Sarcopenic Dysphagia with Low Tongue Pressure Is Associated with Worsening of Swallowing, Nutritional Status, and Activities of Daily Living

Measures for Identifying Malnutrition in Geriatric Rehabilitation: A Scoping Review

Malnutrition is a common condition in geriatric rehabilitation settings; however, the accuracy and predictive validity of the measures to identify malnutrition have not been established. The current scoping review followed the Joanna Briggs Institute's evidence synthesis manual and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews checklist. Literature published through September 2023 was searched using MEDLINE and CINAHL. The inclusion criteria selected studies reporting malnutrition measures, which include static body weight and weight loss. Identified tools were classified as nutritional screening tools, nutritional assessment tools, or diagnostic criteria. The domains of each tool/criterion and their accuracy and predictive validity were extracted. Fifty-six articles fulfilled the inclusion criteria, and six nutritional screening tools, three nutritional assessment tools, and three diagnostic criteria for malnutrition were identified. These measures consisted of various phenotypes, e.g., weight loss, causes such as inflammation/disease, and risk factors of malnutrition, e.g., functional impairment. The predictive validity of nutritional screening tools (n = 6) and malnutrition diagnostic criteria (n = 5) were inconsistently reported, whereas those for nutritional assessment tools were scarce (n = 1). These findings highlight the need to distinguish the functional impairment of nutritional origin from that of non-nutritional origin in nutritional assessment procedures, and the need to study the accuracy and the predictive validity of these measures in geriatric rehabilitation patients.

Exploring Oral Function, Protein Intake, and Risk of Sarcopenia: A Scoping Review

INTRODUCTION

Sarcopenia is loss of both muscle mass and function with age and is associated with inadequate protein intake. However, evidence to suggest an association with oral health is less clear.

OBJECTIVE

To scope peer-reviewed published evidence (2000-2022) pertaining to oral function in relation to sarcopenia and/or protein intake in older people.

METHODS

CINAHL, Embase, PubMed, and Scopus were searched. Included were peer-reviewed studies measuring oral function (e.g., tooth loss, salivary flow masticatory function, strength of muscles of mastication, and tongue pressure) and a measure of protein intake and/or a measure of sarcopenia (appendicular muscle mass and function). Full article screening was conducted by 1 reviewer with a random 10% screened in duplicate by a second reviewer. Relevant content pertaining to study type, country of origin, measures of exposure, and outcomes and key findings was mapped and the balance of data showing a positive versus null association of oral health with outcomes charted.

RESULTS

Of 376 studies identified, 126 were screened in full, yielding 32 included texts, of which 29 were original articles. Seven reported intake of protein and 22 reported measures of sarcopenia. Nine distinct oral health exposures were identified, with ≤4 studies relating to any one of these measures. Most data were cross-sectional in nature (27 studies) and from Japan (20 studies). The balance of data showed associations between tooth loss and measures of sarcopenia and protein intake. However, the balance of data pertaining to any association between chewing function, tongue pressure, or indices of oral hypofunction and sarcopenia was mixed.

CONCLUSION

A broad range of oral health measures have been studied in relation to sarcopenia. The balance of data suggests that tooth loss is associated with risk, but data pertaining to the oral musculature and indices of oral hypofunction are mixed.

KNOWLEDGE TRANSFER STATEMENT

The findings of this research will increase awareness among clinicians of the amount and nature of evidence pertaining to the relationship between oral health and risk of compromised muscle mass and function, including data showing that loss of teeth is associated with increased risk of sarcopenia in older people. The findings highlight to researchers the gaps in the evidence and where further research and clarification of the relationship between oral health and risk of sarcopenia is warranted.

Impact of Poor Oral Health Status on Swallowing Function Improvement in Older Dysphagic Patients

Background This study aimed to explore the relationship between poor oral health status and improvement in swallowing function in older patients with dysphagia across various clinical settings, including acute and post-acute care environments. Methods This retrospective cohort study encompassed patients aged 65 years and older with dysphagia. Oral health status was assessed using the oral health assessment tool (OHAT) or the revised oral assessment guide (ROAG). In this study, an OHAT score of ≥3 or an ROAG score of ≥13 indicated poor oral health status. The primary outcome measured was the change in the food intake level scale (FILS) score, which reflects swallowing function, during the observation period. The association between changes in FILS score and poor oral health status was analyzed using a multivariable linear regression model. Results The study included 361 older patients with dysphagia (mean age 82.7 ± 7.7 years; 47.3% male), of whom 82.5% had poor oral health. A negative association was found between poor oral health status and improvement in FILS score at the endpoint (partial regression coefficient: -0.523, 95% confidence interval: -0.99 to -0.06, P=0.026). Conclusions Our findings underscore the negative impact of poor oral health status on the improvement of swallowing function and emphasize the importance of oral health interventions for older patients. Further study on oral health interventions' effects on improving swallowing function in older patients with dysphagia is warranted.

Sarcopenic Dysphagia and Simplified Rehabilitation Nutrition Care Process: An Update

Sarcopenic dysphagia is characterized by weakness of swallowing-related muscles associated with whole-body sarcopenia. As the number of patients with sarcopenia increases with the aging of the world, the number of patients with sarcopenic dysphagia is also increasing. The prevalence of sarcopenic dysphagia is high in the institutionalized older people and in patients hospitalized for pneumonia with dysphagia in acute care hospitals. Prevention, early detection and intervention of sarcopenic dysphagia with rehabilitation nutrition are essential. The diagnosis of sarcopenic dysphagia is based on skeletal and swallowing muscle strength and muscle mass. A reliable and validated diagnostic algorithm for sarcopenic dysphagia is used. Sarcopenic dysphagia is associated with malnutrition, which leads to mortality and Activities of Daily Living (ADL) decline. The rehabilitation nutrition approach improves swallowing function, nutrition status, and ADL. A combination of aggressive nutrition therapy to improve nutrition status, dysphagia rehabilitation, physical therapy, and other interventions can be effective for sarcopenic dysphagia. The rehabilitation nutrition care process is used to assess and problem solve the patient's pathology, sarcopenia, and nutrition status. The simplified rehabilitation nutrition care process consists of a nutrition cycle and a rehabilitation cycle, each with five steps: assessment, diagnosis, goal setting, intervention, and monitoring. Nutrition professionals and teams implement the nutrition cycle. Rehabilitation professionals and teams implement the rehabilitation cycle. Both cycles should be done simultaneously. The nutrition diagnosis of undernutrition, overnutrition/obesity, sarcopenia, and goal setting of rehabilitation and body weight are implemented collaboratively.

Pre-existing sarcopenia and swallowing outcomes in acute stroke patients

BACKGROUND & AIMS

This study aimed to investigate the associations of pre-existing sarcopenia with swallowing function, oral intake level, and aspiration pneumonia in patients with acute stroke.

METHODS

This observational study included patients (≥60 years of age) with acute ischemic stroke or intracerebral hemorrhage within 7 days of onset who were screened for sarcopenia, malnutrition, and swallowing difficulties in a stroke-care unit within 48 h of admission. Sarcopenia was defined by the Asian Working Group on Sarcopenia 2019 as having a low calf circumference, handgrip strength, and appendicular muscle mass index. The primary outcome was impaired oral intake (functional oral intake scale <5 points) at 3, 7, and 14 days after admission, and the secondary outcome was aspiration pneumonia during hospitalization.

RESULTS

We enrolled 350 patients (median age of 77 years; 63% males) who underwent the aforementioned screening. Sarcopenia was diagnosed in 34% of patients, and malnutrition was found in 66% of patients with sarcopenia. When compared with the comparison group (defined as patients with either or both normal calf circumference and handgrip strength), the sarcopenia group had significantly lower tongue pressure and a higher prevalence of dysphagia. Sarcopenia was associated with functional oral intake scale <5 at 7 days (adjusted odds ratio [OR], 4.72; 95% confidence interval [CI], 1.91-11.71); p = 0.002) and 14 days (adjusted OR, 3.93; 95% CI, 1.47-10.53; p = 0.006) and with aspiration pneumonia during hospitalization (adjusted OR, 6.12; 95% CI, 1.63-22.94; p = 0.007).

CONCLUSION

Acute stroke patients with sarcopenia may have weakness of the swallowing-related muscles which may lead to impaired oral intake and aspiration pneumonia.

Evaluation of usefulness of tongue pressure measurement device for dysphagia associated with treatment of patients with head and neck cancer (ELEVATE)

INTRODUCTION

Dysphagia is often caused by radiotherapy (RT) in patients with head and neck cancer (HNC), and reduced tongue pressure (TP) is often associated with swallowing dysfunction in the oral stage. However, the evaluation of dysphagia by measuring TP has not yet been established in HNC patients. Herein, we conducted a clinical trial to evaluate the usefulness of TP measurement using a TP-measuring device as an objective indicator of dysphagia induced by RT in HNC patients.

METHODS AND ANALYSIS

This ELEVATE trial is a prospective, single-center, single-arm, non-blind, non-randomized trial to evaluate the usefulness of a TP measurement device for dysphagia associated with the treatment of HNC. Eligible participants include patients with oropharyngeal or hypopharyngeal cancer (HPC) undergoing RT or chemoradiotherapy (CRT). The TP measurements are conducted before, during, and after RT. The primary endpoint is the change in the maximum TP values from before RT to 3 months after RT. Moreover, as secondary endpoints, the correlation between the maximum TP value and the findings of video-endoscopic and video-fluoroscopic examinations of swallowing will be analyzed at each evaluation point, as well as changes in the maximum TP value from before RT to during RT and at 0, 1, and 6 months after RT.

DISCUSSION

This trial aimed to investigate the usefulness of evaluation by measuring TP for dysphagia associated with HNC treatment. We expect that an easier evaluation for dysphagia will improve rehabilitation programs for dysphagia. Overall, we expect this trial to contribute to the improvement of patients' quality of life (QOL).

Association of poor oral health status and faecal incontinence in patients with dysphagia: A cross-sectional analysis from the Sarcopenic Dysphagia Database

BACKGROUND

Poor oral health status may alter oral and gut microbiota. Previous studies have shown that poor oral health can exacerbate gut inflammation. Therefore, poor oral health status may be related to faecal incontinence via changes in the gut.

OBJECTIVE

To investigate the association between poor oral health status and faecal incontinence in inpatients with dysphagia.

METHODS

This multicentre cross-sectional study included 423 patients (mean age 79.8 ± 11.5 years, 48.2% female) with dysphagia. Oral health status was assessed at each facility using the Oral Health Assessment Tool (OHAT) or the Revised Oral Assessment Guide (ROAG). Poor oral health status was defined as an OHAT score of ≥3 or a ROAG score of ≥13. A multivariate logistic model was used to analyse the association between poor oral health status and faecal incontinence.

RESULTS

A total of 351 (83.0%) patients had poor oral health and 97 (22.7%) had faecal incontinence. Patients with poor oral health status had a higher proportion of faecal incontinence than those with normal oral health status (25.4% vs. 11.1%, p = .009). A multivariate logistic model revealed an association between faecal incontinence and poor oral health status (adjusted odds ratio = 2.501, 95% confidence interval = 1.065-5.873, p = .035).

CONCLUSIONS

Poor oral health status assessed by OHAT or ROAG in inpatients with dysphagia may adversely affect faecal incontinence. Further studies are needed to determine the causal relationship between poor oral health status and faecal incontinence.

Sarcopenia Is Associated with Fecal Incontinence in Patients with Dysphagia: Implication for Anal Sarcopenia

OBJECTIVES

To examine the relationship between sarcopenia and fecal incontinence in patients with dysphagia.

DESIGN

Cross-sectional study using the Japanese sarcopenic dysphagia database.

SETTING

19 hospitals including 9 acute care hospitals, 8 rehabilitation hospitals, 2 long-term care hospitals, and 1 home visit rehabilitation center.

PARTICIPANTS

460 dysphagic patients, aged 20 years and older.

MEASUREMENTS

Sarcopenia was diagnosed by the 2019 criteria of the Asian Working Group for Sarcopenia. Fecal incontinence was assessed by health care professionals at baseline according to the definition of the Japanese Practice Guidelines for Fecal Incontinence. We examined whether there was a significant difference between the rate of fecal incontinence in patients with/without sarcopenia. Age, sex, type of dwelling, Barthel index, Charlson comorbidity index (CCI), calf circumference, handgrip strength, body mass index, malnourishment, C-reactive protein level, serum albumin level, and delivery of enteral nutrition by nasogastric and/or gastrostomy tube were measured. To examine the relationship between sarcopenia and fecal incontinence, logistic regression analysis was performed with adjustments for age, sex, sarcopenia, CCI, enteral nutrition, and dwelling.

RESULTS

The mean age of patients was 81 ± 10 years. Of the 460 study patients, 404 (88%) patients had sarcopenia and 104 had fecal incontinence (23%). The rate of fecal incontinence was higher in the sarcopenia group than the non-sarcopenia group (25% vs. 7%, P = 0.003). Logistic regression analysis showed that sarcopenia was independently associated with fecal incontinence (odds ratio: 3.114, 95% confidence interval: 1.045, 9.282).

CONCLUSION

The prevalence of fecal incontinence was 23% in patients with dysphagia. Sarcopenia was independently associated with fecal incontinence, which suggests the presence of anal sarcopenia. Defecation control should be assessed in patients with sarcopenia.

Delayed Dysphagia May Be Sarcopenic Dysphagia in Patients After Stroke

OBJECTIVE

In many cases, swallowing function is impaired after the onset of stroke and gradually improves. However, delayed dysphagia has been reported in some post-stroke patients. Recently, several studies have reported that low muscle strength and decreased muscle mass cause dysphagia. This study aimed to investigate whether these conditions are associated with delayed dysphagia after stroke.

DESIGN

A multicenter prospective observational cohort study.

SETTING AND PARTICIPANTS

Participants included 165 patients with post-stroke dysphagia (mean age 79.1 ± 8.0 years, 53.3% women) admitted to rehabilitation wards for post-stroke rehabilitation.

METHODS

Swallowing function was assessed using the Functional Oral Intake Scale. Delayed dysphagia was defined as dysphagia that occurred more than 7 days after stroke onset. We used logistic regression to examine the independent association between low muscle strength and decreased muscle mass and delayed dysphagia development. Furthermore, we examined the relationship between improvement in dysphagia and delayed dysphagia.

RESULTS

Delayed dysphagia was observed in 18 (10.9%) patients. The combination of severely low muscle strength and decreased muscle mass was independently associated with the development of delayed dysphagia (adjusted odds ratio: 4.423, 95% confidence interval: 1.400-13.974, P = .011). Delayed dysphagia had an adverse effect on the improvement of dysphagia during in-hospital rehabilitation (adjusted odds ratio: 0.278, 95% confidence interval: 0.078-0.986, P = .047).

CONCLUSIONS AND IMPLICATIONS

The development of delayed dysphagia was influenced by a combination of severely low muscle strength and decreased muscle mass. Furthermore, delayed dysphagia adversely affects the improvement of dysphagia in patients with stroke and needs to be identified early. Identifying delayed dysphagia using the methods proposed in this study and incorporating early intervention may prevent or delay dependency conditions in this population.