Evaluation of dysphagia risk, nutritional status and caloric intake in elderly patients with Alzheimer's

Identification of eating, drinking and swallowing difficulties for people living with early-stage dementia: A systematic review

BACKGROUND

The prevalence of dementia is increasing, bringing a range of challenges, such as eating, drinking and swallowing (EDS) difficulties, that are associated with aspiration, which can be fatal. Early identification of EDS difficulty in early-stage dementia could prevent complications, but reliable indicators are needed to help develop pathways to support the diagnosis. Previous reviews of this area require updating.

AIMS

To identify reliable and clinically measurable indicators of EDS difficulty used in early-stage dementia.

METHODS & PROCEDURES

A systematic search was conducted using common databases (MEDLINE, EMBASE and PsychInfo). Articles reporting indicators of EDS difficulty in early-stage dementia or mild cognitive impairment were included. The reliability of included studies was critically appraised using the risk of bias tools. Study outcomes were narratively reviewed by considering the reliability, clinical measurability and applicability of EDS indicators to early-stage dementia.

OUTCOMES & RESULTS

Initial searches returned 2443 articles. After removing duplicates, limiting to English language and human studies, 1589 articles remained. After reviewing titles, 60 abstracts were reviewed, yielding 18 full-text articles. A total of 12 articles were excluded that did not report at least one indicator of EDS difficulty in early-stage dementia, or where the reported association was not strong. Six included studies that reported eight indicators of EDS difficulty in early-stage dementia (four studies including people with Alzheimer's disease). On the balance of measurability, reliability and applicability, the most promising indicators of EDS difficulty were: delayed oral transit, rinsing ability, sarcopenia and polypharmacy. Additional, less reliable and applicable indicators included: always opened lips and non-amnestic mild cognitive impairment, especially in men. The delayed pharyngeal response is subjectively measured when instrumental assessment is not available and the 'candy sucking test' cannot be recommended because there is an inherent choking risk.

CONCLUSIONS & IMPLICATIONS

EDS difficulty in early-stage dementia can be highlighted by indicators that could be combined to create enhanced pathways to support the early identification of EDS difficulties for people living with early-stage dementia with a view to preventing complications and facilitating informed discussions regarding wishes in the event of further deterioration. Exploring the experiences of people living with dementia and their families' perspectives on potential indicators of EDS difficulty may add to the existing evidence base.

WHAT THIS PAPER ADDS

What is already known on the subject Early identification of EDS difficulty in early-stage dementia may prevent complications, but more reliable and clinically measurable indicators of EDS difficulty are needed to help develop pathways to support diagnosis. What this paper adds to existing knowledge A comprehensive range of studies related to EDS identification in early-stage dementia have been selected and reviewed. Across six included studies, the most promising indicators of EDS difficulty in early-stage dementia included delayed oral transit, poor rinsing ability, presence of sarcopenia and polypharmacy. What are the potential or actual clinical implications of this work? This study could help to develop pathways to support the early identification of EDS difficulties for people living with early-stage dementia with a view to preventing complications and facilitating informed discussions regarding wishes in the event of further deterioration.

Chewing and Swallowing Abilities of Persons Living With Dementia: A Systematic Review of Psychometric Properties of Instruments

Background and Objectives

It is critical to use validated instruments to diagnose and manage chewing and swallowing problems of persons living with dementia. The study aimed to synthesize the characteristics and psychometric quality of instruments that assess the chewing and swallowing abilities of persons living with dementia.

Research Design and Methods

The systematic review was used to conduct this study. We searched 5 electric databases for records published from January 1, 1980, to July 8, 2022. Records were eligible if they included any instrument to assess chewing ability or swallowing ability in the dementia population. Eight characteristics of eligible instruments were extracted from the records: (1) development process, (2) operationalized concept/construct, (3) sample and setting, (4) administration method, (5) items, (6) scoring format/interpretation, (7) reliability, and (8) validity. The psychometric assessment for self-report and observational tool was used to evaluate 12 psychometric properties of eligible instruments.

Results

In total, 11,074 records were reviewed. Thirty-five eligible instruments, including observational tools, self-report questionnaires, and physiological instruments, were identified from 60 records. All 8 instruments assessing chewing ability were evaluated as having low psychometric quality, and only 3 out of 27 instruments assessing swallowing ability were evaluated as having moderate psychometric quality. Fifteen instruments were tested for only 1 type of psychometric property, limiting the overall evaluation of psychometric evidence.

Discussion and Implications

The study findings inform the use and adaptation of appropriate instruments for practice and research. All existing instruments warrant further validation in larger samples to expand use in diverse care settings. This review described and evaluated current instruments measuring chewing and swallowing abilities and potential use in research and clinical practice to plan for and evaluate the effectiveness of mealtime and oral care practice and reduce health-related negative outcomes of persons living with dementia.

Micro- and Macronutrient Intake and Food Group Frequency Consumed by Subjects with Cognitive Impairment and Dementia in Latin America: A Systematic Review

BACKGROUND

Nutrition has relevant role in the pathogenesis of dementia. However, in Latin American Countries (LAC), it is unknown which type of diet the subjects with dementia and cognitive dysfunction have.

OBJECTIVE

The main purpose of this study was to determine micro- and macronutrients and food frequency intake among the LAC population with mild cognitive impairment (MCI) and dementia.

METHODS

A systematic review using PubMed, Cochrane, Lilacs, and Scielo databases. Energy intake as well as micro- and macronutrients intake were analyzed using a random-effect model and presented in a forest plot.

RESULTS

Nine articles were included, an estimated energy intake of 1598.47 kcal (95% CI 1351.07-1845.88) was obtained. A daily consumption of 73.64 g/day (95% CI 64.07-83.2) of protein; 262.17 g/day (95% CI 214.51-309.93) of carbohydrates, and 57.91 g/day (95% CI 49.16-66.66) of fats were reported. A micronutrients daily intake consumption of 201.35μg/day of vitamin B9 (95% CI 125.32-277.38); 5.61μg/day of vitamin B12 (95% CI 2.53-8.70), and 139.67 mg/day of vitamin C (95% CI 59.33-220.02). Mineral intake of 637.32 mg/day of calcium (95% CI 288.54-986.11) and 9 mg/day of iron (95% CI 2.28-15.71) was obtained. A low intake of fruits and vegetables was found.

CONCLUSION

Individuals with MCI and dementia from LAC have a nutritional deficiency characterized by a lower intake of fruits and vegetables, a high consumption of carbohydrates and protein, adequate fats intake and vitamins B12, vitamin C, and iron consumption, but a low intake of vitamin B9 and calcium.

Dysphagia Profiles Among Inpatients with Dementia Referred for Swallow Evaluation

BACKGROUND

Alzheimer's disease and related dementias (ADRD) patients who are hospitalized often develop oropharyngeal dysphagia, increasing risk for adverse outcomes, such as aspiration pneumonia. However, prevalence estimates of dysphagia are highly variable and often based on patient report or clinical testing rather than visualization of the swallow.

OBJECTIVE

The aims of this study were to determine prevalence and severity of dysphagia among inpatients with ADRD referred for swallowing evaluation.

METHODS

Electronic health record (EHR) abstraction of ADRD diagnosis and presence and severity of clinically-determined dysphagia on bedside swallow evaluation (BSE) and videofluoroscopic swallow study (VFSS).

RESULTS

16% (n = 268) had an ADRD diagnosis or were taking dementia-specific medication based on the EHR. 75% (n = 202) were diagnosed with dysphagia on the BSE. 60% subsequently underwent VFSS (n = 122) with dysphagia confirmation in 92% (n = 112). ADRD inpatients were significantly more likely to be diagnosed with dysphagia based on the BSE (p < 0.0001) than those without ADRD. Additionally, dysphagia on the VFSS was more severe in the ADRD group (p < 0.03).

DISCUSSION

ADRD individuals may be vulnerable to developing or worsening dysphagia during hospitalization. Results underscore the importance of evaluating swallowing function in hospitalized patients with ADRD in order to facilitate targeted intervention.

Dysphagia in Alzheimer's disease: a systematic review

Dysphagia is described as a highly relevant comorbidity of Alzheimer's disease (AD). However, there is a scarcity of studies aiming at the characteristics and progression of dysphagia.

OBJECTIVE

The objective of this study was to identify the specific characteristics, progression, and prevalence of dysphagia in AD.

METHODS

Publications were searched in the PubMed (MEDLINE), EBSCO, ScienceDirect, and BASE databases. Critical appraisal and evidence-level analysis were conducted using the Joanna Briggs Institute and Effective Public Health Practice Project's (EPHPP) tools.

RESULTS

A total of 26 studies were reviewed. Symptoms begin in the early stage of AD, as oral phase impairments, and progress to pharyngeal symptoms and swallowing apraxia in the later stages of AD. Dysphagia progresses, as AD, along a continuum, with severity depending on individual variability. There were no studies found on prevalence.

CONCLUSIONS

Dysphagia is a complex and important comorbidity in AD that impacts the quality of life. No recent publications on prevalence may imply that is not being coded as a potential cause for pneumonia deaths in AD.

Plate waste study among hospitalised patients receiving texture-modified diet

BACKGROUND/OBJECTIVES

While plate waste has been widely investigated in hospitals, there have been minimal studies specific to the texture-modified diet (TMD). This study aims to determine the percentage of plate waste among patients prescribed with TMD and its contributory factors.

SUBJECTS/METHODS

This was a single-centre study conducted in the university hospital on three types of TMD (blended diet, mixed porridge, minced diet) during lunch and dinner meals. Weighing method and visual estimation method assisted by digital photograph were adopted in this study. Face to face interview was carried out to investigate on 1) the food/food service quality factors in terms of patients' satisfaction level towards sensorial quality of food and food services provided and 2) the clinical/external factors including appetite, the provision of oral nutrition support, time taking the diet, the need for feeding assistance and the length of hospital stay.

RESULTS

The mean percentage of overall plate waste of 95 patients receiving TMD was high (47.5%). Blended diet was identified as the most wasted diet (65%) followed by minced diet (56%) and mixed porridge (35%). Satisfaction level among patients was moderate. Patients on TMD in general had higher satisfaction level on the aspect of food service as compared to food quality. Substantial association between sensorial qualities of food and plate waste were varied according to individual TMD type. A multiple linear regression showed that only the satisfaction level toward the aspects of appearance and variety of foods were the predictors of TMD plate waste (R² = 0.254, P < 0.05).

CONCLUSIONS

A significant relationship between the percentage of plate waste and the overall satisfaction level of patients receiving TMD suggests that vigorous strategies are needed to reduce the food waste of TMD which will lead to a better nutritional status and clinical outcomes among the patients.

The relationship of serum 25-hydroxyvitamin D concentration with clinical variables in patients with oropharyngeal dysphagia

BACKGROUND & AIMS

The relationship between vitamin D and oropharyngeal dysphagia (OD) is still poorly understood. The aim of this study was to evaluate 25-hydroxyvitamin D [25(OH)D] concentration in patients with OD and to verify its association to nutritional status, functional independence measure (FIM), time of clinical signs (TCS) and OD severity. This is a cross-sectional study conducted with outpatients. Body mass index (BMI), FIM, TCS, causes of OD, comorbidities, penetration-aspiration scale (PAS) and severity scale were evaluated.

METHODS

A multiple linear regression and effect size were performed to evaluate the association between serum 25(OH)D concentration and independent variables.

RESULTS

Forty-eight participants were included, with a mean age of 60.1 ± 15.3 years. The mean of the 25(OH)D concentration was 26.10 ± 12.0 ng/mL. The prevalence of hypovitaminosis D (<30 ng/mL) was 73%. In the multiple linear regression analysis (adjusted for sex, age, BMI, dietary intake and solar radiation), 25(OH)D concentration was significantly related with the TCS (p = 0.01, f² = 0.48). Patients with hypovitaminosis D had a moderate effect (p = 0.08, δ = 0.36) for a lower FIM score.

CONCLUSIONS

These findings indicate that serum 25(OH)D concentration may be related to the TCS and the functional capacity of patients with OD.

Consistencies and terminologies - the use of the International Dysphagia Diet Standardization Initiative

Introduction

Introduction: this study aimed to verify the ability of speech therapists to identify, sort and name the different consistencies used in neurogenic oropharyngeal dysphagia (NOD) management, and to compare the results with the terms proposed by the International Dysphagia Diet Standardization Initiative (IDDSI). Methods: this research was approved by the ethics committee. Sixty speech therapists who work with NOD patients sorted 5 commercial foods from thinnest to thickest to match IDDSI levels 0 to 4, and then used a term to designate each consistency. Results: most subjects (76.66%) sorted the foods properly. Terminologies were divergent at all levels. For level 0, practitioners assigned 3 different terms. For level 1, 24 different terms were reported; for level 2 there were 25 terms, 23 terms for level 3, and 18 terms for level 4. Level 0 (IDDSI - thin) was designated by most participants as liquid; level 1 (IDDSI - slightly thick) was referred to as semi-thickened liquid; level 2 (IDDSI - mildly thick) as thickened liquid; level 3 (IDDSI - moderately thick) as honey; and level 4 (IDDSI - extremely thick) as pasty by most subjects. A reduced number of participants used terms in accordance with IDDSI. Level 0 was appropriately named by 5 subjects (8.33%); levels 1, 2 and 4 by 2 practitioners each (3.33%); and level 3 by 1 professional (1.66%). None of the subjects named all 5 IDDSI levels correctly. Conclusion: most practitioners progressed consistencies properly. There was a diversity of terminologies used for the same consistency at all levels, with no standardization.

Nutritional and hematological factors associated with the progression of Alzheimer's disease: a cohort study

SUMMARY OBJECTIVE: We studied the users of the Specialized Drug Distribution Program of the public health network. METHODS: A prospective cohort examined the elderly at two intervals of three years and included 30 patients in phase I and 16 in phase II. The methodology was composed of home visits, anthropometric, nutritional and hematological evaluation. For the progression of AD, the Clinical Dementia Rating (CDR) scale was used. RESULTS: According to the CDR, the disease evolved, since in 2014 most of the patients were in CDR 3. In the analysis of the micronutrients, only the B vitamins (B1, B2, B3, B5, B6) presented a significant reduction in 2014. The consumption of carbohydrates and lipids increased in the 2014 evaluation, and protein consumption decreased. As for the average weight of the elderly, there was an increase in 2014, 65.9 (± 15.6) Kg, with a BMI of 26.75 (± 4, 5), in 2011 the average weight was 62.44 kg (± 14, 36), BMI 24.64 (± 4.97). CONCLUSION: The hypothesis that patients are likely to be overweight or obese before the development of AD and that this may be associated with an increased risk of dementia is suggested.

Central inhibition of initiation of swallowing by systemic administration of diazepam and baclofen in anaesthetized rats

Dysphagia is caused not only by neurological and/or structural damage but also by medication. We hypothesized memantine, dextromethorphan, diazepam, and baclofen, all commonly used drugs with central sites of action, may regulate swallowing function. Swallows were evoked by upper airway (UA)/pharyngeal distension, punctate mechanical stimulation using a von Frey filament, capsaicin or distilled water (DW) applied topically to the vocal folds, and electrical stimulation of a superior laryngeal nerve (SLN) in anesthetized rats and were documented by recording electromyographic activation of the suprahyoid and thyrohyoid muscles and by visualizing laryngeal elevation. The effects of intraperitoneal or topical administration of each drug on swallowing function were studied. Systemic administration of diazepam and baclofen, but not memantine or dextromethorphan, inhibited swallowing evoked by mechanical, chemical, and electrical stimulation. Both benzodiazepines and GABA_A receptor antagonists diminished the inhibitory effects of diazepam, whereas a GABA_B receptor antagonist diminished the effects of baclofen. Topically applied diazepam or baclofen had no effect on swallowing. These data indicate that diazepam and baclofen act centrally to inhibit swallowing in anesthetized rats.NEW & NOTEWORTHY Systemic administration of diazepam and baclofen, but not memantine or dextromethorphan, inhibited swallowing evoked by mechanical, chemical, and electrical stimulation. Both benzodiazepines and GABA_A receptor antagonists diminished the inhibitory effects of diazepam, whereas a GABA_B receptor antagonist diminished the effects of baclofen. Topical applied diazepam or baclofen was without effect on swallowing. Diazepam and baclofen act centrally to inhibit swallowing in anesthetized rats.

Evaluation of the Relationship between Nutritional Status and Quality of Life among Nursing Home Residents with Alzheimer's Disease

The purpose of this study was to determine nutritional status and its influence on their quality of life in Alzheimer's disease (AD) patients with Mini Nutritional Assessment (MNA) and anthropometric measurements. This study was conducted with 57 Alzheimer type dementia patients between the ages of 52 and 89 who live in nursing homes in Ankara/Turkey. In this study, it was found that the 57.9% of the AD patients were at risk of malnutrition, and that 19.3% were malnourished. Malnutrition risk rises as the length of stay increases (p< .05). A significant correlation between body weight and quality of life as well as one between calf circumference and quality of life was detected (p< .05). In this study, nutrient intake among aged individuals with AD was found unbalanced; a statistically significant correlation between energy / nutrient intake and quality of life also was not detected.