Aging effects on oropharyngeal swallow and the role of dental care in oropharyngeal dysphagia

The prevalence of presbyphagia in older adults: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Presbyphagia is defined as structural, physiological and innervational alterations in the swallowing process as a result of aging and is considered to be involved in the etiology of dysphagia. This systematic review and meta-analysis aimed to estimate the prevalence of presbyphagia in older adults without disease-related dysphagia.

METHODS

In this study five databases were searched in October 2023 with no time limitation. Combined effect sizes of presbyphagia prevalence were calculated using random effect models. Meta-regression and subgroup analyses were conducted to identify sources of heterogeneity. Egger's test and a funnel plot were employed to examine publication bias.

RESULTS

A total of 19 studies were selected for analysis. Overall, the prevalence of presbyphagia in older adults was 30.8% (95% confidence interval [CI] 24.8-36.7%). Publication bias was adjusted for using the fill-and-trim method and the corrected pooled prevalence of presbyphagia was 17.3% (95% CI 11.0-23.6%). In addition, the meta-regression findings revealed that the assessment tool had significant effects upon heterogeneity.

CONCLUSION

Although the pooled prevalence of presbyphagia in older adults was 17.3%, the lack of large representative studies limited the interpretation of these findings. In the future, further large studies that diagnose presbyphagia using standardized assessment tools would facilitate new avenues to reduce the risk of dysphagia in older adults.

Incidence and Risk Factors for Dysphagia Following Cerebellar Stroke: a Retrospective Cohort Study

The cerebellum is known to play a supportive role in swallowing-related functions; however, wide discrepancies about the incidence rate of swallowing disorders following cerebellar strokes exist within the literature. This study aimed to investigate the incidence rate of dysphagia and the factors which may affect the presence of dysphagia and clinical recovery in individuals diagnosed with cerebellar stroke. A retrospective chart audit of 1651 post-stroke patients (1049 males and 602 females) admitted with a cerebellar stroke to a comprehensive tertiary hospital in China was conducted. Data on demographics, medical, along with swallowing function assessment were collected. Differences between dysphagic and non-dysphagic groups were evaluated using t-tests and Pearson's chi-square test. Univariate logistic regression analysis was performed to establish factors associated with the presence of dysphagia. A total of 11.45% of participants were identified with dysphagia during inpatient admission. Individuals with mixed types of stroke, multiple lesions in the cerebellum, and ages older than 85 years old were more likely to develop dysphagia. Moreover, the prognosis of dysphagia following a cerebellar stroke was associated with lesions in different parts of the cerebellum. The cumulative recovery rates from the best to worse were the right hemisphere group, the cerebellum vermis or peduncle group, and both the hemisphere group and the left hemisphere group, respectively.

Physiological Mechanisms and Associated Pathophysiology of Dysphagia in Older Adults

Dysphagia can be a common secondary sequela of neurological and neurodegenerative disorders in older adults. Early screening, identification, and management of dysphagia is essential to avoid serious complications, including malnutrition, dehydration, aspiration pneumonia; and promote quality of life. Although individuals of all ages may experience swallowing difficulties, dysphagia and its complications are more common in older adults. This literature review aims to provide an overview of the physiological mechanisms of normal swallowing in healthy individuals and age-related changes to swallowing function, the pathophysiology of dysphagia associated with three common neurological disorders affecting older adults (stroke, Parkinson's disease, and dementia), and implications for interdisciplinary clinical practice. Increased awareness of these issues may contribute to a more timely and efficient identification of older adults with dysphagia and to improve overall dysphagia management.

Abnormal Esophageal Clearance Identified During Modified Barium Swallow Study in an Acute Poststroke Cohort

PURPOSE

Dysphagia impacts many poststroke survivors with wide-ranging prevalence in the acute and chronic phases. One relatively unexplored manifestation of poststroke swallowing impairment is that of primary or co-occurring esophageal dysphagia. The incidence of esophageal dysphagia in this population is unknown despite the shared neuroanatomy and physiology with the oropharynx. We aimed to determine the presence of abnormal esophageal clearance in an acute poststroke sample using the Modified Barium Swallow Impairment Profile (MBSImP) Component 17 (esophageal clearance) as our outcome measure.

METHOD

We performed a retrospective, cross-sectional, cohort study of 57 poststroke patients with acute, first-ever, ischemic strokes. All participants received a modified barium swallow study (MBSS) using the MBSImP protocol and scoring metrics. Swallowing impairment was determined using a combination of MBSImP scores and Penetration-Aspiration Scale scores. Swallowing outcome measures were collected including Functional Oral Intake Scale and International Dysphagia Diet Standardization Initiative (IDDSI) scores. We performed tests of association and logistic regression analysis to determine if statistically significant associations exist between judgments of esophageal clearance and other swallowing impairments and/or swallowing outcome measures.

RESULTS

In our study of poststroke patients who received an MBSS as part of their care, 57.9% had abnormal esophageal clearance. Statistically significant associations were also identified in measures of pharyngeal physiology (MBSImP scores) and swallowing outcome measures (IDDSI scores and alternate means of nutrition).

CONCLUSIONS

Abnormal esophageal clearance was identified in greater than half of our poststroke patients. There is a dearth of scientific research regarding esophageal function poststroke. While esophageal visualization during the MBSS is not diagnostic of esophageal impairment, it may serve as an indicator for those poststroke patients who require dedicated esophageal testing to best determine the full nature of their swallowing pathophysiology and make the most effective treatment recommendations.

The Natural Swallow: Factors Affecting Subject Choice of Bolus Volume and Pharyngeal Swallow Parameters in a Self-selected Swallow

Predetermined volumes are used extensively throughout clinical assessment of swallowing physiology, but bolus volumes selected by an individual in their natural swallow can vary greatly from those used in structured assessment. This study aims to identify factors influencing self-selected volume and how the mechanics of self-selected volume swallows differ from predetermined volume swallows. We used pharyngeal high-resolution manometry (HRM) with simultaneous videofluoroscopy to measure swallowing pressures in the velopharynx, hypopharynx, and upper esophageal sphincter (UES). Data were collected from 95 healthy adults during thin liquid swallows of 10 mL and a self-selected comfortable volume. An intraclass correlation coefficient (ICC) was calculated to analyze within-subject self-selected volume reliability. Linear mixed effects regression models were used to examine the association of subject characteristics with self-selected swallow volume and of self-selected volumes on pharyngeal swallowing pressures and timing events. Mean self-selected volume was 16.66 ± 7.70 mL. Increased age (p = 0.002), male sex (p = 0.021), and increased pharyngeal hold area (p = 0.007) were significantly associated with increase in self-selected bolus volume. There was good reliability between subjects' individual swallow volumes (ICC = 0.80). Velopharyngeal maximum pressure and pressure integral, tongue base duration and maximum pressure, UES pre- and post-swallow maximum pressure, and overall pharyngeal contractile integral decreased significantly with self-selected boluses. Understanding a patient's natural swallow volume, and how their natural swallow functions, will be important for designing clinical evaluations that place stress on the patient's natural swallowing mechanics in order to assess for areas of dysfunction.

Quantification of the Swallowing Mechanism Through Muscle Synergy Analysis

Decreased swallowing function increases the risk of choking and aspiration pneumonia. Videofluoroscopy and computed tomography allow for detailed observation of the swallowing movements but have radiation risks. Therefore, we developed a method using surface electromyography (sEMG) to noninvasively assess swallowing function without radiation exposure. A 44-channel flexible sEMG sensor was used to measure the sEMG signals of the hyoid muscles during swallowing in 14 healthy young adult and 14 elderly subjects. Muscle synergy analysis was performed to extract the muscle synergies from the sEMG signals, and the three synergies were extracted from the hyoid muscle activities during the swallowing experiments. The experimental results showed that the three synergies represent the oral, early pharyngeal, and late pharyngeal swallowing phases and that swallowing strength is tuned by the strength of the muscle activities, whereas swallowing volume is controlled by adjusting muscle activation timing. In addition, the timing of the swallowing reflex is slower in elderly individuals. The results confirm that the proposed approach successfully quantifies swallowing function from sEMG signals, mapping the signals to the swallowing phases.

Swallowing disorders and associated factors in older adults living in nursing homes

PURPOSE

The aim of this study was to identify the frequency of swallowing disorders and the associated factors in older adults living in nursing homes.

METHODS

This is a cross-sectional study with a sample of 73 older adults (≥ 60 years; mean age = 80 ± 7.49 years; female = 82.2%) living in five non-profit Brazilian nursing homes. Demographic and clinical data were collected. The frequency of swallowing disorders was determined by the Volume-Viscosity Swallow Test (VVS-T). Covariables with a p-value less than 0.20 according to Pearson's chi-square test or Fisher's exact test were included in the multiple logistic regression analysis model. The level of significance was 5%.

RESULTS

The frequency of swallowing disorders was 63%. The multiple logistic regression model revealed that the chance of an older adult living in a nursing home presenting with swallowing disorders increased by 8% with each 1-year increase in age. Decreases in oral intake level improved the chance of a negative result in the VVS-T by approximately four times, and an individual with a FOIS level below seven was almost 11 times more likely to have a swallowing disorder.

CONCLUSION

The frequency of swallowing disorders in older adults living in nursing homes is high and is associated with age and oral intake. The management care team should be aware of the early detection of these conditions to prevent complications of oropharyngeal 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.

Pediatric dentists can determine chewing performance level in children

OBJECTIVES

The current study was aimed to verify whether pediatric dentists could determine chewing performance level in children by using Karaduman Chewing Performance Scale (KCPS).

MATERIALS AND METHODS

Typical developing children and children with cerebral palsy (CP) who were referred to pediatric dentistry above the age of 2 years were included in the study. The chewing performance level was scored according to KCPS. One experienced physical therapist and three pediatric dentists independently assessed the chewing videos of the children and scored each child's chewing function. The correlation between the KCPS scores of the physical therapist and the pediatric dentists was used for reliability. The agreement between the scorings of the physical therapist and pediatric dentists was assessed using Fleiss kappa statistics.

RESULTS

Fifty-four typical developing children and 43 children with CP were included. A strong positive correlation between the KCPS scoring of the physical therapist and pediatric dentists was found (r=0.911-0.939, p<0.001). An excellent agreement in the KCPS scoring between the physical therapist and the 1st and 3rd dentists (p<0.001, κ 0.754-0.763), and a good agreement in the KCPS scoring between the physical therapist and the 2nd dentist was detected (p<0.001, κ 0.687).

CONCLUSIONS

The study results show that the KCPS is reliable for pediatric dentists in determining the chewing performance level in children. Therefore, it could be suggested that pediatric dentists could use the KCPS in their clinical settings and research studies.

CLINICAL RELEVANCE

The study may have clinical implications in the evaluation of children with chewing difficulty in dental practice.

CLINICAL TRIAL NUMBER

NCT04407455.

Dysphagia in adult myopathies

Dysphagia (impaired swallowing) is not a rare problem in various neuromuscular disorders, both in the pediatric and the adult patient population. On many occasions such patients are first presented to other medical specialists or health professionals. Disorders of deglutition are probably underrecognized in patients with a neuromuscular disease as a result of patient's and doctor's delay. This review will focus on dysphagia in adults suffering from a myopathy. Dysphagia in myopathies usually affects the oropharyngeal phases which rely mostly on voluntary muscle activity of the mouth, pharynx and upper esophageal sphincter. Dysphagia is known to contribute to a reduction of quality of life and may also lead to increased morbidity and mortality. The review includes an overview on symptomatology and tools of assessments, and elaborates on dysphagia in specific hereditary and acquired myopathies.

Association between periodontal disease and tooth loss and mortality in an elderly Chinese population

BACKGROUND

Poor oral health is a risk indicator of poor quality of life and mortality. However, whether these associations remain potent in elderly subjects after adequately considering the confounding factors is not yet clearly elucidated. The present study aimed to investigate the associations between periodontal disease and tooth loss and total mortality and cardiovascular disease (CVD) outcomes in the elderly > 75 years old.

METHODS

A total of 1385 individuals, receiving periodontal treatment in Shanghai, participated in this retrospective study. Data on oral status were obtained from radiographs to calculate the proportion of residual bone. The information about mortality was collected from the Shanghai Municipal Center for Disease Control and Prevention (SCDC). Univariate Cox proportional hazards model, multivariable-adjusted model, and competing risk hazard model were used to analyze the association between periodontal disease or tooth loss and mortality.

RESULTS

Those with severe periodontitis were associated with higher risk of total mortality than healthy individuals [hazard ratio (HR) = 1.48, 95% confidence interval (95% CI) 1.11-1.98]. Further, missing teeth increased the risk of total mortality (HR = 1.02, 95% CI 1.01-1.03). However, no significant difference was detected in the association between periodontitis or tooth loss and CVD mortality. In competing risk hazard model, an increased risk was observed for other-cause mortality, not CVD mortality, in those with severe periodontitis and missing teeth.

CONCLUSION

Periodontal diseases and tooth loss were the potential predictors of total mortality even after adjustment for confounding factors. However, these were not independent indicators for CVD mortality.

Prevalence of Swallowing and Eating Difficulties in an Elderly Postoperative Hip Fracture Population-A Multi-Center-Based Pilot Study

Elderly patients operated for hip fracture are characterized by high age and high degree of comorbidity and need of care, factors previously found to be associated with swallowing and eating difficulties. The aim of this study was to investigate the prevalence of swallowing and eating difficulties in an elderly postoperative hip fracture population and to identify factors associated with swallowing and eating difficulties. A cross-sectional multi-center pilot study was performed, including patients ≥65 years, operated for hip fracture, and able to participate in a swallowing and eating assessment. A clinical assessment was conducted using Danish versions of the standardized tools Volume-Viscosity Swallow Test and Minimal Eating Observation Form-version II. Demographic data and clinical characteristics were examined. A total of 78 patients (mean age 81.4 years (SD 7.8), 30.8% male) were included. Swallowing and eating difficulties were present in 60 patients (77%). Swallowing and eating difficulties were significantly associated with living in a nursing home before hospital admission (p = 0.014), low habitual New Mobility Score (p = 0.018), and absence of cardiac comorbidity (p = 0.023). The results underline the importance of focusing on swallowing and eating difficulties in elderly patients operated for hip fracture to ensure effectivity and safety and optimize the prognosis for the patient.

Swallowing Pressure Variability as a Function of Pharyngeal Region, Bolus Volume, Age, and Sex

OBJECTIVES

Within-individual movement variability occurs in most motor domains. However, it is unknown how pharyngeal swallowing pressure varies in healthy individuals. We hypothesized that: 1) variability would differ among pharyngeal regions; 2) variability would decrease with increased bolus volume; 3) variability would increase with age; and 4) there would be no sex differences.

STUDY DESIGN

Case series.

METHODS

We used pharyngeal high-resolution manometry to measure swallowing pressure in the following regions: velopharynx, tongue base, hypopharynx, and upper esophageal sphincter. Data were collected from 97 healthy adults (41 male) aged 21 to 89 years during thin liquid swallows: 2 mL, 10 mL, and participant-selected comfortable volume. Pressure variability was measured using coefficient of variation. Repeated measures analysis of variance was used to assess impacts of region, bolus volume, age, and sex on pressure variability.

RESULTS

There was a significant region × volume interaction (P < .001) and significant main effect of age (P = .005). Pressures in the hypopharynx region were more variable than all other regions (P ≤ .028), and pressures in the tongue base region were less variable than all other regions (P ≤ .002) except at 2 mL volumes (P = .065). Swallowing pressure variability was significantly different in the velopharynx and upper esophageal sphincter regions, with comfortable volume and 2 mL swallows having greater variability than 10 mL swallows (P ≤ .026). Pressure variability significantly increased with increasing age (P = .002). There were no effects of sex on pressure variability (P ≥ .15).

CONCLUSION

Pharyngeal swallowing pressure variability differs according pharyngeal region, volume, and age but not sex. Abnormal swallowing pressure variability may reflect deviations in motor control in persons with swallowing impairment, and results from this study can be used as normative data for future investigations evaluating swallowing pressure generation.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E52-E58, 2021.

Long-term swallowing, trismus, and speech outcomes after combined chemoradiotherapy and preventive rehabilitation for head and neck cancer; 10-year plus update

BACKGROUND

The objective of this study was to explore the 10-year plus outcomes of Intensity Modulated Radiotherapy with concomitant chemotherapy (CRT) combined with preventive swallowing rehabilitation (CRT+) for head and neck cancer (HNC).

METHODS

Subjective and objective swallowing, trismus, and speech related outcomes were assessed at 10-year plus after CRT+. Outcomes were compared to previously published 6-year results of the same cohort.

RESULTS

Fourteen of the 22 patients at 6-year follow-up were evaluable. Although objective swallowing-related outcomes showed no deterioration (eg, no feeding tube dependency and no pneumonia), swallowing-related quality of life slightly deteriorated over time. No patients had or perceived trismus. Voice and speech questionnaires showed little problems in daily life. Overall quality of life (QOL) was good.

CONCLUSIONS

After CRT with preventive rehabilitation exercises for advanced HNC, swallowing, trismus, and speech related outcomes moderately deteriorated from 6 to 10 years, with an on average good overall QOL after.

The effects of head rotation and tilt on oral pressure and muscle activity

We present basic data on head positions that can serve as compensatory interventions for patients with weak tongue and buccinator muscles. We studied 30 Korean adults (15 males, 15 females; mean age, 23 years; range, 20-30 years). A TPS-100 instrument was used to measure tongue and cheek pressures and suprahyoid and buccinator muscle activities at various head rotations and tilts, as independent variables. The data were subjected to one-way analysis of variance and post-hoc (linear contrast) testing. Tongue elevation pressures differed significantly when the head was flexed or extended compared to the neutral position (P<0.01). Suprahyoid muscle activity varied significantly when the head was rotated left or right compared to neutral, or tilted with the tongue elevated (P<0.01). Cheek pressure varied significantly when the head was rotated left or right compared to neutral, or tilted (P<0.01). Both tongue and cheek pressures increased significantly when the head was extended or rotated contralaterally compared to the neutral position. Suprahyoid muscle activity increased when the head was flexed or extended, or contralaterally or ipsilaterally rotated compared to the neutral position. Therefore, we suggest that head rotation or tilting could be used to vary oral pressure and muscle activity.

A Systematic Review of Physiological Changes in Swallowing in the Oldest Old

Age-related swallowing changes are well-researched in deglutology, usually distinguishing those over 60 years as older aged. World-wide, older adults are healthier and forecast to live longer: many over 85 years. It is necessary for clinicians to understand healthy swallowing changes in this 'oldest old' in order to appropriately manage swallowing complaints in older patients. This systematic review collated and critically appraised studies investigating swallowing changes in adults over 85 years using instrumental assessment. Criteria for inclusion were healthy subjects over 85 years. Exclusion criteria included studies focused on anatomy and oral processing. Studies published until December 2018 were retrieved from BIOSIS, CINAHL, Embase, Medline, and Scopus, totaling 2125 articles. During data screening, 64% of studies investigating age-related swallowing changes were excluded, as the oldest old were not recruited. After PRISMA screening, 44 articles met criteria. These were further reviewed for data extraction, bias and quality. Main quantitative age-related changes in swallowing included increases in delay in swallow onset, bolus transit times, duration of UES opening, pressure above the UES and UES relaxation pressure, and reduction in pressure at the UES. Few studies detected increased residue or airway compromise in the form of aspiration. Results were not easily comparable due to differences in age ranges, methods for deeming participants 'healthy', measures used to define swallowing physiology, and swallowing tasks. Age-related swallowing changes are identified that do not compromise safety. The oldest old are underrepresented in normative deglutition research. It is essential future studies plan accordingly to recruit those over 85 years.

Pharyngeal swallowing in older adults: Kinematic analysis using three-dimensional dynamic computed tomography

OBJECTIVES

To assess the effect of age on swallowing with a focus on structural movement, timing and duration of physiologic events.

DESIGN

Cross-sectional study.

SETTING

Tertiary University Medical Center.

PARTICIPANTS

Community-dwelling adults (3 age groups): younger 20 to 39 (n = 23; mean 32 ± 5), middle-aged 40 to 59 (n = 29; mean 49 ± 5) and older adults 60 to 74 (n = 15; mean 67 ± 5).

INTERVENTION

One 10-mL honey-thick liquid (1700 mPa) swallow was studied using 320-row area detector computed tomography scanning.

MEASUREMENTS

Kinematic analysis was performed for each swallow including temporal characteristics and structural movements.

RESULTS

The duration of velopharyngeal closure and laryngeal closure (including epiglottis inversion, laryngeal vestibule closure, true vocal cord closure) was significantly different by age group (P = 0.002, P < 0.001, P = 0.017, P = 0.041, respectively). Events were prolonged in older adults compared with middle-aged and younger adults. The pharyngeal phase was longer for older adults. Velopharyngeal closure started earlier and continued until after complete UES opening. In younger adults, velopharyngeal and laryngeal opening occurred before complete UES opening. No differences were found in bolus movement through the oropharynx by group.

CONCLUSION

During swallowing, older adults had a longer pharyngeal phase characterised by prolonged velopharyngeal and laryngeal closure. This difference may be a protective mechanism to compensate for age-related weakness. A better understanding of the mechanism by which this adaptation occurs is needed to tailor rehabilitation strategies and to maintain swallowing function during the lifespan.

The Prevalence of Oropharyngeal Dysphagia in Acute Geriatric Patients

Oropharyngeal dysphagia (OD) is underdiagnosed and undertreated in many geriatric centers. The aim of this study is to explore the prevalence of OD in acute geriatric patients. The outcome was mortality during hospitalization, mortality, and rehospitalization within 0–30 and 31–180 days of discharge. A total of 313 consecutive acute geriatric patients (44.1% male, mean age 83.1 years (SD 7.8)) hospitalized from 1 March to 31 August 2016 in the North Denmark Regional Hospital were included in this study. The volume-viscosity swallow test and the Minimal Eating Observation Form-II were conducted for each patient in order to screen for OD. A total of 50% patients presented with OD. In the group of patients with OD, significantly more lived in nursing homes; had a lower weight, DEMMI score, and handgrip strength; and smaller circumference of arms and legs compared with non-dysphagia patients. Patients with OD presented an increased length of stay in hospital of one day (p = 0.70). Intra-hospital mortality was 5.8% vs. 0.7%, (p < 0.001) compared with patients with no symptoms of OD. OD is prevalent in acute geriatric patients, and the mortality is 34% within six months of hospitalization. Screening for OD should be given more attention and included in geriatric guidelines.

Risk factors for laryngeal penetration-aspiration in patients with acute traumatic cervical spinal cord injury

BACKGROUND CONTEXT

Laryngeal penetration-aspiration, the entry of material into the airways, is considered the most severe subtype of dysphagia and is common among patients with acute cervical spinal cord injury (SCI).

PURPOSE

The aim of this study was to investigate risk factors for penetration-aspiration in patients with acute traumatic cervical spinal cord injury (TCSCI).

STUDY DESIGN

This is a prospective cohort study.

PATIENT SAMPLE

Thirty-seven patients with TCSCI were included in the study.

OUTCOME MEASURES

The highest Rosenbek penetration-aspiration scale (PAS; range 1-8) score of each patient was the primary outcome measure. The risk factors consisted of patient characteristics, demographics, and clinical signs observed during a clinical swallowing trial.

MATERIALS AND METHODS

A clinical swallowing trial and videofluoroscopic swallowing study (VFSS) was performed on all patients within 28 days post injury. For group comparisons, the patients were divided into two groups: (1) penetrator-aspirators (PAS score ≥3) and (2) non-penetrator-aspirators (PAS score ≤2).

RESULTS

Of the 37 patients, 83.8% were male. The mean age at the time of the injury was 61.2 years. Most patients had an incomplete TCSCI (78.4%) caused by a fall (75.7%). In the VFSS, 51.4% of the patients were penetrator-aspirators, and 71.4% had silent aspiration. The risk factors for predicting penetration-aspiration were (1) necessity of bronchoscopies, (2) lower level of anterior cervical operation, (3) coughing, throat clearing, choking related to swallowing, and (4) changes in voice quality related to swallowing. Binary logistic regression identified coughing, throat clearing, choking, and changes in voice quality related to swallowing as independent risk factors for penetration-aspiration.

CONCLUSIONS

The necessity of bronchoscopies, postinjury lower cervical spine anterior surgery, coughing, throat clearing, choking, and changes in voice quality related to swallowing was a markedrisk factor for aspiration and penetration following a cervical SCI. These factors and signs should be used to suspect injury-related pharyngeal dysfunction and to initiate preventive measures to avoid complications. The clinical swallowing evaluation is a relevant adjunct in the management of these patients and can improve the detection of penetration and aspiration.

Orofacial Myofunctional Evaluation Protocol for older people: validity, psychometric properties, and association with oral health and age

PURPOSE

To develop a comprehensive assessment protocol for identifying, classifying and grading changes in stomatognathic system components and functions of older people, to determine its psychometric properties and verify its association with oral health and age.

METHODS

The content validity of the Orofacial Myofunctional Evaluation with Scores for Elders protocol (OMES-Elders) was established based on the literature. The protocol contains three domains: appearance/posture, mobility, and functions of the stomatognathic system. Eighty-two healthy elder volunteers (mean age 69±7.24 years) were evaluated using the OMES-Elders. A test-screening for orofacial disorders (reference) was used to analyze the concurrent validity (correlation test), sensitivity, specificity and accuracy (Receiver Operating Characteristic Curve: ROC curve) of the OMES-Elders. The association of the OMES-Elders scores with the Oral Health Index (OHX) and age in the sample was tested.

RESULTS

There was a significant correlation between the OMES-Elders and the reference test (p < 0.001). Reliability coefficients ranged from good (0.89) to excellent (0.99). The OMES-Elders protocol had a sensitivity of 82.9%, specificity of 83.3% and accuracy of 0.83. The scores of the protocol were significantly lower in individuals with worse oral health (OHX ≤ 61%), although individuals with adequate oral health (OHX ≥ 90%) also had myofunctional impairments. The predictors OHX and age explained, respectively, 33% and 30% of the variance in the OMES-Elders total score.

CONCLUSION

As the first specific orofacial myofunctional evaluation of older people, the OMES-Elders protocol proved to be valid, reliable and its total score was associated with oral health and age.

The Prevalence of Oropharyngeal Dysphagia in Danish Patients Hospitalised with Community-Acquired Pneumonia

Community-acquired pneumonia (CAP) and oropharyngeal dysphagia (OD) are prevalent conditions in the elderly. The aim of this study was to explore the relationship between CAP, OD, and frailty in patients admitted to a department of respiratory medicine at a regional hospital. The outcome was mortality during hospitalization and within 30 days of discharge and rehospitalization within 30 days of discharge. A total of 154 consecutive patients (54.5% male, mean age 77.4 years (SD 11.51)) hospitalized because of CAP from September 1, 2013 to March 31, 2014 at North Denmark Regional Hospital were included in this study. The volume-viscosity swallow test was conducted for each patient. A total of 34.42% patients presented with OD. Patients with OD and CAP presented significant differences in age, CURB-65, and dementia compared with those of patients with CAP alone. The majority lived in nursing homes, had a lower body mass index, Barthel 20 score, and handgrip strength, and had poor oral health compared with patients with CAP only. Patients with OD presented an increased length of stay in hospital (P < 0.001), intra-hospital mortality (P < 0.001), and 30-day mortality rate (P < 0.001) compared with those of patients with CAP only. Their rate of rehospitalization 0-30 days after discharge was also increased (P < 0.001) compared with that of patients with CAP only. Thus, OD is related to frailty and poor outcome.

Nutritional Assessment in Primary Care

Alterations in nutritional status are common and can be associated with increased morbidity and mortality. However, for healthcare providers, the definition of malnutrition is vague, insensitive, and poorly standardized. In contrast, nutrition risk is more easily defined, and recognizes that both poor nutritional status and disease severity contribute to increased morbidity and mortality. Clinicians need to identify patients who may already have evidence of nutrient deficiencies or have disease processes that affect nutrition risk. This article reviews risk assessment tools and provides practical tips to screen patients and identify those whose nutrition risk warrants specialized nutrition therapy.

Gastrointestinal Dysmotility in the Elderly

The number of persons 60 years and older has increased 3-fold between 1950 and 2000. Aging alone does not greatly impact the gastrointestinal (GI) tract. Digestive dysfunction, including esophageal reflux, achalasia, dysphagia, dyspepsia, delayed gastric emptying, constipation, fecal incontinence, and fecal impaction, is a result of the highly prevalent comorbid conditions and the medications with which those conditions are treated. A multidisciplinary approach with the expertise of a geriatrician, gastroenterologist, neurologist, speech pathologist, and physical therapist ensures a comprehensive functional and neurological assessment of the older patient. Radiographic and endoscopic evaluation may be warranted in the evaluation of the symptomatic older patient with consideration given to the risks and benefits of the test being used. Treatment of the digestive dysfunction is aimed at improving health-related quality of life if cure cannot be achieved. Promotion of healthy aging, treatment of comorbid conditions, and avoidance of polypharmacy may prevent some of these digestive disorders. The age-related changes in GI motility, clinical presentation of GI dysmotility, and therapeutic principles in the symptomatic older patient are reviewed here.

Oral health screening: feasibility and reliability of the oral health assessment tool as used by speech pathologists

BACKGROUND

The aim of this study was to investigate the feasibility and reliability of the Oral Health Assessment Tool (OHAT) as used by speech pathologists, to become part of a comprehensive clinical swallowing examination.

METHODS

A multicentre study in 132 elderly subjects was conducted by speech pathologists. The inter-rater, test-retest and intra-rater reliabilities of the OHAT were assessed in R statistics, version 3.0.1. Intraclass correlation coefficients (ICCs) were used for the total OHAT, and Kappa statistics were used for the individual categories.

RESULTS

Total OHAT scores showed good inter-rater (ICC = 0.96), intra-rater (ICC ≥ 0.95) and test-retest (ICC ≥ 0.78) agreement. The inter-rater Kappa statistics were almost perfect (κ ≥ 0.83) for seven of the eight individual categories of the OHAT and perfect for 'dental pain' (κ = 1.00). The test-retest Kappa statistics indicated excellent agreement for 'natural teeth' and 'dentures' (κ ≥ 0.86). The intra-rater per cent agreement was excellent for all categories except 'gums and tissues'.

CONCLUSIONS

This is the first study to examine the feasibility and reliability of the OHAT as used by speech pathologists. As the results showed both good feasibility and reliability, the OHAT has the potential to add to the clinical swallowing examination. However, future research investigating actual referral strategies and adaptation of care strategies following assessment with OHAT is needed.

High prevalence of colonization of oral cavity by respiratory pathogens in frail older patients with oropharyngeal dysphagia

BACKGROUND

Aspiration pneumonia (AP) is caused by dysfunctional swallowing resulting in aspiration of material colonized by respiratory pathogens. The aim of this study was to assess and compare the swallowing physiology, health status, oral health status, and oral/nasal microbiota in frail older patients (FOP) with oropharyngeal dysphagia (OD) and a control group.

METHODS

We studied 47 FOP (>70 year) with OD by videofluoroscopy (17 with acute pneumonia -APN-, 15 with prior pneumonia-PNP- and 15 without) and 14 older controls without OD (H). Oral/nasal colonization by five respiratory pathogens was evaluated by qPCR, whereas commensal microbiota composition was assessed by pyrosequencing.

KEY RESULTS

(i) Frail older patients with OD presented similar comorbidities, poor functionality, polymedication, and prevalent videofluoroscopic signs of impaired safety of swallow (33.3-61.5%). However, patients with OD-APN also presented malnutrition, delayed laryngeal vestibule closure (409.23 ± 115.6 ms; p < 0.05), and silent aspirations (15.6%). (ii) Oral health was poor in all groups, 90% presented periodontitis and 72%, caries. (iii) Total bacterial load was similar in all groups, but higher in the oropharynx (>10(8) CFU/mL) than in the nose (<10(6) CFU/mL) (p < 0.0001). Colonization by respiratory pathogens was very high: 93% in OD patients (p < 0.05 vs H); 93% in OD-PNP (p < 0.05 vs H); 88% in OD-APN (p = 0.07 vs H), and lower in controls (67%).

CONCLUSIONS & INFERENCES

Frail older patients with OD had impaired health status, poor oral health, high oral bacterial load, and prevalence of oral colonization by respiratory pathogens and VFS signs of impaired safety of swallow, and were therefore at risk for contracting AP.

A bitter pill to swallow: dysphagia in cervical spine injury

BACKGROUND

Dysphagia is a common complication after cervical spine trauma with spinal cord injury. We sought to characterize the prevalence of dysphagia within a total cervical spinal injury (CSI) population, considering the implications of spinal cord injury status and age on dysphagia development. We hypothesized that while greater rates of dysphagia would be found in geriatric and spinal cord-injured subgroups, all patients presenting with CSI would be at heightened risk for swallowing dysfunction.

METHODS

All trauma admissions to a level II trauma center from January 2010 to April 2014 with CSI were retrospectively reviewed. CSI was classified as any ligamentous or cervical spinous fracture with or without cord injury. Patients failing a formal swallow evaluation were considered dysphagic. The implications of dysphagia development on age and spinal cord injury status were assessed in univariate and multivariate analyses.

RESULTS

A total of 481 patients met study inclusion criteria, of which 123 (26%) developed dysphagia. Within the dysphagic subpopulation, 90 patients (73%) were geriatric, and 23 (19%) sustained spinal cord injury. The dysphagic subpopulation was predominantly free from spinal cord injury (81%). Multivariate analyses found age (adjusted odds ratio: 1.06; 95% confidence interval 1.04-1.07; P < 0.001) and spinal cord injury (adjusted odds ratio: 2.69; 95% confidence interval 1.30-5.56; P = 0.008) to be significant predictors of dysphagia development.

CONCLUSIONS

Despite spinal cord-injured patients being at increased risk for dysphagia, most of the dysphagic subpopulation was free from spinal cord injury. Geriatric and CSI patients with or without cord injury should be at heightened suspicion for dysphagia development.

Postanesthesia Care for the Elderly Patient

PURPOSE

As the general population lives longer, the perioperative physician is more likely to encounter disease states that increase in incidence in an aging population. This review focuses on anesthetic considerations for rational drug choices during the perioperative care of elderly patients. The primary aim of the review was to identify intraoperative and postanesthetic considerations for diseases associated with advancing age; it includes highlights of the commonly impaired major organs (eg, cardiovascular, pulmonary, neurologic, renal, hepatic systems). We also outline an approach to frequent issues that arise in the immediate postsurgical period while caring for these patients.

METHODS

A systematic review was performed on aspects of the perioperative and postoperative periods that relate to the elderly. A list of pertinent key words was derived from the authors, and a PubMed database search was performed.

FINDINGS

The anesthesiologist must account for changes in various organ systems that affect perioperative care, including the cardiovascular, pulmonary, renal, hepatic, and central nervous systems. The pharmacokinetic principles frequently differ and are often unpredictable because of anatomic changes and decreased renal and hepatic function. The most important pharmacodynamic consideration is that elderly patients tend to exhibit an exaggerated hypoactivity after anesthesia.

IMPLICATIONS

Before surgery, it is essential to identify those patients at risk for delirium and other commonly encountered postanesthesia scenarios. Failure to manage these conditions appropriately can lead to an escalation of care and prolonged hospitalization.

INFLUENCE OF AGE ON SWALLOWS OF A HIGHLY VISCOUS LIQUID BOLUS

Background Swallow function has a decline with aging, mainly in those over 80 years old. In the population over 69 years, about 11% of subjects reported symptoms indicative of significant dysphagia. Objectives Our objective was to evaluate the hypothesis that older asymptomatic subjects before 80 years old have compensations to sustain a safe and efficient swallow, at least with swallows of liquid bolus. Methods We performed videofluoroscopic evaluation of swallows in 55 normal volunteers, a younger group with 33 subjects (16 men and 17 women) aged 19 to 55 years, mean 35.5±9.8 years, and an older group with 22 subjects (15 men and 7 women) aged 56 to 77 years, mean 64.8±6.8 years. The subjects swallowed in duplicate 5 mL and 10 mL of liquid barium with a pH of 7.9, density of 1.82 g/cm3, and viscosity of 895 cp. Results The mean duration of pharyngeal transit, pharyngeal clearance, upper esophageal sphincter opening, hyoid movement and oral-pharyngeal transit were longer in the younger group compared with the older group. The relation between pharyngeal clearance duration and hyoid movement duration was similar in younger and older subjects, for 5 mL and 10 mL bolus volumes. Conclusions On average, a highly viscous liquid bolus crosses the pharynx faster in older subjects (56-77 years old) than in younger subjects (19-55 years old), which suggested an adaptation to the aging process to maintain a safe swallow.

Influence of oral health condition on swallowing and oral intake level for patients affected by chronic stroke

BACKGROUND

According to the literature, the occurrence of dysphagia is high in cases of stroke, and its severity can be enhanced by loss of teeth and the use of poorly fitting prostheses.

OBJECTIVE

To verify that the status of oral health influences the level of oral intake and the degree of swallowing dysfunction in elderly patients with stroke in chronic phase.

METHODS

Thirty elderly individuals affected by stroke in chronic phase participated. All subjects underwent assessment of their oral condition, with classification from the Functional Oral Intake Scale (FOIS) and nasoendoscopic swallowing assessment to classify the degree of dysphagia. The statistical analysis examined a heterogeneous group (HG, n=30) and two groups designated by the affected body part, right (RHG, n=8) and left (LHG, n=11), excluding totally dentate or edentulous individuals without rehabilitation with more than one episode of stroke.

RESULTS

There was a negative correlation between the need for replacement prostheses and the FOIS scale for the HG (P=0.02) and RHG (P=0.01). Differences in FOIS between types of prostheses of the upper dental arch in the LHG (P=0.01) and lower dental arch in the RHG (P=0.04). A negative correlation was found between the number of teeth present and the degree of dysfunction in swallowing liquid in the LHG (P=0.05). There were differences in the performance in swallowing solids between individuals without prosthesis and those with partial prosthesis in the inferior dental arch (P=0.04) for the HG.

CONCLUSION

The need for replacement prostheses, type of prostheses, and the number of teeth of elderly patients poststroke in chronic phase showed an association with the level of oral intake and the degree of oropharyngeal dysphagia.

Dental hygiene intervention to prevent nosocomial pneumonias

Nosocomial and ventilator associated pneumonias that plague critically ill, elderly and long-term care residents could be reduced with effective oral hygiene practices facilitated collaboratively between nurses and dental hygienists.

BACKGROUND

Nosocomial pneumonias, specifically aspiration pneumonias and ventilator-associated pneumonias in the elderly and infirm have become a major health care issue, The provision of oral care in hospital and hospital-like facilities presents challenges that can prevent patients from receiving optimal oral care One sequela can be aspiration pneumonia which ranks first in mortality and second in morbidity among all nosocomial infections. Since aspiration pneumonia is linked to the colonization of oral bacteria in dental plaque and biofilm, it is time to look for creative solutions to integrating the expertise of dental hygienists into health care teams in these institutional settings.

METHODS

A comprehensive review of the literature was conducted regarding the etiology and prevalence of health care related pneumonias. Evidence describing the challenges and barriers that the nurses, nursing staff, and dental hygienists face in the provision of oral care in hospitals and long-term care facilities is provided. Intercollaborative solutions to providing optimal oral care in hospitals and long-term care facilities are suggested.

CONCLUSION

Dental hygienists have the expertise and practice experience to provide oral care in hospitals, long-term care and residential facilities. They can contribute to solving oral care challenges through intercollaboration with other health care team members. Yet, there are long-standing systemic barriers that must be addressed in order to provide this optimal care. Dental hygienists becoming better assimilated within the total health care team in hospital and residential facilities can positively impact the suffering, morbidity and mortality associated with aspiration pneumonias.