57.Observation of meals(When to consider discontinuation, how to keep to the conditions)

Explanation

Observation of patients when they are eating allows us to collect information about their eating in a more natural environment than in the strange environment of videofluoroscopy with its set procedures that can make patients nervous. Observation is also helpful during ongoing training because it allows us to determine whether we are achieving the desired effect and to identify any gaps in information provided by the family.

Choose a position that allows for detailed observation. To ensure that information is obtained in a more natural environment, we need to consider, for example, not standing in front of patients as they eat and not talking to them to minimize their awareness of our presence.

Explanation

Important things to look for during observation of appetite are whether patients lose their appetite at the start of a meal or midway through it, refuse to even open their mouth, put a lot of food in their mouth but do not swallow it, and promptly spit out any food put in their mouth. These more often have an unknown cause rather than a localized cause and can be associated with various things such as long-term parenteral nutrition, fatigue from eating, psychological issues, and poor general condition. Measures to address these problems include incorporating their food preferences into their diet, changing food texture (form), changing eating utensils to familiar ones, adjusting mealtimes, selecting where meals are eaten and how the table is set, changing the number of meals provided, having a caregiver provide assistance, considering how medications may be affecting eating, improving the general condition (including issues such as diarrhea and constipation), having patients urinate or defacate before meals, reducing stress, promoting mobilization and increasing activity (to increase sensation of hunger), and having patients use their own hands to eat. Note that we must be mindful when incorporating preferences into their diet and changing food texture because they can actually reduce appetite if patients get tired of eating the same monotonous diet every day.

Explanation

The act of eating begins with the sensory recognition of food. Important things to look for during observation of food recognition include whether or not patients do the following: maintain the same level of alertness while eating, can concentrate while eating, try to bring food to their mouth, stop eating movements while food is still in their mouth, stuff their mouth with food, become aware of all the food on the table, eat different dishes in a balanced manner, forget to eat. Pay careful attention to whether they maintain the same level of alertness while eating and whether they can concentrate while eating because these greatly contribute to the risk of aspiration and silent aspiration. Measures to address problems with alertness level include the following: (1) increasing their daily activity level by measures such as ensuring that they are under stimulation outside of meal times, getting them adjusted to a daily routine, encouraging mobilization, increasing time spent sitting up against gravity, performing standing exercises, and keeping the body parts used in eating (eg, mouth, pharynx, hands, and face) clean to ensure they always feel fresh and clean; and (2) mealtime measures such as verbally encouraging them to eat (while also avoiding mixing in numerous instructions and commands), increasing their awareness of food using their 5 senses, adjusting tableware and food presentation, assisting them with eating movements by guiding their hands, stimulating procedural memory, changing food to a safe texture, eating with a caregiver, and adjusting posture, as well as ensuring proper medication use. Measures to address problems with concentration require changes ot the environment that allow patients to concentrate on their meals, such as muting or turning off the television during mealtimes, avoiding excessive conversation during meals, staggering mealtimes with other patients, deciding whether to have them eat in the cafeteria or in their room, blocking out external stimuli using a partition or curtain, and ensuring that their gaze does not turn away from their food as they eat. Patients with food recognition problems are prone to aspiration due to early termination of eating movements or a time lag before swallowing. So, guidelines for when to discontinue oral eating should be created at the same time as we are creating measures to help these patients with eating.

Explanation

Important things to look for during observation of mastication and food bolus formation include whether patients can determine what food needs to be masticated, can bite off food with their anterior teeth, bring an appropriate amount of food to the mouth, can crush food using their tongue and palate, can use the tip of their tongue to move food onto the molars, create a food bolus by mixing food with saliva, and move the mandible not only up and down but also sideways. Mastication by nature involves coordinated movements, so we need to assess relationships with the teeth, lips, tongue, cheeks, masticatory muscles, saliva, and so forth. Other things that should be observed in patients with issues such as dental caries, periodontal disease, and poorly fitting dentures include how hard the food can be for them to bite and whether they can adequately form food boluses in such circumstances. These problems can naturally be addressed with treatment of the primary disease, but other measures include providing dental treatment and denture adjustment, changing food texture, watching for aspiration during swallowing of mixed solids and liquids, assisting with opening and closing of the mouth, and performing motor exercises for oral structures.

Explanation

Important things to look for during observation of the movement of food into the pharynx include whether the lips close, whether each mouthful amount is appropriate, mastication is sufficient, food bolus formation is sufficient, they have poor posture causing them to face downward, they face upward during bolus transport, the tip of the tongue is touching the gums, and velopharyngeal closure is occurring. These problems can be caused by poor sensory recognition of food, poor intraoral sensation, anorexia, swallowing apraxia, reduced tongue motor function, and velopharyngeal insufficiency. Approaches to take towards these problems include assisting with lip closure, assisting with mouth opening and closing movements, assisting with masticatory movements, assisting to promote voluntary tongue movements, adjusting posture (eg, by reducing the reclining angle), offering meals that incorporate their food preferences, serving thickened liquids and food that does not easily stick in the mouth, spooning food into the mouth at the back of the tongue, handing spoonfuls of food to them, using 2 spoons to assist food transport, performing motor exercises for oral structures, performing exercises by blowing or using party blowers, and stretching the buccal mucosa or tongue. Moving food into the pharynx is strongly associated with triggering of the swallowing reflex, so not being able to effectively move food into the pharynx will also affect triggering of the swallowing reflex, which can result in reduced food intake due to prolonged overall mealtime duration and fatigue. So, we need to look out for these problems during observation.

Explanation

Important things to look for during observation of triggering of the swallowing reflex include whether patients have difficulty in swallowing food that has accumulated in the mouth, they complain that they can't swallow despite trying to swallow, food texture is appropriate for their eating and swallowing abilities, the meals served incorporate their food preferences and stimulate their appetite, each mouthful amount is appropriate for their eating and swallowing abilities, the lips are closing, velopharyngeal closure is occurring, they understand verbal instructions well enough, and they are motivated and prepared to eat. Swallowing after food has accumulated in the mouth for a long time prolongs overall mealtime duration and causes fatigue, and delayed swallowing can cause aspiration, so observe patients specifically to identify these issues. Measures to address these problems include changing food texture to make it easy to swallow, introducing taste stimuli, adjusting posture (eg, anteflexing the neck to prevent aspiration), having them eat with their hands instead of utensils, applying a light pressure stimulus to the back of the tongue with a spoon, performing direct or indirect swallowing training to trigger the swallowing reflex, and improving awareness of swallowing. With patients with swallowing apraxia, note that we need to take the opposite approach, by reducing their awareness of swallowing.

Explanation

The posture is very closely related to eating and swallowing mechanisms. Inappropriate posture, including deteriorating posture, generally increases the risk of aspiration. Important things to look for during observation of posture include whether the body is symmetrical and well balanced, patients can continually maintain a relaxed posture while eating, posture doesn't deteriorate over time, they are not experiencing excessive strain or discomfort, breathing and circulation are stable, their hips are not sliding forward when they sit, the soles of their feet are touching the ground, their body is stable with the face forward, laryngeal elevation is not restricted, the entire length of each arm is stable, arm movement is not restricted, their ability to eat and swallowing has not decreased due to fatigue, and the table has been set to ensure that food is highly visible. Approaches to consider towards these problems include filling excessive gaps between the trunk and the chair of bed, ensuring stability of the arms and soles of the feet, reducing pressure on the back when the bed is elevated, pulling in the jaw and anteflexing the neck, and ensuring arm stability by adjusting table height or position. These will reduce strain and discomfort and enable patients to maintain stable breathing and circulation and a relaxed posture. Adjusting posture in an appropriate way to alleviate symptoms is essential to helping patients eat safely.

Explanation

Evaluation of bringing of food to the mouth should consist of more than a simple evaluation of the upper arm function and ability to use utensils; comprehensive assessment that also considers cognitive function is required. Important things to look for include whether patients can correctly recognize food and utensils and start making eating movements, can recognize the placement of food and utensils, can use utensils to bring food to the mouth (ease of utensil use), and can safely eat without their posture changing (endurance). Observation of whether they can use utensils to bring food to the mouth should not consist solely of general observation of how they use all utensils, but should also look at various specific actions such as correct use of each type of utensil (spoon, fork, and chopsticks) and portioning or cutting the food into bite-size pieces and scooping, stabbing, grabbing, and grasping these pieces using the utensils. We also need to look at whether patients use utensils to bring food to their mouth after reaching for food. When observing whether they can safely eat without their posture deteriorating (endurance), we need to observe whether posture is changing and whether choking, coughing, food bolus propulsion, and aspiration are occurring when they eat while in that posture. Observe where and how they are served meals (eg, with them on the bed, in a wheelchair, or in a chair) and whether they actually need caregiver assistance because these aspects are closely related to bringing food to the mouth. Various things can affect bringing food to the mouth, including restricted joint range of motion, paralysis of the dominant hand, impairment of fine motor skills in the fingers, apraxia, agnosia (not being able to recognize the distance from tableware to the mouth), ataxia, deteriorating posture, and fatigue. Measures to address these problems include verbally guiding the patient as appropriate, assisting with eating movements, simplifying procedures for bringing food to the mouth, selecting appropriate tableware and utensils (ie, tableware that is easy to scoop from, spoons that are easy to put in the mouth, and tableware and utensils that don't require neck extension), changing utensils to suit different food types, adjusting posture so that it's stable and relaxed, being aware of pace and fatigue level during eating, using a table and cushion to stabilize the arms, using an approach that allows them to use their hands, incorporating the unused hand, and switching hand dominance.

Explanation

Important things to look for during observation of mouthful size include whether mouthful size is much too large or too small, the lips are closing, the swallowing reflex is not easily triggered, and patients are choking or coughing due to laryngeal penetration or aspiration. A mouthful is generally defined as the amount of food put into the mouth at one time, and the mouthful amount is greatly influenced by early developmental history, diet, and personal habits. Too much of a mouthful impedes lip closure, which leads to reduced swallowing pressure, impaired pharyngeal transit of food, and pharyngeal retention of food. This tends to result in laryngeal penetration or aspiration and can even cause asphyxiation. Conversely, too small of a mouthful reduces intraoral sensation and taste, which impedes food transport movements and impedes or delays triggering of the swallowing reflex. Typically, about one teaspoon is an appropriate mouthful amount to start with. Approaches to consider size include confirming a safe amount in advance on videofluoroscopy, giving verbal advisement, changing to a small spoon, handing patients a spoon containing the appropriate amount of food, and pre-cutting jelly into pieces.

Explanation

Important things to look for during observation of food spilling from the mouth include whether the lips are closing when food is brought to the mouth, whether there is left-right variation in lip closure, mouthful size is appropriate, food is spilling out while being put in the mouth, food is spilling out after being put in the mouth, and whether it is liquids or solids (or both) that are spilling out of the mouth. When observing lip closure, observe not only eating but also other activities of daily living such as speech, and particularly plosive sounds, because these also help with understand patients' lip closure. Measures to address these problems include selecting spoons that are easy to close the lips around, assisting with lip closure and mandible stabilization, adjusting where food is put into the mouth, determining whether mouthful size is appropriate, adjusting food texture or posture, and performing basic exercises to improve oral function (indirect swallowing training). In addition to these various environmental modifications, helping the patient concentrate on lip closure when bringing food to the mouth is effective. Patients will often unconsciously slurp food when trying to avoid spillage as they bring food to their mouth, but we must carefully monitor for this behavior because it can cause a time lag between inhalation and swallowing and can even cause choking.

Explanation

Important things to look for during observation of eating pace include whether the pace is very fast with food taken in one after another and whether patients have cognitive problems. Like mouthful size, eating pace is greatly influenced by early developmental history, diet, and personal habits. Measures to address these problems include encouraging patients to swallow one mouthful at a time, setting the number of times to chew each mouthful, separating food onto small plates, using a small spoon, and teaching patients to pace themselves by guiding their hands. If patients eat slowly, we need to consider problems with overall food intake and fatigue as possible causes in addition to impairment of smooth swallowing movements.

Explanation

Eating pace greatly contributes to mealtime duration. Important things to look for when observing mealtime duration include alertness level when eating, concentration on eating, whether patients have cognitive problems, whether a single meal takes longer than 30 min, motivation to eat, and fatigue. Measures to address these problems include giving verbal encouragement, changing food properties to make food easy to move through the pharynx, offering meals that incorporate their food preferences, adjusting posture to a stable and relaxed position, setting mealtime duration to 45 min to reduce the risk of aspiration due to fatigue, providing (full or partial) assistance if meals are taking too long, and considering whether supplemental nutrition is needed if assistance does not lead to improvement. We should also note whether mealtimes are too short because this increases the risk of asphyxiation.

Explanation

Important things to look for during observation for choking include whether or not patients choke, the frequency and severity of choking, at what stage of eating they chokes, whether they choke on specific foods, and whether they can speak after choking. Choking while eating is a reaction that protects foreign bodies from entering the larynx and trachea and is suggestive of aspiration. However, it can also indicate that the body's protective responses are functioning normally. Measures to address problems with choking include suctioning, adjusting posture, performing deep breathing to relax breathing after choking, carefully resuming eating after breathing has relaxed, adjusting food properties, and serving thickened liquids (with thickening agent). Due care should also be taken to routinely avoid talking during eating to prevent choking and aspiration. If these measures are implemented but oxygen saturation drops 3% below normal or to ≤ 90% during choking, breath sounds on cervical auscultation change rapidly after swallowing, or the mucous membranes of the airway are damaged and their ability to expel foreign bodies is reduced, then aspiration should be strongly suspected. If patients can't speak after choking, they may be suffocating and the meal should be stopped immediately. Whether or not the meal should be continued or not must be determined after thorough examination, identification of the cause and trigger of choking, and observation of improvement in respiratory status.

Explanation

Important things to look for during observation of voice include at what stage of eating (eg, during or after) voice changes occur (whether patients have a gurgling voice indicative of sputum retention) and posture (primarily the angle of the neck). Possible causes of changes in voice include vocal cord paralysis, laryngeal penetration of food, and reduced pharyngeal clearance. Wet voice, for example, is caused by continuous retention of food or sputum above the vocal cords or in the piriform sinus. A hoarse or whispered voice caused by glottic insufficiency is associated with reduced subglottic pressure, a condition that makes patients prone to aspiration. Any of these signs suggest impairment in the pharyngeal stage, such as pharyngeal retention or aspiration. Effective measures to address these problems include breath-holding while swallowing, alternating sides when swallowing, exhaling after swallowing, and clearing the throat. When a patient's voice changes, eating doesn't need to be stopped right away-we can implement these measures and monitor the patient's response for a while. However, careful examination is necessary if the patient shows no change in symptoms because this suggests impairment in the pharyngeal stage (eg, pharyngeal retention or aspiration).

Explanation

Important things to look for during observation of the diet include whether patients avoid certain foods, have dysgeusia, have an oral disease, and have properly fitted dentures. Some patients with dysphagia tend to unconsciously favor foods that are easy to swallow and avoid foods that are difficult to swallow. This is caused by impairment in the oral and pharyngeal stages, which is originally caused by an oral disease, side effects of a medication, or changes in taste threshold associated with stroke-induced hemiparesis. These problems can naturally be addressed with treatment of the primary disease, but other measures include determining the reason for food avoidance based on the properties of avoided foods, changing to foods that are easy for patients to swallow, consulting their doctor about changing medications that cause taste disturbances or oral disease, consulting their dentist about denture fit, and identifying their food preferences and incorporating them into their diet. Of course, we need to consider supplemental nutrition if patients are not receiving adequately nutrition through oral eating.

References

1. Ichiro Fujishima 『Eat by mouth-Dysphagia Q＆A 3rd edition』 (in Japanese) Chuohoki Publishing CO., 2002 47, 68, 96, 130, 131, 138, 139, 141, 146～152, 159, 160, 176
2. Ichiro Fujishima , Hiroshi Uematsu 『Clinical Text Book of Dysphagia』(in Japanese) NAGAI SHOTEN CO. , 2005 84, 85, 131, 179, 180 for PowerPoint revised P85, 2007
3. Ichiro Fujishima & Junko Fujitani et.al 『swallowing rehabilitation and oral care』(in Japanese) Medical Friend CO. 2001 123～125, 60
4. Ichiro Fujishima & Isamu Shibamoto 『Eating and swallowing rehabilitation shown in the video』(in Japanese) Nakayama Shoten CO. 2004 20～25, 29～31
5. Eiichi Saito ・Yoshiharu Mukai et al 『Eating and swallowing rehabilitation JJN special 52 』( in Japanese ) IGAKU-SHOIN Ltd. 1996 30
6. Tamami Koyama et al. 『Eating and dysphagia Oral intake standardization guide』(in Japanese) nissoken 2005 103～106, 173～187, 276～288, 364. 371～376
7. Mana Yamori et al nissoken,1999 『Learn by step method Eating and swallowing rehabilitation』(in Japanese) 17, 39, 42, 126, 134, 135
8. Tetsuji Yoshida et al 『Dysphagia Q＆A』(in Japanese) Medicine and drug Journal. 2001, 129, 190, 192
9. Tamami Koyama et al 『Comprehensive skills to support the happiness of eating by mouth』 (in Japanese) IGAKU-SHOIN Ltd. 2015 20～23, 36～67, 80～87, 96～107, 113～134