Giselle D. Carnaby

Dysphagia in the elderly: management and nutritional considerations

Dysphagia is a prevalent difficulty among aging adults. Though increasing age facilitates subtle physiologic changes in swallow function, age-related diseases are significant factors in the presence and severity of dysphagia. Among elderly diseases and health complications, stroke and dementia reflect high rates of dysphagia. In both conditions, dysphagia is associated with nutritional deficits and increased risk of pneumonia. Recent efforts have suggested that elderly community dwellers are also at risk for dysphagia and associated deficits in nutritional status and increased pneumonia risk. Swallowing rehabilitation is an effective approach to increase safe oral intake in these populations and recent research has demonstrated extended benefits related to improved nutritional status and reduced pneumonia rates. In this manuscript, we review data describing age related changes in swallowing and discuss the relationship of dysphagia in patients following stroke, those with dementia, and in community dwelling elderly. Subsequently, we review basic approaches to dysphagia intervention including both compensatory and rehabilitative approaches. We conclude with a discussion on the positive impact of swallowing rehabilitation on malnutrition and pneumonia in elderly who either present with dysphagia or are at risk for dysphagia.

Behavioural intervention for dysphagia in acute stroke: a randomised controlled trial

BACKGROUND Swallowing dysfunction after stroke is common, but there is little reliable evidence for how the disorder should be managed. This study compared standard low-intensity and high-intensity behavioural interventions with usual care for dysphagia. METHODS 306 patients with clinical dysphagia admitted to hospital with acute stroke were randomly assigned to receive usual care (n=102), prescribed by the attending physician; standard low-intensity intervention (n=102), comprising swallowing compensation strategies and diet prescription three times weekly for up to a month; or standard high-intensity intervention and dietary prescription (n=102), at least daily for up to a month. The primary outcome measure was survival free of an abnormal diet at 6 months. Analysis was done by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00257764. FINDINGS 60 patients died and three patients were lost to follow up before the 6-month analysis. Of patients randomly allocated usual care, 56% (57/102) survived at 6 months free of an abnormal diet compared with 67% (136/204) allocated standard swallowing therapy (relative risk 1.19, 95% CI 0.98-1.45). Standard swallowing therapy was associated with a non-significant trend toward a reduction in death (0.80, 0.5-1.3), institutionalisation (0.69, 0.4-1.1), and dependency (1.05, 0.8-1.3); a significant reduction in swallowing-related medical complications (0.73, 0.6-0.9), chest infection (0.56, 0.4-0.8), and death or institutionalisation (0.73, 0.55-0.97); and a significant rise in the proportion of patients regaining swallowing function (1.41, 1.03-1.94) by 6 months. Compared with usual care and low-intensity therapy, high-intensity therapy was associated with an increased proportion of patients who returned to a normal diet (p=0.04) and recovered swallowing (p=0.02) by 6 months. INTERPRETATION These data show a consistent trend towards more favourable outcomes in dysphagic stroke patients who are assigned a standard programme of early behavioural swallowing intervention, including active therapeutic approaches and dietary modification.

Functional Benefits of Dysphagia Therapy Using Adjunctive sEMG Biofeedback

This article describes a retrospective analysis of functional outcome, time in therapy, and cost per unit of functional change in patients who received therapy for pharyngeal dysphagia. Twenty-five patients presenting dysphagia following stroke and 20 patients with dysphagia following treatment for head/neck cancer completed a systematic therapy program supplemented with surface electromyographic (sEMG) biofeedback. Eighty-seven percent (39/45) of all patients increased their functional oral intake of food/liquid including 92% of stroke patients and 80% of head/neck cancer patients. Patients with dysphagia following stroke demonstrated greater improvement than those in the head/neck cancer group. Patients in the stroke group completed more therapy sessions thus increasing the total cost of therapy, but they made more functional progress resulting in lower costs per unit of functional change than patients in the head/neck cancer group. Limitations of this study are described in reference to implications for future clinical research on the efficacy of this therapy approach.

Functional and Physiological Outcomes from an Exercise-Based Dysphagia Therapy: A Pilot Investigation of the McNeill Dysphagia Therapy Program

OBJECTIVE To investigate functional and physiological changes in swallowing performance of adults with chronic dysphagia after an exercise-based dysphagia therapy. DESIGN Intervention study: before-after trial with 3-month follow-up evaluation. SETTING Outpatient clinic within a tertiary care academic health science center. PARTICIPANTS Adults (N=9) with chronic (>12 mo) dysphagia after unsuccessful prior therapies. Subjects were identified from among patients referred to an outpatient dysphagia clinic. Subjects had dysphagia secondary to prior treatment for head/neck cancer or from neurologic injury. All subjects demonstrated clinical and fluoroscopic evidence of oropharyngeal dysphagia. No subject withdrew during the course of this study. INTERVENTIONS All subjects completed 3 weeks of an intensive, exercise-based dysphagia therapy. Therapy was conducted daily for 1h/d, with additional activities completed by subjects each night between therapy sessions. MAIN OUTCOME MEASURES Primary outcomes were clinical and functional change in swallowing performance with maintenance at 3 months after intervention. Secondary, exploratory outcomes included physiological change in swallow performance measured by hyolaryngeal elevation, lingual-palatal and pharyngeal manometric pressure, and surface electromyographic amplitude. RESULTS Clinical and functional swallowing performances improved significantly and were maintained at the 3-month follow-up examination. Subject perspective (visual analog scale) on functional swallowing also improved. Four of 7 subjects who were initially feeding tube dependent progressed to total oral intake after 3 weeks of intervention. Physiological indices demonstrated increased swallowing effort after intervention. CONCLUSIONS Significant clinical and functional improvement in swallowing performance followed a time-limited (3 wk) exercise-based intervention in a sample of subjects with chronic dysphagia. Physiological changes after therapy implicate improved neuromuscular functioning within the swallow mechanism.

The impact of music interventions on anxiety for adult cancer patients: a meta-analysis and systematic review.

Introduction. Listening to music can positively benefit neurophysiological and emotional responses as well as promote relaxation, which may be especially beneficial for cancer patients undergoing painful and anxiety inducing treatments. The purpose of the present study was to conduct an evidenced-based systematic review and meta-analysis of randomized controlled trials of music interventions to reduce anxiety for adult cancer patients undergoing medical treatment. Methods. A systematic literature search was conducted and data were abstracted from all eligible studies. Studies were included if they tested a music therapy randomized controlled trial in adult cancer patients (in active treatment), assessed anxiety postintervention using a validated measure, were published in English (or were translatable), and accessible in full text. Studies were qualitatively reviewed by the first author and 2 raters independently assessed each study using the PEDro scale. Standardized mean differences between experimental and control groups were calculated for studies meeting a specified methodological rigor score with accessible means and standard deviations postintervention. Heterogeneity and publication bias were explored. Results. Thirteen randomized controlled trials were included with 4 eligible for meta-analysis. Studies varied in intervention methodology and utilization of anxiety measures. Almost all studies reported either a significant difference in anxiety between groups postintervention or a significant decrease in anxiety over time in the music intervention group. Meta-analytic results of 4 studies (4/13) demonstrated that differences in anxiety between experimental and control groups were not significant in the main analysis or subgroup analysis. Studies demonstrated heterogeneity in anxiety results. Publication bias was not evident. Conclusion. The meta-analytic results failed to demonstrate a positive effect on anxiety among adult cancer patients in treatment but may in part be attributed to the small sample size. These findings are in contrast to a prior meta-analysis that analyzed all studies regardless of methodological rigor. More research is needed to ascertain the most optimal intervention methodology and which cancer populations or treatment modalities are appropriate for such an intervention.

Spontaneous Swallowing Frequency Has Potential to Identify Dysphagia in Acute Stroke

Background and Purpose— Spontaneous swallowing frequency has been described as an index of dysphagia in various health conditions. This study evaluated the potential of spontaneous swallow frequency analysis as a screening protocol for dysphagia in acute stroke. Methods— In a cohort of 63 acute stroke cases, swallow frequency rates (swallows per minute [SPM]) were compared with stroke and swallow severity indices, age, time from stroke to assessment, and consciousness level. Mean differences in SPM were compared between patients with versus without clinically significant dysphagia. Receiver operating characteristic curve analysis was used to identify the optimal threshold in SPM, which was compared with a validated clinical dysphagia examination for identification of dysphagia cases. Time series analysis was used to identify the minimally adequate time period to complete spontaneous swallow frequency analysis. Results— SPM correlated significantly with stroke and swallow severity indices but not with age, time from stroke onset, or consciousness level. Patients with dysphagia demonstrated significantly lower SPM rates. SPM differed by dysphagia severity. Receiver operating characteristic curve analysis yielded a threshold of SPM⩽0.40 that identified dysphagia (per the criterion referent) with 0.96 sensitivity, 0.68 specificity, and 0.96 negative predictive value. Time series analysis indicated that a 5- to 10-minute sampling window was sufficient to calculate spontaneous swallow frequency to identify dysphagia cases in acute stroke. Conclusions— Spontaneous swallowing frequency presents high potential to screen for dysphagia in acute stroke without the need for trained, available personnel.

Impaired laryngopharyngeal sensitivity in patients with COPD: The association with swallow function

Abstract Research indicates that patients with Chronic Obstructive Pulmonary Disease (COPD) have increased aspiration risk. Several factors may pre-dispose a patient to aspiration including a reduction in laryngopharyngeal sensitivity (LPS). Reduced LPS has been associated with increased aspiration risk in pathologies including stroke; however, this has not been examined in COPD. This study aims to explore possible associations between LPS and swallowing function in COPD patients, and determine whether a LPS predictive value may be used as a method of evaluating dysphagia risk in this patient population. Twenty participants with COPD underwent LPS discrimination testing, respiratory function testing, self-reporting swallowing questionnaire, clinical swallowing examination, and fibre-optic endoscopic evaluation of swallowing (FEES). Participants with COPD demonstrated impaired LPS defined by elevated laryngeal adductor reflex thresholds and high incidence of pharyngeal residue on FEES. Positive correlations were identified between their clinical swallowing examination and FEES results for the presence of laryngeal penetration/aspiration (p < 0.04), vallecular residue (p < 0.01), and piriform residue (p < 0.01). In conclusion, COPD patients have reduced laryngopharyngeal mechanosensitivity and impaired swallowing function characterized primarily by pharyngeal stasis. The combination of these deficits may place patients with COPD at increased aspiration risk due to lack of detection of pharyngeal residue and subsequent inhalation of pharyngeal contents.

Prevalence of and risk factors for dysphagia in the community dwelling elderly: A systematic review

ObjectivesThis review clarifies current information regarding the prevalence of and risk factors associated with dysphagia (swallowing disorders) in the community dwelling elderly (CDE). A better understanding of prevalence and characteristics of dysphagia in the CDE will help to determine the scope of this problem. Understanding the scope of dysphagia is a critical first step towards early identification, management, and prevention of dysphagia related morbidities in the CDE.MethodsStudies identified from multiple electronic databases (MEDLINE (Pubmed), PsychInfo, Google Scholar, EBSCO, PROQUEST, Web of Science and WorldCat dissertations and theses) evaluating prevalence and risk factors for dysphagia in the CDE were reviewed. Data from all eligible studies were abstracted by the first author and independently reviewed by two raters, using the Newcastle-Ottawa scale (NOS).Results15 studies (n = 9947 participants) were eligible for inclusion. Studies included were all observational: 14 cross-sectional and 1 prospective cohort. Significant heterogeneity was observed in methodology among studies of dysphagia in the CDE. The average NOS study quality rating was 4.54 points (SD: 0.9), with a mode of 4 points (range 3-6). Only 6 of the 15 studies were identified as high quality research studies, with a mean of 5.33 points (SD: 0.47). Among reviewed studies, the prevalence of swallowing difficulty in the CDE ranged from 5% to 72%. However, the average prevalence of dysphagia estimated from the 6 high quality studies was 15%. Reported risk factors associated with dysphagia include advancing age; history of clinical disease; and physical frailty, including reduced ability to carry out activities of daily living.ConclusionResearch on dysphagia in CDE is modest and consists mostly of observational studies with diverse methodology. However, prevalence rate of 15% from the high quality research suggests a significant public health impact of this impairment. Identification of specific risk factors that cause dysphagia in the CDE is premature, given the rigor of published studies. Future research efforts should focus on developing a valid definition and assessment of dysphagia in this population before clarifying causative risk factors.

Adoption into clinical practice of two therapies to manage swallowing disorders: exercise-based swallowing rehabilitation and electrical stimulation.

Purpose of reviewTo review recent literature depicting a shift in dysphagia rehabilitation in adults. Distinguishing rehabilitation from compensation in dysphagia management, a review of basic exercise principles is followed by description of recent publications depicting exercise-based therapies. Subsequently, transcutaneous electrical stimulation (TES) is reviewed as it may contribute to exercise-based dysphagia rehabilitation in adults. Recent findingsSurveys have documented extensive variability in the clinical application of dysphagia therapy techniques. Despite this variability, two trends are emerging in dysphagia rehabilitation research: documentation of physiologic and functional changes within the swallowing mechanism subsequent to therapy; and prophylactic exercise-based therapies. In addition, extensive efforts have emerged describing the potential application of TES in dysphagia rehabilitation. Though results of these efforts are conflicted, TES may serve a useful role as an adjunct to well developed exercise-based rehabilitation for dysphagia. SummaryThe focus of dysphagia rehabilitation in adults is changing. Current efforts indicate that exercise-based therapies should incorporate multiple principles of exercise physiology and document physiologic change within the impaired swallowing mechanism. TES may function as an adjunctive modality; however, current practices should be evaluated to develop additional parameters of stimulation that are focused toward specific dysphagia impairments.

A Prospective Pilot Study of Psychosocial Functioning in Head and Neck Cancer Patient–Caregiver Dyads

This study explored the psychosocial functioning of 10 head and neck cancer patient–caregiver dyads over the radiation/chemoradiation (radiation or combined chemoradiation) treatment period, including the interdependence in patient–caregiver quality of life (QOL). Dyads were recruited prior to or at the initiation of radiation/chemoradiation treatment. Patient QOL decreased across the treatment trajectory, and many caregiver QOL subscales decreased during the middle of treatment. Caregiver burden increased over the treatment trajectory with levels remaining relatively low. Patients and caregivers demonstrated interdependence in QOL toward the middle and conclusion of treatment. Patients demonstrated more depression than caregivers at all time points. Results suggest that both members of the dyad should be targeted for psychosocial interventions during radiation/chemoradiation treatment period.