34.Dysphagia Severity Scale, Dysphagia Grade, and Food Intake LEVEL Scale

Explanation

Dysphagia is classified according to severity using a number of approaches. In this module we learn about 3 assessments that are widely used in Japan: the Dysphagia Severity Scale, the Dysphagia Grade, and the Food Intake LEVEL Scale. These scoring systems are not overly complicated, so they are convenient for sharing information about a patient's condition in a team and providing information to other medical centers.

Explanation

The Dysphagia Severity Scale (DSS)^1-4 is a 7-point ordinal scale (a sequential scale where the distances between points are not equal; i.e. the difference between DSS scores 1 and 2 does not equal the distance between DSS scores 3 and 4). The DSS measures clinical severity, so it allows determinations to be made at centers that can't perform swallowing fluoroscopy or endoscopy. Note, however, that performing these examinations when possible may enhance the accuracy of DSS. DSS measurements allow us to determine ways of dealing with a patient's dysphagia (including types of foods that can be eaten without causing aspiration), whether tube feeding is required, and whether dysphagia training is needed.

Explanation

The DSS has seven grades scored from 1 to 7 (1 indicates greatest severity; 7 indicates within the normal range). Clinically, cases of aspiration are scored between 1 and 4, and cases of no aspiration are scored between 5 and 7.

Explanation

DSS scores indicate the type of diet that can be managed safely. A DSS score of 7 indicates a regular diet is acceptable. In many cases with a DSS score of 6, soft foods such as soft-cooked rice or vegetables are required. A DSS score of 5 signifies little pharyngeal impairment, so we can consider providing foods that need little mastication and can be readily transported to the pharynx. A DSS score of 4 indicates that a range of preventive measures against aspiration can be effective, meaning that many types of food can be eaten safely, and a regular diet is possible in some cases. A DSS score of 3 indicates that a thickening agent must be added to liquids and liquid food. DSS scores of 1 and 2 indicate tube or intravenous feeding is required.

Explanation

When only a small amount of food can be eaten orally or oral feeding isn't possible due to other medical factors, a gastric fistula is required. A DSS score of 7 does not necessitate direct training. DSS scores of 3 to 5 indicate that direct training is possible at general medical centers. A DSS score of 2 indicates that the risk of aspiration is high. This means that swallowing fluoroscopy and/or endoscopy examinations are needed, so the patient should initially go to a center offering specialized training by a speech therapist, and direct training is possible with careful attention to the types of food provided and patient posture. A DSS score of 1 indicates that direct training is not possible even at a specialized medical facility. Indirect training is possible in cases of a DSS score of ≤ 6.

Explanation

The first step in assessment with the DSS is to determine whether aspiration is occurring. If there is no aspiration, the DSS score will be at least 5. Many elderly patients with dentures have a DSS score of 6. With problems in the anticipatory, preparatory, and oral stages, the DDS score is 5 . When patients are suspected of having clinical aspiration, the DSS score of ≤ 4. When aspiration is suspected with a solid-liquid mixture such as miso soup, the DSS score is 4. When aspiration after water intake is suspected, the DSS score is 3. DSS scores 1 and 2 correspond to patients who show aspiration after solid food intake: DSS score 2 is used in medically stable cases and DSS score 1 is used in medically unstable cases, when aspiration of saliva is considered to occur regularly at night.

Explanation

The DSS is an assessment of severity, so it does not reflect what foods are actually being provided. In other words, when an assessment is actually performed, we may encounter issues, for example, where the patient was assessed as water aspiration but eats a regular diet, or the patient is tube fed even though minor problems were determined on the assessment. Accordingly, we need a separate assessment of eating status distinct from the assessment of severity, and there is a scale for that purpose. This scale involves whether a modified diet is provided or not and involves comparing calorie amounts for food provided by oral feeding and by tube feeding, which is easy to understand conceptually. Also, because medical problems happen if the actual feeding status does not match the severity assessed, the scale has the aspect of medical safety and here we state whether or not the patient is in an unsafe or problematic situation.

Explanation

The Dysphagia Grade^5、6 is a functional assessment tool for determining whether the patient is capable of feeding and swallowing. The Food Intake LEVEL Scale^7-9 is a performance assessment tool for determining the patient's actual feeding and swallowing. When the patient's feeding and swallowing capabilities match their performance, the Dysphagia Grade and Food Intake LEVEL can produce similar results; however, inconsistencies between Dysphagia Grade and Food Intake LEVEL scores are relatively common due to factors extrinsic to the patient.

Explanation

The Dysphagia Grade is scored on a 10-point ordinal scale (grade 1 indicates the most severe dysphagia; grade 10 indicates no dysphagia). Grades 1 to 3 indicate that food cannot be taken orally, Grade 4 indicates oral feeding that can be pleasurable. Grade 5 or above indicate that at least one meal can initially be eaten orally. Grade 7 or above indicate that no supplemental nutrition is required. The symbol "A" is added to the score if dietary intervention is needed (eg. Grade 7A).

Explanation

The Food Intake LEVEL Scale is a 10-point ordinal scale (level 1 indicates the severest condition; level 10 indicates no food intake problems). At levels 1 to 3, meals are not being eaten orally. At levels 4 to 6, supplemental nutrition is required. At level 7 or above, 3 meals are eaten orally and no supplemental nutrition is required.

Explanation

Dysphagia Grade 2 means that only basic dysphagia training-direct training-is possible. Dysphagia Grade 3 and above means that feeding training-indirect training-can be initiated. Food Intake LEVEL 3 means that training is provided for oral feeding but meals are not eaten orally. The difference between Food Intake LEVELs 9 and 10 concerns the presence of any problems suggesting dysphagia.

References

1. Saito, E.: Japanese Ministry of Health and Human Services Grant-in-Aid for Scientific Research 1999 Financial Year (Comprehensive Research on Aging and Health). Comprehensive Study on Treatment and Handling of Dysphagia (in Japanese). Comprehensive Report. Comprehensive Study on Treatment and Handling of Dysphagia. Research Report for Japanese Ministry of Health and Human Services Grant-in-Aid for Scientific Research, 1999 Financial Year (in Japanese). 1999, pp. 1-17.
2. Baba M. Saito E.: Indications for Dysphagia Rehabilitation (in Japanese). Journal of Clinical Rehabilitation. 9(9): 857-863, 2000.
3. Saito E.: Therapeutic Strategies for Dysphagia (in Japanese). Journal of Clinical Rehabilitation. 41(6): 404-408, 2004.
4. Kagaya H., Okada S., Saito E.: Dysphagia Rehabilitation (in Japanese). Respiratory Medicine. 10(3): 230-236, 2006.
5. Fujishima I.: Dysphagia in Stroke Patients (in Japanese). Ishiyaku Publications Inc. Tokyo, 1993, p 72.
6. Fujishima I., Takahashi H.: Development of Dysphagia Training (in Japanese). Sogo Rehabilitation 43:S249, 2006.
7. Fujishima I., Ono T., Takahashi H., et al.: Food Intake LEVEL Assessment - Development of a Simple Assessment Scale for Feeding and Swallowing (in Japanese). Journal of Clinical Rehabilitation, 43: S249, 2006.
8. Kunieda K, Ohno T, Fujishima I, et al.: Reliability and Validity of a Tool to Measure the Severity of Dysphagia: The Food Intake LEVEL Scale. Journal of Pain and Symptom Management 2012 [Epub ahead of print].
9. Fujishima I.: Importance of a Team Approach; Saito E., Mukai Y. (ed.): Dysphagia Rehabilitation (2^nd edition) [in Japanese], Ishiyaku Publications Inc., Tokyo, 2007, pp 114-116.