Swallowing disturbance questionnaire for detecting dysphagia

Patient-Reported Outcome Measures for Swallowing: A Proposed Checklist

PURPOSE

Patient-reported outcome measures (PROMs) are an important tool both in clinical practice and research involving patients with swallowing disorders. There are several challenges to be overcome and methodological details to be adequately reported to ensure rigor and transparency in studies utilizing PROMs in dysphagia research. For this reason, the Framework for RigOr aNd Transparency In REseaRch on Swallowing (FRONTIERS), a critical appraisal tool developed to ensure rigor and transparency in dysphagia research, has devoted a domain to PROMs. The aim of this current article, as part of a larger forum of articles, is to present the PROM section of FRONTIERS and describe its development.

METHOD

A literature review was carried out on PROMs in the field of dysphagia by three members of the FRONTIERS collaborative to identify items that were necessary for the rigorous application and transparent reporting of PROMs utilized in research of swallowing disorders in human subjects. Framework items were then subjected to an iterative process of feedback and consensus among the three members of the working group as well as all members of the FRONTIERS collaborative. Items were flagged for review and revised as needed until consensus was achieved on the final list. The final item list was compared to existing critical appraisal tools for PROMs.

RESULTS

The final checklist for the PROMs domain included 20 "Yes/No" questions that can be broadly divided into three categories: (a) development and validation, (b) patient population, and (c) PROM administration method. Each item is presented with a rationale for its inclusion.

CONCLUSIONS

The use of the FRONTIERS Framework will serve researchers and those appraising quality of research involving PROMs. More broadly, the FRONTIERS Framework will facilitate improved rigor and transparency across dysphagia research. Special considerations and future goals are discussed.

Validation and cultural adaptation of a Greek Version of Pediatric Eating Assessment Tool 10 (PEDI - EAT - 10) in Greek-Cypriot Parents

PURPOSE

The Pediatric Eating Assessment Tool (PEDI-EAT-10) is a parents/caregivers screening tool that assesses pediatric patients at risk of penetration and/or aspiration symptoms. The aim of this study was the validation of PEDI-EAT-10 in the Greek language.

MATERIALS AND METHODS

This cross-sectional study included 222 parents/caregivers of children with (n = 122) and without (n = 100) feeding and/or swallowing disorders, with age range 3 - 12 years. The children were selected from Cypriot schools and health settings. All parents filled out the PEDI-EAΤ-10 questionnaire and after its initial completion, it was re-administered after 2 weeks.

RESULTS

A statistically significant difference was observed in the PEDI-EAT-10 total mean scores between the study's two groups [t (220) = 9.886, p < 0.001]. Internal consistency was high (Cronbach's alpha= 0.801) with very good split-half reliability equal to 0.789. A significant and strong test-retest reliability was computed (r = 0.998, p < 0.001). The PEDI-EAT-10 cutoff point was 11.00 (AUC: 0.869, p < 0.001) for children with feeding and/or swallowing disorders in accordance with the PAS scale.

CONCLUSIONS

In conclusion, the Greek version of PEDI-EAT-10 is shown to be a valid and reliable screening tool for the assessment of the pediatric population with a risk of dysphagia.

Assessing the Swallowing Function in Children with Spinal Muscular Atrophy: An Easily Accessible and Objective Multidimensional Approach

Background

Spinal muscular atrophy (SMA), a genetic neuromuscular disease caused by lack of survival of motor neuron (SMN) protein, is characterized by muscular atrophy and respiratory and bulbar dysfunction. While swallowing disorders are common, they remain poorly studied.

Objectives

Our study aimed to explore 1) intraoral pressure measurements with the Iowa Oral Performance Instrument system and the reliability of a Swallowing Function Assessment Questionnaire (SFAQ) in healthy controls, and 2) evaluate their use as swallowing function biomarkers and the evolution of swallowing function over time in children with SMA.

Methods

We recruited 53 healthy children and 27 SMA patients all treated with SMN gene modulator therapy. Participants completed the SFAQ and underwent at least one measurement of maximal oral pressures (lingual, labial, and masseter).

Results

Mean oral normalized pressure index were lower (all sites p < 0.001) and mean SFAQ scores were higher (p < 0.001) in patients compared with healthy controls. Pressure evolution over 1 year in SMA patients for all three oral sites did not show significant differences. SFAQ scores correlated negatively with oral pressures at all three sites in patients.

Conclusions

Both tools provided new insights on the oral and pharyngeal phase of swallowing in SMA patients. In SMA patients, muscle strength in certain crucial anatomical regions during swallowing is weaker than in healthy children.

Validation of the swallowing disturbance questionnaire in people with multiple sclerosis

BACKGROUND

The DYSPHAGIA IN MULTIPLE SCLEROSIS (DYMUS) questionnaire is the only specific tool developed to screen for dysphagia in people with Multiple Sclerosis (pwMS). However, some limitations of DYMUS could potentially be addressed by the SWALLOWING DISTURBANCE QUESTIONNAIRE (SDQ), which has not yet been validated in pwMS. The objective of this study was to translate and validate the SDQ into the Italian language for use in pwMS to detect swallowing disturbances.

METHODS

We translated the SDQ into Italian and adapted it for use in Italian pwMS. PwMS aged > 18 years, assessed for disability using the Expanded Disability Status Scale (EDSS), completed the SDQ and DYMUS questionnaires and performed the 3-OUNCE WATER SWALLOW TEST (WST). Clinical and demographic data were collected for each patient. The Italian version of the SDQ was retested after 30 days.

RESULTS

A total of 84 pwMS were recruited for the study, consisting of 73.8 % women and 48.8 % with a relapsing-remitting form of MS. The mean age of participants was 44.5 years (SD: ±12.46), with a mean disease duration of 17 years (SD: ±10.27), and a median EDSS of 4 (range 1.5-7.5). The Cronbach's alpha for SDQ (to assess internal consistency) was 0.902, which increased to 0.908 after the elimination of item 15, resulting in the SDQ composed of 14 items. ROC analysis demonstrated good accuracy of the 14-item SDQ in pwMS (AUC: 0.811). By dividing the 14-item SDQ score into quartiles, three risk levels for dysphagia were identified: low (score 1-3), intermediate (score 4-8), and high (score ≥9). 14-item SDQ scores significantly correlated with DYMUS (r = 0.820; p<0.0001) and with EDSS (r = 0.541; p<0.0001). PwMS who reported dysphagia had a significantly higher mean 14-item SDQ score (8.27 ± SD 8.15) compared to those without swallowing problems (2.77 ± SD 4.25; p = 0.003). Additionally, pwMS with a positive WST had a significantly higher mean 14-item SDQ score (10.17 ± SD 8.96) than those with a negative WST (2.96 ± SD 3.93; p = 0.02). The Intraclass Correlation Coefficient for the retest, calculated on 48 pwMS in a stable phase of the disease, was 0.91 (95 % CI 0.84-0.95).

CONCLUSION

The 14-item SDQ has demonstrated high internal consistency, good accuracy, and reliability in pwMS, making it a readily applicable tool for investigating dysphagia in MS.

Factors influencing the decision to introduce alternative nutrition in patients with Duchenne muscular dystrophy

INTRODUCTION/AIMS

Nutritional management of adults with Duchenne muscular dystrophy (DMD) is an important clinical issue. However, it is not clear which dysphagia-related factors should prompt introduction of alternative nutrition (AN). We aimed to determine which patients with DMD were introduced to AN.

METHODS

This retrospective study included 56 patients with DMD (median age, 23.5 years). They were divided into patients able to continue oral feeding (OF) and those introduced to AN. Body weight, frequency of ventilator use, daily meals, history of steroid treatment, results of videofluoroscopic examination of swallowing (VF), and awareness of dysphagia were evaluated.

RESULTS

Of 56 patients, 19 were in the AN group. After AN introduction, 93% of the patients continued oral intake. The proportion of patients who consumed chopped and liquid diets was higher, and body weight was lower, in the AN than in the OF group. There were no significant differences in age, upper limb function of feeding, frequency of ventilator use, or history of steroid therapy between the two groups. The frequencies of aspiration and residue in the pyriform sinus in VF were higher in the AN group than in the OF group. Decision-tree analysis showed that food form and subjective difficulty swallowing solid foods were the most important factors affecting the decision-making for AN.

DISCUSSION

Patients with DMD who had difficulty eating solid foods were started on AN because they were unable to maintain their weight. These findings provide information for future longitudinal studies to assess the value of AN.

The Association Between Dysphagia Symptoms, DIGEST Scores, and Severity Ratings in Individuals with Parkinson's Disease

The Swallow Disturbance Questionnaire (SDQ) is a screening tool developed to identify patients with Parkinson's Disease (PD) in need of objective swallowing evaluation. In a previous investigation, the SDQ did not predict abnormal airway protection on a videofluoroscopic swallowing study (VFSS). This investigation was undertaken to determine whether SDQ scores were more accurate when a global measure was used. The Dynamic Imaging Grade for Swallowing Toxicity (DIGEST) is a validated measure that provides a safety, efficiency, and total severity grade based on VFSS. A secondary analysis was performed using data from 20 patients with PD who had participated in a standardized VFSS protocol. The study sample was predominantly male (80%) with an average age of 71 years, and an average PD duration of 9 years. Using an established cut-off score, participants were subdivided into those with "normal" (n = 10) and "abnormal" SDQ scores (n = 10). Recordings were scored using the DIGEST protocol by two blinded raters who also rated overall dysphagia severity from the VFSS. There was good agreement between the two raters on the DIGEST and strong correlations between DIGEST scores and clinician perceptions of dysphagia severity. Higher SDQ scores were associated with poorer Efficiency on the DIGEST but not Safety or Total scores. Consistent with other PD studies, subjective perceptions of dysphagia were poorly predictive of objective findings on VFSS. There is little information about the validity of the DIGEST for rating neurogenic dysphagia. Our study provides preliminary support for the use of the DIGEST in the PD population.

A Systematic and Universal Artificial Intelligence Screening Method for Oropharyngeal Dysphagia: Improving Diagnosis Through Risk Management

Oropharyngeal dysphagia (OD) is underdiagnosed and current screening is costly. We aimed: (a) to develop an expert system (ES) based on machine learning that calculates the risk of OD from the electronic health records (EHR) of all hospitalized older patients during admission, and (b) to implement the ES in a general hospital. In an observational, retrospective study, EHR and swallowing assessment using the volume-viscosity swallow test for OD were captured over 24 months in patients > 70 yr admitted to Mataró Hospital. We studied the predictive power for OD of 25,000 variables. ES was obtained using feature selection, the final prediction model was built with non-linear methods (Random Forest). The database included 2809 older patients (mean age 82.47 ± 9.33 yr), severely dependent (Barthel Index 47.68 ± 31.90), with multiple readmissions (4.06 ± 7.52); 75.76% had OD. The psychometrics of the ES built with a non-linear model were: Area under the ROC Curve of 0.840; sensitivity 0.940; specificity, 0.416; Positive Predictive Value 0.834; Negative Predictive Value 0.690; positive likelihood ratio (LH), 1.61 and negative LH, 0.146. The ES screens in 6 s all patients admitted to a 419-bed hospital, identifies patients at greater risk of OD, and shows the risk for OD in the clinician's workstation. It is currently in use at our institution. Our ES provides accurate, systematic and universal screening for OD in real time during hospital admission of older patients, allowing the most appropriate diagnostic and therapeutic strategies to be selected for each patient.

Transcranial magnetic stimulation versus transcutaneous neuromuscular electrical stimulation in post stroke dysphagia: A clinical randomized controlled trial

OBJECTIVES

To evaluate the efficacy of high-frequency repeated transcranial magnetic stimulation (rTMS) applied contralesionally versus transcutaneous neuromuscular electrical stimulation (TNES) in acute post-stroke dysphagic patients.

MATERIALS AND METHODS

A randomized, parallel, comparative, controlled trial was conducted on patients with acute ischemic stroke who were admitted to our department. Fifteen patients received rTMS, 15 patients received TNES, and 15 patients were recruited as a control group. Between the second and tenth days after a stroke, patients were enrolled. The study and follow-up periods were completed by all patients.

RESULTS

Among the screened patients, 45 (31.47%) right-handed patients were diagnosed with post-stroke dysphagia with a mean age of 60.53 ± 8.23 years. Immediately after intervention both rTMS and TNES groups significantly improve the swallowing disturbance questionnaire (SDQ) and penetration aspiration scale (PAS), compared to the control (p < 0.001 and p = 0.027), respectively. rTMS was more effective than TNES in reducing SDQ and PAS (p < 0.05). rTMS and TNES improved the Yale Pharyngeal Residue Severity Rating Scale (YPRSRS) significantly (p = 0.002); however, their efficacy was comparable (p > 0.05). A significant (p < 0.001) strong negative correlation was observed between the grade of weakness and all scores.

CONCLUSION

Our findings showed that high-frequency rTMS and TNES effectively improved the clinical condition of acute post-stroke dysphagic patients in terms of swallowing disturbance assessed by SDQ, pharyngeal residue assessed by YPRSRS, and the severity of penetration and aspiration events evaluated by PAS, compared to the controls. The outcomes of high-frequency rTMS were more favorable than those of TNES in terms of SDQ and PAS.

Neurostimulation in People with Oropharyngeal Dysphagia: A Systematic Review and Meta-Analysis of Randomised Controlled Trials-Part II: Brain Neurostimulation

Objective. To assess the effects of brain neurostimulation (i.e., repetitive transcranial magnetic stimulation [rTMS] and transcranial direct current stimulation [tDCS]) in people with oropharyngeal dysphagia (OD). Methods. Systematic literature searches were conducted in four electronic databases (CINAHL, Embase, PsycINFO, and PubMed) to retrieve randomised controlled trials (RCTs) only. Using the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2), the methodological quality of included studies was evaluated, after which meta-analysis was conducted using a random-effects model. Results. In total, 24 studies reporting on brain neurostimulation were included: 11 studies on rTMS, 9 studies on tDCS, and 4 studies on combined neurostimulation interventions. Overall, within-group meta-analysis and between-group analysis for rTMS identified significant large and small effects in favour of stimulation, respectively. For tDCS, overall within-group analysis and between-group analysis identified significant large and moderate effects in favour of stimulation, respectively. Conclusion. Both rTMS and tDCS show promising effects in people with oropharyngeal dysphagia. However, comparisons between studies were challenging due to high heterogeneity in stimulation protocols and experimental parameters, potential moderators, and inconsistent methodological reporting. Generalisations of meta-analyses need to be interpreted with care. Future research should include large RCTs using standard protocols and reporting guidelines as achieved by international consensus.

Factors related to dysphagia-specific quality of life in aged patients with neurologic disorders: A cross-sectional study

This cross-sectional study aimed to analyze dysphagia-specific quality of life and its influencing factors in aged patients with neurologic disorders, and is reported according to the STROBE checklist for observational research. The study included 120 outpatients, aged ≥65 years, diagnosed with neurologic diseases at a general hospital Neurology Department in Seoul, Korea. Data collected during a one-month (March and April 2021) questionnaire survey were statistically analyzed using SPSS. Factors related to dysphagia-specific quality of life were gender, education level, neurological diagnosis, type of diet, subjective swallowing disturbance, and affectionate support-a subscale of social support. The combined explanatory power of these factors was 42.1%. It is essential to note that the factors related to the emotional, functional, and physical domains-the subscales of dysphagia-specific quality of life-are different. Therefore, each factor should be considered when planning nursing interventions to improve dysphagia-specific quality of life.

Endoscopic Characteristics of Dysphagia in Multiple System Atrophy Compared to Parkinson's Disease

BACKGROUND

Dysphagia is a major clinical concern in multiple system atrophy (MSA). A detailed evaluation of its major endoscopic features compared with Parkinson's disease (PD) is lacking.

OBJECTIVE

This study systematically assessed dysphagia in MSA compared with PD and correlated subjective dysphagia to objective endoscopic findings.

METHODS

Fifty-seven patients with MSA (median, 64 [interquartile range (IQR): 59-71] years; 35 women) underwent flexible endoscopic evaluation of swallowing using a specific MSA-flexible endoscopic evaluation of swallowing task protocol. Findings were compared with an age-matched cohort of 57 patients with PD (median, 67 [interquartile range: 60-73] years; 28 women). In a subcohort, subjective dysphagia was assessed using the Swallowing Disturbance Questionnaire and correlated to endoscopy findings.

RESULTS

Patients with MSA predominantly showed symptoms suggestive of oral-phase disturbance (premature spillage, 75.4%, piecemeal deglutition, 75.4%). Pharyngeal-phase symptoms occurred less often (pharyngeal residues, 50.9%; penetration/aspiration, 28.1%). In contrast, pharyngeal symptoms were the most common finding in PD (pharyngeal residues, 47.4%). Oral symptoms occurred less frequently in PD (premature spillage, 15.8%, P < 0.001; piecemeal deglutition, 1.8%, P < 0.01). Patients with MSA had a greater risk for oral-phase disturbances with increased disease severity (P < 0.05; odds ratio, 3.15). Patients with MSA showed a significantly higher intraindividual interswallow variability compared with PD. When correlating Swallowing Disturbance Questionnaire scores with endoscopy results, its cutoff, validated for PD, was not sensitive enough to identify patients with MSA with dysphagia. We developed a subscore for identifying dysphagia in MSA and calculated a new cutoff (sensitivity 85%, specificity 100%).

CONCLUSIONS

In contrast with patients with PD, patients with dysphagic MSA more frequently present with oral-phase symptoms and a significantly higher intraindividual interswallow variability. A novel Swallowing Disturbance Questionnaire MSA subscore may be a valuable tool to identify patients with MSA with early oropharyngeal dysphagia. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Dysphagia in non-intubated patients affected by COVID-19 infection

Purpose

Patients affected by COVID-19 are assumed to be at high risk of developing swallowing disorders. However, to our best knowledge, data on the characteristics and incidence of dysphagia associated with COVID-19 are lacking, especially in non-intubated patients. Therefore, we investigated the onset of swallowing disorders in patients with laboratory-confirmed COVID-19 infection who have not been treated with invasive ventilation, in order to evaluate how the virus affected swallowing function regardless of orotracheal intubation.

Methods

We evaluated 41 patients admitted to the COVID department of our Hospital when they had already passed the acute phase of the disease and were therefore asymptomatic but still positive for SARS-CoV-2 RNA by RT-PCR. We examined patients’ clinical history and performed the Volume-Viscosity Swallow Test (VVST). Each patient also answered the Swallowing Disturbance Questionnaire (SDQ). After 6 months, we performed a follow-up in patients with swallowing disorders.

Results

Eight of 41 patients (20%) presented with dysphagia symptoms during hospitalization and 2 of them (25%) still presented a SDQ high score and swallowing disorders with liquid consistency after 6 months.

Conclusion

Non-intubated patients can experience various grades of swallowing impairment that probably directly related to pulmonary respiratory function alterations and viral direct neuronal lesive activity. Although these symptoms show natural tendency to spontaneous resolution, their impact on a general physical impaired situation should not be underestimated, since it can adversely affect patients’ recovery from COVID-19 worsening health outcomes.

Aesthesiometer-Based Testing for Laryngopharyngeal Hyposensitivity

OBJECTIVES/HYPOTHESIS

To develop a method for threshold estimation of the laryngeal adductor reflex (LAR) response using Cheung-Bearelly monofilaments.

STUDY DESIGN

Cross-sectional.

METHODS

Twenty-two healthy adults (12 men, 10 women) were tested for LAR response outcome using 30 mm 5-0 and 4-0 nylon monofilaments. Tactile stimuli were delivered to the aryepiglottic (AE) fold and medial pyriform sinus (MPS). Dichotomous classifier features and performance (area under the curve (AUC)), the LAR response outcome agreement and disagreement matrix, and test-retest reliability were examined. From those data, a test protocol that would minimize patient burden to estimate the LAR triggering threshold was formulated.

RESULTS

Classifier performance of 5-0 monofilament stimulation of the AE fold (sensitivity = 0.63, specificity = 0.63, PPV = 0.74, NPV = 0.25) and MPS (sensitivity = 0.45, specificity = 0.77, PPV = 0.74, NPV = 0.23,) was slightly below that of 4-0 monofilament stimulation of the AE fold (sensitivity = 0.82, specificity = 0.50, PPV = 0.82, NPV = 0.50) and MPS (sensitivity = 0.84, specificity = 0.64, PPV = 0.90, NPV = 0.56), based on AUC. LAR response outcome agreement for 5-0 and 4-0 stimulations was high (93%) for 5-0 positive response, but low (29%) for 5-0 negative response. Aesthesiometer test-retest reliability for LAR response outcome was excellent (Cronbach's alpha = 0.97).

CONCLUSIONS

Threshold estimation of the LAR response may be operationalized by adopting a decision tree protocol. For negative LAR response to initial 5-0 monofilament stimulation and positive response to subsequent 4-0 monofilament stimulation, the higher threshold is confirmed. Positive LAR response to 5-0 or 4-0 monofilament stimulation is expected in over 90% of asymptomatic adults. Negative LAR response to 4-0 monofilament stimulation identifies patients at risk for laryngopharyngeal hyposensitivity.

LEVEL OF EVIDENCE

3b Laryngoscope, 2021.

Diagnosis and treatment of neurogenic dysphagia - S1 guideline of the German Society of Neurology

Introduction

Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies.

Recommendations

This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with.

Conclusions

The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf).

Dysphagia in Parkinson's disease patients prior to deep brain stimulation: Is screening accurate?

BACKGROUND

Swallowing problems are common in Parkinson's Disease (PD) and aspiration pneumonia is the leading cause of death. Deep brain stimulation (DBS) surgery can successfully manage the motor symptoms of PD when pharmacological management begins to fail. Before DBS it is important to identify baseline dysfunction, but no consensus regarding swallowing screening exists.

OBJECTIVES

This study was undertaken to: 1) identify the prevalence of dysphagia prior to DBS; and 2) determine if screening measures or other characteristics were predictive for reduced airway protection.

METHODS

A standardized protocol was performed for 137 consecutive patients with idiopathic PD and no confounding medical conditions, including those referred for work-up of dysphagia (n = 57) and those prior to DBS (n = 80). Three validated screening measures were completed before videofluoroscopic evaluation.

RESULTS

On videofluoroscopy, there were significant differences in reduced airway protection by group (dysphagia group: 44 %; pre-DBS group: 21 %). Aspiration also differed by group (dysphagia group: 18 %; pre-DBS group: 8 %) although not significantly. Although there were significant between-group differences, none of the screening measures was predictive of reduced airway protection or aspiration in the sample overall. Male gender, previous videofluoroscopic evaluation, history of pneumonia, and previous DBS surgery were associated with increased aspiration-risk. Age also showed a modest correlation.

CONCLUSIONS

Dysphagia is not uncommon prior to DBS. No screening measure accurately predicted reduced airway protection on videofluoroscopy. Abnormal findings on clinical assessment prior to DBS, particularly in patients that are older, male, or have a history of pneumonia, may identify individuals requiring an objective dysphagia evaluation.

Development of the Pediatric Dysphagia Risk Screening Instrument (PDRSI)

OBJETIVO

Desenvolver um instrumento de rastreio para a identificação de crianças com risco para disfagia, em ambiente hospitalar.

MÉTODO

O Instrumento de Rastreio para o Risco de Disfagia Pediátrica (IRRD-Ped), constituído por 23 questões, foi desenvolvido por fonoaudiólogos, após revisão da literatura. Ele foi proposto para ser aplicado aos responsáveis por crianças em internação hospitalar. O IRRD-Ped foi enviado a juízes para análise, tendo sido também realizado um estudo piloto. Para verificar a validade de critério, aplicou-se o IRRD-Ped aos responsáveis por crianças internadas e, posteriormente, realizou-se, com estas crianças, avaliação clínica da deglutição, através do Protocolo de Avaliação da Disfagia Pediátrica (PAD-PED). Os responsáveis assinaram o Termo de Consentimento Livre e Esclarecido. Os sujeitos foram separados em dois grupos (com disfagia e com deglutição normal), sendo verificada a associação entre as questões do IRRD-Ped e o resultado do PAD-PED, através do teste qui-quadrado de Person ou exato de Fisher. Definiu-se o ponto de corte para presença de risco para disfagia através da Curva ROC. A confiabilidade do IRRD-Ped foi verificada pelo coeficiente α de Cronbach.

RESULTADOS

A amostra foi constituída por 40 crianças com mediana de idade de 3,7 meses. Verificou-se associação estatisticamente significativa em oito itens do instrumento. A consistência interna do IRRD-Ped foi de 0,828. O ponto de corte para o risco de disfagia foi de cinco pontos (sensibilidade = 100% e especificidade = 80%).

CONCLUSÃO

Devido aos satisfatórios resultados encontrados, deve-se dar prosseguimento ao processo de validação do IRRD-Ped.

Prevalence and Associated Factors of Drug-Related Problems Among Older People: A Cross-Sectional Study at King Chulalongkorn Memorial Hospital in Bangkok

BACKGROUND AND OBJECTIVE

The use of multiple medications and altered pharmacokinetics/pharmacodynamics may lead to drug-related problems in members of the older population. The aim of this study is to evaluate the prevalence of, and factors related to, drug-related problems in older urban-living Thai people.

METHODS

We conducted a cross-sectional study involving 466 participants (aged ≥ 65 years) whose first-time health screening at the Geriatric Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok was between May and October 2019. Participants were interviewed and assessed for drug-related problems by clinical pharmacists.

RESULTS

In total, 54.5% (254) of the participants were aged 65-69 years and 77.0% (359) of the participants were women. Of the participants, 56.7% had three or more health conditions such as hyperlipidemia (62%), hypertension (46%), and cataract (18%). Fifty-five percent of the participants took five or more health products (polypharmacy) and 16% took ten or more products on a regular basis. Of the 2633 products used, 68% were prescription drugs and 32% were over-the-counter products. The prevalence of drug-related problems according to the criteria suggested by Cipolle-Strand-Morley (2012) was 63.3% (587 drug-related problems). Most of the problems came from: (a) non-adherence (28.6%); (b) needs for additional drug therapy (26.4%); and (c) adverse drug reactions (17.4%). Factors associated with drug-related problems were polypharmacy (odds ratio 2.50, 95% confidence interval 1.60-3.89) and multiple comorbidities [three or more conditions] (odds ratio 2.20, 95% confidence interval 1.41-3.43).

CONCLUSIONS

The prevalence of drug-related problems in urban-living older people at King Chulalongkorn Memorial Hospital in Bangkok was high. Polypharmacy and multiple comorbidities were significantly related to drug-related problems. To decrease the number of drug-related problems, pharmacists should collaborate with healthcare teams and suggest how to correctly reduce the number of health products being consumed by older people.

Cross-cultural adaptation and validation of the Swallowing Disturbance Questionnaire and the Sialorrhea Clinical Scale in Portuguese patients with Parkinson's disease

INTRODUCTION

To date, no valid outcome measure has been developed in European Portuguese (EP) to evaluate the Parkinsons' Disease (PD) patients' (PwP) reports regarding their swallowing disturbances.

OBJECTIVES

The aim of this study was to translate and cross-culturally adapt the Swallowing Disturbance Questionnaire (SDQ) and the Sialorrhea Clinical Scale for PD (SCS-PD) into EP and to determine its clinimetric properties in PwP.

MATERIALS AND METHODS

The original English SDQ and SCS-PD versions were cross-culturally adapted following recommendations established in international guidelines. The validation process involved 75 PwP and 65 healthy sex- and age-matched participants.

RESULTS

The EP versions of the SDQ and SCS-PD are equivalent to the original versions (content, depth, and scoring). Statistical analyses for the SDQ tool revealed good feasibility (missing data <5%), acceptability (no floor or ceiling effects), excellent internal consistency (Cronbach´s α = 0.95), good construct validity (78.5% revealed large to moderate loadings), moderate convergent validity (r = 0.60), good divergent validity (r = 0.40), good known-groups validity (p-value < .05) and a fair sensitivity and specificity (AUC = 0.700). Statistical analyses for the SCS-PD tool shows good feasibility, reasonable acceptability (floor effect), good internal consistency (Cronbach´s α = 0.85), good construct validity (85.7% showed between large to moderate loadings), good convergent validity (r = 0.78), good divergent validity (r = 0.39), good known groups validity (p-value < .05) and a fair sensitivity and specificity (AUC = 0.704).

CONCLUSIONS

The EP versions of the SDQ and SCS-PD maintained the characteristics of the original versions and therefore consistent tools to be used in PwP.

The prevalence and types of oral- and pharyngeal-stage dysphagia in patients with demyelinating diseases based on subjective assessment by the study subjects

BACKGROUND

Studies show that dysphagia is a common problem in patients with demyelinating diseases. However, there are no published studies on dysphagia in this group of patients, which would include the individual phases or the safety and effectiveness of the swallowing process.

OBJECTIVE

The main objective of this study was to assess the prevalence of swallowing disorders and to characterize them based on subjective assessment by the study subjects with multiple sclerosis and Devic's syndrome.

METHOD

The study included 72 patients (47 F, 25 M). Patients at risk of dysphagia were identified using the DYMUS, EAT-10 and SDQ questionnaires. To assess the type of oral- and pharyngeal-stage dysphagia, questions in the questionnaires were classified into groups according to symptoms typical of each stage.

RESULTS

The risk of dysphagia and the need for instrumental examination were identified in 37.5% of the study subjects. Pharyngeal-stage dysphagia (repeated swallowing, increased effort of swallowing, cough, a feeling of food sticking in the throat) was reported to occur at a significantly higher frequency. However, no differences were found between difficulty in swallowing liquids and difficulty in swallowing solid food.

CONCLUSION

There is a need for further research, which should include a detailed dysphagia-oriented diagnosis, with a view to gaining a detailed insight into the pathophysiology of deglutition in this group of patients.

Dysphagia from a neurogeriatric point of view : Pathogenesis, diagnosis and management

Dysphagia is becoming increasingly more common in aging societies and, like the classical geriatric syndromes, it is a relevant functional impairment. The prevalence of dysphagia is highest in the group of old patients with neurological disorders, particularly in patients with stroke, dementia and Parkinson's disease. In the various neurological diseases of older people disease-specific factors often have a decisive influence on the clinical management of dysphagia. In addition, the concept of primary and secondary presbyphagia plays an important role in understanding age-related dysphagia. Whereas at the organ level of the International Classification of Functioning, Disability and Health (ICF) model, the diagnosis and treatment of dysphagia in neurogeriatrics have already made progress, more research is needed on the levels of activity/mobility, social environment, personal factors and the environment. This article summarizes the pathophysiological aspects as well as the current evidence for diagnosis and treatment of neurogeriatric dysphagia. Due to its high clinical relevance dysphagia should be added to the geriatric syndromes as "impaired swallowing".

The Effect of High-Frequency Repetitive Transcranial Magnetic Stimulation on Advancing Parkinson’s Disease With Dysphagia: Double Blind Randomized Clinical Trial

We investigate if rTMS has a therapeutic role in the treatment of dysphagia in patients with Parkinson’s disease (PD). Material and Methods. Thirty-three patients with PD and dysphagia were randomly classified with ratio 1:2 to receive sham or real rTMS (2000 pulses; 20 Hz; 90% resting motor threshold; 10 trains of 10 seconds with 25 seconds between each train) over the hand area of each motor cortex (5 minutes between hemispheres) for 10 days (5 days per week) followed by 5 booster sessions every month for 3 months. Assessments included the Unified Parkinson’s Disease Rating Scale part III (UPDRS), Instrumental Activities of Daily Living (IADL), and Arabic–Dysphagia Handicap Index (A-DHI) before, after the last session, and 3 months later. Video-fluoroscopy measures of pharyngeal transit time (PTT) and time to maximal hyoid elevation (H1-H2) were taken before and after the treatment sessions. Results. There were no significant differences between groups. There was a significant improvement on all rating scales (analysis of variance) after real rTMS with a significant time × group interaction. In particular, there was a significant and long-lasting (3 months) effect of time on all subitems of the A-DHI (functional, P = .0001; physical, P = .0001; emotional, P = .02) but not in the sham group. This was associated with significant improvement in H1-H2 ( P = .03) and PTT ( P = .01) during solid swallows in the real rTMS but not the sham group. Conclusion. Real rTMS improves dysphagia in PD as documented by A-DHI scores and by video-fluoroscopy.

The requirement for a disease-specific patient-reported outcome measure of dysphagia in oculopharyngeal muscular dystrophy

INTRODUCTION

There is no patient-reported outcome (PRO) questionnaire specifically designed to assess oropharyngeal dysphagia in oculopharyngeal muscular dystrophy (OPMD). To select a suitable questionnaire, content validity of the existing questionnaires must be assessed. This study sought (1) to identify dysphagia-related symptoms in OPMD and (2) to assess content validity of currently available PRO for the assessment of dysphagia severity in OPMD.

METHODS

A two-step literature review was conducted of dysphagia-related symptom identification and oropharyngeal dysphagia-related PRO. Symptoms were validated with an expert panel by using a Delphi survey. Content validity of PRO questionnaires was documented through content analysis.

RESULTS

Ten PRO questionnaires were identified. None of the questionnaires cover the entire symptom spectrum in OPMD and thus lack content validity.

DISCUSSION

The development and validation of a new PRO questionnaire to assess dysphagia in OPMD is required to establish the importance of symptomatic relief from new treatments. Muscle Nerve 59:445-450, 2019.

The Easy Dysphagia Symptom Questionnaire (EDSQ): a new dysphagia screening questionnaire for the older adults

PURPOSE

The early detection of dysphagia, a common clinical issue among older adults, is important. However, healthcare professionals sometimes experience difficulties in applying the current screening tools to older adults. Therefore, we developed the Easy Dysphagia Symptom Questionnaire (EDSQ), a simplified tool for the older adults, and investigated its reliability and validity.

METHODS

The 12-item "yes/no" EDSQ assesses dysphagia symptoms, with a total score being the sum of all "yes" responses. Each item was determined by consensus of three physiatrists after reviewing the previous dysphagia questionnaires. Participants were aged 65 years or older who either complained of or were suspected by a physician of facing swallowing disturbance. They completed the EDSQ, modified water swallow test (MWST), and videofluoroscopic swallowing study. The EDSQ's internal consistency was assessed. Correlations between the EDSQ total score and the MWST, American Speech-Language-Hearing Association's National Outcome Measurement System (ASHA NOMS) swallowing scale, and videofluoroscopic dysphagia scale (VDS) were analyzed.

RESULTS

The sample comprised 51 participants (29 male, 56.9%; mean age 76.7 ± 6.6 years). Mean EDSQ total score was 4.33 ± 3.03 (range 0-12). Regarding the EDSQ's reliability, the Cronbach's α coefficient was 0.785. The EDSQ total score correlated with the MWST (r = - 0.468, p = 0.001), ASHA NOMS swallowing scale (r = - 0.635, p < 0.001), and VDS (r = 0.449, p = 0.001). The receiver-operating characteristic analysis revealed an optimal cut-off score of ≥ 5, with a sensitivity of 90.9% and a specificity of 67.5%.

CONCLUSIONS

The EDSQ showed acceptable reliability and validity, indicating its applicability to older adults as a simple screening tool for safe swallowing.

Long-term swallowing performance following transoral robotic surgery for obstructive sleep apnea

OBJECTIVES/HYPOTHESIS

This study aimed to evaluate the long-term swallowing performance following transoral robotic surgery (TORS) to the base of tongue (BOT) in the treatment of obstructive sleep apnea (OSA).

STUDY DESIGN

Retrospective and prospective cohort study.

METHODS

Data analysis of 39 patients who underwent BOT reduction via TORS to treat OSA at our center from September 2013 to April 2016. Long-term swallowing functions were assessed using subjective self-evaluated swallowing disturbances questionnaire (SDQ) and objective fiberoptic endoscopic evaluation of swallowing (FEES).

RESULTS

Seven patients underwent TORS BOT reduction alone, whereas 32 had also uvulopalatoplasty ± tonsillectomy, with a surgical success rate of 71.4%. Mean time for swallowing evaluation was 27.4 ± 9.43 months. Twenty-five patients completed the SDQ with an average score of 9.26 ± 10.05. In 32%, the SDQ was positive for dysphagia. In 10 out of 14 patients who underwent FEES, swallowing problems were noticed. The most common pathological findings were food residue in the vallecula followed by early spillage of food into the hypopharynx, penetration of solid food and liquid on the vocal folds surface, and aspiration.

CONCLUSIONS

BOT reduction via TORS has a negative effect on long-term swallowing function. A self-assessment questionnaire can help detect patients who suffer from swallowing impairment. Postoperative objective swallowing tests are essential not only in the immediate postoperative period but also during late routine follow-up. Proper patient selection and detailed information about surgery and possible late-swallowing effect are important factors before scheduling BOT reduction via TORS for OSA treatment.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:422-428, 2019.

Translation and Validation of the Dysphagia Handicap Index in Hebrew-Speaking Patients

The Dysphagia Handicap Index (DHI) is a 25-item questionnaire assessing the physical, functional, and emotional aspects of dysphagia patients' quality of life (QoL). The study goal was to translate and validate the Hebrew-DHI. 148 patients undergoing fiberoptic endoscopic examination of swallowing (FEES) in two specialized dysphagia clinics between February and August 2017 filled the Hebrew-DHI and self-reported their dysphagia severity on a scale of 1-7. 21 patients refilled the DHI during a 2-week period following their first visit. FEES were scored for residue (1 point per consistency), penetration and aspiration (1 point for penetration, 2 points for aspiration, per consistency). 51 healthy volunteers also filled the DHI. Internal consistency and test-retest reproducibility were used for reliability testing. Validity was established by comparing DHI scores of dysphagia patients and healthy controls. Concurrent validity was established by correlating the DHI score with the FEES score. Internal consistency of the Hebrew-DHI was high (Cronbach's alpha = 0.96), as was the test-retest reproducibility (Spearman's correlation coefficient = 0.82, p < 0.001). The Hebrew-DHI's total score, and its three subscales (physical/functional/emotional) were significantly higher in dysphagia patients compared to those in healthy controls (median 38 pts, IQR 18-56 for dysphagia patients compared to 0, IQR 0-2 for healthy controls, p < 0.0001). A strong correlation was observed between the DHI score and the self-reported dysphagia severity measure (Spearman's correlation coefficient = 0.88, p < 0.0001). A moderate correlation was found between the DHI score and the FEES score (Pearson's correlation coefficient = 0.245, p = 0.003). The Hebrew-DHI is a reliable and valid questionnaire assessing dysphagia patients' QoL.

Utility of Eating Assessment Tool-10 in Predicting Aspiration in Patients with Unilateral Vocal Fold Paralysis

Objective Examine the incidence of penetration/aspiration in patients with unilateral vocal fold immobility and investigate the relationship with self-reported perception of dysphagia. Study Design Case series with chart review. Setting Academic cancer center. Subjects and Methods Adult patients with unilateral vocal fold immobility diagnosed between 2014 and 2016 were reviewed. Patients were stratified into an aspiration group and a nonaspiration group using objective findings on flexible endoscopic evaluation of swallowing, as scored using Rosenbek's Penetration Aspiration Scale. Objective findings were compared to patient perception of dysphagia. Bivariate linear correlation analysis was performed to evaluate correlation between Eating Assessment Tool-10 scores and presence of aspiration. Tests of diagnostic accuracy were calculated to investigate the predictive value of Eating Assessment Tool-10 scores >9 on aspiration risk. Results Of the 35 patients with new-onset unilateral vocal fold immobility were evaluated, 25.7% (9/35) demonstrated tracheal aspiration. Mean ± SD Eating Assessment Tool-10 scores were 19.2 ± 13.7 for aspirators and 7.0 ± 7.8 for nonaspirators ( P = .016). A statistically significant correlation was demonstrated between increasing Eating Assessment Tool-10 scores and Penetration Aspiration Scale scores ( r = 0.511, P = .002). Diagnostic accuracy analysis for aspiration risk in patients with an Eating Assessment Tool-10 score >9 revealed a sensitivity of 77.8% and a specificity of 73.1%. Conclusion Patient perception of swallowing difficulty may have utility in predicting aspiration risk. An EAT-10 of >9 in patients with unilateral vocal fold immobility may portend up to a 5 times greater risk of aspiration. Routine swallow testing to assess for penetration/aspiration may be indicated in patients with unilateral vocal fold immobility.

Feasibility of using risk prompts to prevent falls, dehydration and pulmonary aspiration in nursing homes: a clinical study protocol

Background

Evidence has shown a relationship between dehydration, falls, and pulmonary aspiration among older adults in nursing homes, all of which contribute to loss of independence and quality of life. It is believed that improving communication among healthcare professionals in nursing homes (physicians, nurses, rehabilitation team, psychologist, social workers, dieticians and medical assistants) decreases the number of adverse events in institutionalized patients. This study will evaluate the feasibility of using a set of written signs, designed to caution against the risk of falls, dehydration, and pulmonary aspiration, and will enable the proposal of tailored interventions to manage these events in nursing homes.

Methods/Design

All patients from Campus Neurológico Sénior (CNS) nursing home, at risk of falls and/ordysphagia and/or dehydration will be invited to participate in the study. Patients will undertake a screeningrisk assessment and the corresponding risk prompts will be attributed. Study duration will be a minimum ofthree months per participant, including daily record of falls, dehydration and pulmonary aspiration eventsand monthly interview assessments, conducted by a member of the research team. Data of the events that occur will be compared with historical data extracted retrospectively from medical and nursing charts. This study has been approved by the Ethics Committee of the Medical Academic Center of Lisbon, Faculty of Medicine, University of Lisbon (Ref. 176/15). All participants will give their written informed consent before entering the study.

Discussion

This study is unique in evaluating the feasibility of a communication system in preventing the three major risks in nursing home. Thoughtful selection and display of proper risk prompts in nursing homes could be an essential step along a path toward efficient communication of risks among healthcare teams. We expect that the displays will be easily applicable given their simplicity, low complexity, and minimal physical requirements.

Trial registration

NCT03123601. March 7, 2017. Retrospectively registered.

Patient-reported outcome measures in dysphagia: a systematic review of instrument development and validation

OBJECTIVE

Patient-reported outcome (PRO) measures are commonly used to capture patient experience with dysphagia and to evaluate treatment effectiveness. Inappropriate application can lead to distorted results in clinical studies. A systematic review of the literature on dysphagia-related PRO measures was performed to (1) identify all currently available measures and (2) to evaluate each for the presence of important measurement properties that would affect their applicability.

DESIGN

MEDLINE via the PubMed interface, the Cumulative Index of Nursing and Allied Health Literature, and the Health and Psychosocial Instrument database were searched using relevant vocabulary terms and key terms related to PRO measures and dysphagia. Three independent investigators performed abstract and full text reviews. Each study meeting criteria was evaluated using an 18-item checklist developed a priori that assessed multiple domains: (1) conceptual model, (2) content validity, (3) reliability, (4) construct validity, (6) scoring and interpretation, and (7) burden and presentation.

RESULTS

Of 4950 abstracts reviewed, a total of 34 dysphagia-related PRO measures (publication year 1987-2014) met criteria for extraction and analysis. Several PRO measures were of high quality (MADS for achalasia, SWAL-QOL and SSQ for oropharyngeal dysphagia, PROMIS-GI for general dysphagia, EORTC-QLQ-OG25 for esophageal cancer, ROMP-swallowing for Parkinson's Disease, DSQ-EoE for eosinophilic esophagitis, and SOAL for total laryngectomy-related dysphagia). In all, 17 met at least one criterion per domain. Thematic deficiencies in current measures were evident including: (1) direct patient involvement in content development, (2) empirically justified dimensionality, (3) demonstrable responsiveness to change, (4) plan for interpreting missing responses, and (5) literacy level assessment.

CONCLUSION

This is the first comprehensive systematic review assessing developmental properties of all available dysphagia-related PRO measures. We identified several instruments with robust measurement properties in multiple diseases including achalasia, oropharyngeal dysphagia, post-surgical dysphagia, esophageal cancer, and dysphagia related to neurological diseases. Findings herein can assist clinicians and researchers in making more informed decisions in selecting the most fundamentally sound PRO measure for a given clinical, research, or quality initiative.

Indirect tolerability comparison of Deutetrabenazine and Tetrabenazine for Huntington disease

Background

Vesicular monoamine transporter 2 (VMAT2) inhibitors can improve hyperkinetic movements, and are effective treatment options for chorea of Huntington disease (HD). Tetrabenazine was assessed for treating chorea in the TETRA-HD trial, and while efficacious, there are tolerability concerns possibly due to its pharmacokinetic properties. Deutetrabenazine is a novel VMAT2 inhibitor that contains deuterium, which extends active metabolite half-lives and minimizes drug concentration fluctuations. In the First-HD trial, deutetrabenazine was efficacious in treating chorea and was generally well tolerated. In the absence of a head-to-head trial, we performed an indirect treatment comparison (ITC) of the tolerability of deutetrabenazine and tetrabenazine for the treatment of HD-associated chorea, as observed in the First-HD and TETRA-HD trials, using well-established comparison methods.

Methods

Data from the Phase III, 12-week, parallel-group, clinical trials First-HD (N = 90) and TETRA-HD (N = 84) were used to conduct an ITC of the tolerability of deutetrabenazine versus tetrabenazine using two anchor-based methods: Bucher comparison for unadjusted ITCs, and matching indirect comparison for adjusted ITCs. Overall adverse events (AEs; mild, moderate, and severe), serious AEs, specific AEs occurring in ≥10% of patients, and discontinuations (all-cause and AE-related) were included in the analysis. The risk differences of these outcomes for deutetrabenazine and tetrabenazine were estimated by subtracting the applicable placebo-adjusted risk in First-HD from that of TETRA-HD. Sensitivity analyses were performed to address differences between trials, and p-values were obtained from z-tests.

Results

Compared with tetrabenazine, deutetrabenazine was associated with a significantly lower risk of moderate to severe AEs and neuropsychiatric AEs including agitation, akathisia, depression, depression/agitated depression, drowsiness/somnolence, insomnia, and parkinsonism in both adjusted and unadjusted analyses (p < 0.05 for each). Deutetrabenazine had a significantly lower rate of dose reduction or dose reduction/suspension in the unadjusted and adjusted analyses (p < 0.001 for each). Deutetrabenazine resulted in numerically more mild AEs, such as diarrhea and coughing; however, these results were not statistically significant.

Conclusions

This indirect treatment comparison demonstrates that for the treatment of HD chorea, deutetrabenazine has a favorable tolerability profile compared to tetrabenazine.

Trial registration

ClinicalTrials.gov NCT01795859 and NCT00219804.

European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome

This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization's classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.

European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome

This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization's classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.

Bedside diagnosis of dysphagia: a systematic review

Dysphagia is associated with aspiration, pneumonia, and malnutrition, but remains challenging to identify at the bedside. A variety of exam protocols and maneuvers are commonly used, but the efficacy of these maneuvers is highly variable. We conducted a comprehensive search of 7 databases, including MEDLINE, Embase, and Scopus, from each database's earliest inception through June 9, 2014. Studies reporting diagnostic performance of a bedside examination maneuver compared to a reference gold standard (videofluoroscopic swallow study or flexible endoscopic evaluation of swallowing with sensory testing) were included for analysis. From each study, data were abstracted based on the type of diagnostic method and reference standard study population and inclusion/exclusion characteristics, design, and prediction of aspiration. The search strategy identified 38 articles meeting inclusion criteria. Overall, most bedside examinations lacked sufficient sensitivity to be used for screening purposes across all patient populations examined. Individual studies found dysphonia assessments, abnormal pharyngeal sensation assessments, dual axis accelerometry, and 1 description of water swallow testing to be sensitive tools, but none were reported as consistently sensitive. A preponderance of identified studies was in poststroke adults, limiting the generalizability of results. No bedside screening protocol has been shown to provide adequate predictive value for presence of aspiration. Several individual exam maneuvers demonstrated reasonable sensitivity, but reproducibility and consistency of these protocols was not established. More research is needed to design an optimal protocol for dysphagia detection.

Validation of the persian translation of the swallowing disturbance questionnaire in Parkinson's disease patients

Dysphagia, as a common finding in Parkinson's disease (PD) patients, was estimated to be present in 80–95% of this population during different stages of the disease. The Swallowing Disturbance Questionnaire (SDQ) was created as a self-rated dysphagia screening tool in PD. According to the guidelines for cross-cultural adaptation, Persian version of this questionnaire (SDQ-P) was developed. 59 Persian patients (39 men and 20 women) participated in the study. They responded to the SDQ-P and underwent videofluoroscopic swallowing study (VFSS). Aspiration during VFSS was compared with questionnaire results for each individual. Cronbach's alpha coefficient for the questionnaire was 0.86 and based on SDQ-P 15 patients (25.4%) were dysphagic, while 10 patients (16.9%) showed aspiration during VFSS. SDQ-P sensitivity and specificity in predicting aspiration were 96.7 and 91.2%; therefore, the SDQ-P could be a prognostic tool for aspiration. The positive predictive value (PPV), the negative predictive value (NPV), and the pre- and posttest probabilities of aspiration were 0.67, 1, 16.9%, and 66.7%, respectively. In summary, this study demonstrated the reliability and also the feasibility of SDQ-P for screening of aspiration in Iranian patients with PD. Further evaluation of SDQ-P in larger subject population would be suggested.

The Ability of the 10-Item Eating Assessment Tool (EAT-10) to Predict Aspiration Risk in Persons With Dysphagia

BACKGROUND

Dysphagia is common and costly. The ability of patient symptoms to predict objective swallowing dysfunction is uncertain.

PURPOSE

This study aimed to evaluate the ability of the Eating Assessment Tool (EAT-10) to screen for aspiration risk in patients with dysphagia.

METHODS

Data from individuals with dysphagia undergoing a videofluoroscopic swallow study between January 2012 and July 2013 were abstracted from a clinical database. Data included the EAT-10, Penetration Aspiration Scale (PAS), total pharyngeal transit (TPT) time, and underlying diagnoses. Bivariate linear correlation analysis, sensitivity, specificity, and predictive values were calculated.

RESULTS

The mean age of the entire cohort (N=360) was 64.40 (±14.75) years. Forty-six percent were female. The mean EAT-10 was 16.08 (±10.25) for nonaspirators and 23.16 (±10.88) for aspirators (P<.0001). There was a linear correlation between the total EAT-10 score and the PAS (r=0.273, P<.001). Sensitivity and specificity of an EAT-10>15 in predicting aspiration were 71% and 53%, respectively.

CONCLUSION

Subjective dysphagia symptoms as documented with the EAT-10 can predict aspiration risk. A linear correlation exists between the EAT-10 and aspiration events (PAS) and aspiration risk (TPT time). Persons with an EAT-10>15 are 2.2 times more likely to aspirate (95% confidence interval, 1.3907-3.6245). The sensitivity of an EAT-10>15 is 71%.

A systematic review of self-reported swallowing assessments in progressive neurological disorders

Dysphagia experienced as a consequence of neurodegenerative disease can have severe consequences on a patient's health and well-being. Regular assessment of swallowing function can assist to achieve adequate nutrition and hydration. Here we review subjective swallowing assessments currently available are suitable for use in people with neurodegenerative disease. Measurement properties were reviewed for each tool and coverage of the World Health Organization's International Classification of Functioning, Disability and Health (WHO ICF) was considered. Assessments were identified following a review of the published literature Instruments were reviewed on the basis of reliability and validity, as well as administrative properties, such an interpretability, acceptability, and feasibility. Tools were also evaluated according to the WHO ICF framework. In total, 19 studies were identified for full-text review from 13,315 abstracts. Nine self-reported dysphagia assessment tools suitable for use in progressive neurological disorders were identified. The Swallowing Quality of Life Questionnaire (SWAL-QOL) yields the strongest combination of reliability (including internal consistency and test-retest reliability) and convergent validity while simultaneously covering all WHO ICF domains. Lengthy administration time was identified as a limitation of the SWAL-QOL. The review highlights a relative lack of well-validated self-report questionnaires in dysphagia for people with progressive neurological disease. Additional validation and evaluation of the clinical utility of the tools currently available is required to further promote an informed selection of available assessments.

Screening tools for dysphagia: a systematic review

Purpose:To perform a systematic review of screening instruments for dysphagia available in the literature.Methods:For the selection of studies, the following descriptors were used: "questionários", "questionnaires", "transtornos de deglutição", "deglutition disorders", "programas de rastreamento", and "mass screening". The online databases used for the research were Virtual Health Library (LILACS, IBECS, MEDLINE, Cochrane Library, SciELO) and PubMed. The research was performed from April to June 2013. Selection criteria articles in English, Portuguese, and Spanish, regardless of the year of publication, whose title, abstract, or text had any relation to the purpose of the research. After reading the articles in their entirety, identification data and method of the articles were extracted for later analysis.Results:The research carried out from the proposed descriptors produced 1,012 articles. After reviewing the titles, summaries, and fully reading the articles, 20 studies were chosen. The publications on instruments for the identification of dysphagic patients started in 1999, and 50% of the analyzed studies were carried out in the USA. The methods used on the instruments were questionnaires, observation of patient's clinical signals and symptoms, the request for execution of some orofacial movements, and swallowing test with water or food.Conclusion:Screening instruments in dysphagia are fairly heterogeneous and have been developed for different audiences with the main objective of identifying patients with swallowing disorders.

Sensitivity and specificity of the Eating Assessment Tool and the Volume-Viscosity Swallow Test for clinical evaluation of oropharyngeal dysphagia

BACKGROUND

Oropharyngeal dysphagia (OD) is an underdiagnosed digestive disorder that causes severe nutritional and respiratory complications. Our aim was to determine the accuracy of the Eating Assessment Tool (EAT-10) and the Volume-Viscosity Swallow Test (V-VST) for clinical evaluation of OD.

METHODS

We studied 120 patients with swallowing difficulties and 14 healthy subjects. OD was evaluated by the 10-item screening questionnaire EAT-10 and the bedside method V-VST, videofluoroscopy (VFS) being the reference standard. The V-VST is an effort test that uses boluses of different volumes and viscosities to identify clinical signs of impaired efficacy (impaired labial seal, piecemeal deglutition, and residue) and impaired safety of swallow (cough, voice changes, and oxygen desaturation ≥3%). Discriminating ability was assessed by the AUC of the ROC curve and sensitivity and specificity values.

KEY RESULTS

According to VFS, prevalence of OD was 87%, 75.6% with impaired efficacy and 80.9% with impaired safety of swallow including 17.6% aspirations. The EAT-10 showed a ROC AUC of 0.89 for OD with an optimal cut-off at 2 (0.89 sensitivity and 0.82 specificity). The V-VST showed 0.94 sensitivity and 0.88 specificity for OD, 0.79 sensitivity and 0.75 specificity for impaired efficacy, 0.87 sensitivity and 0.81 specificity for impaired safety, and 0.91 sensitivity and 0.28 specificity for aspirations.

CONCLUSIONS & INFERENCES

Clinical methods for screening (EAT-10) and assessment (V-VST) of OD offer excellent psychometric proprieties that allow adequate management of OD. Their universal application among at-risk populations will improve the identification of patients with OD at risk for malnutrition and aspiration pneumonia.

Sensitivity and specificity of the Eating Assessment Tool and the Volume-Viscosity Swallow Test for clinical evaluation of oropharyngeal dysphagia

BACKGROUND

Oropharyngeal dysphagia (OD) is an underdiagnosed digestive disorder that causes severe nutritional and respiratory complications. Our aim was to determine the accuracy of the Eating Assessment Tool (EAT-10) and the Volume-Viscosity Swallow Test (V-VST) for clinical evaluation of OD.

METHODS

We studied 120 patients with swallowing difficulties and 14 healthy subjects. OD was evaluated by the 10-item screening questionnaire EAT-10 and the bedside method V-VST, videofluoroscopy (VFS) being the reference standard. The V-VST is an effort test that uses boluses of different volumes and viscosities to identify clinical signs of impaired efficacy (impaired labial seal, piecemeal deglutition, and residue) and impaired safety of swallow (cough, voice changes, and oxygen desaturation ≥3%). Discriminating ability was assessed by the AUC of the ROC curve and sensitivity and specificity values.

KEY RESULTS

According to VFS, prevalence of OD was 87%, 75.6% with impaired efficacy and 80.9% with impaired safety of swallow including 17.6% aspirations. The EAT-10 showed a ROC AUC of 0.89 for OD with an optimal cut-off at 2 (0.89 sensitivity and 0.82 specificity). The V-VST showed 0.94 sensitivity and 0.88 specificity for OD, 0.79 sensitivity and 0.75 specificity for impaired efficacy, 0.87 sensitivity and 0.81 specificity for impaired safety, and 0.91 sensitivity and 0.28 specificity for aspirations.

CONCLUSIONS & INFERENCES

Clinical methods for screening (EAT-10) and assessment (V-VST) of OD offer excellent psychometric proprieties that allow adequate management of OD. Their universal application among at-risk populations will improve the identification of patients with OD at risk for malnutrition and aspiration pneumonia.

Psychometric properties of questionnaires on functional health status in oropharyngeal dysphagia: a systematic literature review

INTRODUCTION

Questionnaires on Functional Health Status (FHS) are part of the assessment of oropharyngeal dysphagia.

OBJECTIVE

To conduct a systematic review of the literature on the psychometric properties of English-language FHS questionnaires in adults with oropharyngeal dysphagia.

METHODS

A systematic search was performed using the electronic databases Pubmed and Embase. The psychometric properties of the questionnaires were determined based on the COSMIN taxonomy of measurement properties and definitions for health-related patient-reported outcomes and the COSMIN checklist using preset psychometric criteria.

RESULTS

Three questionnaires were included: the Eating Assessment Tool (EAT-10), the Swallowing Outcome after Laryngectomy (SOAL), and the Self-report Symptom Inventory. The Sydney Swallow Questionnaire (SSQ) proved to be identical to the Modified Self-report Symptom Inventory. All FHS questionnaires obtained poor overall methodological quality scores for most measurement properties.

CONCLUSIONS

The retrieved FHS questionnaires need psychometric reevaluation; if the overall methodological quality shows satisfactory improvement on most measurement properties, the use of the questionnaires in daily clinic and research can be justified. However, in case of insufficient validity and/or reliability scores, new FHS questionnaires need to be developed using and reporting on preestablished psychometric criteria as recommended in literature.