Viridiana Arreola

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.

Diagnosis and Management of Oropharyngeal Dysphagia and Its Nutritional and Respiratory Complications in the Elderly

Oropharyngeal dysphagia is a major complaint among older people. Dysphagia may cause two types of complications in these patients: (a) a decrease in the efficacy of deglutition leading to malnutrition and dehydration, (b) a decrease in deglutition safety, leading to tracheobronchial aspiration which results in aspiration pneumonia and can lead to death. Clinical screening methods should be used to identify older people with oropharyngeal dysphagia and to identify those patients who are at risk of aspiration. Videofluoroscopy (VFS) is the gold standard to study the oral and pharyngeal mechanisms of dysphagia in older patients. Up to 30% of older patients with dysphagia present aspiration—half of them without cough, and 45%, oropharyngeal residue; and 55% older patients with dysphagia are at risk of malnutrition. Treatment with dietetic changes in bolus volume and viscosity, as well as rehabilitation procedures can improve deglutition and prevent nutritional and respiratory complications in older patients. Diagnosis and management of oropharyngeal dysphagia need a multidisciplinary approach.

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).

PREVALENCE OF OROPHARYNGEAL DYSPHAGIA AND IMPAIRED SAFETY AND EFFICACY OF SWALLOW IN INDEPENDENTLY LIVING OLDER PERSONS

To the Editor: Oropharyngeal dysphagia (OD) is a frequent clinical condition in older people and one that can produce two types of potentially severe complications: alterations in the efficacy of swallowing, which may cause malnutrition or dehydration, and impaired safety of swallow, which may lead to aspiration to the respiratory tract with consequent high risk of pneumonia. OD is a risk factor for pneumonia in older adults, an indicator of pneumonia severity, and a risk factor for mortality from pneumonia. The question has been raised as to whether older persons should be routinely screened for dysphagia. A clinical method of assessing patients with clinical signs of dysphagiaFthe Volume-Viscosity Swallow Test (V-VST)Fusing boluses of different volumes and viscosities administered in a progression of increasing difficulty has been developed and validated. Few studies have reported the prevalence of dysphagia in the independently living elderly population, and these studies have used a variety of nonvalidated instruments based on self-reported dysphagic symptoms, thus not reporting the real prevalence of dysphagia because the sensitivity and specificity of the tests were not taken into account. A population-based, crosssectional study of the true prevalence of OD, impaired efficacy of swallowing, impaired safety of swallowing, and aspiration in the independently living, older population using the V-VST is presented. Persons aged 70 and older were randomly selected from a primary care center database in Mataró (Barcelona, Spain). Institutionalized persons or those in palliative care or with a life expectancy of less than 3 months were excluded. Trained general practitioners clinically assessed OD using the V-VST. The test assesses several clinical signs of swallowing efficacy (impaired labial seal, oral or pharyngeal residue, and piecemeal deglutition) and safety (changes in voice quality, cough, or 3% decrease in oxygen saturation measured using a finger pulse oximeter) with boluses of 5, 10, and 20 mL at nectar (270 mPa/s), liquid (20 mPa/s), and pudding (3,900 mPa/s) viscosities. The sensitivity of V-VST is 98% for dysphagia, 92% for impaired efficacy of swallow, 88% for impaired safety, and 100% for aspiration when compared with the criterion standard of videofluoroscopy. To estimate ‘‘real’’ prevalence, the sensitivities mentioned above, the specificity of V-VST, previously assessed in 15 healthy volunteers (the lower limit of the 95% confidence interval (CI) was considered as corresponding to 94%), and the total number of positive and negative V-VST results in the study sample were taken into account. Two hundred fifty-four persons were recruited (66% participation rate) (mean age 78.2 5.6; 136 (53.5%) men, 118 (46.5%) women). Prevalence of signs of OD was 27.2% (95% CI 5 21.7–32.7) over the whole sample, signs of impaired efficacy of swallow were present in 20.5% (95% CI 5 15.5–25.5), signs of impaired safety in 15.4% (95% CI 5 11.0–19.8), and signs of aspiration in 6.7% (95% CI 5 3.6–10.0). No significant differences between the sexes were observed in the prevalence of signs of OD, impaired efficacy, and impaired safety of swallow, but they were more prevalent in participants aged 80 and older than in those aged 70 to 79 (36.4% vs 21.7%, P 5.01; 30.3% vs 14.0 %, P 5.002; 21.2% vs 11.9%, P 5.05, respectively). Likewise, the following true population prevalences were estimated: dysphagia, 23.0% (33.0% in 80 vs 16.6% in 70–79); impaired efficacy of swallow, 16.8% (28.3% vs 9.5%); impaired safety of swallow, 11.4 % (18.6% vs 6.8%); and aspiration, 0.74% (4.4% vs 0%). Signs of OD were statistically associated with older age, low functional capacity (Barthel score), neurodegenerative diseases, treatment with benzodiazepines, depression, low walking speed, and low overall quality of life, although only low functional capacity showed an independent association with dysphagia or impaired safety of swallow when adjusted for other covariables. Older age, low functional capacity, and malnutrition or ‘‘at risk’’ of malnutrition showed an independent association with impaired efficacy of swallow (see Table 1). As far as the authors of this letter know, this is the first study that has reported the ‘‘real’’ prevalence of dysphagia in independently living older persons using a validated clinical method and considering its diagnostic accuracy. It confirms that a large number of older persons in the community have OD and are at risk of nutritional and respiratory complications. Dysphagia is associated with substantial morbidity, poor functionality, impaired quality of life, and high mortality. Multiple underlying factors are involved in its development, and it does not fit into one specific

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.

Natural capsaicinoids improve swallow response in older patients with oropharyngeal dysphagia

Objective There is no pharmacological treatment for oropharyngeal dysphagia (OD). The aim of this study was to compare the therapeutic effect of stimulation of oropharyngeal transient receptor potential vanilloid type 1 (TRPV1) with that of thickeners in older patients with OD. Design A clinical videofluoroscopic non-randomised study was performed to assess the signs of safety and efficacy of swallow and the swallow response in (1) 33 patients with OD (75.94±1.88 years) while swallowing 5, 10 and 20 ml of liquid (20.4 mPa.s), nectar (274.4 mPa.s), and pudding (3930 mPa.s) boluses; (2) 33 patients with OD (73.94±2.23 years) while swallowing 5, 10 and 20 ml nectar boluses, and two series of nectar boluses with 150 μM capsaicinoids and (3) 8 older controls (76.88±1.51 years) while swallowing 5, 10 and 20 ml nectar boluses. Results Increasing bolus viscosity reduced the prevalence of laryngeal penetrations by 72.03% (p<0.05), increased pharyngeal residue by 41.37% (p<0.05), delayed the upper esophageal sphincter opening time and the larynx movement and did not affect the laryngeal vestibule closure time and maximal hyoid displacement. Treatment with capsaicinoids reduced both, penetrations by 50.% (p<0.05) and pharyngeal residue by 50.% (p<0.05), and shortened the time of laryngeal vestibule closure (p<0.001), upper esophageal sphincter opening (p<0.05) and maximal hyoid and laryngeal displacement. Conclusion Stimulation of TRPV1 by capsaicinoids strongly improved safety and efficacy of swallow and shortened the swallow response in older patients with OD. Stimulation of TRPV1 might become a pharmacologic strategy to treat OD.

Sensitivity and specificity of the Eating Assessment Tool and the Volume‐Viscosity Swallow Test for clinical evaluation of oropharyngeal dysphagia

Oropharyngeal dysphagia (OD) is an underdiagnosed digestive disorder that causes severe nutritional and respiratory complications. Our aim was to determine the accuracy of the Eating Assessment Tool (EAT‐10) and the Volume‐Viscosity Swallow Test (V‐VST) for clinical evaluation of OD.

The effects of a xanthan gum-based thickener on the swallowing function of patients with dysphagia.

Increasing bolus viscosity of thin liquids is a basic therapeutic strategy to protect patients with oropharyngeal dysphagia (OD) from aspiration. However, conventional starch thickeners increase post‐deglutitive residue.

Effect of surface sensory and motor electrical stimulation on chronic poststroke oropharyngeal dysfunction

Chronic poststroke oropharyngeal dysfunction (OD) is a common condition, leading to severe complications, including death. Treatments for chronic poststroke OD are scarce. The aim of our study was to assess and compare the efficacy and safety of treatment with surface electrical stimulation (e‐stim) at sensory and motor intensities in patients with chronic poststroke OD.