Clinical Utility of the 3-ounce Water Swallow Test

Discriminant Ability of the 3-Ounce Water Swallow Test to Detect Aspiration in Acute Postoperative Cardiac Surgical Patients

Dysphagia is a common complication of cardiac surgery (CS) contributing to morbidity and mortality. Although early dysphagia detection is important, no current screening guidelines or validated tools exist in the cardiac intensive care setting. We therefore aimed to examine the discriminant ability of the 3-ounce water swallow test (3 oz. WST) to detect aspiration in acute postoperative CS patients. 196 postoperative CS patients were enrolled in this prospective single-center study. Participants completed the 3 oz. WST and a standardized Flexible Endoscopic Evaluation of Swallowing. Independent duplicate ratings of the penetration aspiration scale (PAS) were performed in a blinded fashion (100% agreement criteria). Receiver operating characteristic curve and area under the curve (AUC) analyses were performed with sensitivity, specificity, positive, and negative predictive values (PPV, NPV) derived. Fifty-four CS patients (28%) were confirmed aspirators (PAS ≥ 6), of whom 48% (n = 26) were silent aspirators (PAS = 8). Both the sensitivity and specificity of the 3 oz. WST to identify instrumentally confirmed aspiration was 63% (AUC: 0.63, 95% CI: 0.54, 0.72), and PPV was 39% and NPV 82%. The 3 oz. WST demonstrated fair discriminant ability to detect aspiration in acute postoperative CS patients. The high rate of silent aspiration may explain, in part, these findings given that the screening fail criteria include an overt cough response. In isolation, the 3 oz. WST does not represent a sensitive screen of aspiration in postoperative CS patients with a need to identify alternative screening tools for this setting.

Speech and swallowing deficits in X-Linked Dystonia-Parkinsonism

INTRODUCTION

X-linked Dystonia-Parkinsonism (XDP) is a progressive, disabling disease characterized by the devastating impairment of bulbar function, including speech and swallowing. Despite these detrimental impacts, bulbar impairments in this population are not well characterized.

OBJECTIVES

To identify impairments in the bulbar system measured by oromotor performance in individuals with XDP relative to healthy controls. Secondarily, to detect diagnostic bulbar markers that are sensitive and specific to the initial years of XDP.

METHODS

This case-control study included 25 healthy controls and 30 participants with XDP, divided into two subgroups based on the median of their disease length. Multiple clinical and instrumental oromotor tasks and measures were used to evaluate bulbar motor function.

RESULTS

Differences were found between both the subgroups with XDP and healthy controls on almost all measures, including maximum performance tasks such as tongue strength, alternating motion rate (AMR), and sequential motion rate (SMR) (p < 0.05). Differences were found between the XDP subgroups and the control group for the percentage of pause time during the speech, a rating of speech severity, and a swallowing task (ps < 0.05). Scores on self-reported questionnaires, tongue strength, the number of repetitions produced during an AMR, percent pause, and speech severity demonstrated good sensitivity and specificity to differentiate the initial years of XDP onset from healthy controls.

CONCLUSIONS

Our findings revealed impairments across bulbar functions in participants within the first 7 years of the XDP onset. Highly sensitive and specific bulbar impairment measures were detected in instrumental and self-reported measures that are fundamental for monitoring disease.

Radiation-induced swallowing dysfunction in patients with head and neck cancer: A literature review

Swallowing dysfunction is a prevailing state following radiotherapy in patients with head and neck cancer. Following the advancement of cancer treatment in recent years, the survival rate of head and neck cancer has gradually increased. Simultaneously, patients with head and neck cancer suffer due to the long-duration and more prominent swallowing dysfunction states. Based on an extensive literature review, we aimed to explore the mechanisms, risk factors, and clinical evaluations of swallowing dysfunction and their related symptoms following radiotherapy. These include functional changes of the muscles, trismus, xerostomia, neuropathy, and lymphedema. When swallowing dysfunction occurs, patients usually seek medical help and are referred for rehabilitation therapy, such as muscle strengthening and tongue resistance exercise. Furthermore, clinicians should discuss with patients how and when to place the feeding tube. Only through detailed evaluation and management can swallowing dysfunction resolve and improve the quality of life of patients with head and neck cancer following radiotherapy.

Predictive Value of Cough Frequency in Addition to Aspiration Risk for Increased Risk of Pneumonia in Dysphagic Stroke Survivors: A Clinical Pilot Study

BACKGROUND

Post-stroke dysphagia leads to increased risk of aspiration and subsequent higher risk of pneumonia. It is important to not only diagnose post-stroke dysphagia early but also to evaluate the protective mechanism that counteracts aspiration, i.e., primarily cough. The aim of this study was to investigate the predictive value of cough frequency in addition to aspiration risk for pneumonia outcome.

METHODS

This was a single-center prospective observational study. Patients with first-ever strokes underwent clinical swallowing evaluation, fibreoptic endoscopic evaluation of swallowing (FEES), and overnight cough recording using LEOSound^® (Löwenstein Medical GmbH & Co. KG, Bad Ems, Germany ). Penetration-Aspiration Scale (PAS) ratings and cough frequency measurements were correlated with incidence of pneumonia at discharge.

RESULTS

11 women (37%) and 19 men (63%), mean age 70.3 years (SD ± 10.6), with ischemic stroke and dysphagia were enrolled. Correlation analysis showed statistically significant relationships between pneumonia and PAS (r = 0.521; p < 0.05), hourly cough frequency (r = 0,441; p < 0.05), and categories of cough severity (r = 0.428 p < 0.05), respectively. Logistic regression showed significant predictive effects of PAS (b = 0.687; p = 0.014) and cough frequency (b = 0.239; p = 0.041) for pneumonia outcome.

CONCLUSION

Cough frequency in addition to aspiration risk was an independent predictor of pneumonia in dysphagic stroke survivors.

Swallowing dysfunction in patients hospitalised due to a COPD exacerbation

Objectives

This cross-sectional study aimed to investigate the prevalence of self-reported and clinically screened swallowing dysfunction (dysphagia) in COPD patients with severe exacerbations and to identify any associated factors. Findings were then compared to a control group.

Methods

Participants included 30 patients hospitalised due to a COPD exacerbation. The control group consisted of 30 adults hospitalised with acute cardiac symptoms. Data were derived from spirometry, the 150 mL timed water swallow test, a cookie swallow test and a dyspnoea questionnaire (modified Medical Research Council (mMRC)). Scores from the 10-item Eating Assessment Tool (EAT-10) were calculated to assess patient perception of swallowing dysfunction.

Results

Self-reported swallowing dysfunction and clinical signs thereof were more common in COPD patients than in the control group (67% versus 23% and 80% versus 37%, respectively; p≤0.001). Clinical signs of swallowing dysfunction in the group with acute exacerbation of COPD were associated with self-reported swallowing dysfunction (p=0.02) and xerostomia (p=0.04). Dyspnoea (mMRC ≥2) was more common among the COPD patients (90% versus 47%, p<0.001). There was a significant negative correlation between lung function and self-reported dysphagia (r=−0.39, p=0.03), but not between lung function and clinically screened dysphagia (r=−0.23, p=0.21).

Conclusion

COPD patients hospitalised with an acute exacerbation experienced significantly more self-reported and clinically screened swallowing dysfunction compared to a control group of patients with cardiac symptoms. Both patient groups experienced dyspnoea, but it was twice as common in the group with acute exacerbation of COPD. Both groups also experienced xerostomia.

Patients hospitalised with #AECOPD experienced significantly more self-reported and clinically screened swallowing dysfunction compared to a control grouphttps://bit.ly/32awLkx

The Test of Masticating and Swallowing Solids (TOMASS): Reliability and validity in patients with dysphagia

BACKGROUND

The Test of Masticating and Swallowing Solids (TOMASS) is an international standardized swallowing assessment tool. However, its psychometric characteristics have not been analysed in patients with dysphagia.

AIMS

To analyse TOMASS's (1) inter- and intra-rater reliability in a clinical population of patients with dysphagia, (2) known-group validity, (3) concurrent validity and (4) correlation with meal duration.

METHODS & PROCEDURES

Two age- and gender-matched groups of 39 participants each were recruited: A group of patients with dysphagia and a control group with no history of dysphagia. The TOMASS was carried out in both populations, video-recorded and scored offline by two speech and language therapists (SLT 1 and SLT 2) (inter-rater reliability) and twice by the same SLT (intra-rater reliability). In the clinical group, the TOMASS was carried out three times: (1) to verify understanding of the required tasks, (2) performed concurrently during fibreoptic endoscopic evaluation of swallowing (FEES) to assess validity and (3) during clinical assessment to assess reliability. TOMASS under endoscopic control was recorded and the number of white-out events was counted to compare with the number of observed swallows per cracker during standard TOMASS as a measure of concurrent validity. As additional measures of TOMASS validity, oral dental status, classified as 'functional' or 'partially functional', and duration of a standard meal were assessed by an SLT (SLT 1 or SLT 2), and then correlated with TOMASS.

OUTCOME & RESULTS

TOMASS's inter- and intra-rater reliability were high (intraclass correlation coefficient (ICC) > 0.95) in both the clinical and the control groups. The number of masticatory cycles (p = 0.020), swallows (p = 0.013) and total time (p = 0.003) of TOMASS were significantly lower in the control group than in the clinical group. Patients with 'partially functional' oral dental status showed a significantly higher number of masticatory cycles per cracker and a longer duration of ingestion than patients with a 'functional' one. Concurrent validity suggested a substantial agreement between TOMASS and FEES in defining the number of swallows per cracker. The mean difference of the two measures was -0.02 (95% confidence interval (CI) = -1.7 to 1.2). Meal duration significantly correlated with the 'number of swallows per cracker' (r = 0.49; p = 0.002) and 'total time' (r = 0.41; p = 0.011).

CONCLUSIONS & IMPLICATIONS

Preliminary psychometric analysis of TOMASS in a clinical sample of outpatients with dysphagia suggests that it is a reliable and valid (specifically related to the number of swallows per cracker) tool. TOMASS's application in clinical practice to quantitatively measure solid bolus ingestion is recommended. What this paper adds What is already known on the subject The Test of Masticating and Swallowing Solids (TOMASS) is an international standardized swallowing assessment tool to evaluate oral preparation and oral phase of solids. The TOMASS' reliability and validity were tested on healthy subjects and normative data were gained. What this paper adds to existing knowledge The study provides the first data on the validity and reliability of the TOMASS in a clinical population. The TOMASS was proved to be a reliable and valid tool also in patients with dysphagia and to distinguish between patients with dysphagia and healthy subjects. What are the potential or actual clinical implications of this work? The use of the TOMASS in clinical practice is recommended as a valid and reliable tool to quantitatively measure the ingestion of solid in patients with dysphagia.

Electromyographic activation patterns during swallowing in older adults

Age-related weakness due to atrophy and fatty infiltration in oropharyngeal muscles may be related to dysphagia in older adults. However, little is known about changes in the oropharyngeal muscle activation pattern in older adults. This was a prospective and experimental study. Forty healthy participants (20 older [> 60 years] and 20 young [< 60 years] adults) were enrolled. Six channel surface electrodes were placed over the bilateral suprahyoid (SH), bilateral retrohyoid (RH), thyrohyoid (TH), and sternothyroid (StH) muscles. Electromyography signals were then recorded twice for each patient during swallowing of 2 cc of water, 5 cc of water, and 5 cc of a highly viscous fluid. Latency, duration, and peak amplitude were measured. The activation patterns were the same, in the order of SH, TH, and StH, in both groups. The muscle activation patterns were classified as type I and II; the type I pattern was characterized by a monophasic shape, and the type II comprised a pre-reflex phase and a main phase. The oropharyngeal muscles and SH muscles were found to develop a pre-reflex phase specifically with increasing volume and viscosity of the swallowed fluid. Type I showed a different response to the highly viscous fluid in the older group compared to that in the younger group. However, type II showed concordant changes in the groups. Therefore, healthy older people were found to compensate for swallowing with a pre-reflex phase of muscle activation in response to increased liquid volume and viscosity, to adjust for age-related muscle weakness.

Examining the Relationships Between Lingual Strength, Perihyoid Strength, and Swallowing Kinematics in Dysphagic Adults: A Retrospective Cross-Sectional Analysis

Purpose The aim of this study was to examine the relationships of clinical measures of lingual and perihyoid strength with displacement swallowing kinematics and swallowing safety in a heterogenous group of dysphagic adults. Method A retrospective analysis was completed of videofluoroscopic swallow studies of consecutive dysphagic outpatient adults presenting to a tertiary swallowing center from January 1, 2015, to December 31, 2017. Videofluoroscopic swallow study records were included if containing displacement swallowing kinematics of a 20-ml single liquid swallow and clinical measures of anterior (L-MIPA) or posterior (L-MIPP) lingual maximal isometric press, saliva mean swallowing pressures (S-MSP), and/or open mouth-maximal isometric press (OM-MIP). Regression analyses were used to examine the relationships between clinical measures of lingual (L-MIPA, L-MIPP, S-MSP) and perihyoid (OM-MIP) strength and displacement swallowing kinematics, and binomial logistic regressions were used to examine the relationships between clinical measures of lingual and perihyoid strength and swallowing safety (Penetration-Aspiration Scale [PAS]). Results Multivariate regressions revealed significant relationships of L-MIPA, L-MIPP, S-MSP, and OM-MIP with group-level changes to the displacement swallowing kinematics. Univariate analyses revealed significant relationships of L-MIPA and L-MIPP with pharyngeal constriction ratio, maximal extent of upper esophageal segment opening, and PAS. Conclusions Weak relationships were identified of clinical measures of lingual and perihyoid strength with displacement swallowing kinematics. These findings suggest that clinical measures of lingual and perihyoid strength do not fully explain impairments in swallowing kinematics across a heterogenous group of dysphagic patients. Weak-to-moderate relationships were identified between clinical measures of lingual strength and PAS, suggesting that they may have value in predicting functional measures of swallowing safety. Further research is needed to examine how findings may differ between specific patient populations.

The Effectiveness of Acupuncture for Dysphagia after Stroke: A Systematic Review and Meta-Analysis

Objectives

This study reviewed and evaluated existing evidence of the efficacy of acupuncture as a clinical treatment for dysphagia after stroke.

Methods

Five English and four Chinese databases were searched from inception to March 2020. All randomized controlled trials (RCTs) incorporating acupuncture or acupuncture combined with other interventions for the treatment of dysphagia after stroke were enrolled. All data were independently assessed and extracted by two authors. The bias risk assessment recommended by the Cochrane Collaboration's tool was used to assess the quality of the selected studies. This meta-analysis was conducted by using RevMan 5.3. Pooled analyses were calculated by the mean difference (MD) and 95% confidence interval (CI). Heterogeneity was assessed by the I² test.

Results

Thirty-five studies involving 3024 patients were analyzed. The meta-analysis showed that the therapeutic efficacy of acupuncture combined with other interventions was better than that of the control group for the standardized swallowing assessment (SSA) score (MD = −3.78, 95% CI: −4.64 to −2.91, P < 0.00001), Ichiro Fujishima rating scale (IFRS) score (MD = 1.68, 95% CI: 1.16 to 2.20, P < 0.00001), videofluoroscopic swallowing study (VFSS) score (MD = 2.26, 95% CI: 1.77 to 2.74, P < 0.00001), and water swallowing test (WST) score (MD = −1.21, 95% CI: −1.85 to −0.57, P= 0.0002). In studies reporting adverse effects, no serious outcome from an adverse event was confirmed.

Conclusion

This systematic review indicated that acupuncture could be an effective therapy for treating dysphagia after stroke although stricter evaluation standards and rigorously designed RCTs are needed.

Objective measures of lingual and jaw function in healthy adults and persons with Parkinson's disease: Implications for swallowing

The study examines the effects of age and Parkinson's disease on lingual and jaw function in neurotypical adults, as well as persons with Parkinson's Disease. Preliminary results provide reference measures in these populations and support the systematic collection of objective data regarding lingual strength, lingual range of motion, and jaw range of motion in clinical populations. The application of this clinically meaningful protocol also provides a means to track physiological changes over time in order to maximize the results of rehabilitative efforts to restore swallow function.

Biomechanical correlates of sequential drinking behavior in aging

BACKGROUND

The timed water swallow test (TWST) is a test of sequential swallowing where a measured volume is ingested as quickly as comfortably possible. We undertook a study of the biomechanics underpinning the TWST in healthy young and older participants.

METHODS

Thirty healthy volunteers underwent high-resolution impedance manometry (MMS; Unisensor, 2.7 mm diameter, 32 pressure sensors, 16 impedance segments). Participants were asked to drink 150 mL, 0.9% normal saline solution rapidly. Swallowing biomechanics and bolus flow characteristics were assessed using pressure-flow analysis and compared using t test and Fisher's exact test with significance as P < .05.

KEY RESULTS

Older participants (n = 18; 76 ± 11 years) took longer to complete the TWST (21.2 ± 2.5 vs 9.2 ± 1.0 seconds; P < .001) and displayed reduced volume per swallow (16.6 ± 1.3 vs 27.8 ± 2.9 mL; P < .001) compared to younger participants (n = 12; 29 ± 5 years). Two distinctive pharyngeal swallowing patterns were observed: (a) a single rapid sequence of swallows with or without a clearing swallow (Pattern I) or (b) multiple, shorter sequences interrupted and/or interspersed with single swallows or breaks (Pattern II). Some older participants showed biomechanical evidence of upper esophageal sphincter restriction (n = 7) or impaired deglutitive inhibition (n = 7), associated with the more prolonged Pattern II (TWST duration 30.1 ± 1.5 vs Pattern I 11.9 ± 1.5 seconds; P < .001).

CONCLUSIONS AND INFERENCES

Healthy older participants had an increased duration of TWST, suggesting a need to adapt normative values for this population. Rapid sequential swallowing was associated with evidence of UES restriction and impaired deglutitive inhibition in some older participants.

Translation and adaption of the Yale Swallow Protocol for a Danish intensive care setting

BACKGROUND

Dysphagia related to intubation affects almost one in five patients in the intensive care unit; it may vary due to fluctuations in cerebral status and fatigue and lead to pneumonia, re-intubation and increased mortality. Taking care of patients' nutritional needs is an integral part of nursing and nurses must therefore be able to assess risk of dysphagia at all hours. However, Danish validated methods for use in the critically ill patient population are lacking.

AIM

To translate and adapt the Yale Swallow Protocol method for implementation in a Danish intensive care unit setting.

METHODS

Translation and adaption followed WHO's recommendations for translation and adaption of instruments. Face validity of the Danish version was evaluated in four group interviews. These were digitally recorded, transcribed and analysed using deductive content analysis. All interviewees gave informed consent.

FINDINGS

The translated version of the Yale Swallow Protocol was easy to understand, although nurses needed to have the method explained and needed training in using the method. In addition, the Yale Swallow Protocol must be adapted to local practice in terms of identifying patients at risk of dysphagia and deciding where to document results of the screening.

CONCLUSION

The translated version of the Yale Swallow Protocol proved conceptually and culturally sound and acceptable to intensive care unit nurses. Implementation should be followed by theoretical and practical training to build a nursing vocabulary relating to dysphagia and strengthen nurses' sensitivity to clinical manifestations consistent with dysphagia.

Dysphagia in adult myopathies

Dysphagia (impaired swallowing) is not a rare problem in various neuromuscular disorders, both in the pediatric and the adult patient population. On many occasions such patients are first presented to other medical specialists or health professionals. Disorders of deglutition are probably underrecognized in patients with a neuromuscular disease as a result of patient's and doctor's delay. This review will focus on dysphagia in adults suffering from a myopathy. Dysphagia in myopathies usually affects the oropharyngeal phases which rely mostly on voluntary muscle activity of the mouth, pharynx and upper esophageal sphincter. Dysphagia is known to contribute to a reduction of quality of life and may also lead to increased morbidity and mortality. The review includes an overview on symptomatology and tools of assessments, and elaborates on dysphagia in specific hereditary and acquired myopathies.

Design of the DYNAMO study: a multi-center randomized controlled trial to investigate the effect of pre-thickened oral nutritional supplements in nursing home residents with dysphagia and malnutrition (risk)

Background

Oropharyngeal Dysphagia (OD) and malnutrition are frequently reported conditions in nursing home residents, and are often interrelated. Best care for dysphagic residents with, or at risk of, malnutrition should target adequate nutritional intake and the safety and efficacy of swallowing. The effect of oral nutritional supplements (ONS) suitable for nursing home residents with concurrent OD and malnutrition (risk) on nutritional status has not been investigated before. The current study aims to investigate the effect of daily use of a range of pre-thickened ONS on the body weight of nursing home residents with OD and malnutrition (risk) compared to standard OD and nutritional care.

Methods / design

The DYNAMO study is a randomized, controlled, multi-center, open label trial with two parallel groups. Study participants will be recruited in nursing homes of several care organizations in the south of the Netherlands. Study duration is 12 weeks. Residents in the control group will receive standard OD and nutritional care, and residents in the test group will receive standard OD and nutritional care with extra daily supplementation of pre-thickened ONS.

The main outcome parameter is the difference in body weight change between the control and test groups. An a priori estimation of the required sample size per group (control / test) totals 78. Other outcome parameters are differences in: nutritional intake, health-related quality of life, OD-specific quality of life, activities of daily living, vital signs, and blood nutrient and metabolite levels.

Discussion

Regular ONS could address the nutritional needs of nursing home residents with malnutrition (risk), but might be too thin and unsafe for residents with OD. Pre-thickened ONS is suitable for residents with OD. It offers the advantage of being a ready-to-use amylase-resistant product available in several consistencies which are able to increase swallowing efficacy and safety. The DYNAMO study is the first to investigate the effects of pre-thickened ONS on nutritional status in nursing home residents with concurrent OD and malnutrition (risk).

Trial registration

Netherlands Trial Register (NTR): NTR NL7898. Registered 24 July 2019, https://www.trialregister.nl/trial/7898

Exploring the Validity and Operational Impact of Using Allied Health Assistants to Conduct Dysphagia Screening for Low-Risk Patients Within the Acute Hospital Setting

Purpose The purpose of this study was to examine (a) the agreement between allied health assistants (AHAs) and speech-language pathologists (SLPs) when completing dysphagia screening for low-risk referrals and at-risk patients under a delegation model and (b) the operational impact of this delegation model. Method All AHAs worked in the adult acute inpatient settings across three hospitals and completed training and competency evaluation prior to conducting independent screening. Screening (pass/fail) was based on results from pre-screening exclusionary questions in combination with a water swallow test and the Eating Assessment Tool. To examine the agreement of AHAs' decision making with SLPs, AHAs (n = 7) and SLPs (n = 8) conducted an independent, simultaneous dysphagia screening on 51 adult inpatients classified as low-risk/at-risk referrals. To examine operational impact, AHAs independently completed screening on 48 low-risk/at-risk patients, with subsequent clinical swallow evaluation conducted by an SLP with patients who failed screening. Results Exact agreement between AHAs and SLPs on overall pass/fail screening criteria for the first 51 patients was 100%. Exact agreement for the two tools was 100% for the Eating Assessment Tool and 96% for the water swallow test. In the operational impact phase (n = 48), 58% of patients failed AHA screening, with only 10% false positives on subjective SLP assessment and nil identified false negatives. Conclusion AHAs demonstrated the ability to reliably conduct dysphagia screening on a cohort of low-risk patients, with a low rate of false negatives. Data support high level of agreement and positive operational impact of using trained AHAs to perform dysphagia screening in low-risk patients.

Speech-Language Pathology Management for Adults With COVID-19 in the Acute Hospital Setting: Initial Recommendations to Guide Clinical Practice

Purpose This document outlines initial recommendations for speech-language pathology management of adult patients with COVID-19 in the acute hospital setting. Method The authors initially developed these recommendations by adapting those developed for physical therapists working with patients with COVID-19 by Thomas et al. (2020). The recommendations then underwent review by 14 speech-language pathologists and rehabilitation-focused academics representing seven countries (Belgium, Brazil, Canada, Ireland, Japan, New Zealand, the United States). The authors consolidated and reviewed the feedback in order to decide what should be included or modified. Applicability to a global audience was intended throughout the document. Results The authors had 100% agreement on the elements of the recommendations that needed to be changed/modified or added. The final document includes recommendations for speech-language pathology workforce planning and preparation, caseload management, service delivery and documentation, as well as recommendations for the selection of appropriate personal protective equipment and augmentative and alternative communication equipment in the acute care hospital setting. Conclusions Speech-language pathologists play a critical role in the assessment, management, and treatment of patients with COVID-19. Several important considerations need to be made in order to meet the needs of this unique patient population. As more is learned about the impact of the virus on swallowing and communication, the role of the speech-language pathologist on interdisciplinary care teams will remain paramount.

Validation of the Yale Swallow Protocol in Post-Acute Care: A Prospective, Double-Blind, Multirater Study

Purpose A systematic approach to the diagnosis and treatment of swallowing disorders relies heavily on valid and reliable screening protocols that provide clinicians with clear and objective information. The Yale Swallow Protocol (YSP) has been shown to be a useful, valid, and reliable screening tool for aspiration risk in the acute care setting. However, the YSP was not validated for use in post-acute care. This study evaluated the clinical utility of the YSP in the post-acute care setting. Method This prospective, double-blind, multirater study included a referred sample of 240 individuals, with varying medical diagnoses, who completed the YSP and an endoscopic evaluation of swallowing. Results Sensitivity for the YSP was 95.4%, specificity was 66.9%, positive predictive value was 77.6%, and negative predictive value was 92.4%. Conclusions The data from this prospective study appear to support the use of the YSP in post-acute care due to the ability to use the protocol on virtually all patients-regardless of diagnosis-and its high sensitivity and negative predictive value.

Sensitivity and Specificity of Bedside Screening Tests for Detection of Aspiration in Patients Admitted to a Public Rehabilitation Hospital

Early detection of dysphagia and specifically aspiration is essential to prevent and reduce complications of hospitalized patients in rehabilitation centers. Bedside screening test are often used to evaluate swallowing disorders, but their results may be questionable due to insufficient and inconsistent sensitivity and specificity. To compare the sensitivity and specificity of various bedside screening tests for detecting aspiration in hospitalized rehabilitation patients. A prospective observational study was performed in 150 consecutive patients of a tertiary rehabilitation hospital. Patients were evaluated regarding clinical predictors for aspiration, maximum phonation time (MPT), Eating Assessment Tool 10 (EAT-10) questionnaire, tongue strength and endurance (Iowa Oral Performance Instrument [IOPI]) and a swallowing test (Volume-Viscosity Swallow Test [V-VST]). Flexible Endoscopic Evaluation of Swallowing (FEES) was the reference test. Of the 144 patients included, 22% aspirated on FEES. Previous history of pneumonia, dysarthria, wet voice, and abnormal cough reflex were significantly associated with aspiration. The sensitivity, specificity and accuracy for V-VST (83.3%, 72.6%, 74.8%, respectively) and EAT-10 (82.8%, 57.7%, 62.8%, respectively) to detect aspiration were superior than those of other methods. Maximum tongue strength on IOPI and MPT presented high sensitivity but low specificity to detect aspiration. Clinical predictors of aspiration (previous history of pneumonia, dysarthria, wet voice, and abnormal cough reflex) associated with either V-VST or EAT-10 may be good screening methods to detect aspiration in patients hospitalized in a rehabilitation center.

Systematic Dysphagia Screening of Elderly Persons in the Emergency Department-A Feasibility Study

Identification of elderly patients in risk of dysphagia as early as possible upon hospital admission seems warranted due to the risk of aspiration pneumonia, dehydration, length of stay, and increased mortality. This study aimed to evaluate the feasibility and outcome of dysphagia screening of elderly persons admitted to the emergency department (ED). Inclusion criteria were age ≥ 60 years. A nurse applied the Simple Water Swallow test within one hour of admission. Subsequent assessment was performed by an occupational therapist (OT) using Volume Viscosity Swallow Test and Minimal Eating Observation Form. Of 113 eligible participants (median age 78 years), 75 (66%) were screened in the ED by the nurse, and among those, 12 (16%) were detected with dysphagia. Twenty of the patients not screened in the ED due to critical illness were tested by the OT in the ward after clinical stabilization and 15 patients (75%) were identified with dysphagia. This study demonstrated that it is feasible to perform dysphagia screening of elderly persons by a nurse in the ED, but there are severe limitations according to screening patients with critical illness and patients fasting before surgery in the ED. These patients have a high prevalence of dysphagia and should be screened as early as possible after hospitalization, as it will rarely be possible in the ED.

The investigation of asymptomatic swallowing disorder through surface electromyography in the geriatric population

AIM

Swallowing is a vital activity. The difficulty while swallowing, referred to as swallowing disorder, is strongly associated with serious health problems in the elderly. The aim of this study is to enable early recognition of the swallowing function developing as an asymptomatic condition.

METHOD

Our study was conducted on elderly populations aged 65 years and over who met the exclusion criteria. Firstly, to be able to reach the number of sampling, "EAT-10 questionnaire", which also has a Turkish validation, was used to eliminate those with symptomatic swallowing disorders. The number of patients we reached was 320, but 7 dropped out of the study and therefore the study was carried out with a total of 313 [reached as 97.8% (up 95% G-power)].

RESULT

We used validated sEMG test in the quantitative (objective) detection of asymptomatic swallowing disorder. In this method, asymptomatic swallowing disorder was detected in 39 cases (12.4%).

CONCLUSION

Swallowing disorder without symptoms is frequent and the sEMG test is useful in detecting it in the elderly population.

Predicting Airway Invasion Using Screening Tools and Laryngeal Kinematics in People with Parkinson's Disease: A Pilot Study

BACKGROUND

Dysphagia in Parkinson's disease (PD) is a common manifestation, particularly in advanced disease stages. However, the pathophysiology and time course of dysphagia progression remains unclear in non-advanced disease stages (e.g., Hoehn & Yahr stages I-III). Conflicting reports from investigations of the perception of dysphagia in people with PD further complicates our understanding of dysphagia in this population.

OBJECTIVE

The objectives of this research were to evaluate the ability of screening tools to detect swallowing impairments and how laryngeal kinematics predict the occurrence of abnormal swallowing events.

METHODS

14 individuals with non-advanced PD, no previous history of dysphagia diagnosis, and self-reported difficulty swallowing participated. The Swallow Disturbance Questionnaire (SDQ) and 3-oz water swallow test (WSST) were administered, along with a videoflouroscopic swallow study (VFSS). Laryngeal kinematics were represented by laryngeal vestibule closure reaction time (LVrt) and laryngeal vestibule closure duration (LVCd). The Penetration-Aspiration Scale (PAS) was used to quantify airway invasion.

RESULTS

A logistic regression indicated a significant model of predicting airway invasion from our predictors (p = 0.003). LVrt and SDQ (p < 0.05) provided the largest impact (OR = 1.11; 1.17). The WSST showed no significance in predicting swallow impairment (p > 0.05).

CONCLUSION

Decreased airway safety related to laryngeal kinematic function in PD may be manifesting at non-advanced disease stages to varied degrees. Our results support expectations of dysphagia manifestation in PD although screening practices may not adequately identify impairment. Future research should target specific laryngeal characteristics within this population to better understand the physiological cause of swallowing impairment and developof targeted interventions.

Development of an Accurate Bedside Swallowing Evaluation Decision Tree Algorithm for Detecting Aspiration in Acute Respiratory Failure Survivors

BACKGROUND

The bedside swallowing evaluation (BSE) is an assessment of swallowing function and airway safety during swallowing. After extubation, the BSE often is used to identify the risk of aspiration in acute respiratory failure (ARF) survivors.

RESEARCH QUESTION

We conducted a multicenter prospective study of ARF survivors to determine the accuracy of the BSE and to develop a decision tree algorithm to identify aspiration risk.

STUDY DESIGN AND METHODS

Patients extubated after ≥ 48 hours of mechanical ventilation were eligible. Study procedures included the BSE followed by a gold standard evaluation, the flexible endoscopic evaluation of swallowing (FEES).

RESULTS

Overall, 213 patients were included in the final analysis. Median time from extubation to BSE was 25 hours (interquartile range, 21-45 hours). The FEES was completed 1 hour after the BSE (interquartile range, 0.5-2 hours). A total of 33% (70/213; 95% CI, 26.6%-39.2%) of patients aspirated on at least one FEES bolus consistency test. Thin liquids were the most commonly aspirated consistency: 27% (54/197; 95% CI, 21%-34%). The BSE detected any aspiration with an accuracy of 52% (95% CI, 45%-58%), a sensitivity of 83% (95% CI, 74%-92%), and negative predictive value (NPV) of 81% (95% CI, 72%-91%). Using recursive partitioning analyses, a five-variable BSE-based decision tree algorithm was developed that improved the detection of aspiration with an accuracy of 81% (95% CI, 75%-87%), sensitivity of 95% (95% CI, 90%-98%), and NPV of 97% (95% CI, 95%-99%).

INTERPRETATION

The BSE demonstrates variable accuracy to identify patients at high risk for aspiration. Our decision tree algorithm may enhance the BSE and may be used to identify patients at high risk for aspiration, yet requires further validation.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT02363686; URL: www.clinicaltrials.gov.

Lower Energy Intake among Advanced vs. Early Parkinson's Disease Patients and Healthy Controls in a Clinical Lunch Setting: A Cross-Sectional Study

Unintentional weight loss has been observed among Parkinson's disease (PD) patients. Changes in energy intake (EI) and eating behavior, potentially caused by fine motor dysfunction and eating-related symptoms, might contribute to this. The primary aim of this study was to investigate differences in objectively measured EI between groups of healthy controls (HC), early (ESPD) and advanced stage PD patients (ASPD) during a standardized lunch in a clinical setting. The secondary aim was to identify clinical features and eating behavior abnormalities that explain EI differences. All participants (n = 23 HC, n = 20 ESPD, and n = 21 ASPD) went through clinical evaluations and were eating a standardized meal (200 g sausages, 400 g potato salad, 200 g apple purée and 500 mL water) in front of two video cameras. Participants ate freely, and the food was weighed pre- and post-meal to calculate EI (kcal). Multiple linear regression was used to explain group differences in EI. ASPD had a significantly lower EI vs. HC (-162 kcal, p < 0.05) and vs. ESPD (-203 kcal, p < 0.01) when controlling for sex. The number of spoonfuls, eating problems, dysphagia and upper extremity tremor could explain most (86%) of the lower EI vs. HC, while the first three could explain ~50% vs. ESPD. Food component intake analysis revealed significantly lower potato salad and sausage intakes among ASPD vs. both HC and ESPD, while water intake was lower vs. HC. EI is an important clinical target for PD patients with an increased risk of weight loss. Our results suggest that interventions targeting upper extremity tremor, spoonfuls, dysphagia and eating problems might be clinically useful in the prevention of unintentional weight loss in PD. Since EI was lower in ASPD, EI might be a useful marker of disease progression in PD.

Swallowing Screening: Purposefully Different From an Assessment Sensitivity and Specificity Related to Clinical Yield, Interprofessional Roles, and Patient Selection

Purpose The purpose of this clinical focus article is to summarize the goal and process by which identification of individuals at risk for having feeding problems or dysphagia is clinically screened across the life span by speech-language pathologists (SLPs). The topic of this clinical focus article was presented at the Charleston Swallowing Conference in Chicago, Illinois, in July 2018. The contents of this clinical focus article offer an expanded summary of information discussed at this meeting with focus on critical considerations to guide clinical decisions by SLPs regarding the optimal feeding and dysphagia screening approach and process. Conclusion Screening is a critical first step in the identification of individuals at risk for feeding problems and dysphagia across the life span. Understanding the difference between screening and assessment objectives as well as having the knowledge, skills, and clinical competency to implement psychometrically sound screening approaches is a recommended clinical practice standard for SLPs working with these clinical populations. This clinical focus article summarizes critical considerations for identifying individuals at risk for feeding problems and dysphagia across the life span to guide clinicians working with dysphagia populations.

KSNR Clinical Consensus Statements: Rehabilitation of Patients with Parkinson's Disease

Clinical consensus statements (CCSs) aim to improve care for patients with Parkinson's disease (PD) and reduce the variability of rehabilitation methods in clinical practice. A literature search was conducted to find available evidence on the rehabilitation of patients with PD and to determine the scope of CCSs. The selection of PD rehabilitation domains and key questions was done using the modified Delphi method in 43 expert panels. These panels achieved a consensus on 11 key questions regarding rehabilitation assessment and goal setting, gait and balance, activities of daily living, and swallowing and communication disorders. After the completion of an agreement procedure, 11 key consensus statements were developed by the consensus panel. These statements addressed the needs of rehabilitation as a continuum in patients with PD. They included the appropriate rehabilitation initiation time, assessment items, rehabilitation contents, and complication management. This agreement can be used by physiatrists, rehabilitation therapists, and other practitioners who take care of patients with PD. The consensus panel also highlighted areas where a consensus could not be reached. The development of more focused CCS or clinical practice guidelines that target specific rehabilitation approaches is considered the next needed step.

Dysphagia In Multiple Sclerosis Patients: Diagnostic And Evaluation Strategies

Dysphagia after multiple sclerosis (MS) is a common disabling symptom which can lead to serious complications. Regular screening and assessment of dysphagia in patients with MS are important. Using valid and reliable instruments to measure dysphagia in MS patients is a crucial component in clinical practice and of research quality. There are various strategies to diagnose and assess the dysphagia in patients with MS. Screening strategies are for early diagnosis of the dysphagia. Clinical, non-instrumental strategies are used to verify the presence and to determine the severity and cause of dysphagia. Instrumental strategies are complementary to clinical examination to provide objective data on the various aspects of swallowing dysfunctions. This review revealed a few validated tools for dysphagia assessment in MS. The Dysphagia in Multiple Sclerosis Questionnaire (DYMUS) and the Mann Assessment of Swallowing Ability (MASA) are the only validated MS-specific dysphagia tools. Further development of valid and reliable MS-specific screening and assessment tools that can be administered rapidly and scored easily to detect dysphagia and evaluate clinical outcomes in adults with MS is imperative. Until then, validation and metric evaluation of the screening and assessment tools currently available are required.

Risk factors for the development of aspiration pneumonia in elderly patients with femoral neck and trochanteric fractures: A retrospective study of a patient cohort

Aspiration pneumonia (AP) has been recognized as one of the most common postoperative complications after hip surgery in elderly. The objective of the present study was to evaluate risk for postoperative complications of AP in elderly patients with femoral neck fractures.We recruited 426 patients (age 84.9 ± 7.4 years) with a history of hip surgery carried out at Toyama Municipal Hospital. AP occurred in 18 out of 426 cases (4.23%). Statistical test has found significant differences in age, gender, serum albumin level, and cognitive impairment, between AP and non-AP groups. Subsequently multiple logistic regression analysis was conducted to investigate the risk factors for AP, including age, gender, serum albumin, cognitive impairment, and activities of daily living (ADL). Adjusted odds ratio showed significant differences in age, gender, and serum albumin, whereas no significant differences were found in cognitive impairment and ADL.This study suggested that serum albumin seemed to be a risk factor for AP but were necessary to assess under adjustment of confounding factors, including age and gender. Monitoring serum albumin level seemed to be important for the postoperative management of AP, especially in elderly patients receiving surgery of femoral neck and trochanteric fractures.

Implementation of hospital wide dysphagia screening in a large acute tertiary teaching hospital

Purpose: There are no examples in the literature of successful long-term hospital-wide implementation of nurse-led dysphagia screening. This article aims to describe strategies used to implement hospital-wide dysphagia screening in a large acute tertiary teaching hospital in Australia. It reports on compliance, accuracy and nursing staff satisfaction using the validated Royal Brisbane and Women's Hospital Dysphagia Screening Tool (RBWH DST).Method: A retrospective observational study of audit data was conducted to examine hospital-wide compliance and accuracy of dysphagia screen completion. A nursing staff survey measured staff satisfaction. Implementation included: (1) utilisation of validated tool (RBWH DST); (2) key stakeholder engagement and strong governance; (3) policy development; (4) education; and (5) review and monitoring processes.Result: Audits conducted over a 9-year period (n = 3726) showed an average hospital-wide compliance rate of 74% and an accuracy rate of 82%. A nurse satisfaction survey (n = 109) showed high levels of satisfaction associated with using the RBWH DST.Conclusion: The RBWH DST was implemented in a large acute tertiary teaching hospital with acceptable compliance and accuracy rates and favourable nursing staff satisfaction. Further study is required to objectively evaluate patient health and cost benefits associated with using the RBWH DST.

Smithard D. Assessment and Management of Dysphagia in Acute Stroke: An Initial Service Review of International Practice

The international approach to the assessment and management of dysphagia in the acute phase post stroke is little studied. A questionnaire was sent to clinicians in stroke services that explored the current practice in dysphagia screening, assessment, and management within the acute phase post stroke. The findings from four (the UK, the US, Canada, and Australia) of the 22 countries returning data are analysed. Consistent approaches to dysphagia screening and the modification of food and liquid were identified across all four countries. The timing of videofluoroscopy (VFS) assessment was significantly different, with the US utilising this assessment earlier post stroke. Compensatory and Postural techniques were employed significantly more by Canada and the US than the UK and Australia. Only food and fluid modification, tongue exercises, effortful swallow and chin down/tuck were employed by more than fifty percent of all respondents. The techniques used for assessment and management tended to be similar within, but not between, countries. Relationships were found between the use of instrumental assessment and the compensatory management techniques that were employed. The variation in practice that was found, may reflect the lack of an available robust evidence base to develop care pathways and identify the best practice. Further investigation and identification of the impact on dysphagia outcome is needed.

Aging Effects on Eating Assessment Tool-10 (EAT-10) Total Scores in Healthy, Community-Dwelling Adults

The purpose of this study was to examine how aging and sex impacted scores on the Eating Assessment Tool-10 in a large sample of healthy, non-dysphagic adults. Differences in Eating Assessment Tool-10 total normal (< 3) and abnormal (≥ 3) scores were examined across four age categories (21-39 years, 40-59 years, 60-79 years, 80 years and older) and between sexes. The mean (± SD) Eating Assessment Tool-10 total score for this healthy cohort of 167 individuals was 0.6 (± 1.6), with the majority of participants (75%) earning a score of zero. No significant differences were found in Eating Assessment Tool-10 total scores across age categories (p = .53) or between sexes (p = .79). Post-hoc analyses further explored relationships between Eating Assessment Tool-10 total scores and swallow performance measures as observed during videofluoroscopy. All participants (n = 15) scoring 3 and greater on the Eating Assessment Tool-10 passed an aspiration screen (i.e., 3-ounce water swallow challenge). Nine participants scoring less than 3 and failing the aspiration screen were not observed to have airway invasion as measured by the Penetration-Aspiration Scale during videofluoroscopy. A significant relationship was not observed between Eating Assessment Tool-10 total scores and highest Penetration-Aspiration Scale score. Eating Assessment Tool-10 total scores reported in the current study for patients with gastroesophageal reflux disease were significantly lower (p < .001) than total scores reported in the Eating Assessment Tool-10 validation study by Belafsky et al. (2008). In summary, aging or sex effects did not appear to impact self-report of dysphagia-related symptoms as measured by the Eating Assessment Tool-10. The Eating Assessment Tool-10, therefore, may not demonstrate the sensitivity needed to capture sub-clinical changes of the aging swallowing mechanism.

Swallowing speed is no adequate predictor of aspiration in Parkinson's disease

BACKGROUND

There is still a lack of a clinical test to reliably identify patients with Parkinson's disease (PD) being at risk for aspiration.

METHODS

In this prospective, controlled, cross-sectional study, we assessed if swallowing speed for water is a useful clinical test to predict aspiration proven by flexible endoscopic evaluation of swallowing (FEES). Due to this, we measured the swallowing speed for 90 mL water in 115 consecutive and unselected PD outpatients of all clinical stages and 32 healthy controls.

KEY RESULTS

Average swallowing speed was lower in patients compared with controls (6.5 ± 3.9 mL/s vs 8.5 ± 3.2 mL/s; P < .01). The disease-independent widely used threshold of <10 mL/s showed insufficient sensitivity of 88% and specificity of 19% with high false-positive rates of 63% for patients and 69% for controls. Receiver operating characteristic (ROC) analysis was carried out to define a suitable cutoff value for detection of aspiration of water (area under the curve 0.72, P < .001) in PD patients. The optimized cutoff value was 5.5 mL/s with a sensitivity of 69% and a specificity of 64%.

CONCLUSION AND INFERENCES

Measuring swallowing speed is prone to methodological errors and not suitable as a screening instrument to predict aspiration in PD patients.

Using frailty and quality of life measures in clinical care of the elderly in Canada to predict death, nursing home transfer and hospitalisation - the frailty and ageing cohort study

OBJECTIVE

To assess the value of using frailty measures in primary care for predicting death, nursing home transfer (NHT) and hospital admission.

DESIGN

Cohort study.

SETTING AND PARTICIPANTS

All 380 people, mean age 88.4, living in the community and receiving home-based primary geriatric care from one practice in Victoria, Canada.

INTERVENTIONS/MEASUREMENTS

A 60 min baseline assessment which included: Clinical Frailty Scale (CFS), EuroQol EQ-5D-5L (EQ-5D), EuroQol Visual Analogue Scale (EQ-VAS) and Gait Speed (Gaitspeed).

OUTCOMES

Death, NHT and hospital admission.

RESULTS

During 18 months of follow-up, there were 39 (10.3%) deaths, 48 (12.6%) NHTs and 93 (24.5%) individuals admitted to hospital. All three outcomes were predicted by: CFS Level 6+7/4+5 (HR death 5.92, 95% CI 3.12 to 11.22, NHT 6.00, 95% CI 3.37 to 10.66 and hospital admission 2.92, 95% CI 1.93 to 4.40); EQ-5D Quintile 1/Quintile 5 (death 6.26, 95% CI 2.11 to 18.62; NHT 3.18, 95% CI 1.29 to 7.82 and hospital admission 2.94, 95% CI 1.47 to 5.87); EQ-VAS Q1/Q5 (death 7.0, 95% CI 2.34 to 20.93; NHT 3.38, 95% CI 1.22 to 9.35 and hospital admission 6.69, 95% CI 3.20 to 13.99) and Gaitspeed (death 5.87, 95% CI 1.78 to 19.34; NHT 8.51, 95% CI 3.18 to 22.79 and hospital admission 11.05, 95% CI 5.45 to 22.40). Medical diagnoses, multiple comorbidities and polypharmacy were weaker predictors of these outcomes. Cox regression analyses showed CFS (adjusted HR 2.88, 95% CI 1.23 to 6.68), EQ-VAS (0.96, 95% CI 0.93 to 0.98), estimated glomerular filtration rate (0.97, 95% CI 0.95 to 1.00) and haemoglobin (0.97, 95% CI 0.94 to 0.99) were independently associated with death. Gaitspeed (0.13, 95% CI 0.03 to 0.57), Geriatric Depression Scale (1.39, 95% CI 1.07 to 1.82) and dementia diagnosis (4.61, 95% CI 1.86 to 11.44) were associated with NHT. Only CFS (1.75, 95% CI 1.21 to 2.51) and EQ-VAS (0.98, 95% CI 0.96 to 0.99) were associated with hospital admission. No other diagnoses, polypharmacy nor multiple comorbidities predicted these outcomes.

CONCLUSIONS

For elderly people, standardised simple measures of frailty and health status were stronger predictors of death, NHT and hospital admission than medical diagnoses. Consideration should be given to adding these measures into usual medical care for this age group.

Predictive value of a novel pragmatic tool for post-stroke aspiration risk: The Functional Bedside Aspiration Screen

BACKGROUND

There is still a strong need for an optimal clinician-friendly screening tool for the identification of aspiration risk in stroke patients. In this study, we present the development of a novel, context-specific screening tool for the prediction of aspiration risk on recent stroke survivors, the Functional Bedside Aspiration Screen (FBAS), and examine its construct validity, reliability with the predictive values toward pragmatic patients' outcomes.

METHODS

We conducted a prospective validation study of 104 acute ischemic stroke patients admitted to clinical wards in a tertiary university hospital. A group of experts developed and administered the FBAS 10-point scale to all patients. Outcome measures were compared with those of the validated Yale Swallow Protocol (YSP, reference measure) and health indicators.

KEY RESULTS

A strong association was found between the FBAS cutoff criterion and the YSP (Pearson χ²  = 54.92, P < .001). A score of ≤8 on the FBAS presented with 93.3% sensitivity and 83.3% specificity in deeming patient with reduced safety for oral nutrition (AUC = 0.934, CI = 0.884-0.985). An inverse relationship was found between performance on the FBAS and in-hospital and long-term outcome indicators. Patients who failed the FBAS were 1.82 times more likely to develop aspiration pneumonia (95% CI = 1.42-2.35) and 1.35 times more likely to develop pneumonia within 3 months postonset (95% CI = 1.15-1.59).

CONCLUSIONS AND INFERENCES

The FBAS is a potentially useful tool for timely prediction of aspiration risk and health outcome in acute stroke.

Perception Versus Performance of Swallow Function in Residents of Long-Term Care

Purpose The purpose of this study was to determine if older adults residing in long-term care were able to accurately self-report their swallowing status by comparing subjective complaints of dysphagia and objective methods of swallowing screening. Method Data were collected from 397 residents of long-term care (M _age = 86.8 years ± 7.8; 263 female). Cognitive impairment scores were collected, and each resident was asked (a) if they thought they had a swallowing problem, (b) if they coughed/choked when they ate, and (c) if they coughed/choked when they drank. These responses were compared to results of a swallowing screening tool and mealtime observations of coughing and choking. Results Residents who reported swallowing difficulties (10%, n = 41) were 8 times more likely to fail the swallowing screening (p < .001); however, 80% of residents who failed the swallowing screening did not previously report that swallowing was an issue. There was no significant association between self-reports of coughing and choking at meals and observations. There was no difference in level of cognition between residents who accurately reported swallowing status and those who were inaccurate. Conclusions Residents are largely unable to accurately self-report swallowing difficulties and also have difficulty accurately reporting incidences of coughing and choking. These findings suggest that concerted efforts are required to implement regular, formal swallowing screening protocols in long-term care to objectively identify those at risk.

Reconsideration of three screening tests for dysphagia in patients with cerebrovascular disease performed by non-expert examiners

Dysphagia prevalence has increased with increasing elderly population worldwide. Therefore, early detection of dysphagia has become increasingly important. Repetitive saliva swallowing test (RSST), modified water swallowing test (MWST), and cervical auscultation, which are convenient for non-experts to assess eating and swallowing and have been frequently used in Japan since 20 years. Using aspiration and pharyngeal residues, the objective of this study was to elucidate the efficacy of the three screening tests performed by non-experts in patients who had swallowing disorders. In total, 102 patients with cerebrovascular diseases who were suspected of having dysphagia were assessed. A swallowing team assessed their swallowing capabilities; videofluoroscopy and screening tests were performed. RSST, MWST, and cervical auscultation were performed by junior dentists who were non-experts in dysphagia. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio in each examination were evaluated using results of aspiration in videofluoroscopy and pharyngeal residues. For aspiration, the highest sensitivity with cervical auscultation (VES) was 93.7%. For pharyngeal residue, the highest sensitivity with cervical auscultation (VES) was 84.3%. For piriform sinus residue, the highest sensitivity with cervical auscultation (VES) was 86.4%. Despite being evaluated by a non-expert, the sensitivity of cervical auscultation (VES) and MWST was ≥ 80%, suggesting their effectiveness as prescreening tests, although the range of specificity was 25.5-68.4% in all examinations. These tests are easy to perform and useful to screen for aspiration or pharyngeal residues before precision tests.

The Swallowing Clinical Assessment Score in Parkinson's Disease (SCAS-PD) Is a Valid and Low-Cost Tool for Evaluation of Dysphagia: A Gold-Standard Comparison Study

BACKGROUND

Dysphagia is a predictor of mortality in Parkinson's disease (PD). Developing alternative methods to videofluoroscopy swallowing study (VFSS) for the evaluation of dysphagia is a public health necessity. The Swallowing Clinical Assessment Score in Parkinson's Disease (SCAS-PD) is an alternative and low-cost tool for diagnosis of dysphagia, but had not been properly validated in comparison to the gold-standard method. The objective of this study was to assess the validity and reliability of the SCAS-PD.

METHODS

SCAS-PD was applied to 31 patients with PD, and VFSS was conducted concurrently. This clinical assessment uses different volumes and viscosities to identify signs of swallowing impairments. For validation purposes, the interclass correlation coefficient and the weighted kappa were calculated. The AUC of the ROC curve, sensitivity, and specificity values for detection of penetration/aspiration (PA) were assessed. Internal consistency was calculated by Cronbach's alpha.

RESULTS

Fifty-one percent of patients were classified with dysphagia. SCAS-PD was differentiated between normal/functional deglutition and dysphagia with AUC 0.97, 95% CI 0.92-1.00, and an optimal cutoff at 19 (sensitivity 100% and specificity 87.5%). The internal consistency was α = 0.91 for the total score. The internal consistency of the SCAS-PD domains was oral phase (α = 0.73), pharyngeal phase (α = 0.86), and signs of PA (α = 0.95). The weighted kappa analysis demonstrated a high rate of concordance at 0.71 (p < 0.001) between SCAS-PD and VFSS.

CONCLUSIONS

SCAS-PD has been shown to have a good concordance with the VFSS. Considering this, SCAS-PD is highly applicable in clinical settings, since it is a simple and low-cost diagnostic tool for detecting dysphagia in PD patients.

Evaluation of Swallow Function Post-Extubation: Is It Necessary to Wait 24 Hours?

BACKGROUND

Post-extubation dysphagia is associated with an increased incidence of nosocomial pneumonias, longer hospitalizations, and higher re-intubation rates. The purpose of this study was to determine if it is necessary to delay swallow evaluation for 24 hours post-extubation.

METHODS

A prospective investigation of swallowing was conducted at 1, 4, and 24 hours post-extubation to determine if it is necessary to delay swallow evaluation following intubation. Participants were 202 adults from 5 different intensive care units (ICU).

RESULTS

A total of 166 of 202 (82.2%) passed the Yale Swallow Protocol at 1 hour post-extubation, with an additional 11 (177/202; 87.6%) at 4 hours, and 8 more (185/202; 91.6%) at 24 hours. Only intubation duration ≥4 days was significantly associated with nonfunctional swallowing.

CONCLUSIONS

We found it is not necessary to delay assessment of swallowing in individuals who are post-extubation. Specifically, the majority of patients in our study (82.2%) passed a swallow screening at 1 hour post-extubation.

Open Mouth-Maximal Isometric Press: Development and Norms for Clinical Swallowing Evaluations and Treatment

Purpose The aims of this study were to (a) describe the development and utility of the Open Mouth-Maximal Isometric Press (OM-MIP), a tool designed for the quantitative assessment of suprahyoid-infrahyoid muscle strength; (b) examine the effects of age and sex on the OM-MIP; and (c) establish age- and sex-based OM-MIP norms. Method Two hundred sixteen healthy male and female volunteers were recruited. Participants performed the OM-MIP, and the maximum of 3 trials that were within 10% of each other was recorded. Rest between each trial was allowed to avoid fatigue. Multiple regression examined the influence of age and sex on the OM-MIP. Descriptive statistics outlined normative OM-MIP values for young adult (aged 18-39 years), middle-aged adult (aged 40-59 years), old adult (aged 60-79 years), and very old adult (aged ≥ 80 years) men and women. Two-way analysis of variance determined if normative data differed significantly between the age and sex groups. Results Age and sex significantly influenced the OM-MIP, although no significant interaction effect was identified. Women had lower mean OM-MIPs when compared with men ( p < .0005), and very old adults had lower mean OM-MIPs when compared with young ( p = .001), middle-aged ( p < .0005), and old ( p = .013) adults. Conclusions This study establishes age- and sex-based OM-MIP norms and outlines its potential utility during clinical swallowing evaluations and treatment. By providing these norms, clinicians can begin to quantitatively measure suprahyoid and infrahyoid strength, individualize resistance training programs to patients' OM-MIP 1 repetition maximum, and track strength changes over time in response to therapeutic interventions.

Screening and evaluation tools of dysphagia in adults with neuromuscular diseases: a systematic review

Background:

The purpose of this systematic review was to summarize the different dysphagia screening and evaluation tools, and to identify their measurement properties in adults with neuromuscular diseases (NMDs).

Methods:

A systematic review was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search strategy was conducted across three databases (PubMed, CINAHL and ScienceDirect). Measurement properties of each tools and the Quality Index, developed by Downs and Black, were considered for the different investigated studies.

Results:

The search strategy produced 2221 articles. After removal of duplicates and full-text analysis, 19 studies were included. Most of the publications focused on amyotrophic lateral sclerosis (ALS; n = 10) and Duchenne muscular dystrophy (DMD; n = 4). A total of 12 tools, listed as instrumental and noninstrumental examinations, were retrieved. A total of five of them used videofluoroscopic swallow study (VFSS). Measurement properties of the tools are not completely described in detail in many studies. The neuromuscular disease swallowing status scale, a noninstrumental tool, is the only one that assessed all measurement properties in ALS patients. The median score reported for the Quality Index was 16.

Conclusions:

This systematic review identified 12 different tools for the screening and evaluation of dysphagia in adults with NMD. Majority of the studies presented VFSS as a valid and reliable examination to assess dysphagia in ALS and DMD. Other tools were mainly evaluated in ALS patients, but further studies are needed to complete their measurement properties. In other NMDs, no firm conclusion can be made because of insufficient data and heterogeneity of NMDs.