Luis F. Riquelme

Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework

Dysphagia is estimated to affect ~8% of the world’s population (~590 million people). Texture-modified foods and thickened drinks are commonly used to reduce the risks of choking and aspiration. The International Dysphagia Diet Standardisation Initiative (IDDSI) was founded with the goal of developing globally standardized terminology and definitions for texture-modified foods and liquids applicable to individuals with dysphagia of all ages, in all care settings, and all cultures. A multi-professional volunteer committee developed a dysphagia diet framework through systematic review and stakeholder consultation. First, a survey of existing national terminologies and current practice was conducted, receiving 2050 responses from 33 countries. Respondents included individuals with dysphagia; their caregivers; organizations supporting individuals with dysphagia; healthcare professionals; food service providers; researchers; and industry. The results revealed common use of 3–4 levels of food texture (54 different names) and ≥3 levels of liquid thickness (27 different names). Substantial support was expressed for international standardization. Next, a systematic review regarding the impact of food texture and liquid consistency on swallowing was completed. A meeting was then convened to review data from previous phases, and develop a draft framework. A further international stakeholder survey sought feedback to guide framework refinement; 3190 responses were received from 57 countries. The IDDSI Framework (released in November, 2015) involves a continuum of 8 levels (0–7) identified by numbers, text labels, color codes, definitions, and measurement methods. The IDDSI Framework is recommended for implementation throughout the world.

Prevention of Healthcare-Associated Pneumonia with Oral Care in Individuals Without Mechanical Ventilation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE Evidence is lacking on the preventive effect of oral care on healthcare-associated pneumonia in hospitalized patients and nursing home residents who are not mechanically ventilated. The primary aim of this review was to assess the effectiveness of oral care on the incidence of pneumonia in nonventilated patients. METHODS We searched 8 databases (MEDLINE, Embase, CENTRAL, CINAHL, Web of Science, LILACS, ICHUSHI, and CiNii), in addition to trial registries and a manual search. Eligible studies were published and unpublished randomized controlled trials examining the effect of any method of oral care on reported incidence of pneumonia and/or fatal pneumonia. Relative risks (RR) and 95% confidence intervals were calculated. Risk of bias was assessed for eligible studies. RESULTS We identified 5 studies consisting of 1,009 subjects that met the inclusion criteria. Of these, 2 trials assessed the effect of chlorhexidine in hospitalized patients; 3 studies examined mechanical oral cleaning in nursing home residents. A meta-analysis could only be done on 4 trials; this analysis showed a significant risk reduction in pneumonia through oral care interventions (RRfixed, 0.61; 95% CI, 0.40-0.91; P=.02). The effects of mechanical oral care alone were significant when pooled across studies. (RRfixed, 0.61; 95% CI, 0.40-0.92; P=.02). Risk reduction for fatal pneumonia from mechanical oral cleaning was also significant (RRfixed, 0.41; 95% CI, 0.23-0.71; P=.002). Most studies had a high risk of bias. CONCLUSIONS This analysis suggests a preventive effect of oral care on pneumonia in nonventilated individuals. This effect, however, should be interpreted with caution due to risk of bias in the included trials.

The Role of Cultural Competence in Providing Services to Persons With Dysphagia

Demographics in the United States are requiring dysphagia clinicians to provide increasingly relevant services, with special attention being paid to the culture of the patient. Todays clinician is challenged to broaden the definition of culture and provide culturally sensitive services to all patients. In addition to ethnicity, culture includes behaviors, beliefs, and values of a variety of groups of individuals. Current terminology is discussed and the impact on dysphagia services explored. Language barriers, healthcare disparities, and end-of-life issues are introduced. The article ends with specific clinical suggestions for practice. Resources for additional information are provided.

Understanding Oropharyngeal Dysphagia: From Hospital to Home

Providing services in the home to a patient with oropharyngeal dysphagia remains a clinical challenge. All health care providers involved in the care of patients with dysphagia need to understand the complexities of swallow physiology, its impact on the patients overall well-being, and the experience the patient has recently undergone. Namely, it is important to know if the patient is returning home after an acute care stay, if the patient is returning home after a stay at a rehabilitation center, or if simply the patient has become increasingly decompensated while at home. This will allow the clinician working in the home to understand the work-up and possible treatments the patient has thus far undergone, and possibly better understand the overall etiology. Furthermore, it is important to understand that while returning home may be one of the most exciting moments for the patient and his/her family, it may also be the most stressful, as the patient is probably returning home with a different set of needs. This article provides an in-depth approach and discussion of the subject of swallow physiology, diagnosis, and treatment, and provides a resource for all members of the patient care team. It concentrates on the experience of older adults diagnosed with oropharyngeal dysphagia who are returning home.

Creation and Initial Validation of the International Dysphagia Diet Standardisation Initiative Functional Diet Scale

Objective To assess consensual validity, interrater reliability, and criterion validity of the International Dysphagia Diet Standardisation Initiative Functional Diet Scale, a new functional outcome scale intended to capture the severity of oropharyngeal dysphagia, as represented by the degree of diet texture restriction recommended for the patient. Design Participants assigned International Dysphagia Diet Standardisation Initiative Functional Diet Scale scores to 16 clinical cases. Consensual validity was measured against reference scores determined by an author reference panel. Interrater reliability was measured overall and across quartile subsets of the dataset. Criterion validity was evaluated versus Functional Oral Intake Scale (FOIS) scores assigned by survey respondents to the same case scenarios. Feedback was requested regarding ease and likelihood of use. Setting Web-based survey. Participants Respondents (NZ170) from 29 countries. Interventions Not applicable. Main Outcome Measures Consensual validity (percent agreement and Kendall t), criterion validity (Spearman rank correlation), and interrater reliability (Kendall concordance and intraclass coefficients). Results The International Dysphagia Diet Standardisation Initiative Functional Diet Scale showed strong consensual validity, criterion validity, and interrater reliability. Scenarios involving liquid-only diets, transition from nonoral feeding, or trial diet advances in therapy showed the poorest consensus, indicating a need for clear instructions on how to score these situations. The International Dysphagia Diet Standardisation Initiative Functional Diet Scale showed greater sensitivity than the FOIS to specific changes in diet. Most (>70%) respondents indicated enthusiasm for implementing the International Dysphagia Diet Standardisation Initiative Functional Diet Scale. Conclusions This initial validation study suggests that the International Dysphagia Diet Standardisation Initiative Functional Diet Scale has strong consensual and criterion validity and can be used reliably by clinicians to capture diet texture restriction and progression in people with dysphagia.

Feeding/Swallowing Disorders: Maintaining Quality of Life in Persons with Intellectual Disability

Persons with intellectual disability (ID) have received little attention in systematic studies of healthcare and quality of life. Less attention has been provided to specific disorders, such as those impacting the swallowing mechanism. In comparison to the general population, persons with ID experience noticeably greater healthcare inequalities and despite greater life expectancy, it is still lower than the general population. This paper serves as an introduction to healthcare colleagues regarding the risks involved in choking and swallowing disorders in persons with ID, how to evaluate these potential risks and possible treatments. Associated etiologies are presented. A discussion on feeding disorders versus swallowing disorders is also introduced. The inadequacy of swallowing assessment services to persons with ID may be related to the lack of professionals with specialized training in working with this population, reduced funding for research to explore options for improved nutrition and reduced risk of choking and minimal research on changes in feeding skills and/or swallow physiology in this select group of individuals

The tri-fold risk of malnutrition, dehydration, and dysphagia in persons with dementia: An assessment and management protocol

developed by clinicians affiliated with a long term care provider in PA, was conceptualized, implemented and researched in an active clinical care setting, and thus, represents a viable solution to the growing challenge of improving function for individuals with dementia through rehabilitation services. The NET model incorporates person centered care practices into therapy interventions that draw upon functionally based, familiar activities and are delivered in an environment that supports engagement by individuals with cognitive impairment. Therapists using the NET model receive specialized training and support to increase knowledge about dementia and efficacy in working with this population, and are supported by an coordinated team approach to care. Research on the model has revealed that NET rehabilitation services result in significantly greater engagement in the therapy process and improved functional outcomes. In addition, therapists trained in NET demonstrate improved knowledge and efficacy in their work with individuals with dementia. This presentation will begin by exploring the challenges associated with successfully providing rehabilitation services to individuals with cognitive impairment and the growing need for this type of care. We will then provide participants with an introduction to the NET model and the key dementia care practices that are integrated into therapy services. Finally, we will review the findings from the NET research project conducted in 3 skilled nursing home based rehabilitation programs, exploring the impact on both therapists and clients involved in the NET program. The study looked at outcomes for 46 therapists, i.e. physical, occupational and speech therapists, and 85 short term rehabiliation patients with moderate to severe dementia over the course of 12 weeks and documented positive outcomes in patient engagement and function, as well as therapist knowledge and efficacy in dementia care. Next steps for the NET program and the current challenges to this kind of work within short term rehabiliation systems will be discussed. Specific focus will be on the operational and financial challenges associated with enhanced rehabilitation care for individuals with dementia.