Swallowing function in advanced age

Predictive Factors Associated with Future Decline in Swallowing Function among Japanese Older People Aged ≥ 75 Years

Predictive factors associated with a decline in swallowing function after 2 years were examined in 3409 Japanese older people aged ≥ 75 years who had undergone a dental checkup in Gifu Prefecture, Japan. Participants with normal swallowing function in a baseline survey in April 2018 were followed for 2 years. Swallowing function was assessed using a repetitive saliva swallowing test. In our study, 429 participants (13%) who were swallowing less than three times in 30 s based on a repetitive saliva swallowing test after 2 years were diagnosed as those with decline in swallowing function. Multivariate logistic regression analyses showed the decline in swallowing function after 2 years was associated with the male gender (odds ratio [ORs]: 0.772; 95% confidence interval [CIs]: 0.615-0.969), age ≥ 81 years (presence; ORs: 1.523; 95% CIs: 1.224-1.895), support/care-need certification (presence; ORs: 1.815; 95% CIs: 1.361-2.394), periodontal pocket depth (PPD) ≥ 4 mm (presence; ORs: 1.469; 95% CIs: 1.163-1.856), difficulty in biting hard food (yes; ORs: 1.439; 95% CIs: 1.145-1.808), choking on tea and water (yes; ORs: 2.543; 95% CIs: 2.025-3.193), and dry mouth (yes; ORs: 1.316; 95% CIs: 1.052-1.646) at baseline. Therefore, the dental checkup items associated with a decline in swallowing function after 2 years were a PPD ≥ 4 mm, difficulty in biting hard food, choking on tea and water, and dry mouth. PPD status and confirming to the self-administered questionnaire about biting, choking, and dry mouth may be useful in predicting future decline in swallowing function.

Food Processing and Nutrition Strategies for Improving the Health of Elderly People with Dysphagia: A Review of Recent Developments

Dysphagia, or swallowing difficulty, is a common morbidity affecting 10% to 33% of the elderly population. Individuals with dysphagia can experience appetite, reduction, weight loss, and malnutrition as well as even aspiration, dehydration, and long-term healthcare issues. However, current therapies to treat dysphagia can routinely cause discomfort and pain to patients. To prevent these risks, a non-traumatic and effective treatment of diet modification for safe chewing and swallowing is urgently needed for the elderly. This review mainly summarizes the chewing and swallowing changes in the elderly, as well as important risk factors and potential consequences of dysphagia. In addition, three texture-modified food processing strategies to prepare special foods for the aged, as well as the current statuses and future trends of such foods, are discussed. Nonthermal food technologies, gelation, and 3D printing techniques have been developed to prepare soft, moist, and palatable texture-modified foods for chewing and swallowing safety in elderly individuals. In addition, flavor enhancement and nutrition enrichment are also considered to compensate for the loss of sensory experience and nutrients. Given the trend of population aging, multidisciplinary cooperation for dysphagia management should be a top priority.

Longitudinal association between oral function and underweight onset among community-dwelling older adults: Role of regular self-weighing

AIMS

Regular self-weighing is effective in weight management and may help to mitigate the risk of underweight among older adults. We examined which factors of oral function are associated with a risk for underweight among community-dwelling older adults and whether regular self-weighing can mitigate that risk.

METHODS

This was a cohort study. Self-administered questionnaires were mailed to 7665 older adults in March 2019 (response rate 74.3%) and 7591 in March 2020 (response rate 74.7%). Among those who responded to both surveys, 3594 older adults who were not underweight in March 2019 were included (follow-up rate: 59.2%). We examined the association between dysphagia, poor masticatory function, and dry mouth and the development of underweight, and whether regular self-weighing reduced the risk for underweight.

RESULTS

The average age ± standard deviation of participants was 71.1 ± 3.4 years. There was a significant association between swallowing difficulty and the occurrence of underweight (odds ratio = 1.65, p = .012). However, this relationship did not differ significantly with regular self-weighing (p = .477).

CONCLUSIONS

These study findings suggest that to prevent underweight among community-dwelling older adults, it is important to focus on those with poor swallowing function.

Validation of dysphagia perception to predict the risk for dysphagia in non-institutionalized older adults

BACKGROUND AND AIMS

Dysphagia is a swallowing disorder that affects mainly the older adults and can compromise quality of life, and increase the risk for malnutrition and aspiration. Early diagnosis is, therefore, essential to prevent adversities. We aimed to evaluate the validity of self-perceived dysphagia in community-dwelling older adults (60 years or older) from Pelotas, Brazil, participants in the "COMO VAI?"

STUDY

METHODS

The Eating Assessment Tool (EAT-10) was used as the reference tool to identify the risk for dysphagia and the self-perception of dysphagia was assessed using the following question: "Do you have swallowing difficulties?" (Yes/No). The parameters of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were described with 95% confidence intervals (95% CI) and according to independent variables (sex, age, economic level, and education).

RESULTS

The prevalence of dysphagia risk according to EAT-10 and self-perception was 12.9% (95% CI 10.2-16.1) and 8.8% (95% CI 6.6-11.6), respectively. Sensitivity was 34.8% (95% CI 23.5-47.6) and the highest values were observed in women and the older individuals (80 years or older). Specificity was 95.1% (95% CI 92.6-96.9). PPV was 51.1% (95% CI 35.8-66.3), NPV 90.8% (95% CI 87.8-93.2) and accuracy 87.3%.

CONCLUSIONS

Considering the low sensitivity and PPV, the self-perception of dysphagia analyzed with a single question should be used with caution, as an individual at risk for dysphagia may not realize their condition.

Development and Implementation of Integrated Radiologist-Speech Pathologist Report for Modified Barium Swallow Study: Experience at a Multi-hospital Single Health Care System

Dysphagia, or a disorder of swallowing, is very common and is reported in 1 out of 25 adults with approximately 1 million new cases per year in the United States alone. This also disproportionately impacts elderly patients, with a prevalence of 17%. Patients with dysphagia may have severe clinical complications such as starvation, dehydration, and airway obstruction- which may further increase mortality. Hence, timely and accurate diagnosis of dysphagia is hence crucial in management considerations. The gold standard for evaluating and diagnosing dysphagia is a modified barium swallow study (MBSS). The study is typically performed as a collaborative effort between a speech language pathologist (SLP) and a radiologist, who bring their individual skill sets to the table. Current MBSS reporting involves separately dictated and interpreted reports from the SLP and radiologist. In this paper, we elucidate our experience in a multi-institutional healthcare system wherein we have devised a single, integrated report for MBSS, which involves collaborative effort between SLP and the radiologist. We weight the advantages and disadvantages of unified reporting, the challenges of implementing it in a large healthcare system, and note how it can help improve efficiency and deliver unified patient care. We hope that this would be a template for other institutions as well as improve standardization of reporting techniques.

Age-related changes in oral sensitivity, taste and smell

Oropharyngeal sensitivity plays a vital role in the initiation of the swallowing reflex and is thought to decline as part of the aging-process. Taste and smell functions appear to decline with age as well. The aim of our study was to generate data of oral sensitivity in healthy participants for future studies and to analyse age-related changes and their interdependence by measuring oral sensitivity, taste, and smell function. The experiment involved 30 participants younger than and 30 participants older than 60. Sensitivity threshold as a surrogate of oral sensitivity was measured at the anterior faucial pillar by electrical stimulation using commercially available pudendal electrode mounted on a gloved finger. Smell and taste were evaluated using commercially available test kits. Mean sensitivity was lower in young participants compared to older participants (1.9 ± 0.59 mA vs. 2.42 ± 1.03 mA; p = 0.021). Young participants also performed better in smell (Score 11.13 ± 0.86 vs 9.3 ± 1.93; p < 0.001) and taste examinations (Score 11.83 ± 1.86 vs 8.53 ± 3.18; p < 0.001). ANCOVA revealed a statistical association between sensitivity and smell (p = 0.08) that was moderated by age (p = 0.044). Electrical threshold testing at the anterior faucial pillar is a simple, safe, and accurate diagnostic measure of oral sensitivity. We detected a decline of oral sensitivity, taste, and smell in older adults.

Trial registration: Clinicaltrials.gov, NCT03240965. Registered 7th August 2017—https://clinicaltrials.gov/ct2/show/NCT03240965.

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

OBJECTIVES

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

DESIGN

Cross-sectional study.

SETTING

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

PARTICIPANTS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

Fiberoptic Endoscopic Evaluation of Swallowing in Resistant Hypertensive Patients With and Without Sleep Obstructive Apnea

Resistant arterial hypertension (RAH) is strongly associated with obstructive sleep apnea (OSA). Individuals with OSA may have subclinical swallow impairment, diagnosed by instrumental assessments, such as videofluoroscopy and fiberoptic endoscopic evaluation of swallowing (FEES). However, few studies have evaluated this population and included a control group of individuals without OSA. To evaluate, through FEES, the swallowing characteristics of resistant hypertensive patients with and without OSA and to investigate the association between the signs of swallow impairment and OSA. This was an observational study in which individuals with RAH underwent baseline polysomnography and were diagnosed with and without OSA. All participants underwent an initial assessment with the collection of demographic characteristics and FEES. Individuals were divided into 2 groups based on the presence or absence of OSA. Seventy-nine resistant hypertensive patients were evaluated: 60 with OSA (19 with mild OSA, 21 with moderate OSA, and 20 with severe OSA) and 19 without OSA. The most prevalent swallowing differences between groups with and without OSA were piecemeal deglutition, in 61.7% and 31.6%, respectively (p = 0.022); spillage, in 58.3% and 21.1% (p = 0.005); penetration/aspiration, in 55% and 47.4% (p = 0.561); and pharyngeal residue, in 51.5% and 26.3% (p = 0.053). The prevalence of swallow impairment among the participants in this study was 58.3% and 47.4% in the groups with OSA and without OSA, respectively (p = 0.402). This study shows a high prevalence of swallow impairment both in hypertensive patients with OSA and without OSA. The characteristics of swallowing associated with hypertensive patients with OSA are spillage, piecemeal deglutition, and the onset of the pharyngeal phase in the hypopharynx.

The Frequency of Atypical and Extreme Values for Pharyngeal Phase Swallowing Measures in Mild Parkinson Disease Compared to Healthy Aging

Purpose Dysphagia is thought to be prevalent and a leading cause of morbidity and mortality in people with Parkinson disease (PwPD). The aim of this study was to compare the frequencies of atypical and extreme values for measures of swallowing physiology in PwPD and in an age- and sex-matched cohort of healthy adults. Atypical and extreme values were defined, respectively, as values falling in the 25% and 5% tails of the reference distribution for healthy adults under age 60 years. Method A standard videofluoroscopy (VF) protocol was performed in 17 adults with mild PD and 17 age- and sex-matched healthy adults using 20% w/v liquid barium ranging from thin to extremely thick consistency. Blinded VF analysis was performed according to the Analysis of Swallowing Physiology: Events, Kinematics and Timing Method. Frequencies for atypical and extreme values were tabulated by cohort and compared using odds ratios. Results Increased frequencies of atypical values (> 25%) were seen in the PwPD for prolonged swallow reaction time, prolonged time-to-laryngeal-vestibule-closure (LVC), and poor pharyngeal constriction. However, these findings were also observed in the healthy controls. The PwPD showed significantly higher odds of atypical values for narrow upper esophageal sphincter (UES) diameter on thin liquids, a short hyoid-burst-to-UES-opening interval on extremely thick liquids, and prolonged time-to-LVC, LVC duration, and UES opening duration on multiple consistencies. The frequencies of extreme values failed to show any significant cohort differences for any parameter. Conclusions In this study, a group of people with mild PD did not show clear evidence of swallowing impairments distinct from the changes seen in a healthy age-matched control group when odds ratios were used to compare the frequencies of atypical values between PwPD and the control group; only a few parameters showed significant differences. These were findings of significantly higher frequencies in PwPD of prolonged LVC and UES opening duration. Supplemental Material https://doi.org/10.23641/asha.15032241.

Swallowing dysfunction and the onset of fever in older residents with special care needs: a thirteen-month longitudinal prospective study

A decline in swallowing function is frequently observed among older residents in nursing homes. We investigated whether swallowing dysfunction was related to the onset of fever in such individuals. Older residents aged ≥ 65 years from three nursing homes were included in this prospective study conducted from July 2017 to May 2019. The follow-up period was 13 months. The outcome was fever incidence in relation to the swallowing dysfunction. Baseline data on the activities of daily living, cognitive function, swallowing function, respiratory function, tongue pressure, and comorbidity conditions were collected. Dates on which the axillary temperature measured ay of participants was > 37.5 °C during the follow-up period were also recorded. For the statistical analyses, swallowing function assessed by the modified water swallow test (MWST) score was used to divide the participants into three groups: scores ≤ 3, 4, and 5. A total of 52 participants [median age, 89.5 years (67-104)] were enrolled. Kaplan-Meier analysis showed that the average periods until onset of fever in participants with MWST scores of ≤ 3, 4, and 5 were 8.0 (6.0-11.0), 10.0 (7.0-12.0), and 12.0 (10.0-13.0) months, respectively. Cox's proportional hazards regression model revealed that participants with an MWST score ≤ 3 were at a higher risk of fever than those with an MWST score of 5 (hazard ratio 11.5, 95% confidence interval 1.5-63.4, adjusted for possible confounders. The swallowing dysfunction correlated with the risk of fever in older residents of nursing homes.

Ultrasonographic Measurement of Masseter Muscle Thickness Associates with Oral Phase Dysphagia in Institutionalized Elderly Individuals

BACKGROUND & AIMS

Oral phase dysphagia is dependent on ability to chew. As people age, general muscle atrophy contributes to decreased masseter strength. The main objective of this study was to assess the relationship between the thickness of the masseter muscle measured by ultrasonography and the presence of dysphagia in a group of institutionalized elderly people. As a secondary objective, we aimed to establish cutoff points of masseters muscle thickness (MMT) to identify elderly individuals at risk of oral dysphagia.

METHODS

Cross-sectional study of all residents from 3 nursing homes. All individuals underwent ultrasonographic measurements of left and right MMT and were classified according to the presence of dysphagia assessed by both the EAT-10 screening questionnaire and the volume-viscosity swallow test (V-VST).

RESULTS

469 patients (69% women, mean age 84.7 yrs) were recruited. Dysphagia was present in 41.6% and 26% of individuals according the EAT-10 and V-VST, respectively. Multivariate logistic regression showed that 1 mm increase in MMT reduced the risk of dysphagia by 21% according to the EAT-10 tool and by 30% using the V-VST after adjusting for age, sex, mini-nutritional assessment score, and body mass index. We used receiver operative characteristic (ROC) curves to identify cutoff points of MMT to detect dysphagic individuals according to either EAT-10 or V-VST.

CONCLUSIONS

The MMT measured by ultrasonography is reduced in elderly individuals with dysphagia. Based on MMT, clinicians may be better informed about the patients'´ ability to masticate solid foods and identify potential nutrient deficiencies in geriatric settings.

Which Physiological Swallowing Parameters Change with Healthy Aging?

Research suggests there are age-related changes in swallowing that do not constitute impairment ("presbyphagia"). The goal of this study was to explore the influence of age on quantitative measures of healthy swallowing by controlling for the effects of sex and sip volume in order to determine the specific characteristics of presbyphagia. Videofluoroscopy recordings of thin liquid swallows from 76 healthy adults (38 male), aged 21-82 were analysed. Blinded duplicate ratings of swallowing safety, efficiency, kinematics, and timing were made using the ASPEKT method. Hierarchical regression models were used to determine the effects of age, sex, and sip-volume on swallowing. There were no age-related changes in sip volume, number of swallows per bolus, frequency or severity of penetration-aspiration, duration of the hyoid-burst (HYB)-to-upper-esophageal-sphincter (UES) opening interval, time-to-laryngeal-vestibule-closure (LVC), peak hyoid position, hyoid speed, or pharyngeal residue. Significant changes seen with increasing age included: longer swallow reaction time, UES opening duration and LVC duration; larger pharyngeal area at rest and maximum constriction; and wider UES diameter. Male participants had larger sip volume and pharyngeal area at rest. Larger sip volumes were associated with multiple swallows per bolus and shorter hyoid-burst-to-UES opening intervals. These results help to define presbyphagic changes in swallowing that can be expected in healthy older adults up to 80 years of age, and distinguish them from changes that represent impairment. Certain parameters showed changes that were opposite in direction to changes that are usually considered to reflect impairment: longer UES opening, longer LVC duration and wider UES opening. These changes may reflect possible compensations for slower bolus transit. Further research is needed to determine the points along the age continuum where observed age-related changes in swallowing begin to emerge.

Characterization of Geriatric Dysphagia Diagnoses in Age-Based Cohorts

OBJECTIVE

An aging population requires increased focus on geriatric otolaryngology. Patients aged ≥65 years are not a homogenous population, and important physiologic differences have been documented among the young-old (65-74 years), middle-old (75-84), and old-old (≥85). We aim to analyze differences in dysphagia diagnoses and swallowing-related quality-of-life among these age subgroups.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care laryngology clinic.

SUBJECTS AND METHODS

We identified chief complaint, diagnosis, and self-reported swallowing handicap (Eating Assessment Tool [EAT-10] score) of all new patients aged ≥65 years presenting to the Johns Hopkins Voice Center between April 2015 and March 2017. Dysphagia diagnoses were classified by physiologic etiology and anatomic source. Diagnostic categories and EAT-10 score were evaluated as functions of patient age and sex.

RESULTS

Of 839 new patients aged ≥65 years, 109 (13.0%) reported a chief complaint of dysphagia and were included in this study. The most common dysphagia etiologies were neurologic and esophageal. Most common diagnoses were diverticula (15.6%), reflux (13.8%), and radiation induced (8.3%). Diverticula, cricopharyngeal hypertonicity, and radiation-induced changes were associated with higher EAT-10 score (P < .001). Significant differences by sex were found in anatomic source of dysphagia, as men and women were more likely to present with oropharyngeal and esophageal disease, respectively (P = .023). Dysphagia etiology and EAT-10 score were similar across age subgroups.

CONCLUSION

Important differences among dysphagia diagnosis and EAT-10 score exist among patients aged ≥65 years. Knowledge of these differences may inform diagnostic workup, management, and further investigations in geriatric otolaryngology.