Elisabet Palomera

The effect of bolus viscosity on swallowing function in neurogenic dysphagia.

To assess the pathophysiology and treatment of neurogenic dysphagia.

Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration *

AIMS To determine the accuracy of the bedside volume-viscosity swallow test (V-VST) for clinical screening of impaired safety and efficacy of deglutition. METHODS We studied 85 patients with dysphagia and 12 healthy subjects. Series of 5-20 mL nectar (295.02 mPa.s), liquid (21.61 mPa.s) and pudding (3682.21 mPa.s) bolus were administered during the V-VST and videofluoroscopy. Cough, fall in oxygen saturation > or =3%, and voice changes were considered signs of impaired safety, and piecemeal deglutition and oropharyngeal residue, signs of impaired efficacy. RESULTS Videofluoroscopy showed patients had prolonged swallow response (> or =1064 ms); 52.1% had safe swallow at nectar, 32.9%, at liquid (p<0.05), and 80.6% at pudding viscosity (p<0.05); 29.4% had aspirations, and 45.8% oropharyngeal residue. The V-VST showed 83.7% sensitivity and 64.7% specificity for bolus penetration into the larynx and 100% sensitivity and 28.8% specificity for aspiration. Sensitivity of V-VST was 69.2% for residue, 88.4% for piecemeal deglutition, and 84.6% for identifying patients whose deglutition improved by enhancing bolus viscosity. Specificity was 80.6%, 87.5%, and 73.7%, respectively. CONCLUSIONS The V-VST is a sensitive clinical method to identify patients with dysphagia at risk for respiratory and nutritional complications, and patients whose deglutition could be improved by enhancing bolus viscosity. Patients with a positive test should undergo videofluoroscopy.

Pathophysiology of oropharyngeal dysphagia in the frail elderly.

Background  Oropharyngeal dysphagia is a major complaint among the elderly. Our aim was to assess the pathophysiology of oropharyngeal dysphagia in frail elderly patients (FEP).

Oropharyngeal dysphagia is a prevalent risk factor for malnutrition in a cohort of older patients admitted with an acute disease to a general hospital.

BACKGROUND & AIMS Oropharyngeal dysphagia and malnutrition are prevalent conditions in the older. The aim of this study was to explore the relationship between oropharyngeal dysphagia, nutritional status and clinical outcome in older patients admitted to an acute geriatric unit. METHODS We studied 1662 patients ≥70 years consecutively hospitalized with acute diseases, in whom dysphagia could be clinically assessed by the volume-viscosity swallow test and nutritional status with the Mini Nutritional Assessment(®). Anthropometric and laboratory measurements were taken and mortality recorded during hospital stay, at 6 months and one year after discharge was recorded. RESULTS 47.4% (95% CI 45-49.8%) patients presented oropharyngeal dysphagia and 30.6% (95% CI 27.9%-33.3%), malnutrition. Both conditions were associated with multimorbidity, multiple geriatric syndromes and poor functional capacity (p < 0.001). However, patients with dysphagia presented increased prevalence of malnutrition (MNA(®) < 17 45.3% vs 18%, p < 0.001) regardless of their functional status and comorbidities (OR 2.31 (1.70-3.14)) and lower albumin and cholesterol levels. Patients with malnutrition presented an increased prevalence of dysphagia (68.4% (95% CI 63.3-73.4)). Patients with dysphagia and patients with malnutrition presented increased intrahospital, 6-month and 1-year mortality rates (p < 0.05). The poorest outcome was for patients with both conditions (1-year mortality was 65.8%). CONCLUSIONS Prevalence of dysphagia was higher than malnutrition in our older patients. Dysphagia was an independent risk factor for malnutrition, and both conditions were related to poor outcome.

Oropharyngeal dysphagia is a risk factor for community-acquired pneumonia in the elderly

The aim of this study was to explore whether oropharyngeal dysphagia is a risk factor for community-acquired pneumonia (CAP) in the elderly and to assess the physiology of deglutition of patients with pneumonia. In the case–control study, 36 elderly patients (aged ≥70 years) hospitalised with pneumonia were matched by age and sex with two independently living controls. All subjects were given the volume–viscosity swallow test to identify signs of oropharyngeal dysphagia. In the pathophysiological study, all cases and 10 healthy elderly subjects were examined using videofluoroscopy. Prevalence of oropharyngeal dysphagia in the case–control study was 91.7% in cases and 40.3% in controls (p<0.001). Adjusting for functionality and comorbidities, dysphagia showed an independent effect on pneumonia (OR 11.9, 95% CI 3.03–46.9). Among cases in the pathophysiological study, 16.7% showed safe swallow, 30.6% high penetrations, 36.1% severe penetrations and 16.7% silent aspirations during videofluoroscopy, while in the healthy elderly subjects these percentages were 80%, 20%, 0% and 0%, respectively (p<0.001). A delay in closure of the laryngeal vestibule (0.414±0.029 s versus 0.200±0.059 s, p<0.01) was the main mechanism of impaired airway protection. In elderly subjects, oropharyngeal dysphagia is strongly associated with CAP, independently of functionality and comorbidities. Elderly patients with pneumonia presented a severe impairment of swallow and airway protection mechanisms. We recommend universal screening of dysphagia in older persons with pneumonia.

Inhaled drugs as risk factors for community-acquired pneumonia

The effect of inhaled drugs in community-acquired pneumonia (CAP) is unclear. This case–control study was designed to determine whether inhaled drugs were risk factors for CAP. All incident cases of confirmed CAP that occurred over 1 yr in patients with chronic bronchitis (CB), chronic obstructive pulmonary disease (COPD) or asthma were included, as well as CB, COPD and asthma controls. Risk factors for CAP and inhaled treatment were recorded during a personal interview. An effect of inhaled drugs on the risk of CAP was observed in COPD and asthma patients after adjusting for the effect of other respiratory diseases and their concomitant treatments. In COPD patients, inhaled steroids had a risk OR of 3.26 (95% CI 1.07–9.98) and in asthma patients inhaled anticholinergics had a risk OR of 8.80 (95% CI 1.02–75.7). In CB patients, no association with CAP was observed for any inhaler. These effects were independent of adjusting variables related to severity and other respiratory and non-respiratory risk factors for CAP, including vaccines. Inhaled &bgr;2-adrenergic agonists did not show a significant effect on the risk of CAP in any of the respiratory diseases. Inhaled steroids may favour CAP in COPD patients, whereas anticholinergics may favour CAP in asthma patients. It is difficult to differentiate the effect of inhaled therapy from the effect of COPD or asthma severity on the risk of CAP, and these relationships may not be causal, but could call attention to inhaled therapy in COPD and asthma patients.

Gastrointestinal peptides, gastrointestinal motility, and anorexia of aging in frail elderly persons

Background  The mechanisms involved in anorexia in frail elderly people remain unclear. The objective of this study was to establish whether fasting and postprandial levels of gastrointestinal peptides, gastrointestinal motility, and hunger are modified by age and frailty.

Relationship between Plasma Ghrelin Levels and Sarcopenia in Elderly Subjects: A Cross-Sectional Study.

ObjectiveThe aim of this study was to investigate the relationship between plasma ghrelin levels and sarcopenia in elderly people.DesignCross-sectional study.SettingHealth consortium medical centers in the Maresme region, Barcelona (Spain).ParticipantsTwo groups of subjects: persons ≥ 70 years (elderly group) and persons 25–65 years (young adults).MeasurementsSarcopenia, diagnosed according to the EWGSOP definition, fasting and postprandial plasma ghrelin levels, body composition, hand grip, Barthel score, and frailty using Fried criteria.ResultsFifty-five elderly subjects and 33 young adults were recruited. In both age groups, mean ghrelin levels were significantly higher in women than in men. However, mean ghrelin levels were similar in elderly and young men (716 vs. 752 pg mL-1, P = 0.763) as well as in elderly and young women (859 vs. 995 pg mL-1, P = 0.190). In the elderly group, subjects with sarcopenia showed significantly lower ghrelin levels than those without sarcopenia (650 vs. 899 pg mL-1, P = 0.036), but these differences disappeared when stratifying by gender. Elderly subjects without sarcopenia had the same ghrelin levels as young adults (899.3 vs. 899.6 pg mL-1). In young women, ghrelin levels correlated with fat free mass (rs = 0.58, P = 0.007) and muscular mass (rs = 0.54, P = 0.015) but these correlations were not observed in men nor in elderly women.ConclusionThis cross-sectional study does not allow a definitive conclusion about the relationship between ghrelin levels and sarcopenia. Further large prospective studies are needed to test this hypothesis.

Evaluation of conut for clinical malnutrition detection and short-term prognostic assessment in hospitalized elderly people

ObjectivesTo assess agreement between the CONUT and Mini Nutritional Assessment (MNA) instruments in detecting malnutrition in hospitalized elderly patients and to determine their prognostic value compared to that of serum albumin alone in relation to in-hospital and 1-month and 6-month post-discharge mortality rates.DesignProspective observational study.SettingA Catalan regional hospital.Participants2155 patients admitted to an acute geriatric unit were assessed using MNA and CONUT and were followed up for 6 months after discharge.MeasurementsOn admission, data were collected on age, sex, referral, geriatric syndromes, cognitive status, functional status and nutritional status according to MNA (as the gold standard). Plasma albumin, total cholesterol and lymphocyte levels were recorded to implement CONUT. Mortality was recorded until 6 months after discharge.ResultsSample characteristics: 61.3% females, mean age 84.9 years, mean Charlson index 2.2. CONUT sensitivity and specificity for malnutrition were 43% and 71.6%, respectively, with positive and negative predictive values of 88.9% and 19.2%. MNA, CONUT and albumin alone were good predictors of mortality but showed similar sensitivity and specificity results.ConclusionCONUT agreement with MNA in nutritional risk assessments for elderly people is poor. Although CONUT is a good predictor of short-and medium-term mortality, it adds little to information provided by albumin alone.

Relationship between the Use of Inhaled Steroids for Chronic Respiratory Diseases and Early Outcomes in Community-Acquired Pneumonia

Background The role of inhaled steroids in patients with chronic respiratory diseases is a matter of debate due to the potential effect on the development and prognosis of community-acquired pneumonia (CAP). We assessed whether treatment with inhaled steroids in patients with chronic bronchitis, COPD or asthma and CAP may affect early outcome of the acute pneumonic episode. Methods Over 1-year period, all population-based cases of CAP in patients with chronic bronchitis, COPD or asthma were registered. Use of inhaled steroids were registered and patients were followed up to 30 days after diagnosis to assess severity of CAP and clinical course (hospital admission, ICU admission and mortality). Results Of 473 patients who fulfilled the selection criteria, inhaled steroids were regularly used by 109 (23%). In the overall sample, inhaled steroids were associated with a higher risk of hospitalization (OR=1.96, p = 0.002) in the bivariate analysis, but this effect disappeared after adjusting by other severity-related factors (adjusted OR=1.08, p=0.787). This effect on hospitalization also disappeared when considering only patients with asthma (OR=1.38, p=0.542), with COPD alone (OR=4.68, p=0.194), but a protective effect was observed in CB patients (OR=0.15, p=0.027). Inhaled steroids showed no association with ICU admission, days to clinical recovery and mortality in the overall sample and in any disease subgroup. Conclusions Treatment with inhaled steroids is not a prognostic factor in COPD and asthmatic patients with CAP, but could prevent hospitalization for CAP in patients with clinical criteria of chronic bronchitis.