Instrumental Swallowing Assessment in Adults in Residential Aged Care Homes: A Scoping Review

Systematic approach to contextualize findings of flexible endoscopic evaluation of swallowing in neurogenic dysphagia- towards an integrated FEES report

Flexible endoscopic evaluation of swallowing (FEES) is one of the most important methods for instrumental swallowing evaluation. The most challenging part of the examination consists in the interpretation of the various observations encountered during endoscopy and in the deduction of clinical consequences. This review proposes the framework for an integrated FEES-report that systematically moves from salient findings of FEES to more advanced domains such as dysphagia severity, phenotypes of swallowing impairment and pathomechanisms. Validated scales and scores are used to enhance the diagnostic yield. In the concluding part of the report, FEES-findings are put into the perspective of the clinical context. The potential etiology of dysphagia and conceivable differential diagnoses are considered, further diagnostic steps are proposed, treatment options are evaluated, and a timeframe for re-assessment is suggested. This framework is designed to be adaptable and open to continuous evolution. Additional items, such as novel FEES protocols, pathophysiological observations, advancements in disease-related knowledge, and new treatment options, can be easily incorporated. Moreover, there is potential for customizing this approach to report on FEES in structural dysphagia.

Gustatory stimulus interventions for older adults with dysphagia: a scoping review

BACKGROUND

Gustatory stimulus interventions have been shown to improve swallowing function in older adults with dysphagia. However, the optimal intervention strategies as well as their effects and safety remain unclear.

AIMS

To explore current evidence regarding gustatory stimulus interventions for dysphagia in older adults.

METHODS

Nine electronic databases (PubMed, Web of Science, Embase, CINAHL, Cochrane Library, China National Knowledge Infrastructure, Wanfang Database, China Science and Technology Journal Database, and Sinomed) were searched from their inception to August 2022.

RESULTS

This review identified 263 articles, and 15 met the inclusion criteria. The types of gustatory stimulus interventions included spicy (n = 10), sour (n = 3), and mixed (sour-sweet) stimuli (n = 2), with most studies focusing on spicy stimuli. The most frequently reported spicy stimulus was capsaicin. Further, the most commonly reported intervention frequency was thrice a day before meals for 1-4 weeks. The stimuli concentrations and dosages could not be standardized due to the among-study heterogeneity. These studies reported 16 assessment tools and 42 outcomes, which mainly included videofluoroscopy and swallowing response time respectively. More than half of the included studies reported no adverse effects of gustatory stimulus interventions.

CONCLUSION AND DISCUSSIONS

Gustatory stimulus interventions improved swallowing function in older adults with dysphagia. However, assessment tools and outcomes for dysphagia should be standardized in the future, and explore personalized interventions based on different diseases and their stages, to determine the most cost-effective interventions, and to prevent its complications.

Instrumental swallowing assessment in adults in residential aged care homes: Practice patterns and opportunities

OBJECTIVE

To describe practice patterns in the use of instrumental swallowing assessment (ISA) for older adults in residential aged care homes (RACHs).

METHODS

A retrospective audit of medical records of residents living in RACHs in Melbourne, Australia to extract data on speech-language pathologist (SLP) involvement, indications for ISA and ISA practice patterns.

RESULTS

Medical files of 323 residents across four Melbourne facilities were reviewed. 36% (n = 115) of residents were referred to SLP for swallowing assessment. Referral to SLP was related to length of stay (U = 7393.00, p < 0.001), dementia status (χ2 [1] = 7.06, p = 0.008), texture modification (χ2 [1] = 93.34, p < 0.001) and an existing dysphagia diagnosis (χ2 [1] = 112.89, p < 0.001). There were no referrals for ISA and no instances of ISA being used. Among 115 residents who were referred to SLP for swallowing assessment, there were 33 instances where ISA might be clinically relevant according to ISA indicators.

CONCLUSIONS

Instrumental swallowing assessment is not being used for the management of swallowing in RACHs in Australia despite a clinical need for ISA and a potential role for ISA to improve swallowing care quality. Lack of timely ISA may fail to meet the complex health-care needs of older adults living with dysphagia in RACHs, increasing their vulnerability to complications of dysphagia and its management.

Predictors of complete oral feeding resumption after feeding tube placement in patients with stroke and dysphagia: A systematic review

AIMS

The aim was to synthesise and discuss predictors of complete oral feeding resumption after feeding tube placement in stroke patients with dysphagia.

DESIGN

This was a systematic review, following the PRISMA 2020 checklist.

DATA SOURCES

Eight databases (PubMed, Web of Science, Embase, Cochrane, CINAHL, CNKI, WanFang and Vip) were searched for eligible studies from inception up to June 2021.

REVIEW METHODS

The JBI Manual for Evidence Synthesis was used to guide this systematic review. Any cross-sectional survey, longitudinal study, cohort study or case-control study that explored the recovery from tube feeding to complete oral feeding in patients with dysphagia after stroke was included. Qualitative studies, review articles, case reports and conference abstracts were excluded. Two reviewers independently screened and appraised the studies. The Newcastle-Ottawa scale was used for quality assessment. Content analysis was used to categorise factors predicting feeding tube removal in stroke patients with dysphagia.

RESULTS

This review included a total of 15 studies consisting of 1746 participants, of which 2 were case-control studies and 13 were cohort studies. Four studies were rated as having low risk of bias, and the other 11 had high risk of bias. The factors examined in the studies were categorised into demographic characteristics (age and sex), swallowing function (instrumental assessments and non-instrumental assessments), stroke characteristics (stroke severity, past stroke history and location of the stroke), functional status (cognitive function and physical function) and clinical measures (body mass index, geriatric nutritional risk index, white blood cell count and C-reactive protein level).

CONCLUSIONS

The major limitation of this review is the failure to identify predictors of different tube feeding types. Although the current evidence is insufficient to support or oppose the predictive effect of any single factor, these factors are still valuable data for clinical staff that provide information that researchers can use in developing prognostic models. Rigorously designed and high-quality research is needed to further explore the predictive value of these factors.

REGISTRATION

This review was registered prospectively with PROSPERO [CRD42021272552].

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers should strengthen the monitoring of swallowing function in patients with stroke to promote complete oral feeding resumption. As the predictive value of the identified factors is still uncertain, large, well-designed, studies are needed to better clarify the importance of these predictors.

NO PATIENT OR PUBLIC CONTRIBUTION

No patient or public was involved in the design, analysis, preparation or writing of this review.

Complications during Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in 5680 examinations

OBJECTIVE

To evaluate retrospectively the incidence of complications during Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in 5680 examinations.

PATIENTS AND METHODS

5680 patients were evaluated at the Department of Otorhinolaryngology, Audiology and Phoniatrics of Pisa University Hospital between January 2014 and December 2018, involving both inpatients and outpatients. Most common comorbidities included neurological pathologies such as stroke (11.8%), neurodegenerative diseases (28.9%) and a history of previous head and neck surgery (24.6%). The evaluation was conducted by clinicians with experience in swallowing for a minimum of 10 years with the assistance of one or more speech language pathologists.

RESULTS

In all patients studied the endoscope insertion was tolerated and it was possible to visualize the pharyngo-laryngeal structures. Most patients reported discomfort In a minority of patients, complications were recorded, such as anterior epistaxis, posterior epistaxis, vasovagal crises and laryngospasm. Laryngospasm was recorded in patients affected by Amyotrophic Lateral Sclerosis (ALS). Multivariate binary logistic regression showed that discomfort, chronic gastrointestinal diseases, neurodegenerative diseases and brain tumors were risk factors associated with minor complications.

CONCLUSIONS

FEES proved to be easy to perform, well tolerated by the patients and cost-effective. It can be performed at the patient's bedside and it is characterized by low rate of complications. As a matter of fact, normally only discomfort, gagging and/or vomit are reported. Only rarely complications occur, such as anterior or posterior epistaxis episodes or vasovagal crises, but these are still easily managed. Exceptionally, more severe complications are reported: adverse drug reactions to substances such as blue dye (methylene blue) and local anesthetics (not used in our protocol), and laryngospasm.

The Role of Instrumental Swallowing Assessment in Adults in Residential Aged Care Homes: A National Modified Delphi Survey Examining Beliefs and Practices

Many adults in residential aged care homes (RACHs) live with oropharyngeal dysphagia (OD) and its physiological, psychosocial, and economic sequalae. Timely, evidence-based assessment of OD can help healthcare teams to create OD management plans that optimize consumer health and minimize healthcare costs. Instrumental swallowing assessment (ISA), specifically flexible endoscopic evaluation of swallowing (FEES) and videofluoroscopic swallowing studies (VFSS), is generally accepted to be an important component of dysphagia assessment and management in older adults. However, its role in RACHs has not been empirically examined. This study aimed to explore the role and use of ISA in adults in RACHs from the perspective of speech-language-pathologists (SLPs) experienced in a RACH setting and/or FEES and VFSS. A three-round electronic Delphi study was conducted to guide 58 SLPs in Australia towards consensus using a combination of multiple-choice questions, statements with five-point Likert scale agreement options, and open-ended questions. Participants' responses were analyzed using descriptive statistics and content analysis after each survey round. Feedback about group responses was provided before subsequent surveys. Consensus was defined as 70% or greater agreement. Participants reached consensus about obstacles and facilitators to the use of ISA in RACHs. Participants agreed that FEES was a valuable tool in RACHs and that a mobile service model may have advantages over standard off-site assessment. SLPs believed that appropriate governance processes, infrastructure and education were necessary to develop a safe, high-quality service. These views support equitable access to ISA across settings, aligning with person-centered care, re-ablement, and care-in-place.