Prevalence of Oropharyngeal Dysphagia in Adults in Different Healthcare Settings: A Systematic Review and Meta-analyses

Accuracy of tongue strength, endurance, and pressure using Iowa oral performance instrument and predictors of dysphagia in community-dwelling older adults: a cross-sectional study

BACKGROUND

Decreased tongue strength, pressure, and endurance are key indicators in determining oropharyngeal dysphagia (OD). This study aimed to examine the accuracy of the Iowa Oral Performance Instrument (IOPI) in assessing tongue strength, endurance, and pressure, and to identify predictors of OD.

METHODS

In this study, we analyzed data of community-dwelling older adults (age ≥ 65 years) collected between March to December 2022. The accuracy for IOPI was examined with Receiver operating characteristic curve using area under the ROC curve (AUC), sensitivity (Se) and specificity (Sp) and optimal cutoff with Youden index (J). Bivariate and multivariate logistic regression analysis for predictors of OD were performed presenting odds ratio (OR) with 95% confidence interval (CI).

RESULTS

The cohort consisted of 85 older adults with mean age of 83.25 years (SD 6.76), of which 64 (75.3%) were female. The prevalence of OD using EAT-10 was 8.3%. Tongue strength demonstrated better diagnostic accuracy using anterior tongue strength (ATS): cut-off: 37.5 kPa (AUC: 0.79, Se: 0.86, and Sp: 0.65) and posterior tongue strength: cut-off: 31.5 kPa (AUC: 0.73, Se: 0.71, and Sp: 0.79). Tongue endurance demonstrated better diagnostic accuracy using anterior endurance target second (ATE-Target Sec): cut-off: 2.4 (AUC: 0.96, Se: 0.86, and Sp: 0.90), PTE-Target Sec: cut-off: 1.7 (AUC: 0.93, Se: 0.86, and Sp: 0.83), ATE-Target Max with cut-off: 34.4 kPa (AUC 0.81, Se = 0.86, and Sp = 0.64), and PTE-Target Max with cut-off: 29.5 kPa (AUC: 0.77, Se = 0.86, and Sp = 0.69). Tongue pressure revealed limited diagnostic accuracy using saliva swallowing pressure with cut-off: 23.3 kPa (AUC: 0.60) and effortful swallowing pressure with cut-off: 28.5 kPa (AUC: 0.62). Significant predictors for OD were frailty (3.02, 95%CI: 1.56-5.88), age (1.17, 95%CI: 1.01-1.35), nutritional status (0.72, 95%CI: 0.57-0.92), ATS (0.86, 95%CI: 0.77-0.97), ATE-Target Max (0.90, 95%CI: 0.84-0.97), PTE-Target Max (0.92, 95%CI: 0.86-0.99), ADL (0.91), IADL (0.67), and depression (1.32).

CONCLUSIONS

The findings suggest that tongue strength and endurance, measured by IOPI, are more effective parameters than tongue pressure, with frailty, age, nutritional status, ATS, ATE-Target Max, PTE-Target Max, ADL, IADL, and depression being essential for early screening of OD in community-dwelling older adults.

CLINICAL TRIAL NUMBER

Not applicable.

Dysphagia development in heart failure patients: A scoping review

OBJECTIVE

Dysphagia significantly affects older adults, particularly those with heart failure (HF). This scoping review aimed to delineate the development of dysphagia and its contributing factors in patients with HF.

METHODS

We systematically searched MEDLINE, EMBASE, CINAHL, and CENTRAL databases up to September 2023, focusing on studies involving HF patients aged 60 and above, particularly those assessing post-hospitalization dysphagia.

RESULTS

Of 1,076 identified studies, nine were relevant. The prevalence of dysphagia at admission was 23.6 % (14.1 - 32.9), with 9.4 % (4.5 - 13.8) persisting until discharge. The evaluation of dysphagia primarily relies on oral intake assessments, highlighting several risk factors, including high inflammation, low energy intake, advanced age, low Barthel Index scores, poor oral health, antipsychotic usage, and low maximum tongue pressure. It is important to note potential author bias and overlap among study populations.

CONCLUSIONS

This review highlights the significant development of dysphagia in patients with HF, and the prevalence of newly developed dysphagia was 23.6 % (14.1 - 32.9). Key risk factors include older age, high inflammation, low activities of daily living, and sarcopenia, which is suggested as a pathogenic mechanism in dysphagia. Future research should focus on diverse samples, investigate the impact of sarcopenia and cachexia, and objectively assess swallowing function.

Using concept mapping to guide dysphagia service enhancements in Singapore: Recommendations from the speech-language pathology workforce

PURPOSE

Optimising dysphagia service delivery is crucial to minimise personal and service impacts associated with dysphagia. However, limited data exist on how to achieve this in Singapore. This study aimed to develop prioritised enhancements that the speech-language pathology workforce perceived as needed to improve dysphagia services in Singapore.

METHOD

Using a concept mapping approach, 19 speech-language pathologists (SLPs) and 10 managers listed suggestions for dysphagia service optimisation. Within their groups, the collated suggestions were sorted based on similarity, and individually rated on a 5-point scale based on importance and changeability. Using cluster and bivariate analysis, clusters of similar suggestions and prioritised suggestions for service optimisation were identified.

RESULT

The SLPs and managers proposed 73 and 51 unique suggestions respectively. Six clusters were identified for each group, with similar themes suggesting agreement of service improvements. All clusters were rated as more important than changeable. The managers perceived services as easier to change. The SLPs and managers rated 37% (27/73) and 43% (22/51) of suggestions, respectively, as high priority, with similarities relating to workforce capacity and capability, support and services access, care transitions, and telehealth services.

CONCLUSION

Prioritised enhancements identified by SLPs and managers provide direction for dysphagia service optimisation in Singapore.

A Retrospective Cohort Study of High-Flow Nasal Cannula Oxygen and Swallowing

Background: High-flow nasal cannula (HFNC) is an oxygen therapy delivery method used with severely ill patients. The literature regarding the effects of HFNC on overall swallowing function and aspiration risk is limited, and results from current studies are mixed. This study aimed to investigate the possible association between HFNC and swallowing impairment. Methods: This was a single-center, within-subjects, repeated-measures retrospective study of 21 hospitalized subjects. Participants underwent flexible endoscopic evaluation of swallowing (FEES) while receiving oxygen therapy via HFNC and had another instrumented swallow assessment, a FEES or a modified barium swallow study, when they no longer required HFNC oxygen. Three markers of swallowing function were extracted from reports-aspiration, silent aspiration, and overall swallowing function, and statistical analyses were conducted to assess their relationship to HFNC status. Results: There was a statistically significant difference in the proportion of subjects who aspirated while they were receiving oxygen via HFNC as compared to when they were not on HFNC (P = .033). When on HFNC, 61.9% (13/21) of subjects had an aspiration event during instrumented swallow evaluation; and when off HFNC, 23.8% (5/21) of subjects aspirated. Findings related to silent aspiration during instrumented swallowing evaluation were not significant (P = .32). When subjects were on HFNC, their overall swallowing function was significantly more impaired than when they were off HFNC (P < .001). Conclusions: The results of this study indicate that HFNC is a factor to consider when determining if a patient is appropriate for oral alimentation. Given the limited data on HFNC and swallowing function and the fragility of this population, instrumented examination of swallowing prior to initiation of oral intake may be beneficial. Future prospective studies with larger populations that stratify subjects into risk categories based on subject characteristics and pathophysiology are needed.

Implications of health professionals' awareness and involvement in oropharyngeal dysphagia management on inpatient outcomes in a National Hospital in Kenya: a case study

ABSTRACT

Introduction

The complex, multifaceted nature of oropharyngeal dysphagia calls for all health professionals to be aware and involved in its management. Drawing on the WHO's Interprofessional Collaboration model, this study assessed the implications of health professionals' awareness and involvement in the management of oropharyngeal dysphagia among inpatients in the acute care facility of a national (level-six) hospital in Kenya. The research questions were (1) what roles do health professionals play in the management of oropharyngeal dysphagia among adult inpatients in the acute care facility of a Kenyan national hospital? (2) what implications do health professionals' awareness and involvement in oropharyngeal dysphagia management have on the outcomes of inpatients in the acute care facility of a Kenyan national hospital diagnosed with this condition?

Methods

This study adopted a cross-sectional, descriptive design. Data collection involved semistructured interviews with 15 health professionals handling dysphagia inpatients in the facility. The resulting data were transcribed verbatim, analysed thematically and presented through narrations.

Results

The analysis revealed that health professionals perform several oropharyngeal dysphagia management roles that fall into two broad complementary categories: those contributing directly to oropharyngeal dysphagia management and those supporting patients with the condition. However, some participants were uncertain of their roles in dysphagia management. The analysis also identified several potential implications of health professionals' awareness/non-awareness and involvement/non-involvement in oropharyngeal dysphagia management. The implications were grouped into three themes: patient outcomes, professionalism and the healthcare system.

Conclusions

Increased involvement of all health professionals in the facility in oropharyngeal dysphagia management may result in improved patient outcomes and professionalism. As a recommendation, the hospital's management should implement programmes emphasising holistic collaboration among health professionals working in its acute care facility to facilitate oropharyngeal dysphagia management and enhance patient outcomes.

eTWST: An Extension to the Timed Water Swallow Test for Increased Dysphagia Screening Accuracy

We aimed to fine-tuning the Timed Water Swallow Test (TWST) screening procedure to provide the most reliable prediction of the Flexible Endoscopic Evaluation of Swallowing (FEES) assessment outcomes, with age, sex, and the presence of clinical signs of dysphagia being considered in the assessment. Participants were healthy people and patients with suspected dysphagia. TWST performance and participants' reported dysphagia symptoms were assessed in terms of their utility in predicting the outcome of a FEES assessment the same day. The FEES assessors were blinded to the nature of the TWST performance. The water swallowing capacity levels and clinical observations during a screening performance that were indicative of dysphagia/no symptoms in FEES were determined. Convergent validity was assessed as the agreement with the Functional Oral Intake Scale (FOIS) in the FEES assessment. TWST predicted FEES findings (aspiration and dysphagia) with a sensitivity of 72 and 45% and a specificity of 75% and 80%, respectively. Extended analysis of the TWST procedure (eTWST) identified aspiration (sensitivity = 92%, specificity = 62%) and dysphagia (sensitivity = 70%, and specificity = 72%) more accurately and showed a high correlation with FOIS (ɸ = 0.37). Excellent inter-rater reliability was further observed (Kw = 0.83). The extended evaluation of TWST performance has superior criterion validity to that of TWST. eTWST displayed high convergent validity and excellent interrater reliability. We therefore believe that eTWST can be highly relevant for clinical dysphagia screening.

Racial and Ethnic Disparities in Speech-Language Pathology Utilization for Patients With Oropharyngeal Dysphagia in Acute Care

PURPOSE

Disparities in health care utilization are modifiable drivers of disparities in health outcomes but have not been explored regarding speech-language pathology utilization for patients with dysphagia. This study explores racial and ethnic disparities in the utilization of speech-language pathology services among adult patients diagnosed with oropharyngeal dysphagia during acute care hospitalizations.

METHOD

We analyzed New York State Inpatient Data on acute care hospitalizations in 2019. We identified adults with a diagnosis of oropharyngeal dysphagia and determined whether they received speech-language pathology services via revenue center codes, which indicate receipt of a speech-language pathology evaluation or treatment. Using generalized estimating equations, we estimated the effect of race/ethnicity (White, Black, Hispanic, and Other race) on speech-language pathology utilization (yes, no) during the acute care hospitalization, controlling for patient clinical characteristics (e.g., acute diagnoses and clinical comorbidities), demographic characteristics (e.g., insurance status, rural-urban status), and health system factors (e.g., hospital size). Subgroup analyses were conducted for select primary diagnoses (i.e., stroke, sepsis, and aspiration pneumonia).

RESULTS

We identified 56,198 individuals with a diagnosis of oropharyngeal dysphagia; 60.7% received speech-language pathology services. In the full sample analysis, the adjusted odds of speech-language pathology utilization were lower in Black relative to White individuals (odds ratio [OR] = 0.87 [0.76, 0.98], p = .026). Racial and ethnic disparities were present in the subgroup analyses, most notably for sepsis, where speech-language pathology utilization was significantly lower for Black, Hispanic, and Other race individuals (ORs from 0.61 to 0.77) relative to White individuals.

CONCLUSIONS

We found evidence of racial and ethnic disparities in the utilization of speech-language pathology services for patients with oropharyngeal dysphagia in the acute care setting that varied by primary diagnosis. Further research is needed to replicate these findings and to begin to understand the reasons behind these disparities.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.26791741.

Prevalence of Oropharyngeal Dysphagia in Patients with Stroke: A Systematic Review and Meta-Analysis

Oropharyngeal dysphagia (OD) is a prevalent and clinically significant challenge among patients with stroke, affecting their quality of life and overall prognosis. This systematic review aims to comprehensively assess and synthesize existing evidence on the prevalence of OD in a patient’s stroke. A comprehensive literature search was performed in major medical databases, including PubMed, Scopus, and Web of Science, from inception to March 2023. Studies revealed the prevalence of OD in adult stroke patients. Two reviewers independently assessed the titles, abstracts, and full texts of potentially eligible studies. The studies were evaluated for bias using the Joanna Briggs Institute’s critical appraisal checklist. Data from the studies were extracted, and a meta-analysis was performed to estimate the pooled prevalence of OD in stroke patients. The initial search yielded 1,272 relevant studies, of which eight met the inclusion criteria for the systematic review. The combined sample size of the studies included was 1,830 patients. The pooled prevalence of OD in stroke patients was estimated to be 31.0% (95% confidence interval [CI]: 11.0-55.0%). Subgroup analysis based on stroke type (ischemic vs. hemorrhagic), stroke location (left hemisphere vs. right hemisphere vs. brainstem), and time since stroke onset was conducted to explore potential sources of heterogeneity. In conclusion, the study highlights the significant burden of OD in patients with stroke, emphasizing the need for early detection, comprehensive assessment, and tailored interventions to improve patient outcomes and identify risk factors.

Impact of Modified Diet, Swallowing Exercises, and Electrostimulation on Quality of Life of Older Patients Suffering from Oropharyngeal Dysphagia

Background and Objectives: Oropharyngeal dysphagia is defined as a swallowing disorder in which it becomes difficult to form a bolus and move food from the mouth to the proximal part of the esophagus. Several factors can cause this disorder in geriatric patients. With oropharyngeal dysphagia, the patient's social isolation and the risk of depression increase, while the quality of life deteriorates. Materials and Methods: In this study, oropharyngeal dysphagia was suspected based on the EAT-10 questionnaire and diagnosed with the water drink test and endoscopic swallowing evaluation, which assesses the aspiration risk by using an eight-point Penetration-Aspiration scale. Patients with oropharyngeal dysphagia received complex treatment: exercises to strengthen the swallowing muscles, electrostimulation of the swallowing muscles, and a modified diet. The quality of life of 64 patients was assessed by using the DHI, SWAL-QoL, and EAT-10 questionnaires before complex treatment and after treatment. The results show that the quality of life improved after the complex treatment of oropharyngeal dysphagia. Results: The mean age of patients was 77.8 (9.1) years, and 56.3% of patients were women. At baseline, mild oropharyngeal dysphagia was found in 18.8% of patients; moderate-in 51.6%; and severe-in 29.7%. Aspiration risk was low in 28.1% of patients; medium-in 39.1%; and high-in 32.8%. The severity of oropharyngeal dysphagia and aspiration risk significantly decreased after treatment (p = 0.002). The EAT-10 score mean was 15.23 (8.92) points before treatment and decreased to 11.50 (6.12) points after treatment (p < 0.001). Before treatment, the DHI physical score was 15.75 (6.813), the DHI functional score was 14.56 (8.659), and the DHI emotional score was 11.06 (7.848) (p < 0.001), and after complex treatment, the DHI physical score was 14.56 (8.659), the DHI functional score was 9.74 (7.165), and the DHI emotional score was 7.94 (6.588) (p < 0.001). The total SWAL-QoL score mean was 132.71 (34.392) points before treatment and increased to 152.42 (30.547) points after treatment (p < 0.001). Conclusions: Complex treatment of oropharyngeal dysphagia plays an important role in improving the quality of life and reducing aspiration risk in older people affected by this condition.

Oesophageal fluoroscopy in adults-when and why?

Oesophageal fluoroscopy is a radiological procedure that uses dynamic recording of the swallowing process to evaluate morphology and function simultaneously, a characteristic not found in other clinical tests. It enables a comprehensive evaluation of the entire upper gastrointestinal tract, from the oropharynx to oesophagogastric bolus transport. The number of fluoroscopies of the oesophagus and the oropharynx has increased in recent decades, while the overall use of gastrointestinal fluoroscopic examinations has declined. Radiologists performing fluoroscopies need a good understanding of the appropriate clinical questions and the methodological advantages and limitations to adjust the examination to the patient's symptoms and clinical situation. This review provides an overview of the indications for oesophageal fluoroscopy and the various pathologies it can identify, ranging from motility disorders to structural abnormalities and assessment in the pre- and postoperative care. The strengths and weaknesses of this modality and its future role within different clinical scenarios in the adult population are discussed. We conclude that oesophageal fluoroscopy remains a valuable tool in diagnostic radiology for the evaluation of oesophageal disorders.

Transition experiences of patients with post stroke dysphagia and family caregivers: A longitudinal, qualitative study

BACKGROUND

Stroke patients with dysphagia and family caregivers will experience multiple transitions during the whole process of the disease and various nursing needs will be generated. There is a lack of knowledge about their experiences at different transition stages. Thus, we aimed to explore the transition experiences of patients with post stroke dysphagia and family caregivers from admission to discharge home.

METHODS

A semi-structured interview based on Meleis's transition theory was used during hospitalization and telephone follow-up interviews were conducted in the first, third, and sixth month after the diagnosis of dysphagia. Interview transcripts were analyzed using the conventional content analysis method.

RESULTS

A total of 17 participants enrolled in the first face-to-face interview, 16 participants took part in the first month's telephone follow-up interview, 14 participants in the third month, and 12 participants in the sixth month. The transition experiences of patients with post stroke dysphagia and family caregivers could be summarized into three themes: (1)transition from onset to admission; (2)transition from discharge to other rehabilitation institutions; and (3)transition from discharge to home. Each theme had identified interrelated subthemes.

CONCLUSIONS

The experiences of patients with post stroke dysphagia and family caregivers during transition are a dynamic process with enormous challenges in each phase. Collaboration with health care professionals, follow-up support after discharge, and available community and social support should be integrated into transitional nursing to help patients facilitate their transition.

Prevalence and risk factors associated with dehydration of patients with dysphagia in eastern China: A cross-sectional study

AIMS

Dehydration is one of the common complications of dysphagia and poses significant risks including hospitalization and mortality, but the relationship between dysphagia and dehydration has received little attention. This study aims to determine the prevalence and risk factors for dehydration of patients with dysphagia in eastern China, and to provide reference for early identification and prevention of dehydration.

METHODS

A descriptive, cross-sectional design was conducted. Three hundred and thirty-seven (n = 337) patients with dysphagia participated in the study between August and December 2022. Information relating to participants' demographic variables, nutrition, cognition, functional, hydration status and fluid intake was collected. Univariate analysis was used to examine related impact factors, and then binary logistic regression analysis was conducted to determine reliable impact factors.

RESULTS

Among 337 patients with dysphagia, the average age was 63.47 ± 16.96, most participants were male (72.1%) and married (91.7%). The prevalence of dehydration was calculated to be 43.9%, the mean plasma osmolality score was 293.53 mmol/L. Diseases with the highest prevalence were stroke (78.3%), followed by hypertension (63.5%). The risk for dehydration increased with older age, usage of more medicines such as diuretics and beta-blockers, worse functional status and lower fluid intake.

CONCLUSION

This study found a high percentage of dehydration in patients with dysphagia. Findings can provide a basis for targeted nursing interventions for clinical prevention and treatment of dehydration.

Exploring the diagnostic accuracy and applicability of the Gugging Swallowing Screen in children with feeding and/or swallowing disorders

BACKGROUND

The Gugging Swallowing Screen (GUSS) is a bedside dysphagia screening tool that has been designed to determine the risk of aspiration in acute stroke patients. There is no evidence in the literature for the GUSS for the pediatric population. The present study aimed to determine the diagnostic accuracy of GUSS as a screening tool in the Greek language for children with dysphagia.

METHODS

Eighty-Greek-Cypriot children aged 3-12 years who had dysphagia participated in this retrospective study. The translated into Greek GUSS was administered twice (pre- and post-therapy) to each patient throughout 24 sessions of dysphagia therapy.

KEY RESULTS

The GUSS showed a high internal consistency (Cronbach's α = 0.826), good test-retest reliability (rs = 0.767), convergent validity compared to the Greek Pediatric Eating Assessment tool-10 (PEDI-EAT-10) total score (rs = -0.365), and inter-rater reliability (κ = 0.863). A total cutoff points equal to 13.00 was also calculated. Aspiration was identified by the GUSS with low sensitivity and high specificity (PPV 100%, NPV 57%, LR+ NA, LR- 0.79); dysphagia/penetration was identified with high sensitivity and low specificity (PPV 33%, NPV 100%, LR+ 0.102, LR- NA).

CONCLUSIONS & INFERENCES

The pediatric version of GUSS has been found to be a valuable tool in identifying the risk of aspiration as that of adults. It proved to be used as a good screening guide for selecting and confirming the existence of dysphagia from instrumental assessments. This is the first study of the pediatric version of GUSS, and future studies on this topic are needed.

Comparing Homogenized Instantaneous Meals and Traditional Pureed Foods in Patients Affected by Dysphagia: A Pilot Study

Background: Institutionalized individuals with dysphagia are particularly at risk for malnutrition. This study investigated two texture-modified models for patients with dysphagia, as follows: (i) traditional homemade pureed food (PF) and (ii) homogenized meals obtained from dehydrated and rehydrated instantaneous preparations (IPs). Methods: A retrospective pilot study was performed. It included patients affected by medium-severity dysphagia admitted to the nursing home "Sacra Famiglia" Institute of Cocquio Trevisago, Varese. The patients were aged 41-81 years old and all had complex disabilities. They underwent anthropometric and biochemical parameter assessments at baseline, as well as at two months and four months follow-up. Results: The study involved 30 patients, 15 received the IP meal. The comparison between the baseline and the follow-up did not show significant anthropometric and biochemical parameter differences. Conversely, the IP group reported significantly higher levels of consumption and satisfaction, evaluated using a modified Chernoff scale based on three levels of smiles, than the PF group. Conclusions: The present findings provide promising indications to improve the diet of patients affected by dysphagia, since meal satisfaction is a relevant factor that has been shown to be associated with better patient mood, motivation to eat, and adherence to prescribed diet.

Predictors of medical staff's knowledge, attitudes and behavior of dysphagia assessment: A cross-sectional study

PURPOSE

This study aimed to explore the predictors of medical staff's Knowledge, Attitudes and Behavior of dysphagia assessment, to provide reference suggestions for constructing the training program and improving the rate of dysphagia assessment.

METHODS

This study was a cross-sectional study. A total of 353 nurses and doctors from four provinces (Guangdong, Hunan, Guangxi, and Shaanxi) who were selected by convenience sampling and invited to complete the questionnaire through WeChat, DingTalk, and Tencent instant messenger from May 23 to 31, 2022. A self-reported questionnaire was used to assess participants' Knowledge, Attitude and Behavior regarding dysphagia assessment. Participants' sociodemographic, training, and nursing experience were measured using the general information sheet and analyzed as potential predictors of medical staff's Knowledge, Attitudes and Behavior of dysphagia assessment. A multiple linear regression model was used to identify the predictors.

RESULTS

The mean scores for Knowledge, Attitudes and Behavior of dysphagia assessments were (15.3±2.7), (35.9±4.9) and (41.4±14.4) respectively. Knowledge and Behavior of medical staff were medium, and attitude was positive. Multiple linear regression results indicated that experience in nursing patients with dysphagia, related training for dysphagia, working years in the field of dysphagia related diseases, specialized training (geriatric, swallowing and rehabilitation) and department (Neurology, Rehabilitation, Geriatrics) were significant predictors of Behavior, accounting for 31.5% of the variance. Working years in the field of dysphagia related diseases, department (Neurology, Rehabilitation, Geriatrics) and title were significant predictors of medical staff's knowledge, accounting for 7.8% of variance. Education, experience in nursing patients with dysphagia, department (Neurology, Rehabilitation, Geriatrics) and related training for dysphagia were significant predictors of medical staff's attitude, accounting for 12.9% of variance.

CONCLUSIONS

The study findings implied that nursing experience, training, and work for patients with swallowing disorders could have positive effects on the Knowledge, Attitudes and Behavior of medical staff regarding dysphagia assessment. Hospital administrators should provide relevant resources, such as videos of dysphagia assessment, training centers for the assessment of dysphagia, and swallowing specialist nurses.

Prevalence of dysphagia in patients after orthopedic surgery

OBJECTIVES

Oropharyngeal dysphagia is one of the most prevalent health complications in older adults. The prevalence of postoperative dysphagia is expected to rise with the increasing number of older patients undergoing orthopedic surgery; however, the specific prevalence and contributing factors remain unclear. This scoping review aimed to identify the prevalence and factors related to postoperative dysphagia in older orthopedic patients.

METHODS

This review included studies published up to September 2022 on postoperative patients aged ≥ 60 years who underwent orthopedic surgery. We searched MEDLINE, EMBASE, CINAHL, CENTRAL, Web of Science, and Ichushi-Web.

RESULTS

In total, 21 of the 2158 identified studies were reviewed. The studies were classified into the three categories according to the surgical site: cervical spine disease (n = 12), hip fracture (n = 7), and others (n = 2). The estimated dysphagia prevalence rates [95 % confidence interval] of cervical spine disease, hip fractures, and others were 16 % [8-27], 32 % [15-54], and 6 % [4-8], respectively. Factors related to postoperative dysphagia included cervical alignment in cervical spine disease, being older within the cohort, preoperative health status, malnutrition, and sarcopenia in hip fractures.

CONCLUSIONS

The prevalence of postoperative dysphagia after orthopedic surgery was highest for hip fractures, followed by cervical spine and others. These results suggest non-neurogenic dysphagia in older patients undergoing orthopedic surgery and indicate that sarcopenia may contribute to postoperative dysphagia in this population. Therefore, further research should clarify the trajectory of postoperative dysphagia and the effectiveness of rehabilitation for postoperative dysphagia after orthopedic surgery.

Complications of oropharyngeal dysphagia in older individuals and patients with neurological disorders: insights from Mataró hospital, Catalonia, Spain

Background

Oropharyngeal dysphagia (OD) significantly impacts older individuals and neurologically compromised patients, hindering safe ingestion of food and liquids. Despite its prevalence, OD remains underdiagnosed and undertreated, leading to severe complications such as malnutrition, dehydration, respiratory infections, and aspiration pneumonia (AP), and increases hospital readmissions.

Objectives

This study analyzes the intricate relationship between OD and various clinical complications in older individuals and patients with neurological disorders.

Methods

Utilizing retrospective analysis and narrative review, our work consolidates findings from prior studies on Hospital de Mataro's dysphagia patient cohort. Revisiting OD's intricate association with clinical complications, it presents data via odds ratios (OR), incidence ratios (IR), and hazard ratios (HR) from univariate and multivariate analyses.

Results

Five studies (2001-2014) involving 3,328 patients were scrutinized. OD exhibited independent and significant associations with various complications among older patients. Older individuals with OD faced heightened 1-month (ODDS 3.28) and 1-year (OR 3.42) mortality risks post-pneumonia diagnosis. OD correlated with a 2.72-fold risk of malnutrition, 2.39-fold risk of lower respiratory tract infections, 1.82-fold pneumonia readmissions (IR), and 5.07-fold AP readmissions (IR). Post-stroke OD is linked to neurological impairment (OR 3.38) and respiratory (OR 9.54) and urinary infections (OR 7.77), alongside extended hospital stays (beta coefficient 2.11).

Conclusion

Oropharyngeal dysphagia causes and significantly exacerbates diverse clinical complications in older and post-stroke patients, emphasizing the urgent need for proactive identification, comprehensive assessment, and tailored management. Acknowledging OD's broader implications in general medical practice is pivotal to improving patient outcomes and healthcare quality.

Prevalence of swallowing disorder in different dementia subtypes among older adults: a meta-analysis

BACKGROUND

Ageing process and abnormal protein accumulation in dementia damage neural pathways affecting the swallowing process and leading to swallowing disorder.

OBJECTIVE

To estimate the prevalence of swallowing disorder among older adults with different dementia subtypes.

METHODS

We conducted a systematic search across multiple databases, including PubMed, Embase, Scopus, Web of Science and OVID Medline. The meta-analysis employed R (version 4.0.2) and utilised a generalised linear mixed model with a random-effect approach to estimate the pooled prevalence of swallowing disorder among older adults, considering various dementia subtypes. The quality of included studies was assessed using Hoy's criteria. Heterogeneity was identified through Cochrane's Q and I2 statistics. To further explore heterogeneity, moderator analysis was performed to identify the contributing variables among the included studies.

RESULTS

Eighteen studies with 12,532 older adults with different dementia subtypes were enrolled in our meta-analysis. The pooled prevalence of swallowing disorder among older adults with dementia was 58%, with 46.5% for Alzheimer's dementia, 34.9% for Parkinson's dementia, 18.8% for vascular dementia, 16.3% for mixed dementia and 12.2% for Lewy body dementia. According to assessment tools, Alzheimer's dementia had the highest prevalence, with 58% in instrumental assessments and 39% in clinical assessments. Medical history, Alzheimer's dementia, moderate-to-severe Clinical Dementia Rating, delayed oral phase, delayed pharyngeal phase and poor tongue motility contributed to the heterogeneity of the included studies.

CONCLUSIONS

More than half of older adults with dementia demonstrate to have swallowing disorder. Our findings offer valuable insights to healthcare professionals for the identification of swallowing disorder in ageing population with dementia.

Identification of a know-do gap: An observational study of the assessment and treatment of dysphagia during inpatient stroke rehabilitation in primary healthcare in Norway

PURPOSE

Oropharyngeal dysphagia is a common swallowing impairment post-stroke managed by speech language pathologists (SLP). This article aims to demonstrate a local know-do gap assessment for usual dysphagia care for patients undergoing inpatient stroke rehabilitation in primary healthcare in Norway, which included an assessment of the functional level of the patients and characteristics and outcomes of treatment.

MATERIALS AND METHODS

In this observational study, we assessed the outcomes and interventions of patients admitted to inpatient rehabilitation following stroke. The patients received usual care from SLPs while the research team administered a dysphagia assessment protocol that included assessment of several swallowing domains including oral intake, swallowing, patient self-reported functional health status and health-related quality of life, and oral health. The treating SLPs documented the treatments provided in a treatment diary.

RESULTS

Of 91 patients who consented, 27 were referred for SLP and 14 received treatment. During the median treatment period of 31.5 days (IQR = 8.8-57.0), patients received 7.0 treatment sessions (IQR = 3.8-13.5) of 60 minutes (IQR = 55-60). The patients who received SLP treatment demonstrated no/minor disorders (n = 7) and moderate/severe disorders (n = 7). Dysphagia treatments primarily included oromotor training and advice on bolus modification and were provided without association to dysphagia severity. Patients with moderate/severe swallowing impairments received slightly more SLP sessions over a longer time.

CONCLUSIONS

This study identified gaps between current and best practices and opportunities to improve assessment, decision-making, and implement evidence-based practices.

Dysphagia and dementia: a 'double dilemma'

PURPOSE OF REVIEW

Dementia and its variants, including Alzheimer's disease, become more prevalent with age. Dysphagia, that is, difficulty swallowing, also occurs with aging, and is often associated with dementia. Currently, there is no cure for dementia, and dysphagia, unrecognized or untreated, can have life-altering, even fatal consequences. Prolonged ability to eat safely and effectively could contribute to improved quality of life in a fragile population. In this review, difficulties associated with the management of dysphagia in individuals with dementia, as well as promising possibilities for continued investigation, will be discussed.

RECENT FINDINGS

Recent reports point to unique problems related to understanding the comorbidities of dysphagia and dementia. These include delays in identifying dysphagia in affected individuals, as well as a lack of prevalence data for dysphagia in types and stages of dementia, or according to setting, for example, residential center, hospital. Emphasis on new tools, and new applications of existing tools, are needed.

SUMMARY

New evidence not only underscores complexities and shortcomings of our understanding of dysphagia in dementia but also points to existing applications with potential for improving the situation, and new investigational directions that may elaborate our further understanding of these comorbidities.

Expert Consensus on Clinical Decision Making in the Disease Trajectory of Oropharyngeal Dysphagia in Adults: An International Delphi Study

To date, no consensus exists on the complex clinical decision-making processes involved in oropharyngeal dysphagia, or swallowing disorders. This study aimed to develop an international consensus on a clinical decision tree for the disease trajectory of oropharyngeal dysphagia in adults, taking into account physiological impairments of swallowing, risk factors for the development of complications from oropharyngeal dysphagia, and prognostic factors for treatment outcomes. Using the Delphi technique, consensus was achieved among dysphagia experts across 31 countries, resulting in a total of 10 physiological impairments, 23 risk factors and 21 prognostic factors identified as relevant factors in the clinical decision-making process. Factors most contributing to the severity of oropharyngeal dysphagia were 'Aspiration', 'Incomplete ejection or failure to eject aspirated materials from the airways', 'Weak or absent cough', 'Choking' and 'Sensory deficits in the oropharynx'. To connect the existing theoretical framework to clinical practice, future research will develop the current findings by corroborating the domains based on relevant factors for clinical decision making and those that contribute to the severity of oropharyngeal dysphagia.

The Clinical Frailty Scale as a Risk Assessment Tool for Dysphagia in Older Inpatients: A Cross-Sectional Study

BACKGROUND

Dysphagia is a common problem with potentially serious consequences including malnutrition, dehydration, pneumonia, and death. However, there are challenges in screening for dysphagia in older adults. We assessed the feasibility of using the Clinical Frailty Scale (CFS) as a risk assessment tool for dysphagia.

METHODS

This cross-sectional study was conducted at a tertiary teaching hospital from November 2021 to May 2022 and included 131 older patients (age ≥65 years) admitted to acute wards. We used the Eating Assessment Tool-10 (EAT-10), which is a simple measure for identifying individuals at risk of dysphagia, to assess the relationship between EAT-10 score and frailty status as measured using the CFS.

RESULTS

The mean age of the participants was 74.3±6.7 years, and 44.3% were male. Twenty-nine (22.1%) participants had an EAT-10 score ≥3. The CFS was significantly associated with an EAT-10 score ≥3 after adjusting for age and sex (odds ratio=1.48; 95% confidence interval [CI], 1.09-2.02). The CFS was able to classify the presence of an EAT-10 score ≥3 (area under the receiver operating characteristic [ROC] curve=0.650; 95% CI, 0. 544-0.756). The cutoff point for predicting an EAT-10 score ≥3 was a CFS of 5 according to the highest Youden index, with a sensitivity of 82.8% and a specificity of 46.1%. The positive and negative predictive values were 30.4% and 90.4%, respectively.

CONCLUSION

The CFS can be used as a tool to screen for the risk of swallowing difficulty in older inpatients to determine clinical management encompassing drug administration routes, nutritional support, prevention of dehydration, and further evaluation of dysphagia.

Acute Antipsychotic Use and Presence of Dysphagia Among Older Veterans with Heart Failure

OBJECTIVE

Examine whether new antipsychotic (AP) exposure is associated with dysphagia in hospitalized patients with heart failure (HF).

DESIGN

Retrospective cohort.

SETTINGS AND PARTICIPANTS

AP-naïve Veterans hospitalized with HF and subsequently discharged to a skilled nursing facility (SNF) between October 1, 2010, and November 30, 2019.

METHODS

We linked Veterans Health Administration (VHA) electronic medical records with Centers for Medicare & Medicaid (CMS) Minimum Data Set (MDS) version 3.0 assessments and CMS claims. The exposure variable was administration of ≥1 dose of a typical or atypical AP during hospitalization. Our main outcome measure was dysphagia presence defined by (1) inpatient dysphagia diagnosis codes and (2) the SNF admission MDS 3.0 swallowing-related items to examine post-acute care dysphagia status. Inverse probability of treatment weighting was used for risk adjustment.

RESULTS

The analytic cohort consisted of 29,591 Veterans (mean age 78.5 ± 10.0 years; female 2.9%; n = 865). Acute APs were administered to 9.9% (n = 2941). Those receiving APs had differences in prior dementia [37.1%, n = 1091, vs 22.3%, n = 5942; standardized mean difference (SMD) = 0.33] and hospital delirium diagnoses (7.7%, n = 227 vs 2.8%, n = 754; SMD = 0.22). Acute AP exposure was associated with nearly double the risk for hospital dysphagia diagnosis codes [adjusted (adj.) relative risk (RR) 1.9, 95% CI 1.8, 2.1]. At the SNF admission MDS assessment, acute AP administration during hospitalization was associated with an increased dysphagia risk (adj. RR 1.2, 95% CI 1.0, 1.5) both in the oral (adj. RR 1.7, 95% CI 1.2, 2.0) and pharyngeal phases (adj. RR 1.3, 95% CI 1.0, 1.7).

CONCLUSIONS AND IMPLICATIONS

In this retrospective study, AP medication exposure was associated with increased dysphagia coding and MDS assessment. Considering other adverse effects, acute AP should be cautiously administered during hospitalization, particularly in those with dementia. Swallowing function is critical to hydration, nutrition, and medical management of HF; therefore, when acute APs are initiated, a swallow evaluation should be considered.

Relating Physiologic Swallowing Impairment, Functional Swallowing Ability, and Swallow-Specific Quality of Life

Many studies include functional swallowing ability and quality of life information to indicate a response to a specific swallowing intervention or to describe the natural history of dysphagia across diseases and conditions. Study results are difficult to interpret because the association between these factors and actual swallowing impairment is not understood. We set out to test the associations between components of physiologic swallowing impairment, functional swallowing ability, and swallow-specific quality of life using standardized and validated measurement tools: Modified Barium Swallow Impairment Profile (MBSImP), Functional Oral Intake Scale (FOIS), Eating Assessment Tool (EAT-10), and Dysphagia Handicap Index (DHI). We specifically aimed to understand which factors may contribute to the overall relationships between these measurement tools when analyzed using total scores and item-level scores. This study included a heterogeneous cohort of 273 outpatients who underwent a modified barium swallow study (MBSS). We found significant correlations between MBSImP total scores and FOIS scores and DHI total scores, but not between MBSImP total scores and EAT-10 total scores. Significant correlations were also found between MBSImP item-level component scores and FOIS scores, EAT-10 total scores, and DHI total scores. Detailed item-level analyses revealed the MBSImP components of bolus transport/lingual motion, oral residue, and tongue base retraction were correlated with EAT-10 item-level scores and DHI item-level scores. The clinically modest associations between physiologic swallowing impairment, functional swallowing ability, and swallow-specific quality of life reveal different factors that uniquely contribute to patients' overall dysphagic profile, emphasizing the clinical impact of a comprehensive swallowing assessment.

Multidisciplinary Assessment and Individualized Nutritional Management of Dysphagia in Older Outpatients

INTRODUCTION

The evidence on the efficacy of nutrition therapy to prevent complications of dysphagia is based on observational studies that used different tools for nutritional and dysphagia assessment, and different scales for the definition of diet textures, rendering their results incomparable and the knowledge on dysphagia management inconclusive.

METHODS

This retrospective observational study was performed in 267 older outpatients who were assessed for dysphagia and nutritional status by a multidisciplinary team at the Clinical Nutrition Unit of IRCCS INRCA geriatric research hospital (Ancona, Italy) from 2018 to 2021. GUSS test and ASHA-NOMS measurement systems were used for dysphagia assessment, GLIM criteria for the assessment of nutritional status, and the IDDSI framework to describe the texture-modified diets. Descriptive statistics were used to summarize the characteristics of the subjects evaluated. Sociodemographic, functional and clinical parameters were compared between patients with and without BMI improvement overtime by an unpaired Student's t test, Mann-Whitney U test or Chi square test, as appropriate.

RESULTS

Dysphagia was diagnosed in more than 96.0% of subjects; 22.1% (n = 59) of dysphagic subjects were also malnourished. Dysphagia was treated exclusively by nutrition therapy, prevalently by individualized texture-modified diets (77.4%). For the classification of diet texture, the IDDSI framework was used. The follow-up visit was attended by 63.7% (n = 102) of subjects. Aspiration pneumonia was registered only in one patient (less than 1%), and BMI improved in 13 of 19 malnourished subjects (68.4%). The improvement of nutritional status was primarily reached in subjects whose energy intake was increased and texture of solids modified, in younger subjects, and in those taking less drugs and not reporting any weight loss before the first assessment.

CONCLUSIONS

The nutritional management of dysphagia must guarantee both an adequate consistency and energy-protein intake. Evaluations and outcomes should be described with universal scales, in order to allow for comparison between studies and contribute to the collection of a critical mass of evidence on the efficacy of texture-modified diets in the management of dysphagia and its complications.

Measuring mealtime performance in older adults with suspected oropharyngeal dysphagia: an updated systematic review of psychometric properties

PURPOSE

To update a previous review of psychometric properties of performance-based outcome measurement instruments (PerFOMs) for task performance in the context of meal activity of older adults (≥65 years) with suspected oropharyngeal dysphagia (OD).

MATERIALS AND METHODS

Systematic searches were conducted in PubMed, CINAHL, EMBASE, SCOPUS, and Web of Science. Studies on PerFOMs that covers items reflecting skills in the pre-oral, oral, and pharyngeal stages of ingestion during meals were included. Two review authors independently screened, extracted, and evaluated the methodological rigour and quality of the reported psychometric properties in the included studies using the guidelines of the COnsensus-based Standards for the Selection of health Measurement INstruments (COSMIN).

RESULTS

Twenty-three articles featuring nine original PerFOMs and five translated versions were included. PerFOM development and content validity were rated with inadequate or doubtful methodological quality across all studies. The quality of the evidence across the additional psychometric properties of the PerFOMs was very low for two, ranged from very low to moderate for six, and from very low to high for five.

CONCLUSIONS

There is limited evidence of the psychometric properties of available PerFOMs for measuring task performance during meals in older adults with OD, and further validation is warranted.Implication for rehabilitationAssessing the mealtime performance of older adults with oropharyngeal dysphagia (OD) provides important information.Performance-based outcome measurement instruments (PerFOMs) need to be valid and reliable.Clinicians need to be careful when choosing PerFOMs to assess the mealtime performance of older adults with OD as there is insufficient evidence on the quality of available instruments.Established guidelines and standards should be used when developing and investigating psychometric properties of PerFOMs assessing mealtime performance of older adults with OD.

Expanding Rehabilitation Options for Dysphagia: Skill-Based Swallowing Training

Over the past four decades, our understanding of swallowing neural control has expanded dramatically. However, until recently, advances in rehabilitation approaches for dysphagia have not kept pace, with a persistent focussing on strengthening peripheral muscle. This approach is no doubt very appropriate for some if not many of our patients. But what if the dysphagia is not due to muscles weakness? The purpose of this clinical manuscript is to reflect on where we have been, where we are now and perhaps where we need to go in terms of our understanding of swallowing motor control and rehabilitation of motor control impairments. This compilation is presented to clinicians in the hope that suggesting approaches "outside the box" will inspire clinicians to focus their attention "inside the box" to ultimately improve rehabilitation and long-term outcomes for patients with dysphagia.