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

Oropharyngeal Dysphagia in Hospitalized Older Adults with Dementia: A Prospective Cohort Study

OBJECTIVE

Oropharyngeal dysphagia (dysphagia) is highly prevalent (up to 86%) in hospitalized patients with Alzheimer disease and related dementias (ADRD). This study aims to describe the management and clinical course of dysphagia in hospitalized patients with ADRD.

DESIGN

Prospective observational cohort study.

SETTING AND PARTICIPANTS

The study was conducted across 10 hospitals within a large health system in New York. Participants were older adults with ADRD admitted to the medicine service and diagnosed with dysphagia to liquids on speech-language pathologist (SLP) assessment and were recruited between January and June 2023.

METHODS

Baseline characteristics [eg, dementia Functional Assessment Staging Tool (FAST)], dysphagia management (eg, prescribed diet), and clinical course (eg, dysphagia improvement, respiratory complications) were collected.

RESULTS

Of patients with ADRD and dysphagia (n = 62), the average age was 86.5 and 66.1% were FAST Stage 7. On admission, 48.4% had pneumonia, 79.0% had delirium, and 69.4% were made nil per os (NPO) for aspiration risk. Of those who received SLP reassessment after diet initiation (n = 25), 76% demonstrated dysphagia improvement; 75% of patients with FAST stage 7 demonstrated improvement. Respiratory complications occurred in 21.0% of patients on the following diets: NPO, nasogastric tube feeding, dysphagia diets, and comfort feeds. In univariate analyses, hospital-acquired dehydration, no dysphagia improvement, and delirium were associated with respiratory complications.

CONCLUSIONS AND IMPLICATIONS

The potential for dysphagia improvement in hospitalized patients with ADRD (even those with advanced dementia) highlights the critical need for standardizing reassessment. Further studies are needed to evaluate factors associated with respiratory complications in this population.

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.

Hypoxemic Cardiac Arrest from Aspiration of a Cracker in the Postanesthesia Care Unit: A Case Report

A 71-year-old woman with coronary artery disease presented for carotid artery revascularization. After general anesthesia, the patient arrived in stable condition to the postanesthesia care unit. While awaiting transfer to her inpatient room, telemetry alarms alerted her nurse, who found the patient unresponsive, cyanotic, and pulseless. Advanced cardiovascular life support was initiated, with return of spontaneous circulation obtained after 1 round of chest compressions. On oropharyngeal examination, food particles were observed and suctioned. The patient then coughed up additional cracker pieces. This case highlights the risk of aspiration from dry, solid foods in the elderly during the postanesthesia recovery period.

Evaluating the Effect of Gastroesophageal Reflux Disease on Postoperative Dysphagia Following Anterior Cervical Spine Surgery-A Prospective, Multicenter Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

The purpose of this study was to prospectively evaluate the impact of a preoperative diagnosis of gastroesophageal reflux disease on the incidence and severity of postoperative dysphagia in a multicenter population.

METHODS

After Institutional Review Board approval, written informed consent was obtained from all participating patients. Patients over 18 years of age who underwent an elective anterior cervical discectomy and fusion for a degenerative condition were prospectively enrolled at two academic centers from the years 2018 to 2020. Patients were separated into two groups: those with and without a preoperative diagnosis of GERD. Continuous variables were assessed using either an independent t-test or Mann Whitney U-test for parametric and non-parametric data. All categorical variables were compared using a chi-square test.

RESULTS

A total of 116 patients met study criteria and were subsequently enrolled. Overall rates of postoperative dysphagia increased to 47.3% (n = 53) at 2-weeks but eventually decreased towards the preoperative prevalence of 25.0% at the 24-week mark. Patients with preoperative diagnosis of GERD had lower dysphagia severity scores on a continuous variable analysis in both the DSQ and EAT-10 surveys at 2-week follow-up in addition to the Bazaz survey at 24-week follow-up. Our follow up at 24-weeks was 85.7%.

CONCLUSIONS

Our study shows that having a preoperative diagnosis of GERD has no significant effect on the incidence of dysphagia following ACDF. Nevertheless, having a preoperative diagnosis of GERD does seem to provide some protective effect on the severity of dysphagia that this patient population develops at multiple intervals over a 24-week postoperative period.

Prevalence of Self-Reported Swallowing Difficulties and Swallowing-Related Quality of Life Among Community-Dwelling Older Adults in India

Self-reported swallowing difficulties are highly prevalent but underreported among older adults. The aging population in India is increasing, yet there is a lack of empirical data on self-reported swallowing difficulties in older adults. In the present study, we aimed to estimate the prevalence of self-reported swallowing difficulties and assess the swallowing-related quality of life (QOL) among community-dwelling older adults in India. We recruited 361 older adults (60-91 years) from the community. Participants completed the Eating Assessment Tool-10 (EAT-10) to assess self-reported swallowing difficulties and the Dysphagia Handicap Index (DHI) to assess swallowing-related QOL. Participants rated the EAT-10 from 0 for 'no problem' to 4 for 'severe problem'. The DHI rating included 0 for 'never', 2 for 'sometimes', and 4 for 'always'. The total scores of EAT-10 and DHI were summarised using descriptive statistics. Statistically significant differences between pass-fail groups of EAT-10 and DHI were evaluated using an independent t-test and multivariate analysis of variance test, respectively. The overall mean score for EAT-10 was 3.34, and 7.56 for DHI, with higher scores observed among females. 36.6% of older adults self-reported experiencing swallowing difficulties, while 47.4% self-reported having poor swallowing-related QOL at p < 0.05. A strong positive correlation (r = 0.86) was found between EAT-10 and total DHI scores at p < 0.001. The present study sheds light on the widespread yet underreported issue of self-reported swallowing difficulties and the impact on swallowing-related QOL among older adults in India. These findings emphasize the urgent need for early swallowing screening programs among older adults.

Prevalence of dysphagia in patients after orthopedic surgery

OBJECTIVES

Oropharyngeal dysphagia is one of the most prevalent health complications in older adults. The prevalence of postoperative dysphagia is expected to rise with the increasing number of older patients undergoing orthopedic surgery; however, the specific prevalence and contributing factors remain unclear. This scoping review aimed to identify the prevalence and factors related to postoperative dysphagia in older orthopedic patients.

METHODS

This review included studies published up to September 2022 on postoperative patients aged ≥ 60 years who underwent orthopedic surgery. We searched MEDLINE, EMBASE, CINAHL, CENTRAL, Web of Science, and Ichushi-Web.

RESULTS

In total, 21 of the 2158 identified studies were reviewed. The studies were classified into the three categories according to the surgical site: cervical spine disease (n = 12), hip fracture (n = 7), and others (n = 2). The estimated dysphagia prevalence rates [95 % confidence interval] of cervical spine disease, hip fractures, and others were 16 % [8-27], 32 % [15-54], and 6 % [4-8], respectively. Factors related to postoperative dysphagia included cervical alignment in cervical spine disease, being older within the cohort, preoperative health status, malnutrition, and sarcopenia in hip fractures.

CONCLUSIONS

The prevalence of postoperative dysphagia after orthopedic surgery was highest for hip fractures, followed by cervical spine and others. These results suggest non-neurogenic dysphagia in older patients undergoing orthopedic surgery and indicate that sarcopenia may contribute to postoperative dysphagia in this population. Therefore, further research should clarify the trajectory of postoperative dysphagia and the effectiveness of rehabilitation for postoperative dysphagia after orthopedic surgery.

Association between Malnutrition Severity and Swallowing Function in Convalescent Rehabilitation Wards: A Multi-Center Cohort Study in Malnourished Patients with Sarcopenic Dysphagia

OBJECTIVES

To evaluate the characteristics of sarcopenic dysphagia (SD) and the prognosis of swallowing function in convalescent rehabilitation hospital patients; and to investigate the association between malnutrition severity and SD.

DESIGN

A prospective, multi-center, cohort study.

SETTING

We extracted registry data from the Japanese Sarcopenic Dysphagia Database, focusing on patients admitted to convalescent rehabilitation hospitals.

PARTICIPANTS

A total of 207 participants were recruited and stratified according to the presence or absence of SD. Next, the participants were divided into groups based on nutrition status using the Global Leadership Initiative on Malnutrition criteria: normal nutrition, moderate malnutrition, and severe malnutrition. We also compared the outcomes between patients with SD (SD group) and those without SD (no-SD group) according to malnutrition status.

MEASUREMENTS

The Food Intake LEVEL Scale (FILS) score was the outcome measure. Higher scores on the FILS indicate better swallowing function. We compared the patient characteristics between the SD and non-SD groups among all patients and then according to the severity of malnutrition.

RESULTS

A total of 207 patients were recruited. 11 were diagnosed with normal nutrition, 72 with moderate malnutrition, and 124 with severe malnutrition. There were 128 participants with SD and 79 participants without SD; the prevalence of SD was 61.8%. Hip fracture was the most common disease among the SD patients (34.4%). The median time to the end of follow-up was 73.5 days for the SD group and 84.0 days for the no-SD group. There was no significant difference in the FILS score between the SD and no-SD groups, but the increase in the FILS score was significantly lower in the SD group than the no-SD group among patients with severe malnutrition after adjusting for confounding factors (age, sex, FILS at admission, BMI, cognitive functional independence measure, and care level before onset) (β = -0.206, p = 0.011, 95% confidence interval = -0.723, -0.098).

CONCLUSION

Orthopedic diseases are the most common type of disease among SD patients in convalescent rehabilitation hospitals. Swallowing dysfunction was particularly severe in malnourished patients with SD. This result suggests the importance of the definition of SD for malnourished patients. We should practice nutritional management as soon as possible in severely malnourished patients diagnosed with SD.

Muscle Thickness and Echogenicity Measured by Ultrasound Could Detect Local Sarcopenia and Malnutrition in Older Patients Hospitalized for Hip Fracture

BACKGROUND

The aim of this work was to assess whether the muscle thickness and echogenicity were associated with dysphagia, malnutrition, sarcopenia, and functional capacity in acute hospital admission for a hip fracture.

METHODS

Observational study that assessed nutritional status by Global Leadership Initiative on Malnutrition, risk of dysphagia and sarcopenia by European Working Group on Sarcopenia in Older People and Barthel functional index. We measured muscle thickness and echogenicity of masseter, bicipital, and quadriceps rectus femoris (RF) and vastus intermedius (VI) by ultrasound.

RESULTS

One hundred and one patients were included in the study (29.7% sarcopenia and 43.8% malnutrition). Logistic regression models adjusted for age, sex, and body mass index showed an inverse association of the masseter thickness with both sarcopenia (OR: 0.56) and malnutrition (OR: 0.38) and quadriceps with sarcopenia (OR: 0.74). In addition, patients at high risk of dysphagia had lower masseter thickness (p: 0.0001) while patients able to self-feeding had thicker biceps (p: 0.002) and individuals with mobility on level surfaces higher thickness of biceps (p: 0.008) and quadriceps (p: 0.04).

CONCLUSION

Thickness of the masseter was associated with risk of dysphagia, biceps with the ability to self-feed, and that of the quadriceps RF-VI with mobility.

Oropharyngeal dysphagia in older patients with hip fracture

BACKGROUND

oropharyngeal dysphagia (OD) and hip fracture are common problems in older patients, both associated with important complications.

OBJECTIVE

the aim of this study was to measure the prevalence and identify the main risk factors of dysphagia in older patients with hip fracture.

DESIGN

a prospective study in an orthogeriatric unit of a university hospital over 10 months.

METHODS

a total of 320 patients (mean age 86.2 years, 73.4% women) were assessed for dysphagia within 72 hours post-surgery using the Volume-Viscosity Swallow Test. Geriatric assessment, hip fracture management and complications were examined to determine their relationship with the presence of OD.

RESULTS

dysphagia was present in 176 (55%) patients. Multivariate logistic regression analysis showed that the presence of delirium during hospitalization and the inability to perform instrumental activities of daily living before admission were associated with OD.

CONCLUSIONS

the prevalence of OD is high in hip fracture patients. Objective dysphagia assessment should be routinely included as part of the geriatric assessment of such patients.

Systematic Dysphagia Screening of Elderly Persons in the Emergency Department-A Feasibility Study

Identification of elderly patients in risk of dysphagia as early as possible upon hospital admission seems warranted due to the risk of aspiration pneumonia, dehydration, length of stay, and increased mortality. This study aimed to evaluate the feasibility and outcome of dysphagia screening of elderly persons admitted to the emergency department (ED). Inclusion criteria were age ≥ 60 years. A nurse applied the Simple Water Swallow test within one hour of admission. Subsequent assessment was performed by an occupational therapist (OT) using Volume Viscosity Swallow Test and Minimal Eating Observation Form. Of 113 eligible participants (median age 78 years), 75 (66%) were screened in the ED by the nurse, and among those, 12 (16%) were detected with dysphagia. Twenty of the patients not screened in the ED due to critical illness were tested by the OT in the ward after clinical stabilization and 15 patients (75%) were identified with dysphagia. This study demonstrated that it is feasible to perform dysphagia screening of elderly persons by a nurse in the ED, but there are severe limitations according to screening patients with critical illness and patients fasting before surgery in the ED. These patients have a high prevalence of dysphagia and should be screened as early as possible after hospitalization, as it will rarely be possible in the ED.