McGill Ingestive Skills Assessment (MISA): Development and First Field Test of an Evaluation of Functional Ingestive Skills of Elderly Persons

Appendices

Definition of Scales and Sample Items

Abstracted from the McGill Ingestive Skills Assessment User's Manual, Draft Version 2.

For ease of reading, the following text uses the male gender to refer to male or female patients.

Positioning

The purpose of the Positioning Scale is to assess the patient's ability to maintain a position that is safe for feeding. The observer should not alter the patient's position during the meal; this task should be left to the regular caregiver or the patient himself.

Maintains Symmetry of Posture

For this item, observe whether or not the patient leans to the right or the left during the meal.

• 1 Score 1 if the patient spends all or nearly all of the time leaning to one side and does not straighten himself even when he is taking a new mouthful or when he is are swallowing.

• 2 Score 2 if the patient spends more than half of the meal leaning to one side. The patient may lean from time to time and then reposition or may lose his position after a few minutes of the meal and does not regain a symmetric posture.

• 3 Score 3 if the patient spends about less than half of the meal leaning to one side. The patient may lean from time to time and then reposition or may lose his position partway through the meal and does not regain a symmetric posture.

• 4 Score 4 if the patient is able to maintain a symmetrical posture or if he adopts an asymmetric position only transitionally. The patient should be symmetric when taking a mouthful or swallowing. If he is not, score 2 or 3 as appropriate. Some individuals habitually shift their weight from side to side; if they come back to the centre, score 4.

Has Adequate Head Control for Feeding

For this item, observe the patient's ability to hold his head in a neutral position. During eating, the neck should not be extended or flexed more than a few degrees, so that the chin is tucked in.

• 1 Score 1 if the patient requires a head support to prevent loss of position or if he is never able to hold his head in a stable position.

• 2 Score 2 if the patient is able to bring his head into a neutral position and maintain it for a few seconds but does not have head control for the majority of the meal.

• 3 Score 3 if the patient is able to maintain his head position for the majority of the meal duration but has occasional loss of control, allowing his neck to flex or extend.

• 4 Score 4 if the patient is able to maintain his head position throughout the meal. Some individuals may voluntarily look around the room or voluntarily flex or extend to relax stiffness; these individuals should also be scored 4 if these movements are voluntary. If there are involuntary movements in addition to these, score 2 or 3 as appropriate.

Texture Management

The purpose of the Texture Management Scale is to assess the individual's ability to accept food textures. The purpose is not to assess the safety of the consumption of these textures; that aspect is addressed later. In this scale, we are assessing the individual's judgment, discretion, and sensitivity to different textures.

Each of the items is prefaced by the word accepts. This word is to be interpreted as the willing consumption of the texture described. If an individual does not accept the food, he may turn away or refuse to open the mouth. Some individuals realize that they are unable to handle a texture only when it is in the mouth. If an individual spits out a food, appears anxious, cries, or otherwise demonstrates hesitancy or resistance to swallowing, this should be interpreted as not accepting the texture. Some individuals may take a mouthful and then refuse to eat any more; this should be interpreted as nonacceptance unless the patient makes a statement that he dislikes the taste of the food.

Feeding Skills

The purpose of this scale is to assess the individual's ability to manage the meal activity independently and functionally. The scale touches on various aspects of meals, including preparation, self-feeding, behavior, judgment, and appetite.

Sets Up Tray Independently

This item is concerned with the patient's ability to arrange platters appropriately on the tray or table, open wrappers, remove lids, and prepare utensils.

• 1 Score 1 if the patient requires someone else to carry out all or part of these tasks.

• 2 Score 2 if the patient is able to carry out the tasks independently if he is given precise verbal instructions (“pick up the crackers, hold the plastic in each hand, and pull”) or if he is given a physical demonstration without the helper doing the task for him.

• 3 Score 3 if the patient needs only a verbal prompt (“the butter for your bread is on the tray”).

• 4 Score 4 if the patient is able to complete all tasks without assistance or prompting.

Able to Grasp Utensil Functionally

For this item, observe how the patient holds the utensil. The style of grasp is not important. Rather, the utensil should be held in such a way as to prevent spillage of the food before the utensil reaches the mouth.

• 1 Score 1 if the patient is fed by an assistant or if he almost never grasps the utensil functionally.

• 2 Score 2 if the patient self feeds and grasps the utensil functionally for less than half of the meal.

• 3 Score 3 if the patient self feeds and holds the utensil functionally for more than half of the meal.

• 4 Score 4 if the patient always uses a functional grasp.

Liquid Ingestion

The purpose of this scale is to assess the patient's ability to consume regular and thickened liquids. The scale should be scored whether the patient takes the liquid from a glass, cup, or spoon. The scale addresses the various motor functions associated with drinking and the observable signs of pharyngeal function and airway protection.

Seals Lips on Cup

This item addresses the patient's ability to close his lips on the cup when he drinks. Observe the closure of the lips with particular attention to the bottom lip. The glass or cup should rest on the bottom lip during drinking, and the upper lip should close towards the inside of the glass. Some individuals do not completely oppose the upper lip to the surface of the cup; this is considered normal.

• 1 Score 1 if the patient almost never closes his lips on the cup. This may be seen by stabilization of the glass on the lower teeth and/or a lax lower lip. Score 2 if the patient takes liquids from a spoon.

• 2 Score 2 if the patient closes his lips on the cup less than half of the time. He may stop closing his lips partway through the meal or close them only on occasion throughout the meal.

• 3 Score 3 if the patient closes his lips on the cup more than half of the time. He may stop closing his lips partway through the meal or close them only on occasion throughout the meal.

• 4 Score 4 if the patient closes his lips consistently for the entire meal.

Demonstrates Same Voice Quality After Drinking

This item assesses the patient's ability to protect the airway from penetration of liquid. The presence of aspiration and penetration is associated with a change in the patient's voice. A hoarse voice generally becomes deeper and takes on a rough quality. A gurgly voice can be described as sounding “well,” as if there is liquid on the vocal cords. The patient should be observed throughout the meal to determine if this phenomenon appears with fatigue.

• 1 Score 1 if the patient loses his voice after drinking or if he is unable to verbalize at the outset of the meal. A loss of voice on one occasion without any other abnormalities is scored 1.

• 2 Score 2 if the patient demonstrates a change in voice after drinking a small quantity of liquid or if this occurs near the beginning of the meal.

• 3 Score 3 if the patient demonstrates a change in voice after drinking a large quantity of liquid or if this occurs near the end of the meal.

• 4 Score 4 if there is never any change in voice after drinking.

Solid Ingestion

The purpose of this scale is to assess the patient's motor skills for eating, as well as to evaluate the observable signs of pharyngeal dysfunction. The patient should be observed as he consumes all foods of a solid texture, including purees and puddings.

Opens Mouth in Anticipation

This item assesses the patient's preparation to receive food. The patient should open his mouth to admit the utensil whether he is being fed or is self-feeding. The patient should open at the sight or smell of the food approaching, on a verbal cue from a feeder, or, in the case of individual with multiple sensory deficits, as the utensil is touched to the lower lip. Unless there is a physical limitation to the range of motion in the jaw, the mouth should open wide enough to allow the utensil to pass without stretching the corners of the mouth.

• 1 Score 1 if the patient almost never opens his mouth in anticipation. If the patient needs to be coerced to open his mouth or consistently opens his mouth so little that the utensil cannot pass, score 1.

• 2 Score 2 if the patient opens his mouth less than half of the time or opens his mouth widely enough only on occasion.

• 3 Score 3 if the patient opens his mouth more than half of the time or only occasionally does not open widely enough for the utensil to pass.

• 4 Score 4 if the patient consistently opens his mouth widely enough in anticipation.

Retains Food in Mouth

This item assesses the patient's ability to form a bolus and control the bolus in the mouth, as well as the ability of the lips to contain solid food. This should be scored based on the patient's performance throughout the processing of the bolus in preparation for the swallow.

• 1 Score 1 if the patient loses any amount of food on a consistent basis or if there is occasional loss of large quantities of the bolus.

• 2 Score 2 if the patient loses small amounts of food frequently. This may occur at intervals throughout the meal or begin to occur consistently as the patient becomes fatigued as the meal progresses.

• 3 Score 3 if the patient loses small quantities on occasion, either periodically throughout the meal or consistently for a short period of time.

• 4 Score 4 if the patient never loses food during oral processing.