Dysphagia and aspiration pneumonia in older adults

Dysphagia is associated with increased mortality risk after hip fracture surgery

PURPOSE

This study aims to explore the prevalence of dysphagia, as well as mortality associated with dysphagia in the elderly population receiving surgical treatment for a hip fracture.

METHODS

A retrospective cohort study was completed at an academic level 1 tertiary care center. Patients older than or equal to 65 admitted with a hip fracture diagnosis from January 2015 to December 2020 (n = 617) were included. The main outcome was the prevalence of dysphagia and association with mortality. Secondary analysis included timing of dysphagia and contributions to mortality.

RESULTS

Fifty-six percent of patients had dysphagia, and the mortality rates were higher in patients with dysphagia (8.9%) versus those without dysphagia (2.6%), chi-square p = 0.001, and odds ratio 3.69 (CI 1.6-8.5). Mortality rates in patients with acute dysphagia were also higher (12.4%) than those with chronic dysphagia (5%) and chi-squared p = 0.02. Mortality rates in patients with a perioperative dysphagic event (13.9%) were higher than those with non-perioperative dysphagia (4%) and chi-squared p = 0.001. Mortality rates in patients who had acute perioperative dysphagia (21.2%) were higher than those with chronic dysphagia that presented perioperatively (6.8%) and chi-squared p = 0.006.

CONCLUSIONS

This study demonstrates high rates of dysphagia in the elderly hip fracture population and a significant association between dysphagia and mortality. Timing and chronicity of dysphagia were relevant, as patients with acute perioperative dysphagia had the highest mortality rate. Unlike other identified risk factors, dysphagia may be at least partially modifiable. More research is needed to determine whether formal evaluation and treatment of dysphagia lowers mortality risk.

Severe aspiration pneumonia in the elderly

The global population is aging at an unprecedented rate, resulting in a growing and vulnerable elderly population in need of efficient comprehensive healthcare services that include long-term care and skilled nursing facilities. In this context, severe aspiration pneumonia, a condition that carries substantial morbidity, mortality, and financial burden, especially among elderly patients requiring admission to the intensive care unit, has attracted greater concern. Aspiration pneumonia is defined as a pulmonary infection related to aspiration or dysphagia in etiology. Prior episodes of coughing on food or liquid intake, a history of relevant underlying conditions, abnormalities on videofluoroscopy or water swallowing, and gravity-dependent shadow distribution on chest imaging are among the clues that suggest aspiration. Patients with aspiration pneumonia tend to be elderly, frail, and suffering from more comorbidities than those without this condition. Here, we comprehensively address the epidemiology, clinical characteristics, diagnosis, treatment, prevention, and prognosis of severe aspiration community-acquired pneumonia in the elderly to optimize care of this high-risk demographic, enhance outcomes, and minimize the healthcare costs associated with this illness. Emphasizing preventive measures and effective management strategies is vital in ensuring the well-being of our aging population.

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.

Factors associated with the oral health status of patients with schizophrenia: A cross-sectional study

BACKGROUND

Oral function deterioration attributed to ageing and medications is one of the main contributory factors of dysphagia. Therefore, oral health management is essential in older patients with schizophrenia. However, no previous studies have evaluated the oral function in patients with schizophrenia.

OBJECTIVE

We surveyed patients with schizophrenia to identify factors associated with ageing-related variations in oral function.

METHODS

This cross-sectional study included 34 male patients diagnosed with schizophrenia who were hospitalised at a psychiatric hospital between July and September 2021 and underwent a screening examination during dental care. The survey items included basic information, oral hygiene information, oral (oral diadochokinesis [ODK] and tongue pressure), physical function, and nutritional status. Thirty-six male community-dwelling older individuals were included as controls, and their outcomes were compared with those of patients with schizophrenia.

RESULTS

Compared with healthy older adults, patients with schizophrenia demonstrated significantly lower teeth numbers, ODK, and calf circumference (CC) (p < .05). Multiple regression analysis revealed that ODK was associated with age and schizophrenia (p < .05). Conversely, tongue pressure was associated with CC (p < .05), suggesting different factors' association with the parameters indicating decreased oral function.

CONCLUSIONS

Our study findings suggest that older patients with schizophrenia have decreased tongue pressure and generalised muscle mass, highlighting the need to manage oral function. Interventions for tongue pressure were more strongly associated with muscle mass and could be easier to manage than those with disease-dependent changes in ODK.

TRIAL REGISTRATION

Retrospectively registered.

The importance of taste on swallowing function

The world's population is aging. Pneumonia is the leading cause of death among the older adults, with aspiration pneumonia being particularly common. Aspiration pneumonia is caused by a decline in swallowing function. Causes can include age-related sarcopenia of swallowing muscles, cognitive decline, cerebrovascular and other diseases or even changes in individual taste preference. Currently, the main treatment approach for dysphagia is resistance training of swallowing-related muscles. This approach has not been effective and establishment of novel methods are required. In this review, we introduce and discuss the relationship between taste, taste preference, carbonation and swallowing function. Taste and preference improve swallowing function. Recently, it has been shown that a carbonated beverage that combines the functionality of a thickening agent, the appeal of taste, and the stimulation of carbonation improves swallowing function. This may be very useful in the recovery of swallowing function. It is important to note that deliciousness is based not only on taste and preference, but also on visual information such as food form. Umami taste receptors are expressed not only in taste buds but also in skeletal muscle and small intestine. These receptors may be involved in homeostasis of the amino acid metabolic network, i.e., the process of amino acid ingestion, intestine absorption, and storage in skeletal muscle. Proper stimulation of umami receptors in organs other than taste buds may help maintain nutritional status and muscle mass. Umami receptors are therefore a potential therapeutic target for dysphagia.

Knowledge, attitudes, and behaviors of dysphagia clinicians regarding oral health-An international study

AIM

The aim of this study was to investigate the knowledge, attitudes, and behaviors of dysphagia clinicians regarding oral health care.

METHODOLOGY AND RESULTS

An 11-question and 37-statement survey inquiring the clinicians' descriptive information, knowledge, attitudes, and behaviors related to oral health was administered via Google forms. A total of 234 dysphagia clinicians responded on behalf of themselves. The findings showed that 41.5% (n = 97) of the clinicians had a high level of knowledge about oral health. There was a significant relationship between the level of oral health knowledge and the clinicians' oral health education (p < .05). A percentage of 6.4 (n = 15) of the clinicians had a high level of attitude toward oral health. Oral health education status of clinicians and their profession was significantly related to the attitude toward oral health (p < .05). Most of the clinicians (44.0%, n = 103) had low behavior level. The level of behavior was significantly associated with status of receiving oral health education, their professions, duration of experience, and institution (p < .05).

CONCLUSIONS

The study showed that clinicians exhibit moderate mean knowledge, attitudes, and behaviors scores, and these states are significantly associated with oral health education. This can serve as a stimulus for clinicians caring for dysphagia patients to receive oral health education during their university education.

Decreased serum creatinine to cystatin C ratio is associated with low tongue pressure

AIM

Tongue strength plays an important role in the process of food intake, and low tongue pressure has been associated with aspiration pneumonia, cognitive decline, and mortality. However, special equipment for tongue pressure measurement is uncommon in general practice. Recently, the serum creatinine-to-cystatin C (Cr/CysC) ratio has been validated as a marker of muscle volume mass. Thus, we aimed to investigate the association of the serum Cr/CysC ratio with tongue pressure in a cross-sectional study.

METHODS

This single-center, cross-sectional study enrolled 73 participants (mean age, 71.7 years; men, 49.3%) who regularly attended the hospital for treatment of chronic disease. A tongue pressure of <30 kPa was defined as low tongue pressure. We evaluated the relationships between the serum Cr/CysC ratio and tongue pressure using multiple regression analysis.

RESULTS

The serum Cr/CysC ratio was correlated with tongue pressure (R2  = 0.25, P < 0.0001). In multiple regression analyses adjusted for confounders including age, sex, body mass index, and serum albumin, the association remained significant (P = 0.0001). In logistic analyses, the multivariable-adjusted odds ratios of the Cr/CysC ratio for tertiles 1 and 2 compared with tertile 3 for low tongue pressure were 7.81 (95% confidence interval, 1.45-51.73) and 2.71 (95% confidence interval, 0.60-13.19), respectively.

CONCLUSIONS

We demonstrated that a decreased serum Cr/CysC ratio was associated with a higher risk of low tongue pressure. Our findings suggest that this simple serum surrogate marker may be a first step toward an intervention for oral function by general practitioners. Geriatr Gerontol Int 2024; 24: 102-108.

Assessing Knowledge, Usage, and Perceptions of the Frazier Free Water Protocol: A Pilot Study

INTRODUCTION

Dysphagia is very common among hospitalized patients and is associated with increased length of hospital stay, morbidity, and mortality. Diet restrictions for dysphagia cause dehydration and discontent. The Frazier Free Water Protocol (FFWP) was developed to improve hydration and quality of life in dysphagia patients by establishing the safety of allowing sips of water between meals. Despite these potential benefits, we hypothesized that the FFWP is not widely utilized. We sought to determine barriers to utilization by assessing the familiarity, usage, and perceptions of the FFWP among health-care providers at our institution.

METHODS

We distributed an anonymous questionnaire to a convenience sample of nurses in the hospital during daily huddles. The questionnaire was adapted from a validated framework to assess provider acceptability of health-care interventions.

RESULTS

Of the 66 surveys distributed, we had 58 completed (88%). Only 10 nurses (17%) had heard of the "FFWP" by name. For those that were familiar with the indications, benefits, and risks of giving free water to patients with dysphagia (n = 18), less than half (39%) reported doing so. No nurses that had less than 10 y of patient care experience gave water to dysphagia patients, even if they knew the indications, benefits, and risks. Similarly, less than a fifth (19%) of all nurses surveyed were comfortable giving water to dysphagia patients, but comfort increased for some if the protocol was recommended by a speech-language pathologist (33%) or physician (13%). Nursing experience of >10 y or in intensive care settings did not yield significant differences in knowledge, usage, or comfort level than those with less years or nonintensive care experience, respectively.

CONCLUSIONS

Nurses are essential to the implementation of the FFWP, yet many are unfamiliar and uncomfortable with utilizing it. Education about the protocol is necessary to improve patient outcomes and quality of life. We plan to provide targeted education about the FFWP as well as assess other members of the health-care team, in an attempt to increase utilization of the protocol and improve dysphagia management.

Consumer Acceptance of Texture-Modified Mackerel Stew Products in Older Adults

Along with concerns regarding societal aging, the dietary requirements of older adults have become a priority. Older adults in Korea experience difficulties consuming animal protein sources as they age. Therefore, this study aimed to develop a senior-friendly food product using mackerel. Accordingly, carbohydrates and proteins were added to the brine solution before saturated vapor treatment. Calcium lactate and poly-gamma-glutamic acid were added to the sauce, and when compared to four commercial products (GT_R, GT_K, PC_K, and AC_G) in an acceptance test, the product was found to exhibit the highest overall liking score (p < 0.001). Higher flavor-liking and familiarity ratings were found to increase purchase intention, while higher flavor-liking, overall-liking, and familiarity ratings increased recommendation intention. Those in mid-to-late adulthood preferred the GT_R and PC_K samples, whereas the AC_G sample was preferred by those in very late adulthood. AC_G sample analysis suggested that those in the very late adulthood group had a relatively higher acceptance of spiciness. In this study, a calcium-added mackerel stew product was manufactured, meeting the standards for senior-friendly food in Korea. It will serve as a baseline for further research on fish- and mackerel-based foods for older adults, which is in its early stages.

Evaluation of Esophageal Dysphagia in Elderly Patients

PURPOSE OF REVIEW

While guidelines exist for the evaluation and management of esophageal dysphagia in the general population, dysphagia disproportionately affects the elderly. In this article, we reviewed the literature on evaluating esophageal dysphagia in elderly patients and proposed a diagnostic algorithm based on this evidence.

RECENT FINDINGS

In older patients, dysphagia is often well compensated for by altered eating habits and physiologic changes, underreported by patients, and missed by healthcare providers. Once identified, dysphagia should be differentiated into oropharyngeal and esophageal dysphagia to guide diagnostic workup. For esophageal dysphagia, this review proposes starting with endoscopy with biopsies, given its relative safety even in older patients and potential for interventional therapy. If endoscopy shows a structural or mechanical cause, then further cross-sectional imaging should be considered to assess for extrinsic compression, and same session endoscopic dilation should be considered for strictures. If biopsies and endoscopy are normal, then esophageal dysmotility is more likely, and high-resolution manometry and additional workup should be performed following the updated Chicago Classification. Even after diagnosis of the root cause, complications including malnutrition and aspiration pneumonia should also be assessed and monitored, as they both result from and can further contribute to dysphagia. The successful evaluation of esophageal dysphagia in elderly patients requires a thorough, standardized approach to collecting a history, selection of appropriate diagnostic workup, and assessment of risk of potential complications, including malnutrition and aspiration.

Development and validation of a nomogram for predicting dysphagia in long-term care facility residents

BACKGROUND

Dysphagia is a common problem that can seriously affect the health of elderly residents in long-term care facilities. Early identification and targeted measures can significantly reduce the incidence of dysphagia.

AIM

This study aims to establish a nomogram to evaluate the risk of dysphagia for elderly residents in long-term care facilities.

METHODS

A total of 409 older adults were included in the development set, and 109 were included in the validation set. Least absolute shrinkage selection operator (LASSO) regression analysis was used to select the predictor variables, and logistic regression was used to establish the prediction model. The nomogram was constructed based on the results of logistic regression. The performance of the nomogram was evaluated by receiver operating characteristic (ROC) curve, calibration, and decision curve analysis (DCA). Internal validation was performed using tenfold cross-validation with 1000 iterations.

RESULTS

The predictive nomogram included the following variables: stroke, sputum suction history (within one year), Barthel Index (BI), nutrition status, and texture-modified food. The area under the curve (AUC) for the model was 0.800; the AUC value for the internal validation set was 0.791, and the AUC value for the external validation set was 0.824. The nomogram showed good calibration in both the development set and validation set. Decision curve analysis (DCA) demonstrated that the nomogram was clinically valuable.

DISCUSSION

This predictive nomogram provides a practical tool for predicting dysphagia. The variables included in this nomogram were easy to assess.

CONCLUSIONS

The nomogram may help long-term care facility staff identify older adults at high risk for dysphagia.

Poor Oral Health in the Etiology and Prevention of Aspiration Pneumonia

Aspiration pneumonia (AP), inflammation of the lung parenchyma initiated by aspirated microorganisms into the lower airways from proximal sites, including the oral cavity, is prevalent in, and problematic for, the elderly, especially those in institutions, and for those with several important risk factors. Many factors influence the pathogenesis of AP, including dysphagia, poor oral hygiene, diminished host defense, and underlying medical conditions. This article reviews the epidemiology, microbiology, pathogenesis, and prevention of AP, focusing on the role of poor oral health as a risk factor for, and on dental care for the prevention and management of, this important infection.

A Newly Discovered Tendon Between the Genioglossus Muscle and Epiglottic Cartilage Identified by Histological Observation of the Pre-Epiglottic Space

Epiglottic retroversion is difficult to explain anatomically. One reason is inadequate structural identification of the ligaments in the submucosal tissue anterior to the epiglottis (pre-epiglottic space, PES). Although studies have shown that tongue root movement plays a role in epiglottic retroversion, few morphological reports have investigated the attachment of the lingual muscles to the epiglottis. This study reconstructed the fiber structure of the PES by comprehensively analyzing fiber alignment in the PES focusing on the hyoepiglottic ligament, which runs between the lingual muscles and the epiglottis. Gross and microscopic observations of the submucosal structures from the tongue to the larynx of 20 cadavers (10 men, 10 women; mean age 79 years) were performed. A tendon continuing from the posterior part of the genioglossus muscle and attaching to the center of the epiglottic cartilage was identified in the midline area of the epiglottis. We named this tendon the glossoepiglottic tendon. In contrast, the hyoepiglottic ligament is found between the hyoid bone and the epiglottis and is attached from the lateral margin of the epiglottic cartilage to its base. Furthermore, the glossoepiglottic tendon consists of a high-density fiber bundle that is thicker than the hyoepiglottic ligament. These results show that the conventional hyoepiglottic ligament has a two-layer structure consisting of an upper fiber bundle connected to the genioglossus muscle and a lower fiber bundle connected to the hyoid bone. Sustained contraction of the posterior part of the genioglossus muscle therefore places the epiglottis under persistent traction, suggesting that its relaxation may cause epiglottic retroversion.

Expanding Rehabilitation Options for Dysphagia: Skill-Based Swallowing Training

Over the past four decades, our understanding of swallowing neural control has expanded dramatically. However, until recently, advances in rehabilitation approaches for dysphagia have not kept pace, with a persistent focussing on strengthening peripheral muscle. This approach is no doubt very appropriate for some if not many of our patients. But what if the dysphagia is not due to muscles weakness? The purpose of this clinical manuscript is to reflect on where we have been, where we are now and perhaps where we need to go in terms of our understanding of swallowing motor control and rehabilitation of motor control impairments. This compilation is presented to clinicians in the hope that suggesting approaches "outside the box" will inspire clinicians to focus their attention "inside the box" to ultimately improve rehabilitation and long-term outcomes for patients with dysphagia.

Tracheoesophageal Diversion and Laryngotracheal Separation Procedures for Radiotherapy-Related Intractable Aspiration Pneumonia in Nasopharyngeal Carcinoma

Background

Intractable aspiration and aspiration pneumonia are complications after radiotherapy for nasopharyngeal carcinoma (NPC), and they may be life-threatening in severe cases. In the past, the efficacy of controlling aspiration and aspiration pneumonia in such patients was not ideal.

Objectives

We aimed to evaluate the effect of tracheoesophageal diversion and laryngotracheal separation (TED-LTS) procedures for these patients. Material and Methods. We retrospectively analyzed the medical data of five patients with intractable aspiration and recurrent aspiration pneumonia caused by NPC radiotherapy who underwent TED-LTS surgery. The patients were evaluated in terms of aspiration pneumonia control, body weight improvement, removal of tube feeding, oral feeding, and complications.

Results

Intractable aspiration and aspiration pneumonia were completely controlled in all cases, and the patients' body weight increased from 46.46 ± 4.6 (38.9-50.3) kg to 55.32 ± 2.7 (51.4-56.7) kg. Four patients were able to consume an oral semisolid diet, and one patient maintained an oral liquid diet. Tube feeding was not required in 4 patients. One patient developed postoperative esophageal fistula, which improved after conservative treatment.

Conclusion

TED-LTS is effective for intractable aspiration and aspiration pneumonia caused by NPC radiotherapy and can be used to restore partial oral feeding. However, strict surgical indications should be followed.

Laryngeal and swallow dysregulation following acute cervical spinal cord injury

Laryngeal function is vital to airway protection. While swallow is mediated by the brainstem, mechanisms underlying increased risk of dysphagia after cervical spinal cord injury (SCI) are unknown. We hypothesized that loss of descending phrenic drive affects swallow and breathing differently, and loss of ascending spinal afferent information alters swallow regulation. We recorded electromyograms from upper airway and chest wall muscles in freely breathing pentobarbital-anesthetized cats and rats. Inspiratory laryngeal activity increased ~two-fold following C2 lateral-hemisection. Ipsilateral to the injury, crural diaphragm EMG amplitude was reduced during breathing (62 ± 25% change post-injury), but no animal had complete termination of activity; 75% of animals increased contralateral diaphragm recruitment, but this did not reach significance. During swallow, laryngeal adductor and pharyngeal constrictor muscles increased activity, and diaphragm activity was bilaterally suppressed. This was unexpected because of the ipsilateral-specific response during breathing. Swallow-breathing coordination was also disrupted and more swallows occurred during early expiration. Finally, to determine if the chest wall is a major source of feedback for laryngeal regulation, we performed T1 total transections in rats. As in the C2 lateral-hemisection, inspiratory laryngeal recruitment was the first feature noted. In contrast to the C2 lateral-hemisection, diaphragmatic drive increased after T1 transection. Overall, we found that SCI alters laryngeal drive during swallow and breathing, and reduced swallow-related diaphragm activity. Our results show behavior-specific effects, suggesting SCI affects swallow more than breathing, and emphasizes the need for additional studies on the effects of ascending afferents from the spinal cord on laryngeal function.

Scoring the Penetration-Aspiration Scale (PAS) in Two Conditions: A Reliability Study

A widely applied metric for identifying airway invasion events is the Penetration-Aspiration Scale (PAS). PAS scores are often included as primary outcome measures in clinical interventional studies, applied to characterize airway protection in a particular disease, used to establish a normal referent for control group comparisons without dysphagia, and as determinants or predictors of clinical outcomes. Despite the widespread use of the PAS, there is variability in scoring condition. One common method used in research studies includes rater scores applied to each single swallow that occurred during a modified barium swallow study (MBSS) of the same patient. A second common method includes raters scoring single swallow segments that have been spliced from full MBSS from different patients. These single swallow segments are then randomly distributed and the rater is blinded to all swallows that occurred during that patient MBSS. The potential effects of different scoring conditions on rater reliability and score accuracy have not been studied and may have high relevance for the conclusion drawn from the result. The primary aim of this investigation is to determine the impact of two scoring conditions on rater reliability and score accuracy: 1. Contextual, unblinded scoring condition and 2. Randomized, blinded condition. Results of the present study show that no statistically significant differences in PAS rater reliability and score accuracy were found between the two scoring conditions. If findings from this pilot study are reproduced in larger sample sizes, the time and intensity involved in splicing and randomizing MBSS for scoring may not be necessary.

The association of dementia on perioperative complications following primary total hip arthroplasty for femoral neck fractures

INTRODUCTION

Studies evaluating the association of dementia in patients undergoing total hip arthroplasty (THA) for femoral neck fractures are limited. The aim was to investigate whether patients who have dementia undergoing THA for femoral neck fractures have higher rates of (1) in-hospital lengths of stay (LOS); 2) complications (medical and prostheses-related); and 3) healthcare expenditures.

METHODS

A retrospective query using the PearlDiver database from January 1st, 2005 to March 31st, 2014 to identify patients with dementia undergoing primary total hip arthroplasty for the treatment of femoral neck fractures was performed. Dementia patients were 1:5 ratio matched to controls which yielded 22,758 patients in the study with (n = 3,798) and without (n = 18,960) dementia. Primary outcomes included comparing LOS, complications, and costs. A logistic regression was constructed to calculate the odds-ratios (OR) of dementia on complications. A p-value less than 0.004 was significant.

RESULTS

Dementia patients had longer LOS (7-days vs. 6-days, p < 0.0001) and higher incidence and odds of medical complications (41.52 vs. 17.77%; OR 3.76, p < 0.0001), including cerebrovascular events (5.66 vs. 1.64%; OR 2.35, p < 0.0001), pneumoniae (9.98 vs. 3.82%; OR 1.82, p < 0.0001), and acute kidney injury (8.37 vs. 3.27%; OR 1.62, p < 0.0001). Study group patients had higher frequency of prostheses-related complications (9.53 vs. 8.31%; OR: 1.16, p = 0.012). The study group had greater total healthcare expenditures ($28,879.57 vs. $26,234.10, p < 0.0001) when analyzing ninety-day episode of care charges.

CONCLUSION

Patients with dementia undergoing THA due to femoral neck fracture have increased LOS, medical and prostheses-related complications, and cost of care compared to their counterparts.

A risk prediction model for dysphagia in older patients: a single-center prospective study

Surveys based on western populations have identified many risk factors for dysphagia in older people, but the potential risk factors consistent with the demographic characteristics of older, hospitalized Chinese patients require further study. This single-center prospective study aimed to determine the incidence of dysphagia in western China, and to develop and validate a model to predict the risk of dysphagia among older patients. A total of 343 inpatients (aged ≥ 65 years without dysphagia and cognitive impairment) were included. A score ≥ 2 on the Eating Assessment Tool-10 was defined as dysphagia. After a six-month follow-up, 70 (20.4%) patients were found to have dysphagia. The final model included age, wearing dentures, activities of daily living, cerebral vascular disease, coronary heart disease, and malignancy. The developed model has high predictive accuracy and can be easily implemented in daily practice.

Barriers and enablers to switching from a solid to a liquid formulation of Parkinson's medication: a theory-based mixed methods investigation

BACKGROUND

Swallowing tablets/capsules can become difficult and dangerous for People with Parkinson's (PwP) who develop oropharyngeal dysphagia. Switching to a liquid delays the need for progressing to last line patches/injections. However, liquids are rarely used therefore a change in prescribing practice is warranted but, as with any change in behaviour, may be met with resistance.

AIM

To characterise PwPs and carers' barriers and enablers (determinants) of switching from solid to liquid Parkinson's medication formulations.

METHOD

Underpinned by the Theoretical Domains Framework, focus groups with PwPs and carers were convened to identify determinants of switching, which were then used to develop a questionnaire distributed across the UK. Determinants were prioritised if ≥ 50% of respondents agreed/strongly agreed that they were important to their decision to switch to a liquid formulation. Percentage precisions were reported as 95% confidence intervals.

RESULTS

From three focus groups and 131 questionnaires responses, PwPs and carers prioritised nine determinants. Three enablers had almost unanimous agreement: liquids' flexibility for incremental dosing (72% ± 8); decline in Parkinson's control (72% ± 8); prescriber's endorsement to switch (70% ± 8). The barriers: perception that tablets/capsules are easier to dose than liquids (72% ± 8); and prescriber's opposition to switching (70% ± 8), attracted similarly high agreement.

CONCLUSION

There is a desire to switch to liquids when Parkinson's progresses and for their use beyond this to offer flexibility in dosing, a previously unrecognised indication for switching. The only notable resistance to switching may be addressed by innovations from the pharmaceutical industry to make liquids easier to measure.

Progressive Protrusive Tongue Exercise Does Not Alter Aging Effects in Retrusive Tongue Muscles

Purpose: Exercise-based treatment approaches for dysphagia may improve swallow function in part by inducing adaptive changes to muscles involved in swallowing and deglutition. We have previously shown that both aging and progressive resistance tongue exercise, in a rat model, can induce biological changes in the genioglossus (GG); a muscle that elevates and protrudes the tongue. However, the impacts of progressive resistance tongue exercise on the retrusive muscles (styloglossus, SG; hyoglossus, HG) of the tongue are unknown. The purpose of this study was to examine the impact of a progressive resistance tongue exercise regimen on the retrusive tongue musculature in the context of aging. Given that aging alters retrusive tongue muscles to more slowly contracting fiber types, we hypothesized that these biological changes may be mitigated by tongue exercise.

Methods: Hyoglossus (HG) and styloglossus (SG) muscles of male Fischer 344/Brown Norway rats were assayed in age groups of young (9 months old, n = 24), middle-aged (24 months old, n = 23), and old (32 months old, n = 26), after receiving an 8-week period of either progressive resistance protrusive tongue exercise, or sham exercise conditions. Following exercise, HG and SG tongue muscle contractile properties were assessed in vivo. HG and SG muscles were then isolated and assayed to determine myosin heavy chain isoform (MyHC) composition.

Results: Both retrusive tongue muscle contractile properties and MyHC profiles of the HG and SG muscles were significantly impacted by age, but were not significantly impacted by tongue exercise. Old rats had significantly longer retrusive tongue contraction times and longer decay times than young rats. Additionally, HG and SG muscles showed significant MyHC profile changes with age, in that old groups had slower MyHC profiles as compared to young groups. However, the exercise condition did not induce significant effects in any of the biological outcome measures.

Conclusion: In a rat model of protrusive tongue exercise, aging induced significant changes in retrusive tongue muscles, and these age-induced changes were unaffected by the tongue exercise regimen. Collectively, results are compatible with the interpretation that protrusive tongue exercise does not induce changes to retrusive tongue muscle function.

The effectiveness of care manager training in a multidisciplinary plan-do-check-adjust cycle on prevention of undesirable events among residents of geriatric care facilities

AIM

Undesirable events, such as falls, aspiration, and pressure ulcers, are associated with functional decline and lower quality of life among older adults. This study describes the frequency of such events among residents of geriatric care facilities and assesses the effect of training care managers in a multidisciplinary plan-do-check-adjust cycle on preventing such events.

METHODS

This was a Japan-based, non-randomized cluster intervention study. The intervention group comprised geriatric care facilities from which care managers had attended a training course, while the control group comprised facilities with care managers who did not receive this training. Six-month pre-admission and 3-month post-admission incidences of undesirable events were collected from both groups, and the two groups were compared.

RESULTS

Valid data were collected from 862 residents (416 and 446 from the intervention and control groups, respectively) from 130 facilities (60 and 70, respectively). Three-month post-admission incidences were 27.8%, 20.0%, and 11.3% for falls, fever, and pressure ulcers, respectively. There was no difference between the groups regarding post-admission incidence for any event type. Training care managers reduced the post-admission incidence of pressure ulcers among residents with a history of such ulcers.

CONCLUSIONS

The training of care managers in a multidisciplinary risk-management cycle was not effective for preventing falls, fever, or pressure ulcers. Results underscore the difficulty of preventing risk events in geriatric care facility residents even with organizational training efforts. The authors believe it is important to share such risks with residents and their families. Geriatr Gerontol Int 2021; 21: 842-848.

Predictors of Aspiration Pneumonia and Mortality in Patients with Dysphagia

OBJECTIVES/HYPOTHESIS

To identify risk factors for pneumonia incidence in patients with dysphagia undergoing a videofluoroscopic swallow study (VFSS) in an outpatient tertiary-care center.

STUDY DESIGN

Historical cohort study.

METHODS

All individuals undergoing a VFSS between 10/02/13 and 07/30/15 were identified and followed historically for 2 years. Demographic information, medical history, and fluoroscopic data were collected. The 2-year incidence of pneumonia was obtained from the medical records and telephone interview. The incidence of pneumonia and death were calculated and risk factors for pneumonia and mortality were ascertained.

RESULTS

689 patients were followed for 2 years. The mean age (±standard deviation) of the cohort was 65 (±15.5) years. 49% (338/689) were female. The most common causes of dysphagia were cricopharyngeus muscle dysfunction (270/689), head and neck cancer (175/689), and neurodegenerative disease (56/689). The incidence of pneumonia was 22% (153/689). The incidence of death was 11%. Multivariable logistic regression revealed that chronic obstructive pulmonary disorder [COPD] (odds ratio [OR] = 2.36, 95% confidence interval [CI]: 1.33-4.19), hypertension (OR = 1.82, 95% CI: 1.23-2.73), tracheotomy status (OR = 2.96, 95% CI: 1.09-7.99), and vallecular residue (OR = 1.88, 95% CI: 1.24-2.85) were all significantly associated with an elevated risk of pneumonia. Kidney disease (OR = 1.27, 95% CI: 1.02-9.9), COPD (OR = 3.27, 95% CI: 1.65-6.49), vallecular residue (OR = 2.35, 95% CI: 1.35-4.1), male gender (OR = 2.21, 95% CI: 1.25-3.92), and low body mass index (OR: 1.12, 95% CI: 1.06-1.19) were independent adjusted risk factors for death.

CONCLUSIONS

The incidence of aspiration pneumonia (22%) and death (11%) within 2-years of a VFSS was high. The greatest adjusted risk factors for incident pneumonia were tracheotomy (OR = 3.0), COPD (OR = 2.4) and vallecular residue (OR = 1.9). The greatest adjusted risk factors for death were COPD (OR = 3.3), vallecular residue (OR = 2.3), and male gender (OR = 2.2).

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Association Between the Swallowing Reflex and the Incidence of Aspiration Pneumonia in Patients With Dysphagia Admitted to Long-term Care Wards: A Prospective Cohort Study of 60 Days

OBJECTIVE

To investigate the association between the Simple Swallowing Provocation Test (SSPT) and the incidence of aspiration pneumonia in patients with dysphagia in long-term care (LTC) wards.

DESIGN

The study design was a prospective cohort study. Participants were followed for 60 days from admission.

SETTING

LTC wards.

PARTICIPANTS

Study participants were patients with dysphagia aged ≥65 years who were admitted to LTC wards between August 2018 and August 2019. In total, 39 participants were included in the analysis (N=39; 20 male, 19 female; mean age, 83.8±8.5y). Participants were divided into 2 groups based on SSPT results: normal swallowing reflex (SSPT normal group) and abnormal swallowing reflex (SSPT abnormal group). The covariates were age and sex, primary disease, history of cerebrovascular disease, Glasgow Coma Scale, body mass index, Geriatric Nutritional Risk Index, the Mann Assessment of Swallowing Ability, Food Intake Level Scale, FIM, and Oral Health Assessment Tool.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The outcome was the incidence of aspiration pneumonia during the first 60 days of hospitalization, and the predictive factor was SSPT: 0.4 mL.

RESULTS

The incidence of aspiration pneumonia was 33.3% in the SSPT normal group and 76.2% in the SSPT abnormal group. The φ coefficient (a measure of association for 2 binary variables) was 0.43, the risk ratio (the ratio of the probability of an outcome in an exposed group to the probability of an outcome in an unexposed group) was 2.29, and the 95% confidence interval was 1.14-4.58 for the SSPT abnormal group.

CONCLUSIONS

Our findings suggest that the SSPT provides a valid index for the development of aspiration pneumonia in older patients with dysphagia admitted to LTC wards.

Effectiveness of fibreoptic endoscopic evaluation of swallowing and dietary intervention during home-visit dental care in older individuals

BACKGROUND

Currently, patients with dysphagia are receiving dietary management that deviates from their original swallowing function.

OBJECTIVE

To evaluate the clinical significance of fibreoptic endoscopic evaluation of swallowing (FEES) and dietary intervention (DI) by multi-professional collaboration during visit care for determining the actual oral intake status in patients with dysphagia.

METHODS

Five hundred and eighteen patients with dysphagia underwent FEES, focusing on the penetration-aspiration scale, and DI. Oral intake status was categorised using the functional oral intake scale (FOIS). FOIS scores at the first visit, after FEES, and at the reassessment were compared.

RESULTS

At the first visit, 34.7% of the patients had an FOIS score of level 1 (no oral intake) and 65.3% had a score of level 2 or higher (capable of oral intake). Following FEES, 7.1% of patients had an FOIS score of level 1, and 44.4% had a score of level 2 with resumption of oral intake. At the reassessment, 489 patients (94.4%) were capable of oral ingestion (FOIS level 2 or higher). There were significant differences between the distributions of FOIS scores at the first visit and following FEES (P < .01) and between those at the first visit and at the reassessment (P < .01). Regarding tube feeding, 17 (5.9%) of 289 patients, who had received tube feeding at the first visit, were completely capable of oral intake following FEES and at the reassessment.

CONCLUSION

Appropriate evaluation of swallowing function using FEES and DI helps to understand the definite swallowing function in patients with dysphagia.

Oropharyngeal dysphagia frequency in older adults living in nursing homes: an integrative review

PURPOSE

To synthesize the scientific knowledge on the frequency of oropharyngeal dysphagia in older adults living in nursing homes.

RESEARCH STRATEGIES

The study question followed the PECO strategy and the search was performed in the Pubmed/Medline, Web of Science, Scopus, LILACS and SciELO databases, using keywords and specific free terms.

SELECTION CRITERIA

articles with no time or language restrictions that reported the frequency of oropharyngeal dysphagia in older adults living in nursing homes and the diagnostic criteria.

DATA ANALYSIS

it was analyzed the population characteristics, the concept of "oropharyngeal dysphagia", the methods for identifying the outcome and the frequency of oropharyngeal dysphagia. The evaluation of the methodological quality of the articles followed the criteria of Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

RESULTS

Fifteen articles were included. There was great variability in relation to the sample size, with a predominance of longevous old women. The concept of dysphagia, when mentioned, was heterogeneous. Diagnostic criteria were diverse and mostly comprised of questionnaires or clinical trials results. No studies used instrumental tests. The frequency of oropharyngeal dysphagia in the studied population ranged from 5.4% to 83.7%, being higher in studies that used clinical tests, but with greater precision of confidence intervals in studies that used questionnaires and large sample size.

CONCLUSION

The frequency of oropharyngeal dysphagia in older adults living in nursing homes has wide variability. Methodological discrepancies among studies compromise the reliability of frequency estimates and highlight the need for research with better defined and standardized methodological criteria.

Profiles of polypharmacy in older adults and medication associations with signs of aspiration

BACKGROUND

Polypharmacy and specific medication classes are prevalent in older adults. Their relationships with swallowing disorders are not well explored, which would best be managed holistically, with consideration of medication profiles. This study aimed to establish profiles of polypharmacy in older adults and investigate the associations of polypharmacy and medication class with signs of aspiration during swallowing.

METHODS

This was a secondary retrospective analysis of data from 291 adults aged 60 years and older. Polypharmacy was profiled numerically and described. Multivariate logistic regression was used to identify associations between medication classes with signs of aspiration, while controlling for independent variables of demographics, functional status, and medical history.

RESULTS

Three distinct profiles of polypharmacy were described. Higher numbers of medications were associated with higher age, lower functional status, nursing home residency, multimorbidity, and showing signs of aspiration. Thirty-four classes of medications were found in this study, benzodiazepines were the only class independently associated with signs of aspiration.

CONCLUSIONS

Different profiles of polypharmacy can be observed in older adults, but none were independently associated with signs of aspiration. In addition to known demographic and functional status variables, benzodiazepine-use was found to be independently associated with signs of aspiration (p = .005, B = 7.94).

Poor Oral Health in the Etiology and Prevention of Aspiration Pneumonia

Aspiration pneumonia (AP), inflammation of the lung parenchyma initiated by aspirated microorganisms into the lower airways from proximal sites, including the oral cavity, is prevalent in, and problematic for, the elderly, especially those in institutions, and for those with several important risk factors. Many factors influence the pathogenesis of AP, including dysphagia, poor oral hygiene, diminished host defense, and underlying medical conditions. This article reviews the epidemiology, microbiology, pathogenesis, and prevention of AP, focusing on the role of poor oral health as a risk factor for, and on dental care for the prevention and management of, this important infection.

Influencing Factors of Hospital-Acquired Pneumonia Infection in the Middle-Aged and Elderly Patients With Schizophrenia

Introduction: Pneumonia is an important cause of death in patients with schizophrenia. It is critical to understand the risk factors of hospital-acquired pneumonia (HAP) and determine prevention strategies to reduce HAP. The aim of this study is to elucidate the risk factors for HAP in the middle-aged and elderly hospitalized patients with schizophrenia. Methods: We retrospectively reviewed the medical records of 2,617 the middle-aged and elderly patients (age ≥ 50) with schizophrenia who were admitted for the first time to a large-scale psychiatric hospital between 2016 and 2020. The factors related to the incidence of HAP in patients were analyzed, including personal characteristics, antipsychotics, and non-antipsychotics. Results: The HAP infection rate of hospitalized the middle-aged and elderly patients with schizophrenia was 7.8%. Chi-square analyses showed that older age, male, and ≥60 days of hospitalization were risk factors for HAP infection (χ² = 94.272, p < 0.001; χ² = 22.110, p < 0.001; χ² = 8.402, p = 0.004). Multivariate logistic regression showed that quetiapine, clozapine, and olanzapine significantly increased the incidence of HAP (OR = 1.56, 95% CI = 1.05-2.32, p = 0.029; OR = 1.81, 95% CI = 1.26-2.60, p = 0.001; OR = 1.68, 95% CI = 1.16-2.42, p = 0.006). Antipsychotic drugs combined with aceglutamide had an effect on HAP (OR = 2.19, 95% CI = 1.38-3.47, p = 0.001). Conclusion: The high HAP infection rate in hospitalized the middle-aged and elderly patients with schizophrenia may be related to the increase of age and the use of antipsychotic drugs. The types and dosages of antipsychotic drugs should be minimized while paying attention to the mental symptoms of patients.

Protecting Patient Safety and Preventing Modifiable Complications After Acute Ischemic Stroke

TOPIC

Protecting patient safety and preventing modifiable complications after acute ischemic stroke.

CLINICAL RELEVANCE

Stroke is a leading cause of death and disability in adults. Stroke survivors often experience a variety of deficits related to mobility, nutrition, immunity, mood, and cognition. These post-stroke complications and residual effects can adversely affect safety, placing the patient at risk for further injury. In order to develop a plan of care that protects patient safety, critical care and progressive care nurses must understand the unique needs of this patient population.

PURPOSE

To describe selected ischemic stroke-related physiological changes, how these changes contribute to safety risks, and methods of enhancing patient safety.

CONTENT COVERED

Stroke physiology and stroke-specific interventions that can enable nurses to reduce the risk of falls, dysphagia, malnutrition, dehydration, altered glucose metabolism, device-related infections, aspiration pneumonia, delirium, and depression.

Older US adults like sweetened colas, but not other chemesthetic beverages

Many older adults suffer from difficulty swallowing thin beverages like water or coffee. To improve swallowing safety, beverages are typically thickened. This creates a new problem: the thickened beverages can be disgusting. New research suggests chemesthesis, particularly spiciness, carbonation, or intense sourness, could improve swallowing without the need for thickeners. Yet, whether such beverages would be liked by older adults is unknown. We thus conducted this experiment to establish older adults' sensory perception and liking/disliking of commercially available chemesthetic beverages. We recruited participants to rate sweetness, sourness, fizziness, stinging, and liking/disliking of unsweetened carbonated waters (1 plain, 5 flavored), sour orange juice, spicy ginger beer, and colas (sugar or aspartame-sweetened). Initial tests (N = 30 older adults) indicated sour orange juice, spicy ginger beer, and two of the flavored waters were not well-liked, so other beverages were selected for a second test (N = 94, 30 younger adults, 64 older adults). Sweetened, carbonated colas were the best-liked of the beverages. The unsweetened, flavored carbonated waters were in general not liked. Regarding comparisons of sensory ratings between older and younger adults, only sweetness differed between age groups. In particular, intensity ratings for the chemesthetic aspects of the beverages (stinging/burning/spiciness, fizziness) and the sour taste did not differ by age. As the chemesthetic properties are the most likely reason the beverages could aid in swallowing safety, observing no suppression of these sensations in older adults is encouraging for the potential of these products as a treatment option.

[Severe pneumonia and delirium in a 90-year-old male patient with postdeglutition regurgitation]

Pneumonia and in particular aspiration pneumonia, is a common disease in geriatrics. These aspirations are often due to dysphagia, which is frequently first noticed in the context of a geriatric assessment. The reasons for dysphagia are manifold. In this geriatric department several patients have been detected in recent months in whom a Zenker diverticulum was the cause of recurrent aspiration pneumonia. The swallowing disorder was already apparent during the logopedic examination on admission to hospital. A supplementary fiber optic endoscopic evaluation of swallowing (FEES) revealed a postswallow hypopharyngeal reflux (PSHR), which is typical for a Zenker diverticulum. A supplementary contrast esophagography confirmed the findings. In the present case the treatment of choice was a myotomy with a flexible endoscope performed by gastroenterologists. After successful treatment, swallowing was again possible with no indications of penetration or aspiration in the FEES control. The case highlights the importance of logopedic diagnostics and treatment in geriatric patients with recurrent pneumonia. With the aid of early diagnostics it was possible to quickly recognize the finding of a PSHR that is typical for a Zenker diverticulum. The findings in this case could be clearly demonstrated based on the images of the FEES and contrast esophagography.

Supplied Food Consistency and Oral Functions of Institutionalized Elderly

Background

Maintaining good oral function is one of the goals of dental treatment. The Japanese national insurance system newly introduced the concept of management of oral function according to the life stage. For the application of management of oral functions of the elderly, seven kinds of examination is a must for the diagnosis: xerostomia, oral hygiene status, maximum occlusal pressure, tongue and labium function, tongue pressure, chewing ability, and swallowing function. We analyzed the relationship between oral functions and supplied food consistency.

Methods

Oral functions and supplied food consistency of sixty-nine institutionalized elderly were investigated. There were 13 men and 56 women, and their mean age was 86.23 ± 7.02. Oral functions were measured and evaluated according to the Japanese insurance system. Data were analyzed by item response theory analysis, ROC analysis, and decision analysis.

Results

By the item response theory analysis, tongue pressure and swallowing functions had high discrimination ability. The subjects who had malfunction of the tongue and labium all had processed food. The subjects with difficulty in swallowing, even without malfunction of the tongue and labium, all had processed food.

Conclusion

Supplied food consistency may depend on the oral functions. However, as oral function has some dimension, a systematic evaluation system is necessary to decide the supplied food consistency.

Implementation of a Risk Assessment Tool to Reduce Aspiration Pneumonia in Nonstroke Patients

BACKGROUND

Aspiration pneumonia is one of the most common forms of pneumonia in hospitalized adults. Aspiration is potentially preventable when healthcare providers take action to decrease its occurrence. Standardized protocols can improve consistency with identification, assessment, and treatment of hospitalized patients at risk of aspiration pneumonia.

PROBLEM/PURPOSE

There was no process in place to identify patients at risk of aspiration who did not present with stroke symptoms. The aims of this project were to assess that action steps were taken in patients who assessed positive for aspiration risk and to determine the aspiration risk assessment tool's impact on the incidence of aspiration pneumonia.

METHODS

After implementing an adapted evidence-based aspiration risk assessment tool and aspiration precautions protocol, consistency of actions taken was assessed descriptively, and rates of aspiration pneumonia were compared from preimplementation to postimplementation using χ analysis.

INTERVENTIONS

An aspiration risk assessment tool was adapted to include local hospital findings and implemented.

RESULTS

All adult patients admitted (n = 10 973) during the initial evaluation period (July 2016 to December 2016) were screened using the adapted aspiration risk assessment tool. Three hundred twenty-six patients (19%) were identified at risk of aspiration and referred to speech therapy for evaluation, with 87.1% evaluated in less than 24 hours. Signs for aspiration risk and speech therapy recommendations were posted on 40% (n = 12). During the 18-month preintervention and postintervention period, hospital-acquired aspiration pneumonia decreased from preimplementation (n = 58 cases/26 738 admissions, 0.22%) to postimplementation (37/28 164, 0.13%), P = .018.

CONCLUSIONS

Implementation of an adapted aspiration risk assessment screening tool to document risk of hospital-acquired aspiration pneumonia and aspiration precautions protocol was associated with a decrease in aspiration pneumonia rates.

Infrequent Denture Cleaning Increased the Risk of Pneumonia among Community-dwelling Older Adults: A Population-based Cross-sectional Study

Pneumonia is a leading cause of death among older adults. The effectiveness of oral care in preventing pneumonia in nursing homes and hospitals has been reported. However, in community-dwelling older adults, the role of denture cleaning in preventing pneumonia remains unknown. We aimed to investigate the association between infrequent denture cleaning and the risk of pneumonia in community-dwelling older adults. This cross-sectional study was based on the self-reported questionnaire targeting towards community-dwelling older adults aged ≥65 years. Responses of 71,227 removable full/partial denture users were included. The incidence of pneumonia within the last one-year and the frequency of denture cleaning (daily/non-daily) were treated as dependent and independent variables, respectively. The odds ratio (OR) and 95% confidence interval (CI) were calculated by the inverse probability weighting (IPW) method based on the logistic regression model. The mean age of the participants was 75.2 ± 6.5 years; 48.3% were male. Overall, 4.6% of the participants did not clean their dentures daily; 2.3% and 3.0% who did and did not clean their dentures daily, respectively, experienced pneumonia. After IPW, infrequent denture cleaning was significantly associated with pneumonia incidence (OR = 1.30, 95% CI = 1.01–1.68)). This study suggests that denture cleaning could prevent pneumonia among community-dwelling older adults.

Oropharyngeal dysphagia among patients newly discharged to nursing home care after an episode of hospital care

BACKGROUND

Oropharyngeal dysphagia (OPD) is a common but under-recognized problem among older residents in nursing homes. If not detected and properly managed, it is a risk factor for failure to thrive and aspiration pneumonia. Discharge to nursing home from hospital may provide an opportunity for detection and subsequent management.

OBJECTIVE

To assess the extent of transfer of communication of swallow disorders in patients newly discharged to nursing homes from a university teaching hospital and catalogue recommendations suggested at discharge.

SETTING

University teaching hospital METHOD: Speech and language therapy (SLT) consultation notes of referrals from 100 consecutive patients discharged to nursing homes for the first time are reviewed for presence of a swallow disorder. The discharge documentation was then assessed to determine transfer recommendations for management of swallow disorders.

RESULTS

Fifty-three patients had been referred to SLT for suspected OPD during hospitalization. At time of discharge, 35 (35%) continued to present with OPD and swallow recommendations were made as part of the management plan. An SLT report was transmitted to the nursing home in 80% of these cases.

CONCLUSIONS

OPD is present at discharge in over one-third of patients newly discharged to nursing home following a hospital admission, and this may be an under-estimate. This is significant in terms of planning of future care of management in nursing homes. It is important that the syndrome is duly noted in transfer documentation and that appropriate multi-disciplinary support arranged for residents in nursing homes with OPD.

Proportion of Aspiration Pneumonia Cases Among Patients With Community-Acquired Pneumonia: A Single-Center Study in Korea

Objective

To investigate the proportion of aspiration pneumonia cases among patients with community-acquired pneumonia in Korea.

Methods

This retrospective study included patients with community-acquired pneumonia who had been admitted to the emergency department of a university-affiliated tertiary hospital in Gyeonggi Province, Korea between January 1, 2016 and December 31, 2016. Among these patients, those with aspiration pneumonia were identified using ICD-10 codes (J69.^*). Patients with recurrent pneumonia were excluded, as were those who were immunocompromised. The proportion of cases of aspiration pneumonia was calculated, and the characteristics and clinical outcomes of patients with aspiration pneumonia and non-aspiration pneumonia were compared.

Results

The proportion of aspiration pneumonia cases among patients with community-acquired pneumonia was 14.2%. Patients with aspiration pneumonia were significantly more likely to be older (p<0.001) and male (p<0.001), and to have a higher confusion, uremia, respiratory rate, blood pressure, and age ≥65 years (CURB-65) score (p<0.001) as compared to patients with non-aspiration pneumonia. They were also more likely to require admission to the intensive care unit (p<0.001) and a longer hospital stay (p<0.001).

Conclusion

Aspiration pneumonia accounts for 14.2% of all cases of community-acquired pneumonia in Korea. These data may contribute to the establishment of healthcare strategies for managing aspiration pneumonia among Korean adults.

Comparison of Dysphagia Between Infratentorial and Supratentorial Stroke Patients

Objective

To compare dysphagia between infratentorial stroke patients and supratentorial stroke patients.

Methods

Subjects of this study were patients with post-stroke dysphagia (PSD) who were admitted to our medical institution between May 2014 and June 2017. We evaluated a total of 64 patients with PSD. A videofluoroscopic swallowing study (VFSS) was performed to determine dysphagia severity. We measured the following parameters: pharyngeal transit time (PTT), post-swallow pharyngeal remnant, Penetration Aspiration Scale (PAS) scores, and Functional Dysphagia Scale (FDS). We analyzed patient’s results from VFSS performed at admission. All VFSS images were recorded using a camcorder running at 30 frames per second. An AutoCAD 2D screen was used to measure post-swallow pharyngeal remnant.

Results

In this study, PTT and FDS were similar (p>0.05) between infratentorial stroke patients and supratentorial stroke patients. However, there were significant differences in pharyngeal remnant and PAS scores between the two groups (p<0.01 and p<0.05, respectively).

Conclusion

Both pharyngeal remnant and PAS score registered higher levels from VFSS test for infratentorial stroke patients than those for supratentorial stroke patients. This suggests greater chances of problems occurring with swallowing, the major functions of pons. Thus, clinicians should pay particular attention to active dysphagia evaluation and treatment in PSD of infratentorial stroke patients.

Sarcopenia is associated with tongue pressure in older patients with type 2 diabetes: A cross-sectional study of the KAMOGAWA-DM cohort study

AIM

Death as a result of pneumonia is an important issue in patients with diabetes. Tongue pressure is associated with swallowing function, which has a close association with aspiration pneumonia. However, no previous studies have shown the association between sarcopenia and tongue pressure in older patients with type 2 diabetes.

METHODS

In the present cross-sectional study, we investigated body composition, handgrip strength and tongue pressure. Skeletal muscle mass index (kg/m² ) was defined as appendicular muscle mass / the square of the height. Sarcopenia was defined when both handgrip strength <26 kg for men and <18 kg for women, and the skeletal muscle mass index <7.0 kg/m² for men and <5.7 kg/m² for women existed.

RESULTS

Among 144 patients (82 men, 71.4 years [SD 6.7 years]), 11.8% had sarcopenia. Tongue pressure was associated with skeletal muscle mass index and handgrip strength (r = 0.361, P < 0.001 and r = 0.387, P < 0.001, respectively, in men; and r = 0.300, P = 0.018 and r = 0.538, P < 0.001, respectively, in women). Tongue pressure was associated with the prevalence of sarcopenia after adjusting for covariates (OR 3.83, 95% CI 1.06-13.9, P = 0.041). According to the receiver operating characteristic curve analysis, the optimal cut-off value of handgrip strength for the presence of low tongue pressure was 27.7 kg (AUC 0.70, 95% CI 0.53-0.83, sensitivity 0.78, specificity 0.64) in men and 18.3 kg (AUC 0.71, 95% CI 0.54-0.84, sensitivity 0.82, specificity 0.54) in women.

CONCLUSIONS

Sarcopenia, especially handgrip strength, is associated with tongue pressure in older patients with type 2 diabetes. We should consider a decrease of swallowing function when examining patients with sarcopenia. Geriatr Gerontol Int 2019; 19: 153-158.

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.

Management of the risk of bronchoaspiration in patients with oropharyngeal dysphagia

ABSTRACT Objective: to manage the risk of bronchoaspiration in patients with oropharyngeal dysphagia through signalizing plates in the hospital bed. Methods: a descriptive, quantitative study, developed in the medical clinic I (diagnostic investigation), medical clinic II (infectology / pneumology), surgical clinics and intensive care unit of the University Hospital of the Federal University of Sergipe, from February to August 2017. It was composed of patients in the age group ≥ 18 years of age, of both sexes, diagnosed with oropharyngeal dysphagia, based on the application of the adapted protocol of clinical evaluation in the hospital bed and instrumental examination of swallowing, when pertinent. Following the clinical evaluation and identification of the risk of bronchoaspiration due to oropharyngeal dysphagia, the signs were inserted at the hospital bed by the speech therapist. Results: the study included 43 patients at risk of bronchoaspiration due to oropharyngeal dysphagia, average age of 53.7 ± 3.53 years old, with 51.1% (n = 22) females and 48.9% (n = 21) males. A predominance of neuropathies (53.4%) and severe neurogenic oropharyngeal dysphagia (37.2%) was observed. The intensive care unit stood out with 44.18% (n = 19) of the application of signs of risk of bronchoaspiration. Conclusion: the management of bronchoaspiration risk has been shown to be a promising measure to reduce adverse events, which affect the patient's safety and consequently the quality of care in the hospital environment, as well as a possible strategy for measuring respiratory complications triggered by aspiration of oropharyngeal contents.

Feasibility of Providing Safe Mouth Care and Collecting Oral and Fecal Microbiome Samples from Nursing Home Residents with Dysphagia: Proof of Concept Study

Individuals with dysphagia who reside in nursing homes often receive inadequate mouth care and experience poor oral health. From a policy perspective, the combination of absent evidence-based mouth care protocols coupled with insufficient dental coverage create a pool of individuals at great risk for preventable infectious illnesses that contribute to high health care costs. The purpose of the current study was to determine (a) the safety of a mouth care protocol tailored for individuals with dysphagia residing in nursing homes without access to suction equipment, and (b) the feasibility of collecting oral and fecal samples for microbiota analyses. The mouth care protocol resulted in improved oral hygiene without aspiration, and oral and fecal samples were safely collected from participants. Policies supporting ongoing testing of evidence-based mouth care protocols for individuals with dysphagia are important to improve quality, demonstrate efficacy, and save health care costs. [Journal of Gerontological Nursing, 43(9), 9-15.].

Project SITUP: An Interdisciplinary Quality Improvement Initiative to Reduce Aspiration Pneumonia

The purpose of this quality improvement initiative was to improve oropharyngeal dysphagia screening and reduce aspiration pneumonia rates on 3 inpatient hospital medical units. Guided by a Plan-Do-Study-Act methodology, an interdisciplinary health team developed and implemented a systematic process for oropharyngeal dysphagia screening and management. As a result, use of the screening protocol increased, timely initiation of speech language pathology consultations increased, and aspiration pneumonia rates decreased.

Tongue exercise and ageing effects on morphological and biochemical properties of the posterior digastric and temporalis muscles in a Fischer 344 Brown Norway rat model

OBJECTIVE

This study sought to examin effects of age and tongue exercise on the posterior digastric (opener) and the temporalis (closer). We hypothesized 1) age would result in differing morphological (cross sectional area) and biochemical (myosin heavy chain isoform) components of these muscles; 2) tongue exercise would result in coactivation of these muscles inducing a decrease in age-related differences between age groups.

DESIGN

Young adult (9 months) and old (32 months) Fischer 344 Brown Norway rats were randomized into a tongue exercise or control group. Post-training, posterior digastric and temporalis muscles were harvested and analyzed using: 1) Sodium Dodecyl Sulfate-Polyacrylamide Gel Electrophoresis (SDS-PAGE) to assess percent myosin heavy chain (MyHC) content; 2) Immunohistochemical staining to determine cross sectional area (CSA).

RESULTS

A larger proportion of slowly contracting MyHC isoforms in the posterior digastric and temporalis muscles were found in old. No significant main effects for age or exercise in fiber size were found in posterior digastric muscle. An interaction between age and exercise for temporalis cross sectional area indicated the old exercise group had smaller average cross sectional area than all other groups. CONCLUSIONS FINDINGS: suggest that: 1) Increasing age induces biochemical changes in muscles of the jaw, specifically showing an increase the proportion of slower contracting MyHC isoforms; 2) Increasing age and tongue exercise induce a reduction in muscle fiber cross sectional area in the temporalis muscle only. However, continued study of these cranial muscle systems is warranted to better understand these changes that occur with age and exercise.

PEG and Thickeners: A Critical Interaction Between Polyethylene Glycol Laxative and Starch-Based Thickeners

Clinicians commonly encounter dysphagia and constipation in a skilled nursing population. Increasing the viscosity of liquids, usually with a starch- or xanthan gum-based thickener, serves as a key intervention for patients with dysphagia. We report a newly identified and potentially dangerous interaction between polyethylene glycol 3350 laxative (PEG) and starch-thickened liquids. A patient requiring nectar-thickened liquids became constipated, and medical staff prescribed PEG for constipation. His nurse observed that the thickened apple juice immediately thinned to near-water consistency when PEG was added. She obtained the same results with thickened water and coffee. We quantified this phenomenon by isothermal rotational rheology. Results confirmed a precipitous loss of thickening when PEG was added to starch-based thickeners but not with xanthan gum-based thickeners. Clinicians and front-line staff should be aware of this potentially critical interaction between PEG- and starch-based thickeners. Although confirmatory studies are needed, our preliminary data suggest that PEG may be compatible with xanthan gum-- based thickeners.

Social networks, leisure activities and maximum tongue pressure: cross-sectional associations in the Nagasaki Islands Study

OBJECTIVES

Social environment is often associated with health outcomes, but epidemiological evidence for its effect on oral frailty, a potential risk factor for aspiration, is sparse. This study aimed to assess the association between social environment and tongue pressure, as an important measure of oral function. The study focused on family structure, social networks both with and beyond neighbours, and participation in leisure activities.

DESIGN

A population-based cross-sectional study.

SETTING

Annual health check-ups in a rural community in Japan.

PARTICIPANTS

A total of 1982 participants, all over 40 years old. Anyone with missing data for the main outcome (n=14) was excluded.

OUTCOME MEASURES

Tongue pressure was measured three times, and the maximum tongue pressure was used for analysis. A multivariable adjusted regression model was used to calculate parameter estimates (B) for tongue pressure.

RESULTS

Having a social network involving neighbours (B=2.43, P=0.0001) and taking part in leisure activities (B=1.58, P=0.005) were independently associated with higher tongue pressure, but there was no link with social networks beyond neighbours (B=0.23, P=0.77). Sex-specific analyses showed that for men, having a partner was associated with higher tongue pressure, independent of the number of people in the household (B=2.26, P=0.01), but there was no association among women (B=-0.24, P=0.72; P-interaction=0.059).

CONCLUSIONS

Having a social network involving neighbours and taking part in leisure activities were independently associated with higher tongue pressure. Marital status may be an important factor in higher tongue pressure in men.