[Age-related changes in swallowing. Physiology and pathophysiology]

Degree of swallowing impairment in the elderly: clinical and instrumental assessment

OBJECTIVE

To classifying the degree of swallowing impairment in the elderly, comparing clinical and instrumental assessment.

METHODS

This is a cross-sectional study with quantitative and qualitative analysis of clinical and instrumental assessment of 37 elderly, aged 60-82 years, of both genders without neurological, oncological or systemic diseases, participated in this study. All participants were submitted to clinical evaluation and their results compared through fiberoptic endoscopic evaluation of swallowing considering liquid, pudding and solid food consistencies. Data were analyzed descriptively and statistically using the analysis of variance test (two-way ANOVA) and Tukey's post hoc test (p <  0.05).

RESULTS

In the clinical evaluation there was a higher occurrence of moderate swallowing impairment, followed by functional swallowing, while in fiberoptic endoscopic evaluation of swallowing the severity of the impairment was greater for moderate and mild degrees. There was no statistical difference between the clinical and instrumental evaluation methods. However, there was a significant interaction between the variables, with a difference for liquid consistency in the instrumental evaluation method.

CONCLUSION

Healthy elderly have different degree of swallowing impairment according to food consistency. The clinical assessment using a scale that considers the physiological changes of the elderly, presented results similar to those found in the instrumental examination.

LEVEL OF EVIDENCE: 2

Comparison of Two Types of Electrodes for Measuring Submental Muscle Activity During Swallowing

PURPOSE

This study aimed to investigate the potential of a newly developed small electrode to accurately record muscle activity during swallowing.

MATERIAL AND METHODS

This study included 31 healthy participants. The participants underwent swallowing trials with three types of material. The recordings involved the following conditions: 1) swallowing saliva, 2) swallowing 3 mL water, and 3) swallowing 5 mL water. Two types of electrodes, a conventional electrode (CE) and a newly developed small electrode (NE), were symmetrically positioned on the skin over the suprahyoid muscle group, starting from the center. From the surface electromyography data, the swallowing duration (s), peak amplitude, and rising time (duration from swallowing onset to peak amplitude: s) were measured. Additionally, the equivalence of characteristics of the waveform of muscle activities was calculated by using the variance in both the upper and lower confidence limits in duration and rising time.

RESULTS

No significant differences in baseline, swallowing duration or rising time between the CE and NE were observed for any swallowing material. The peak amplitude was significantly higher for the NE than for the CE for all swallowing materials. The CE and NE displayed no significant difference in the equivalence of characteristics of the waveform of muscle activities for any swallowing material.

CONCLUSIONS

The gold-plated small electrodes utilized in this study indicated the ability to record the same characteristics of muscle activity as conventional electrodes. Moreover, it was able to capture the muscle activity of each muscle group with improved sensitivity in a narrow area, such as under the submandibular region, with more precision than that of conventional electrodes.

Food Processing and Nutrition Strategies for Improving the Health of Elderly People with Dysphagia: A Review of Recent Developments

Dysphagia, or swallowing difficulty, is a common morbidity affecting 10% to 33% of the elderly population. Individuals with dysphagia can experience appetite, reduction, weight loss, and malnutrition as well as even aspiration, dehydration, and long-term healthcare issues. However, current therapies to treat dysphagia can routinely cause discomfort and pain to patients. To prevent these risks, a non-traumatic and effective treatment of diet modification for safe chewing and swallowing is urgently needed for the elderly. This review mainly summarizes the chewing and swallowing changes in the elderly, as well as important risk factors and potential consequences of dysphagia. In addition, three texture-modified food processing strategies to prepare special foods for the aged, as well as the current statuses and future trends of such foods, are discussed. Nonthermal food technologies, gelation, and 3D printing techniques have been developed to prepare soft, moist, and palatable texture-modified foods for chewing and swallowing safety in elderly individuals. In addition, flavor enhancement and nutrition enrichment are also considered to compensate for the loss of sensory experience and nutrients. Given the trend of population aging, multidisciplinary cooperation for dysphagia management should be a top priority.

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.

Association between Dysphagia and Frailty in Older Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Increasing bodies of epidemiological evidence indicate potential associations between dysphagia and the risk of frailty in older adults. We hypothesized that older adults with symptoms of dysphagia might have a higher prevalence of frailty or prefrailty than those without dysphagia.

METHODS

We systematically searched the PubMed, Embase, and Cochrane Library databases for relevant studies published through 20 April 2022. Cross-sectional and longitudinal studies that examined the associations between dysphagia and the existence of frailty or prefrailty in community-dwelling, facility-dwelling, or hospitalized adults aged 50 years or older were synthesized. The Newcastle-Ottawa Scale was used to evaluate study quality.

RESULTS

The meta-analysis comprised 12 cohorts, including 5,503,543 non-frailty participants and 735,303 cases of frailty or prefrailty. Random-effect meta-analysis demonstrated a significant association between dysphagia and the risk of frailty and prefrailty (OR, 3.24; 95% CI, 2.51-4.20). In addition, we observed consistent results across the subgroups and heterogeneity assessments.

CONCLUSIONS

We propose including dysphagia assessment as a critical factor in the cumulative deficit model for identifying frailty in older adults. Understanding dysphagia and the potential role of nutritional supplements in older adults may lead to improved strategies for preventing, delaying, or mitigating frailty.

Age-related changes in oral sensitivity, taste and smell

Oropharyngeal sensitivity plays a vital role in the initiation of the swallowing reflex and is thought to decline as part of the aging-process. Taste and smell functions appear to decline with age as well. The aim of our study was to generate data of oral sensitivity in healthy participants for future studies and to analyse age-related changes and their interdependence by measuring oral sensitivity, taste, and smell function. The experiment involved 30 participants younger than and 30 participants older than 60. Sensitivity threshold as a surrogate of oral sensitivity was measured at the anterior faucial pillar by electrical stimulation using commercially available pudendal electrode mounted on a gloved finger. Smell and taste were evaluated using commercially available test kits. Mean sensitivity was lower in young participants compared to older participants (1.9 ± 0.59 mA vs. 2.42 ± 1.03 mA; p = 0.021). Young participants also performed better in smell (Score 11.13 ± 0.86 vs 9.3 ± 1.93; p < 0.001) and taste examinations (Score 11.83 ± 1.86 vs 8.53 ± 3.18; p < 0.001). ANCOVA revealed a statistical association between sensitivity and smell (p = 0.08) that was moderated by age (p = 0.044). Electrical threshold testing at the anterior faucial pillar is a simple, safe, and accurate diagnostic measure of oral sensitivity. We detected a decline of oral sensitivity, taste, and smell in older adults.Trial registration: Clinicaltrials.gov, NCT03240965. Registered 7th August 2017- https://clinicaltrials.gov/ct2/show/NCT03240965 .

A risk prediction model for dysphagia in older patients: a single-center prospective study

Surveys based on western populations have identified many risk factors for dysphagia in older people, but the potential risk factors consistent with the demographic characteristics of older, hospitalized Chinese patients require further study. This single-center prospective study aimed to determine the incidence of dysphagia in western China, and to develop and validate a model to predict the risk of dysphagia among older patients. A total of 343 inpatients (aged ≥ 65 years without dysphagia and cognitive impairment) were included. A score ≥ 2 on the Eating Assessment Tool-10 was defined as dysphagia. After a six-month follow-up, 70 (20.4%) patients were found to have dysphagia. The final model included age, wearing dentures, activities of daily living, cerebral vascular disease, coronary heart disease, and malignancy. The developed model has high predictive accuracy and can be easily implemented in daily practice.

Oropharyngeal dysphagia in elderly persons: Etiology, pathophysiology and symptomatology

Swallowing disorders can occur at any age, although they occur more often in old age when the physiology of swallowing changes due to aging. Oropharyngeal dysphagia is a very common clinical condition affecting 13% of the total population over 65 years of age and 51% of institutionalized older people. Given that oropharyngeal dysphagia can lead to increased morbidity and mortality in the elderly, it is necessary to prevent the occurrence of dysphagia in this population group as much as possible. In relation to this, the paper aims to provide insight into contemporary research into the etiology, pathophysiology, and symptomatology of oropharyngeal dysphagia in the elderly. In this review study, the electronic databases of Google Scholar Advanced Search and the Consortium of Serbian Libraries for Unified Procurement - KoBSON were searched. The following keywords and phrases were used in the search: swallowing, dysphagia, oropharyngeal dysphagia, aging, age and dysphagia, etiology of oropharyngeal dysphagia, the clinical picture of oropharyngeal dysphagia, pathophysiology of oropharyngeal dysphagia. This systematic review and meta-analysis of papers showed significant progress in the effective diagnostic approach of oropharyngeal dysphagia during the last years but also a significant lack of knowledge about adequate modifications of drugs applied during the treatment of patients with dysphagia. A good understanding of the etiology, pathophysiology, and symptomatology of oropharyngeal dysphagia would eliminate the harmful effects of pharmacological substances on the function of swallowing, given that the elderly, on the advice of a doctor, use them daily.

[Dysphagia - from Pathophysiology to Treatment]

More than 5 million persons in Germany suffer from swallowing disorders (dysphagia), predominantly oropharyngeal dysphagia. Due to the demographic changes in our population, the prevalence rates are expected to increase. Multiple conditions may be the cause of dysphagia and dysphagia may lead to various symptoms. Esophageal dysphagia is predominantly accompanied by regurgitation, vomiting, pain and foreign body sensation in the esophageal region. Oropharyngeal dysphagia is characterized by cough, hawking and airway disease. In some patients with oropharyngeal dysphagia, symptoms may be completely absent or are not attributed to dysphagia. Both forms of dysphagia are regularly accompanied by difficulties with nutritional intake and consecutive malnutrition. Therefore, the diagnostic and therapy of dysphagia should always be accompanied by nutritional support.

Evaluation of Oropharyngeal Dysphagia in Elderly Patients with Pharyngeal Aberrant Internal Carotid Artery Using the Eating Assessment Tool-10 (EAT-10)

Pharyngeal aberrant internal carotid artery (PAICA) has been reported to be a cause of oropharyngeal dysphagia (OD) in case reports. However, as there have been no clinical studies, the relationship between PAICA and OD is not clear. The aim of this study was to investigate the perception of OD in elderly PAICA patients using the Eating Assessment Tool-10 (EAT-10). A study group (Group 1) was formed of patients diagnosed with PAICA from the visualization of a pulsatile mass in the pharynx in flexible fiberoptic endoscopic examination and carotid magnetic resonance angiography tests, and a control group (Group 2) was formed of age-matched healthy volunteers. The study group was subdivided as patients with unilateral PAICA (Group 1a) and patients with bilateral PAICA (Group 1b). The Turkish version of the EAT-10 was applied to all the participants. Total EAT-10 points of ≥ 3 were accepted as abnormal. Normal (< 3) and abnormal (≥ 3) total EAT-10 points were determined in 88.9% (24/27) and 11.1% (3/27), respectively, of the control group, in 55.2% (16/29) and 44.8% (13/29) of Group 1, in 70.6% (12/17) and 29.4% (5/17) of Group 1a, and in 33.3% (4/12) and 66.7% (8/12) of Group 1b. A statistically significant difference was determined between the control group and Group 1 and Group 1b in respect of abnormal (≥ 3) EAT-10 total points (p = 0.007, p = 0.001, respectively). No statistically significant difference was determined between the control group and Group 1a (p = 0.227). Problems (EAT point ≥ 1) in item 4 (swallowing solids takes extra effort) were experienced by 13 (44.8%) patients in Group 1, 9 (75%) patients in Group 1b, and 5 (18.5%) subjects in the control group (p < 0.05). These results demonstrated that unilateral PAICA does not significantly affect swallowing, whereas bilateral PAICA created a significant negative effect. These patients experience more problems when swallowing solid food.

Supracricoid laryngectomy: the impact of senescence on swallowing safety

Objective:

To investigate the association between aging and the functional aspects of swallowing (laryngeal penetration and laryngotracheal aspiration) in individuals who underwent supracricoid laryngectomy in the late period and without complaints.

Methods:

A total of 70 patients, 56 (80%) aged >60 years and 14 (20%) <60 years, under outpatient follow-up, after cancer treatment and with no complaints of swallowing, performed functional evaluation using the swallowing videofluoroscopy. Image classification was performed using the penetration-aspiration scale developed by Rosenbek. The χ² test and logistic regression were applied to associate the age categories to the outcomes (penetration and aspiration).

Results:

Patients aged over 60 years had a higher prevalence of penetration (24.29%) and aspiration (48.57%) than patients aged under 60 years. In this sample, aspiration was associated with age. Patients aged over 60 years were more likely to present penetration (27% more) during swallowing than patients under 60 years. Patients aged over 60 years had an approximately four-fold greater probability of laryngotracheal aspiration than patients aged under 60 years.

Conclusion:

In patients without complaints of swallowing in the late postoperative period of supracricoid laryngectomy, there is a greater probability of laryngotracheal aspiration in elderly aged over 60 years than in individuals under 60 years.

Effect of Capsaicinoids on Neurophysiological, Biochemical, and Mechanical Parameters of Swallowing Function

Oropharyngeal dysphagia is prevalent in age-related neurological disorders presenting with impaired efficacy and safety of swallowing due to a loss of muscle force and sensory deficits. Stimulating the oropharynx with capsaicin that mediates Substance P release is an emerging pharmacological treatment option which needs further scientific evidence. Our aim was to comprehensively evaluate the effect of capsaicin on biochemical, neurophysiological, and biomechanical parameters of swallowing function. In a randomized study on healthy individuals, the impact of orally administered capsaicinoids at different dosages and application durations in comparison to non-carbonated water was evaluated. Time course and magnitude of salivary Substance P increase were monitored. Magnetoencephalography was used to detect cortical swallowing network alterations. Modifications in swallowing biomechanics were measured applying high-resolution pharyngeal manometry. Capsaicinoids at 10 μmol/L improved swallowing efficacy as seen by a significant increase of pharyngeal contractile integral and upper esophageal sphincter activation and relaxation times in manometry. Significant improvement of precision in a challenging swallow task accompanied by a reduction in swallowing-related submental electromyographic power was observed with capsaicinoids preconditioning at 10 μmol/L over 5 min, but not with continuous stimulation. The cortical activation pattern remained unchanged after any intervention. A significant increase of salivary Substance P was not detected with 10 μmol/L but with 50 μmol/L and lasted for 15 min after application. Capsaicinoids mediate dose-dependent Substance P release and positively alter swallowing biomechanics in healthy subjects. The results provide supportive evidence for the value of natural capsaicinoids to improve swallowing function.

Predictors of Pharyngeal Dysphagia in Patients with Parkinson's Disease

BACKGROUND

Diagnosis of pharyngeal dysphagia in patients with Parkinson's disease is often difficult as reliable screening methods are lacking so far and clinical examination fails to adequately assess the pharyngeal phase of swallowing.

OBJECTIVE

To identify clinical predictors indicating the presence of pharyngeal dysphagia in patients at risk.

METHODS

We examined pharyngeal dysphagia in a large cohort of patients with Parkinson's disease (n = 200) divided in three clinical subtypes (tremor-dominant (TD), mainly bradykinetic (BK) and early postural instability and gait difficulty PIGD)) by using flexible endoscopic evaluation of swallowing. ANOVA-multivariance analysis and following t-tests as well as binary logistic regression analysis were performed to detect group differences and to identify clinical predictors for dysphagia.

RESULTS

Statistically significant differences were found in the dysphagic group: age, male gender, disease duration, stage of the disease, Levodopa equivalent dose and higher scores on the Unified Parkinson's disease rating scale III and II, item 7. The PIGD subtype was affected more frequently than the TD and BK subtype. In a logistic regression model higher age (>63.5 years p < 0.05) and Levodopa equivalent dose (>475 mg, p < 0.01) were identified to be independent predictors for the presence of pharyngeal dysphagia.

CONCLUSION

Particularly patients with an age > 63.5 years and a daily Levodopa equivalent dose >475 mg show an increased risk for pharyngeal dysphagia. These findings may partly be influenced by presbyphagia but are likely to represent disease progression. The PIGD subtype seems to be a risk factor due to more pronounced dyscoordination of oropharyngeal muscle movements.

Comfort and clinical events at the end of life of nursing home residents with and without dementia: The six-country epidemiological PACE study

OBJECTIVES

We aimed to investigate the occurrence rates of clinical events and their associations with comfort in dying nursing home residents with and without dementia.

METHODS

Epidemiological after-death survey was performed in nationwide representative samples of 322 nursing homes in Belgium, Finland, Italy, the Netherlands, Poland, and England. Nursing staff reported clinical events and assessed comfort. The nursing staff or physician assessed the presence of dementia; severity was determined using two highly discriminatory staff-reported instruments.

RESULTS

The sample comprised 401 residents with advanced dementia, 377 with other stages of dementia, and 419 without dementia (N = 1197). Across the three groups, pneumonia occurred in 24 to 27% of residents. Febrile episodes (unrelated to pneumonia) occurred in 39% of residents with advanced dementia, 34% in residents with other stages of dementia and 28% in residents without dementia (P = .03). Intake problems occurred in 74% of residents with advanced dementia, 55% in residents with other stages of dementia, and 48% in residents without dementia (P < .001). Overall, these three clinical events were inversely associated with comfort. Less comfort was observed in all resident groups who had pneumonia (advanced dementia, P = .04; other stages of dementia, P = .04; without dementia, P < .001). Among residents with intake problems, less comfort was observed only in those with other stages of dementia (P < .001) and without dementia (P = .003), while the presence and severity of dementia moderated this association (P = .03). Developing "other clinical events" was not associated with comfort.

CONCLUSIONS

Discomfort was observed in dying residents who developed major clinical events, especially pneumonia, which was not specific to advanced dementia. It is crucial to identify and address the clinical events potentially associated with discomfort in dying residents with and without dementia.

Entwicklung eines neuen Screeninginstruments zum Screening auf Dysphagie bei geriatrischen Patienten: das Dysphagie Screening-Tool Geriatrie

Hintergrund

Die oropharyngeale Dysphagie ist bei geriatrischen Patienten weit verbreitet und fast immer multikausal bedingt. Sie führt zu schwerwiegenden Komplikationen und wird oft unzureichend detektiert. Alle bekannten und etablierten Screeningmaßnahmen fokussieren sich auf Patienten mit neurologischer Grunderkrankung, insbesondere nach Schlaganfall.

Material und Methoden

In der Arbeitsgruppe „Dysphagie“ der Deutschen Gesellschaft für Geriatrie (DGG), in der Ärzte, Logopäden und Schlucktherapeuten zusammengeschlossenen sind, erfolgte eine selektive Literaturrecherche zum Dysphagiescreening. Basierend auf Ergebnissen der Literaturrecherche und eigenen Erfahrungen wurde durch eine Konsensgruppe ein neues Screeninginstrument für geriatrische Patienten entwickelt und konsentiert.

Ergebnisse

Das Screeninginstrument zur Erfassung einer oropharyngealen Dysphagie bei geriatrischen Patienten gliedert sich in 3 Teile: 1. Vigilanz und Sitzposition, 2. Speichelschluck, Zungenbeweglichkeit und Hustenstoß sowie 3. Wasserschlucktest. Das Screeninginstrument kann durch geschultes medizinisches Personal angewendet werden und ist einfach in den Arbeitsalltag zu integrieren.

Diskussion

Das neu entwickelte Screeninginstrument ist speziell für die Anwendung bei geriatrischen Patienten vorgesehen. Es hat Vorteile gegenüber bisher empfohlenen Screeningtests. Bisherige Erfahrungen zeigen eine gute Praktikabilität und Akzeptanz im geriatrischen Team. Weitere Studien müssen die Validität des Instruments prüfen.

Interventions for oropharyngeal dysphagia in acute and critical care: a protocol for a systematic review and meta-analysis

BACKGROUND

Oropharyngeal dysphagia or swallowing difficulties are common in acute care and critical care, affecting 47% of hospitalised frail elderly, 50% of acute stroke patients and approximately 62% of critically ill patients who have been intubated and mechanically ventilated for prolonged periods. Complications of dysphagia include aspiration leading to chest infection and pneumonia, malnutrition, increased length of hospital stay and re-admission to hospital. To date, most dysphagia interventions in acute care have been tested with acute stroke populations. While intervention studies in critical care have been emerging since 2015, they are limited and so there is much to learn about the type, the delivery and the intensity of treatments in this setting to inform future clinical trials. The aim of this systematic review is to summarise the evidence regarding the relationship between dysphagia interventions and clinically important patient outcomes in acute and critical care settings.

METHODS

We will search MEDLINE, EMBASE, CENTRAL, Web of Science, CINAHL and clinical trial registries from inception to the present. We will include studies conducted with adults in acute care settings such as acute hospital wards or units or intensive care units and critical care settings. Studies will be restricted to randomised controlled trials and quasi-randomised controlled trials comparing a new dysphagia intervention with usual care or another intervention. The main outcomes that will be collected include length of time taken to return to oral intake, change in incidence of aspiration and pneumonia, nutritional status, length of hospital stay and quality of life. Key intervention components such as delivery, intensity, acceptability, fidelity and adverse events associated with such interventions will be collected to inform future clinical trials. Two independent reviewers will assess articles for eligibility, data extraction and quality appraisal. A meta-analysis will be conducted as appropriate.

DISCUSSION

No systematic review has attempted to summarise the evidence for oropharyngeal dysphagia interventions in acute and critical care. Results of the proposed systematic review will inform practice and the design of future clinical trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD 42018116849 (http://www.crd.york.ac.uk/PROSPERO/).

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".

[Swallowing in the elderly : Physiological changes, dysphagia, diagnostics and treatment]

Increasing age leads to a number of physiological as well as disease-related pathological changes that among others also affect structures involved in swallowing. These changes not only increase the risk of developing dysphagia but as a result can lead to pneumonia, malnutrition, exsiccosis, a relevant impairment of the quality of life and increased mortality. To evaluate the nature and extent of dysphagia, clinical swallowing tests as well as instrumental approaches, such as the endoscopic evaluation of swallowing are available. Depending on the findings from these examinations, the underlying disease and estimation of the individual patient prognosis, several treatment approaches ranging from diet adaptation, logopedic exercises and compensatory maneuvers up to tube feeding are available. The optimal treatment requires close cooperation of all disciplines involved.

Association between Dysphagia and Frailty in Community Dwelling Older Adults

OBJECTIVES

Dysphagia is described as a geriatric syndrome that occurs more frequently with aging. It is associated with the deterioration in functionality however, it is usually ignored. Frailty is a geriatric syndrome that is recognized more with its well-known adverse consequences. Very recently, dysphagia has been suggested to accompany frailty in older adults. We aimed to investigate the association between dysphagia and frailty in the community dwelling older adults.

DESIGN

Prospective, cross-sectional study.

SETTING

Geriatric outpatient clinic.

PARTICIPANTS

Older adults aged ≥60 years.

MEASUREMENTS

Dysphagia was evaluated by EAT-10 questionnaire and frailty by FRAIL scale. Handgrip strength (HGS) was evaluated by hand-dynamometer. Gait speed was evaluated by 4-meter usual gait speed (UGS). Nutritional status was assessed by mini-nutritional assessment-short form (MNA-SF).

RESULTS

1138 patients were enrolled. Mean age was 74.1±7.3 years. EAT-10 questionnaire was answered by all and FRAIL-scale by 851 subjects. EAT-10 score >15 points was regarded as significant dysphagia risk. The participants with EAT-10>15 points were older when compared to the participants with EAT-10<=15 points (p=0.002). Among participants with EAT-10>15 points, women gender and neurodegenerative diseases were more prevalent (p=0.04, p=0.002; respectively); number of chronic diseases, number of drugs and FRAIL score were higher (p=0.001 for each), and HGS, UGS, MNA-SF scores were lower (p=0.002, p=0.01, p<0.001; respectively). In multivariate analyses, the factors independently associated with presence of EAT-10 score>15 were FRAIL score and the number of drugs.

CONCLUSION

Dysphagia is associated with frailty irrespective to age, presence of neurodegenerative diseases, number of chronic diseases and drugs. To our knowledge, this is the largest serie in the literature providing data on independent association of dysphagia with frailty.

The Effect of Improved Dysphagia Care on Outcome in Patients with Acute Stroke: Trends from 8-Year Data of a Large Stroke Register

BACKGROUND

Early dysphagia screening and appropriate management are recommended by current guidelines to reduce complications and case fatality in acute stroke. However, data on the potential benefit of changes in dysphagia care on patient outcome are limited. Our objective was to assess the degree of implementation of dysphagia guidelines and determine the impact of modifications in dysphagia screening and treatment practices on disease complications and outcome in stroke patients over time.

METHODS

In this prospective register-based study ("Stroke Register of Northwestern Germany"), all adult stroke patients admitted to 157 participating hospitals between January, 2008 and December, 2015 were included (n = 674,423). Dysphagia incidence upon admission, the proportion of patients receiving a standardized swallowing screening, and the percentage of dysphagic patients being referred to a speech language therapist (SLT) for treatment were obtained per year. Pneumonia rate, modified Rankin Scale (mRS) at discharge, and in-hospital mortality were compared between groups of dysphagic vs. non-dysphagic patients over time.

RESULTS

Screening proportions continuously increased from 47.2% in 2008 to 86.6% in 2015. But the proportion diagnosed with dysphagia remained stable with about 19%. The number of dysphagic patients receiving SLT treatment grew from 81.6 up to 87.0%. Pneumonia incidence was higher in dysphagic stroke cases (adjusted OR 5.4 [5.2-5.5], p < 0.001), accompanied by a worse mRS at discharge (adjusted OR for mRS ≥3: 3.1 [3.0-3.1], p < 0.001) and higher mortality (adjusted OR 3.1 [3.0-3.2], p < 0.001). The order of magnitude of these end points did not change over time.

CONCLUSION

Although advances have been made in dysphagia care, prevalent screening and treatment practices remain insufficient to reduce pneumonia rate, improve functional outcome, and decrease case fatality in dysphagic stroke patients. More research is urgently needed to develop more effective swallowing therapies.

What is the value of fibre-endoscopic evaluation of swallowing (FEES) in neurological patients? A cross-sectional hospital-based registry study

OBJECTIVES

Fibre-endoscopic evaluation of swallowing (FEES) to detect dysphagia is gaining more and more importance as a diagnostic tool. Therefore, we have investigated the impact of FEES in neurological patients in a clinical setting.

DESIGN

Cross-sectional hospital-based registry.

SETTING

Primary acute care in a neurological department of a German university hospital.

PARTICIPANTS

241patients with various neurological diseases who underwent FEES procedure.

PRIMARY AND SECONDARY OUTCOME MEASURES

Dysphagia and related comorbidities.

RESULTS

267 FEES were performed in 241 patients with various neurological diagnoses. Dysphagia was diagnosed in 68.9% of the patients. In only 33.1% of the patients, appropriate oral diet was chosen prior to FEES. A relevant dysphagia occurred more often in patients with structural brain lesions (83.1% vs 65.3%, P=0.001), patients with dysphagia had a longer hospitalisation (median 18 (IQR 12-30) vs 15 days (IQR 9.75-22.75), P=0.005) and had a higher mortality (8.4% vs 1.3%, P=0.041). When the oral diet was changed, we observed a lower pneumonia rate (36% vs 50%, P=0.051) and a lower mortality (3.7% vs 11.3%, P=0.043) in comparison to no change of oral diet. A restriction of oral diet was identified more often in older patients (median 75 years (IQR 66.3-82 years) vs median 72 years (IQR 60-79 years), P=0.01) and in patients with structural brain lesions (86.8% vs 73.1%, P=0.05).

CONCLUSION

On clinical investigation, dysphagia was misjudged for the majority of the patients. FEES might help to compensate this drawback, revising the diet regime in nearly 70% of the patients.

Calf circumference is associated with dysphagia in acute-care inpatients

The aim of the study was to determine the association between decreased muscle mass and dysphagia in older acute-care patients. A cross-sectional study was performed on 103 patients aged ≥65 years who were consecutively admitted to acute-care wards. Muscle mass and strength were evaluated by assessing calf circumference (CC) and handgrip strength, respectively. Dysphagia and swallowing difficulty were assessed using the Dysphagia Severity Scale (DSS). Univariate and multivariate analyses were used to determine whether CC was associated with dysphagia. There were 58 women and 45 men (mean age, 80 ± 8 years) with a mean CC of 28.2 ± 4.4 cm, and a mean HG of 11.8 kg. Dysphagia was observed in eight patients (8%). Based on the multivariate analysis, CC was independently associated with DSS after adjusting for possible confounders. Future studies to evaluate dysphagia in acute-care older patients with low skeletal muscle mass (i.e., sarcopenia) are required.

[Neurogenic dysphagia]

Approximately half of neurological and geriatric inpatients suffer from oropharyngeal dysphagia. This often leads to pneumonia, malnutrition and dehydration; however, the underlying dysphagia is frequently not diagnosed and treated. This is particularly the case for patients with so-called silent aspiration. Knowledge on the physiology of swallowing, including the central nervous system control of swallowing and the therapeutic options have achieved considerable progress in recent years. In particular, the increasing implementation of flexible endoscopic evaluation of swallowing (FEES) has significantly contributed to this knowledge. It provides the ability to identify the individual pattern of oropharyngeal dysphagia leading to a suitable selection of therapeutic and compensatory strategies for individual patients. The various therapeutic options range from modification of the consistency of the diet, over diverse logopedic strategies and stimulation techniques up to interventional procedures.

Tongguan Liqiao acupuncture therapy improves dysphagia after brainstem stroke

Tongguan Liqiao acupuncture therapy has been shown to effectively treat dysphagia after stroke-based pseudobulbar paralysis. We presumed that this therapy would be effective for dysphagia after bulbar paralysis in patients with brainstem infarction. Sixty-four patients with dysphagia following brainstem infarction were recruited and divided into a medulla oblongata infarction group (n = 22), a midbrain and pons infarction group (n = 16), and a multiple cerebral infarction group (n = 26) according to their magnetic resonance imaging results. All patients received Tongguan Liqiao acupuncture for 28 days. The main acupoints were Neiguan (PC6), Renzhong (DU26), Sanyinjiao (SP6), Fengchi (GB20), Wangu (GB12), and Yifeng (SJ17). Furthermore, the posterior pharyngeal wall was pricked. Before and after treatment, patient swallowing functions were evaluated with the Kubota Water Test, Fujishima Ichiro Rating Scale, and the Standard Swallowing Assessment. The Barthel Index was also used to evaluate their quality of life. Results showed that after 28 days of treatment, scores on the Kubota Water Test and Standard Swallowing Assessment had decreased, but scores on the Fujishima Ichiro Rating Scale and Barthel Index had increased in each group. The total efficacy rate was 92.2% after treatment, and was most obvious in patients with medulla oblongata infarction (95.9%). These findings suggest that Tongguan Liqiao acupuncture therapy can repair the connection of upper motor neurons to the medulla oblongata motor nucleus, promote the recovery of brainstem infarction, and improve patient's swallowing ability and quality of life.

Oropharyngeal dysphagia in older persons - from pathophysiology to adequate intervention: a review and summary of an international expert meeting

Oropharyngeal dysphagia (OD) is a highly prevalent and growing condition in the older population. Although OD may cause very severe complications, it is often not detected, explored, and treated. Older patients are frequently unaware of their swallowing dysfunction which is one of the reasons why the consequences of OD, ie, aspiration, dehydration, and malnutrition, are regularly not attributed to dysphagia. Older patients are particularly vulnerable to dysphagia because multiple age-related changes increase the risk of dysphagia. Physicians in charge of older patients should be aware that malnutrition, dehydration, and pneumonia are frequently caused by (unrecognized) dysphagia. The diagnosis is particularly difficult in the case of silent aspiration. In addition to numerous screening tools, videofluoroscopy was the traditional gold standard of diagnosing OD. Recently, the fiberoptic endoscopic evaluation of swallowing is increasingly utilized because it has several advantages. Besides making a diagnosis, fiberoptic endoscopic evaluation of swallowing is applied to evaluate the effectiveness of therapeutic maneuvers and texture modification of food and liquids. In addition to swallowing training and nutritional interventions, newer rehabilitation approaches of stimulation techniques are showing promise and may significantly impact future treatment strategies.