Oropharyngeal dysphagia in older adults: A review

Understanding Dysphagia Care in Pakistan: A Survey of Current Speech Language Therapy Practice

Dysphagia affects individuals across all ages and has pervasive and potentially life-threatening consequences. Individuals with dysphagia are assessed and treated by speech and language therapists (SLTs), however, little attention has been paid to their practices in Pakistan. This study aimed to explore SLTs practices for dysphagia assessment, signs and symptoms observed during evaluation, and management strategies, alongside barriers and facilitators to service delivery in Pakistan. A 45-item survey was distributed to SLTs online. Responses were received from 101 participants and analyzed descriptively, and open-text responses were analyzed using content analysis. Results revealed that 65.3% SLTs worked across the lifespan, and most (79.4%) had dysphagia-related experience of five years or less. SLTs were an active workforce engaged with varying ages, disorders, and settings, yet dysphagia contributed to a small caseload percentage for most. Analyses found informal clinical exams were more frequently used than instrumental assessments. A variety of service provision facilitators were described, such as supportive teams and accessible resources, and responses about barriers revealed gaps in awareness, education, and guidance. This exploratory study presents novel and unexplored data which provides a deeper understanding of dysphagia-related care in Pakistan.

Assessment of oral hypofunction and its association with age among Korean community-dwelling older adults

BACKGROUND

Due to the increasing proportion of older adults in Korea and growing interest in aging, the concepts of oral aging and oral hypofunction have recently been introduced. Thus, it is necessary to investigate the age-specific oral function levels of Korean older adults and develop expert intervention methods for healthy aging.

METHODS

Dysphagia, independence of daily living, and oral hypofunction were assessed in 206 older adults living in Wonju, Gangwon State, South Korea. Subjective dysphagia was assessed through self-report questionnaires using the Dysphagia Handicap Index (DHI), the Korean version of Eating Assessment Tool-10, and the Korean version of the Modified Barthel Index. In addition, the oral hypofunction assessment items included decreased chewing ability, occlusal pressure, tongue pressure, oral dryness, and oral cleanliness.

RESULTS

DHI increased significantly with age, with those in their 80 s reporting the most difficulty swallowing. Oral function in terms of chewing ability (maximum occlusal pressure and number of remaining teeth), maximum occlusal pressure, and maximum tongue pressure also declined with increasing age. While there was no significant difference in oral dryness by age, those in their 80 s had dry mouth according to the criteria of the oral moisture checking device.

CONCLUSIONS

In an assessment of oral function in community-dwelling, independent Korean older adults, the number of items that were assessed as oral hypofunction increased with age. The findings can be used to standardize the oral hypofunction assessment item and develop age-based individualized intervention plans for the early management of oral health and individual oral myofunctional rehabilitation in Korean community-dwelling older adults.

Polysaccharide-dextrin thickened fluids for individuals with dysphagia: recent advances in flow behaviors and swallowing assessment methods

The global aging population has brought about a pressing health concern: dysphagia. To effectively address this issue, we must develop specialized diets, such as thickened fluids made with polysaccharide-dextrin (e.g., water, milk, juices, and soups), which are crucial for managing swallowing-related problems like aspiration and choking for people with dysphagia. Understanding the flow behaviors of these thickened fluids is paramount, and it enables us to establish methods for evaluating their suitability for individuals with dysphagia. This review focuses on the shear and extensional flow properties (e.g., viscosity, yield stress, and viscoelasticity) and tribology (e.g., coefficient of friction) of polysaccharide-dextrin-based thickened fluids and highlights how dextrin inclusion influences fluid flow behaviors considering molecular interactions and chain dynamics. The flow behaviors can be integrated into the development of diverse evaluation methods that assess aspects such as flow velocity, risk of aspiration, and remaining fluid volume. In this context, the key in-vivo (e.g., clinical examination and animal model), in-vitro (e.g., the Cambridge Throat), and in-silico (e.g., Hamiltonian moving particles semi-implicit) evaluation methods are summarized. In addition, we explore the potential for establishing realistic assessment methods to evaluate the swallowing performance of thickened fluids, offering promising prospects for the future.

Evaluation of Social Determinants of Health on Dysphagia Care Pathways at a Tertiary Care Facility

OBJECTIVES

Limited research exists evaluating the impact of social determinants of health in influencing care pathways for patients with dysphagia. A better understanding of whether these determinants correlate to altered care and resource utilization is essential as it relates to patient outcomes.

STUDY DESIGN

Retrospective chart review.

METHODS

All adult patients seen at a tertiary midwestern hospital were screened for ICD codes of dysphagia diagnoses from 2009 to 2019. Demographic information was collected from these patients with dysphagia including sex, race, ethnicity, and insurance status. Subgroup analysis was performed to assess referral pattern rates and types of diagnostic interventions ordered (none, videofluoroscopic swallow study, esophagram, and esophagogastroduodenoscopy).

RESULTS

A total of 31,858 patients with dysphagia were seen at our institution during the study period, with a majority being female (56.36%), Caucasian (79.83%), and publicly insured (63.16%), at a median age of 60.35 years. There were no significant care delivery pattern differences based on geography/zip code analyses. African American patients were significantly more likely to have imaging or interventions performed (odds ratio [OR] 1.463, p = 0.005). Patients with public insurance also had higher rates of diagnostic study utilization (OR 1.53, p = 0.01). Only 3% of all patients with dysphagia were seen by laryngologists.

CONCLUSION

No significant differences were seen in dysphagia evaluation modalities based on zip code analyses surrounding this tertiary care facility. African American patients and those with public insurance had significantly higher utilization of subsequent testing and intervention for dysphagia care. Further studies are necessary to delineate causes and outcome differences for these measurable differences in dysphagia care pathways.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1139-1146, 2024.

History and Science behind the Eating Assessment Tool-10 (Eat-10): Lessons Learned

INTRODUCTION

Oropharyngeal dysphagia (OD) is an underdiagnosed medical condition with a high prevalence in populations such as patients with frailty, neurological disease, or head and neck pathology. Potential barriers to its diagnosis include lack of (or low) awareness of the existence and severity of the condition, the hidden nature of the condition within the 'normal ageing' process, clinical limitations, and socioeconomic reasons. Consequently, an effective treatment is not systematically offered in a timely manner, and complications, such as dehydration and respiratory infections or aspiration pneumonia, can arise. To overcome this issue, the early use of screening questionnaires to identify people at risk of swallowing disorders represents the cornerstone of preventive medicine. Several screening tools have been created but few are widely used in clinical practice. The Eating Assessment Tool-10 (EAT-10) was developed as a quick, easy-to-understand, and self-administered screening tool for OD.

METHODS

A literature review was conducted in five databases with no restrictions on the language, date of publication, or design of the study to identify aspects of the validation, applicability, and usefulness of EAT-10.

RESULTS AND CONCLUSIONS

Transcultural adaptation and translation studies, as well as studies involving various types of patients with dysphagia in different settings have shown the validity and reliability of EAT-10 in relation to the gold standard and other validation tools. The use of this standardised screening tool could be used as a primary screening instrument of dysphagia in routine clinical practice across a wide range of diseases and settings and thereby increase the likelihood of early diagnosis and management of a condition that lead to serious complications and impaired quality of life.

Effect of Dysphagia on the Older Adults' Nutritional Status and Meal Pattern

INTRODUCTION/OBJECTIVES

Dysphagia is a widespread clinical condition among older adults. Although known as a risk factor for nutritional status and dehydration, dysphagia also affects meal patterns. This study aimed to determine the relationship between dysphagia and undernutrition, as well as dietary consumption patterns in older adults.

METHODS

268 older adults (144 women, 124 men) were included in the study. Mini Nutritional Assessment (MNA), dysphagia assessment (EAT-10), oral examination, and Semi-quantitative Food Frequency Questionnaire (SFFQ) were used for collecting data. Odds ratio and Chi square were used to compare independent variables in subjects with and without undernutrition as well as those who intake texture modified and non-texture modified diet.

RESULTS

Mean age of the undernutrition and normal nutrition groups was 68.9 ± 6.1 and 68.8 ± 6.0 years, respectively. The undernutrition group's activities of daily living (ADL) were 19.7 ± 0.9, and the normal nutrition group was 19.8 ± 0.7. Older adults with dysphagia were 4.8 times more likely to experience undernutrition than older adults without dysphagia (95% CI = 1.75-13.13, P = .002). There was a statistically difference between the meal patterns among the dysphagic older adult group and the normal-swallowing older adults' group at the .05 level.

CONCLUSIONS

According to this study, dysphagia was associated with the nutritional status of older adults and dietary patterns. The study results suggested some recommendations for dental health personnel on oral care related to dietary consumption and dietary patterns in older adults.

Screening of dysphagia in geriatrics

BACKGROUND

The oropharyngeal dysphagia is an underestimated symptom with various causes in the geriatric population. Clinical presentation is often insidious and dysphagia symptoms are seldomly mentioned by elderly patients although causing many life-threatening complications. The aim of this work was to introduce an easy applicable tool to be used by the caregivers and general practitioners for screening of dysphagia in geriatrics for early detection of at risk individuals.

METHODS

A sample of 200 Egyptian Arabic-speaking elderly patients (65 years or older) not complaining of dysphagia was recruited from nursing homes in Greater Cairo Area. They or their caregivers completed the designed screening tool, including; the designed questionnaires of dysphagia manifestations and eating habits. General, oral motor and bedside evaluation were also performed. In addition to filling in the EAT10 questionnaire and FEES that was performed for only suspected cases for the purpose of validation of the screening tool.

RESULTS

The dysphagia manifestations questionnaire was significantly correlated with EAT 10 with p value of 0.001. It was correlated in some of its aspects with FEES showing quite reliability with p values' range between 0.012 and 0.044. The Questionnaire of eating habits reliability of r- value of 0.568 slightly exceeding EAT10 reliability of r -value of 0.721 in the subjects under study. The cutoff point of total score of the dysphagia manifestations was > 5, with a sensitivity of 17.65% & a specificity of 94.20%. The cutoff point of total score of the bedside evaluation was ≤ 1 with a sensitivity of 66.9% & a specificity of 56.9%.

CONCLUSION

the use of this easy applicable screening tool managed to suspect and later on diagnose cases with oropharyngeal dysphagia in non-complaining aging subjects.

Designing food for the elderly: the critical impact of food structure

Ageing is an unavoidable progressive process causing many changes of the individual life. However, if faced in an efficient way, living longer in a healthy status could be an opportunity for all. In this context, food consumption and dietary patterns are pivotal factors in promoting active and healthy ageing. The development of food products tailored for the specific needs of the elderly might favour the fulfilment of nutritionally balanced diets, while reducing the consequences of malnutrition. To this aim, the application of a food structure design approach could be particularly profitable, being food structure responsible to the final functionalities of food products. In this narrative review, the physiological changes associated to food consumption occurring during ageing were firstly discussed. Then, the focus shifted to the possible role of food structure in delivering target functionalities, considering food acceptability, digestion of the nutrients, bioactive molecules and probiotic bacteria.

Evaluation of Oropharyngeal Dysphagia in Older Patients for Risk Stratification of Pneumonia

Objective

Nasogastric tube (NGT) and percutaneous endoscopic gastrostomy (PEG) are widely used techniques to feed older patients with oropharyngeal dysphagia. Aspiration pneumonia is the most common cause of death in these patients. This study aimed to evaluate the role of oropharyngeal dysphagia in older patients on long-term enteral feeding for risk stratification of pneumonia requiring hospitalization.

Methods

We performed modified flexible endoscopic evaluation of swallowing to evaluate oropharyngeal dysphagia in older patients and conducted prospective follow-up for pneumonia requiring hospitalization. A total of 664 oral-feeding patients and 155 tube-feeding patients were enrolled. Multivariate Cox analysis was performed to identify risk factors of pneumonia requiring hospitalization.

Results

Multivariate analyses showed that the risk of pneumonia requiring hospitalization significantly increased in older patients and in patients with neurological disorders, tube feeding, and oropharyngeal dysphagia. Subgroup analysis revealed that the risk of pneumonia requiring hospitalization was significantly lower in patients with PEG than in those with NGT among the patients with oropharyngeal dysphagia (adjusted hazard ratio 0.26, 95% confidence interval: 0.11–0.63, P = 0.003).

Conclusions

For older patients with oropharyngeal dysphagia requiring long-term enteral tube feeding, PEG is a better choice than NGT. Further research is needed to elucidate the role of oropharyngeal dysphagia in enteral feeding in older patients.

Endoscopic removal of accidental aspirated and ingested dental foreign bodies: A cross-sectional study

The incidence of accidental ingestion and aspiration of foreign body (FB) is likely to occur. Many FBs are discharged spontaneously, but many dental FBs are often sharp and may remain in the pharynx, esophagus, and stomach, causing serious complications such as hemorrhage, asphyxia, perforation of the digestive tract, mediastinal emphysema, peritonitis, and ileus. We aimed to examine which type of dental foreign bodies can be removed by endoscope.In this study, we enrolled 32 patients who were evaluated at the Emergency and Critical Center between January 2014 and December 2019 and who accidentally ingested or aspirated dental FBs. Medical records were reviewed to determine the patients' sex, age, medical history, time from accidental ingestion of a FB to consultation, cause, location, occurrence status, nature of the FB, location of retained FB, treatment, complications, and outcome.We enrolled 32 patients (14 men, 18 women), with a mean age of 74.5 ± 12.8 years. Accidental ingestion at treatment was common. The most frequent site where the FB was retained was upper gastrointestinal tract (26 cases, 81.3%). In this study, endoscopic removal was indicated for dentures under the size of 43.3 mm, for dental FB (except dentures) more than 13.6 mm. In dentures, between the number of missing teeth, clasp, type, and endoscopic removal was not statistically significant.Dentures under the size of 43.3 mm was likely to be removed by endoscope. Dental FB (except dentures) more than the size of 13.6 mm was likely to be removed by endoscope. There were no indications for endoscopic removal except for size.

Evaluation of Swallowing Function according to the Stage of Alzheimer's Disease

BACKGROUND

Alzheimer's disease (AD) is a progressive neurodegenerative disease, and swallowing difficulties may occur as the disease progresses. Dysphagia has many consequences, such as aspiration and pneumonia. In particular, in the advanced stage, approximately 70% of the causes of death in AD involve aspiration pneumonia. Therefore, it is vital to assess the presence or absence of dysphagia in AD.

OBJECTIVE

This study aims to describe swallowing difficulty across the stages of AD.

METHODS

Thirty-five AD patients were evaluated. The Mini-Mental State Examination was conducted. A bedside water swallow test (BWST) and the Eating Assessment Tool (EAT-10) were administered. Finally, fiberoptic endoscopic evaluation of swallowing was used to evaluate residual, aspiration and penetration conditions.

RESULTS

EAT-10 scores, BWST results, and penetration-aspiration status were statistically significantly different according to AD stage (p < 0.05). Among all patients, 74.3% had residue, 25.7% had penetration, and 2.9% had aspiration.

CONCLUSIONS

This study has demonstrated that swallowing dysfunction begins at a mild stage and progressively worsens toward the advanced stage in patients with AD. At all stages of AD, residue was observed, and this poses a risk for the development of penetration-aspiration. Therefore, it is necessary to evaluate the early dysphagia of individuals.

Translation and transcultural adaptation of the Modified Swallowing Assessment (MSA) to Brazilian Portuguese

PURPOSE

To translate and adapt the Modified Swallowing Assessment (MSA) protocol for post-stroke patients into Brazilian Portuguese.

METHODS

This is an initial stage of the Brazilian Portuguese Modified Swallowing Assessment validation process. Translation was performed by two bilingual speech therapists and the translations synthesis evaluations by two external dysphagia experts. The synthesis version in the target language (Portuguese) was back-translated into the source language (English). After the synthesis of the translated versions, the instrument was applied to 22 post-stroke individuals.

RESULTS

Health professionals discussed all the results of the study stages considering the instrument concept and the target population. The semantic, linguistic and conceptual equivalences found in the translation and adaptation process were adequate, not requiring modifications since the items were consistent with the Brazilian culture.

CONCLUSION

MSA was translated and adapted to Brazilian Portuguese (MSA-BR). The translation and cross-cultural adaptation process included all the items of the original protocol and maintained the standards and characteristics of the instrument.

Incidental Laryngeal Findings on Bedside Flexible Endoscopic Evaluation of Swallowing in a Community Hospital Setting

OBJECTIVE

The purpose of this study was to evaluate the incidence of laryngeal pathology found during bedside flexible endoscopic evaluation of swallowing (FEES) in a community hospital.

METHODS

A retrospective study among patients who underwent a bedside FEES examination from May 2018 to May 2019. Criteria to perform a bedside FEES exam were patients who were identified through nursing screening swallowing evaluation and failed a bedside clinical evaluation of swallowing by a speech language pathologist. Patient demographics, recent intubation, duration of intubation, dysphonia complaints, laryngeal exam findings, consultation to otolaryngology and intervention were reviewed.

RESULTS

Seventy-five patients had an inpatient bedside FEES. All (100%) had subjective complaints of swallowing. 29 (38.66%) had laryngeal pathology identified on FEES examination including unilateral vocal fold immobility (9), fungal infections (6), vocal fold lesion (3), edema (3), erythema (3), vocal process granuloma (2), unilateral TVF Hemorrhage (1), unilateral TVF paresis (1), suspected superior laryngeal nerve palsy (1). Seventeen of the twenty-nine (58.6%) examinations with incidental laryngeal finding received an otolaryngology referral. Twenty-three of the twenty-nine patients with laryngeal findings (79.3%) were intubated during the hospitalization.

CONCLUSION

Bedside FEES is a well-established method to evaluate swallowing function in an inpatient population. Even in a community hospital, routine FEES examinations led to a high rate of detection of clinically significant laryngeal pathology.

Effect of Thermal Processing on Flow Properties and Stability of Thickened Fluid Matrices Formulated by Tapioca Starch, Hydroxyl Distarch Phosphate (E-1442), and Xanthan Gum Associating Dysphagia-Friendly Potential

The flow behavior of the administrated fluid matrices demands careful assessments for stability when consumed by individuals with dysphagia. In the present study, we incorporated tapioca starch (TS), hydroxypropyl distarch phosphate (HDP), and xanthan gum (XG) as thickeners into different nectars (300 ± 20 mPa.s) undergoing thermal processing and evaluated their stability. The thickened nectars presented better water holding and oil binding capacities at 25 °C than 4 °C, and the nectars with TS provided the best results for both capacities as well as the highest solubility index and swelling power (p < 0.05). All prepared nectars appeared to be shear-thinning fluids with yield stress closely fitting the power law and Casson models. XG-containing nectars presented a higher yield stress and consistency index. Matrices thickened by HDP exhibited a higher viscoelastic property compared to those thickened by TS during thermal processing. TS nectars presented viscous behavior, whereas HDP and XG nectars presented elastic behavior at 80 °C processing. The 3 min thermal processing HDP nectars remained stable and met dysphagia-friendly requirements under 4 °C storage for 28 days, regardless of the type of fluid base (distilled water, sport drink, or orange juice). The employed thickeners present adequate physicochemical properties to be potentially utilized for producing dysphagia-friendly formulations.

Better Medicines for Older Patients: Considerations between Patient Characteristics and Solid Oral Dosage Form Designs to Improve Swallowing Experience

Oral drug administration provided as solid oral dosage forms (SODF) remains the major route of drug therapy in primary and secondary care. There is clear evidence for a growing number of clinically relevant swallowing issues (e.g., dysphagia) in the older patient population, especially when considering the multimorbid, frail, and polymedicated patients. Swallowing impairments have a negative impact on SODF administration, which leads to poor adherence and inappropriate alterations (e.g., crushing, splitting). Different strategies have been proposed over the years in order to enhance the swallowing experience with SODF, by using conventional administration techniques or applying swallowing aids and devices. Nevertheless, new formulation designs must be considered by implementing a patient centric approach in order to efficiently improve SODF administration by older patient populations. Together with appropriate SODF size reductions, innovative film coating materials that can be applied to SODF and provide swallowing safety and efficacy with little effort being required by the patients are still needed. With that in mind, a literature review was conducted in order to identify the availability of patient centric coating materials claiming to shorten esophageal transit times and improve the overall SODF swallowing experience for older patients. The majority of coating technologies were identified in patent applications, and they mainly included well-known water soluble polymers that are commonly applied into pharmaceutical coatings. Nevertheless, scientific evidence demonstrating the benefits of given SODF coating materials in the concerned patient populations are still very limited. Consequently, the availability for safe, effective, and clinically proven solutions to address the increasing prevalence of swallowing issues in the older patient population is still limited.

Sensitivity and Specificity of Bedside Screening Tests for Detection of Aspiration in Patients Admitted to a Public Rehabilitation Hospital

Early detection of dysphagia and specifically aspiration is essential to prevent and reduce complications of hospitalized patients in rehabilitation centers. Bedside screening test are often used to evaluate swallowing disorders, but their results may be questionable due to insufficient and inconsistent sensitivity and specificity. To compare the sensitivity and specificity of various bedside screening tests for detecting aspiration in hospitalized rehabilitation patients. A prospective observational study was performed in 150 consecutive patients of a tertiary rehabilitation hospital. Patients were evaluated regarding clinical predictors for aspiration, maximum phonation time (MPT), Eating Assessment Tool 10 (EAT-10) questionnaire, tongue strength and endurance (Iowa Oral Performance Instrument [IOPI]) and a swallowing test (Volume-Viscosity Swallow Test [V-VST]). Flexible Endoscopic Evaluation of Swallowing (FEES) was the reference test. Of the 144 patients included, 22% aspirated on FEES. Previous history of pneumonia, dysarthria, wet voice, and abnormal cough reflex were significantly associated with aspiration. The sensitivity, specificity and accuracy for V-VST (83.3%, 72.6%, 74.8%, respectively) and EAT-10 (82.8%, 57.7%, 62.8%, respectively) to detect aspiration were superior than those of other methods. Maximum tongue strength on IOPI and MPT presented high sensitivity but low specificity to detect aspiration. Clinical predictors of aspiration (previous history of pneumonia, dysarthria, wet voice, and abnormal cough reflex) associated with either V-VST or EAT-10 may be good screening methods to detect aspiration in patients hospitalized in a rehabilitation center.

Texture-Modified Diet for Improving the Management of Oropharyngeal Dysphagia in Nursing Home Residents: An Expert Review

OBJECTIVES

This paper provides evidence-based and, when appropriate, expert reviewed recommendations for long-stay residents who are prescribed texture-modified diets (TMDs), with the consideration that these residents are at high risk of worsening oropharyngeal dysphagia (OD), malnutrition, dehydration, aspiration pneumonia, and OD-associated mortality, poorer quality of life and high costs.

DESIGN

Nestlé Health Science funded an initial virtual meeting attended by all authors, in which the unmet needs and subsequent recommendations for OD management were discussed. The opinions, results, and recommendations detailed in this paper are those of the authors, and are independent of funding sources.

SETTING

OD is common in nursing home (NH) residents, and is defined as the inability to initiate and perform safe swallowing. The long-stay NH resident population has specific characteristics marked by a shorter life expectancy relative to community-dwelling older adults, high prevalence of multimorbidity with a high rate of complications, dementia, frailty, disability, and often polypharmacy. As a result, OD is associated with malnutrition, dehydration, aspiration pneumonia, functional decline, and death. Complications of OD can potentially be prevented with the use of TMDs.

RESULTS

This report presents expert opinion and evidence-informed recommendations for best practice on the nutritional management of OD. It aims to highlight the practice gaps between the evidence-based management of OD and real-world patterns, including inadequate dietary provision and insufficient staff training. In addition, the unmet need for OD screening and improvements in therapeutic diets are explored and discussed.

CONCLUSION

There is currently limited empirical evidence to guide practice in OD management. Given the complex and heterogeneous population of long-stay NH residents, some 'best practice' approaches and interventions require extensive efficacy testing before further changes in policy can be implemented.

A Systematic Review of Physiological Changes in Swallowing in the Oldest Old

Age-related swallowing changes are well-researched in deglutology, usually distinguishing those over 60 years as older aged. World-wide, older adults are healthier and forecast to live longer: many over 85 years. It is necessary for clinicians to understand healthy swallowing changes in this 'oldest old' in order to appropriately manage swallowing complaints in older patients. This systematic review collated and critically appraised studies investigating swallowing changes in adults over 85 years using instrumental assessment. Criteria for inclusion were healthy subjects over 85 years. Exclusion criteria included studies focused on anatomy and oral processing. Studies published until December 2018 were retrieved from BIOSIS, CINAHL, Embase, Medline, and Scopus, totaling 2125 articles. During data screening, 64% of studies investigating age-related swallowing changes were excluded, as the oldest old were not recruited. After PRISMA screening, 44 articles met criteria. These were further reviewed for data extraction, bias and quality. Main quantitative age-related changes in swallowing included increases in delay in swallow onset, bolus transit times, duration of UES opening, pressure above the UES and UES relaxation pressure, and reduction in pressure at the UES. Few studies detected increased residue or airway compromise in the form of aspiration. Results were not easily comparable due to differences in age ranges, methods for deeming participants 'healthy', measures used to define swallowing physiology, and swallowing tasks. Age-related swallowing changes are identified that do not compromise safety. The oldest old are underrepresented in normative deglutition research. It is essential future studies plan accordingly to recruit those over 85 years.

Socio-demographic factors and diet-related characteristics of community-dwelling elderly individuals with dysphagia risk in South Korea

BACKGROUND/OBJECTIVES

The objective of this study was to determine dysphagia risk among community-dwelling elderly people living at home. We also examined the impact of socio-demographic variables on dysphagia risk as well as the relationship between dysphagia risk and dietary characteristics.

SUBJECTS/METHODS

The study sample included 568 community-dwelling individuals, aged 65 years and above, who were living independently in their own home in Seoul, Gyeonggi, or Gwangju in South Korea. We used a dysphagia risk assessment scale to screen for dysphagia risk and the Mini nutritional assessment to evaluate the nutritional status. Associations between dysphagia risk and other variables were assessed using logistic regression analysis.

RESULTS

Of the 568 subjects, 350 (61.6%) were classified into the dysphagia risk group (DR) and 218 (38.4%) were classified into the normal group (non-DR). Being female (odds ratio (OR) = 1.82, 95% confidence interval (CI) = 1.28-2.59), being 75 years and older (OR = 2.40, 95% CI = 1.69-3.42), having a lower education level (OR = 2.29, 95% CI = 1.33-3.97), and having a lower perceived economic status (OR = 2.18, 95% CI = 1.32-3.60) were more frequently observed with dysphagia risk compared to those who did not have such characteristics. Lowered mastication ability (OR = 14.40, 95% CI = 4.43-46.95), being at risk of malnutrition or malnourished (OR = 2.72, 95% CI = 1.75-4.23), lowered appetite (OR = 3.27, 95% CI = 2.16-4.93), and decreased food intake (OR = 2.95, 95% CI = 1.83-4.78) were observed more frequently in the DR group than in the non-DR group when adjusting for potential confounding factors.

CONCLUSIONS

It is necessary to develop and apply integrated programs to improve the dietary habits and nutritional status of elderly individuals at risk for dysphagia, especially for women aged 75 years or older with lower educational and economic levels.

Clinical applications of IDDSI framework for texture recommendation for dysphagia patients

Dysphagia is a highly prevalent eating and swallowing disorder among elderly people, impacting negatively on the health and well-being of those afflicted. With increasing populations of elderly people, food industries are under growing pressure to produce appropriately texture-modified food for safe consumption by these vulnerable populations. Recently published International Dysphagia Diet Standardisation Initiative (IDDSI) framework provides a new global guideline on texture modification and standardization for dysphagia patients. This work was designed to test the feasibility of IDDSI framework for clinical applications by assessing the correlation between swallowing capability of dysphagia patients and the IDDSI texture levels. Altogether 26 elderly subjects were recruited and assessed for their dysphagia grades using the Water Drinking Test. Subjects were provided with fluid samples constituted at different consistencies from a commercial product and swallowing performance (time of swallowing, number of swallows, and number of coughs) was monitored and recorded. Correlations among swallowing capability parameters were observed. Most importantly, results from this work clearly demonstrated that the severity of dysphagia by water-based swallow tests correlates positively with the IDDSI fluid thickness aimed at reducing dysphagia symptoms in those patients, confirming the reliability and feasibility of IDDSI framework for clinical applications.

PRACTICAL APPLICATIONS

Swallowing disorder or dysphagia occurs commonly among many elderly people and imposes negative impacts on their health and well-being. Medical professionals can diagnose eating and swallowing capability in a qualitative manner, but have difficulty in making diet recommendation because of the lack of texture guidance. This work confirmed the feasibility of IDDSI framework for clinical and bedside applications. The correlation between the capability grades of swallowing and IDDSI texture levels established in this work provides a useful measure for such applications.

Case report of meningiomatosis with aspiration of a dental bridge improved by comprehensive rehabilitation therapy

[Purpose] The aim of this study was to ascertain the effect of comprehensive rehabilitation therapy on a quadriplegic patient with meningiomatosis and severe dysphagia. [Subject and Methods] Meningiomatosis is defined as multiple meningiomas involved in several intracranial regions, which occurs more frequently in elderly patients. The prognosis of meningiomatosis is mostly reported as benign, but the prognosis for some malignant cases can be poor. Furthermore, dysphagia in elderly patients with brain lesions may lead to foreign body aspiration, which can be fatal. The removable type of dental prosthesis is a common cause of aspiration, but aspiration is rare with the fixed type. [Results] This report presents a rare case of bronchial aspiration involving a fixed dental prosthesis in an elderly meningiomatosis patient that was improved following comprehensive rehabilitation therapy. [Conclusion] Thorough evaluation and individualized assessment of rehabilitation goals is recommended for the care of severe comorbid elderly patients.

The effect of aging on mastication and swallowing parameters according to the hardness change of solid food

As part of the aging process, multiple oral physiologic changes occur and these changes may cause individuals to reduce food intake or switch the types of food texture. Thus, the need to develop food products for the elderly has increased. To evaluate the suitability of the food products for the elderly, the evaluation method should be verified and it is important to identify the parameters of mastication and swallowing. Therefore, the purpose of this study was to compare the differences of mastication and swallowing parameters between the young adults and the elderly depending on the varying hardness of rice food product. Subjects included 20 young adults and 40 elderly and bolus transit times of video-fluoroscopic swallowing study (VFSS) were used. Four types of rice products with different hardness were provided including cooked rice, soft-boiled rice, rice gruel and thin rice gruel. In the elderly group, the chewing number, oral processing time, post-faucial aggregation time, valleculae aggregation time (VAT), first subsequence duration and total duration were significantly different according to the changes in food hardness. Of the bolus transit times, the VAT and the second subsequence duration (S-S2) were significantly different between the two groups. These results suggest that VAT and S-S2, key VFSS parameters, as well as the chewing number and total duration are useful tools for evaluating the effect of aging on mastication and swallowing of solid foods.

PRACTICAL APPLICATIONS

In Korea, the aging population is rapidly increasing. According to recent surveys, a large number of elderly Koreans have reported chewing difficulties and many of them are in the state of under-nutrition. As aging progresses, multiple physiologic changes occur in mastication and swallowing functions. These changes may cause individuals to reduce their food intake or switch to soft food products. Therefore, the development of texture-modified food products for the elderly is needed and they should be developed based on the understandings of the physiology of mastication and swallowing according to different rheological properties of food products consumed in Korea, which are quite different from those of the western countries. In this study, we compared the differences of mastication and swallowing parameters between the young adults and the elderly depending on the varying hardness of rice food product.

A Nationwide Study of the Impact of Dysphagia on Hospital Outcomes Among Patients With Dementia

OBJECTIVES

To assess the impact of dysphagia on clinical and operational outcomes in hospitalized patients with dementia.

DESIGN

Retrospective cohort study.

SETTING

2012 Nationwide Inpatient Sample.

PARTICIPANTS

All patients discharged with a diagnosis of dementia (N = 234,006) from US hospitals in 2012.

MEASUREMENTS

Univariate and multivariate regression models, adjusting for stroke and patient characteristics, to assess the impact of dysphagia on the prevalence of comorbidities, including pneumonia, sepsis, and malnutrition; complications, including mechanical ventilation and death; and operational outcomes, including length of stay (LOS) and total charges for patients with dementia.

RESULTS

Patients having dementia with dysphagia (DWD) had significantly higher odds of having percutaneous endoscopic gastrostomy placement during the admission (odds ratio [OR]: 13.68, 95% confidence interval [CI]: 12.53-14.95, P < .001), aspiration pneumonia (OR: 6.27, 95% CI: 5.87-6.72, P < .001), pneumonia (OR: 2.84, 95% CI: 2.67-3.02, P < .001), malnutrition (OR: 2.5, 95% CI: 2.27-2.75, P < .001), mechanical ventilation (OR: 1.69, 95% CI: 1.51-1.9, P < .001), sepsis (OR: 1.52, 95% CI: 1.39-1.67, P < .001), and anorexia (OR: 1.29, 95% CI: 1.01-1.65, P = .04). Mean LOS was 2.16 days longer (95% CI: 1.98-2.35, P < .001), mean charge per case was US$10,703 higher (95% CI: US$9396-US$12,010, P < .001), and the odds of being discharged to a skilled nursing, rehabilitation, or long-term facility was 1.59 times higher (95% CI: 1.49-1.69, P < .001) in the DWD cohort compared to patients having dementia without dysphagia.

CONCLUSION

Dysphagia is a significant predictor of worse clinical and operational outcomes including a 38% longer LOS and a 30% increase in charge per case among hospitalized patients with dementia. Although these findings may not be surprising, this new evidence might bring heightened awareness for the need to more thoughtfully support patients with dementia and dysphagia who are hospitalized.

Swallowing Quality of Life After Zona Incerta Deep Brain Stimulation

OBJECTIVES

The management of Parkinson's disease (PD) has been improved, but management of signs like swallowing problems is still challenging. Deep brain stimulation (DBS) alleviates the cardinal motor symptoms and improves quality of life, but its effect on swallowing is not fully explored. The purpose of this study was to examine self-reported swallowing-specific quality of life before and after caudal zona incerta DBS (cZI DBS) in comparison with a control group.

METHODS

Nine PD patients (2 women and 7 men) completed the self-report Swallowing Quality of Life questionnaire (SWAL-QOL) before and 12 months after cZI DBS surgery. The postoperative data were compared to 9 controls. Median ages were 53 years (range, 40-70 years) for patients and 54 years (range, 42-72 years) for controls.

RESULTS

No significant differences were found between the pre- or postoperative scores. The SWAL-QOL total scores did not differ significantly between PD patients and controls. The PD patients reported significantly lower scores in the burden subscale and the symptom scale.

CONCLUSIONS

Patients with PD selected for cZI DBS showed good self-reported swallowing-specific quality of life, in many aspects equal to controls. The cZI DBS did not negatively affect swallowing-specific quality of life in this study.

A randomised trial of the effect of different fluid consistencies used in the management of dysphagia on quality of life: a time trade-off study

BACKGROUND

thickened fluids are commonly advised to minimise the risk of aspiration in people with dysphagia, although many do not comply with this treatment. In health economics, utilities are values that reflect an individual's preferences for different health states. We examined the healthcare utilities, elicited using a time trade-off approach (TTO), from healthcare professionals and non-dysphagic patients, associated with long-term use of thickened fluids.

METHODS

the risk of aspiration with thin fluids was explained to consecutive hospital patients without dysphagia (n = 76) and to a convenience sample of healthcare professionals (n = 75) who were then randomly allocated to drink as much as possible of 200 ml of pre-prepared water of Grade 1 (very mildly thick) or Grade 2 (mildly thick) consistency. A standardised script with a ping-pong approach was then used to elicit TTO utilities for use of thickened fluids using a 10-year horizon.

RESULTS

median (inter-quartile range) utilities were 0.7 (0.5-0.9) for those receiving Grade 1 and 0.5 (0.3-0.7) for those receiving Grade 2 consistency fluid (Mann-Whitney test, P = 0.001). Thus, for example, on average those allocated to Grade 2 fluid would be willing to sacrifice 5 years of a 10-year lifespan not to be restricted to fluid of that consistency. There were no significant differences between patient and professional values.

CONCLUSION

patients and professionals judge that long-term use of thickened fluids would significantly impair quality of life. Utilities associated with more viscous fluids are particularly low.

Risk of swallowing-related chest infections in patients with nasopharyngeal carcinoma treated with definitive intensity-modulated radiotherapy

BACKGROUND

Pulmonary complications secondary to dysphagia may be encountered in patients with nasopharyngeal carcinoma (NPC) after definitive intensity-modulated radiotherapy. The purpose of this study was to identify patients with NPC at risk of developing swallowing-related chest infections (SRCIs).

METHODS

Retrospective chart review was performed on 217 patients with stage I to IVB NPC treated definitively with radiotherapy or chemoradiotherapy.

RESULTS

Twenty-six patients (12.0%) developed SRCIs; 4 of these patients (15.3%) required intensive care unit (ICU) admission and 9 (34.6%) died of the complication. The median time interval between completions of radiotherapy to the development of SRCIs was 24.5 months. Advanced age, recurrent disease, and concurrent chemoradiotherapy were significantly associated with the development of SRCIs in the multivariable analysis.

CONCLUSION

SRCI is a common and potentially fatal complication for postirradiated patients with NPC. Advanced age, concurrent chemoradiotherapy, and recurrent cancer were strong risk factors for postirradiated patients with NPC to develop SRCIs. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1660-E1665, 2016.

Associations between chronic diseases and choking deaths among older adults in the USA: a cross-sectional study using multiple cause mortality data from 2009 to 2013

OBJECTIVES

To examine whether the strengths of the associations between chronic diseases and overall choking differ from those of the associations between chronic diseases and only food-related choking.

DESIGN

This cross-sectional study used nationwide multiple cause mortality files.

SETTING

The USA.

PARTICIPANTS

Older adults aged 65 years or more died between 2009 and 2013.

MAIN OUTCOME MEASURES

Mortality ratio (observed/expected) of number of deaths from both causes (chronic diseases and choking) and 95% CIs.

RESULTS

We identified 76543 deaths for which the death certificates report choking (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes W78, W79 and W80 combined) as a cause of death and only 4974 (6.5%) deaths were classified as food-related choking (ICD-10 code W79). Schizophrenia, Parkinson's disease, Alzheimer's disease and oral cancer are four chronic diseases that had significant associations with both overall and food-related choking. Stroke, larynx cancer and mood (affective) disorders had significant associations with overall choking, but not with food-related choking.

CONCLUSIONS

We suggest using overall choking instead of only food-related choking to better describe the associations between chronic diseases and choking.

[Position paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery and the German Society of Phoniatrics and Pediatric Audiology - current state of clinical and endoscopic diagnostics, evaluation, and therapy of swallowing disorders in children and adults]

Position Paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery and the German Society of Phoniatrics and Pediatric Audiology - Current State of Clinical and Endoscopic Diagnostics, Evaluation, and Therapy of Swallowing Disorders in Children and AdultsSwallowing disorders are frequent. The main concern is mortality due to aspiration induced pneumonia and malnutrition. On the other hand quality of life is severely affected. The demographic trend indicates an increase of dysphagia in the future. Neurodegenerative diseases, tumors of the digestive tract and sequelae of tumor treatment in the head and neck region are the main pathologic entities.Predominantly ENT physicians and phoniatrists, are asked for diagnostics and therapy who will coordinate the interdisciplinary treatment according to the endoscopic findings.A differentiated approach in history, diagnostics, and symptom oriented treatment is necessary for the mostly complex disorders. The integration of non-medical personnel such as logopeds (speech language pathologists), physiotherapists, and occupational therapists in planning and executing an effective therapy expands and completes the patient-oriented care. Conservative treatment by these therapists is an important pillar in the treatment. Parts of the specific diagnostics can be taken over by them in close cooperation.In particular an interdisciplinary cooperation with the staff from intensive care medicine is indispensable.The diagnostic procedures of specific endoscopy as described in this position paper are part of the primary and fundamental tasks of ENT specialists and phoniatrists.Endoscopy is a medical service that is basically not delegable. Consequently substitution of the physician is precluded.

Translation and cross-cultural adaptation of the Northwestern Dysphagia Patient Check Sheet to Brazilian Portuguese

PURPOSE

To present the translation and cross-cultural adaptation of the Brazilian version of the Northwestern Dysphagia Patient Check Sheet (NDPCS).

METHODS

The translation to Portuguese was performed by two Brazilian bilingual speech language pathologists, followed by a back translation conducted by a bilingual native speaker of the original language. Afterwards, the three versions were compared by a committee of three speech language pathologists. Initially, the final translated version of the NDPCS was applied with 35 volunteers aged between 62 and 92 years old (74.77±7.08), who had no dementia or complaints of swallowing disorder. After some adjustments, the instrument was applied with other 27 volunteers aged between 60 and 87 years old (76.56±7.07) with the same profile.

RESULTS

There was divergence in semantic equivalence in relation to one item, which was modified in the translated version. The tasks requested for observation during deglutition were adapted in relation to the solid food and the volumes used in pudding and liquid consistencies. The instrument maintained the same structure as the original version, with five categories and into 28 items, three brief variables, and four closures.

CONCLUSION

The equivalence between the original and the translated version of the NDPCS was preserved after its translation and adaptation to Brazilian Portuguese. The validation process of the psychometric properties of the instrument is in progress.

Designing food structures for nutrition and health benefits

In addition to providing specific sensory properties (e.g., flavor or textures), there is a need to produce foods that also provide functionality within the gastrointestinal (GI) tract, over and above simple nutrition. As such, there is a need to understand the physical and chemical processes occurring in the mouth, stomach, small intestine, and large intestine, in addition to the food structure-physiology interactions. In vivo techniques and in vitro models have allowed us to study and simulate these processes, which aids us in the design of food microstructures that can provide functionality within the human body. Furthermore, it is important to be aware of the health or nutritional needs of different groups of consumers when designing food structures, to provide targeted functionality. Examples of three groups of consumers (elderly, obese, and athletes) are given to demonstrate their differing nutritional requirements and the formulation engineering approaches that can be utilized to improve the health of these individuals. Eating is a pleasurable process, but foods of the future will be required to provide much more in terms of functionality for health and nutrition.