Jacqueline A. Hind

The Effects of Lingual Exercise on Swallowing in Older Adults

Objectives: To determine the effects of an 8‐week progressive lingual resistance exercise program on swallowing in older individuals, the most “at risk” group for dysphagia.

Comparison of 2 Interventions for Liquid Aspiration on Pneumonia Incidence A Randomized Trial

Context Patients with dysphagia are at increased risk for aspiration pneumonia. Contribution This trial involved 515 adults with dementia or Parkinson disease and videofluoroscopically demonstrated aspiration. Participants were randomly assigned to drink thin liquids with a chin-down posture or to drink nectar- or honey-thick liquids in a head-neutral position. At 3 months, the cumulative incidence of pneumonia was about 10%, 8%, and 15% in the thin, nectar-thick, and honey-thick liquid groups. Dehydration was more common with thick than thin liquids. Caution Findings were inconclusive. The incidence of pneumonia was lower than expected, and confidence bounds around differences between groups were wide. The Editors Swallowing disorders are associated with increased morbidity and mortality. An estimated 18 million adults will require care for dysphagia-related malnutrition, dehydration, pneumonia, and reductions in quality of life by 2010 (13). Patients with dysphagia have an increased incidence of aspiration pneumonia because the aspirated material is heavily colonized with bacteria. Pneumonia is the fifth leading cause of infectious death in the United States among persons age 65 years or older and the third leading cause of death for persons age 85 years or older (4). One hospital admission for pneumonia is estimated to cost

Neurophysiology of swallowing: effects of age and bolus type.

7166 (5). Rates of hospital discharge for Medicare beneficiaries with pneumonia as a primary diagnosis have increased by 93.5% in the past decade (6), along with length of stay and death rates (4). Liquid aspiration is the most common type of aspiration in elderly persons (1). Relative risk for pneumonia is highest in patients with dementia, followed by those who are institutionalized (7). As many as 50% of patients with parkinsonism are estimated to have dysphagia (8), and one third aspirate silentlythat is, with no external sign (such as coughing) to eject material or alert caregivers (9). Many short- and long-term care facilities use thickened liquid diets to treat aspiration (10). In these diets, thin liquids (for example, water, tea, and coffee) are eliminated, even in the absence of efficacy data, at a substantial cost in financial and quality-of-life terms. It costs approximately

Tongue Strength Is Associated with Jumping Mechanography Performance and Handgrip Strength but Not with Classic Functional Tests in Older Adults

200 per month for an individual to drink thickened liquids (11, 12). A common alternative to thickened liquids is use of a chin-down posture (1317). Welch and coworkers (13) noted that posterior shift of anterior pharyngeal structures with the chin-down posture improved airway protection. Whereas previous studies have provided a basis for the widespread clinical use of chin-down posture, none has provided long-term health outcome data. Results from a previously reported portion of this study (18) demonstrated that short-term elimination of aspiration during the videofluorographic swallowing evaluation occurred most often with honey-thick liquids, followed by nectar-thick liquids and chin-down position. We sought to compare the effectiveness of chin-down posture and thickened liquids (nectar thick and honey thick) on the incidence of pneumonia in participants with dementia or Parkinson disease during 3 months of treatment. Methods Design The study design and methods are described in detail elsewhere (19). In brief, between enrollment initiation on 9 June 1998 and closure on 16 September 2005, 47 acute-care hospitals and 79 subacute residential facilities combined their patients to enroll 515 participants, a total that was 65 participants short of the recruitment goal. Follow-up was completed on 9 December 2005. The Data and Safety Monitoring Committee recommended discontinuing enrollment, on the basis of a futility analysis suggesting that enrolling additional participants would not change the findings. Participants were enrolled in this 3-month follow-up study if they were observed to aspirate when swallowing 3 mL of thin liquids from a spoon or when drinking from a cup without an intervention during videofluoroscopy of swallowing. Aspiration was defined as barium observed below the vocal folds. Participants who qualified were then given boluses to perform 3 conditions in random order: thin liquid (15 centipoise) swallowed in a chin-down posture, nectar-thick liquid (300 centipoise) swallowed in a head-neutral position, and honey-thick liquid (3000 centipoise) swallowed in a head-neutral position. Participants who did equally well (all conditions eliminated aspiration) or equally poorly (no conditions eliminated aspiration) but wished to continue oral intake, despite being warned about risk for pneumonia, were randomly assigned to 1 of the conditions as an intervention and followed for 3 months. Participants who aspirated during 1 or 2 of the conditions were not randomly assigned. On-site speech-language pathologists, nurses, and direct care and dietary staff who completed rigorous training about facilitation of the chin-down posture and proper techniques to thicken liquids supervised administration of the interventions. The number of participants under supervision by a speech-language pathologist ranged from 1 to 93 (median, 4 participants). Clinicians were instructed to refrain from using concomitant active or compensatory interventions with participants during the study period. Research staff made monthly site visits to monitor protocol adherence. All participants or their representatives provided written informed consent. Each facilitys institutional review board of record, as approved by the Office for Human Research Protections, Department of Health and Human Services, approved the study. Setting and Participants Inclusion criteria were a physician-identified diagnosis of dementia (Alzheimer type, single or multistroke type, or other nonresolving types) or Parkinson disease and patient age (50 to 95 years). Exclusion criteria were tobacco use in the past year, current alcohol abuse, history of head or neck cancer, insulin-dependent diabetes for 20 years or more, nasogastric tube, other progressive or infectious neurologic diseases, or pneumonia within 6 weeks of enrollment. Outpatients and inpatients from participating acute and subacute care facilities who were suspected of aspirating liquids by their physicians and speech-language pathologists during standard clinical care were referred for a videofluoroscopic swallowing study at a participating acute-care facility. The speech-language pathologist or research personnel completed the informed consent process with the patient and care provider before the swallowing study. After the swallowing study, participants returned to their living situation (acute care, subacute care, or home) while the videofluoroscopic images were analyzed. Participants were randomly assigned to an intervention group within 24 hours. Randomization and Interventions The primary interventions were chin-down posture while consuming thin liquids versus consuming thickened liquids (nectar thick or honey thick; Resource ThickenUp, Nestl HealthCare Nutrition [formerly Novartis Medical Nutrition], St. Louis Park, Minnesota) in a head-neutral position. The thin, nectar-thick, and honey-thick barium solutions (Varibar, E-Z-EM, Lake Success, New York) were manufactured in a standardized formulation for this study. Standardized recipes matching the viscosities of the barium products were developed for a wide variety of thickened beverages. Participants were randomly assigned centrally by a telephone system controlled by the Statistical and Data Center at the EMMES Corporation (Rockville, Maryland). A study speech-language pathologist called a central telephone number and entered participant criteria when prompted to, by using the telephone keys. If the patient was eligible, an intervention was assigned and a summary page that included intervention assignment and meal-monitoring was faxed to the speech-language pathologist. Randomization sequences for primary assignment (chin-down posture vs. thickened liquids) were developed by a statistician at the Statistical and Data Center. The sequences were stratified by participant age (50 to 79 years or 80 to 95 years) and diagnosis (Parkinson disease with or without dementia, or dementia only) and included randomly assigned block sizes of 32, 40, or 48 within each of the 4 strata. If a participant was assigned to thickened liquids, a second randomization was done to assign the participant to nectar-thick liquids or honey-thick liquids with equal probability. Neither the participants nor direct caregivers were blinded to intervention assignment, but neither group made outcome judgments. We expected that all liquids, regardless of amount or frequency of administration, would be provided to participants consistent with the intervention to which the participant was randomly assigned. All participants continued nonliquid nutritional intake in the same manner as before enrollment. Eight percent received nutrition by means of a gastrostomy tube. Measurements and Outcomes Primary Outcome The primary outcome for the study was definite pneumonia. Definite pneumonia was defined as evidence of pneumonia on chest radiography or 3 or more of the following: sustained fever (temperature >100F [38C]), rales or rhonchi on chest auscultation, sputum Gram stain showing substantial leukocytes, or sputum culture showing a respiratory pathogen. Suspected pneumonia was defined as at least 2 of the 4 features of definite pneumonia (except evidence of pneumonia on a chest radiograph). The primary care physician determined the need for chest radiography or sputum culture as part of standard clinical care. Chest radiography was done in all 52 patients with pneumonia; 2 of these patients did not have evidence of pneumonia on chest radiography but had 3 or 4 of the features of definite pneumonia. Secondary Outcomes and Comparisons A secondary outcome of interest was definite pneumonia or death. Secondary comparisons of interest were relative effectiveness of the 2 degre

The Effects of Intraoral Pressure Sensors on Normal Young and Old Swallowing Patterns

This study examined age-related changes in swallowing from an integrated biomechanical and functional imaging perspective in order to more comprehensively characterize changes in swallowing associated with age. We examined swallowing-related fMRI brain activity and videoflouroscopic biomechanics of three bolus types (saliva, water and barium) in 12 young and 11 older adults. We found that age-related neurophysiological changes in swallowing are evident. The group of older adults recruited more cortical regions than young adults, including the pericentral gyri and inferior frontal gyrus pars opercularis and pars triangularis (primarily right-sided). Saliva swallows elicited significantly higher BOLD responses in regions important for swallowing compared to water and barium. In separate videofluoroscopy sessions, we obtained durational measures of supine swallowing. The older cohort had significantly longer delays before the onset of the pharyngeal swallow response and increased residue of ingested material in the pharynx. These findings suggest that older adults without neurological insult elicit more cortical involvement to complete the same swallowing tasks as younger adults.

Challenges in the design and conduct of a randomized study of two interventions for liquid aspiration

To determine whether classic muscle function tests and jumping mechanography (JM) are related to tongue strength.

Effects of Device-Facilitated Isometric Progressive Resistance Oropharyngeal Therapy on Swallowing and Health-Related Outcomes in Older Adults with Dysphagia

Lingual pressure generation plays a crucial role in oropharyngeal swallowing. To more discretely study the dynamic oropharyngeal system, a 3-bulb array of pressure sensors was designed with the Kay Elemetrics Corporation (Lincoln Park, NJ). The influence of the device upon normal swallowing mechanics and boluses representative of flow relative to age and bolus condition was the focus of this study. Twelve healthy adults in two age groups (31 ± 5 years, 2 males and 4 females, and 78 ± 7 years, 2 males and 4 females) participated. Each subject was instructed to swallow four boluses representative of conditions with and without three pressure sensors affixed to the hard palate. Postswallow residue at four locations, Penetration/Aspiration Scale scores, and three bolus flow timing measures were assessed videofluoroscopically with respect to age and bolus condition. The only statistically significant influences attributable to the presence of the pressure sensors were slight increases in residue in the oral cavity and upper esophageal sphincter with some bolus consistencies, 8% more frequent trace penetration of the laryngeal vestibule predominantly with effortful swallowing, and variances in oral clearance duration. We conclude that the presence of the pressure sensors does not significantly alter normal swallowing patterns of healthy individuals.

The Effects of Lingual Intervention in a Patient With Inclusion Body Myositis and Sjögren's Syndrome: A Longitudinal Case Study

Background Liquid aspiration during swallowing has been linked to pneumonia, the most common cause of infectious death in the elderly. This paper examines the key issues in the design and implementation of the first multisite, randomized behavioral trial in dysphagia in an aging population. The study evaluated two commonly used treatments with respect to short-term and long-term management of liquid aspiration and subsequent pneumonia in dysphagic geriatric participants with dementia and/or Parkinsons disease. Methods Discussed are lessons learned during the conduct of this trial and include (1) ethical and methodological design issues, (2) pragmatic implementation of procedures and forms, (3) importance of multiple communication and monitoring strategies, (4) response to funding issues, and (5) changes in staff and facilities. Results In order to complete this trial the researchers were required to provide more support than anticipated in tasks such as completion of regulatory requirements by sites, supplementing site staff to identify potential study participants using a ‘circuit rider’ approach, continued recruitment of new sites and staff throughout the course of the trial, adapting forms and procedures and managing within economic constraints in a changing trial environment. Limitations Many of the challenges faced by the researchers were not anticipated when the study began. Successful strategies are described for these unanticipated difficulties, based on retrospective evaluation. Conclusions Successful conduct of clinical trials in long-term care environments that are heavily impacted by changes extraneous to the trial design and with staff typically new to clinical trials is possible but success depends on logistical flexibility.

Esophageal Clearance Patterns in Normal Older Adults as Documented with Videofluoroscopic Esophagram

Swallowing disorders (dysphagia) are associated with malnutrition, aspiration pneumonia, and mortality in older adults. Strengthening interventions have shown promising results, but the effectiveness of treating dysphagia in older adults remains to be established. The Swallow STRengthening OropharyNGeal (Swallow STRONG) Program is a multidisciplinary program that employs a specific approach to oropharyngeal strengthening—device‐facilitated (D‐F) isometric progressive resistance oropharyngeal (I‐PRO) therapy—with the goal of reducing health‐related sequelae in veterans with dysphagia. Participants completed 8 weeks of D‐F I‐PRO therapy while receiving nutritional counseling and respiratory status monitoring. Assessments were completed at baseline, 4, and 8 weeks. At each visit, videofluoroscopic swallowing studies were performed. Dietary and swallowing‐related quality of life questionnaires were administered. Long‐term monitoring for 6–17 months after enrollment allowed for comparison of pneumonia incidence and hospitalizations to the 6–17 months before the program. Veterans with dysphagia confirmed with videofluoroscopy (N = 56; 55 male, 1 female; mean age 70) were enrolled. Lingual pressures increased at anterior (effect estimate = 92.5, P < .001) and posterior locations (effect estimate = 85.4, P < .001) over 8 weeks. Statistically significant improvements occurred on eight of 11 subscales of the Quality of Life in Swallowing Disorders (SWAL‐QOL) Questionnaire (effect estimates = 6.5–19.5, P < .04) and in self‐reported sense of effort (effect estimate = −18.1, P = .001). Higher Functional Oral Intake Scale scores (effect estimate = 0.4, P = .02) indicated that participants were able to eat less‐restrictive diets. There was a 67% reduction in pneumonia diagnoses, although the difference was not statistically significant. The number of hospital admissions decreased significantly (effect estimate = 0.96; P = .009) from before to after enrollment. Findings suggest that the Swallow STRONG multidisciplinary oropharyngeal strengthening program may be an effective treatment for older adults with dysphagia.

Case Study: Application of Isometric Progressive Resistance Oropharyngeal Therapy Using the Madison Oral Strengthening Therapeutic Device

OBJECTIVE To report the 5-year course of a patients swallowing disorder in the context of progressive neuromuscular disease and the effectiveness of a lingual strengthening treatment program. DESIGN This is a case report that describes a lingual treatment protocol that was repeated 3 times over a 5-year period with and without maintenance periods. SETTING The study was completed in 2 settings-an outpatient swallowing clinic at an acute care hospital and the patients home. PARTICIPANT The subject was a 77-year-old woman who was diagnosed with inclusion body myositis and Sjögrens syndrome. INTERVENTION The patient participated in an intensive 8-week lingual strengthening protocol 3 times (at years 1, 4, and 5) and a subsequent maintenance program twice (at years 4 and 5). MAIN OUTCOME MEASURES Three outcome measures were collected during the study: (1) lingual manometric pressures at the anterior and posterior tongue, measured by using a lingual manometric device, (2) airway invasion measured by using an 8-point Penetration-Aspiration Scale, and (3) clearance of the bolus measured by using a 3-point residue scale. RESULTS Isometric lingual strengthening was effective in maintaining posterior tongue lingual pressure and Penetration-Aspiration Scale scores during the treatment periods. Residue scale scores did not significantly change during treatment. CONCLUSIONS We conclude that, in this patient, lingual strengthening slowed the progression of disease-related lingual strength loss and extended functional swallowing performance. Thus, this type of intervention may hold promise as an effective swallowing treatment option for patients with neurodegenerative inflammatory diseases such as inclusion body myositis and Sjögrens syndrome.