The importance of meal assessment in ALS patients

Background: the importance of instrumental evaluation of swallowing in ALS patients is highly recognized in order to assess swallowing safety and prevent pulmonary complications. However, swallowing performance during instrumental assessment may not be representative of what happens when consuming meals in everyday life. Indeed, as fatigue is a common feature in ALS patients, swallowing efficacy may progressively decline during mealtime consumption and food and liquid oral intake may not be sufficient. Objectives: to investigate the relationship between the performance during mealtime consumption and the efficacy of oral and pharyngeal phase of swallowing in ALS patients. Methods: thirteen ALS patients, 7 males and 6 females with a median age of 68.5 years (range 51-78) were enrolled in the study. Fiberoptic endoscopic evaluation of swallowing (FEES) was conducted testing liquids, semisolids and, whether possible, solids. The Penetration-Aspiration Scale (PAS) and the Dysphagia Outcome and Severity Scale (DOSS) were used to assess the FEES. The Test of Mastication and Swallowing Solids (TOMASS) was performed. Tongue strength and resistance were assessed through the Iowa Oral Performance Instrument (IOPI). Patients completed the Eating Assessment Tool-10, a self-reported questionnaire. Typical oral intake was recorded using the Functional Oral Intake Scale (FOIS). Meal consumption was observed and scored through the Mealtime Assessment Scale (MAS); the time the patients needed to consume a meal was recorded. Correlations between MAS total score or time and PAS, DOSS, EAT-10, FOIS, TOMASS and IOPI measures were studied using Spearman’s correlation coefficient. Results: a statistically significant correlation was found between MAS total scores and FOIS (r=0.755, p=0.007), EAT-10 (r=-0.724, p=0.012), tongue strength (r=0.718, p=0.019) and TOMASS total time (r=-0.709, p=0.046). Time needed to consume a meal significantly correlated with tongue resistance (r=0.675, p=0.032) and number of discrete bites during TOMASS (r=-0.793, p=0.033). No statistically significant correlations were found between MAS and PAS or DOSS. Discussion and conclusion: these preliminary results suggest that instrumental assessment of swallowing, especially FEES, may not be exhaustive in ALS patients as it does not predict patient’s performance during meals. Efficacy of swallowing oral phase seems to be related to meal consumption more than pharyngeal phase. Therefore, our data stress the need of a comprehensive swallowing evaluation in ALS patients, including instrumental, oral phase and mealtime assessment, in order to estimate the risk of both pulmonary and nutritional complications related to dysphagia.