Food bolus‐forming ability predicts incidence of aspiration pneumonia in nursing home older adults: A prospective observational study

Degree of swallowing impairment in the elderly: clinical and instrumental assessment

OBJECTIVE

To classifying the degree of swallowing impairment in the elderly, comparing clinical and instrumental assessment.

METHODS

This is a cross-sectional study with quantitative and qualitative analysis of clinical and instrumental assessment of 37 elderly, aged 60-82 years, of both genders without neurological, oncological or systemic diseases, participated in this study. All participants were submitted to clinical evaluation and their results compared through fiberoptic endoscopic evaluation of swallowing considering liquid, pudding and solid food consistencies. Data were analyzed descriptively and statistically using the analysis of variance test (two-way ANOVA) and Tukey's post hoc test (p <  0.05).

RESULTS

In the clinical evaluation there was a higher occurrence of moderate swallowing impairment, followed by functional swallowing, while in fiberoptic endoscopic evaluation of swallowing the severity of the impairment was greater for moderate and mild degrees. There was no statistical difference between the clinical and instrumental evaluation methods. However, there was a significant interaction between the variables, with a difference for liquid consistency in the instrumental evaluation method.

CONCLUSION

Healthy elderly have different degree of swallowing impairment according to food consistency. The clinical assessment using a scale that considers the physiological changes of the elderly, presented results similar to those found in the instrumental examination.

LEVEL OF EVIDENCE: 2

Tongue pressure during swallowing is an independent risk factor for aspiration pneumonia in middle-aged and older hospitalized patients: An observational study

AIM

To evaluate oral frailty features present in hospitalized older patients with aspiration pneumonia.

METHODS

We enrolled hospitalized patients aged ≥50 years and classified them into three groups: the community-acquired, aspiration, and non-community-acquired pneumonia groups. Oral frailty was defined as meeting three or more criteria from the following: choking, and decreased occlusal force, masticatory function, tongue-lip motor function, tongue pressure, and tongue pressure during swallowing.

RESULTS

Of 168 patients enrolled, the incidence of aspiration pneumonia was 23.9% (17/71) in patients admitted with pneumonia as the primary diagnosis. The occlusal force and masticatory function were significantly poorer and tongue pressure and tongue pressure during swallowing were significantly lower in the aspiration pneumonia group than in the other two groups. A higher number of chronic comorbidities, poor oral health, and lower tongue pressure during swallowing were significantly associated with aspiration pneumonia. A tongue pressure during swallowing of <10.32 kPa might be a cutoff point for predicting the risk of aspiration pneumonia.

CONCLUSIONS

Hospitalized patients aged ≥50 years with multiple comorbidities, poor oral hygiene, and oral frailty during swallowing are at a higher risk of developing aspiration pneumonia, especially when their tongue pressure during swallowing is <10.32 kPa. Aspiration pneumonia is a preventable disease. Healthcare professionals should incorporate tongue pressure measurements or other screening tools into routine clinical practice to facilitate the early detection of this condition and intervention. Geriatr Gerontol Int 2024; 24: 351-357.

Kinematic Features of Mandibular Movement during Mastication in Geriatric Individuals Who Are Provided with a Dysphagia Diet at Long-Term Care Facilities

Providing a normal diet to a care recipient who is unable to form an adequate bolus may cause suffocation or aspiration pneumonia. We investigated whether differences in kinematic data of mandibular movements during mastication can be used as an indicator of the need for a dysphagia diet in the elderly in long-term care facilities. We included 63 participants who were provided with solid food in two long-term care facilities. The primary outcome variable was the kinematic data on mandibular movement during cracker chewing. The analysis results were compared between the normal and dysphagia diet groups. Logistic regression analysis and receiver operating characteristic curve analyses were performed. Significant differences were observed in the masticatory time, cycle frequency, total change amount, number of linear motions, and circular motion frequency between the normal and modified diet groups. The odds ratio for the circular motion frequency was -0.307, and the calculated cutoff value was 63%, with a sensitivity of 71.4%, a specificity of 73.5%, and an area under the curve of 0.714. Thus, these characteristics may be useful for detecting care recipients who need to be provided with a dysphagia diet. Moreover, the circular motion frequency could be used as a screening test to identify people who need a dysphagia diet.

Prevalence of chewing difficulty in older people in long-term care: A systematic review and meta-analysis

BACKGROUND

Many factors can influence chewing, including age. The ageing process causes morphophysiological changes in the body, including in the performance of the stomatognathic system, which directly affect chewing and swallowing.

OBJECTIVE

To determine the prevalence of chewing difficulty in older people in long-term care.

METHODS

We searched six electronic databases and the grey literature. Qualitative and quantitative analyses, including risk of bias, were performed on studies that met the inclusion criteria. The meta-analysis of proportions with a random effects model was performed, and heterogeneity was explored by meta-regression. Risk of bias was determined using the Joanna Briggs Institute's Critical Appraisal Checklist. The certainty of evidence was verified using the GRADE tool.

RESULTS

Twelve articles were included in the meta-analysis. The pooled prevalence estimate was 35% (95% confidence interval, 0.19-0.54). As heterogeneity still persisted even after sensitivity analysis, the predictors of mean sample age and sample size were meta-regressed to assess whether these covariates explained the variance between effect sizes. The covariable sample size of the study included in the analysis explained 84.3% of the heterogeneity existing in the analysis (R²  = 84.3%; P = .0008). The risk of bias was low in three studies, eight studies had a moderate risk of bias and one study had a high risk of bias. As for the prevalence of chewing difficulty, the GRADE criteria were considered very low.

CONCLUSION

About one in three older people in long-term care have difficulty in chewing.

Maria MT, Marito P, Takano H, Khaing AMM, Nokubi T, Ono T. Masticatory Performance Test Using a Gummy Jelly for Older People with Low Masticatory Ability

Evaluation of masticatory ability has become more important in an aging society because decreased masticatory ability has the potential to affect the general health of older people. A new masticatory performance test, intended for older people with low masticatory ability, has been developed using gummy jelly half the size of that used in the conventional masticatory performance test. This study aimed to investigate the compatibility between the new and conventional tests and the adaptation of the new test. The new test using the 8-grade visual score with half-size gummy jelly was performed among 137 removable denture wearers (mean age 75.8 ± 9.0 years) with low masticatory performance (a score of ≤4 on a conventional test). The correlation between the scores of half-size gummy jelly (VS-H) in the new test and those of full-size gummy jelly (VS) in the conventional test was evaluated. VS-H among the groups divided by VS were also compared. A strong positive correlation was detected between VS-H and VS (r_s = 0.70). In groups with VS of 0 and 1, VS-H values were widely distributed from 0 to 7. There were significant differences in VS-H between the groups with VS of 0-2 but no significant differences in VS-H between the groups with VS of 2-4. Therefore, the masticatory performance test using half-size gummy jelly is suitable for a detailed evaluation of masticatory ability in older people with low masticatory ability when their visual score of full-size gummy jelly in the conventional test is 2 or less.

Risk Factors for Aspiration Pneumonia among Elderly Patients in a Community-Based Integrated Care Unit: A Retrospective Cohort Study

We aimed to clarify the physical factors associated with the incidence of aspiration pneumonia in a community-based integrated care unit. This retrospective cohort study included 412 patients aged 65 years or older admitted to a community-based integrated care unit. A new diagnosis of aspiration pneumonia made by the attending physician based on physical examination, imaging findings, and blood test data after 48 h of admission was considered as an incidence of aspiration pneumonia. Basic patient information, activities of daily living, swallowing function, nutritional status, cognitive function, oral health-related factors, and energy intake were retrospectively investigated. We classified the patients into a pneumonia group and a non-pneumonia group, and examined the factors associated with the development of aspiration pneumonia. The mean age was 86.9 ± 8.1 years, and the pneumonia group comprised 49 participants. Comparison between the groups showed significant differences in oral environment, denture use, cognitive functional independence measure, and discharge to home. In multivariate logistic regression analysis, oral environment (odds ratio (OR) = 0.229, 95% confidence interval (CI): 0.070–0.753, p = 0.015) and use of dentures (OR = 0.360, 95% CI: 0.172–0.754, p = 0.007) were independently associated with aspiration pneumonia. Oral care and the use of dentures may be effective in preventing aspiration pneumonia.

Prosthetic rehabilitation status, dental prosthesis functionality and masticatory function in nursing home residents

OBJECTIVE

To evaluate the association of masticatory function with prosthetic rehabilitation status and dental prosthesis functionality in nursing home residents.

BACKGROUND

Prosthetic rehabilitation status and dental prosthesis functionality may adversely affect mastication of older people, and this relationship is underestimated in nursing home residents.

MATERIALS AND METHODS

This cross-sectional study included 179 nursing home residents who used dental prostheses [mean (SD) age: 78.9 (9.0) years]. Masticatory function data were determined by assessing (a) masticatory performance using two-colour chewing gum, and (b) swallowing thresholds by counting the number of peanut chewing cycles. Older adults were categorised as: (1) using dental prostheses in both jaws (n = 100) and (2) partially dentate using removable partial dental prostheses (RPDPs) or complete dentures (CDs) in only one jaw (n = 41), or (3) edentulous using CD in only one jaw (n = 38). Stability, retention, occlusion, vertical dimension and defects were considered in assessing dental prosthesis functionality.

RESULTS

Greater variance of hue (VOH) of the chewing gum and lower swallowing thresholds (worse masticatory function) was associated with edentulous using CD in only one jaw. Older adults wearing dental prostheses with poor occlusion and vertical dimensions presented worse masticatory function. Dental prosthesis stability was associated with lower VOH values. Higher number of chewing cycles while eating peanuts was associated with non-broken dental prosthesis use.

CONCLUSION

Edentulous participants using CD in only one jaw and non-functional dental prosthesis use negatively affect the masticatory function of nursing home residents.

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

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

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

OBJECTIVES

To systematically describe evidence on the use of instrumental swallowing assessment for residents of aged care homes.

DESIGN

Scoping review using the Joanna Briggs Institute methodology for scoping reviews.

SETTING AND PARTICIPANTS

Published peer-reviewed and gray literature written in English between 2000 and 2020 about instrumental swallowing assessment (ISA) in adults in residential aged care homes (RACHs).

MEASURES

A systematic, 3-tiered search of databases including Medline, CINAHL, Embase, Scopus, and Cochrane Database of Systematic Reviews, and gray literature databases was conducted. Content analysis identified common themes.

RESULTS

Forty-two sources, 30 from peer-reviewed journals, 12 gray literature publications, and 66 websites of mobile ISA providers that discussed videofluoroscopic swallowing studies (VFSS) and/or fiberoptic endoscopic evaluation of swallowing (FEES) use in RACHs were included. Most peer-reviewed sources were referenced narratives or surveys of speech pathology practice patterns (53.3%). Researchers in 3 studies used onsite mobile FEES and in 2 studies off-site VFSS, with adults living in RACHs, as part of their research design (16.7%). There were 66 mobile instrumental swallowing assessment provider websites, based within the United States. Three countries (Australia, United States, United Kingdom) had professional guidelines that stipulated minimal requirements for the safe and appropriate provision of ISA services across settings. Themes identified across sources included (1) the approach to swallowing management and clinical indicators for ISA, (2) the role of ISA, (3) service and consumer influences on ISA, and (4) mobile FEES.

CONCLUSIONS AND IMPLICATIONS

There is a paucity of quality research on instrumental swallowing assessment in adults living in RACHs. There are broad regional and international variances in the way that videofluoroscopy and FEES are accessed and used. A more robust evidence base is required to guide health professionals to design tailored ISA care pathways for residents of RACHs, to achieve high-quality health, social, and economic outcomes.

Characteristic Factors of Aspiration Pneumonia to Distinguish from Community-Acquired Pneumonia among Oldest-Old Patients in Primary-Care Settings of Japan

Background: Aspiration pneumonia (AsP), a phenotype of community-acquired pneumonia (CAP), is a common and problematic disease with symptomless recurrence and fatality in old adults. Characteristic factors for distinguishing AsP from CAP need to be determined to manage AsP. No such factorial markers in oldest-old adults, who are often seen in the primary-care settings, have yet been established. Methods: From the database of our Primary Care and General Practice Study, including the general backgrounds, clinical conditions and laboratory findings collected by primary care physicians and general practitioners, the records of 130 patients diagnosed with either AsP (n = 72) or CAP (n = 58) were extracted. Characteristic factors associated with the diagnosis of AsP were statistically compared between AsP and CAP. Results: The patients were older in the AsP group (median 90 years old) than in the CAP group (86 years old). The body temperature, heart rate, and diastolic blood pressure were lower in the patients with AsP than in those with CAP. Witnessed meal dysphagia by families and caregivers was reported only in AsP. Living in a nursing home, comorbidities of cerebral infarction and dementia (as positive factors) and hypertension (as a negative factor) were considered predictive to diagnose AsP in a stepwise logistic regression analysis. Conclusions: Among oldest-old adults in primary-care settings, living in a nursing home and the dysphagia risks are suggested to be characteristic factors for diagnosing AsP. Age and some relevant clinical information may help manage AsP and also be useful for families and caregivers.