Explanation
Feeding assistance helps people to continue eating orally when they can't eat safely by themselves and improves their quality of life (QOL). For patients with dysphagia, feeding assistance also serves as functional and compensatory rehabilitation. Patients with dysphagia often have a number of comorbidities such as motor paralysis, sensory disturbance, cognitive impairment, respiratory disorder, and digestive disorder. It is necessary to manage the risks of aspiration pneumonia, dehydration, malnutrition, suffocation, and deterioration of QOL when providing feeding assistance to them. In addition, we should be mindful that feeding assistance ultimately aims to help care receivers become independent and feel fulfilled and happy. Caregivers can be medical professionals, elderly care professionals, and family members, and smooth collaboration among them is crucial. Elderly care professionals and family members should be involved in feeding assistance only after safety of their involvement has been confirmed by a medical professional and when care receivers rely solely on oral nutrition. In this module, we cover compensatory techniques and feeding assistance that facilitate patients' independence in eating, focusing on problems that can occur in the process from pre-oral preparation to swallowing.
Explanation
Elements of feeding assistance
1) Create an environment that is safe and heightens appetite
① Choose an appropriate location depending on patients' eating and swallow function. Patients should be mobile if possible (except in cases where patients require training on the bed, etc).
② Clear away any urine or feces before mealtimes, and provide oral, pharyngeal, hand, and facial care.
③ Create a relaxing atmosphere for both patients and caregivers.
④ Turn off the TV and radio to create a quiet environment that helps patients to concentrate on the meal. Avoid noisy and busy environments.
⑤ Be mindful about talking with patients during feeding. Avoid unnecessary conversation when food is in their mouth (otherwise, the risk of aspiration will be increased because the lips and the glottis are open and breathing-swallowing coordination is disturbed).
⑥ In case of emergency, have an evacuator, catheters, gloves, and a device for measuring the degree of arterial oxygen saturation ready for use.
Explanation
Elements of feeding assistance
2) Important points in feeding assistance
① Encourage patients to stay awake so that brain function is activated (eg, visual, olfactory, tactile, and gustatory senses).
② Implement direct training and indirect exercises (eg, psychological and physical relaxation, stabilization of the head and neck, massaging around the oral cavity, and stretching).
③ Ensure a safe posture, appropriate meal content, and use of appropriate methods of feeding to improve their QOL.
④ Do not fully cover the neck with an apron or a towel, so the swallowing reflex can be observed in the laryngeal area.
⑤ For patients, stabilize both of their arms. If self-feeding is possible, adjust the position of the table in line with their elbows so that their elbows remain rested on the table when the spoonhead is inserted in their mouth. Both of their hands should be placed outside of the apron, and both elbows should be on the table to improve maneuverability.
⑥ Position the patients so they can see the entire food tray and all actions of the caregiver.
⑦ To facilitate neck flexion in patients during feeding, ensure caregivers are positioned correctly (if caregivers are standing, the patients need to look up, which extends the neck).
⑧ Assisting facing the patient from a lower position. Use the right hand when assisting patients from the right side and the left hand when assisting them from the left side.
⑨ Implement individually designed measures when using compensatory head rotation or when feeding patients with severe unilateral lip motor paralysis or unilateral impairment of spatial abilities due to executive function deficits.
⑩ Provide feeding assistance with the aim of facilitating self-care.
⑪ Remember to provide oral care after meals.
⑫Keep patients in a sitting position or elevate the head of the bed ≥ 45°-and not in the supine position-for about 1 h after meals to prevent gastroesophageal reflux and aspiration of refluxed material.
Explanation
Elements in the pre-preparatory phase include recognition, posture, motion, and eating utensils. If patients have an impaired cognitive function, be sure to prepare the mealtime environment so they can adequately use their 5 senses (visual, olfactory, auditory, tactile, and gustatory senses) to enhance their cognitive function. Also, position patients where their head and neck, torso, arms, legs, and soles of the feet are stabilized, and adjust the angle as necessary. As the head is elevated higher, tension in the head and neck rises, which increases the possibilities of respiratory disturbance and early pharyngeal penetration due to glossoptosis. So, we must carefully consider the volume and texture of liquids and foods. When patients are self-feeding, choose the table and eating utensils based on safety. Use the right hand when assisting patients from their right side and the left hand when assisting them from their left side, so that food can be placed in their mouth safely and comfortably.
Explanation
When patients have difficulties using their lips to take in the food (1)
The following approaches can be used. ① Preferably use a spoon with a small shallow head that can fit in the mouth at the center of the tongue. If a big spoon is used, patients tend to slurp the food on the spoon, which results in disturbance of breathing-swallowing coordination and causes choking. Also, patients inhale more air as they try to avoid spillage. ② For patients with difficulties opening their mouth because of cognitive impairment, provide verbal and visual guidance and then place a loaded spoon softly on the lower lip until the mouth opens. Alternatively, gently lower their mandible using the index finger. ③ If their lip muscles are too tense to accept a spoon, try inserting the spoon between the lips slightly without creating strong resistance and then move the spoon further into the mouth when the lips relax.
If patients have difficulties closing their lips, it can be effective to lightly press and lift the corners of their mouth along the orbicularis oris muscle with the fingers immediately after putting food in their mouth. This assisted mouth closure increases pressure for swallowing and triggers the swallowing reflex. ④ Optimizing the amount of food transferred to the mouth per spoonful is also important for safe feeding. If it is too much, food will spill from the mouth and slurping of spilt food increases the risk of choking and aspiration. On the other hand, if it is too little, tactile and gustatory sensation is not sufficient and this results in delayed food transport and swallowing movements.
Explanation
When patients have difficulties using their lips take in the food (2)
⑤ Place jellies and purees at the center of the tongue using a spoon. Place food requiring mastication at the apex of the tongue. Note that in a position with a head elevation of 30°, liquids tend to trigger choking and early pharyngeal penetration. ⑥ Give verbal instructions (eg, "Close your mouth tightly") so that the entire spoon head is placed inside the mouth. If patients can't close their mouth, caregivers can assist manually. ⑦ Withdraw the spoon in a diagonally upward direction: the spoon should slide on the upper lip. Ensure that the chin is not lifted. If food consists of liquids and solids (eg, miso soup), put these in the mouth separately. Otherwise, slurping of the liquid portion may result in early pharyngeal penetration of the liquid.
Explanation
When patients have difficulties in the preparatory phase (mastication and bolus formation)
① Ensure that the food is prepared with adequate solidity, texture, and viscosity according to individual problems. Take care with jelly, because fragmented jelly pieces produced by mastication will spread throughout the oral cavity, resulting in gentle and continuous transport to the pharynx. So, a slice of jelly (prepared by the slice method) should be swallowed at one swallow. Avoid verbal instructions such as "Please chew". ② It is important to maintain good oral condition (eg, teeth and artificial teeth) for effective mastication. ③ Help patients to masticate consciously by giving verbal instructions like "Close your mouth and chew well." ④ If food spillage and retention on the paralyzed side is noticeable, encourage mastication on the unaffected side. Food tends to remain at the paralyzed side due to motor and sensory impairment. Patients can confirm this using a mirror, if possible, and such visual input will enhance their perception. ⑤ Indirect training is recommended so that patients gradually become able to masticate food on both sides.
Explanation
When patients have difficulties in the oral phase
The following approaches can be used. ① Start with liquids or jelly that are less sticky and can be transported and swallowed easily. The slice method should be used for jelly. ② If the oral transit phase is lengthy in a sitting position, evaluate this in a reclined sitting position to utilize the effects of gravity. ③ If patients have unilateral tongue paralysis (usually ipsilateral to the body paralysis), placing the spoon or food on the unaffected side of the tongue will help with oral transit. ④ Encouraging patients to think about mouth closure (facial paralysis ipsilateral to body paralysis is common), closing the mouth purposefully, and providing sensory and locomotor stimulation (eg, softly pressing the tongue with a spoon) will facilitate voluntary movement of the tongue.
Explanation
When patients have difficulties in the pharyngeal phase (swallowing) (1)
The following approaches can be used. ① Comprehensively and individually assess the level of difficulty to determine the posture, food texture, and compensatory techniques that should be used. If patients choke while swallowing liquid, consider adding a thickening agent (0.5%-1%) or using liquid in the form of jelly. ② In case of choking, patients need to be assisted to lean forward to cough effectively: no food or drink should be put in the mouth until breathing stabilizes. ③ Once breathing stabilizes, it is a good idea to restart feeding with a small quantity of easy-to-swallow food (eg, jelly) or liquid. ④ If adverse symptoms such as pharyngeal retention and choking appear, careful observation is required using a pulse oximeter or by auscultation of the neck. ⑤ Report any signs of aspiration observed to the physician to decide the action to be taken.
Explanation
When patients have difficulties in the pharyngeal phase (swallowing) (2)
⑥ Perform indirect training such as exercising the muscles around the mouth and thermal-tactile stimulation of the whole oral cavity or anterior palatine arch before feeding according to individual needs. ⑦ The swallowing reflex can be stimulated by pressure stimulation with the spoon when transferring food onto the tongue. ⑧ Even if the swallowing reflex is not easily stimulated, avoid excessive manipulation and touching of the perilaryngeal muscle, because pain and discomfort caused may prevent swallowing movements. ⑨ When the swallowing reflex is confirmed (laryngeal elevation), offer the next spoonful at a good pace. ⑩ When oral residue is observed and pharyngeal residue is suspected, assist feeding using the following techniques: adjust the amount of food put in the mouth; use the "think swallow technique"; and try to clear residue with multiple swallows, additional swallows, or alternate swallows and head rotation.
Explanation
When patients have difficulties in the esophageal phase (from the esophagus to the stomach)
The following approaches can be used. ① Long term oral feeding while also having a nasogastric tube can inhibit swallowing movement and cause gastroesophageal reflux and discomfort. Use a tube with as small a diameter as possible (oblique placement of the tube should be avoided). ② Choking before and after swallowing and coughing after a meal suggest disturbance or impairment of bolus passage through the esophagus. For patients with such symptoms, carefully decide on a suitable posture (angle) for mealtimes and choose appropriate food texture. ③ Easy-to-digest food is recommended. If patients have the sensation of something being stuck in the chest or has reflux, adjust the texture. Consult a physician when patients have comorbid diseases. ④ Patients should remain in the sitting position for 0.5-1 h after meals to prevent gastroesophageal reflux. Note that patients with history of gastrointestinal surgery are at particular risk of aspiration pneumonia due to reflux. If remaining in a sitting position is difficult, patients should be helped to remain in a position with the head elevated at ≥ 45°: monitor for back pain and pressure ulcers in such cases.
Explanation
Several facilitation and compensatory techniques can be used in patients with dysphagia.
① Method for swallowing sliced jelly without mastication: This method uses a slice of jelly, which is a bolus that can be easily swallowed without mastication. Swallowing a slice of jelly without mastication prevents pharyngeal retention and aspiration. Compared with a scooped mouthful of jelly, a piece of sliced jelly does not break down in the oral cavity or pharynx, so it passes through the pharynx and the esophageal orifice smoothly. If oral transit is impaired, put the slice of jelly in the back of the tongue. A spoon with a small and shallow head is recommended. Ensure the neck is bent forward, because otherwise the whole slice of jelly may be aspirated if the neck is extended. Do not mash jelly or food with a similar texture.
② Multiple swallows: This method uses multiple swallows to clear pharyngeal residue and prevent aspiration after swallowing. Provide instructions such as "Please swallow it again." For training, multiple swallows can be performed with or without patients having the sensation of pharyngeal residue. (Note that, even when there is residue, patients with oral and pharyngeal sensory impairment may not perceive it.)
③ Additional swallows: This method uses an additional small quantity of liquid or jelly to trigger swallowing movements if patients with oral or pharyngeal residue can not perform a dry swallow on command.
④ Alternate swallows: This method helps to clear pharyngeal retention by giving patients difficult-to-swallow food and easy-to-swallow food alternately. Alternate swallowing of highly sticky food (eg, gruel) or dry food and then non-sticky food (eg, jelly) or liquid will clear oral and pharyngeal retention. It is advisable to finish the meal with green-tea jelly or liquid.
Explanation
We need to understand what movements are involved in eating and what are the key observation points in order to help patients improve their self-care. The following process is repeated during meals: maintaining a good posture, being able to see the food, putting food in the mouth, masticating, bolus transport to the back of the mouth, and swallowing. Through observation, identify any weak parts of the process and provide compensatory support accordingly for patients to help them with self-feeding, thus improving their QOL.
Explanation
Here we see the process toward self-feeding shown schematically. The following items, as well as eating and swallowing function, should be comprehensively assessed in order to modify feeding assistance individually so that patients can work toward and hopefully achieve self-feeding: willingness to eat, systemic condition, respiratory condition, oral condition, perception, mastication and oral transit, swallowing, posture and endurance, eating movements, activities, level of food intake, and food texture and nutrients. For such comprehensive assessment, it is advisable to use the KT balance chart, which involves multidisciplinary assessment of patients through observation and feeding assistance.
Explanation
Here we see cautions to be taken during assisted feeding and self-feeding in reclined sitting positions with different head elevation angles. When the elevation is still low, feeding must be fully assisted and food that doesn't require mastication should be offered. The following should be individually adjusted depending on the angle: the type of assistance; position of the head and neck, trunk, arms, and legs; and position of the table and utensils.
Explanation
Keep in mind that feeding assistance is aimed at helping patients to use both their hands when eating, thereby improving their ability for self-care. Even for patients with hemiplegia, involve the ipsilateral arm, such as placing it on the table to keep dishes in position. Use the right hand when assisting patients from their right side and use the left hand when assisting them from their left side. If they have difficulty scooping food out of the dish, help them to manually scoop food and put it in their mouth. In this case, don't hold their joints and/or hand too tightly. Instead, use of a spoon with a long handle that allows you to give gentle support with your fingers. Use utensils such as anti-slip mats, self-help dishes, and spring-assisted chopsticks according to individual needs. Consider the length of the meal so that patients do not get too tired and can finish the meal within an appropriate time. Also, comprehensively assess whether an adequate amount of food is eaten to meet daily nutritional requirements and also assess appetite, pleasure when eating, and eating time allocation. Prepare a detailed plan of future goals for information sharing.
References
- Tamami Koyama :Comprehensive skills to support the happiness of eating by mouth-Utilization and support of KT balance chart- ( in Japanese ), p12-94, IGAKU-SHOIN Ltd. , 2017.
- Tamami Koyama Keisuke Maeda ；KT Balance Chart Essence Note ( in Japanese ), p2-71, IGAKU-SHOIN Ltd. , 2018.
- Eiichi Saito, Koichiro Ueda:Dysphagia Rehabilitation 3rd Edition ( in Japanese ),p286-290,Ishiyaku Publisher ,2017.
- Ichiro Fujishima, Koichiro Ueda et al :Summary of training methods ( in Japanese ), Journal of the Japanese Society of Eating and Swallowing Rehabilitation13(1):31-49, 2016.
