Explanation
The mealtime environment and feeding assistance including eating utensils and posture while eating sometimes influence the occurrence of choking, spilling, and aspiration. In dysphagia especially, aspiration pneumonia and suffocation may result from the mealtime environment and feeding assistance, and malnutrition and dehydration may also occur because of decreased food and fluid intake. If patients have difficulties bringing food into the mouth, adjusting their eating utensils and the mealtime environment can often help them achieve independence in eating.
Adjusting eating utensils and the mealtime environment and providing appropriate feeding assistance are therefore crucial elements in supporting safe independent self-feeding.
Explanation
Welfare equipment is designed for people with disabilities and can be classified into 2 types: one that helps patients become independent and the other that helps caregivers reduce their workload. Self-help devices, which belong to the former category, are designed to help patients with impaired physical function or structural problems perform daily activities safely and independently as possible.
Explanation
A suitable spoon to use is one with a small shallow head and holds 3-4 g of food. It can be put in the mouth easily even when patients have difficulties opening their mouth. The spoon presses on the tongue, and this stimulation triggers mastication and the swallowing reflex. A long, easy-to-hold handle helps caregivers feed patients and also helps patients eat independently.
When holding a spoon with 3 fingers, resting the end of the spoon handle on the thenar will increase stability. An easily maneuverable spoon helps with feeding assistance, and it also helps patients gain independence in eating. The spoon handle should not be held too rigidly, otherwise it can interfere with tongue movements.
Explanation
When a cup is used for drinking, the chin will be elevated, which makes difficult to hold the liquid in the oral cavity. Also, head and neck are likely to be extended. This carries a risk of aspiration. Use of a shallow wide-mouth cup or a cup with a notch on the rim to avoid contact between the nose and cup and allowing patients to sip, hold the liquid in their oral cavity, and swallow without elevating their chin. If they have adequate sucking ability, using of a mug with a straw allows patients to adjust the volume of liquid taken per sip and swallow without elevating the chin.
Explanation
Using a thick and lightweight handle is suitable for patients who have difficulties holding a spoon or a fork because of impaired function or weak arm muscles. Attaching a piece of silicon sponge or the spiral silicon grip to the handle will allow patients with a weak grip to hold the utensils. Also, using a hand-attachable device such as a Universal Cuff and a Will One helps patients hold cutlery and be independent in eating.
Explanation
Using chopsticks is a part of Japanese culture and is of particular significance to the elderly. Using familiar eating utensils may help patients with cognitive impairment to recognize food, thereby boosting their motivation to eat and helping them eat independently. For those with impaired motor skills and muscle strength, using spring-assisted chopsticks is helpful.
Explanation
By placing an antislip pad on the back of a dish, patients can scoop up food without holding the dish. Also, dishes with a sloped bottom and a curled and raised edge helps food to be scooped up with one hand without spillage. Using an anti-slip mat is also effective for patients who have difficulties holding dishes while eating.
Explanation
The tensile strength of springs can help patients with severe motor paralysis to bring food into their mouth by themselves even with reduced arm strength.
Explanation
Mealtime posture has a considerable impact on mastication and swallowing function. Posture during eating is influenced by the bed, chair, and table used. A table on which patients can rest both elbows will help them maintain posture and eat independently.
Explanation
In supporting safe and independent eating, it's essential for the environment to help patients recognize food and concentrate on their meal. In addition to creating a quiet environment, it's also important to adjust the auditory and visual information in the environment, such as tidying up the table or tray and having clear but minimal verbal communication. Any urine or feces must be cleaned away and any objects used must be cleaned and packed away before meals, so that patients can comfortably focus on eating. To help with food recognition, place the meal at a slightly lower position in front of patients and adjust their head/neck to a flexed position so that the food is in their line of sight. Caregivers should be in a position where they can see both the food and the patient, so that the safe and effective support including risk management is provided.
Explanation
As is obvious from its use as a compensatory technique, mealtime posture is strongly associated with swallowing. Poor posture interferes with eating function and also affects the respiratory and circulatory systems, which can lead to aspiration and suffocation, make independent eating more difficult, and reduce food intake. To prevent aspiration and provide safe feeding assistance, it is essential that we adjust mealtime posture so that patients can function fully.
1) When patients eat in bed, fill any large gaps between the body and the bed with cushions or bath towels to stabilize the body. The posterior pelvic tilt causes pressurization of the abdomen and chest and consequent increases in the tension of the muscle group involved in swallowing. So, correct sacral sitting posture by lifting patients upward.
2) Ensure good stability of the soles of the feet to help patients maintain their posture and increase the strength of swallowing and coughing.
3) The weight of the arms can increase the muscle tension around the neck and the burden on respiration, so ensure the elbows are supported. When the angle of the head-of-bed elevation is low, we also need to provide support of the scapular arch.
4) Placing the table a fist length away from the torso at the height between the navel and the axillary fossa will stabilize the upper body and prevent loss of posture. Also, encourage patients to rest their elbows on the table while bringing food to their mouth, facilitating independence.
5) The passage from the mouth to the trachea aligns in a straight line when the neck is in an extended position, and this is structurally prone to aspiration. Also, the muscles around the neck become overly tense, preventing swallowing movements. So, adjust the neck to a flexed position.
Explanation
Wheelchairs are means of transportation, so we need to adjust patients' posture when it is used during mealtimes. The back support of an old wheelchair tends to bow outward, so we need to correct for this.
(1) The position of the buttocks is important. Position the buttocks securely at the back of the seat to prevent sacral sitting.
(2) Place the soles of the feet firmly on the floor. A foot stool can be used when the soles are not fully in contact with the floor. Using the wheelchair footrests shifts the position of the soles away from the body, causing posterior pelvic tilt, so placing the soles slightly nearer to the body helps patients lean forward and maintain a suitable posture for eating.
(3) Rest both their elbows on the table.
(4) Placing the edge of the table a fist length away from the trunk at the height between the navel and the axillary fossa will stabilize the upper body and prevent loss of posture. Also, patients can rest their elbows on the table while bringing food to their mouth, and in this way are less likely to get tired. This helps them eat independently.
(5) To help patients with food recognition, place the meal at a slightly lower position in the front of them, and their neck in a flexed position so they can see the food in their line of sight.
Explanation
Assisted feeding from a high position makes swallowing difficult, and the elevation of the chin will lead to aspiration. Also, if an appropriate spoon isn't used, then this can cause abnormal movement and findings such as failure of mouth opening, retention of food in the oral cavity, and failure of swallowing.
(1) Ensure patients can see the food because visual input enhances their recognition of food and they become cognitively prepared for the food.
(2) Insert the spoon in a direction parallel to the tongue. Inserting it from a higher position extends the neck and can result in chocking, early pharyngeal penetration, and pharyngeal retention.
(3) When feeding patients food categorized as code 2 or below (food that can be directly swallowed or crushed without mastication) according to the Japanese Dysphagia Diet 2013, established by the Dysphagia Diet Committee of the Japanese Society of Dysphagia Rehabilitation, placing a spoon at the center of the dorsum of the tongue will facilitate smooth transport of food to the pharynx. When feeding patients food categorized as code 3 or above (food that needs to be masticated), placing a spoon on the center of the tongue will facilitate smooth transition to masticatory movements.
(4) Encourage patients to close their lips so that when removing the spoon in a diagonally upward direction, the upper lip will be stimulated as the spoon slides on it. The chin tends to raise when removing the spoon, but this must be avoided. Closing the lips will prevent swallowing with an open mouth and will facilitate transport to the pharynx and increase pressure in the oral cavity.
Explanation
The pace of feeding is associated with duration of mealtimes, fatigue due to eating, occurrence of chocking and aspiration, and food intake. Once a spoonful is put in the mouth, make the next spoonful visible to patients and put it in their mouth immediately after the previous spoonful is swallowed. Keeping a good feeding pace will help patients focus on the meal, shorten the mealtime, reduce eating-related fatigue, and increase food intake, helping to achieve safe, efficient, and effective support.
To maintain a good pace of feeding, caregivers should position themselves where they can see the food and observe swallowing status (ie, both are within a 90° field of view). If caregivers feed patients using their right hand from the left side, the spoon can't be inserted straight in the mouth and neck rotation while swallowing may lead to aspiration. So, be sure to prepare the environment in order that caregivers use their right hand from the right side or their left hand from the left side.
