Editorial: Dysphagia, Dementia and Frailty

Preoperative dysphagia and adverse postoperative outcomes in middle aged and older adults

BACKGROUND

Dysphagia is a swallowing impairment with adverse health consequences. The impact of preoperative dysphagia on postoperative outcomes is not known. This study will examine the association between preoperative dysphagia and postoperative outcomes.

METHODS

This is a retrospective, observational study of patients ≥50 years of age undergoing surgery not directly involving the swallowing mechanism (i.e., oral cavity, larynx, pharynx, or esophagus). The National COVID Cohort Collaborative (N3C) database from January 1st, 2020 to August 31st, 2023 was used. The N3C database comprises electronic health record (EHR) data from more than 75 US health systems and harmonizes these data in a centralized resource. The main predictor was dysphagia with or without malnutrition in the 3 months prior to surgery. Logistic regression models assessed the association between our main predictor and outcomes of mortality, readmission, and medical/surgical complications adjusted for covariates. A negative binomial regression model was used for length of stay (LOS).

RESULTS

380,869 adults ≥50 years old were included, mean age 66.0 (SD = 9.2), 52.6 % male. 7.9 % had dysphagia and/or malnutrition 3 months preoperatively including 3.0 % preoperative dysphagia alone, 3.8 % preoperative malnutrition alone, and 1.1 % both. Adjusted models demonstrated higher odds of mortality (1-year mortality odds ratio (OR) 1.37, 95 % confidence interval (CI) 1.29 to 1.44), readmission (90-day readmission OR 1.19, 95 % CI 1.14 to 1.24), and medical/surgical complications (OR 1.35, 95 % CI 1.28 to 1.42) among patients with 3 months preoperative dysphagia with or without malnutrition compared to patients with neither condition.

CONCLUSION

Patients with 3 months preoperative dysphagia with and without malnutrition had poor postoperative outcomes. These findings highlight the rationale for integrating dysphagia screening and intervention into routine preoperative protocols to mitigate the risk of adverse postoperative outcomes.

Detection and management of suspected infections in people with dementia - A scoping review of current practices

People with dementia have an increased risk of hospitalization and mortality due to infections. We aimed to explore decision-making processes and interventions for detecting and managing suspected infections in people with dementia and involved actors and determinants. We conducted a scoping review, searching CINAHL and PubMed, and synthesized data through mapping and narratively. We identified 22 studies, based mostly on nursing homes and US data. Decision-making processes included recognition of infections based on observations of early signs and symptoms, actions when suspecting infections, and proxy/family involvement. Interventions included antimicrobial stewardship and other decision-support tools. Determinants included healthcare staff perceptions, and other system/person-related factors. Healthcare staff were the main actors, proxy/family were mentioned scarcely, and people with dementia only once. Our findings show scarcity of evidence on people with dementia and outside of the nursing homes. We highlight knowledge gaps and inform research shaping interventions for improving infection detection and management.

Use of EAT-10 in Individuals with Alzheimer's Disease: Who Should be the Source of Information?

This study aimed to examine the compatibility between individuals with Alzheimer's disease (IwAD) and Eating Assessment Tool (EAT-10) results obtained from their caregivers and to compare EAT-10 results obtained from IwAD and caregivers with fiberoptic endoscopic swallow evaluation (FEES) results. EAT-10 questions were read aloud to the IwAD; simultaneously, the caregiver was asked to complete the EAT-10 by thinking of the IwAD in a different room. Aspiration, penetration, and residual status were first assessed as "present" or "absent" using FEES, then the Penetration Aspiration Scale (PAS) was used. EAT-10 items were analyzed with agreement between IwAD and caregiver.The sensitivity and specificity of IwAD and caregiver EAT-10 results for aspiration, penetration, and residue were assessed. EAT-10 cut-off scores were determined for IwAD according to different sources of information.Agreement of the EAT-10 total measurements of IwAD and caregiver was determined to be poor. There was no statistically significant correlation between PAS scores and EAT-10 total IwAD (p = 0.072) and caregiver (p = 0.195) scores. In the aspiration, penetration, and residue measurements of the participants, the area under the ROC curve was not statistically significant (p > 0.05) according to both IwAD and caregiver responses. It was observed that IwAD's statement for aspiration, penetration, and residue in mild stage AD; IwAD for aspiration, caregiver for penetration, both for residue in moderate stage; caregivers for advanced stage gave more accurate results in differentiating individuals with aspiration, penetration, and residue.In conclusion, in this study, according to the information obtained from IwAD or caregivers, it was determined that the agreement between EAT-10 and FEES results was low, especially in recognizing IwAD with aspiration. Therefore, the use of the EAT-10 in IwAD does not provide adequate diagnosis; there is a need to develop other swallowing assessment tools that also provide information about the effectiveness and safety of swallowing specific to IwAD.

Effects of healthy aging on tongue-jaw kinematics during feeding behavior in rhesus macaques

Several age-related oral health problems have been associated with neurodegenerative diseases such as Alzheimer's Disease (AD), yet how oromotor dysfunction in healthy aging differ from those found in pathological aging is still unknown. This is partly because changes in the cortical and biomechanical ("neuromechanical") control of oromotor behavior in healthy aging are poorly understood. To this end, we investigated the natural feeding behavior of young and aged rhesus macaques (Macaca mulatta) to understand the age-related differences in tongue and jaw kinematics. We tracked tongue and jaw movements in 3D using high-resolution biplanar videoradiography and X-ray Reconstruction of Moving Morphology (XROMM). Older subjects exhibited a reduced stereotypy in tongue movements during chews and a greater lag in tongue movements relative to jaw movements compared to younger subjects. Overall, our findings reveal age-related changes in tongue and jaw kinematics, which may indicate impaired tongue-jaw coordination. Our results have important implications for the discovery of potential neuromechanical biomarkers for early diagnosis of AD.

Supporting safe swallowing of care home residents with dysphagia: How does the care delivered compare with guidance from speech and language therapists?

INTRODUCTION

Dysphagia affects up to 70% of care home residents, increasing morbidity and hospital admissions. Speech and language therapists make recommendations to support safe nutrition but have limited capacity to offer ongoing guidance. This study aimed to understand if recommendations made to support safe and effective care are implemented and how these relate to the actual care delivered.

METHODS

Eleven mealtimes with residents with dysphagia were observed during 2020 using a tool capturing 12 elements of expected practice. Staff actions during mealtimes were compared with adherence to residents' care plans and speech and language therapist recommendations.

RESULTS

Written recommendations predominantly focused on food and fluid modification. Observations (n = 66) revealed food texture, posture, and alertness were adhered to on 90% of occasions, but alternating food and drink, prompting and ensuring swallow completed adherence was less than 60%. Thickened fluids frequently did not align with required International Dysphagia Diet Standardisation Initiative levels. Nutrition care provided in the dining room was less safe due to a lack of designated supervision.

CONCLUSION

Care homes need to be supported to establish a safe swallowing culture to improve residents' safety and care experience.

WHAT THIS PAPER ADDS

What is already known on this subject? Dysphagia is associated with considerable morbidity and mortality and has been identified as an independent risk factor for mortality in nursing home residents. There is evidence that compensatory swallowing strategies, safe feeding advice and dietary modifications can reduce the risk of aspiration pneumonia. Care for nursing home residents at mealtimes is often task-centred and delegated to those with limited training and who lack knowledge of useful strategies to support the nutrition and hydration needs of residents with dysphagia. What this study adds? Written advice from speech and language therapists on safe nutrition and hydration for residents with dysphagia is focused mainly on food and fluid modification. Nurses and healthcare assistants have limited understanding of International Dysphagia Diet Standardisation Initiative levels or safe swallowing strategies and recommended practices to support safe nutrition care for residents with dysphagia are inconsistently applied especially when residents are eating in dining areas. Care homes are not aware of Royal College of Speech and Language Therapists guidance on how safe nutrition care of residents with dysphagia should be supported. What are the clinical implications of this work? Care homes need to prioritise a safe swallowing culture that ensures that residents with swallowing difficulties are assisted to eat and drink in a way that enhances their mealtime experience and minimises adverse events that may result in hospital admission. Speech and language therapists could play an important role in training and supporting care home staff to understand and use safe swallowing strategies with residents with dysphagia. The Royal College of Speech and Language Therapists could provide more assistance to care homes to support and guide them in how to implement safe feeding routines. Care home staff have limited knowledge about how to implement safe feeding routines and need more guidance from speech and language specialists on how they can support residents with dysphagia to eat safely. Creating a safe swallowing culture within care homes could help to improve nutrition care and enhance patient safety.

To Be Frail or Not to Be Frail: This Is the Question-A Critical Narrative Review of Frailty

Many factors have contributed to rendering frailty an emerging, relevant, and very popular concept. First, many pandemics that have affected humanity in history, including COVID-19, most recently, have had more severe effects on frail people compared to non-frail ones. Second, the increase in human life expectancy observed in many developed countries, including Italy has led to a rise in the percentage of the older population that is more likely to be frail, which is why frailty is much a more common concern among geriatricians compared to other the various health-care professionals. Third, the stratification of people according to the occurrence and the degree of frailty allows healthcare decision makers to adequately plan for the allocation of available human professional and economic resources. Since frailty is considered to be fully preventable, there are relevant consequences in terms of potential benefits both in terms of the clinical outcome and healthcare costs. Frailty is becoming a popular, pervasive, and almost omnipresent concept in many different contexts, including clinical medicine, physical health, lifestyle behavior, mental health, health policy, and socio-economic planning sciences. The emergence of the new "science of frailty" has been recently acknowledged. However, there is still debate on the exact definition of frailty, the pathogenic mechanisms involved, the most appropriate method to assess frailty, and consequently, who should be considered frail. This narrative review aims to analyze frailty from many different aspects and points of view, with a special focus on the proposed pathogenic mechanisms, the various factors that have been considered in the assessment of frailty, and the emerging role of biomarkers in the early recognition of frailty, particularly on the role of mitochondria. According to the extensive literature on this topic, it is clear that frailty is a very complex syndrome, involving many different domains and affecting multiple physiological systems. Therefore, its management should be directed towards a comprehensive and multifaceted holistic approach and a personalized intervention strategy to slow down its progression or even to completely reverse the course of this condition.

Italian guidance on Dementia Day Care Centres: A position paper

Dementia Day Care Centres (DDCCs) are defined as services providing care and rehabilitation to people with dementia associated with behavioural and psychological symptoms (BPSD) in a semi-residential setting. According to available evidence, DDCCs may decrease BPSD, depressive symptoms and caregiver burden. The present position paper reports a consensus of Italian experts of different disciplines regarding DDCCs and includes recommendations about architectural features, requirements of personnel, psychosocial interventions, management of psychoactive drug treatment, prevention and care of geriatric syndromes, and support to family caregivers. DDCCs architectural features should follow specific criteria and address specific needs of people with dementia, supporting independence, safety, and comfort. Staffing should be adequate in size and competence and should be able to implement psychosocial interventions, especially focused on BPSD. Individualized care plan should include prevention and treatment of geriatric syndromes, a targeted vaccination plan for infectious diseases including COVID-19, and adjustment of psychotropic drug treatment, all in cooperation with the general practitioner. Informal caregivers should be involved in the focus of intervention, with the aim of reducing assistance burden and promoting the adaptation to the ever-changing relationship with the patient.

Importance of feeding status evaluation in older patients undergoing hemodialysis

Older hospitalized patients undergoing hemodialysis are increasingly experiencing malnutrition caused by dysphagia. However, only a few studies have focused on this problem. We used the Kuchikara Taberu Balance Chart (KTBC) to evaluate the patients' feeding status and examined its association with their nutritional status and prognosis. This study included elderly patients undergoing hemodialysis who were hospitalized at Nagasaki Renal Center for > 3 days between June 2021 and February 2022. In total, 82 inpatients were included [mean age, 73.4 ± 10.0 years; men, 57.3%; median dialysis vintage, 79.0 months (interquartile range, 37.3-164.8)]. We classified patients with lower than the median KTBC score (57 points) as being at risk for dysphagia; 37 patients (45.1%) were at risk for dysphagia. Spearman's rank correlation coefficient (ρ) elucidated that the KTBC total score was significantly associated with each nutritional indicator [serum albumin level (ρ = 0.505, p < 0.001); geriatric nutritional risk index (ρ = 0.600, p < 0.001); and nutritional risk index (ρ = -0.566, p < 0.001)]. The KTBC score was also closely associated with the body mass index (ρ = 0.228, p = 0.04). Patients with a lower KTBC score showed poor prognosis (log-rank test: p = 0.001), and age- and sex-adjusted Cox proportional analysis showed that the KTBC score was associated with life prognosis (hazard ratio, 0.90; 95% confidential interval, 0.86-0.94; p < 0.001). Therefore, we concluded that the patients at risk of dysphagia, identified using the KTBC score, were malnourished and had a poor prognosis. Hence, the evaluation of dysphagia using the KTBC is encouraged to prevent malnutrition in vulnerable older patients undergoing hemodialysis.

South African speech-language therapists' practices regarding feeding tube placement in people with advanced dementia

BACKGROUND

 Studies related to tube feeding in people with dementia (PWD) remain a contested topic, neglecting the importance of speech-language therapists' (SLTs) role in dysphagia management. Furthermore, SLT practices and beliefs regarding tube feeding in people with advanced dementia in an upper-middle-income country, such as South Africa, are unexplored.

OBJECTIVE

 This study aimed to determine the practices and beliefs of SLTs in South Africa regarding tube feeding placement in PWD.

METHOD

 A self-compiled online survey was distributed using social media platforms and was completed by 83 South African SLTs with experience in swallowing and feeding management of PWD.

RESULTS

 Most SLTs (78.8%) strongly believed they play a vital role in the decision-making regarding feeding tube insertion in PWD. This role is often met with several challenges, such as limited support from other healthcare professionals. Speech-language therapists with more experience and increased involvement in palliative care appeared to be more confident in supporting and counselling families of PWD on tube feeding. Many SLTs still recommend tube feeding despite its known negative consequences for PWD.

CONCLUSION

 The findings indicate a need for continued professional development for South African SLTs on feeding decisions in advanced dementia to increase knowledge and confidence in clinical practice. Speech-language therapists require guidelines by professional bodies and further dialogue amongst healthcare professionals to guide difficult feeding decisions in people with advanced dementia.

Improving nutrition and hydration in older people with dementia in care homes

Dementia can have significant adverse effects on people's ability to eat and drink sufficiently. People with dementia can experience malnutrition and unintentional weight loss at any stage of the condition, but these occur more often in the middle and late stages. It is important that nurses and care staff working in care homes have the appropriate knowledge and skills to provide optimal nutritional care to residents, thereby improving their health, well-being and quality of life. This article provides an overview of nutrition and hydration issues commonly experienced by people with dementia. It explores common causes of suboptimal nutrition and hydration, outlines tools for nutritional screening and assessment and discusses interventions to improve the nutritional care of care home residents with dementia.

Dysphagia Profiles Among Inpatients with Dementia Referred for Swallow Evaluation

BACKGROUND

Alzheimer's disease and related dementias (ADRD) patients who are hospitalized often develop oropharyngeal dysphagia, increasing risk for adverse outcomes, such as aspiration pneumonia. However, prevalence estimates of dysphagia are highly variable and often based on patient report or clinical testing rather than visualization of the swallow.

OBJECTIVE

The aims of this study were to determine prevalence and severity of dysphagia among inpatients with ADRD referred for swallowing evaluation.

METHODS

Electronic health record (EHR) abstraction of ADRD diagnosis and presence and severity of clinically-determined dysphagia on bedside swallow evaluation (BSE) and videofluoroscopic swallow study (VFSS).

RESULTS

16% (n = 268) had an ADRD diagnosis or were taking dementia-specific medication based on the EHR. 75% (n = 202) were diagnosed with dysphagia on the BSE. 60% subsequently underwent VFSS (n = 122) with dysphagia confirmation in 92% (n = 112). ADRD inpatients were significantly more likely to be diagnosed with dysphagia based on the BSE (p &lt; 0.0001) than those without ADRD. Additionally, dysphagia on the VFSS was more severe in the ADRD group (p &lt; 0.03).

DISCUSSION

ADRD individuals may be vulnerable to developing or worsening dysphagia during hospitalization. Results underscore the importance of evaluating swallowing function in hospitalized patients with ADRD in order to facilitate targeted intervention.

Relationship between Dysphagia and Home Discharge among Older Patients Receiving Hospital Rehabilitation in Rural Japan: A Retrospective Cohort Study

Dysphagia refers to swallowing difficulty, which impacts patients' quality of life. Dysphagia influences clinical outcomes, including mortality rates and length of hospital stay of older hospitalized patients. Dysphagia may affect the current and future quality of life of these patients. However, its exact impact remains unclear. We aimed to clarify the impact of dysphagia on discharge to home in older patients in a rural rehabilitation unit. We conducted a secondary analysis using data from a retrospective cohort study including patients aged over 65 years who had been discharged from a community hospital rehabilitation unit in rural Japan. Data from the participants had been previously collected from April 2016 to March 2020. The primary outcome was home discharge. The average participant age was 82.1 (standard deviation, 10.8) years; 34.5% were men. Among medical conditions, brain stroke (44.3%) was the most frequent reason for admission; the most frequent orthopedic condition was femoral fracture (42.9%). The presence of dysphagia (odds ratio [OR] = 0.38, 95% confidence interval [CI]: 0.20-0.73), polypharmacy (OR = 0.5, 95% CI: 0.32-0.90), and admission for internal medicine diseases (OR = 0.44, 95% CI: 0.26-0.77) were negatively associated with home discharge. High motor domain scores of the Functional Independence Measure were positively associated with home discharge (OR = 1.07, 95% CI: 1.05-1.08). Dysphagia was negatively associated with home discharge as were polypharmacy and admission for internal medicine diseases and conditions. By clarifying effective interventions through interventional studies, including approaches to managing multimorbidity and polypharmacy through interprofessional collaboration, the health conditions of older patients in rural areas may be improved.

Factors associated with frailty in patients with neurodegenerative diseases

PURPOSE

To identify the factors associated with frailty in patients with neurodegenerative diseases.

METHODS

Cross-sectional study, whose sample consisted of 150 patients diagnosed with neurodegenerative diseases seen at a speech-language therapy clinic in a reference hospital in southern Brazil. A secondary exploratory analysis of the medical records of patients treated at this clinic between April 2016 and May 2019 was performed. The information collected was sex, age, education, type of neurodegenerative disease, time of disease, frailty (Edmonton Frail Scale-EFS), swallowing (Northwestern Dysphagia Patient CheckSheet-NDPCS, Eating Assessment Tool-EAT 10), and cognition (Mini-Mental State Examination-MMSE and Montreal Cognitive Assessment-MoCA). Continuous quantitative variables were analyzed using mean and standard deviation and categorical quantitative variables from absolute and relative frequency, as well as their association with the outcome using the Chi-square test. Crude and adjusted Prevalence Ratios were assessed using Poisson regression with robust variance. All statistical tests were considered significant at a level of 5%.

RESULTS

The significant factors associated with frailty were the presence of oropharyngeal dysphagia and altered cognitive performance. Individuals with frailty have a higher prevalence of oropharyngeal dysphagia (PR= 1.772(1.094-2.872)), while cognition alteration presented a lower prevalence (PR= 0.335(0.128-0.873).

CONCLUSION

Oropharyngeal dysphagia can be an important clinical predictive factor for consideration in cases of frailty in patients with neurodegenerative diseases.

Bionic design of the oral swallowing in vitro and its application in the dysphagia

Dysphagia, the swallowing disorder, is a common disease among the elders and stroke patients. Therefore, based on the bionic swallowing device (BSD) in vitro of similar human-tongue motion during swallowing, the development of functional food is necessary to improve the food swallowing quality of the deglutition disorders patients. In this study, the tongue motion was thoroughly investigated by extracting the characteristic data, and appropriate mechanisms in vitro were adopted to replicate the motion of the tongue swallowing according to the normal swallowing oropharyngeal data. The application of the BSD was also investigated at different swallowing grades (SGs). The study results indicated that the tongue motion consisted of tongue root point (TRP) and several tongue motor points (TMPs). The cam-link and push-rod mechanisms showed ellipse lines for TRP motion and straight lines for TMPs, respectively. Higher correlation coefficients between the tongue trajectories in the oropharyngeal data and simulated curves of the combined mechanism were observed. The average correlation coefficients between the tongue trajectories of patients at five SGs and those of the BSD were 0.87, proving its effectiveness and potential application. Furthermore, the corn-paste experiments of the BSD showed that dysphagia at five SGs could be a suitable choice for certain food concentrations. This will provide valuable insight into developing more functional foods in vitro for high deglutition disorders.

Exploring perceptions of eating with dementia: Findings from a massive open online course

People with dementia are at high risk of malnutrition as a result of progressive symptoms that affect eating. Maximising opportunities to enhance nutrition and strategies to encourage eating are a crucial part of providing care. Caregiver knowledge and a person-centred approach to eating is essential to reduce symptom burden and maintain quality of life. There is currently limited research investigating first person perceptions of eating with dementia, particularly beyond small sample sizes. Therefore, this paper aims to explore community perceptions of how best to encourage eating for people with dementia using findings from an online course. Within the Understanding Dementia Massive Open Online Course, responses to the following statement were collected: 'If I had dementia, the things that might help me to eat include…'. A total of 3,651 participant responses were collected from the 2018 and 2019 course enrolments and analysed using structural topic modelling and secondary thematic analysis. The majority of participants were female, tertiary educated Australians over 50 years old. A third were paid caregivers. Thirteen topics were isolated from topic modelling that can be reduced into six broad categories: food type personalisation, meal choice, meal presentation, eating environment, eating assistance and end of life nutrition. Participant responses demonstrated diverse awareness of important aspects to encourage eating in dementia. Findings support the need for improved uptake of nutritional strategies in practice and education on eating with dementia to support caregivers.

A Pilot Survey: Oral Function as One of the Risk Factors for Physical Frailty

BACKGROUND

The aim of this study was to examine the association of the multiple facets of oral, motor, and social functions in community-dwelling older adults, to identify factors that might influence the risk of frailty.

METHODS

Of the 82 participants included in the study, 39 (5 males and 34 females) were young-old adults, with an average age of 70.5 ± 2.8 years, and 43 (14 males and 29 females) were old-old adults, with an average age of 78.7 ± 2.9 years. We assessed the risk factors for frailty among oral, motor, and social functions.

RESULTS

Statistical analysis showed a significant difference in the oral diadochokinesis between the groups (p = 0.006). According to the Spearman correlation analysis, a significant association was observed with age and oral diadochokinesis (rs = -0.262, p = 0.018), and social support (rs = -0.219, p = 0.049). Moreover, binomial logistic regression analysis revealed a significant association of frailty with the occlusal force (odds ratio, 0.031; 95% confidence interval (95% CI), 0.002-0.430; p = 0.010), General Oral Health Index (odds ratio, 0.930; 95% CI, 0.867-0.999, p = 0.046), and availability of social support (odds ratio, 0.803, 95% CI, 0.690-0.934, p = 0.004).

CONCLUSIONS

To prevent frailty at an early stage, assessments of oral functions, and also that of the availability of social support, are important.

Reduced Pneumonia Risk in Advanced Dementia Patients on Careful Hand Feeding Compared With Nasogastric Tube Feeding

OBJECTIVES

To compare survival and pneumonia risk among hospitalized patients with advanced dementia on nasogastric tube feeding (NGF) vs careful hand feeding (CHF) and to examine outcomes by feeding problem type.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Advanced dementia patients aged ≥60 years with indication for tube feeding admitted to 2 geriatric convalescent hospitals between January 1, 2015, and June 30, 2019.

METHODS

Comparison on the effect of NGF and CHF on survival and pneumonia risk using Kaplan Meier survival analysis and Cox proportional hazards models.

RESULTS

Of the 764 patients (mean age 89 years, 61% female, 74% residential care home residents), 464 (61%) were initiated on NGF and 300 (39%) on CHF. The primary feeding problem types were dysphagia (50%), behavioral feeding problem (33%), or both (17%). There was no difference in 1-year survival rate between NGF and CHF groups (36% vs 37%, P = .71) and survival did not differ by feeding problem type. Nasogastric tube feeding was not a significant predictor for survival (adjusted hazard ratio 1.15, 95% CI 0.94-1.39). Among 577 (76%) patients who survived to discharge, pneumonia rates were lower in the CHF group (48% vs 60%, P = .004). After adjusting for cofounders, NGF was a significant risk factor for pneumonia (adjusted hazard ratio 1.41, 95% CI 1.08-1.85). In subgroup analyses, NGF was associated with increased pneumonia risk for patients with both dysphagia and behavioral feeding problem (P = .01) but not in patients with behavioral feeding problem alone (P = .24) or dysphagia alone (P = .30).

CONCLUSIONS AND IMPLICATIONS

For advanced dementia patients with feeding problems, there is no difference in survival between NGF and CHF. However, NGF is associated with a higher pneumonia risk, particularly for patients with both dysphagia and behavioral feeding problem. Further research on how the feeding problem type impacts pneumonia risk for patients on NGF is needed.

An Interactive Workshop on Managing Dysphagia in Older Adults With Dementia

Introduction

Nearly six million American adults live with dementia, and dysphagia is a common comorbidity impacting their nutrition and quality of life. There is a shortfall in the number of geriatricians available to care for older adults. Thus, primary care physicians should be equipped with the knowledge to adequately care for the geriatric population. Modified diets are routinely prescribed for patients with dementia despite limited evidence that they protect patients from the sequelae of dysphagia and some suggestion of poor side-effect profiles.

Methods

We created a onetime, interactive, case-based session to educate medical residents on how to evaluate and treat dementia-associated dysphagia and address the discrepancy between the limited evidence for dietary modifications and their routine use. The session had a mixture of small-group discussion and didactic learning as well as a participatory component during which learners were able to sample thickened liquids.

Results

The session was implemented in an established primary care curriculum. Based on survey responses, which were obtained from 15 out of 17 participants, the session significantly improved participants' knowledge of dysphagia-associated dementia and increased their comfort with caring for patients with dysphagia.

Discussion

Dementia-associated dysphagia, although an increasingly common clinical problem, remains an underexamined area of medicine. We successfully implemented a session on this topic for internal medicine residents on the primary care track. Limitations included generalizability due to the small number of residents in the course and inability to gather sufficient data to see if knowledge learned was sustained over time.

Patterns of oral bisphosphonate deprescribing in older nursing home residents with dementia

In a national sample of Medicare nursing home residents with dementia treated with bisphosphonates, 20% had bisphosphonates deprescribed. Residents with clinical characteristics representing decreased likelihood for long-term benefit were more likely to have bisphosphonates deprescribed. Future studies are needed to evaluate outcomes of deprescribing bisphosphonates in this population.

INTRODUCTION

To determine incidence of deprescribing bisphosphonates among nursing home (NH) residents with dementia and identify factors associated with deprescribing.

METHODS

2015-2016 Medicare claims, Part D prescriptions, Minimum Data Set (MDS) 3.0, and Nursing Home Compare for non-skilled NH residents aged 65 + with dementia and prescriptions for oral bisphosphonates overlapping the first 14 days of the stay. Our primary definition for deprescribing was a 90-day gap in medication supply; we also explored the reliability of different deprescribing definitions (30-, 90-, 180-day gaps). We estimated associations of NH, provider, and resident characteristics with deprescribing bisphosphonates using competing risks regression models.

RESULTS

Most NH residents with dementia treated with bisphosphonates (n = 5312) were ≥ 80 years old (72%), white (81%), and female (90%); about half were dependent for transfers (50%) or mobility (45%). Using a 90-day gap in supply, the 180-day cumulative incidence of deprescribing bisphosphonates was 14.8%. This increased to 32.1% using a 30-day gap and decreased to 11.7% using a 180-day gap. Factors associated with increased likelihood for bisphosphonate deprescribing were age ≥ 90 years, newly admitted (vs. prevalent stay), dependent for mobility, swallowing difficulty, > 1 hospitalization in the prior year, CCRC facility, and nurse practitioner primary provider (vs. physician). Cancer and western geographic region were associated with reduced likelihood for deprescribing.

CONCLUSION

In a national sample of NH residents with dementia, bisphosphonate deprescribing was uncommon, and associated with clinical characteristics signifying poor prognosis and decreased likelihood for long-term benefit. Future studies should evaluate clinical outcomes of deprescribing bisphosphonates in this population.

Prevalence of Oropharyngeal Dysphagia and Risk of Pneumonia, Malnutrition, and Mortality in Adults Aged 60 Years and Older: A Meta-Analysis

INTRODUCTION

Oropharyngeal dysphagia (OD) is a serious health condition associated with poor survival and quality of life in adults aged 60 years and older. Comprehensive assessment and management of OD could lead to better and improved health outcomes for older adults. Therefore, we performed the first meta-analysis to determine the pooled prevalence of OD and risk of pneumonia, malnutrition, and mortality.

METHODS

Databases including Ovid-MEDLINE, Web of Science, Embase, PubMed, Cochrane, and CINAHL were searched up to January 2021. Data analysis was conducted using logistic-normal for prevalence rate and DerSimonian-Lard random-effects models for outcomes and associated factors of OD, providing odds ratio (OR) and corresponding 95% confidence interval (CI).

RESULTS

The pooled prevalence of OD in 39 studies with 31,488 participants was 46% associated with higher pooled OR for risk of pneumonia 2.07 (95% CI, 1.58-2.72), malnutrition 2.21 (95% CI, 1.43-3.41), and mortality 2.73 (95% CI, 1.62-4.60). Geriatric syndromes including fecal incontinence 6.84 (4.955-9.44), immobility syndrome 6.06 (5.28-6.96), pressure ulcers 4.02 (2.46-6.56), sarcopenia 3.10 (1.89-5.09), urinary incontinence 2.75 (1.81-4.19), frailty 2.66 (1.16-6.13), delirium 2.23 (1.73-2.87), and falls 1.47 (1.19-1.81) and comorbidities including dementia 3.69 (2.36-5.78) and stroke 1.92 (1.47-2.52) were associated with OD.

CONCLUSION

Early identification and management of OD should consider geriatric syndromes and neurogenic comorbidities to prevent malnutrition and pneumonia and reduce mortality in adults aged 60 years and older.

High prevalence of malnutrition and frailty among older adults at admission to residential aged care

INTRODUCTION Malnutrition is an under-recognised and under-treated problem often affecting older adults. AIM The aim of this study was to evaluate the prevalence of and factors associated with malnutrition and frailty among older adults at early admission to residential aged care. METHODS A cross-sectional study was undertaken among eligible older adults within the first week of admission to residential aged care. Participants were assessed for malnutrition risk using the Mini Nutritional Assessment Short Form, frailty using the Fried phenotype criterion, muscle strength using a grip strength dynamometer and gait speed using a 2.4-m walk test. A Cox regression analysis was conducted to identify factors associated with malnutrition risk and frailty status. RESULTS Of 174 participants (mean age 85.5 years, 61% women), two-thirds (66%) were admitted to residential aged care from the community. Most (93%) were either malnourished (48%) or at risk of malnutrition (45%). A total of 76% of participants were frail and 24% were pre-frail. Forty-three percent were both malnourished and frail. Low risk of malnutrition was associated with increases in muscle strength [0.96 (0.93-0.99)], gait speed [0.27 (0.10-0.73)] and pre-frailty status [0.32 (0.12-0.83)]. DISCUSSION This study provides preliminary evidence for high prevalence of malnutrition and frailty at admission to residential aged care. Almost all participants were malnourished or at nutrition risk. Findings highlight the need for strategies to prevent, detect and treat malnutrition in community health care and support nutrition screening at admission to residential aged care.

Overcoming protein-energy malnutrition in older adults in the residential care setting: A narrative review of causes and interventions

Malnutrition, in particular protein-energy malnutrition, is a highly prevalent condition in older adults, and is associated with low muscle mass and function, and increased prevalence of physical frailty. Malnutrition is often exacerbated in the residential care setting due to factors including lack of dentition and appetite, and increased prevalence of dementia and dysphagia. This review aims to provide an overview of the available literature in older adults in the residential care setting regarding the following: links between sarcopenia, frailty, and malnutrition (in particular, protein-energy malnutrition (PEM)), recognition and diagnosis of malnutrition, factors contributing to PEM, and the effectiveness of different forms of protein supplementation (in particular, oral nutritional supplementation (ONS) and protein-fortified foods (PFF)) to target PEM. This review found a lack of consensus on effective malnutrition diagnostic tools and lack of universal requirement for malnutrition screening in the residential care setting, making identifying and treating malnutrition in this population a challenge. When assessing the use of protein supplementation in the residential care setting, the two primary forms of supplementation were ONS and PFF. There is evidence that ONS and PFF increase protein and energy intakes in residential care setting, yet compliance with supplementation and their impact on functional status is unclear and conflicting. Further research comparing the use of ONS and PFF is needed to fully determine feasibility and efficacy of protein supplementation in the residential care setting.

The Contribution of Temporal Flat Lateral Position on the Mortality and Discharge Rates of Older Patients with Severe Dysphagia

Severe dysphagia leads to mortality in older patients and hinders their discharge from hospitals. The temporal flat lateral position (TFLP) enables them to continuously eat, thus resolving the aforementioned issues. We aimed to explore the effect of TFLP on the mortality and discharge rates of older patients with severe dysphagia. This interventional study comprised a historical control of patients admitted to a rural community hospital from January 2019 to December 2020 and diagnosed with severe dysphagia. The primary outcomes included the mortality and the rate of discharge from the hospital. While the intervention group was treated with TFLP, the control group underwent no treatment. We selected 79 participants (intervention group = 26, control group = 53), with an average age of 87.9 years. The discharge rate was significantly higher in the intervention group than in the control group (57.7% vs. 26.4%, p = 0.012). The mortality rate was also significantly lower in the intervention group compared to the control group (34.6% vs. 71.7%, p = 0.003). TFLP can improve the discharge and mortality rates in community hospitals, thereby improving patient outcomes. Clinicians should focus on practical education and the implementation of TFLP in communities in order to promote it.

Combining Liquid Oral Drugs with Thickener: Compatibility and Changes in Viscosity

Older adults with oropharyngeal dysphagia (OD) are unable to swallow pills safely, so some of them use liquid-formulated drugs mixed with thickeners to ensure safety. The aim of this study was to analyze the physical compatibility of a group of drugs with a thickener formulated with modified starch (Thick & Easy®). A secondary goal was to evaluate the amount of thickener needed to obtain the thickness levels 2, 3, and 4 defined by IDDSI framework for each drug. For this purpose, the rheological properties of the mixtures obtained were determined. Samples of each drug were prepared and 7, 10, and 12 g of thickener were added. Physical compatibility of the mixtures was observed; the apparent viscosity of the samples was measured using a rotational viscometer, and the results obtained were compared with the reference drug-free sample. We analyzed 45 medicinal products (38 active substances). Three drugs (almagate, ibuprofen, and macrogol) were found to be physically incompatible with the thickener and should not be mixed. Viscosity measurements indicated that clarithromycin and plantago ovata increased the viscosity of the mixture and required lower amount to achieve the target textures (110 cP, 590 cP, and 2620 cP for 7 g, 10 g, and 12 g in drug-free samples, respectively), whereas another subset reduced viscosity and required more thickener. This proved very relevant for acetylcysteine, amoxicillin, calcifediol, ferrous gluconate, fosfomycin, lactitol, lactulose, mepifiline, paracetamol, rivastigmine, sertraline, and tramadol. Measurements were below 1750 cP. Awareness of how each drug behaves when combined with thickeners is essential to avoid potential complications in OD.

Effect of an Oral Frailty Measures Program on Community-Dwelling Elderly People: A Cluster-Randomized Controlled Trial

INTRODUCTION

Oral frailty describes a trivial decline in the oral function and is considered to be related to frailty. Thus, effective management of oral frailty could prevent or ameliorate physical frailty and the need for care. However, there is a lack of consensus regarding specific interventions for oral frailty. In this cluster-randomized controlled trial, we investigated the effects of a newly developed oral frailty measures program mentored by dentists and dental hygienists for elderly people in a clinical setting.

METHODS

Of 3,296 participants included in a field survey, 219 who regularly visited dental clinics and met at least 3 of the following 6 criteria for oral frailty were considered eligible: <20 natural teeth, decreased chewing ability, decreased articulatory oral-motor skills, decreased tongue pressure, and substantial subjective difficulties in eating and swallowing. After applying the inclusion and exclusion criteria, we studied 51 patients in the intervention group (14 men and 37 women; mean age, 78.6 years) and 32 patients in the control group (7 men and 25 women; mean age, 78.0 years). We implemented a 12-week oral frailty measures program only for the intervention group. The program included preparatory oral exercises, mouth-opening training, tongue pressure training, prosodic training, and masticatory training. Primary outcome measures were the chewing ability score, articulatory oral motor skill for /ta/, tongue pressure, subjective difficulty in eating tough foods, and subjective difficulty in swallowing. We compared baseline characteristics using the Mann-Whitney U and χ2 tests for continuous and categorical variables, respectively. A repeated-measures two-way ANOVA was used to determine the efficacy of independent intervention variables, following the Wilcoxon signed-rank test. The groups (intervention/control) and time (baseline/week 12) were the independent variables. Oral frailty measures were the dependent variables.

RESULTS

Baseline characteristics and assessment results were similar between groups. We observed significant improvements in the intervention group in terms of articulatory oral motor skill for /ta/ and tongue pressure (p < 0.001). No improvements were observed in the control group.

DISCUSSION/CONCLUSION

Our results suggest that our oral frailty measures program effectively alleviates oral frailty. Future studies are needed to clarify the impact on preventing physical frailty and improving the nutritional status.

Videofluoroscopic Swallowing Study Findings Associated With Subsequent Pneumonia in Patients With Dysphagia Due to Frailty

Dysphagia in frailty or deconditioning without specific diagnosis that may cause dysphagia such as stroke, traumatic brain injury, or laryngeal pathology, has been reported in previous studies; however, little is known about which findings of the videofluoroscopic swallowing study (VFSS) are associated with subsequent pneumonia and how many patients actually develop subsequent pneumonia in this population. In this study, we followed 190 patients with dysphagia due to frailty or deconditioning without specific diagnosis that may cause dysphagia for 3 months after VFSS and analyzed VFSS findings for the risk of developing pneumonia. During the study period, the incidence of subsequent pneumonia was 24.74%; regarding the VFSS findings, (1) airway penetration (PAS 3) and aspiration (PAS 7 and 8) were associated with increased risk of developing pneumonia, and (2) the functional dysphagia scale (FDS) scores of the patients who developed subsequent pneumonia were higher than those of the patients who did not develop subsequent pneumonia. Our study findings might assist clinicians in making clinical decisions based on the VFSS findings in this population.

Association between Dysphagia and Surgical Outcomes across the Continuum of Frailty

This study examined the relationship between dysphagia and adverse outcomes across frailty conditions among surgical patients ≥50 years of age. A retrospective cohort analysis of surgical hospitalizations in the Healthcare Cost and Utilization Project's National Inpatient Sample among patients ≥50 years of age undergoing intermediate/high risk surgery not involving the larynx, pharynx, or esophagus. Of 3,298,835 weighted surgical hospitalizations, dysphagia occurred in 1.2% of all hospitalizations and was higher in frail patients ranging from 5.4% to 11.7%. Dysphagia was associated with greater length of stay, higher total costs, increased non-routine discharges, and increased medical/surgical complications among both frail and non-frail patients. Dysphagia may be an independent risk factor for poor postoperative outcomes among surgical patients ≥50 years of age across frailty conditions and is an important consideration for providers seeking to reduce risk in vulnerable surgical populations.

Increased Risk of Autopsy-Proven Pneumonia with Sex, Season and Neurodegenerative Disease

There has been a markedly renewed interest in factors associated with pneumonia, a leading cause of death worldwide, due to its frequent concurrence with pandemics of influenza and Covid-19 disease. Reported predisposing factors to both bacterial pneumonia and pandemic viral lower respiratory infections are wintertime occurrence, older age, obesity, pre-existing cardiopulmonary conditions and diabetes. Also implicated are age-related neurodegenerative diseases that cause parkinsonism and dementia. We investigated the prevalence of autopsy-proven pneumonia in the Arizona Study of Aging and Neurodegenerative Disorders (AZSAND), a longitudinal clinicopathological study, between the years 2006 and 2019 and before the beginning of the Covid-19 pandemic. Of 691 subjects dying at advanced ages (mean 83.4), pneumonia was diagnosed postmortem in 343 (49.6%). There were 185 subjects without dementia or parkinsonism while clinicopathological diagnoses for the other subjects included 319 with Alzheimer's disease dementia, 127 with idiopathic Parkinson's disease, 72 with dementia with Lewy bodies, 49 with progressive supranuclear palsy and 78 with vascular dementia. Subjects with one or more of these neurodegenerative diseases all had higher pneumonia rates, ranging between 50 and 61%, as compared to those without dementia or parkinsonism (40%). In multivariable logistic regression models, male sex and a non-summer death both had independent contributions (ORs of 1.67 and 1.53) towards the presence of pneumonia at autopsy while the absence of parkinsonism or dementia was a significant negative predictor of pneumonia (OR 0.54). Male sex, dementia and parkinsonism may also be risk factors for Covid-19 pneumonia. The apolipoprotein E4 allele, as well as obesity, chronic obstructive pulmonary disease, diabetes, hypertension, congestive heart failure, cardiomegaly and cigarette smoking history, were not significantly associated with pneumonia, in contradistinction to what has been reported for Covid-19 disease.

The Mass of Geniohyoid Muscle Is Associated with Maximum Tongue Pressure and Tongue Area in Patients with Sarcopenic Dysphagia

OBJECTIVES

We investigated the associations about the mass of geniohyoid and tongue muscle and the maximum tongue pressure in patients with sarcopenic dysphagia using ultrasonography.

DESIGN

Cross sectional study.

SETTING

5 hospitals including 3 acute and 2 rehabilitation hospitals and 1 older facility.

PARTICIPANTS

36 inpatients with sarcopenic dysphagia.

MEASUREMENTS

Ultrasonography was performed for geniohyoid muscle and tongue. The area for geniohyoid and tongue muscles in sagittal plane and the mean brightness level (0-255) in the muscle area were calculated. Maximum tongue pressure as strength of swallowing muscle were investigated. Partial correlation coefficient and multiple regression analysis adjusting for age and sex were performed.

RESULTS

The mean age was 81.1 ± 7.9. Men were 23. The mean BMI was 19.0 ± 4.1. The mean maximum tongue pressure was 21.3 ± 9.3 kPa. The mean cross sectional area for geniohyoid muscles was 140 ± 47 mm2. The mean brightness for geniohyoid muscle was 18.6 ± 9.0. The mean cross sectional area for tongue muscles was 1664.1 ± 386.0 mm2. The mean brightness for tongue muscles was 34.1 ± 10.6. There was a significant positive correlation between area of geniohyoid muscle and maximum tongue pressure (r = 0.38, p = 0.04). Geniohyoid muscle area was an explanatory factor for maximum tongue pressure (p = 0.012) and tongue muscle area (p = 0.031) in multivariate analysis.

CONCLUSIONS

Geniohyoid muscle mass was an independent explanatory factor for maximum tongue pressure and tongue muscle mass.

The Alzheimer patient from the dermatologist's point of view

Alzheimer's disease (AD) is characterized by a cluster of signs and symptoms that include memory loss, language disturbances, psychological and psychiatric changes and difficulty in carrying out daily activities. Although it may seem to be far from a dermatologic competence, the ageing of populations in industrialized and developing countries has changed things, making AD a multidisciplinary question. Indeed, this neurodegenerative disorder is not exclusively neurological, but rather may involve multiple tissues and organs. The abnormalities in metabolic and biochemical processes described in affected brains are also present in the skin and may condition specific dermatological manifestations. In fact, although a history of non-melanoma skin cancer is linked to a significantly reduced risk of developing AD, this is not so for melanoma. Several biological, social and environmental hypotheses can be advanced to explain these correlations. AD patients' memory problems and the partial inability to express an informed consent, could make a simple tumor excision challenging for a dermatologic surgeon. Moreover, attention should also be paid to the possibility of pharmacological interactions with AD therapies and to surgery timing. Observational studies have provided evidence for a non-spurious correlation between bullous pemphigoid (BP) and dementia. The demonstration of neurological isoforms of both BP180 and BP230 in the central nervous system has provided partial explanations for these findings and raised the question as to whether AD patients should be given accurate screening for BP and vice versa. Some adverse skin reactions have been observed with AD drugs and although mainly localized others are diffuse. Importantly, some of these drugs are available for administration in a patch or systemic form. When dealing with bedridden patients, the skin examination should be as complete as possible, since ulcer location is not only influenced by pressure and paratonia but also by spasticity, conditioning wounds in atypical sites.

The associations of the number of medications and the use of anticholinergics with recovery from tubal feeding: a longitudinal hospital-based study

Background

Several medications, such as anticholinergics, are considered to affect the swallowing function adversely; however, whether or not anticholinergics or polypharmacy should be avoided to prevent eating dysfunction in elderly populations remains unclear. We therefore examined whether or not the number of medications or the use of anticholinergics was associated with recovery from tubal feeding in elderly inpatients.

Methods

We conducted a retrospective 1-year observation study in 95 Japanese hospitalized patients (83.3 ± 9.7 years old) receiving nutrition through a feeding tube. The anticholinergic cognitive burden scale (ACBs) was used as an index for quantifying the anticholinergic action.

Results

Thirty-six (37.9%) subjects recovered from tubal to oral feeding during the observation period. The logistic regression models showed that an increased number of prescribed medications and an increase in ACBs decreased the incidence of recovery from tubal feeding (odds ratio [95% confidence interval]: 0.66 [0.50–0.87], P = 0.003 and 0.52 [0.29–0.92], P = 0.024, respectively). Furthermore, the cumulative incidence of recovery from tubal feeding was significantly lower in the subjects who were given an additional ≥3 medications during the observation period than in those who were not (hazard ratio [95% confidence interval]: 0.08 [0.01–0.59], P = 0.014).

Conclusions

The findings of this study suggest that an increased exposure to medications, especially anticholinergics, may be an important factor interfering with recovery from tubal feeding in hospitalized elderly patients.

Oropharyngeal dysphagia in elderly population suffering from mild cognitive impairment and mild dementia: Understanding the link

PURPOSE

To evaluate the prevalence of oropharyngeal dysphagia in elderly patients suffering from minimal or mild cognitive decline.

PATIENTS AND METHODS

We retrospectively collected the data of patients suffering from mild cognitive impairment or mild dementia and were undergoing management for suspected oropharyngeal dysphagia, in our department. All our patients were subjected to Mini Mental State Examination test, MD Anderson dysphagia inventory and caregiver mealtime and dysphagia questionnaire. We performed a mealtime observation study and endoscopic evaluation of swallowing in all our patients. Following evaluation, we then analysed the data statistically.

RESULTS

Out of 708 patients who visited us for cognitive decline and suspected oropharyngeal dysphagia in the last two years, 52 patients were confirming to the inclusion criteria of this study. Classification of oropharyngeal dysphagia patients according to ASHA-NOMS scale showed that 32.7% of patients presented with grade 4 of dysphagia followed by another 32.7% with grade 5 and 30.8% presented with grade 6. Only 3.8% of our patients were considered normal (grade 7 of ASHA-NOMS scale). MD Anderson dysphagia inventory could collected swallowing alterations in only 23.1% of the cases. The caregiver mealtime and dysphagia questionnaire showed acceptable caregivers patient management in 53.8% of patients.

CONCLUSION

Our study underscores the fact that oropharyngeal dysphagia is present in many cases of mild cognitive decline. While patients understate their swallowing problems, the caregivers are not competent enough to manage this situation in a great percentage of cases. Only a mealtime observation by a speech-language pathologist along with FEES is able to identify the true prevalence of the condition.

Interrupting the trajectory of frailty in dementia with Lewy bodies with anabolic exercise, dietary intervention and deprescribing of hazardous medications

An 87-year-old man with dementia with Lewy bodies, living in residential aged care, exhibited rapid functional decline and weight loss associated with injurious falls over 9 months. Independent clinicians (geriatrician and exercise physiologist) assessed him during an extended wait-list period prior to his commencement of a pilot exercise trial. The highly significant role of treatable factors including polypharmacy, sarcopenia and malnutrition as contributors to frailty and rapid functional decline in this patient are described. The results of a targeted intervention of deprescribing, robust exercise and increased caloric intake on his physical and neuropsychological health status are presented. This case highlights the need to aggressively identify and robustly treat reversible contributors to frailty, irrespective of advanced age, progressive ‘untreatable’ neurodegenerative disease and rapidly deteriorating health in such individuals. Frailty is not a contraindication to robust exercise; it is, in fact, one of the most important reasons to prescribe it.

Does the Formulation of Oral Solid Dosage Forms Affect Acceptance and Adherence in Older Patients? A Mixed Methods Systematic Review

OBJECTIVES

Age-related changes mean that the older population can encounter barriers toward taking medication orally. Further work is needed to identify the characteristics of oral solid dosage forms that will improve patient acceptance and adherence. The aim of this systematic review was to identify if and how formulation aspects of oral solid dosage forms affect acceptance and adherence in older people.

DESIGN

Mixed methods systematic review using a data-based convergent synthesis design.

SETTING AND PARTICIPANTS

Articles were selected if they included participants aged 60 years and older, or included health care professionals, social care professionals, and informal carers of patients aged 60 years and older.

METHODS

A systematic search of the following databases was undertaken: Web of Science, MEDLINE, Scopus, and The Cochrane Databases. The search of databases was supplemented by a search of gray literature, and reference lists of included papers were manually searched.

RESULTS

A total of 16 studies were included in the final synthesis. Three themes were generated from the thematic analysis: (1) dimensions, (2) palatability, and (3) appearance. The dimensions and palatability are often modified to improve swallowability by breaking tablets in half or taste masking with food. Polypharmacy can lead to patients using the appearance to identify tablets; however, this can lead to confusion when products appear similar. No study was identified that explored formulation characteristics across all 3 categories directly in the older population.

CONCLUSION AND IMPLICATIONS

Manufacturers should take into account practical problems older people may encounter when considering the dimensions, palatability, and appearance of the final drug product. These characteristics should be optimized to aid visual identification and swallowability. Medical providers and pharmacists have an important role in ensuring that these patient-centric drug products are prescribed and dispensed appropriately so that patients receive the most suitable formulation.

Self Reported Dysphagia is not Associated with Sarcopenia Defined by the Revised EWGSOP2 Criteria and Regional Thresholds at the Hospital Among Ambulatory Older Patients

Introduction:

Dysphagia and sarcopenia are geriatric syndromes, and they are shown to be related. There is no study on dysphagia and sarcopenia with the revised European Working Group on Sarcopenia in Older People (EWGSOP)2 criteria.

Aim:

We aimed to evaluate dysphagia and sarcopenia with the revised criteria implementing regional thresholds for skeletal muscle mass (SMM) in hospitalized older patients.

Methods:

Ambulatory patients ≥60 years of age from the Internal Medicine Department of our hospital were taken into the study. Grip strength, SMM via bioelectrical impedance analysis, nutritional status, dysphagia screening with Eating Assessment Tool-10, prior hospitalizations and diet were evaluated. Sarcopenia was defined by EWGSOP2 criteria using regional SMM thresholds adjusted to body mass index (BMI) (SMMI (BMI)).

Results:

Out of 112, 61 patients were enrolled. Sarcopenia, nutritional risk, and dysphagia were shown in 36.1%, 88.5%, and 14.8% of the patients. The risk of dysphagia was not associated with sarcopenia (p=0.263). Hospitalizations (≥1) in one year with pneumonia, modified diet, malnutrition, and low SMMI (BMI) were more common in patients with dysphagia risk than in the patients without (p=0.001, p<0.01, p=0.011, p=0.008, respectively). The median age and BMI were higher where SMMI (BMI) was lower in the group with dysphagia risk than in the group without (p=0.016, p=0.034, p=0.032), respectively.

Conclusion:

We found that self-reported dysphagia was not associated with sarcopenia defined by the EWGSOP2 criteria in ambulatory hospitalized patients over 60 years of age. Further studies using revised criteria, different adjustments and thresholds are needed to reveal possible differences.

Recent progress in the use of functional foods for older adults: A narrative review

The number and proportion of older adults are increasing globally, and it is predicted that in 2020, there will be 723 million people worldwide aged 66 and older. In recent decades, numerous studies showed that healthy eating is positively associated with better nutritional status and quality of life, and the decreased incidence of noncommunicable diseases. As older adults become health conscious, the demand for foods and beverages rich in nutrients and bioactive compounds has increased. The increased demand for healthy food stimulated a recent rapid increase in designing, producing, and marketing functional foods to prevent or correct nutrient deficiencies and to improve the nutritional status of older adults. These functional products contain and/or are enriched with dietary fiber; omega-3 polyunsaturated fatty acids; phytoestrogens; polyphenols; carotenoids such as alpha- and beta-carotene; lutein and zeaxanthin; pre-, pro-, and synbiotics; and plant sterols and stanols. A limited number of publications have thoroughly addressed the effect of functional foods on the nutritional status of older adults. The goal of this review was to review existing recent research on the role of functional foods in healthy and active aging.

Association Between Dysphagia and Inpatient Outcomes Across Frailty Level Among Patients ≥ 50 Years of Age

Frail patients may have heightened risk of dysphagia, a potentially modifiable health factor. Our aim is to examine whether the relationship between dysphagia and adverse health outcomes differs by frailty conditions among inpatients ≥ 50 years of age. Medical or surgical hospitalizations among patients ≥ 50 years of age in the Healthcare Cost and Utilization Project's National Inpatient Sample from 2014 through the first three quarters of 2015 were included. Adverse outcomes included length of stay (LOS), hospital costs, in-hospital mortality, discharge status, and medical complications. Dysphagia was determined by ICD-9-CM codes. Frailty was defined as (a) ≥ 1 condition in the10-item Johns Hopkins Adjusted Clinical Groups (ACG) frailty measure and a frailty index for the (b) ACG and (c) a 19-item Frailty Risk Score (FRS) categorized as non-frail, pre-frail, and frail. Weighted generalized linear models for complex survey designs using generalized estimating equations were performed. Of 6,230,114 unweighted hospitalizations, 4.0% had a dysphagia diagnosis. Dysphagia presented in 3.1% and 11.0% of non-frail and frail hospitalizations using the binary ACG (p < 0.001) and in 2.9%, 7.9%, and 16.0% of non-frail, pre-frail, and frail hospitalizations using the indexed FRS (p < 0.001). Dysphagia was associated with greater LOS, higher total costs, increased non-routine discharges, and more medical complications among both frail and non-frail patients using the three frailty definitions. Dysphagia was associated with adverse outcomes in both frail and non-frail medical or surgical hospitalizations. Dysphagia management is an important consideration for providers seeking to reduce risk in vulnerable populations.

Equipping Nurses and Care Staff to Manage Mealtime Difficulties in People With Dementia: A Systematic Scoping Review of Training Needs and Interventions

Purpose Mealtime difficulties are prevalent in dementia, posing major challenges to people with dementia (PWD), carers, and clinical services. Speech-language pathologists have a recognized role in providing training to carers of PWD who have mealtime difficulties. The aims of this study are (a) to identify the training needs of nurses and care staff with regard to managing mealtime difficulties in PWD, (b) to describe existing training interventions on this topic, and (c) to investigate the extent to which these interventions are relevant to the needs of nurses and care staff. Method A systematic search was carried out to identify studies relevant to the aims of the review. Data were extracted and then synthesized using thematic analysis and a synthesis matrix. Study quality was appraised using a validated appraisal tool. Results Various themes were identified in relation to the training needs of nurses and other care staff who manage mealtime difficulties in PWD. These were as follows: person-centered care; dealing with uncertainty; strategies, skills, and knowledge; and creating the right environment. Existing training interventions were described and compared against the training needs. The review found some correspondence between interventions and staff needs, but also some gaps. Conclusions Training interventions on this topic should be more systematically developed and better reported to facilitate effective implementation. Evidence to date indicates that training should do more to help staff deal with uncertainty. Further research assessing the benefits of speech-language pathologists' involvement in the development of training interventions is recommended because of this profession's specialist skills and knowledge with regard to both dysphagia and communication.

Nutritional interventions to prevent and treat frailty

PURPOSE OF REVIEW

Frailty is a multidimensional condition common in older adults, where reduced resiliency leads to adverse outcomes. It has strong links with malnutrition and sarcopenia, mostly through muscle health. This review explores the links between nutrition and frailty from different perspectives.

RECENT FINDINGS

Studies linking malnutrition and frailty show that most malnourished persons are frail, and malnutrition risk is increased in frail people. Energy and protein intake and some micronutrients are linked to frailty. Research on the role of microbiota and specific amino acids is increasing. Recent literature on the prevention of frailty with nutrition confirms that an appropriate intake of proteins, vitamin D and other nutrients is needed, but this information is still not in the public domain. Interventions to reverse frailty and sarcopenia should include exercise and nutrition interventions, usually with a multidomain approach including other elements.

SUMMARY

Public health recommendations to eat an optimal diet with the right amount of energy and proteins should be moved to the public domain. Whenever frailty is present, nutrition has a role in reverting it and avoiding adverse outcomes, but high-quality research is still needed in this area.

Malnutrition Screening and Assessment in Hospitalised Older People: a Review

Malnutrition (undernutrition) remains one of the most serious health problems for older people worldwide. Many factors contribute to malnutrition in older people, including: loss of appetite, polypharmacy, dementia, frailty, poor dentition, swallowing difficulties, social isolation, and poverty. Malnutrition is common in the hospital setting, yet often remains undetected by medical staff. The objective of this review is to compare the validity and reliability of Nutritional Screening Tools (NSTs) for older adults in the hospital setting. We also provide an overview of the various nutritional screening and assessment tools used to identify malnutrition in hospitalised older adults. These include: Subjective Global Assessment (SGA), the Mini Nutritional Assessment (MNA), MNA-short form (MNA-SF), Malnutrition Universal Screening Tool (MUST), Simplified Nutritional Appetite Questionnaire (SNAQ), Geriatric Nutrition Risk Index (GNRI) and anthropometric measurements. The prevalence and outcomes of malnutrition in hospitalised older adults are also addressed.