Nicole Rogus-Pulia

Bedside diagnosis of dysphagia: A systematic review

Dysphagia is associated with aspiration, pneumonia, and malnutrition, but remains challenging to identify at the bedside. A variety of exam protocols and maneuvers are commonly used, but the efficacy of these maneuvers is highly variable. We conducted a comprehensive search of 7 databases, including MEDLINE, Embase, and Scopus, from each databases earliest inception through June 9, 2014. Studies reporting diagnostic performance of a bedside examination maneuver compared to a reference gold standard (videofluoroscopic swallow study or flexible endoscopic evaluation of swallowing with sensory testing) were included for analysis. From each study, data were abstracted based on the type of diagnostic method and reference standard study population and inclusion/exclusion characteristics, design, and prediction of aspiration. The search strategy identified 38 articles meeting inclusion criteria. Overall, most bedside examinations lacked sufficient sensitivity to be used for screening purposes across all patient populations examined. Individual studies found dysphonia assessments, abnormal pharyngeal sensation assessments, dual axis accelerometry, and 1 description of water swallow testing to be sensitive tools, but none were reported as consistently sensitive. A preponderance of identified studies was in poststroke adults, limiting the generalizability of results. No bedside screening protocol has been shown to provide adequate predictive value for presence of aspiration. Several individual exam maneuvers demonstrated reasonable sensitivity, but reproducibility and consistency of these protocols was not established. More research is needed to design an optimal protocol for dysphagia detection.

Changes in Swallowing Physiology and Patient Perception of Swallowing Function Following Chemoradiation for Head and Neck Cancer

Patients treated with chemoradiation for head and neck cancer often report difficulty with swallowing and are frequently diagnosed with dysphagia. The extent to which patient awareness of dysphagia corresponds to observed physiologic changes in swallowing is unclear. The purpose of this study was to determine how both patient awareness of swallowing function and swallowing physiology individually change following chemoradiation and then to clarify the relationship between them. Twenty-one patients with head and neck cancer treated with chemoradiation were assessed before and after treatment and matched with twenty-one control subjects. The modified barium swallow test was utilized to examine swallowing physiology. Each subject was also given a series of items regarding awareness of specific dysphagia symptoms. Results showed decreased swallow efficiencies, higher percentages of residue, and more occurrences of penetration and aspiration following chemoradiation. Patients also had significantly higher ratings for 4 of the 12 items (“dry mouth,” “food sticking in my mouth,” “need water to help food go down,” and “change in sense of taste”). Only one strong and significant correlation was found between ratings for “I have difficulty swallowing” and swallow efficiency values. Based on these findings, it appears that patients sense a general difficulty with swallowing but have less awareness of specific symptoms of dysphagia.

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

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.

Bolus effects on patient awareness of swallowing difficulty and swallow physiology after chemoradiation for head and neck cancer.

Patients treated for head and neck cancer frequently develop dysphagia. Bolus characteristics are altered during fluoroscopic swallowing studies to observe the impact on swallowing function. The purpose of this study was to determine bolus volume and consistency effects on oropharyngeal swallowing physiology and patient awareness of swallowing difficulty.

Approaches to the rehabilitation of dysphagia in acute poststroke patients.

Dysphagia occurs frequently following stroke and may result in serious health consequences including pneumonia, malnutrition, dehydration, and mortality. Prevention of these negative health outcomes requires early identification and treatment of dysphagia. The speech-language pathologist, as part of a multidisciplinary team, holds the primary responsibility for selection of an effective dysphagia rehabilitation program for these patients. Because much research has focused on patients with chronic dysphagia, this review will focus on treatment of patients within the acute phase of recovery poststroke. Although some acute patients may experience transient dysphagia that resolves spontaneously, many will go on to develop chronic dysphagia that may be prevented with provision of early and intensive treatment. An overview of dysphagia following stroke will be provided with information regarding incidence, complications, evaluation, and causes of dysphagia. A thorough discussion of evidence supporting varying approaches to dysphagia rehabilitation will follow with inclusion of several current, novel, and experimental techniques. The importance of the multidisciplinary team and regular reevaluation will be emphasized as well.

Understanding Dysphagia in Dementia: The Present and the Future

Dysphagia is common in patients with dementia of varying types and often results in serious health consequences, including malnutrition, dehydration, aspiration pneumonia, and even death. Due to progressive cognitive and functional decline, patients with dementia experience difficulties throughout the eating process which encompasses all aspects of self-feeding and swallowing function. Variations in underlying neuropathology and disease severity may influence specific swallow disorders observed. New functional neuroimaging modalities offer exciting possibilities to increase understanding of neural control of swallowing that will lead to design of novel treatments. Current treatment approaches include a combination of compensatory strategies for swallowing, cueing from caregivers, and modifications to the dining experience that maximize independence during mealtime. A new focus on development of treatment regimens, possibly involving taste and smell receptor stimulation and rehabilitative exercise that may be implemented during the prodromal stages of dementia, is necessary to prevent or delay further swallowing decline.

A four-phase approach for systematically collecting data and measuring medication discrepancies when patients transition between health care settings

BACKGROUND No methodological standards are available for researchers and clinicians to examine medication discrepancies between health care settings. Systematic methods of examining medication discrepancies will allow researchers and clinicians to better understand factors driving medication discrepancies, to better measure effects of medication reconciliation interventions, and to compare findings across studies. OBJECTIVE This article proposes a four-phase approach for systematically collecting medication data and measuring medication discrepancies between a hospital and community pharmacies. Methodologic considerations related to studying medication discrepancies in health services research are also discussed. METHODS A multi-disciplinary study team developed a four-phase systematic approach to improve quality of data and study rigor: 1) operationalization of a medication discrepancy, 2) acquiring medication data, 3) abstraction of medication data and creation of dataset, and 4) measuring and reporting medication discrepancies. RESULTS Using this phase-based approach, the study team successfully identified and reported medication discrepancies between a hospital and community pharmacies at the patient, medication, and community pharmacy units of analyses. CONCLUSIONS Systematically measuring medication discrepancies that occur in the care transitions process is a critical step as researchers, clinicians, and other stakeholders work to improve health care quality and patient outcomes. This article detailed how a phase-based approach can be used in research to examine medication discrepancies as well as address the complexity of collecting medication data and analyzing medication discrepancies. Such methods should be considered when developing, conducting, and reporting research on medication discrepancies.

Comparison of Maximal Lingual Pressure Generation During Isometric Gross and Fine Sensorimotor Tasks in Healthy Adults

OBJECTIVES To (1) compare 2 distinct isometric lingual press tasks, fine sensorimotor versus gross sensorimotor, at multiple sensor locations in relation to age and sex; and (2) provide a normative data set using a lingual-strengthening device. DESIGN Cohort study. SETTING University. PARTICIPANTS Healthy men and women (N=71; age range, 21-82y) recruited from the community. INTERVENTIONS Participants were stratified by age and sex and divided into 3 age groups. Participants completed, in random order, 2 isometric tasks: (1) fine sensorimotor: tongue press maximally and discreetly against each of 5 sensors; and (2) gross sensorimotor: tongue press maximally against all 5 sensors simultaneously. MAIN OUTCOME MEASURES Primary outcome was maximum isometric pressure in hectopascals (hPa). Secondary outcomes were time to reach peak pressure (s) and pressure gradient (hPa/s). RESULTS Maximum pressures were significantly lower in those of older age for both fine and gross sensorimotor lingual tasks (P<.01), with the front and back sensors showing the greatest decline (35% and 45%, respectively). Pressure differences between tasks (P=.0012) resulted in the fine sensorimotor task generating higher pressures at the front sensor for all age groups. However, the gross sensorimotor task generated faster maximum pressures at all sensor locations for all age groups. For both sensorimotor tasks, subjects of older age as a whole generated less steep pressure gradients (P<.001). CONCLUSIONS Age-related decline in tongue strength is greater at the anterior and posterior tongue. Results indicate a simpler gross sensorimotor task may be more beneficial for targeting timing as a biomechanical parameter during therapy, and the fine sensorimotor task may be more beneficial for targeting strength.

Patient Adherence to Dysphagia Recommendations: A Systematic Review

Patient adherence to treatment recommendations is an important issue for healthcare providers, in a multitude of specialties, and is critical when assessing the efficacy and effectiveness of a particular treatment approach. Patients who have swallowing impairment often require complex and specific interventions requiring altered daily patterns of behavior. Patients with dysphagia who do not follow recommendations or prescribed exercises may not receive maximum benefit of an intervention. Poor adherence also makes it more difficult to evaluate efficacy of a treatment both clinically and in experimental settings. Further, swallow safety can be compromised if certain recommendations are not followed. Our purpose was to systematically review the literature to understand what is known about adherence within the field of dysphagia treatment. We systematically identified 12 studies that tracked and reported patient-specific adherence. In this review, we found that the average adherence rate from these studies ranges between 21.9 and 51.9%. Adherence to prophylactic treatment recommendations for patients with head and neck cancer was the focus in 9/12 studies. The findings of this review identify a large gap in knowledge regarding adherence to dysphagia treatment. Few studies account for adherence within their study designs. When planning dysphagia treatment studies, it is imperative that investigators include information regarding patient adherence to accurately interpret findings. Given the variable adherence rates found in this review, factors influencing patient adherence with dysphagia treatments should be identified to increase adherence in future trials.

Inferring the effects of saliva on liquid bolus flow using computer simulation

Computer simulation of liquid bolus flow is used to test the assumption that a slip boundary condition approximates a healthy swallow due to the presence of saliva lubricating the bolus. Six dynamic, 320-row area detector CT (ADCT) sequences of normal subjects swallowing thin, nectar, and honey-thick liquids are used in this work. The aerodigestive tract is segmented from the images in order to create a dynamic 3D geometry, which is subsequently used to drive a Smoothed Particle Hydrodynamics (SPH) fluid simulation of the bolus. The results show that the no-slip simulation, approximating no-lubrication, provides a closer match to the ADCT bolus images than the slip simulation, particularly in the oral phase. This finding suggests that the role of saliva in swallowing liquid boluses is not to lubricate the aerodigestive tract, and that there is another reason for its importance in normal swallowing of liquids.