Early intervention to promote oral feeding in patients with intracerebral hemorrhage: a retrospective cohort study

<p>Abstract</p> <p>Background</p> <p>Stroke is a major cause of dysphagia, but little is known about when and how dysphagic patients should be fed and treated after an acute stroke. The purpose of this study is to establish the feasibility, risks and clinical outcomes of early intensive oral care and a new speech and language therapist/nurse led structured policy for oral feeding in patients with an acute intracerebral hemorrhage (ICH).</p> <p>Methods</p> <p>A total of 219 patients with spontaneous ICH who were admitted to our institution from 2004 to 2007 were retrospectively analyzed. An early intervention program for oral feeding, which consisted of intensive oral care and early behavioral interventions, was introduced from April 2005 and fully operational by January 2006. Outcomes were compared between an early intervention group of 129 patients recruited after January 2006 and a historical control group of 90 patients recruited between January 2004 and March 2005. A logistic regression technique was used to adjust for baseline differences between the groups. To analyze time to attain oral feeding, the Kaplan-Meier method and Cox proportional hazard model were used.</p> <p>Results</p> <p>The proportion of patients who could tolerate oral feeding was significantly higher in the early intervention group compared with the control group (112/129 (86.8%) vs. 61/90 (67.8%); odds ratio 3.13, 95% CI, 1.59-6.15; P < 0.001). After adjusting for baseline imbalances, the odds ratio was 4.42 (95% CI, 1.81-10.8; P = 0.001). The incidence of chest infection was lower in the early intervention group compared with the control group (27/129 (20.9%) vs. 32/90 (35.6%); odds ratio 0.48, 95% CI, 0.26-0.88; P = 0.016). A log-rank test found a significant difference in nutritional supplementation-free survival between the two groups (hazard ratio 1.94, 95% CI, 1.46-2.71; P < 0.001).</p> <p>Conclusions</p> <p>Our data suggest that the techniques can be used safely and possibly with enough benefit to justify a randomized controlled trial. Further investigation is needed to solve the eating problems that are associated with patients recovering from a severe stroke.</p

A Dentist-Led Oral Care System Can Prevent Stroke-Associated Pneumonia: The Effects of Early Intervention by Dental Team

Kenichiro Ozaki,1,2 Haruka Tohara,2 Mikoto Baba,1 Satoshi Teranaka,1,3 Yosuke Kawai,1,3 Satoru Komatsumoto4,5 1Department of Physical Medicine and Rehabilitation, Ashikaga Red Cross Hospital, Ashikaga, Tochigi, Japan; 2Dysphagia Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan; 3Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan; 4Ashikaga Red Cross Hospital, Ashikaga, Tochigi, Japan; 5Fujita Health University, Toyoake, Aichi, JapanCorrespondence: Kenichiro Ozaki, Department of Physical Medicine and Rehabilitation, Ashikaga Red Cross Hospital, 284-1, Yobe-cho, Ashikaga, Tochigi, 326-0843, Japan, Tel +81-284-21-0121, Fax +81-284-21-6810, Email [email protected]: Our facility’s dental team consists of a full-time dentists and dental hygienists who work exclusively in the wards to implement best practices in oral healthcare. We executed the dental care system (DCS) that includes lectures and practical training for nurses conducted by dentists and dental hygienists, the introduction to oral assessment, standardization of oral care procedures, a process for nurses to request the dental team, and early bedside oral screening conducted by the dental team. This study investigated the DCS’s effects on the incidence of stroke-associated pneumonia (SAP).Methods: This single-center retrospective cohort study included 2,771 acute stroke patients who were newly hospitalized between April 1, 2012, and March 31, 2020. The 8-year period was divided into four phases at two-year intervals as follows: Pre (N=632), Post-1 (N=642), Post-2 (N=716), and Post-3 (N=781). Pre was prior to DCS practice. Post-1 was an early introduction to DCS. Post-2 simplified dental team requests from nurses, and Post-3 added bedside oral screening within 72 hours of admission by the dental team. Statistical analysis was performed using the Cochran-Armitage trend test, followed by multivariate logistic regression.Results: A decrease in SAP rates was observed across the four groups (P< 0.0001). Logistic regression analysis revealed a significant difference for respiratory disease (odds ratio 7.74, 95% confidence interval 5.49– 10.90), hypertension (2.28, 1.39– 3.73), cardiac failure (1.72, 1.04– 2.85), and diabetes (1.59, 1.11– 2.26), 3-digit code on the Japan coma scale (3.57, 2.53– 5.05 [reference ≤ 2-digit code]), age ≥ 90 years (2.34, 1.15– 4.77 [reference 18– 59 years]), male (1.86, 1.31– 2.67), and the Post-1 (0.49, 0.31– 0.76 [reference Pre]), Post-2 (0.38, 0.25– 0.61 [reference Pre]), and Post-3 (0.24, 0.15– 0.40 [reference Pre]) periods.Conclusion: The suppression of SAP is effectively achieved through early intervention and education of nurses by dental professionals.Plain Language Summary: Pneumonia is a dangerous disease that kills millions of individuals around the world every year. Stroke patients are susceptible to developing pneumonia because their swallowing reflex is sometimes impaired. This risk may be reduced by maintaining oral hygiene through advanced oral care involving dentists and dental hygienists. For this reason, our acute care hospital has a dental team consisting of a full-time dentists and dental hygienists dedicated to the ward. In 2014, the dental team launched a program for nurses on how to provide oral care to inpatients. Additionally, we have introduced a system that enables nurses to contact the dental team immediately if oral care becomes difficult for nurses due to problems in the patient’s mouth. Furthermore, the dental team began evaluating the oral health of all stroke patients within 72 hours after hospitalization. We studied the changes in the frequency of pneumonia in stroke patients at our hospital before the application of this approach and 6 years after its introduction. The rate of pneumonia decreased steadily during this period. Overall, the pneumonia rates in stroke patients at our hospital reduced by approximately 60%, suggesting that this system is an effective way to prevent pneumonia.Keywords: hospital dental services, hospital dentistry, special care dentistry, oral health management, oral care, acute stroke, stroke-associated pneumonia, team approac

Relationship between jaw opening force and hyoid bone dynamics in healthy elderly subjects

Hiromichi Shinozaki, Haruka Tohara, Mariko Matsubara, Nobuhiro Inokuchi, Yasuhiro Yamazaki, Ayako Nakane, Yoko Wakasugi, Shunsuke Minakuchi Department of Gerodontology, Tokyo Medical and Dental University, Tokyo, Japan Purpose: This study aimed to examine the relationship between jaw opening force and hyoid bone dynamics and resting position in elderly individuals based on gender. Subjects and methods: Subjects were 36 healthy elderly individuals aged &ge;65&nbsp;years without dysphagia (16 men and 20 women; mean age 75.5&nbsp;years, range 65&ndash;88&nbsp;years). Videofluorographic images during the swallowing of 10&nbsp;mL of 40% (w/v) barium sulfate were obtained and the degrees of anterior, superior, and hypotenuse displacements of the hyoid bone and maximum/resting hyoid position were evaluated. Jaw opening force was measured three times using a jaw opening force sthenometer; the mean of these three measurements was used for analysis. Results: In men, there was a positive correlation between jaw opening force and resting hyoid position and negative correlations among all the degrees of anterior, superior, and hypotenuse displacements of the hyoid bone. In women, there was no statistically significant correlation between jaw opening force and any of the measurement items. There was no statistically significant correlation between jaw opening force and maximum hyoid position in either men or women. Conclusion: Our findings suggest that low jaw opening force leads to low resting hyoid position only in elderly men, and a lower hyoid position in healthy elderly men results in a larger total amount of hyoid displacement during swallowing. Moreover, a maximum hyoid position in healthy individuals of either gender does not differ depending on their jaw opening force. Keywords: aging, deglutition disorders, dysphasia, gender difference

Relationship between tongue strength, lip strength, and nutrition-related sarcopenia in older rehabilitation inpatients: a cross-sectional study

Kotomi Sakai,1,2 Enri Nakayama,2 Haruka Tohara,3 Keiji Kodama,4 Takahiro Takehisa,5 Yozo Takehisa,6 Koichiro Ueda2 1Department of Rehabilitation Medicine, Setagaya Memorial Hospital, 2Department of Dysphagia Rehabilitation, Nihon University School of Dentistry, 3Gerodontology and Oral Rehabilitation, Department of Gerontology and Gerodontology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 4Department of Internal Medicine, 5Department of Orthopaedic Surgery, Setagaya Memorial Hospital, Tokyo, 6Department of Internal Medicine, Hakuai Memorial Hospital, Tokushima, Japan Objective: The objective of this study was to clarify the relationship between tongue strength, lip strength, and nutrition-related sarcopenia (NRS).Patients and methods: A total of 201 older inpatients aged &ge;65&nbsp;years (70 men, median age: 84&nbsp;years, interquartile range: 79&ndash;89&nbsp;years) consecutively admitted for rehabilitation were included in this cross-sectional study. The main factors evaluated were the presence of NRS diagnosed by malnutrition using the Mini-Nutrition Assessment &ndash; Short Form, sarcopenia based on the criteria of the Asian Working Group for Sarcopenia, tongue strength, and lip strength. Other factors such as age, sex, comorbidity, physical function, cognitive function, and oral intake level were also assessed.Results: In all, 78 (38.8%) patients were allocated to the NRS group, and 123 (61.2%)&nbsp;patients were allocated to the non-NRS group. The median tongue strength and lip strength (interquartile range) were significantly lower in the NRS group (tongue: 22.9&nbsp;kPa [17.7&ndash;27.7&nbsp;kPa] and lip: 7.2&nbsp;N [5.6&ndash;9.8&nbsp;N]) compared with the non-NRS group (tongue: 29.7&nbsp;kPa [24.8&ndash;35.1&nbsp;kPa] and lip: 9.9&nbsp;N [8.4&ndash;12.3&nbsp;N], P&lt;0.001 for both). Multivariable logistic regression analysis showed that NRS was independently associated with tongue strength (odds ratio [OR] =0.93, 95% confidence interval [CI] 0.87&ndash;0.98, P=0.012) and lip strength (OR =0.76, 95% CI 0.66&ndash;0.88, P&lt;0.001), even after adjusting for age, sex, comorbidity, physical function, cognitive function, and oral intake level.Conclusion: The likelihood of occurrence of NRS decreased when tongue strength or lip strength increased. Tongue strength and lip strength may be important factors for preventing and improving NRS, regardless of the presence of low oral intake level in older rehabilitation inpatients. Keywords: sarcopenia, rehabilitation, tongue, lip, malnutritio

Excessive anterior cervical muscle tone affects hyoid bone kinetics during swallowing in healthy individuals

Yasuhiro Yamazaki, Haruka Tohara, Koji Hara, Ayako Nakane, Yoko Wakasugi, Kohei Yamaguchi, Shunsuke Minakuchi Department of Gerodontology, Tokyo Medical and Dental University, Tokyo, Japan Purpose: This study aimed to determine whether excessive neck muscle tone affects hyoid bone kinetics during swallowing using videofluorography (VF) in an unnatural posture in healthy individuals. Subjects and methods: Subjects were 28 healthy adults (12 men, 16 women; mean age, 39.75&plusmn;9.50 years) without any history or present complaints of swallowing disorders. We first established the participant&rsquo;s posture a reclining wheelchair that was adjusted to a 30-degree angle with the headrest (without excessive neck muscle tone) or without headrest (with excessive neck muscle tone), used an electromyogram above the mylohyoid muscle to represent the suprahyoid muscles and above the sternohyoid muscle to represent the infrahyoid muscles to confirm neck muscle tone, and then conducted VF of swallowing measurements. Videofluorographic images were obtained when 5 mL of 50% (w/v) barium sulfate was being swallowed, and hyoid bone coordinate (the resting position and the elevated position), extent of horizontal and vertical hyoid bone elevation, as well as duration and velocity of hyoid bone elevation were evaluated (x-axis and y-axis coordinates for the resting position of hyoid bone are referred to as Xr and Yr, respectively; those for the elevated hyoid bone position induced during swallowing are referred to as Xs and Ys, respectively). Results: In the resting position of the hyoid bone, the Yr coordinates in those with excessive neck muscle tone were significantly lower than in those without excessive neck muscle tone. Vertical hyoid bone elevation and hyoid bone elevation velocity were significantly higher with excessive neck muscle tone than without excessive neck muscle tone, whereas horizontal elevation showed no significant differences. Conclusion: Our findings suggest that the generation of neck muscle tone due to inappropriate posture may encourage hyoid depression and increase the extent of hyoid bone elevation, thereby increasing the risk of aspiration. Keywords: dysphagia, swallow, muscle tone, hyoid bone, infrahyoid muscles, suprahyoid muscle