JoAnne Robbins

A penetration-aspiration scale.

The development and use of an 8-point, equalappearing interval scale to describe, penetration and aspiration events are described. Scores are determined primarily by the depth to which material passes in the airway and by whether or not material entering the airway is expelled. Intra-and interjudge reliability have been established. Clinical and scientific uses of the scale are discussed.

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.

Senescent Swallowing: Impact, Strategies, and Interventions

The risk for disordered oropharyngeal swallowing (dysphagia) increases with age. Loss of swallowing function can have devastating health implications, including dehydration, malnutrition, pneumonia, and reduced quality of life. Age-related changes increase risk for dysphagia. First, natural, healthy aging takes its toll on head and neck anatomy and physiologic and neural mechanisms underpinning swallowing function. This progression of change contributes to alterations in the swallowing in healthy older adults and is termed presbyphagia, naturally diminishing functional reserve. Second, disease prevalence increases with age, and dysphagia is a comorbidity of many age-related diseases and/or their treatments. Sensory changes, medication, sarcopenia, and age-related diseases are discussed herein. Recent findings that health complications are associated with dysphagia are presented. Nutrient requirements, fluid intake, and nutrition assessment for older adults are reviewed relative to dysphagia. Dysphagia screening and the pros and cons of tube feeding as a solution are discussed. Optimal intervention strategies for elders with dysphagia ranging from compensatory interventions to more rigorous exercise approaches are presented. Compelling evidence of improved functional swallowing and eating outcomes resulting from active rehabilitation focusing on increasing strength of head and neck musculature is provided. In summary, although oropharyngeal dysphagia may be life threatening, so are some of the traditional alternatives, particularly for frail, elderly patients. Although the state of the evidence calls for more research, this review indicates that the behavioral, dietary, and environmental modifications emerging in this past decade are compassionate, promising, and, in many cases, preferred alternatives to the always present option of tube feeding.

Differentiation of Normal and Abnormal Airway Protection during Swallowing Using the Penetration–Aspiration Scale

Abstract. Accidental loss of food or liquids into the airway while eating or drinking is perhaps the most clinically significant consequence of dysphagia. Although videofluoroscopic recording of swallowing is the current gold standard for identifying and determining remediation for aspiration, results are generally described in descriptive terms, thus limiting information and lending to errors of interpretation. We previously published an 8-point scale to quantitate selected aspects of penetration and aspiration conveying depth of airway invasion and whether or not material entering the airway is expelled (Rosenbek et al., 1996, Dysphagia 11:93–98). The present study defines the distribution of the Penetration–Aspiration Scale scores in healthy normal subjects of different genders and ages. The scale was also used with two groups of patients known to have significant dysphagia relative to stroke or head and neck cancer. Significant differences found among groups are discussed.

Swallowing after unilateral stroke of the cerebral cortex: Preliminary experience

In an attempt to impose an organizational format on the specific effects that isolated stroke syndromes have on swallowing ability, we have developed a systematic approach to investigating the underlying neural control mechanisms in patients with clinical and computed tomographic evidence of unilateral ischemic stroke involving the cerebral cortex. When compared to findings in normal controls, initiation of the pharyngeal response was delayed in all stroke subjects. Left cortical stroke dysphagia was characterized primarily by impaired oral stage function, difficulty initiating coordinated motor activity, and apraxia. Right cortical stroke dysphagia was characterized primarily by pharyngeal pooling, penetration, and aspiration. Thus, these preliminary data indicate distinct patterns of dysphagia after unilateral cortical stroke and challenge the traditional classification of swallowing as a bilateral and brainstem-mediated activity.

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

Swallowing after unilateral stroke of the cerebral cortex

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

The SWAL-QOL Outcomes Tool for Oropharyngeal Dysphagiain Adults: II. Item Reduction and Preliminary Scaling

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

Thermal application reduces the duration of stage transition in dysphagia after stroke.

We report differential patterns of swallowing in 40 patients with their first ischemic middle cerebral artery (MCA) stroke and compare these to 20 nonstroke controls. Stroke patients were divided a priori, into groups by right or left and, post hoc, primarily anterior or posterior MCA territory lesions. The left hemisphere subgroup was differentiated from controls by longer pharyngeal transit durations and from the right hemisphere group by shorter pharyngeal response durations. The right hemisphere subgroup was characterized by longer pharyngeal stage durations and higher incidences of laryngeal penetration and aspiration of liquid. Anterior lesion subjects demonstrated significantly longer swallowing durations on most variables compared to both normal and posterior lesion subjects. Changes in the consistency of foods and other modifications for safe nutrition should be considered during the first month of recovery for unilateral stroke patients with swallowing difficulty.

Dysphagia in the Elderly

The SWAL-QOL outcomes tool was constructed for use in clinical research for patients with oropharyngeal dysphagia. The SWAL-QOL was constructed a priori to enable preliminary psychometric analyses of items and scales before its final validation. This article describes data analysis from a pretest of the SWAL-QOL. We evaluated the different domains of the SWAL-QOL for respondent burden, data quality, item variability, item convergent validity, internal consistency reliability as measured by Cronbachs alpha, and range and skewness of scale scores upon aggregation and floor and ceiling effects. The item reduction techniques outlined reduced the SWAL-QOL from 185 to 93 items. The pretest of the SWAL-QOL afforded us the opportunity to select items for the ongoing validation study which optimally met our a priori psychometric criteria of high data quality, normal item distributions, and robust evidence of item convergent validity.