Explanation
The first step in conducting a dysphagia assessment is to interview the patient. In this stage, we begin to deduce what kinds of impairment the patient might have and the likelihood of each kind. A medical interview also serves to screen patients before moving on to tests such as the repetitive saliva swallowing test and the modified water swallowing test or more advanced diagnostic tests such as videofluoroscopic evaluation of swallowing. So, we must not only ascertain the patient's subjective symptoms, but we must also intentionally and systematically ask about symptoms related to dysphagia in aggregate in order to identify problematic symptoms or abnormalities. Questionnaires enable us to interview patients in an intentional, systematic, and efficient way. Questionnaires can also be used for other purposes besides screening, including monitoring progress or evaluating the effectiveness of guidance provided.
Although physicians generally conduct the medical interviews in a clinical setting, nurses and other non-physician medical professionals can carry out part of the task by using questionnaires.
This module on the use of screening questionnaires covers question criteria, specific questionnaire content, interpretation of results, and things to note when administering questionnaires. It also covers a recently developed comprehensive assessment tool called the KT Balance Chart.
Explanation
Screening questionnaires, which are designed to help practitioners work out what problems patients might have, must be designed to systematically include not only symptoms such as "difficulty swallowing" or "choking", but also symptoms related to the impairment of swallowing during its various stages (anticipatory, oral, preparatory, pharyngeal, and esophageal stages) and the general symptoms of secondary impairment such as undernutrition, dehydration, and pneumonia. Screening questionnaires also must include objective symptoms that can be observed by family members or other caregivers because the people who eat with patients may detect symptoms that the patients don't report as subjective symptoms themselves.
Accurate screening requires validity, reliability, and reproducibility, as well as cutoff points that are set based on sensitivity and specificity calculated against a gold-standard test such as videofluoroscopic evaluation of swallowing.
The term "gold standard" refers to the diagnostic criteria used to clearly define the presence of a condition or disease and make a true diagnosis.
A cutoff point is the value used to determine whether a test result is positive or negative (abnormal or normal) based on the distribution of test results. In other words, the cutoff point is the point above which the result is considered positive and below which the result is considered negative. If the cutoff point is set too high, the test may overlook people with mild dysphagia.
Explanation
The questionnaires used in Japan are the Seirei Swallowing Questionnaire, the Modified Dysphagia Risk Assessment Scale for elderly persons, the Family-Assessment Scale for Dysphagia Risk of Elderly Persons, and the Japanese version of the Eating Assessment Tool-10 (EAT-10).
The Seirei Swallowing Questionnaire is a scale developed to screen for dysphagia in patients with chronic cerebrovascular disease. The Modified Dysphagia Risk Assessment Scale is a scale developed to screen for dysphagia risk in community-dwelling elderly adults based on subjective symptoms. the Family-Assessment Scale for Dysphagia Risk of Elderly Persons is a scale developed to screen for dysphagia risk in community-dwelling elderly adults based on objective symptoms.
The Japanese version of the Eating Assessment Tool-10 (EAT-10) is the Japanese language version of the Eating Assessment Tool-10 developed by Belafsky et al. in 2008.
Explanation
Here we see the Seirei Swallowing Questionnaire.
Explanation
The Seirei Swallowing Questionnaire is composed of 15 items that reflect patient characteristics such as history of pneumonia, nutrition, oral/pharyngeal/esophageal function, and glottic closure. It has been verified as a reliable questionnaire based on its Cronbach's alpha of 0.85. The alpha value indicates how well all items measure the same properties (ie, internal consistency) and ranges from 0 to 1. A value of 0.7 is good for group-level comparisons, but the value must be 0.90 or higher for measures used to make important decisions at the individual level.
The questionnaire has high sensitivity (92%) and high specificity (90.1%). Sensitivity refers to the percentage of patients identified as having dysphagia by the screening questionnaire divided by that of patients identified as having dysphagia by the gold-standard test of videofluoroscopic evaluation of swallowing. Specificity refers to the percentage of patients identified as not having dysphagia by the screening questionnaire divided by that of patients identified as not having dysphagia by videofluoroscopic evaluation of swallowing.
Explanation
In the Seirei Swallowing Questionnaire, swallowing function over the past 2 to 3 years is evaluated according to 3 grades: "A: Severe or frequent symptoms"; "B: Mild or infrequent symptoms"; and "C: No symptoms". "A" refers to symptoms that clearly impede activities of daily living, and "B" refers to symptoms that are of concern only.
Patients who circle "A" for any of the 15 items is considered to have dysphagia. Patients who circle "B," even for several items, are considered to have suspected or clinically insignificant dysphagia.
Explanation
Here we see the Modified Dysphagia Risk Assessment Scale for elderly persons.
Explanation
The Modified Dysphagia Risk Assessment Scale for elderly persons is composed of 23 items. It has a 4-part structure consisting of items about impairment of swallowing during the pharyngeal stage (No. 1-7), aspiration (No. 8-12), impairment of swallowing during the preparatory and oral stages (No. 13-20), and impairment of swallowing during the esophageal stage (No. 21-23).
Its Cronbach's alpha, a value that indicates how well all items measure the same properties (ie, internal consistency), is 0.92. This value meets the criterion of being ≥ 0.90 for making decisions about important matters at the individual level.
The sensitivity of the scale is 57.1% (sensitivity = the percentage of patients identified as being at risk for dysphagia by the scale's cutoff point [total score ≥ 6 points] divided by that of patients identified as being at risk for dysphagia by the gold-standard test of videofluoroscopic evaluation of swallowing. Its specificity is 56.0% (specificity = the percentage of patients identified as not being at risk for dysphagia by the questionnaire [total score < 6 points] divided by that of patients identified as not being at risk for dysphagia by videofluoroscopic evaluation of swallowing). The sensitivity and specificity are both lower than 60%, which means it is not very accurate. So, it is a good idea to pair it with another test such as a food test.
Explanation
The Modified Dysphagia Risk Assessment Scale for elderly persons asks about the frequency of symptoms during eating over the past 3 months or so and uses a 4-point scale ("always", "sometimes", "rarely", "almost never").
Dysphagia risk is determined by totaling points: 3 points for "always"; 2 points for "sometimes"; 1 point for "rarely"; and 0 points for "almost never". A total score of ≥ 6 indicates that the person is at risk of dysphagia.
Explanation
Here we see the Family-Assessment Scale for Dysphagia Risk of Elderly Persons.
Explanation
The Family-Assessment Scale for Dysphagia Risk of Elderly Persons is composed of 12 items in two categories: (1) impairment of swallowing during the preparatory/oral/pharyngeal stages and (2) aspiration.
Its Cronbach's alpha is 0.89. This value is close to the criterion of ≥ 0.90 for making decisions about important matters at the individual level.
The sensitivity of the scale is 58.3% (sensitivity = the percentage of patients identified as being at risk for dysphagia by the scale's cutoff point [total score ≥ 3 points] divided by that of patients identified as being at risk for dysphagia by the gold-standard test of videofluoroscopic evaluation of swallowing). Its specificity is 50.0% (specificity = the percentage of patients identified as not being at risk for dysphagia by the questionnaire [total score < 3 points] divided by that of patients identified as not being at risk for dysphagia by videofluoroscopic evaluation of swallowing). The sensitivity and specificity are both lower than 60%, indicating it is not very accurate. So, it is a good idea to pair it with another test such as a food test.
Explanation
The Family-Assessment Scale for Dysphagia Risk of Elderly Persons asks about the frequency of symptoms during eating over the past 3 months or so on a 4-point scale ("always", "sometimes", "rarely", "almost never").
Dysphagia risk is determined by totaling points: 3 points are awarded for "always"; 2 points for "sometimes"; 1 point for "rarely"; and 0 points for "almost never". A total score of ≥ 3 indicates that the person is at risk of dysphagia.
Explanation
Here is the Japanese version of the Eating Assessment Tool-10 (EAT-10).
Explanation
The Japanese EAT-10 was completed by forward- and back-translation of the original EAT-10 developed by Belafsky et al. in 2008 to ensure consistency between the two versions, which was then followed by two rounds of preliminary testing.
Its Cronbach's alpha is 0.946. This value exceeds the criterion of ≥ 0.90 for making decisions about important matters for individuals.
Its accuracy has not been compared against videofluoroscopic evaluation of swallowing, which is generally considered the gold standard. However, its sensitivity and specificity have been compared against the Dysphagia Severity Scale (DSS) as a gold standard. The DSS grades severity on a 7-point scale. A score of 7 corresponds to within normal limits, 6 to minimum problems, 5 to oral problems, 4 to occasional aspiration, 3 to water aspiration, 2 to food aspiration, and 1 to saliva aspiration. A score of 6 (minimum problems) or lower is considered to indicate dysphagia, and a score of 4 (occasional aspiration) or lower is considered to indicate aspiration. The sensitivity of the Japanese EAT-10 is 52.2% for dysphagia and 75.8% for aspiration (sensitivity = the percentage of patients with a total score above the cutoff [≥ 3 points] divided by that of patients identified as having dysphagia or aspiration by the DSS). The specificity of the EAT-10 is 89.7% for dysphagia and 74.9% for aspiration (specificity = the percentage of patients with a total score below the cutoff [< 2 points]divided by that of patients identified as not having dysphagia or aspiration by the DSS). So, the Japanese EAT-10 has both high sensitivity and specificity of over 70% for clinically apparent aspiration, but it is good to also perform a physical examination of the respiratory system to detect silent aspiration.
Explanation
The Japanese EAT-10 asks respondents to rate their experiences with swallowing problems on a 5-point scale ("0: No problem" to "4: Severe problem"). Inability to complete this questionnaire ""'or a total score of ≥ 3 points on the 10 items is considered to indicate a high likelihood of problems with swallowing function.
Explanation
The Kuchikara Taberu Balance Chart® (KTBC®) was created by Koyama et al. in 2015 as a tool for comprehensive feeding support. The KTBC is a tool that includes support skills and a care approach for identifying patients' potential and strengths while addressing their weaknesses that can be used as a visual common language to help multidisciplinary teams carry out treatment, care, and rehabilitation.
The KTBC consists of 13 items from the following 4 interlocking perspectives:
- Physical and mental health from a medical perspective (① Willingness to eat, ② Overall condition, ③ Respiratory condition, ④ Oral condition)
- Eating and swallowing function (⑤ Cognitive function while eating, ⑥ Mastication and propulsion, ⑦ Swallowing)
- Position and activities (⑧ Position and endurance while eating, ⑨ Eating behavior, ⑩ Daily living activities)
- Food intake, food modification, and nutrition (⑪ Food intake level, ⑫ Food modification, ⑬ Nutrition)
Explanation
The chart is scored by assigning a score of 1 to 5 for each of the 13 indicators and filling out a radar chart. Next, the patient's weaknesses and strengths are identified, and the specific care approach is planned by assessing the causes of and contributing factors to those weaknesses. The approach laid out by the tool is that a multidisciplinary team should devise a plan to best carry out the treatment, care, and rehabilitation needed to address low-scoring items, in efforts to improve scores by at least 1 point in order to physically and mentally prepare the patient to actively participate in their life. The team should simultaneously work to maintain and strengthen high-scoring items, and repeat this cycle while responding to feedback provided by the results. However, this tool does not simply look at increases in points. The team should take an individualized approach and work to ensure that the results lead to maintaining or improving the patient's QOL. It is also important for team members to properly assess background factors that contribute to the patient's scores in order to determine if the score for a particular item needs to be improved even if the score is the same as that of another item, and to share information with all stakeholders in the patient's care.
Explanation
The reliability and validity of the KTBC have been verified by correlation with the results of eating and swallowing function (Functional Oral Intake Scale; FOIS), ADL (Barthel Index; BI), nutritional status (Mini Nutritional Assessment Short Form; MNA-SF), and cognitive function (Cognitive Performance Scale; CPS). The weighted kappa coefficient for inter-rater reliability was 0.54 to 0.96, and Cronbach's alpha for intra-rater reliability was 0.892. The Spearman correlation coefficients for KTBC score compared with the FOIS, BI, MNA-SF, and CPS were 0.790, 0.830, 0.582, and -0.673, respectively (all p < 0.001). These results demonstrate the tool's reliability and validity.
Explanation
The KTBC reflects a patient's overall situation visually through a radar chart. This allows users not only to evaluate the results but also to see changes over time due to care or interventions, and it can be understood by all stakeholders in the patient's care, including the patient and their family members. This tool has a comprehensive range of features that facilitate feeding support, including that it is usable (simple), allows for evaluation by daily observation (noninvasive), can be completed in a few minutes (convenient), displays the results visually in a radar chart (visual understanding), shows how to address weaknesses (plan-oriented), and reflects the results of interventions (provides feedback).
The approach laid out by the tool is that a multidisciplinary team should devise a plan to best carry out the treatment, care, and rehabilitation needed to address low-scoring items, in efforts to improve scores by at least 1 point in order to physically and mentally prepare the patient to actively participate in their life. The team should simultaneously work to maintain and strengthen high-scoring items, and repeat this cycle while responding to feedback provided by the results. However, this tool does not simply look at increases in points. The team should take an individualized approach and work to ensure that the results lead to maintaining or improving the patient's QOL. It is also important for team members to properly assess background factors that contribute to the patient's scores in order to determine if the score for a particular item needs to be improved even if the score is the same as that of another item, and to share information with all stakeholders in the patient's care.
Explanation
We should note the following points when administering a questionnaire: (1) when having a patient complete a questionnaire directly, the person administering the questionnaire should clearly explain the details, particularly the purpose and methods, to the patient and their family; (2) questionnaire items ask about symptom frequency and severity, but the person administering the questionnaire should not offer their own assessments in an attempt to help the patient or their family member decide on their answers; and (3) screening questionnaires have been tested for accuracy against the results of videofluoroscopic evaluation of swallowing, but because no scale is 100% accurate, it is necessary to understand ranges of validity, reliability, and accuracy when using questionnaires. Also, no subjective scale based on comprehensive assessment is 100% accurate, so it is necessary to understand ranges of validity, reliability, and accuracy when using scales.
References
- Ohkuma R, Fujishima I, Kojima C, et al.: Development of a questionnaire to screen dysphagia. Jpn J Dysphagia Rehabil, 6 (1), 3-8, 2002.
- Fujishima I, Ohkuma R, Kozu R, et al.: Development of a simple questionnaire for dysphagia screening. Ministry of Health and Welfare Grant-in-Aid for Comprehensive Research on Aging and Health 1997 Annual Research Report, 94-99, 1997.
- Fukada J, Kamakura Y, Banzai T, et al.: Development of Dysphagia Risk Screening System for Elderly Persons . Jpn J Dysphagia Rehabil, 2006; 10(1), 31-42, 2006.
- Fukada J, Kamakura Y, Banzai T, et al.: Development of Family-Assessment Scale for Dysphagia Risk of Elderly Persons. Jpn J Dysphagia Rehabil, 10(3), 220-230, 2006.
- Wakabayashi H, Kayashita J: Translation, reliability, and validity of the Japanese version of the 10-item Eating Assessment Tool (EAT-10) for the screening of dysphagia. J Jpn Soc Parenter Enter Nutr, 29(3): 871-876, 2014
- Belafsky PC, Mouadeb DA, Rees CJ, et al.: Validity and reliability of the Eating Assessment Tool (EAT-10). Ann Otol Rhinol Laryngol. 117(12): 919-24, 2008.
- Koyama T, ed: Comprehensive skills for feeding support to promote enjoyment of oral ingestion: Use of the KT Balance Chart and support for use, 2nd Edition, Igaku-Shoin, 2017.
- Maeda K, Shamoto H, Wakabayashi H, Enomoto J, Takeichi M, Koyama T. Reliability and Validity of a Simplified Comprehensive Assessment Tool for Feeding Support: Kuchi-Kara Taberu Index. Journal of the American Geriatrics Society. DOI: 10.1111/jgs.14508. 2016.
