Dysphagia in Older Adults

History and Science behind the Eating Assessment Tool-10 (Eat-10): Lessons Learned

INTRODUCTION

Oropharyngeal dysphagia (OD) is an underdiagnosed medical condition with a high prevalence in populations such as patients with frailty, neurological disease, or head and neck pathology. Potential barriers to its diagnosis include lack of (or low) awareness of the existence and severity of the condition, the hidden nature of the condition within the 'normal ageing' process, clinical limitations, and socioeconomic reasons. Consequently, an effective treatment is not systematically offered in a timely manner, and complications, such as dehydration and respiratory infections or aspiration pneumonia, can arise. To overcome this issue, the early use of screening questionnaires to identify people at risk of swallowing disorders represents the cornerstone of preventive medicine. Several screening tools have been created but few are widely used in clinical practice. The Eating Assessment Tool-10 (EAT-10) was developed as a quick, easy-to-understand, and self-administered screening tool for OD.

METHODS

A literature review was conducted in five databases with no restrictions on the language, date of publication, or design of the study to identify aspects of the validation, applicability, and usefulness of EAT-10.

RESULTS AND CONCLUSIONS

Transcultural adaptation and translation studies, as well as studies involving various types of patients with dysphagia in different settings have shown the validity and reliability of EAT-10 in relation to the gold standard and other validation tools. The use of this standardised screening tool could be used as a primary screening instrument of dysphagia in routine clinical practice across a wide range of diseases and settings and thereby increase the likelihood of early diagnosis and management of a condition that lead to serious complications and impaired quality of life.

Knowledge and Perceptions of Speech-Language Pathology Students Participating in a Feeding Training Program: A Pilot Study

This study examined the knowledge and perceptions of speech-language pathology students working with older adults before and after their participation in a feeding training program. A secondary objective evaluated the feeding training program in terms of improving students' knowledge and skills. A repeated measures design was used to assess changes in perceptions and knowledge over time of students participating in a feeding training program assisting older adults at a skilled nursing facility. Twenty-four students in the communication sciences and disorders department from a university were recruited. Data were collected on the perceptions of working with older adults, knowledge of feeding and swallowing, and the evaluation of the program. Participants reported feeling less fearful of assisting older adults with feeding issues and appeared to acquire a higher level of knowledge in certain areas post-training. Analysis of the evaluation forms revealed that students were positive about their experience. The findings provide additional support that perceptions become more favorable following early exposure to older adults through participation in service-learning experiences. This study supplements the literature about the knowledge and perceptions of speech-language pathology students working with older adults. This information may be used to improve the quality of care for older adults in various settings.

Post-extubation Dysphagia-Early Detection by Serial Tongue Pressure Measurements: Is it Practical?

How to cite this article: Paul S, Pande RK. Post-extubation Dysphagia-Early Detection by Serial Tongue Pressure Measurements: Is it Practical? Indian J Crit Care Med 2022;26(12):1233-1234.

Pharmacological Management of Dysphagia in Patients with Alzheimer's Disease: A Narrative Review

Alzheimer's disease (AD) and dysphagia are important health and socioeconomic problems in the aging population. Currently, the medical treatment of dysphagia in AD patients remains insufficient, and there are significant gaps in the management and clinical needs to postpone tube feeding. Literatures published over the last 30 years were searched in the PubMed and Embase databases. All relevant and promising pharmacological management studies were included. Because of the heterogeneity in design and methodology, only narrative reports were mentioned. Nine studies were included with two case reports, two case series, and two observational and three randomized controlled trials. The key approaches and clinical problems related to dysphagia include onset pattern, dementia stage, review of offending drugs and polypharmacy, and comorbidities (cerebrovascular disease, hypertension, parkinsonism, depression, and anorexia). The corresponding strategies of pharmacological treatments are further proposed and discussed comprehensively, with transient receptor potential channel modulators as promising treatment. With the integration of adequate and potential pharmacomanagement, AD patients with dysphagia can achieve a good prognosis and postpone tube feeding to maintain a better quality of life. More rigorous studies are needed to verify the effectiveness of innovative strategies and develop targets for neurostimulation.

Review of protein intake and suitability of foods for protein-fortification in older adults in the UK

Protein is a vital dietary component for combating negative health outcomes associated with malnutrition in older adults, including sarcopenia, functional decline and reduced quality of life. Yet, recommended daily protein intake is consistently unmet, as evidenced in the literature and reaffirmed in this review. Poor appetite is recognized as a major determinant of protein-energy undernutrition and thus fortification of regular food or drinks provides a flexible and relevant approach for older adults with reduced appetite. To increase the likelihood of fortified products being successfully incorporated into the diets of older adults, they must be adaptable to older adults eating patterns, cater for their preferences and take the specific age-related problems that complicate food intake into account. This paper aims to highlight older adults' current sources of protein, shopping habits, typical eating patterns and commonly consumed foods, and hence consider appropriate carriers for protein enrichment. Data were reanalyzed from a combination of freely available UK datasets, including the National Dietary and Nutrition Survey and the Food and You Survey, alongside data purchased from market research consultancy, Kantar. These insights draw attention to the potential suitability of foods for fortification purposes, with the ultimate objective to promote eating pleasure and prevent malnutrition.

Atypical Presentation of Pill Aspiration in Older Adults with Dysphagia: A Picture Not To Be Forgotten

Nonconventional clinical presentations of diseases are common in older adults. Even dramatic events, such as foreign body (FB) inhalation, can occur in a subtle and non-specific manner. Pill aspiration is a rare yet overlooked cause of airway injury. It accounts for approximately 7% of all FB aspirations. In contrast, oral dysphagia and polypharmacology, mainly administrated in solid oral dosage forms (SDOF), like tablets and pills, are common conditions in older adults. Herein, we present a case of SDOF aspiration in a 78-year-old man. FB inhalation developed with general clinical deterioration and neurological impairment (delirium) rather than overt respiratory symptoms. Bronchoscopy provided remarkable images of this unexpected finding. Caregivers and healthcare workers must be aware of the risk of SDOF aspiration and adopt proper safety measures. Early recognition and bronchoscopy for diagnostic and therapeutic purposes can be lifesaving in such cases.

New Understanding on the Pathophysiology and Treatment of Constipation in Parkinson’s Disease

Constipation, one of the most common prodromal non-motor symptoms of Parkinson’s disease (PD), usually occurs several years earlier than the onset of motor symptoms. Previous studies have shown that constipation occurrence increases as the disease progresses. However, the mechanism underlying this pathologic disorder is not clear yet. Moreover, chronic constipation causes slowness in gastric emptying and, therefore, may lead to a delay in the absorption of medications for PD, including levodopa and dopamine agonists. Accordingly, it is necessary to understand how the pathophysiological factors contribute to constipation during PD as well as pursue precise and effective treatment strategies. In this review, we encapsulate the molecular mechanism of constipation underlying PD and update the progress in the treatments of PD-associated constipation.

Dietary fat intake and quality in long-term care residents in two cohorts assessed 10 years apart

Purpose

To describe and compare detailed dietary fat intake, fat quality and associative factors between two measuring points 10 years apart of residents living in long-term care facilities, and to reflect how fat composition and fat quality corresponds to current nutrition recommendations.

Methods

In 2007 long-term care residents (n = 374) of 25 assisted-living facilities and nursing homes and in 2017–18 long-term care residents (n = 486) of 17 respective facilities in Helsinki metropolitan area were recruited for this study. Information on the residents’ heights, demographic information and use of calcium and vitamin D supplementation were retrieved from medical records. Residents’ clinical assessment included Clinical Dementia Rating (CDR), the Mini Nutritional Assessment (MNA) and questionnaire related to nutrition care. Participants’ energy and fat intake were determined from 1--2-day food diaries kept by the ward nurses, and fat quality indicators calculated.

Results

Age, gender distribution, MNA score or body mass index did not differ between the two cohorts. Residents’ cognitive status, subjective health and mobility were poorer in 2017 compared to 2007. Total fat and saturated fatty acid (SFA) intakes were higher and fat quality indicators lower in the 2017 cohort residents than in the 2007 cohort residents. Sugar intake, male gender, eating independently, eating larger amounts and not having dry mouth predicted higher SFA intake in the 2017 cohort.

Conclusions

The fat quality in long-term care residents in our study worsened in spite of official recommendations between the two measurement points.

Latent changes in the pharyngeal stage of swallowing in non-aspirating older adults

PURPOSE

The characteristic changes in the swallowing mechanism with aging are collectively termed presbyphagia. Although several studies have investigated presbyphagia in older adults, few have assessed oldest-old adults. We aimed to characterize the latent changes of swallowing function in oldest-old adults and to consider risk ages for presbyphagia.

METHODS

We analyzed the records of 85 individuals (44 males and 41 females, aged 25-101 years) who underwent videofluoroscopic swallowing studies. The included participants had penetration and aspiration scores of ≤ 2 and no history of aspiration, pneumonia, or diseases that affect swallowing. They were divided into four age groups: 25-64 years (non-older), 65-74 years (young-old), 75-84 years (middle-old), and ≥ 85 years (oldest-old). We analyzed and compared the pharyngeal delay time (PDT), duration of tongue base and posterior pharyngeal wall contact, duration and dimension of upper esophageal sphincter opening (UES-O), and maximal hyoid bone displacement between the age groups.

RESULTS

Among the older groups, the oldest-old showed significantly longer PDT than younger-old adults, and the UES-O tended to be wider in the former. However, no other remarkable differences were found between the oldest-old and other old groups. Statistical comparisons between the < 75 and ≥ 75-year age groups revealed significant age-related changes in the PDT and duration and dimension of UES-O.

CONCLUSION

On videofluoroscopic evaluation, physiological changes with aging affected few parameters of swallowing in our cohort. These findings indicate that in non-aspirating oldest-old adults, any deterioration may be adjusted for by compensatory changes to maintain swallowing function.

Factors and Outcomes Associated With Dysphagia in Hospitalized Persons With Dementia

OBJECTIVES

Dysphagia is prevalent in older adults with dementia, particularly in the acute care setting. The objective of this study was to use an innovative approach to extract a more representative sample of patients with dysphagia from the electronic health record (EHR) to determine patient characteristics, hospital practices, and outcomes associated with dysphagia in hospitalized persons with dementia.

DESIGN

A retrospective study of hospitalized adults (aged ≥65 years) with dementia was conducted in 7 hospitals across the greater New York metropolitan area.

SETTING AND PARTICIPANTS

Data were obtained from the inpatient EHR with the following inclusion criteria: age ≥65 years; admitted to one of 7 health system hospitals between January 1, 2019, and December 31, 2019; and documented past medical diagnosis of dementia (based on International Classification of Diseases, Ninth Revision).

METHODS

A diagnosis of dysphagia was defined as nurse documentation of a positive bedside swallow screening, nurse documentation of "difficulty swallowing" as reason for not performing bedside swallow screening, and physician documentation of a dysphagia diagnosis.

RESULTS

Of adults with dementia (N = 8637), the average age was 84.5 years, 61.6% were female, and 18.1% were Black and 9.3% Hispanic. Dysphagia was identified in 41.8% (n = 3610). In multivariable models, dysphagia was associated with invasive mechanical ventilation [odds ratio (OR) 4.53, 95% CI 3.55-5.78], delirium (OR 1.53, 95% CI 1.40-1.68), increased length of stay (B = 3.29, 95% CI 2.98-3.60), and mortality (OR 4.44, 95% CI 3.54-5.55).

CONCLUSIONS AND IMPLICATIONS

Given its high prevalence, underrecognition, and associated poor outcomes, improving large-scale dysphagia identification can impact clinical care and advance research in hospitalized persons with dementia.

A Simple Risk Scoring System for Predicting the Occurrence of Aspiration Pneumonia After Gastric Endoscopic Submucosal Dissection

BACKGROUND

Aspiration pneumonia after endoscopic submucosal dissection (ESD) is rare, but can be fatal. We aimed to investigate risk factors and develop a simple risk scoring system for aspiration pneumonia.

METHODS

We retrospectively reviewed medical records of 7833 patients who underwent gastric ESD for gastric neoplasm under anesthesiologist-directed sedation. Candidate risk factors were screened and assessed for significance using a least absolute shrinkage and selection operator (LASSO)-based method. Top significant factors were incorporated into a multivariable logistic regression model, whose prediction performance was compared with those of other machine learning models. The final risk scoring system was created based on the estimated odds ratios of the logistic regression model.

RESULTS

The incidence of aspiration pneumonia was 1.5%. The logistic regression model showed comparable performance to the best predictive model, extreme gradient boost (area under receiver operating characteristic curve [AUROC], 0.731 vs 0.740). The estimated odds ratios were subsequently used for the development of the clinical scoring system. The final scoring system exhibited an AUROC of 0.730 in the test dataset with risk factors: age (≥70 years, 4 points), male sex (8 points), body mass index (≥27 kg/m2, 4 points), procedure time (≥80 minutes, 5 points), lesion in the lower third of the stomach (5 points), tumor size (≥10 mm, 3 points), recovery time (≥35 minutes, 4 points), and desaturation during ESD (9 points). For patients with total scores ranging between 0 and 33 points, aspiration pneumonia probabilities spanned between 0.1% and 17.9%. External validation using an additional cohort of 827 patients yielded AUROCs of 0.698 for the logistic regression model and 0.680 for the scoring system.

CONCLUSIONS

Our simple risk scoring system has 8 predictors incorporating patient-, procedure-, and sedation-related factors. This system may help clinicians to stratify patients at risk of aspiration pneumonia after ESD.

Emerging Role of Ultrasound in Dysphagia Assessment and Intervention: A Narrative Review

Ultrasonography has gained increasing attention as a non-invasive and radiation-free instrument for the assessment of swallowing function. In the past decades, an extensive repertoire of ultrasonographic techniques, such as, B-mode dynamic scanning, pixel analysis, M-mode, Doppler, 3D reconstruction, and sonoelastography, has been applied in the evaluation of oropharyngeal structures and movement. Yet, a universal consensus on the examination protocols and clinical implications remains to be established. This review aimed to provide a brief introduction of the application of ultrasound in dysphagia assessment and intervention, encompassing the ultrasonography of swallowing-related muscles, tongue movement, and hyolaryngeal excursion, as well as ultrasound-guided interventions in the management of dysphagia. In addition to non-invasiveness, ultrasonography, a portable, easy to use, and low-cost technique, could compliment videofluoroscopic swallowing study as a first-line screening and follow-up tool for the evaluation of swallowing function, although further study is warranted to provide quantitative diagnostic and prognostic values. Finally, ultrasonography aids in the precisely targeted injection of botulinum toxin in patients exhibiting oropharyngeal muscle spasticity.

A Systematic Review of Oropharyngeal Dysphagia Models in Rodents

Oropharyngeal dysphagia is a condition characterized by swallowing difficulty in the mouth and pharynx, which can be due to various factors. Animal models of oropharyngeal dysphagia are essential to confirm the cause-specific symptoms, pathological findings, and the effect of treatment. Recently, various animal models of dysphagia have been reported. The purpose of this review is to organize the rodent models of oropharyngeal dysphagia reported to date. The articles were obtained from Medline, Embase, and the Cochrane library, and selected following the PRISMA guideline. The animal models in which oropharyngeal dysphagia was induced in rats or mice were selected and classified based on the diseases causing oropharyngeal dysphagia. The animal used, method of inducing dysphagia, and screening methods and results were collected from the selected 37 articles. Various rodent models of oropharyngeal dysphagia provide distinctive information on atypical swallowing. Applying and analyzing the treatment in rodent models of dysphagia induced from various causes is an essential process to develop symptom-specific treatments. Therefore, the results of this study provide fundamental and important data for selecting appropriate animal models to study dysphagia.