Rehabilitative management of oropharyngeal dysphagia in acute care settings: data from a large Italian teaching hospital

Comprehensive assessment and treatment strategies for dysphagia in the elderly population: Current status and prospects

As the population ages, the prevalence of dysphagia among older adults is a growing concern. Age-related declines in physiological function, coupled with neurological disorders and structural changes in the pharynx associated with aging, can result in weakened tongue propulsion, a prolonged reaction time of the submental muscles, delayed closure of the laryngeal vestibule, and delayed opening of the upper esophageal sphincter (UES), increasing the risk of dysphagia. Dysphagia impacts the physical health of the elderly, leading to serious complications such as dehydration, aspiration pneumonia, malnutrition, and even life-threatening conditions, and it also detrimentally affects their psychological and social well-being. There is a significant correlation between frailty, sarcopenia, and dysphagia in the elderly population. Therefore, older adults should be screened for dysphagia to identify both frailty and sarcopenia. A reasonable diagnostic approach for dysphagia involves screening, clinical assessment, and instrumental diagnosis. In terms of treatment, multidisciplinary collaboration, rehabilitation training, and the utilization of new technologies are essential. Future research will continue to concentrate on these areas to enhance the diagnosis and treatment of dysphagia, with the ultimate aim of enhancing the quality of life of the elderly population.

The role of the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke (GLOBE-3S) in the prevention of stroke-associated pneumonia (SAP)

Background and purpose

Stroke-associated pneumonia (SAP) affects 10 to 38% of patients in the acute phase of stroke. Stroke patients diagnosed with dysphagia have an 11-fold higher risk of developing SAP. Thus, identifying dysphagic patients through a highly accurate screening tool might be crucial in reducing the incidence of SAP. We present a case–control study designed to evaluate efficacy in reducing the risk of SAP between two swallowing screening tools, the classic water swallow test (WST) and a recently validated tool such as the GLOBE-3S (the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke), which is a highly sensitive swallowing screening tool particularly accurate in detecting silent aspiration as well.

Methods

We analyzed the occurrence of dysphagia in 100 acute stroke patients distributed in two groups: half were screened with WST and the other half with GLOBE-3S.

Results

Dysphagia was diagnosed in 28 patients. The main result is that, among patients who passed the dysphagia screenings, none of those screened with the GLOBE-3S method developed pneumonia compared to 31.82% in the WST group. Discriminant function analysis (DFA) showed that NIH Stroke Scale (NIHSS) score and the dysphagia screening method (i.e., GLOBE-3S vs. WST) were the two main factors in the SAP’s predicting model and the only significant ones per se.

Conclusions

The new GLOBE-3S screening test can reduce the risk of SAP compared to WST.

Screening dysphagia risk in 534 older patients undergoing rehabilitation after total joint replacement: a cross-sectional study

BACKGROUND

Older people affected by severe osteoarthritis could need to undergo total joint replacement, with a consequent hospitalization and rehabilitation. In this postacute phase, they might suffer from other symptoms, including dysphagia, defined as a dysfunction of the digestive system, characterized by an objective difficulty or a sensation of difficulty in swallowing. It is considered as a very challenging problem in older people and early detection is fundamental for a prompt and effective management. However, up to date, there is a lack of data on dysphagia risk screening in orthopedic rehabilitation inpatients.

AIM

The aim of this study was to evaluate dysphagia risk through Eating Assessment Tool (EAT-10) in older people undergoing rehabilitation after total hip or knee arthroplasty.

DESIGN

Cross-sectional study.

SETTING

Rehabilitation Unit.

POPULATION

All consecutive patients undergone total hip or knee arthroplasty, aged ≥65 years, referring to Orthopedics Rehabilitation Unit "Mons. Luigi Novarese" Hospital, Moncrivello, Italy, for a 24-month period (from 1^st January 2018 to 31^st December 2019). We excluded patients with: 1) diagnosis of neurological diseases; 2) pharyngeal or esophageal cancer; 3) maxillofacial cancer; 4) tracheotomy.

METHODS

Dysphagia risk was assessed through EAT-10. The cohort was divided into two groups, according to water swallowing test (WST), in order to evaluate differences in terms of different EAT-10 scores. Furthermore, based on pathological WST, we have stratified study participants by the American Speech-Language-Hearing Association (ASHA)'s National Outcomes Measurement System (NOMS) swallowing scale in order to evaluate differences in terms of the different EAT-10 scores.

RESULTS

We included 534 participants (180 men, 357 women), mean aged 74.8±5.6 years. Thirty-one patients (5.8%) had pathological WST and 34 (6.4%) reported EAT-10 ≥3. There were significant differences (P<0.001) between groups (pathological WST vs. normal WST) in terms of all EAT-10 total scores. EAT-10 reported a high specificity (96.8% if ≥3 and 98.4% if ≥4), but a low sensitivity (58.1% if ≥3 and 54.8% if ≥4).

CONCLUSIONS

EAT-10 might be considered as useful screening tools for dysphagia in older people, considering the high specificity of EAT-10≥4.

CLINICAL REHABILITATION IMPACT

Screening dysphagia risk should be recommended also in patients undergoing rehabilitation in order to set up an early diagnosis and management.

Dysphagia screening in subacute care settings using the Italian version of the Royal Brisbane and Women's Hospital (I-RBWH) dysphagia screening tool

The large majority of the available dysphagia screening tools has been developed for the stroke population. Only few screening tools are suitable for heterogeneous groups of patients admitted to a subacute care unit. The Royal Brisbane and Women's Hospital (RBWH) dysphagia screening tool is a nurse-administered, evidence-based swallow screening tool for generic acute hospital use that demonstrates excellent sensitivity and specificity. No Italian version of this tool is available to date. The aim of this study was to determine the reliability and screening accuracy of the Italian version of the RBWH (I-RBWH) dysphagia screening tool. A total of 105 patients consecutively admitted to a subacute care unit were enrolled. Using the I-RBWH tool, each patient was evaluated twice by trained nurses and once by a speech and language pathologist (SLP) blind to nurses' scores. The SLP also performed standardised clinical assessment of swallowing using the Mann assessment of swallowing ability (MASA). During the first and the second administration of the I-RBWH by nurses, 28 and 27 patients, respectively, were considered at risk of dysphagia, and 27 were considered at risk after SLP assessment. Intra- and inter-rater reliability was satisfactory. Comparison between nurse I-RBWH scores and MASA examination demonstrated a sensitivity and specificity of the I-RBWH dysphagia screening tool up to 93% and 96%, respectively; the positive and negative predictive values were 90% and 97%, respectively. Thus, the current findings support the reliability and accuracy of the I-RBWH tool for dysphagia screening of patients in subacute settings. Its application in clinical practice is recommended.

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.

Dysphagia in the elderly: focus on rehabilitation strategies

Prevalence of oropharyngeal dysphagia among the elderly is high, but underestimated and underdiagnosed. It may give raise to relevant complications impacting on morbidity, hospital length of stay and health care costs. Dysphagia evaluation and management is a multidisciplinary task; it includes a detailed history taking, clinical and instrumental exams, and identification of the risk of aspiration. Long-standing individual abilities and impairments determine the goals of an ad hoc rehabilitation program. Currently there are no standard algorithmic approaches for the management of dysphagia in the elderly. Education of health professionals on early diagnosis and improvement of therapeutic strategies are mainstays to allow maximal recovery potential in this population. This narrative review summarizes the current rehabilitation approaches for dysphagia in the elderly. The aim is to inform the treating health care professionals, whether caring physician, physical medicine doctor, speech/swallowing therapist or nurse, on the state-of-the-art and stimulate discussion in the scientific community.

Swallowing rehabilitation of dysphagic tracheostomized patients under mechanical ventilation in intensive care units: a feasibility study

Objective

The aim of the present study was to assess the feasibility of the early implementation of a swallowing rehabilitation program in tracheostomized patients under mechanical ventilation with dysphagia.

Methods

This prospective study was conducted in the intensive care units of a university hospital. We included hemodynamically stable patients under mechanical ventilation for at least 48 hours following 48 hours of tracheostomy and with an appropriate level of consciousness. The exclusion criteria were previous surgery in the oral cavity, pharynx, larynx and/or esophagus, the presence of degenerative diseases or a past history of oropharyngeal dysphagia. All patients were submitted to a swallowing rehabilitation program. An oropharyngeal structural score, a swallowing functional score and an otorhinolaryngological structural and functional score were determined before and after swallowing therapy.

Results

We included 14 patients. The mean duration of the rehabilitation program was 12.4 ± 9.4 days, with 5.0 ± 5.2 days under mechanical ventilation. Eleven patients could receive oral feeding while still in the intensive care unit after 4 (2 - 13) days of therapy. All scores significantly improved after therapy.

Conclusion

In this small group of patients, we demonstrated that the early implementation of a swallowing rehabilitation program is feasible even in patients under mechanical ventilation.

Clinical prognostic indicators of dysphagia following prolonged orotracheal intubation in ICU patients

Introduction

The development of postextubation swallowing dysfunction is well documented in the literature with high prevalence in most studies. However, there are relatively few studies with specific outcomes that focus on the follow-up of these patients until hospital discharge. The purpose of our study was to determine prognostic indicators of dysphagia in ICU patients submitted to prolonged orotracheal intubation (OTI).

Methods

We conducted a retrospective, observational cohort study from 2010 to 2012 of all patients over 18 years of age admitted to a university hospital ICU who were submitted to prolonged OTI and subsequently received a bedside swallow evaluation (BSE) by a speech pathologist. The prognostic factors analyzed included dysphagia severity rate at the initial swallowing assessment and at hospital discharge, age, time to initiate oral feeding, amount of individual treatment, number of orotracheal intubations, intubation time and length of hospital stay.

Results

After we excluded patients with neurologic diseases, tracheostomy, esophageal dysphagia and those who were submitted to surgical procedures involving the head and neck, our study sample size was 148 patients. The logistic regression model was used to examine the relationships between independent variables. In the univariate analyses, we found that statistically significant prognostic indicators of dysphagia included dysphagia severity rate at the initial swallowing assessment, time to initiate oral feeding and amount of individual treatment. In the multivariate analysis, we found that dysphagia severity rate at the initial swallowing assessment remained associated with good treatment outcomes.

Conclusions

Studies of prognostic indicators in different populations with dysphagia can contribute to the design of more effective procedures when evaluating, treating, and monitoring individuals with this type of disorder. Additionally, this study stresses the importance of the initial assessment ratings.

Avaliação clínica da deglutição em unidade de terapia intensiva

OBJETIVO: Relatar os resultados da avaliação clínica completa da deglutição em pacientes críticos de um hospital de ensino de grande porte na cidade de São Paulo. MÉTODOS: Foi realizado um estudo prospectivo, descritivo, no período de setembro a novembro de 2009, em uma unidade de terapia intensiva de emergências clínicas de trinta leitos, de um hospital terciário de grande porte do Brasil. Foram encaminhados 35 pacientes para a avaliação fonoaudiológica clínica da deglutição. Para a avaliação clínica completa da deglutição na unidade de terapia intensiva, foram preconizados os seguintes protocolos: Protocolo de Avaliação Preliminar (PAP), Protocolo de Avaliação do Risco para Disfagia (PARD) e Protocolo de Introdução e Transição da Alimentação por Via Oral (PITA). RESULTADOS: Neste estudo, foi constatada uma prevalência de 63% de disfagia orofaríngea (DO) na UTI, sendo a maioria destas classificadas como moderada e moderada-grave (39%). Entre os pacientes encaminhados para avaliação da deglutição, 74% apresentaram intubação orotraqueal prévia. A análise estatística revelou as variáveis que poderiam classificar corretamente os pacientes como tendo ou não DO nos testes clínicos. Esses indicadores clínicos incluíram: força da tosse, coordenação pneumofonoarticulatória, gravidade da disfonia e elevação laríngea. Vinte e seis pacientes (74%) completaram todos os protocolos. Desse total, 38% retornaram à dieta regular. CONCLUSÃO: A prática com protocolos padronizados mostra-se como uma importante opção no gerenciamento da disfagia orofaríngea na unidade de terapia intensiva.

Rehabilitative management of swallowing and oral-motor movements in patients with tetanus of a public service in Brazil

When looking at developing countries, the prolonged intensive medical and nursing care required by many patients places extra demands on an already stretched healthcare budget. The purpose of this study was to verify the effectiveness of a systematic rehabilitative program for swallowing and oral-motor movements in intensive care unit patients with the diagnosis of tetanus. Forty-five patients who were clinically diagnosed with tetanus were included in the study. Participants were divided in two groups: GI - consisted of 18 tetanus patients who were consecutively admitted to the infectious disease ICU from January 2002 to December 2005, prior to the existence of a systematic swallowing and oral-motor intervention; GII - consisted of 27 tetanus patients who were consecutively admitted to the infectious disease ICU from January 2006 to December 2009 and were submitted to a specific rehabilitative management of swallowing and of the oral-motor movements. Results indicate that the proposed rehabilitative program reduced by approximately 50% the time patients remained in the ICU. The significant improvement observed in patients with tetanus who were submitted to the rehabilitative program for swallowing and oral-motor movements occurred in conjunction with a reduction in the amount of time necessary to reintroduce oral feeding, to decannulate and to remove the feeding tubes. In conclusion, swallowing/muscle exercise, in patients with severe/very severe tetanus, seem to promote the remission of muscle tension and seem to maximize functional swallowing.

Quality indicators for integrated care of dysphagia in hospital settings

This article proposes a panel of quality indicators for the management of swallowing rehabilitation (SR) therapy in a hospital setting. There were four stages in developing these indicators: identifying procedures to be managed; generating indicators and standardizing data collection; identifying the correlation among indicators; and formulating the panel of indicators. The following 12 quality indicators were developed: swallowing evaluation index; individual care index; speech-language pathologist (SLP) care index; number of assisted patients index; severity rate; swallowing diagnosis rate per hospital unit; swallowing rehabilitation demand index; time until first swallowing evaluation; SLP index per hospital bed; time until removal of feeding tube; time until reintroduction of oral feeding; and time until decannulation. The proposed indicators were designed to improve the management of dysphagia in a hospital setting. Measuring these indicators is essential to understanding the patient's needs and providing quality care. Managing care using these indicators will make it easier to track the patient's rehabilitation process, measure the effectiveness of new therapeutic processes and technologies, and evaluate the performance of hospital units relative to other providers in the area. The management of SR using quality indicators allows the effectiveness and efficiency of rehabilitation programs to be clearly evaluated.

The role of the epiglottis in the swallow process after a partial or total glossectomy due to a neoplasm

Repeatable epiglottic movement patterns were recorded during a videofluoroscopic swallow evaluation of 95 patients who had undergone a total or partial glossectomy due to a neoplasm. Because no epiglottic function assessment was performed preoperatively, for the purpose of this study it was assumed that epiglottic mobility was “normal” during this time and that all abnormalities found afterward resulted from the growth of the neoplasm and the glossectomy. It was noted that in the early postoperative period, absence of epiglottic movement was accompanied by aspiration and made swallowing incompetent in a majority of cases (9 of 10). A correlation of movement between the epiglottis and the extent of oral tissue excision was found. Epiglottic mobility was evaluated as “normal” in 72% of the patients, i.e., in 67 of 91 (74%) patients after a partial or nearly total glossectomy and in 1 of 4 people who underwent a total glossectomy. In the subgroup (16%) of patients who underwent a total or nearly total glossectomy and then had videofluoroscopic examinations, 60% of the cases had normal epiglottic movements and 40% had an immobile epiglottis. Compensatory mechanisms implemented by the patients on their own initiative, such as additional swallows and prolonged apnea during deglutition, enabled them to avoid aspiration. However, upward head movement and downward chin tilting during deglutition as compensatory mechanisms used by patients with no epiglottic movement did not reduce the aspiration risk in the early postoperative period and were found to accompany incompetent swallowing attempts.