Oropharyngeal dysphagia as a risk factor for malnutrition and lower respiratory tract infection in independently living older persons: a population-based prospective study

OBJECTIVE

to assess the role of oropharyngeal dysphagia (OD) as a risk factor for malnutrition and/or lower respiratory tract infection (LRTI) in the independently-living population of 70 years and over.

DESIGN

a population-based cohort study.

SUBJECTS AND SETTING

persons 70 years and over in the community (non-institutionalised) were randomly selected from primary care databases.

MEASUREMENTS

the volume-viscosity swallow test (V-VST) was administered by trained physicians at baseline to identify subjects with clinical signs of OD and impaired safety or efficacy of swallow. At the one year follow-up visit, hand grip, functional capacity (Barthel score), nutritional status (mini nutritional assessment, MNA) and LRTI (clinical notes) were assessed.

RESULTS

two hundred and fifty-four subjects were recruited (46.5% female; mean age, 78 years) and 90% of them (227) were re-evaluated one year later. Annual incidence of 'malnutrition or at risk of malnutrition' (MNA <23.5) was 18.6% in those with basal signs of OD and 12.3% in those without basal signs of OD (P = 0.296). However, prevalent cases of 'malnutrition or at risk of malnutrition' at follow up were associated with basal OD (OR = 2.72; P = 0.010), as well as with basal signs of impaired efficacy of swallow (OR = 2.73; P = 0.015). Otherwise, LRTI's annual incidence was higher in subjects with basal signs of impaired safety of swallow in comparison with subjects without such signs (40.0 versus 21.8%; P = 0.030; OR = 2.39).

CONCLUSIONS

OD is a risk factor for malnutrition and LRTI in independently living older subjects. These results suggest that older persons should be routinely screened and treated for OD to avoid nutritional and respiratory complications.

Metastatic lymph node ratio versus number of metastatic lymph nodes as a prognostic factor in gastric cancer

OBJECTIVE

Knowledge of prognostic factors in gastric cancer is essential to decide on single patient management. We aim to establish the value of lymph node ratio compared to lymph node involvement in the prediction of gastric cancer survival and treatment approach.

METHODS

Charts of ninety-six consecutive patients undergoing gastrectomy for resectable gastric cancer were reviewed between January 1996 and December 2005. Receiver operating characteristic (ROC) curves were plotted to verify the accuracy of metastatic lymph node ratio (MLNR) and number of metastatic lymph node (NMLN) cut-off values for survival prediction. Patients were divided into two groups according to ROC curve cut-offs and accuracy in prognosis was reviewed.

RESULTS

ROC curves showed that 5 metastatic nodes and a node ratio value of 20% had the best survival prognostic correlation. The median survival of patients with MLNR and NMLN were similar according to cut-off determinations (≤ 5/> 5 metastatic nodes and ≤20/>20% lymph node ratio). Five-year survival rates were 70.9% vs 17.1% and 72.4% vs 15.6%, respectively (p < 0.001). Positive correlation coefficient was found between the number of excised nodes and the number of metastatic nodes.

CONCLUSION

Number of metastatic lymph nodes showed greater accuracy than lymph node ratio for survival prediction in gastric cancer.

Aging phenotype and its relationship with IGF-I gene promoter polymorphisms in elderly people living in Catalonia

OBJECTIVES

Genetic variations in the Insulin/IGF-I genes pathway have been related to longevity, dementia, metabolic diseases and cancer. The purpose of the present study was to investigate the 192 bp allele of IGF-I gene promoter and its relationship with metabolic syndrome (MS) components, mental and nutritional state, muscle strength and functional capacity in an aged Spanish population.

DESIGN

Population-based study (Mataró Ageing Study), including 292 subjects (144 men and 148 women, mean age 77.0±5.4). Anthropometric variables, lipid profile, glucose and blood pressure (BP) were measured; mental state (MMSE), nutritional state (MNA) and Barthel scale were performed, and were correlated to the presence of the 192 bp allele of IGF-1 gene promoter polymorphisms.

RESULTS

MS (ATP-III criteria) was found in 49.5% (41.4% in men and 57.6% in women). The 192 bp allele of IGF-I gene promoter was distributed as: 41.9% homozygous, 44.3% heterozygous and 13.9% were non-carriers of this allele. A lower prevalence of metabolic syndrome was observed in homozygous (41.9% vs 54.9% in heterozygous+non-carriers, p=0.031). Mental state (MMSE), nutritional state (MNA) and Barthel scale were better in homozygous individuals compared to heterozygous and non-carriers (p=0.015, p=0.026 and 0.047, respectively). In men, MNA was better in homozygous with no differences in MMSE and Barthel scales. In homozygous women, BP was lower (p=0.009) and Barthel scale was better (p=0.05) with no differences in MMSE and MNA.

CONCLUSION

Homozygosity for the 192 bp allele of the IGF-I gene polymorphism suggests a healthier aging condition, with less prevalence of cardiometabolic disturbances, and better mental, nutritional and functional state.

Cognitive processing variables in breast cancer: worry and distress at the end of treatment

This study assessed the influence of cognitive processing variables on cancer worries and distress after breast cancer treatment. In multivariate analyses, while independent variables were intolerance of uncertainty and intrusive thoughts, constructs' variables were anxiety and depression symptoms and cancer-related worries. The intolerance to uncertainty had a tendency to influence on distress and concerns about cancer after the end of treatment (Wilks' λ = 0.687, p = 0.074). Whereas, thought intrusion had a significant influence on distress and cancer related worries (Wilks' λ = 0.228, p = 0.000). Cognitive variables could be addressed by the oncology nurse when considering the patients' concerns related to cancer and psychological distress.

Iodine nutritional status in pregnant women of two historically different iodine-deficient areas of Catalonia, Spain

OBJECTIVE

Catalonia (Spain) has a historically worse situation of mild iodine deficiency in the Pyrenees Mountains compared with the coastal region. The aim of this study was to evaluate the current iodine status in pregnant women living in these two areas.

METHODS

An epidemiologic prospective survey included 267 consecutive pregnancies in the Catalan mountains (n = 139) and coast (n = 128) studied during the first trimester; an additional subset of 135 women from the initial cohort was available for evaluation in the third trimester. Urinary iodine (UI) was measured, and questionnaires to determine iodized salt and sea fish consumption and potassium iodide supplementation were administered.

RESULTS

The median UI in the first trimester was 163 μg/L for the entire cohort, with differences between mountain and coastal regions (209 versus 142 μg/L, P = 0.007). The highest prevalence of iodized salt consumption was in the mountain area (58% versus 36.4%, P < 0.001). For the entire group, a higher median UI was found in iodized salt consumers compared with non-consumers (193 versus 134 μg/L, P < 0.001). In the third trimester, an increase of median UI was seen in those to whom iodine supplements were given during pregnancy (190 versus 154 μg/L, P = 0.015).

CONCLUSION

A reversal in the historically iodine-deficient situation was observed in the Catalan Pyrenees compared with the coastal area, with a globally acceptable iodine status in pregnant women of the two geographic locations. Iodized salt consumption seems to have contributed to maintaining an acceptable iodine status in this population.

Magnetic resonance imaging as a predictor of response to somatostatin analogs in acromegaly after surgical failure

CONTEXT

Transsphenoidal surgery is considered first-line therapy for acromegaly; however, there is often a need for adjunctive therapy. Somatostatin analogs (SSA) have greatly improved the effectiveness of medical treatment, but one third of patients are resistant.

OBJECTIVE

The aim was to evaluate whether magnetic resonance imaging (MRI) signal could predict long-term response to SSA in patients with active acromegaly after neurosurgery.

PATIENTS AND METHODS

Sixty-two patients who were active acromegalic after surgery were included in this retrospective study. Remaining pituitary tumor was classified as hyper-, iso-, or hypointense by evaluating T2-weighted MRI signal. Treatment with SSA at maximal effective doses was prescribed and evaluated at 6 and 12 months by monitoring IGF-I, GH, and T2 MRI.

RESULTS

Complete response to SSA treatment (defined as normal IGF-I) at 6 months was observed in 30%, partial response (defined as IGF-I between 2 and 3 sd score) in 15%, and no response in 55% of patients. At 12 months, 28, 20, and 52% were observed, respectively. MRI signal was hypointense in 40%, hyperintense in 48%, and isointense in 12%. At 6 months, complete response to SSA was observed in 71% of cases having hypointense MRI signal and in 20% of hyperintense (P = 0.04). At 12 months, 62% of hypointense remained well controlled, whereas in the hyperintense group, good, partial, or no response results did not change from that observed at 6 months (P = 0.04).

CONCLUSION

In active acromegalic patients after surgery, a hypointense T2-weighted MRI signal is associated with a better response to SSA treatment at 6 and 12 months.

Pathophysiology of oropharyngeal dysphagia in the frail elderly

BACKGROUND

Oropharyngeal dysphagia is a major complaint among the elderly. Our aim was to assess the pathophysiology of oropharyngeal dysphagia in frail elderly patients (FEP).

METHODS

A total of 45 FEP (81.5 +/- 1.1 years) with oropharyngeal dysphagia and 12 healthy volunteers (HV, 40 +/- 2.4 years) were studied using videofluoroscopy. Each subject's clinical records, signs of safety and efficacy of swallow, timing of swallow response, hyoid motion and tongue bolus propulsion forces were assessed.

KEY RESULTS

Healthy volunteers presented a safe and efficacious swallow, faster laryngeal closure (0.157 +/- 0.013 s) upper esophageal sphincter opening (0.200 +/- 0.011 s), and maximal vertical hyoid motion (0.310 +/- 0.048 s), and stronger tongue propulsion forces (22.16 +/- 2.54 mN) than FEP. By contrast, 63.63% of FEP presented oropharyngeal residue, 57.10%, laryngeal penetration and 17.14%, tracheobronchial aspiration. Frail elderly patients with impaired swallow safety showed delayed laryngeal vestibule (LV) closure (0.476 +/- 0.047 s), similar bolus propulsion forces, poor functional capacity and higher 1-year mortality rates (51.7%vs 13.3%, P = 0.021) than FEP with safe swallow. Frail elderly patients with oropharyngeal residue showed impaired tongue propulsion (9.00 +/- 0.10 mN), delayed maximal vertical hyoid motion (0.612 +/- 0.071 s) and higher (56.0%vs 15.8%, P = 0.012) 1-year mortality rates than those with efficient swallow.

CONCLUSION & INFERENCES

Frail elderly patients with oropharyngeal dysphagia presented poor outcome and high mortality rates. Impaired safety of deglutition and aspirations are mainly caused by delayed LV closure. Impaired efficacy and residue are mainly related to weak tongue bolus propulsion forces and slow hyoid motion. Treatment of dysphagia in FEP should be targeted to improve these critical events.

Long-term effect of ghrelin on nutritional status and functional capacity in the elderly: a population-based cohort study

BACKGROUND

Ghrelin stimulates GH release and hunger at a central level. Ghrelin declines with age, which may be partially responsible for functional impairment and frailty.

OBJECTIVE

To describe the evolution of nutritional status and functional capacity of noninstitutionalized old people over a 2-year period, as well as to evaluate the relationship between ghrelin and long-term changes in nutritional and functional status in this population.

DESIGN

A population-based cohort study was designed in which 313 randomly selected persons, 70 years old or older, were followed for a 2-year period. Functional (Barthel and Guralnik scores and hand grip) and nutritional (MNA-SF, weight and BMI) assessments were performed during basal and 2-year follow-up visits. Ghrelin and hormonal components of the gonadotrophe and somatotrophe axis were determined.

RESULTS

During follow-up, 13% of men and 20% of women showed a >5% weight loss, and the nutritional status of 18% of men and 39% of women deteriorated. Men lost 12.1% and women lost 9.7% of their initial hand grip strength. In men, low basal ghrelin levels were associated with higher weight loss and poorer hand grip but not with the MNA-SF measure, whereas in women, low basal ghrelin levels were associated with a decline in nutritional status (MNA-SF) but not with weight loss and hand grip decline.

CONCLUSION

Low ghrelin levels have been related to worsening nutritional status in a 2-year follow-up period in people 70 years old or older, which suggests this hormone could become a useful therapeutic target in the elderly.

Inhaled drugs as risk factors for community-acquired pneumonia

The effect of inhaled drugs in community-acquired pneumonia (CAP) is unclear. This case-control study was designed to determine whether inhaled drugs were risk factors for CAP. All incident cases of confirmed CAP that occurred over 1 yr in patients with chronic bronchitis (CB), chronic obstructive pulmonary disease (COPD) or asthma were included, as well as CB, COPD and asthma controls. Risk factors for CAP and inhaled treatment were recorded during a personal interview. An effect of inhaled drugs on the risk of CAP was observed in COPD and asthma patients after adjusting for the effect of other respiratory diseases and their concomitant treatments. In COPD patients, inhaled steroids had a risk OR of 3.26 (95% CI 1.07-9.98) and in asthma patients inhaled anticholinergics had a risk OR of 8.80 (95% CI 1.02-75.7). In CB patients, no association with CAP was observed for any inhaler. These effects were independent of adjusting variables related to severity and other respiratory and non-respiratory risk factors for CAP, including vaccines. Inhaled β(2)-adrenergic agonists did not show a significant effect on the risk of CAP in any of the respiratory diseases. Inhaled steroids may favour CAP in COPD patients, whereas anticholinergics may favour CAP in asthma patients. It is difficult to differentiate the effect of inhaled therapy from the effect of COPD or asthma severity on the risk of CAP, and these relationships may not be causal, but could call attention to inhaled therapy in COPD and asthma patients.

Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia

BACKGROUND

oropharyngeal dysphagia is a common condition among the elderly but not systematically explored.

OBJECTIVE

to assess the prevalence and the prognostic significance of oropharyngeal dysphagia among elderly patients with pneumonia.

DESIGN

a prospective cohort study.

SETTING

an acute geriatric unit in a general hospital.

SUBJECTS

a total of 134 elderly patients (>70 years) consecutively admitted with pneumonia.

METHODS

clinical bedside assessment of oropharyngeal dysphagia and aspiration with the water swallow test were performed. Demographic and clinical data, Barthel Index, Mini Nutritional Assessment, Charlson Comorbidity Index, Fine's Pneumonia Severity Index and mortality at 30 days and 1 year after admission were registered.

RESULTS

of the 134 patients, 53% were over 84 years and 55% presented clinical signs of oropharyngeal dysphagia; the mean Barthel score was 61 points indicating a frail population. Patients with dysphagia were older, showed lower functional status, higher prevalence of malnutrition and comorbidities and higher Fine's pneumonia severity scores. They had a higher mortality at 30 days (22.9% vs. 8.3%, P = 0.033) and at 1 year of follow-up (55.4% vs. 26.7%, P = 0.001).

CONCLUSIONS

oropharyngeal dysphagia is a highly prevalent clinical finding in elderly patients with pneumonia and is an indicator of disease severity in older patients with pneumonia.

Effect of age and frailty on ghrelin and cholecystokinin responses to a meal test

BACKGROUND

Ghrelin and cholecystokinin (CCK) are among the peripheral signals that regulate hunger and satiety.

OBJECTIVE

The objective was to assess whether ghrelin and CCK responses to a standard nutritional load are related to age and frailty.

DESIGN

Ghrelin, CCK, insulin, glucose, and 4-h visual analog hunger scale curves after a standard nutritional load test (380 kcal) were described and compared between 3 groups: old (>75 y) and frail persons (group A), old (>75 y) but nonfrail persons (group B), and young (25-65 y) adults (group C).

RESULTS

Frail persons showed no postprandial ghrelin suppression, and old subjects, frail and nonfrail, showed no significant postprandial ghrelin recovery compared with young adults. Frailty was also associated with lower fasting ghrelin concentrations. No differences in fasting CCK were observed between young and old persons; however, postprandial CCK concentrations were enhanced in young persons, whereas no frailty effect on the CCK curve was observed in the old subjects. No correlations between mean ghrelin and hunger values over time were found, but strong negative correlations were shown between CCK and hunger (group A: r(s) = -0.88, P = 0.009; group B: r(s) = -0.86, P = 0.014; group C: r(s) = -0.71, P = 0.071) and insulin and hunger (group A: r(s) = -0.901, P = 0.006; group B: r(s) = -0.964, P < 0.001; group C: r(s) = -0.929, P = 0.003).

CONCLUSIONS

Advanced age determines a poorer ghrelin postprandial recuperation phase, a reduced CCK postprandial response, and an exaggerated postprandial insulin release. A loss of ghrelin prandial rhythm is present in old frail persons. The impaired response of these hunger regulatory hormones with age might contribute to the mechanisms of anorexia associated with aging.

Relationship between ghrelin and the metabolic syndrome in the elderly: a longitudinal population-based study

CONTEXT

Ghrelin regulates energy homeostasis and may contribute to the development of the metabolic syndrome (MS) in the elderly.

OBJECTIVE

To study the relationship between ghrelin and the MS, IGF-I and life style factors over a 2-year follow-up.

DESIGN

Longitudinal population-based study, starting from 2002; 2 years follow-up.

PARTICIPANTS

Three hundred and thirteen (153 men/160 women) individuals living independently older than 70 years.

RESULTS

MS was found in 54.9% of men and 61% of women. In the 229 subjects available at follow-up, ghrelin was higher in men than in women at basal (P = 0.002) and 2-year follow-up (P = 0.004). Ghrelin decreased over time in both genders (P < 0.01). Ghrelin was lower in individuals showing MS compared to non-MS (P = 0.08), but this difference was more evident at 2-year follow-up (P = 0.016), mostly due to men with MS (P = 0.002) and even after adjustment for BMI, gender and age. Individuals with MS had an OR of 1.67 (95% CI: 1.0-2.78) for low ghrelin (< first tertile); when adjusting by BMI, gender and age, only high triglycerides with OR 1.8 (1.0-3.3), remained statistically significant among the MS components. IGF-I showed a positive correlation with ghrelin only in individuals without MS (r(s) 0.403, P < 0.001) with no gender differences; this relationship was not found in MS (r(s) 0.120, P = 0.129). A positive association of ghrelin was found with academic level, alcohol consumption and smoking.

CONCLUSIONS

Ghrelin is higher in old men in comparison to women and decreases over time with a steeper decline in subjects with MS; moreover, in these subjects ghrelin/IGF-I correlation is lost.

Hormonal determinants of depression and cognitive function in independently-living elders

OBJECTIVE

To study the potential associations among circulating insulinlike growth factor 1 (IGF-1) and adrenal and gonadal steroids with cognitive status and depression in a group of independently-living elders.

DESIGN

Population-based cross sectional study.

METHODS

A total of 313 individuals (160 women and 153 men, with a mean age of 76.7±7 years) participated in this study. A physical examination, assessment of functional capacity, cognitive function, depression, educational level and measurement of plasma cortisol, dehydroepiandrosterone (DHEA) and its sulphate (DHEAs), testosterone, estradiol, and IGF-1 were performed.

RESULTS

In women, adrenal steroids showed a negative correlation with global cognition (β=-0.79; p=0.03 for DHEA and β=-0.27; p=0.002 for cortisol). A positive correlation with IGF-1 (β=0.026; p=0.04) was found for cognition in women after adjustment for depression. For memory function, DHEA correlated negatively but no relationship with IGF-1 and cortisol was observed. No relationships with cognition were observed in men for any of the steroids or other hormones studied. Educational level showed the highest protective effect (odds ratio [OR] = 6.25) for preserved cognition for both sexes; in women, OR for deteriorated cognition with age, DHEA and cortisol were 1.14, 1.57 and 1.09, respectively. No associations between depression and hormonal profile were found in either sex.

CONCLUSIONS

Educational level was positively associated with cognitive function in independently-living elderly men and women, while adrenal steroids were associated with impaired cognition in elderly women but not in men. The hormonal milieu seemed to have little or no influence on depression in the men and women studied.

Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration

AIMS

To determine the accuracy of the bedside volume-viscosity swallow test (V-VST) for clinical screening of impaired safety and efficacy of deglutition.

METHODS

We studied 85 patients with dysphagia and 12 healthy subjects. Series of 5-20 mL nectar (295.02 mPa.s), liquid (21.61 mPa.s) and pudding (3682.21 mPa.s) bolus were administered during the V-VST and videofluoroscopy. Cough, fall in oxygen saturation > or =3%, and voice changes were considered signs of impaired safety, and piecemeal deglutition and oropharyngeal residue, signs of impaired efficacy.

RESULTS

Videofluoroscopy showed patients had prolonged swallow response (> or =1064 ms); 52.1% had safe swallow at nectar, 32.9%, at liquid (p<0.05), and 80.6% at pudding viscosity (p<0.05); 29.4% had aspirations, and 45.8% oropharyngeal residue. The V-VST showed 83.7% sensitivity and 64.7% specificity for bolus penetration into the larynx and 100% sensitivity and 28.8% specificity for aspiration. Sensitivity of V-VST was 69.2% for residue, 88.4% for piecemeal deglutition, and 84.6% for identifying patients whose deglutition improved by enhancing bolus viscosity. Specificity was 80.6%, 87.5%, and 73.7%, respectively.

CONCLUSIONS

The V-VST is a sensitive clinical method to identify patients with dysphagia at risk for respiratory and nutritional complications, and patients whose deglutition could be improved by enhancing bolus viscosity. Patients with a positive test should undergo videofluoroscopy.

Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration

AIMS

To determine the accuracy of the bedside volume-viscosity swallow test (V-VST) for clinical screening of impaired safety and efficacy of deglutition.

METHODS

We studied 85 patients with dysphagia and 12 healthy subjects. Series of 5-20 mL nectar (295.02 mPa.s), liquid (21.61 mPa.s) and pudding (3682.21 mPa.s) bolus were administered during the V-VST and videofluoroscopy. Cough, fall in oxygen saturation > or =3%, and voice changes were considered signs of impaired safety, and piecemeal deglutition and oropharyngeal residue, signs of impaired efficacy.

RESULTS

Videofluoroscopy showed patients had prolonged swallow response (> or =1064 ms); 52.1% had safe swallow at nectar, 32.9%, at liquid (p<0.05), and 80.6% at pudding viscosity (p<0.05); 29.4% had aspirations, and 45.8% oropharyngeal residue. The V-VST showed 83.7% sensitivity and 64.7% specificity for bolus penetration into the larynx and 100% sensitivity and 28.8% specificity for aspiration. Sensitivity of V-VST was 69.2% for residue, 88.4% for piecemeal deglutition, and 84.6% for identifying patients whose deglutition improved by enhancing bolus viscosity. Specificity was 80.6%, 87.5%, and 73.7%, respectively.

CONCLUSIONS

The V-VST is a sensitive clinical method to identify patients with dysphagia at risk for respiratory and nutritional complications, and patients whose deglutition could be improved by enhancing bolus viscosity. Patients with a positive test should undergo videofluoroscopy.

A short acute octreotide test for response prediction of long-term treatment with somatostatin analogues in acromegalic patients

The usefulness of the acute octreotide test in the selection of acromegalic patients for chronic somatostatin depot analogues treatment is controversial. The aim of the present study was to determine its accuracy for chronic response prediction, and the reliability of a short version of the classic 6-hour test. The data from 26 acromegalics (19 women, 7 men, mean age 52.6+/-13.1 years) studied with an acute octreotide test (6 hours sampling for GH measurement after octreotide 100 microg s. c.) were retrospectively analyzed. Eighteen of them followed chronic somatostatin depot analogues treatment for 12 months. GH nadir was always detected at 2 hours (mean decrease 75.9+/-24%). GH levels at 2 hours positively correlated with the other time-points (r(s) 0.97, 0.98, 0.97, 0.96 at 3, 4, 5 and 6 h, respectively; p<0.0001). During chronic treatment with maximal effective dose for 12 months, 61% of the patients achieved IGF1 <3 SD and 22% reached IGF1 <2 SD. GH nadir correlated with IGF1 decrease at 12 months (r(s) 0.76, p<0001). GH nadir of 9.2 ng/ml predicts IGF1 <3 SD with 82% sensitivity and 58% specificity (75% PPV, 67% NPV); for IGF1<2 SD, 75% sensitivity and 58% specificity are obtained for GH nadir 3.6 ng/ml, with 33% PPV and 89% NPV. Acute octreotide test reliably predicts response to long-term treatment; the short, 2-hour version is fully informative for therapeutic decisions in acromegalic patients.

The effect of bolus viscosity on swallowing function in neurogenic dysphagia

AIM

To assess the pathophysiology and treatment of neurogenic dysphagia.

METHODS

46 patients with brain damage, 46 with neurodegenerative diseases and eight healthy volunteers were studied by videofluoroscopy while swallowing 3-20 mL liquid (20.4 mPa s), nectar (274.4 mPa s) and pudding (3931.2 mPa s) boluses.

RESULTS

Volunteers presented a safe and efficacious swallow, short swallow response (< or =740 ms), fast laryngeal closure (< or =160 ms) and strong bolus propulsion (> or =0.33 mJ). Brain damage patients presented: (i) 21.6% aspiration of liquids, reduced by nectar (10.5%) and pudding (5.3%) viscosity (P < 0.05) and (ii) 39.5% oropharyngeal residue. Neurodegenerative patients presented: (i) 16.2% aspiration of liquids, reduced by nectar (8.3%) and pudding (2.9%) viscosity (P < 0.05) and (ii) 44.4% oropharyngeal residue. Both group of patients presented prolonged swallow response (> or =806 ms) with a delay in laryngeal closure (> or =245 ms), and weak bolus propulsion forces (< or =0.20 mJ). Increasing viscosity did not affect timing of swallow response or bolus kinetic energy.

CONCLUSIONS

Patients with neurogenic dysphagia presented high prevalence of videofluoroscopic signs of impaired safety and efficacy of swallow, and were at high risk of respiratory and nutritional complications. Impaired safety is associated with slow oropharyngeal reconfiguration and impaired efficacy with low bolus propulsion. Increasing bolus viscosity greatly improves swallowing function in neurological patients.