嚥下障害の食形態と液体粘度調整：系統的レビュー

成人の嚥下障害に対する食形態調整と液体の粘度調整に関する系統的レビューとエビデンスに基づいた推奨の論文を紹介します。

Ulla Tolstrup Andersen, et al. Systematic review and evidence based recommendations on texture modified foods and thickened fluids for adults (≥18 years) with oropharyngeal dysphagia. e-SPEN Journal, http://dx.doi.org/10.1016/j.clnme.2013.05.003

低栄養、脱水、誤嚥、誤嚥性肺炎の予防の4つの臨床上の疑問に対する系統的レビューを行い、その後にエビデンスに基づいた推奨を行いました。

結果ですが、誤嚥性肺炎の予防には、慢性の嚥下障害の場合、液体の粘度調整より“chin down”手技と液体が第一選択です(A)。急性期では、個別のカウンセリング、食形態調整、液体の粘度調整を行うべきです(A)。

栄養状態の改善には、慢性の嚥下障害を認める高齢者の場合、食形態を工夫（ピューレ状やミンチ状：きざみ）した栄養豊富な食事や、液体の粘度調整（ネクター、はちみつ、プディング：プリン）が推奨されます(B*)。

質の高い研究が少ないため、推奨度は強くない結果になりました。慢性と急性の嚥下障害に対するより多くの食形態調整と液体の粘度調整の研究が必要という結論です。

食形態調整と液体の粘度調整に関しては、おそらく海外より日本のほうが進んでいると思います。ただその研究成果を英語で発信することが容易でなく、日本語での発信にとどまっているのが現状でしょう。今月下旬のIAGG（国際老年学会）では少しだけそういったことも発表してきます。

Abstract

Background

& Aims: In a number of countries, including Denmark, there are written guidelines describing the various types of texture modified foods and thickened fluids. None of these are based on a systematic review of texture modified food and thickened fluid as being more sufficient than regular food and fluid, and thereby preventing or reducing the impact of dysphagia. The present article aims to provide recommendations based on evidence for adults (≥ 18 years) with oropharyngeal dysphagia as soon as possible after diagnosis in order to ensure sufficient and safe oral consumption of nutrition as long as possible and thereby preventing malnutrition, dehydration, aspiration and aspiration pneumonia.

Methods

A systematic review was performed after definition of four clinical questions regarding prevention of malnutrition, dehydration, aspiration and aspiration pneumonia. Answers to the clinical questions led to the development of recommendations according to the evidence hierarchy (A indicates the highest level of recommendation).

Results

To reduce risk of aspiration pneumonia, “chin down” procedure and thin fluid should be first choice rather than thickened fluid in cases of chronic dysphagia (A), and in the acute phase individual counselling with follow up and adjustment of the consistency of texture modified food and thickened fluid should be given (A). To improve nutritional status, special made and nutritionally enriched, texture modified foods (pureed and minced) and thickened fluids (nectar, honey and pudding consistency) are recommended for elderly persons with chronic dysphagia (B*).

Conclusion

Since there are only a few, high quality studies, the evidence in favour of texture modified foods and thickened fluids as being effective in preventing or reducing the impact of dysphagia is not strong. More studies are needed to show whether texture modified foods and thickened fluids are effective in the management of chronic and acute dysphagia.