Effects of cognitive and motor dual-tasks on oropharyngeal swallowing assessed with FEES in healthy individuals

How do visual, auditory and motor dual-tasking each affect swallowing and chewing function?

BACKGROUND

It can be challenging to perform a second task at the same time as swallowing.

OBJECTIVE(S)

The study aimed to investigate the effect of visual, auditory and motor dual-tasking on swallowing and chewing function in healthy young adults.

METHOD

Right-handed healthy adults without any psychological and cognitive problems were included in the study. Swallowing was evaluated based on the dysphagia limit in different liquid textures such as water and nectar consistencies, and chewing was evaluated by the Test of Masticating and Swallowing Solids. For the second task, visual and auditory performance was assessed using reaction time, and the motor performance was assessed using a bilateral tapping task. Assessments were performed in two steps: baseline and dual-task. For baseline, all evaluation methods were applied individually. After completing the baseline assessment, dual-task assessment were carried out the following day. For dual-task assessment, the swallowing and chewing tasks were performed simultaneously with visual, auditory and motor tasks.

RESULTS

Results showed a significant decrease in dysphagia limit in the nectar consistency, and significant increase in chewing time, visual reaction time and tapping rate (right-left) when compared to baseline and dual-task conditions (χ2(3) = 9.61, p = .02; χ2(3) = 9.02, p = .02; χ2(3) = 28.09, p < .001; χ2(3) = 28.97, p < .001; χ2(3) = 21.56, p < .001, respectively). However, there were no differences in dysphagia limit in the water and auditory reaction time compared to baseline and dual-task conditions (χ2(3) = 3.18, p = .36; χ2(3) = 2.56, p = .50, respectively).

CONCLUSION

Results shedding light on how simultaneous dual tasks can influence swallowing and chewing. Dual-tasking cause a decrease in both swallowing/chewing and the visual/motor performances. These results may provide valuable information for designing interventions or strategies aimed at improving or maintaining optimal swallowing and chewing during in various populations during daily life.

Validation of the DIGEST-FEES as a Global Outcome Measure for Pharyngeal Dysphagia in Parkinson's Disease

Flexible Endoscopic Evaluation of Swallowing (FEES) is one of two diagnostic gold standards for pharyngeal dysphagia in Parkinson's disease (PD), however, validated global outcome measures at the patient level are widely lacking. The Dynamic Imaging Grade of Swallowing Toxicity for Flexible Endoscopic Evaluation of Swallowing (DIGEST-FEES) represents such an outcome measure but has been validated primarily for head and neck cancer collectives. The objective of this study was, therefore, to investigate the validity of the DIGEST-FEES in patients with PD. Content validity was evaluated with a modified Delphi expert survey. Subsequently, 66 FEES videos in PD patients were scored with the DIGEST-FEES. Criterion validity was determined using Spearman's correlation coefficient between the DIGEST-FEES and the Penetration-Aspiration Scale (PAS), the Yale-Residue-Rating-Scale, the Functional-Oral-Intake-Scale (FOIS), and the swallowing-related Unified-Parkinson-Disease-Rating-Scale (UPDRS) items. Inter-rater reliability was determined using 10 randomly selected FEES-videos examined by a second rater. As a result, the overall DIGEST-FEES-rating exhibited significant correlations with the Yale-Valleculae-Residue-Scale (r = 0.84; p < 0.001), the Yale-Pyriform-Sinus-Residue-Scale (r = 0.70; p < 0.001), the FOIS (r =  - 0.55, p < 0.001), and the UPDRS-Swallowing-Item-Score (r = 0.42, p < 0.001). Further, the DIGEST-FEES-safety subscore correlated with the PAS (r = 0.63, p < 0.001). Inter-rater reliability was high for the overall DIGEST-FEES rating (quadratic weighted kappa of 0.82). Therefore, DIGEST-FEES is a valid and reliable score to evaluate overall pharyngeal dysphagia severity in PD. Nevertheless, the modified Delphi survey identified domains where DIGEST-FEES may need to be specifically adapted to PD or neurological collectives in the future.

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.

Normative Reference Values for FEES and VASES: Preliminary Data From 39 Nondysphagic, Community-Dwelling Adults

PURPOSE

The aim of this study was to establish preliminary reference values for the Visual Analysis of Swallowing Efficiency and Safety (VASES)-a standardized rating methodology used to evaluate swallowing safety and efficiency for flexible endoscopic evaluation of swallowing (FEES).

METHOD

FEES were completed in nondysphagic, community-dwelling adults using a standardized protocol of 15 swallowing trials that varied by bolus size, consistency, contrast agent, and swallowing instructions. FEES were blindly analyzed using VASES. Primary outcome measures included bolus location at swallow onset, Penetration-Aspiration Scale (PAS) scores, and percentage-based residue ratings for six anatomic landmarks. Secondary outcome measures included sip size, bite size, and number of swallows.

RESULTS

Thirty-nine healthy adults completed the study, yielding an analysis of 584 swallows. Swallows were initiated with the bolus in the pharynx for 41.8% of trials. PAS 1 was the most common score, accounting for 75.3% of trials, followed by PAS 3, which accounted for 18.8% of trials. When residue was present (> 0%), the amount was relatively small across all anatomic landmarks, with median residue ratings of 2.0% (oropharynx), 1.5% (hypopharynx), 3.0% (epiglottis), 3.0% (laryngeal vestibule), and 3.5% (vocal folds). Five events of aspiration were observed, which were characterized by subglottic residue ratings of 1%, 3%, 10%, 24%, and 90%. The average sip size of self-selected volume cup sips of water was 19.8 ml, and the average bite size of a 3.0-g saltine cracker was 1.33 g. Moreover, 78% of the trials in this study protocol (except 90-ml trials) were completed in a single swallow.

DISCUSSION

The results from this study provide preliminary norms for VASES that could be used as a reference when assessing functional swallowing outcomes during FEES. While this is an important first step in establishing norms for FEES and VASES, clinicians and researchers should be mindful that the normative reference values from this study are from a relatively small study sample (N = 39), with most people below the age of 60 years (n = 30). Future research should expand on these norms by including a greater number of people across the age continuum and with greater racial, ethnic, and gender diversity.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23504325.

Safety and Tolerability of High-Resolution Esophageal Manometry in Children and Adults

INTRODUCTION

While high-resolution manometry (HRM) is widely accepted as a safe procedure, no study has assessed the safety profile of HRM in clinical practice. This study aimed to determine the safety and tolerability of HRM and to investigate potential determinants of intolerability.

METHODS

We obtained HRM procedure reports, demographics, and clinical data (2005-2022) at a tertiary center using electronic chart review. Our primary outcome was HRM tolerability. Multivariable regression was performed to identify associations between the outcome and covariates including age, sex, race, and comorbidities.

RESULTS

A total of 5,107 patients (60.3% female) were included. Of them, 5,050 patients (98.9%) tolerated HRM well and 57 patients (1.1%) did not. Age had a statistically significant effect on tolerance: those younger than 18 years had more than a 5-fold increase in not tolerating HRM compared with those aged 18-79 years (5.77% vs 0.99%; odds ratio [OR] = 5.44, 95% confidence interval [CI] 1.60-18.45; P = 0.007), and those aged 80 years or older were also more likely to terminate HRM (2.43% vs 0.99%; OR = 2.56, 95% CI 1.13-5.76; P = 0.024). While prior foregut surgery had a significant effect on tolerance (OR = 8.06, 95% CI 2.29-28.39; P = 0.001), other factors of race, sex, body mass index, and psychological or cognitive disorders had no significant impact. No serious complications were identified.

DISCUSSION

HRM is safe and well-tolerated with approximately 1 in every 100 patients being unable to tolerate HRM. Intolerance was more commonly seen in children and seniors due to minor symptoms of discomfort without serious complications. These data points are crucial to counsel patients in whom HRM is being considered.

Association between the number of remaining teeth and disability-free life expectancy, and the impact of oral self-care in older Japanese adults: a prospective cohort study

Background

Tooth loss has been reportedly associated with shorter disability-free life expectancy (DFLE). However, no study has explored whether oral self-care offsets reduction in DFLE. The present study aimed to assess the association between oral self-care and DFLE in older individuals with tooth loss.

Methods

Data on the 13-year follow-up from a cohort study of 14,206 older Japanese adults aged ≥ 65 years in 2006 were analyzed. Information on the number of remaining teeth was collected using a questionnaire, and the participants were then categorized into three groups (0–9, 10–19, and ≥ 20 teeth). Additionally, “0–9” and “10–19” groups were divided into two subgroups based on whether they practiced oral self-care. DFLE was defined as the average number of years a person could expect to live without disability, and was calculated by the multistate life table method based on a Markov model.

Results

DFLE (95% confidence interval) was 19.0 years (18.7–19.4) for 0–9 teeth, 20.1 (19.7–20.5) for 10–19 teeth, and 21.6 (21.2–21.9) for ≥ 20 teeth for men. For women, DFLE was 22.6 (22.3–22.9), 23.5 (23.1–23.8), and 24.7 (24.3–25.1), respectively. Practicing oral self-care was associated with longer DFLE, by 1.6–1.9 years with brushing ≥ 2 times a day in people with 0–9 and 10–19 teeth, and by 3.0–3.1 years with the use of dentures in those with 0–9 teeth.

Conclusions

Practicing oral self-care is associated with an increase in DFLE in older people with tooth loss.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03541-2.

Comparison of Simultaneous Swallowing Endoscopy and Videofluoroscopy in Neurogenic Dysphagia

OBJECTIVE

In the evaluation of oropharyngeal dysphagia, instrumental procedures, for example, flexible endoscopic evaluation of swallowing or videofluoroscopic swallowing study, are essential to improve diagnostic accuracy for salient findings such as penetration, aspiration, or pharyngeal residue. To date, it is unclear which of the 2 methods represents the diagnostic gold standard. The aim of this study, therefore, was to compare videofluoroscopy and swallowing endoscopy during a simultaneous swallowing examination in a large cohort of patients with oropharyngeal dysphagia.

DESIGNS

Prospective observational study.

SETTING AND PARTICIPANTS

In this study, 49 patients with oropharyngeal dysphagia (mean age 70.0 ± 10.8 years) were evaluated using simultaneous swallowing endoscopy and videofluoroscopy. Furthermore, the effect of narrow-band imaging in swallowing endoscopy on the assessment of penetration and aspiration was investigated in a subgroup of 19 patients.

MEASURES

The Penetration-Aspiration Scale and the Yale Pharyngeal Residue Severity Rating Scale were rated independently based on both modalities.

RESULTS

Both modalities showed a high correlation between penetration, aspiration, and pharyngeal residue. Causes for a higher score on the Penetration-Aspiration Scale in videofluoroscopy were intradeglutitive events that were not visible in swallowing endoscopy or false-positive events because of the loss of the lateral dimension in videofluoroscopy. A typical reason for a higher score on this scale in swallowing endoscopy was the better visualization of the anatomical structures. Narrow-band imaging in swallowing endoscopy resulted in a higher score on the Penetration-Aspiration Scale for liquids and semisolids in individual cases, although overall there was no statistically significant difference between scores using white light or narrow-band imaging.

CONCLUSIONS AND IMPLICATIONS

Videofluoroscopy and swallowing endoscopy may equally be considered as a diagnostic gold standard for oropharyngeal dysphagia regarding penetration, aspiration, and pharyngeal residue. Narrow-band imaging may increase the sensitivity for penetration and aspiration in individual cases.

Effect of cognitive and motor dual-task on oropharyngeal swallowing in Parkinson's disease

BACKGROUND

Dysphagia frequently occurs in patients with Parkinson's disease (PD) and is associated with severe complications. However, the underlying pathology is poorly understood at present. This study investigated the effect of cognitive and motor dual-task interference on oropharyngeal swallowing in PD.

METHODS

Thirty PD patients (23 men, mean age 65.90 ± 9.32 years, mean Hoehn and Yahr stage 2.62 ± 0.81, mean UPDRS 18.00 ± 7.18) were examined using flexible endoscopic evaluation of swallowing (FEES). FEES was performed during three paradigms: at baseline without interference, during a cognitive dual-task, and during a motor dual-task. Oropharyngeal swallowing function was rated using a score which was validated to detect changes in PD related dysphagia. The three paradigms were compared using a two-way-repetitive-measures-ANOVA and a post-hoc-analysis.

RESULTS

Mean swallowing score in baseline FEES was 10.67 ± 5.89. It significantly increased (worsened) to 15.97 ± 7.62 (p < 0.001) in the motor dual-task and to 14.55 ± 7.49 (p < 0.001) in the cognitive dual-task. Premature bolus spillage and pharyngeal residue both significantly increased during both of the dual-task conditions whereas penetration/aspiration events did not change.

CONCLUSION

Oropharyngeal swallowing in patients with PD is not purely reflexive but requires mental capacity. Additional allocation of attentional resources in the central control of swallowing seems to be an effective compensatory mechanism in PD-related dysphagia: The proposed dual-task protocol may be useful to challenge swallowing functional reserve. Conversely, as a therapeutic strategy, it could be beneficial to focus attention on swallowing and to avoid dual-task situations.