Association between Dysphagia and Frailty in Community Dwelling Older Adults

Possible sarcopenia and its association with hospital-associated dysphagia and decline in physical function: Findings from a heart failure patients prospective cohort study

BACKGROUND & AIMS

There is limited evidence regarding the association of sarcopenia with dysphagia and physical function in patients with heart failure. This study examined the association between possible sarcopenia and both swallowing and physical function in individuals with acute heart failure (AHF).

METHODS

This prospective cohort study included hospitalized patients with AHF. Possible sarcopenia was assessed on admission using calf circumference and grip strength according to an international diagnostic criteria. The primary outcome was dysphagia at discharge using the Food Intake Level Scale (FILS), and the secondary outcome was physical function at discharge using the Barthel Index (BI). Multiple regression analysis and logistic regression, adjusted for potential confounders, were used to examine the association between possible sarcopenia at admission and FILS and BI at discharge.

RESULTS

A total of 320 patients (mean age 81.5 years; 170 women) were included in the analysis; 199 (59.4%) were diagnosed with possible sarcopenia. Multivariate analysis showed that possible sarcopenia at admission was significantly associated with FILS at discharge (β = -0.1204; p = 0.039). Possible sarcopenia at admission was not significantly associated with BI at discharge (OR = 2.066; 95% CI, 0.910-4.692, p = 0.083).

CONCLUSIONS

Possible sarcopenia was associated with decline in swallowing function during hospitalization in patients with AHF. These findings highlight the need for early detection and treatment of possible sarcopenia in this setting.

Factors associated with presbyphagia in patients with community-acquired pneumonia: A cross-sectional study

BACKGROUND

Presbyphagia, an age-related decline in swallowing function, is considered a precursor stage of dysphagia and a risk state that can lead to aspiration pneumonia and malnutrition. We examined factors associated with presbyphagia in patients with community-acquired pneumonia (CAP).

METHODS

A cross-sectional study was conducted with 80 patients with CAP aged ≥65 years admitted to an acute care hospital between June 2021 and April 2024. Presbyphagia was assessed using the 10-item Eating Assessment Tool. The survey items included grip strength, body mass index, the Mini-Cog©, repetitive saliva swallowing test, tongue pressure, and evaluations for sarcopenia and frailty. Logistic regression analysis was performed to examine the factors associated with presbyphagia after adjusting for age and sex.

RESULTS

Of 80 patients, 44 (55%) had presbyphagia. The presbyphagia group was older, had lower Barthel Index scores, and had a higher proportion of history of cerebrovascular accident, sarcopenia and frailty than the non-presbyphagia group. Logistic regression analysis revealed frailty (adjusted odds ratio: 3.106, 95% confidence interval: 1.161-8.313, p = 0.024) was significantly associated with presbyphagia.

CONCLUSIONS

Our results revealed a significant association between presbyphagia and frailty in patients with CAP. The relationship between presbyphagia and frailty suggests that these conditions are not caused by a single functional decline or structural change but by a combination of factors. Therefore, it is crucial to comprehensively evaluate presbyphagia in patients with CAP to provide appropriate interventions.

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

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

Differences in prevalence of self-reported oral hypofunction between older adult patients with rheumatoid arthritis and the general older population: A cross-sectional study using propensity score matching

OBJECTIVE

To examine the association between rheumatoid arthritis (RA) and oral hypofunction (OHF) using propensity score matching (PSM) to adjust for differences between older adults with RA and the general older adult population.

METHODS

We conducted a cross-sectional survey among 189 older adults with RA in 2019 (mean age, 71.9 ± 3.6) and 47 178 independent older adult residents in 2016 (mean age, 71.6 ± 4.0), respectively. The questionnaire covered information on socio-demographic characteristics and OHF for both groups. Age, sex, educational level and smoking history were used to determine PSM. Prevalence ratios (PRs) and 95% confidence intervals (CIs) of self-reported OHF (fewer remaining teeth, decreased masticatory function, deterioration of swallowing function and oral dryness) were estimated using Poisson regressions.

RESULT

OHF was observed in 44.4% of patients with RA and 27.5% of residents. Before PSM, the prevalence of OHF among patients with RA was higher than that of residents (PR, 1.75; 95% CI, 1.50-2.05). After PSM, there were 189 patients with RA and residents, and the prevalence of OHF among patients with RA was still higher (PR, 1.61; 95% CI, 1.22-2.13). Poisson regression showed that the prevalence of 19 or fewer teeth (PR, 1.06; 95% CI, 0.82-1.36), difficulties eating tough foods (PR, 1.18; 95% CI, 0.90-1.55), difficulties swallowing tea or soup (PR, 1.77; 95% CI, 1.19-2.63), and dry mouth (PR, 2.79; 95% CI, 1.90-4.07) was higher among patients with RA than residents.

CONCLUSION

Compared with the general older adult population, patients with RA have a higher prevalence of self-reported OHF.

Identifying Non-Traditional Approaches to Swallowing Rehabilitation: A Scoping Review

In recent years, dysphagia care has shifted toward a more patient-centered approach. This means that dysphagia clinicians are considering more factors in the treatment process including the goals of care, quality of life, and cultural values. The purpose of this scoping review was to examine relevant research and identify dysphagia interventions outside of those traditionally used by dysphagia clinicians that may improve swallowing function. A review of relevant studies was conducted using search terms related to swallowing and treatment. The search yielded 8439 unique studies. Of the 283 articles that underwent a full-text review, 37 articles were included in the final review. These articles highlighted three potential areas of non-traditional dysphagia intervention that may serve to provide holistic care, while also aiming to improve swallowing mechanisms: acupuncture and Eastern medicine interventions, vocal exercises, and physical function exercises. The results suggest that dysphagia clinicians should work collaboratively with other allied health professionals and consider non-traditional approaches to dysphagia care. Through the identification of potentially effective but non-traditional or non-Eurocentric interventions for dysphagia care, clinicians may promote a culturally relevant, patient-centered approach, in turn increasing patient acceptance of treatment plans and compliance. Future research should explore the efficacy and feasibility of these interventions in dysphagia rehabilitation, as well as their effectiveness compared to more traditional approaches.

The relationship between dysphagia and frailty among Chinese hospitalized older patients: a serial mediation model through self-perceived oral health and self-reported nutritional status

BACKGROUND

Frailty contributes to adverse outcomes in older adults and places a heavy burden on healthcare resources. Dysphagia is associated with frailty, but the mechanisms by which dysphagia affects frailty in older adults are unclear. This study aimed to investigate a serial mediating effect of self-perceived oral health and self-reported nutritional status in the relationship between dysphagia and frailty among hospitalized older patients in China.

METHODS

This cross-sectional study included 1200 patients aged ≥ 65 years in the Department of Geriatrics, Shaanxi Provincial People's Hospital. A structured face-to-face interview was used to survey the following questionnaires: General Information Questionnaire, Tilburg Frailty Indicators (TFI), Eating Assessment Tool-10 (EAT-10), 30mL Water Swallow Test (WST), Geriatric Oral Health Assessment Index (GOHAI), and Short-Form Mini-Nutritional Assessment (MNA-SF). A total of 980 participants with complete data were included in the analysis. Statistical analysis was performed using SPSS 26.0 and Amos 28.0 software. Spearman's correlation analysis was used for correlation analysis of study variables. The results of the multivariate linear regression analysis for frailty were used as covariates in the mediation analysis, and the structural equation model (SEM) was used to analyze the mediating effects among the study variables.

RESULTS

Dysphagia, self-perceived oral health, self-reported nutritional status, and frailty were significantly correlated (P<0.001). Dysphagia was found to directly affect frailty (β = 0.161, 95%CI = 0.089 to 0.235) and through three significant mediation pathways: (1) the path through self-perceived oral health (β = 0.169, 95%CI = 0.120 to 0.221), accounting for 36.98% of the total effect; (2) the path through self-reported nutritional status (β = 0.050, 95%CI = 0.023 to 0.082), accounting for 10.94% of the total effect; (3) the path through self-perceived oral health and self-reported nutritional status (β = 0.077, 95%CI = 0.058 to 0.102), accounting for 16.85% of the total effect. The total mediation effect was 64.77%.

CONCLUSIONS

This study indicated that dysphagia was significantly associated with frailty. Self-perceived oral health and self-reported nutritional status were serial mediators of this relationship. Improving the oral health and nutritional status of hospitalized older patients may prevent or delay the frailty caused by dysphagia.

Magnesium Oxide as an Unexpected Bronchial Foreign Body in an Elderly Patient

As cases of magnesium oxide pill aspiration are rare, the associated airway proinflammatory properties and appropriate analytic strategies remain unclear. An 81-year-old woman presenting with dyspnea was diagnosed with magnesium oxide pill aspiration. Computed tomography, a "mixing test" with levodopa, and a magnesium content analysis revealed a similar density between the foreign body and her prescribed magnesium oxide pill. The patient recovered without airway complications after foreign body removal. Clinicians should be aware of magnesium oxide tablets as potential bronchial foreign bodies in elderly patients because they may not dissolve without exposure to gastric juices.

Self-Reported Dysphagia and Psychosocial Health Among Community-Dwelling Older Adults: Results of a National Study

BACKGROUND

The risk of dysphagia increases with age, affecting up to 33% of adults over the age of 65. Older adults with dysphagia are at increased risk for negative physical health outcomes such as aspiration pneumonia and death. However, the relationship between dysphagia and psychosocial health is uncertain in this population.

OBJECTIVE

We aimed to assess the associations between dysphagia and psychosocial health among older adults (≥ 65) with self-reported dysphagia.

DESIGN

We performed a cross-sectional assessment of the National Health and Aging Trends Study (NHATS) conducted in 2019.

MAIN MEASURES

Weighted logistic and linear regression models were used to assess the relationship between self-reported dysphagia and psychosocial health using established patient-reported outcome measures including those for depression, anxiety, and social isolation previously used in NHATS analyses, while adjusting for demographics, comorbid conditions, and risk factors for dysphagia identified by purposeful selection.

KEY RESULTS

Among the 4041 adults in this cohort, almost half (40%) were between 70 and 74 years old, more than half were female (55%), and a significantly higher proportion were White, non-Hispanic respondents (78.1%, p < 0.01) compared with other races and ethnicities. There were 428 (10.5%) respondents reporting dysphagia symptoms within the previous month. In the multivariable model, dysphagia was associated with significantly increased odds of anxiety (OR 1.33 [1.06, 1.67]) and a significantly decreased sense of well-being (coefficient - 1.10 [- 1.66, - 0.54]), but no association was detected for social isolation.

CONCLUSIONS

When accounting for factors associated with underlying physical health status, self-reported dysphagia is independently associated with negative psychosocial health and warrants attention by healthcare providers. Future studies should aim to identify causal factors and the extent to which interventions may mitigate these factors.

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.

Association of daily physical activity and leisure-time exercise with dysphagia risk in community-dwelling older adults: a cross-sectional study

This study aimed to clarify the association of daily physical activity and leisure-time exercise with the risk of dysphagia in community-dwelling Japanese older adults using a questionnaire-based survey. We analyzed 3070 participants (1657 men, 1413 women; age 66 ± 4 years [mean ± SD]) of the Shizuoka and Daiko studies within the Japanese Multi-Institutional Collaborative Cohort study. We used the Dysphagia Risk Assessment for the Community-dwelling Elderly questionnaire to assess dysphagia risk and the International Physical Activity Questionnaire to assess daily physical activity and leisure-time exercise. Logistic regression analyses were used to evaluate the independent association of the amount of physical activity and leisure-time exercise with dysphagia risk. The proportion of participants with dysphagia risk was 27.5% (n = 844) and the risk was significantly higher in women (29.8%, n = 421) than in men (25.5%, n = 423; P = 0.008). Daily physical activity was not associated with dysphagia risk. A greater amount of leisure-time exercise was associated with lower dysphagia risk (P for trend = 0.003) and individuals in the highest leisure-time exercise quartile had a significantly lower odds ratio (0.68, 95% CI 0.52-0.89) than those in the lowest quartile, even after adjusting for the covariates.

Dysphagia is closely related to frailty in mild-to-moderate Alzheimer's disease

INTRODUCTION

Physical phenotype and the cumulative deficit model are two well-known concepts of frailty. One of the main components of frailty is loss of muscle mass and function, which may also include swallowing muscles, therefore is a risk factor for dysphagia. Since dysphagia is seen starting from the early stages of Alzheimer's Disease (AD), in this study we aimed to reveal the relationship between frailty and dysphagia and dysphagia-related quality of life through Swallow Quality of Life (SwalQoL) tool in patients with AD and compare them with cognitively intact older adults.

METHODS

Comprehensive geriatric assessment, dysphagia evaluation by Eating-Assessment Tool (EAT-10) and SwalQoL questionnaire, and frailty assessment via FRAIL and Clinical Frailty Scale (CFS) were performed on all 101 participants of the study. Thirty-five patients were cognitively intact, 36 patients were diagnosed with mild AD, and 30 patients were diagnosed with moderate AD.

RESULTS

Sex distribution was similar between the groups, however, there was a statistically significant age difference. The prevalence of frailty increased according to both frailty indexes as the cognitive status deteriorated. All parameters of SwalQoL except fear and sleep parameters deteriorated as cognitive status impaired. In quantile regression of the total score of the SwalQoL questionnaire and multivariable logistic regression of EAT-10, frailty, as defined by CFS and FRAIL, was associated with dysphagia and poor quality of life regardless of age, presence of dementia, as well as nutritional status.

CONCLUSION

Swallowing difficulties in AD negatively affects the quality of life, and it is closely related to frailty in mild-to-moderate AD.

Dysphagia and its association with other health-related risk factors in institutionalized older people: A systematic review

BACKGROUND

Dysphagia is considered a geriatric syndrome that is characterized by inability to or difficulty in safely and effectively forming or moving the food bolus toward the esophagus. This pathology is very common and affects approximately 50% of institutionalized older people. Dysphagia is often accompanied by high nutritional, functional, social, and emotional risks. This relationship implies a higher rate of morbidity, disability, dependence, and mortality in this population. This review is aimed at studying the relationship between dysphagia and different health-related risk factors in institutionalized older people.

METHOD

We conducted a systematic review. The bibliographic search was performed in the Web of Science, Medline, and Scopus databases. Data extraction and methodological quality were evaluated by two independent researchers.

RESULTS

Twenty-nine studies met the inclusion and exclusion criteria. A clear relationship between the development and progression of dysphagia and a high nutritional, cognitive, functional, social, and emotional risk in institutionalized older adults was found.

CONCLUSIONS

There is an important relationship between these health conditions that shows the need for research and new approaches to considerations such as their prevention and treatment as well as the design of protocols and procedures that will help reduce the percentage of morbidity, disability, dependence, and mortality in older people.

New horizons in understanding oral health and swallowing function within the context of frailty

Frailty is a complex and multidimensional condition wherein declines in physiologic reserve and function place individuals in a state of heightened vulnerability and decreased resiliency. There has been growing interest in both research and clinical settings to understand how to best define, assess and characterise frailty in older adults. To this end, various models and clinical assessment tools have been used to define and measure frailty. While differences exist among these models and tools, a common unifying theme is a focus on physical function and activity. Notably absent across many available conceptual models and clinical tools are items directly related to oral and swallowing function. This is an important oversight as widespread changes to both oral and swallowing function are evident in older adults. Indeed, emerging evidence suggests many of the functional domains affected in frail older adults, such as nutrition and sarcopenia, have cyclical relationships with impairments in oral (oral hypofunction) and swallowing function (dysphagia) as well. The increasing appreciation for the interrelationships among oral hypofunction, dysphagia and frailty provides an opportunity for refinement of frailty assessment and characterisation in older adults to incorporate metrics specific to oral and swallowing function.

How common is dysphagia in older adults living at home and what are the potential risk factors?

Dysphagia, or difficulty swallowing food or drink, can lead to poorer health outcomes and serious complications such as aspiration pneumonia. Dysphagia can often go undetected and is known to be common amongst hospitalised older adults and those living in institutional care. Less is known about the prevalence of dysphagia amongst older adults who live at home. This commentary critically appraises a systematic review that determines prevalence rates and risk factors for dysphagia in the community-dwelling elderly.

Editorial: Social Determinants of Maintaining Nutrition in Older Adults with Advanced Dementia

Dysphagia is recognised as part of the frailty syndrome, especially for those at the end of life. There is a tension in management between the need to optimize nutrition status as part of the management of oral frailty, and respecting the wishes of patients and/or family members in the form of advance care planning and advance directives regarding to artificial nutrition and hydration. Management will likely be influenced by many social determinants, rather than solely be based on evidence from clinical research.

Dysphagia is associated with worse clinical outcomes in geriatric trauma patients

Introduction

Dysphagia is associated with increased morbidity, mortality, and resource utilization in hospitalized patients, but studies on outcomes in geriatric trauma patients with dysphagia are limited. We hypothesized that geriatric trauma patients with dysphagia would have worse clinical outcomes compared with those without dysphagia.

Methods

Patients with and without dysphagia were compared in a single-center retrospective cohort study of trauma patients aged ≥65 years admitted in 2019. The primary outcome was mortality. Secondary outcomes included intensive care unit (ICU) length of stay (LOS), hospital LOS, discharge destination, and unplanned ICU admission. Multivariable regression analyses and Bayesian analyses adjusted for age, Injury Severity Score, mechanism of injury, and gender were performed to determine the association between dysphagia and clinical outcomes.

Results

Of 1706 geriatric patients, 69 patients (4%) were diagnosed with dysphagia. Patients with dysphagia were older with a higher Injury Severity Score. Increased odds of mortality did not reach statistical significance (OR 1.6, 95% CI 0.6 to 3.4, p=0.30). Dysphagia was associated with increased odds of unplanned ICU admission (OR 4.6, 95% CI 2.0 to 9.6, p≤0.001) and non-home discharge (OR 5.2, 95% CI 2.4 to 13.9, p≤0.001), as well as increased ICU LOS (OR 4.9, 95% CI 3.1 to 8.1, p≤0.001), and hospital LOS (OR 2.1, 95% CI 1.7 to 2.6, p≤0.001). On Bayesian analysis, dysphagia was associated with an increased probability of longer hospital and ICU LOS, unplanned ICU admission, and non-home discharge.

Conclusions

Clinically apparent dysphagia is associated with poor outcomes, but it remains unclear if dysphagia represents a modifiable risk factor or a marker of underlying frailty, leading to poor outcomes. This study highlights the importance of screening protocols for dysphagia in geriatric trauma patients to possibly mitigate adverse outcomes.

Level of evidence

Level III.

Frequency and associated factors for swallowing impairment in community-dwelling older persons: a systematic review and meta-analysis

INTRODUCTION

Swallowing impairment (SI) is an underdiagnosed dysfunction frequently seen as an expected condition of aging. However, SI can lead to health complications and considerable social impact.

METHODS

The objective of this systematic review with meta-analysis was to evaluate the frequency and associated factors with SI in community-dwelling older persons. Searches were performed in 13 electronic databases including MEDLINE and EMBASE (from inception to September 18, 2021). Data extraction and methodological quality assessment of included studies were performed by two independent reviewers. Meta-analysis of proportions with 95% confidence interval (CI) and prediction interval (PI) was used to pool estimates. Subgroup analysis by Country and Assessment Method was performed. General meta-analysis was used to pool measures of association between potential risk factors and SI occurrence (odds ratio [OR] or prevalence ratio [PR]).

RESULTS

The worldwide estimated frequency of SI in community-dwelling older persons was 20.35% (95%CI 16.61-24.68%, 95%PI 4.79-56.45, I² 99%, n = 33,291). This estimation varied across assessment methods and by country. The main factors associated with SI were a dry mouth (OR 8.1, 95%CI 4.9-13.4), oral diadochokinesis (OR 5.3, 95%CI 1.0-27.3), ≥ 80 years old (OR 4.9, 95%CI 2.6-9.2), genetic factor (SNPrs17601696) (OR 4.8, 95%CI 2.7-8.3), and partial dependence (OR 4.3, 95%CI 2.0-9.3). And the main factors associated with SI estimated by PR were dry mouth sensation (PR 4.1, 95%CI 2.6-6.5), oral sensorimotor alteration (PR 2.6, 95%CI 1.4-4.9), osteoporosis (PR 2.51, 95%CI 1.2-5.3), and heart diseases (PR 2.31, 95%CI 1.1-5.0).

CONCLUSION

One in five older adults worldwide are expected to experience SI and factors associated with this underdiagnosed dysfunction included biological and physiological changes related to aging, physical and psychological conditions, and poor oral health. Early assessment is paramount for the prevention of future clinical complications and should be a high priority in health care practices.

Association of Oral Function and Dysphagia with Frailty and Sarcopenia in Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis

Studies investigating the associations of oral function and dysphagia with frailty and sarcopenia in community-dwelling older adults are increasing; however, they have not been systematically summarized. We conducted a systematic review to investigate these associations. We searched electronic databases and synthesized relevant data using conventional (frequentist-style) and Bayesian meta-analyses. Twenty-four studies were found to be eligible for our review, including 20 cross-sectional and four prospective cohort studies. Older adults with frailty or sarcopenia had lower tongue pressure, according to the results of conventional meta-analysis (mean difference [95% confidence interval or credible interval]: -6.80 kPa [-10.22 to -3.38] for frailty and -5.40 kPa [-6.62 to -4.17] for sarcopenia) and Bayesian meta-analysis (-6.90 kPa [-9.0 to -4.8] for frailty, -5.35 kPa [-6.78 to -3.89] for sarcopenia). People with frailty had a higher odds ratio (OR) for dysphagia according to the results of conventional meta-analysis (3.99 [2.17 to 7.32]) and Bayesian meta-analysis (1.38 [0.77 to 1.98]). However, the results were inconclusive for people with sarcopenia. A prospective association could not be determined because of the lack of information and the limited number of studies. Decreased oral function and dysphagia can be important characteristics of frailty and sarcopenia in community-dwelling older adults.

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.

Screening for frailty and sarcopenia in community-dwelling older adults: a cross-sectional study from the Eastern Black Sea region of Turkey

AIM

The purpose of this study was to investigate the prevalence of frailty, sarcopenia and associated factors among community-dwelling older adults living in the Eastern Black Sea region of Turkey.

METHODS

The study sample comprised 404 community-dwelling older adults living in the Eastern Black Sea region of Turkey. These subjects or proxies were contacted by mobile phone or the internet. The sociodemographic characteristics, falls and chronic pain were recorded. Frailty, sarcopenia, malnutrition, activities of daily living and instrumental activities of daily living were assessed using the FRAIL scale, SARC-F, Mini Nutrition Assessment-Short Form, Barthel Index and Lawton instrumental activities of daily living scale, respectively.

RESULTS

The 404 older adults comprised 62% females and 38% males with a mean age of 73.4 ± 7.4 years. The prevalence of positive frailty and sarcopenia screening were detected as 37.4% and 46.8%, respectively. The strongest associations with frailty were the presence of chronic lung disease [Odds ratio (OR) = 10.3; 95% confidence interval (CI) = 2.1, 49.8] and chronic pain [OR = 6.9; 95% CI = 3.2, 15.0]. The associations with sarcopenia were falls (OR = 7.4; 95% CI = 4.2, 12.9), dependence in instrumental activities of daily living (OR = 4.3; 95% CI = 2.2, 8.4), advancing age (OR = 2.6; 95% Cl = 1.4, 4.7), and dependence in daily living activities (OR = 2.2; 95% Cl = 1.3, 4.0). Female gender and falls were found to be co-related factors for frailty and sarcopenia.

CONCLUSIONS

Female gender and falls were independently associated with frailty and sarcopenia. In addition, chronic lung disease and chronic pain were major risk factors for frailty, while advancing age and dependence in daily living activities were major risk factors for sarcopenia. These factors should be considered to be able to identify individuals at high risk of frailty and sarcopenia and to prevent these geriatric syndromes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Correlation between Forced Vital Capacity and the Severity of Frailty-Induced Dysphagia

Introduction: Frailty syndrome is a complex condition characterized by the gradual deterioration of an individual’s physical, mental, and social functions. Dysphagia is a dysfunction triggered by frailty. However, in patients with frailty syndrome, dysphagia is often undermined, and a proper evaluation is not performed. Therefore, we tried to identify the factors that can provide proper information regarding dysphagia in the frail population. Methods: Patients with dysphagia were divided into those with frailty-induced dysphagia and those with brain-lesion-induced dysphagia. Factors related to the participants’ pulmonary function test (PFT) results were evaluated. The severity of dysphagia was evaluated by determining modified videofluoroscopic dysphagia scale (mVDS) and penetration−aspiration scale (PAS) scores based on videofluoroscopic swallowing studies. Statistical analysis was performed to determine the correlation between PFT results and the parameters indicating dysphagia severity. Results: Multivariate logistic regression analysis revealed that forced vital capacity (FVC) was significantly correlated with mVDS scores in frailty-induced dysphagia (p < 0.05). However, no such significance was detected in brain-lesion-induced dysphagia (p ≥ 0.05). Conclusion: FVC was correlated with the severity of dysphagia (mVDS scores) in patients with frailty-induced dysphagia. Thus, serial FVC-based follow-up can be helpful for understanding patients’ dysphagia status. However, studies with a general population of patients with frailty-induced dysphagia are needed for definite generalization.

Effects of Presbyphagia on Oropharyngeal Swallowing Observed during Modified Barium Swallow Studies

OBJECTIVES

Understanding how aging impacts swallowing can help differentiate typical from atypical behaviors. This study aimed to quantify age-related swallowing alterations observed during a modified barium swallow study.

DESIGN

Cross-sectional study.

SETTING

Adult fluoroscopy suite in a metropolitan hospital at an academic center.

PARTICIPANTS

195 healthy adults distributed across 3 age categories: 21-39; 40-59; 60+ years.

MEASUREMENTS

17 physiologic components of swallowing across three functional domains (oral, pharyngeal, esophageal), including summed composite scores (Oral Total [OT] and Pharyngeal Total [PT]), from the validated and standardized Modified Barium Swallow Impairment Profile.

RESULTS

Most components (65%) demonstrated no impairment (scores of "0"). The odds of a worse (higher) score increased significantly with age for: Tongue Control during Bolus Hold, Hyolaryngeal Movement, Laryngeal Closure, Pharyngeal Contraction, and Pharyngoesophageal Segment Opening. OT and PT scores for 40-59-year-olds were worse than the youngest group (p=.01 and p <.001, respectively). Adults 60+ years had significantly worse PT scores among all groups (p-values <.01).

CONCLUSION

Oropharyngeal swallowing physiology evolves as healthy adults age and should be considered during clinical decision-making.

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.

Association between swallowing function, malnutrition and frailty in community dwelling older people

BACKGROUND & AIMS

Swallowing function decreases with age and impacts nutritional state and frailty. The aim of the study was to test the relationship between swallowing function, dysphagia, frailty, malnutrition and depression in community dwelling older participants.

METHODS

Community dwelling older participants (n = 180), were enrolled (74 men aged 75.9 ± 7.8, 65-91 years, and 107 women aged 75.9 ± 8.0, 65-95 years). Swallowing function was assessed by the Test of Mastication and Swallowing Solids (TOMASS) and the Timed Water Swallow Test (TWST). Dysphagia was identified using Hebrew 10-Item Eating Assessment Tool (H-EAT-10). Frailty was assessed by grip strength and the FRAIL Questionnaire. The Mini Nutritional Assessment - Short Form (MNA-SF) was used to identify nutritional status. Depression was screened with the Geriatric Depression Scale - Short Form (GDS-SF).

RESULTS

18.3% of the participants had a score of 3 or above in H-EAT-10, indicating suspected dysphagia. 17.8% of the participants were malnourished or at risk of malnutrition, and 48.3% were defined as frail or pre-frail. The odds of being malnourished/at risk of malnutrition were 3 times greater in those with suspected dysphagia. The odds of being frail/pre-frail were also 3 times greater in those with suspected dysphagia. Moreover, suspected dysphagia and frail/pre-frail health status coincided in 69.7% of participants. Participants that were malnourished/at risk of malnutrition required more masticatory cycles (p < .05) and more time (p < .05) to eat a cracker and drink 150 mL of water (p < .05), and had reduced swallowing capacity (volume/sec) in the TWST (p < .05) than those who were at normal nutritional statues. Similar results were found for frail/pre-frail participants versus robust health status. A decrease in grip strength was associated with increased (worse) frailty score, decreased nutritional score, decreased chewing function in TOMASS and decreased water drinking function in TWST (p < .05). MNA-SF score, age, GDS-SF score and EAT-10 were the best predictors of FRAIL score.

CONCLUSION

A simple multi-dimensional screen should be employed by trained allied health professionals, nurses and their assistants to improve early identification and early referral to relevant health providers in order to provide preventive intervention for dysphagia, nutrition, frailty and depression.

Muscle Thickness and Echogenicity Measured by Ultrasound Could Detect Local Sarcopenia and Malnutrition in Older Patients Hospitalized for Hip Fracture

BACKGROUND

The aim of this work was to assess whether the muscle thickness and echogenicity were associated with dysphagia, malnutrition, sarcopenia, and functional capacity in acute hospital admission for a hip fracture.

METHODS

Observational study that assessed nutritional status by Global Leadership Initiative on Malnutrition, risk of dysphagia and sarcopenia by European Working Group on Sarcopenia in Older People and Barthel functional index. We measured muscle thickness and echogenicity of masseter, bicipital, and quadriceps rectus femoris (RF) and vastus intermedius (VI) by ultrasound.

RESULTS

One hundred and one patients were included in the study (29.7% sarcopenia and 43.8% malnutrition). Logistic regression models adjusted for age, sex, and body mass index showed an inverse association of the masseter thickness with both sarcopenia (OR: 0.56) and malnutrition (OR: 0.38) and quadriceps with sarcopenia (OR: 0.74). In addition, patients at high risk of dysphagia had lower masseter thickness (p: 0.0001) while patients able to self-feeding had thicker biceps (p: 0.002) and individuals with mobility on level surfaces higher thickness of biceps (p: 0.008) and quadriceps (p: 0.04).

CONCLUSION

Thickness of the masseter was associated with risk of dysphagia, biceps with the ability to self-feed, and that of the quadriceps RF-VI with mobility.

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.

Profiles of polypharmacy in older adults and medication associations with signs of aspiration

BACKGROUND

Polypharmacy and specific medication classes are prevalent in older adults. Their relationships with swallowing disorders are not well explored, which would best be managed holistically, with consideration of medication profiles. This study aimed to establish profiles of polypharmacy in older adults and investigate the associations of polypharmacy and medication class with signs of aspiration during swallowing.

METHODS

This was a secondary retrospective analysis of data from 291 adults aged 60 years and older. Polypharmacy was profiled numerically and described. Multivariate logistic regression was used to identify associations between medication classes with signs of aspiration, while controlling for independent variables of demographics, functional status, and medical history.

RESULTS

Three distinct profiles of polypharmacy were described. Higher numbers of medications were associated with higher age, lower functional status, nursing home residency, multimorbidity, and showing signs of aspiration. Thirty-four classes of medications were found in this study, benzodiazepines were the only class independently associated with signs of aspiration.

CONCLUSIONS

Different profiles of polypharmacy can be observed in older adults, but none were independently associated with signs of aspiration. In addition to known demographic and functional status variables, benzodiazepine-use was found to be independently associated with signs of aspiration (p = .005, B = 7.94).

Association of swallowing problems with frailty in Chinese hospitalized older patients

Objective

To estimate the prevalence of dysphagia and frailty among hospitalized older patients and to analyze the relationship between dysphagia and frailty in these people.

Methods

Data were collected on 386 participants aged 65 and older in a general hospital from April to December 2017. Patients were asked to complete a self-designed demographic questionnaire. Frailty and swallowing function assessments were performed using the Fried frailty phenotype and the 30-ml water swallowing test, respectively. Multiple stepwise logistic regression analyses were used to identify the association between frailty and dysphagia.

Results

Dysphagia developed in 31.1% of older people, and 24.4% developed frailty. Frailty was statistically significantly related with dysphagia. Dysphagia was more prevalent in frail and pre-frail patients (48.9% and 32.4%, respectively) than those who were non-frail (13.6%). In multivariate analyses, frail（OR, 5.420; 95% CI, 2.684–10.944；P＜0.001） and history of choking/coughing while drinking（OR, 2.954; 95% CI, 1.844–4.733；P＜0.001）were associated with dysphagia.result.

Conclusions

Frailty is associated with dysphagia. More attention should be paid to frailty and dysphagia of the elderly and further studies are needed to evaluate the correlated mechanism and develop targeted nursing interventions.

Effect of TRP-Stimulating Compounds to Reduce Swallowing Response Time in the Elderly: A Systematic Review

There is still controversy on evidence supporting compounds that stimulate the transient receptor potential cation channel (TRP) receptor, which can reduce the latency of swallowing reflex. This systematic review aims to evaluate the effectiveness of TRP-stimulating compounds to reduce swallowing reflex time in the elderly. We searched the following databases: PubMed, EMBASE, OVID, Central, Scopus, ISI, CINALH, LILACS, CRD database, and Open grey until June 1st, 2019. We included randomized controlled trials (RCTs) which compared swallowing time between TRP-stimulating compounds and placebo or no treatment in population aged more than 60 years old. We assessed bias using the Cochrane risk of bias tool. Three authors independently screened and selected studies. Quality assessment and data extraction were performed by two authors independently. Of 363 reviews, we included four RCTs. Two RCTs used black pepper, one RCT used capsaicinoids, and the other one used capsaicin ointment to stimulate the TRPV1 receptor. All of the studies were assessed at unclear bias except the study, which used capsaicin ointment with assessed as low risk of bias. Meta-analysis could not be done in this study due to the different baseline characteristics and definition of swallowing reflex time. This review demonstrates the potential effect of TRPV1-stimulating compounds to reduce swallowing response time in the elderly were remains unclear. Most studies had an unclear bias. Further larger and well-designed RCTs are needed to draw robust conclusions.

Item analysis of the Eating Assessment Tool (EAT-10) by the Rasch model: a secondary analysis of cross-sectional survey data obtained among community-dwelling elders

Background

The Eating Assessment Tool (EAT-10) is increasingly used to screen for self-perceived oropharyngeal dysphagia (OD) in community-dwelling elders. A summated EAT-10 total score ranges from 0 to 40, with a score ≥ 3 indicative of OD. When using cut-points of a summated score, important requirements for the measurements are specific objectivity, validity, and reliability. Analysis by the Rasch model allows investigation of whether scales like EAT-10 satisfy these requirements. Currently, a few studies have found that EAT-10 responses from clinical populations with OD do not adequately fit the Rasch model.

Purpose

The aim of this study was to determine whether measurements by EAT-10 fit the Rasch model when applied in screening self-perceived OD in non-clinical populations.

Methods

Secondary analysis was conducted on data from a cross-sectional survey of community-dwelling elders living in a municipal district of Tokyo, Japan, in which 1875 respondents completed the Japanese version of EAT-10 (J-EAT-10). Data were cleaned and recoded for the purpose of the analysis in this study, which resulted in inclusion of J-EAT-10 responses from 1144 respondents. Data were analyzed using RUMM2030 and included overall model fit, reliability, unidimensionality, threshold ordering, individual item and person fits, differential item functioning, local item dependency, and targeting.

Results

The analysis identified that the response categories from zero to four were not used as intended and did not display monotonicity, which necessitated reducing the five categories to three. Considerable floor effect was demonstrated and there was an inappropriate match between items’ and respondents’ estimates. The person separation reliability (PSI = 0.65) was inadequate, indicating that it is not possible to differentiate between different levels of OD. Several items displayed misfit with the Rasch model, and there were local item dependency and several redundant items.

Conclusions

J-EAT-10 performed less than optimally and exhibited substantial floor effect, low reliability, a rating scale not working as intended, and several redundant items. Different improvement strategies failed to resolve the identified problems. Use of J-EAT-10 in population-based surveys cannot therefore be recommended. For such purpose, alternative screening tools of self-perceived OD should be chosen or a new one should be developed and validated.

Self-reported Swallowing and Nutrition Status in Community-Living Older Adults

More New Zealanders are forecast to grow older in the community, ranging in levels of abilities and needs. Many health conditions can affect swallowing function or nutrition status in older age. However, older adults may not be aware of risk factors and when to seek help. A nationwide survey was conducted of self-reported swallowing ability and nutrition status in community-living New Zealanders aged 65 years and older to assess whether undisclosed swallowing and nutrition problems exist. Respondents completed an amalgamated questionnaire including two validated screening tools: Eating Assessment Tool (EAT-10) and Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN-II). A convenience sample of 1020 adults aged 65-96 years old was obtained. Mean EAT-10 score was 2.15 (SD = 4.3); 22.1% scored above the normative score (3 or more). Mean SCREEN-II score was 48.50 (SD = 6.5); 46.9% scored below normal (< 50 for adults under 85 years old, < 49 for adults over 84 years old). EAT-10 scores significantly correlated with SCREEN-II scores (p < 0.001). Scores did not correlate with age or differ between age groups. Significantly more respondents with medical history associated with dysphagia disclosed swallowing and nutrition problems (p < 0.001). This data suggest increased prevalence of swallowing difficulties in older age is attributed to health conditions and medications, rather than ageing itself. Swallowing complaints from community-living older adults should not be ignored or attributed to the normal ageing process. This study supports routine nutrition screening in older adults.

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.

Association between Skeletal Muscle Strength and Dysphagia among Chinese Community-Dwelling Elderly Adults

OBJECTIVES

Swallowing disorder is a health burden for the elderly in China. This study aimed to investigate the prevalence of dysphagia and to test the association between skeletal muscle strength and swallowing problems among community-dwelling older adults.

DESIGN

A cross-sectional study.

SETTING

Community-dwelling Chinese elderly in China.

PARTICIPANTS

3361 adults aged 65 years or above were involved, among which 1740 (51.8%) were female, with average age of 72.64 (Standard deviation, SD=6.10) years old.

MEASUREMENTS

Handgrip strength (HGS) was used to evaluate skeletal muscle strength. Dysphagia assessment was performed using the Eating Assessment Tool-10 (EAT-10) and the 30mL water swallow test (WST). Binary logistic regression was used to evaluate the relationship between skeletal muscle strength and dysphagia, and covariates as age, gender, material status, etc. were adjusted.

RESULTS

The prevalence of dysphagia were 5.5% and 12.9%, screened by EAT-10 and 30mL WST respectively. Participants with dysphagia showed lower HGS (21.73 ± 9.20 vs. 25.66 ± 11.32, p<0.001, by EAT-10; 20.26 ± 9.88 vs. 26.22 ± 11.28, p<0.001, by WST). The adjusted model suggested that muscle strength is a protective factor for swallowing disorders (adjusted OR=0.974, 95%CI: 0.950-0.999, by EAT-10; adjusted OR=0.952, 95%CI: 0.933-0.972, by WST). Subgroup analyses of WST found the effects were significant among participants aged in 70-74 years group and ≥75 years group, rather than those aged under 70.

CONCLUSION

Dysphagia was significantly associated with skeletal muscle strength among the community-dwelling elderly population. Effective interventions should be taken to manage the decline of muscle strength for the older adults, especially early prevention before 70 years old.