia is a major health problem in this population.

One reason for the high prevalence of dysphagia in the elderly may be that diseases that can cause dysphagia increase with age (6). However, it is not uncommon to observe elderly patients developing dysphagia in the absence of any disease that is known to directly cause dysphagia. Another reason may be that a wide variety of stressors, such as acute illness, can induce dysphagia because the elderly have a diminished functional reserve available for swallowing (6). Although the latter hypothesis seems plausible, it does not fully explain the underlying mechanism considering that some patients have persistent or progressive dysphagia in the absence of acute illness. Thus, currently there are no well-grounded hypotheses that can account for the underlying mechanism that result in the increased incidence of dysphagia in the elderly.

In order to provide effective intervention, further understanding of the underlying mechanism is mandatory. In the present study, we conducted a retrospective investigation comparing clinical characteristics between those with and without dysphagia among the hospitalized elderly. The aim of this study was to determine the factors associated with dysphagia in hospitalized older adults.

Subjects and methods

Subjects were retrospectively selected from patients admitted to a hospital for acute care between April 2013 and September 2014. Included were patients aged 65 years or older who were rated as having “malnutrition” or being “at risk of malnutrition” by the Mini Nutritional Assessment Short-Form (MNA-SF) (7) and who underwent a series of nutritional and physical assessments as described below. Excluded were those with active malignancy and those with feeding tubes. A total of 86 patients (33 men and 53 women) with a mean age (standard deviation [SD]) of 85.7 (7.7) years were enrolled as subjects. Primary diseases on admission were respiratory disease (n = 46), orthopedic disease (n = 8), digestive disease (n = 7), cardiac disease (n = 6), renal disease (n = 4), inactive cancer (n = 4), and others (n = 11). Patients who were referred to speech therapists for swallowing management during hospitalization were defined as the dysphagia group and those who had no problems with swallowing, as the non-dysphagia group. The dysphagia group consisted of 46 patients (23 men and 23 women) while the non-dysphagia group consisted of 40 patients (10 men and 30 women). The severity of dysphagia was evaluated using the food intake level scale, with a range from 1 (no oral intake and no swallowing training) to 10 (normal oral food intake) (8). The scores of the dysphagia group ranged from 3 to 9 (median = 5) while all subjects in the non-dysphagia group scored 10.

Nutritional assessment included MNA-SF scores, calf circumference (CC), mid-upper arm circumference (MUAC), mid-arm muscle circumference (MAMC), and serum albumin levels. Physical ability was evaluated with a mobility index, measured as follows: 0, completely bedridden; 1, able to sit with a little assistance; 2, able to sit without assistance; 3, able to move from bed to wheel chair with a little assistance; 4, able to move from bed to wheelchair without assistance; 5, able to walk with a little assistance; and 6, able to walk without assistance. cymbalta The two groups were compared for the age, sex, presence of respiratory disease (as a primary disease on admission), dementia, and other neurological diseases, and the above variables. In order to make the analyses more readily comparable, the continuous variables were converted into dichotomous variables based on cut off points. The cut-off points were applied for age (85 or older), MNA-SF score (< 8, suggesting malnutrition), CC (< 31.3 cm for men and < 29.9 cm for women), MUAC (< 22.5 cm for men and < 20.8 cm for women), MAMC (< 19.1 cm for men and < 16.6 cm for women), and serum albumin levels (< 2.8 g/dL). The cut-off points of the anthropometrics were values 2 standard deviations below the normal population aged 40-44 years for each sex (9).

Comparative analyses between the two groups were performed using the Student’s t-test, Mann-Whitney test, and chi square test. Logistic regression analysis was performed using dysphagia as the dependent variable and other dichotomous measures as independent variables. In the multivariate analysis, respiratory disease was excluded from the analysis because it is clearly a frequent result of dysphagia (5). Statistical significance was set at p < 0.05.

Results

Comparison between the dysphagia group and the non-dysphagia group is shown in Table 1. The dysphagia group was older (p < 0.001) and had significantly higher rates of male sex (p = 0.014), respiratory disease on admission (p < 0.001), dementia (p < 0.001), other neurological disease (p = 0.047), and impaired mobility (p < 0.001) than the non-dysphagia group. The dysphagia group also showed significantly lower MNA-SF scores (p < 0.001) and serum albumin levels (p = 0.03), but no significant differences in MUAC (p = 0.141) and MAMC (p = generic cymbalta 0.206) measures. The results from the analysis using dichotomous variables were similar to those from the above analysis using continuous variables with the exception that the dysphagia group exhibited a significantly higher rate of decreased MAMC compared with the non-dysphagia group (p = 0.018), and the difference in the rate of decreased CC did not reach a significant level ( p = 0.090).

Table 1 Comparison between the dysphasia group and non-dysphagia group

Logistic regression analysis showed that the factors significantly and independently associated with dysphagia were impaired mobility (OR 13.70 95% CI 3.43-54.80), dementia (OR 11.0 95% CI 3.01-40.10), and male gender (OR 6.81 95% CI 1.69-27.50) (Table 2).

Table 2 Variables associated with dysphagia (multivariate logistic regression analysis)

Discussion

The dysphagia group was older than the non-dysphagia group, which was consistent with previous studies (1-3, 5). It is of note that our results showed that male gender was significantly associated with dysphagia, which was inconsistent with the findings from Spanish studies (1-3, 5). Considering that a Korean study (10) and a Japanese study (11) also reported the association of male gender with dysphagia, such an association may be related to ethnicity.

Dementia and neurological disease were significantly associated with dysphagia which was consistent with previous findings (2, 5). However, such an association was not observed in a study in independently living elderly (3), which was probably related to the very low prevalence (< 10%) of each condition in the study cohort. Therefore, we consider that the association between dysphagia and dementia or neurological condition is typically apparent only in clinical populations.

The dysphagia group exhibited significantly impaired mobility compared to the non-dysphagia group. Furthermore, the multivariate analyses showed that impaired mobility was the most important predictor of dysphagia. Given that many studies have also demonstrated the association between dysphagia and activities of daily living in the elderly (1-5), the relationship between swallowing impairment and physical disability is of importance. Recent studies have proposed that sarcopenia is a common underlying cause of impaired physical ability and dysphagia (12-14). Further investigations regarding the effects of the loss of muscle mass and strength on swallowing function are needed.

The dysphagia group showed significantly lower values in the nutritional measures of MNA-SF score and serum albumin levels, suggesting an association between dysphagia and malnutrition. Anthropometric assessment using dichotomous variables also showed that the dysphagia group had significantly higher rate of decreased MAMC, suggesting a reduction of muscle mass may be a predictor for dysphagia. The difference in CC lost significance after applying the dichotomous variables, which was probably related to the very high prevalence (85% or more) of the decreased condition.

Taken together, the results of the present study showed that older patients with dysphagia are likely to present with impaired mobility, dementia, and malnutrition. The results were mostly consistent with recent findings (2-5). We consider that dysphagia in elderly patients is rarely a condition specific to the swallowing mechanism, and in many cases, it can be understood as part of a systemic decline including physical, mental, and nutritional deterioration. Currently, there is no sound evidence that traditional dysphagia intervention techniques are effective for this clinical population. Given that many countries are facing challenges associated with aging populations, there is a great need to clarify the underlying mechanism of dysphagia in the elderly in order to improve its prevention and treatment.

The limitations of this study were as follows: First, the study sample was small and obtained from one institution, which may limit the generalization of the results. Second, dysphagia was assessed only with an observational scale. Third, the cross-sectional design did not allow for causative analysis.

In conclusion, hospitalized elderly with dysphagia are likely to present with problems including physical and mental disabilities and malnutrition.

Conflicts of interests: The author has no conflict of interest to disclosure, and do not receive any funding for this study.

 

References

1. Serra-Prat M, Hinojosa G, Palomera E, Arreola V, Clavé P. Prevalence of oropharyngeal dysphagia and impaired safety and efficacy of swallowing in independently living older persons. JAGS 2011; 59: 186-187.

2. Carrión S, Cabré M, Monteis R, Roca M, Palomera E et al. Oropharyngeal dysphagia is a prevalent risk factor for malnutrition in a cohort of older patients admitted with an acute disease to a general hospital. Clin Nutr 2015; 34: 436-442.

3. Serra-Prat M, Palomera M, Gomez C, Sar-Shalom D, Saiz A et al. Orpharyngeal dysphagia is a risk factor for malnutrition and lower respiratory tract infection in independently living older persons: a population-based prospective study. Age Aging 2012; 41: 376-381.

4. Wakabayashi H, Matsushima M. Dysphagia assessed by the 10-item eating assessment tool is associated with nutritional status and activities of daily living in elderly individuals requiring long-term care. J Nutr Health Aging 2015. doi:10.1007/s12603-015-0481-4.

5. Cabré M, Serra-Prat M, Force LI, Almirall J, Palomera E et al. Oropharyngeal dysphagia is a risk factor for readmission for pneumonia in the very old persons: observational prospective study. J Gerontol A Biol Sci Med Sci 2014; 69: 330-337.

6. Ney D, Weiss J, Kind A, Robbins J. Senescent swallowing: impact, strategy and interventions. Nutr Clin Pract 2009; 24: 395-413.

7. Kaiser ML, Bauer JM, Ramsch C, Uter W, Guigoz Y et al. Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging 2009; 13: 782-788.

8. Kunieda K, Ohno T, Fujishima I, Hojo K, Morita T. Reliability and validity of a tool to measure the severity of dysphagia: the food intake level scale. J Pain Symptpm Manage 2913; 46: 201-206.

9. Hosoya N, Okada T, Muto Y, Yamamoru H, Tashiro T et al. Japanese anthropometric reference data 2001 (JARD 2001). Jpn J Nutr Assess 2002; 19(Suppl): 1-81 (Japanese).

10. Yang EJ, Kim MH. Lim JY, Paik NJ. Oropharyngeal dysphagia in a community-based elderly cohort: the Korean longitudinal study on Health and Aging. J Korean Med Sci 2013; 28: 1534-1539.

11. Furuta M, Komiya N. Akifusa S, Shimazaki Y, Adachi M et al. Interrelationship of oral health status, swallowing function, nutritional status and cognitive ability with activities of daily living in Japanese elderly people receiving home care services due to physical disabilities. Community Dent Oral Epidemiol 2013; 41: 173-181.

12. Kuroda Y. Relationship between swallowing function, functional and nutritional status in hospitalized elderly individuals. Int J Speech Lang Pathol Audiol 2014; 2: 20-26.

13. Wakabayashi H. Presbyphagia and sarcopenic dysphagia: association between age, sarcopenia, and deglutition disorders. J Frail Aging 2014; 3: 97-103.

14. Maeda K, Akagi J. Sarcopenia is an independent risk factor of dysphagia in hospitalized older people. Geriatric Gerontol Int 2015. doi:10.1111/ggi.12486.

AN EXPLORATORY STUDY OF THE MEALTIME EXPERIENCE OF OLDER PEOPLE WITH DYSPHAGIA

S. Ullrich1, J. Buckley2, J. Crichton3, A. Esterman4

 

1. University of South Australia Adelaide, South Australia; 2. Medical Statistics, Chair of Biostatistics Sansom Institute of Health Service Research and School of Nursing and Midwifer; 3. Nutritional Physiology Research Centre Sansom Institute for Health Research University of South Australia; 4. Program Director School of Communication, international Studies and Languages University of South Australia.

Corresponding Author: Sandra Ullrich, Research/ Consultant, University of Sout Australia, Nursing and Midwifery, GPO BOX 2471, Adelaide, South Australia 5001, Australia, +61883022749, work: +61882911079, FAX: +6182911085, Sandra.Ullrich@ unisa.edu.au

 

Abstract

People with dysphagia are at high risk of malnutrition. To maintain safe oral intake, solid food may be texture modified but this is associated with a reduction in the enjoyment of the eating experience. A recent approach to improving the enjoyment of eating texture-modified food has been to mould the food into the shape of the food that has been modified. The aim of this exploratory study was to describe and explain the mealtime experience of older people with dysphagia. Design: Qualitative and exploratory. Participants: In total, thirty http://cymbaltaonline-pharmacy.com/ five participants (nursing, care workers, lifestyle assistants, catering staff and residents) were involved in non-participant observations and individual interviews for the qualitative assessment of the eating experience. Intervention: Moulded texture-modified food. The intervention occurred at lunchtime for a period of 3 consecutive days. Qualitative assessment: Non-participant observations and individual interviews were conducted before and after the intervention. Analysis: Interpretative, descriptive and explanatory. Findings: Residents with dysphagia are separated from the dining experience and fostering good relationships between residents at mealtimes may lessen the effects of the challenging eating behaviours that often isolate residents with dysphagia from the dining environment. Non-moulded texture-modified

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food was viewed negatively by all participants and contributed to problems of interaction between care staff and residents by weakening those conversations and interactions that underpin the social dining experience. Residents also experienced difficulties adjusting to texture-modified food. Conclusion: Residents’ experience of adjustment to texture-modified food is difficult and non-moulded texture-modified meal that is unrecognisable and indescribable creates a problem of interaction between care staff and residents during mealtimes. The implementation of moulded texture-modified food has resulted in positive qualitative outcomes in the perception of texture- modified food and has improved the verbal interaction between care staff and residents.

 

Key words: Texture-modified food, elderly, dysphagia, aged care, exploratory.

 

Introduction

Malnutrition remains a recognised problem within residential aged care facilities. Age-related changes and the catabolic effects of acute or chronic diseases place older people at high risk of malnutrition (1). An international review of the prevalence of malnutrition across residential aged care facilities suggests that between 12 percent and 85 percent of residents are malnourished, with up to 100 percent of residents at nutritional risk (1). There is a lack of information on the prevalence of malnutrition in Australian residential aged care facilities. However, a recent study reported the prevalence of malnutrition in a number of Queensland residential aged care facilities to be at 50 percent (2). Furthermore, an investigation into nutritional risk in one residential care facility in Victoria found that 11 percent of residents were underweight and 68 percent had low levels of at least one serum marker, indicating that nearly 75 percent may have been at risk of nutrition related diseases (3).

People with dysphagia are at high risk of malnutrition. Dysphagia is defined as difficulty with swallowing; specifically it refers to a sensation causing one to perceive impairment in the passage of food from mouth to stomach (4). Up to 60% of residents in residential aged care facilities experience dysphagia (4). Dysphagia is a common condition, especially among people with disability and those of increasing age. Improving the delivery of nutritional care to older people with dysphagia will be an increasingly important healthcare issue because of the ageing population (5).

Dysphagia is an important safety concern for health care providers because it affects eating habits by causing anxiety or panic during mealtimes and leads to feelings of social isolation and depression (6-8). To maintain safe oral intake, solid food may be texturally modified according to The Australian Standards for Texture Modified Food and Fluids (5). Consequently, texture-modified foods are rarely a diet of choice, but a diet of necessity for individuals with dysphagia if they are to maintain their nutritional needs orally (5). Whilst texture-modification of food decreases consumer acceptance of the meal and diminishes nutritional intake (9-12), moulded texture-modified food has been shown to increase the nutrient intake and body weight of older people with dysphagia (13). However, the association between texture-modified food and the

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concept of nutritional `necessity’ has resulted in little research in this area and the identification of a number of knowledge gaps related to standardised production, inappropriate use of texture-modified food, the nutritional quality and low acceptability of texture-modified food (13, 8). Although the issues associated with the use of texture- modified foods has become increasingly recognised (8), few studies exist which explore, describe and explain the mealtime experience of older people with dysphagia.

 

Design, methods and setting

The study was conducted by the University of South Australia, in collaboration with Medirest Australia which provides specialist food, hospitality and support services to some hospitals and seniors living in residential aged care facilities throughout Australia, and Eldercare which is a large aged care provider currently offering approximately 1000 licensed aged care beds across 12 sites in metropolitan Adelaide and the Yorke Peninsula in South Australia. The study was conducted across two

(i.e. Site A and Site B) of Eldercare’s aged care sites. The study was approved the University of South Australia’s Human Research Ethics Committee in 2013. In order to participate in the study all participants were asked to provide written consent.

Design

This exploratory study seeks to find how older people with dysphagia experience mealtimes within a isotretinoin accutane residential aged care context and what concerns them. This study is also explanatory as it seeks to describe the effects of moulded texture-modified food on the mealtime experience of older people with dysphagia (14). The following questions will be explored:

1. What factors that influence the delivery of texture- modified food to older people with dysphagia.

2. How does moulded texture-modified food enhance the mealtime experience of older people with dysphagia compared to non-moulded texture-modified food?

3. Why does moulded texture-modified food enhance the mealtime experience of older people with dysphagia compared to non-moulded texture-modified food?

Non-moulded texture-modified food refers to pureed food that is shapeless and does not resemble the food that it represented prior to its modification. Moulded texture- modified food refers to pureed food that is formed into the shape of the food (e.g. broccoli, carrots, peas, fish etc…) that it represented prior to its modification. It is shaped using durable food grade polypropylene moulds.

For this study, the moulded texture-modified food was not flavour enhanced or coloured. The intervention occurred at lunchtime for a period of 3 consecutive days. All participants received the same menu cycle (i.e. a series of menus planned for a particular period of time) and the texture was adjusted for all residents, when needed, with the assistance of a dietician.

Participant inclusion and exclusion criteria

Thirty-five participants (nursing, care staff, catering staff and residents) were involved in the non-participant observations and individual interviews were conducted with twenty-nine care staff (nursing, care workers, lifestyle assistants and catering staff) and 6 residents. All participants were screened according to the following inclusion or exclusion criteria:

Inclusion criteria

1. Residents aged between 65 and 95 years of age with dysphagia which is defined as a condition, a disorder or a symptom that may be genetic, developmental, acquired, functional or iatrogenic in origin. It can be caused by structural, physiological and /or neurological impairments affecting one or more stages of swallowing, namely the preparatory, oral, pharyngeal, and/or oesophageal stages. This may present as a difficulty with sucking, drinking, eating, controlling saliva, protecting the airway or swallowing (1).’

2. Residents able to provide informed consent (or consent was provided by residents’ next-of-kin/legal representative).

3. Care staff (i.e. nurses, care workers and catering staff) able to provide informed consent.

Exclusion criteria

1. Terminally ill residents receiving palliative care were excluded from the study.

Methods

Overt non-participant observations were collected, through field notes, by the primary researcher before and during the intervention of moulded texture-modified food. The observation schedule was informed by Spradley’s (1980) Developmental Research Sequence to observational data collection (15). Non-participant observations provided information about the behaviours, actions, and interactions of the participants in order to understand complex situations. The primary researcher conducted non-participant observation which allowed for the identification of relevant questions for subsequent individual interviews (15). Semi- structured individual interviews were also conducted to provide descriptive data and explain the patterns and associations between experiences, behaviours and perspectives, and relevant characteristics of the study population. Data collection continued until data saturation was reached. The interview data was transcribed verbatim and were returned to participants for member checking (16, 17). Triangulation was used to check the integrity of, and extend the inferences drawn from the data (18). Data management was conducted using NVIVO 9 data management software (19).

Analysis of non-participant observation field notes and individual interview data was qualitative and conducted by the primary researcher, using the interpretative, descriptive and explanatory approach of the Analytic Hierarchy (20, 21). The Analytic Hierarchy is described in the form of conceptual scaffolding where the process of data management and analysis is non-linear across nine `viewing platforms’. The application of the Analytic Hierarchy involved three distinct but interrelated processes: data management, descriptive accounts and explanatory accounts. Data management involved identifying initial concepts and labelling the data by way of indexing. Data with similar properties were located together and associatively analysed by noting the concepts that weaved in and out of each other. The data associated with these central concepts were extracted as evidence for later representation. Descriptive accounts drew on the previous analysis and involved the exploration of data by detection, categorisation and classification with the aim of presenting explanatory accounts that are authentic, meaningful and provide content that is illuminating (20, 21).

 

Findings

The dining environment

Lunchtime commenced at 1200 at Site A and at 1230 at Site B. The architectural design of the mealtime settings were similar, however, aesthetically the environments varied considerably between sites. For example, wall partitions were moveable at Site A and enabled care staff to reconfigure the environment to accommodate a variety of meaningful resident activities, but remained fixed at the other. The mealtime environment was functionally orientated at Site A and presented limited dining cues for residents and care staff, whereas, the mealtime environment was domestically orientated at Site B and provided a number of important dining cues to residents and care staff (22). Dining cues included: the use of table cloths, napkins, placement of condiments on the table and a board to indicate the menu for the day.

Both mealtime environments presented similarities in terms of the clinical and non-clinical activities that occurred during resident mealtimes. The use of a mortar and pestle to crush medications occurred at both sites and medication trolleys were also prominently positioned within the dining rooms at mealtimes. Differences across sites included where care workers chose to cut up resident meals. At Site A, the cutting up of meals was done at the servery and at Site B this was done at the table in front of the resident and only after permission was sought from the resident. A Maître Dee (i.e. a care worker who oversaw the delivery of meals to residents) was found at Site B but not at Site A. White clothing protectors were placed on most residents at Site A, whereas blue checkered clothing protectors were placed on 3 residents at Site B, the rest being provided with white napkins.

Care staff, at both sites, stated that the mealtime environment was noisy, rushed and one care worker said that it felt like a ‘production line’. The dining room had some inherent design challenges that included its large size, the inadequate arrangement of tables, the lack of space and the inappropriate use of wall partitions which had the unintended effect of denying residents who were seated in air-comfort chairs (also known as princess chairs which manage pressure problems and offers much better quality of life for the resident) access to their usual mealtime seating position.

Residents’ (who consumed texture-modified food) seating arrangement at mealtimes varied across the two residential aged care sites. At Site A, seven residents were seated in air-comfort chairs, in a semi-circle, adjacent to the main dining area and not at dining tables; rather over-way tables were used to place the meal upon. At Site B, three residents (seated in air-comfort chairs) were positioned at tables in the main dining area.

Residents’ separation from the dining experience

Care staff were aware of the separation of residents seated in air-comfort chairs from the main dining environment. Terms such as: ‘them and us’, segregation’, ‘isolation’, ‘outcasts’ and being ‘singled out’ were used to describe these residents’ experiences of mealtimes as shown in the following examples:

Care worker [5]: ‘It’s just very ‘them and us’ isn’t it? Sitting in a circle watching each other eat.’

Care worker [1]: ‘People that have the vitamised food are just like outcasts at the moment, sitting in a different area.’

A sense of empathy was found amongst care and catering staff about the seating arrangement of residents in air-comfort chairs:

Catering staff member [1]: ‘I mean Jeff, I mean what is he thinking? He must be thinking ‘Why am I over here and they’re over there?’’

Care worker [3]: ‘I actually empathise, there’s a lady downstairs that sits at a table with three other residents who have normal meals and she has to have vitamised.’

Perceptions of non-moulded texture-modified food

Interviews with care staff and residents found that opinions of the non-moulded texture-modified food were negative. These comments were primarily about the look of the food not appearing appetising:

Resident [1] husband: ‘Oh she’s getting sick of it being vitamised up like that. It doesn’t look nice. I’ll stay here for the evening meal most times and she’ll look at it, but she doesn’t like the look of it. It doesn’t look very nice, but she’s hungry so she eats it.’

Lifestyle assistant (engage residents in leisure and meaningful activities) [1]: ‘I’ve seen a lot of residents look at this and roll their eyes and sort of go ‘eugh’. Like ‘why bother eating that then?’’

Care worker [3]: ‘ That’ s Mond ay, Tuesday, Wednesday, Thursday, Friday, Saturday or Sunday.’

Identification as guess work

Non-participant observations and interviews with care staff and one resident found that ‘guess work’ was involved in an attempt to identify the non-moulded texture-modified food. Neither the care staff nor the residents were aware of what the food was that was being served. The following comments were typical:

Resident [5]: ‘Well I mean I don’t know what it is, I don’t know whether that’s carrots or mango or pumpkin.’ Care worker [9]: ‘You go up to someone and I’ve

had people say ‘oh what’s that?’ and you’re thinking pumpkin, carrot, sweet potato – god only knows and you just take a stab online Paxil in the dark.’

The non-moulded texture-modified meal and problems of interaction

Non-participant observations found that there was a lack of interaction between care staff and residents when serving non-moulded texture-modified food. Care staff were also observed describing the non-moulded texture-modified food in nondescript deictic or generic terms such as ‘this, that, it, lunch, dessert and sweets’. Care staff reported finding it difficult to describe the non-moulded texture-modified meal to residents and to engage with them socially at mealtimes:

 

Figure 1: Non-mounded texture-modified food.

 

Care worker [5]: ‘I guess they all look very similar, so I don’t really know how to explain it to residents.’

Care worker [4]: ‘It doesn’t look like anything, it doesn’t tell you anything and I don’t know what it is, I can’t see what it is.’

Lifestyle [2]: ‘My conversation would be completely different. Reminiscing would be very challenging on the left hand side (non-moulded texture-modified food), but I would be reminiscing with the right side definitely (normal food).’

Care staff described a variety of negative feelings associated with serving non-moulded texture-modified food to residents.

Care worker [6]: ‘I can’t begin to feel happy about serving it myself. How can I be happy about serving something like that if I wouldn’t eat that myself?’

Care worker [4]: ‘I feel terrible putting it in front of her.’

Care staff also described ‘self-conscious’ emotions when serving non-moulded texture-modified food to residents including emotions of guilt, dishonesty and embarrassment as shown in the following examples:

Care worker [4]: ‘I probably feel guilty handing someone food that looks like that (non-moulded texture- modified food) and I mean there are some residents that I do apologise to and wish that it was better. I suppose it’s more of a guilt thing.’

Care worker [9]: ‘If they ask me what they were eating, then it gets tricky because it’s obviously easier to explain to someone who is eating a normal diet what they’re eating and how it looks scrumptious, but if you try and describe the blobs (non-moulded texture-modified food) to someone, you’re like ‘Oh look, that looks like you’ve got some yummy fish there’ but it’s just not sincere, you’re trying, but you’re just looking at it thinking ‘that’s just crap.’’

Care worker [12]: ‘When I take the vitamised diet around, I often feel quite embarrassed.’

 

Figure 2: Moulded texture-modified food (27)

 

Lack of access to the dining experience

Non-participant observations found that residents, who were seated in air-comfort chairs and removed from the main dining area, were accessing the mealtime environment by sight, that is, they Paxil generic were watching what was happening around them and looking at the meal that was served to them.

Staff articulated a number of assumptions about providing eating assistance to residents with dysphagia and in particular those who were seated in air-comfort chairs. These included that these residents were unable to comprehend what was happening around them during mealtimes.

Care worker [1]: ‘You just assume when your dropping off a vitamised meal – one, you have to feed them and two, they’re not going to understand or talk to, or listen to you anyway.’

Care worker [7]: ‘I wouldn’t say anything purely and simply because they probably wouldn’t have a clue what you were saying anyway. You know what I mean, cause they’re very sick.’

The lack of flavour in texture-modified food

Another assumption articulated by care staff concerned the flavour of the non-moulded texture- modified food and that the residents with dysphagia, in particular those seated in air-comfort chairs did not require a flavoursome meal:

Field note:

Care worker giving vitamised meal to Dorothy.

Care worker [12]: ‘Tastes nice?’ Resident: ‘No.’

Care worker [12]: ‘Oh, it does.’

Care worker [1]: ‘Oh they love their salt and pepper. But I think a lot of people do and that’s something we normally don’t give people, like, you don’t serve up a vitamised meal and say ‘would you like pepper on that?’, ‘would you like some salt with that?’ you just assume they don’t.’

Enrolled Nurse [1]: ‘I haven’t actually tasted it. I go more on the visual, if there’s a visual aspect and the food’s well-presented. As long as it is well presented and the plate looks nice.’

Catering [2]: ‘Well, I don’t personally when I’m doing it. If I’m doing chicken rissoles, that’s what I vitamise and I might put a bit of white sauce in it for the liquid. So, I vitamise the same thing anyway. So, no, I don’t think it needs it (flavour enhancement).’

When asked about their opinions of the taste of the non-moulded texture-modified food three residents responded that the food was repetitive and tasteless:

Resident [5]: ‘It’s horrible, there’s no taste and they made it taste like saw dust. They can also leave the meat, it tastes just like chalk.’

Resident [3]: ‘The food’s good, but it’s drab.’ Investigator: ‘So the food is good, but it’s drab?’ Resident [3]: ‘I get my grandson to buy me chutney.’ Investigator: ‘So you put chutney on it? Why is it drab though?’

Resident [3]: ‘It’s just tasteless.’

Investigator sitting with resident in lounge room talking about vitamised food

Resident [4] seated in wheelchair looking down and shaking her head.

Resident [4]: ‘It’s just terrible, same old, same old.’

When residents were asked about whether non- moulded texture-modified required more flavour they responded that flavour was a very important component to their enjoyment of their meal. Importantly, the flavour of a meal also evoked certain memories for some residents:

Investigator: ‘Would you like more flavour in your vitamised meal?’

Resident [5]:’ I had some mango chutney that I put in and that made a hell of a difference.’

Investigator: ‘So flavour is very important to you?’ Resident [5]: ‘Oh yeah, it’s better as a stronger flavour.’ Resident [3]: ‘That’s what I like. You see the thing is I lived in India for many years and of the course the food is ahhhh [smiling]. I used to live in India you see, I had a wonderful cook who knew exactly what I liked, full of spice. I don’t like it hot, but I like it spicy.’

Resident [1]: ‘The spices, mmm’ (smiling) Investigator: ‘The spices?’

Resident [1]: ‘They’re wonderful.’

Investigator: ‘Is there any particular spice that you like?’

Resident [1]: ‘All of them.’

When the residents were asked whether they were involved in any food survey which elicits feedback about texture-modified food, they responded that they had never been asked for their opinions about texture- modified food.

Difficulties adjusting to texture-modified food

A key finding that emerged from the resident interviews was residents’ experiences of their transition from normal food to texture-modified food. Residents stated that the transition was difficult and that eating texture-modified food required some ‘getting used to’:

Resident [3]: ‘I don’t mind either to tell you the honest truth, I got used to it now.’

Investigator: ‘So you had to get used to it?’

Resident [3]: ‘Yes, even now, I mean, as I say, if I didn’t have some chutney or something I wouldn’t eat it. I often don’t.’

Resident [2]: ‘It was hard. I have to get on with it because that’s the way it is. I like skate (a species of fish). I can’t have it – that’s what I have (resident points to non- moulded texture-modified food).’

Wife of resident [6]: ‘Well, when he moved in here nearly 5 years ago he was eating normal food and then it got to the stage where he knew he was getting different food and it was hard for him. If this (moulded texture- modified food) happened twelve months ago, it would have made a difference.’

Resident [2]: ‘It was sort of gradual and there’s no point in being upset about it, cause that’s the way it is.’

Care worker [9]: ‘Maria was devastated having to go on the vitamised, yeah she used to hate it.’

Moulded texture-modified food

Non-participant observations found that there was greater interaction between care staff and residents when serving moulded texture-modified food. Care staff provided more detail about what was being served to the resident as shown in the following field notes:

Field notes:

Care worker [15] ‘Here we go have some carrots, potato, chicken and broccoli and gravy of course.’

Care worker [19] ‘It looks like we’re having fish today, see!’

Care worker [23] ‘It’s broccoli, that’s it, try some broccoli.’

During the individual interviews participants responded positively toward the moulded texture- modified food. Responses included:

Care worker [12]: ‘I think that looks amazing. I think that looks much better. It’s a lot more appetising for the resident. The meal doesn’t look as different to someone else’s, it all looks the same.’

Resident [5]: ‘Oh that looks better. Definitely looks more appetising than those (pointing to non-moulded texture-modified food).’

Investigator: ‘What do you particularly like about it?’ Resident [5]: ‘The way it’s laid out. Looking at that

(moulded texture-modified food), and looking at that (non-moulded texture-modified food) – no comparison.’

Care staff also described positive feelings and ‘self- conscious’ emotions associated with moulded texture- modified food including feeling better and emotions of pride:

Registered Nurse [1]: ‘I would be quite happy with this one, even myself, it looks much better. I would be more proud to offer this food.’

Care worker [12]: ‘I would feel more proud handing that over because it looks more presentable and plus I can tell what each item is.’

 

Discussion

The key findings of this study suggest that the mealtime experience of residents with dysphagia is fraught with a number of challenges. These include the separation of residents with dysphagia (seated in air- comfort chairs) from the dining experience, the negative influence of texture-modified food on the interaction between care staff and residents, and the difficulties experienced by residents with dysphagia as they adjust to texture-modified food.

The first key finding from the study was the identification of two very difference service styles: the service style that incorporated a number of contextualisation cues into the dining experience and the service style that demonstrated limited verbal and visual cues. Bastone’s (22) analysis of the mealtime experience in an industrial setting and Gumperz’s (23) notion of contextualisation cues provide insight into how the mealtime environment can affect the quality of the dining experience for both residents and staff. A contextualization cue has been defined as ‘any verbal or non-verbal sign that helps speakers hint at, or clarify, and listeners to make such inferences’ (23). For example, this might be the rising of the voice as a signal of encouragement to a resident following the successful swallow of a bolus of food. Non-verbal behaviors function as contextualisation cues through laughter, eye contact and touch. Importantly, there is a conceptual link between the artifacts that constitute the mealtime environment and the inferences that people make from these objects (24). Objects that may be found in the aged care mealtime environment include over- way tables, clothing protectors, medication trolleys, barrack-style table arrangements and functional crockery (e.g. lipped plates) and cutlery designed for healthcare. These objects can trigger presuppositions, whereby staff retrieve from their memory the understanding of mealtimes within institutionalised spaces, such as a hospital. Consequently, staff act, either functionally or domestically, according to those presuppositions within the given mealtime space (22). The relationship between contextualisation cues and their influence on our social world (e.g. the social mealtime event) poses further questions concerning the influence that these contextualisation cues have on residents upon entering into a residential aged care facility that espouses a ‘home- like’ dining environment, but where many verbal, non- verbal and artifact contextualisation cues may present otherwise.

The second key finding of this study suggests that care staff hold certain presuppositions toward residents seated in air-comfort chairs and that these chairs (as a contextualisation cue) impose perceived limitations on residents. For example, care staffs’ inability to interact normally with these residents and the inability of residents to respond normally to care staff place certain limitations on the interaction itself. Therefore, when care staff understand, and notice residents’ inability to interact normally (i.e. an understanding that is made tactic through care plans and at handover) interpretive processes are taken for granted and tend to go unnoticed. Consequently, care staff do not react to any new verbal or non-verbal cues sent by the resident or care staff become unaware of the function of these new cues, interpretations may differ and misunderstandings may occur (23, 24). For instance, a finding of this study found that a care worker dismissed a resident’s (seated in an air-comfort chair) negative response to the taste of the food. This response may be due to the care worker’s presuppositions toward the resident seated in the air- comfort chair and that these presuppositions are taken for granted despite the resident’s complaint. Gumperz (25) suggests that when this happens and when a difference in interpretation is brought to a person’s attention, it tends to be seen in attitudinal terms. Consequently, the resident may be perceived as being ‘difficult’ rather than the food actually tasting bad. This then reshapes an entire course of interaction whereby the staff may misinterpret residents need for flavorsome meals. The same cues may be interpreted entirely differently by care staff when a resident is seated at a dining table and on a standard chair. The relationship between the objects that are used within institutional mealtime environments and social interaction poses important questions about the use of contextualisation cues within the mealtime environment and how changing these cues may improve the quality of the dining experience for residents and the service provided by staff.

The third key finding of this study calls for further exploration into how contextualisation cues influence our ‘self-conscious’ emotions. Non-moulded texture- modified food elicited negative responses toward the meal and participants also experienced difficulties describing the components of the meal (i.e. carrots, broccoli etc…). The presence of strong negative feelings and the absence of a description created a problem of interaction between care staff and residents. Importantly, when care staff articulated feelings of guilt and embarrassment at serving non-moulded texture- modified food to residents the role of care staff was compromised because they had to mitigate their negative feelings toward the meal and their inability to describe the meal with the caring value of trust held between the residents and themselves. Tangney and colleagues (26) suggest that our ‘self-conscious’ emotions represent a key element of our human moral apparatus, influencing the link between moral standards and moral behavior. Shame, guilt, embarrassment and pride are members of a family of ‘self-conscious’ emotions that are evoked by self-reflection and self-evaluation. For the care staff in this study, the ‘self-conscious’ emotions of guilt and embarrassment place them in a precarious position of having to find coherence between the truth (e.g. non- moulded texture-modified food is ‘crap’) and articulating a falsehood by encouraging and prompting the resident to eat using positive terminology. The relationship between the aesthetic cue of food and interaction will require further qualitative investigation.

This study shows that moulded-texture-modified food improved the mealtime experience of residents with dysphagia and that preparing food that is recognisable and describable changed the way in which care staff communicated to these residents and how they felt about serving texture-modified food. However, the study demonstrates that residents’ adjustment to texture- modified food was difficult and that these experiences may potentially extend to residents’ families. There is limited available evidence about how older people with dysphagia adjust to texture-modified food, with the majority of research focusing on adjustments to the resident’s diet to maintain or restore the safety of oral feeding (1). Further investigation is required into the nature of adjustment, highlighting the experiences and events as older people with dysphagia come to terms with their swallowing difficulties and changes to their diet.

Whilst evidence suggests that there is some decline in the taste and olfactory receptors of older people, the qualitative findings of this study has found that the flavour of texture-modified food plays an important part in the dining experience of residents with dysphagia. Further investigation is warranted into the use of flavour enhancers and aroma to improve the eating experience of residents with dysphagia. Furthermore, despite food satisfaction being crucial to the mealtime experience of residents and in ensuring adequate nutrition, neither site elicited feedback from residents about their level of satisfaction with texture-modified foods. A survey is warranted that examines the food satisfaction of people with dysphagia, specifically focusing on the domains of meal choice, food characteristics, eating assistance and mealtime experience, anxiety or worry with eating, global satisfaction, swallowing and chewing difficulties.

 

Limitations

Limitations to this study include the exploratory nature of the research and the multiple comorbidities experienced by older people in residential aged care facilities, resulting in the high study withdrawal rate from the initially planned 22 residents in this study trial to 12 residents. Care should be taken when extrapolating findings to other residential aged care facilities.

 

Conclusion

Residents’ experience of adjustment to texture- modified food is difficult and food that is unrecognisable and indescribable creates a problem of interaction between care staff and residents during mealtimes. The implementation of moulded texture-modified food resulted in positive qualitative outcomes in the perception of texture-modified food and improved the verbal interaction between care staff and residents, indicating a more positive dining experience. Further targeted research is required into this important area of nutritional care in order to ensure that all residents are provided with nourishing, tasty and socially inclusive meals.

 

Conflict of interests: None

 

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