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

Natural history of swallow function during the three-month period after stroke

Oropharyngeal dysphagia is a prevalent complication following stroke (PS-OD), and one that is sometimes spontaneously recovered. This study describes the natural history of PS-OD between admission and three months post-stroke, and the factors associated with its prevalence and development. PS-OD was assessed with the volume- iscosity swallow test (V-VST) in all stroke patients on admission and at the three-month follow-up. We analyzed clinical, demographic, and neuroanatomical factors of 247 older post-stroke patients (National Institute of Health Stroke Scale (NIHSS) = 3.5 ± 3.8), comparing among those with PS-OD the ones with and without spontaneous recovery. PS-OD prevalence on admission was 39.7% (34.0% impaired safety; 30.8%, efficacy) and 41.7% (19.4% impaired safety; 39.3%, efficacy) at three months. Spontaneous swallow recovery occurred in 42.4% of patients with unsafe and in 29.9% with ineffective swallow, associated with younger age and optimal functional status. However, 26% of post-stroke patients developed new signs/symptoms of ineffective swallow related to poor functional, nutritional and health status, and institutionalization. PS-OD prevalence on admission and at the three-month follow-up was very high in the study population. PS-OD is a dynamic condition with some spontaneous recovery in patients with optimal functional status, but also new signs/symptoms can appear due to poor functionality. Regular PS-OD monitoring is needed to identify patients at risk of nutritional and respiratory complications

Effect of a gum-based thickener on the safety of swallowing in patients with poststroke oropharyngeal dysphagia

Altres ajuts: This work has been supported by Danone Nutricia Research, Fundació Salut del Consorci Sanitari del Maresme, Furega (Fundació per a la Recerca en Gastroenterologia) and Centro de Investigación en Red en Enfermedades Hepáticas y Digestivas (CIBERehd).Background: Increasing viscosity with thickening agents is a valid therapeutic strategy for oropharyngeal dysphagia (OD). To assess the therapeutic effect of a xanthan gum-based thickener (Nutilis Clear) at six viscosities compared with thin liquid in poststroke OD (PSOD) patients. Methods: A total of 120 patients with PSOD were studied in this controlled, multiple-dose, fixed-order, and single-blind study using videofluoroscopy (VFSS). A series of boluses of 10 mL thin liquid and 2000, 1400, 800, 450, 250, and 150 mPa s viscosities were given in duplicate, interrupted in case of aspiration. We assessed the safety and efficacy of swallow and the kinematics of the swallow response. Key Results: A total of 41.2% patients had safe swallow at thin liquid which significantly increased for all viscosities from 71.9% at 150 mPa s to 95.6% at 1400 mPa s (P <.001). PAS score (3.7 ± 2.3) at thin liquid was also reduced by increasing bolus viscosity (P <.001). The prevalence of patients with aspiration at thin liquid was 17.5% and decreased at all viscosities (P <.01), except at 150 mPa s. Increasing viscosity shortened time to laryngeal vestibule closure (LVC) at all viscosities (P <.01) and reduced bolus velocity at ≥450 mPa s (P <.05). The prevalence of patients with pharyngeal residue at each viscosity 37.7%-44.7% was similar to that at thin liquid (41.2%). Conclusions and Inferences: The prevalence of unsafe swallow with thin liquids is very high in PSOD. Increasing shear bolus viscosity with this xanthan gum-based thickener significantly increased the safety of swallow in patients with PSOD in a viscosity-dependent manner without increasing the prevalence of pharyngeal residue

Sucesión estacional de las asociaciones de los grupos taxonómicos del zooplancton en aguas superficiales de Bahía de Navidad, México (noviembre 2010 - diciembre 2011)

Se analizó la sucesión estacional de la abundancia de 19 grupos del zooplancton recolectados quincenalmente (aunque promediados mensualmente) de noviembre 2010 a diciembre 2011 en Bahía de Navidad, Jalisco (19°09´03N, 104° 44´50O) en función de las variaciones hidro-climáticas estacionales. Los eventos de surgencias costeras causaron condiciones frías y con un somero límite superior del estrato hipóxico (&gt; 20 m, &lt; 1.5 ml L-1) durante la mayor parte del año, excepto durante junio-agosto, cuando prevalecieron condiciones estratificadas. Los copépodos (66%), larvas de decápodos (11%), anfípodos (5%), ostrácodos (4%), cladóceros (4%), huevos de peces (3%), eufáusidos (2%), quetognatos (1.5%) y pterópodos (1.5%) contabilizaron el 95% de la abundancia zooplanctónica total. Las abundancias totales fueron elevadas durante noviembre 2010 a mayo (media geométrica 1173 ind m-3), disminuyendo gradualmente hasta alcanzar los valores más bajos durante junio-agosto (28 ind m-3) y registrándose abundancias moderadas durante septiembre-diciembre 2011 (405 ind m-3). El número de grupos taxonómicos de zooplancton se incrementó durante mayo-junio (período de transición de las condiciones de mezcla y estratificación). El análisis de redundancia mostró una clara sucesión estacional de la abundancia relativa y estructura de la comunidad zooplanctónica, agrupando las unidades de muestreo estacionalmente por períodos hidro-climáticos (mezclado, semi-mezclado y estratificado). La temperatura y salinidad a 10 m, la profundidad de la capa de mezcla y el índice de surgencia costera, fueron las principales variables ambientales que influyeron en la sucesión de grupos del zooplancton durante los tres períodos hidro-climáticos. Se concluye que durante el periodo de estudio la composición y abundancia de los principales grupos taxonómicos que habitan en esta región costera tropical, se explica principalmente por la variación estacional en la intensidad y duración de los eventos locales de surgencia

Natural History of Swallow Function during the Three-Month Period after Stroke

Oropharyngeal dysphagia is a prevalent complication following stroke (PS-OD), and one that is sometimes spontaneously recovered. This study describes the natural history of PS-OD between admission and three months post-stroke, and the factors associated with its prevalence and development. PS-OD was assessed with the volume-viscosity swallow test (V-VST) in all stroke patients on admission and at the three-month follow-up. We analyzed clinical, demographic, and neuroanatomical factors of 247 older post-stroke patients (National Institute of Health Stroke Scale (NIHSS) = 3.5 &plusmn; 3.8), comparing among those with PS-OD the ones with and without spontaneous recovery. PS-OD prevalence on admission was 39.7% (34.0% impaired safety; 30.8%, efficacy) and 41.7% (19.4% impaired safety; 39.3%, efficacy) at three months. Spontaneous swallow recovery occurred in 42.4% of patients with unsafe and in 29.9% with ineffective swallow, associated with younger age and optimal functional status. However, 26% of post-stroke patients developed new signs/symptoms of ineffective swallow related to poor functional, nutritional and health status, and institutionalization. PS-OD prevalence on admission and at the three-month follow-up was very high in the study population. PS-OD is a dynamic condition with some spontaneous recovery in patients with optimal functional status, but also new signs/symptoms can appear due to poor functionality. Regular PS-OD monitoring is needed to identify patients at risk of nutritional and respiratory complications

Efecto terapéutico de la estimulación eléctrica transcutánea en la disfagia orofaríngea postictus crónico : ensayo clínico aleatorizado y controlado con dos intensidades de estimulación

Introducció: La disfàgia orofaríngia crònica posterior a un ictus (DOCPI) s'associa a una funció sensitiva / motora orofaríngia deteriorada. El nostre objectiu va ser avaluar l'efecte de l'estimulació elèctrica transcutània (EET) a intensitat sensorial (SES) i motora (NMES) sobre la seguretat de la deglució, residu orofaringi i els resultats clínics en pacients amb DOCPI en un assaig controlat aleatoritzat de seguiment de un any. Justificació científica: Durant molts anys la disfàgia orofaríngia adquirida post ictus, s'ha tractat mitjançant tractaments convencionals, que compensen la deglució, però no aconsegueixen una modificació de la resposta motora orofaríngea de la deglució Hipòtesi i Objectius: La disfàgia orofaríngia en la fase crònica de l'ictus (≥3 mesos d'evolució) secundària a una disfunció severa sensitiva i motora de la faringe causa una important alteració de la resposta motora orofaríngia i una alta prevalença d'aspiracions, penetracions i residu orofaríngeo. L'estimulació elèctrica transcutània tant a nivell sensorial (SES) com a motor (NMES), és un tractament efectiu en pacients amb disfàgia orofaríngia en la fase crònica de l'ictus. És una estratègia de tractament segura i tolerable sense efectes adversos que permet reduir l'ús de espessidors necessaris per mantenir una deglució segura. Les millores terapèutiques es mantenen a curt, mitjà i llarg termini. Mètodes: Estudi prospectiu, obert, aleatoritzat, controlat amb tres grups de tractament (Clinicaltrials.gov: NCT02379182). Noranta pacients amb DOCPI i alteració de la seguretat de la deglució van ser aleatoritzats per: a) tractament compensatori (TC), b) TC + SES, c) TC + NMES. Els pacients dels grups d'EET van ser tractats amb dos cicles de tractament (amb 6 mesos de diferència) amb 15 sessions d'EET d'1 hora durant dues setmanes i, el grup de TC va seguir recomanacions d'adaptació de dieta i viscositat de líquids. Es va realitzar un seguiment de 4-5 avaluacions clíniques i videofluoroscòpia (VFS) durant un any. Resultats clau: Pacients DOCPI en estat basal amb una mitjana de 74,1 ± 11,5 anys, puntuació de NIHSS 3,64 ± 4,07, puntuació de Rankin modificat 2,6 ± 1,68. L'escala de penetració-aspiració (PAS) basal va ser de 4,61 ± 1,75, el temps de retard fins al tancament de el vestíbul laringi (LVC) de 396,4 ± 108,7 ms, el temps de retard d'obertura de esfínter esofàgic superior (UESO) 280,4 ± 115,4 i els signes d'eficàcia alterats de el 92,4%. Els paràmetres de deglució dels grups EET van millorar significativament després del primer tractament i a l'any de seguiment: prevalença de pacients amb una deglució segura (p <0,001), PAS mitjà (p <0,001), temps fins a la LVC (p <0, 01), i reducció de necessitat d'espessidors (p <0,001). Després del segon cicle de tractament als 6 mesos, no hi va haver millores significatives en comparació del primer cicle de tractament. Els pacients en la TC van presentar una millora menys intensa dels signes d'alteració de la seguretat de la deglució, sense canvis significatius en el temps fins al LVC ni en UESO. No es van observar diferències entre els grups per a la mortalitat a 1 any (6,1%), les infeccions respiratòries (9,6% dels pacients), l'estat nutricional i funcional, la qualitat de vida i les taxes de reingrés hospitalari ( 27,6%). No es van observar esdeveniments adversos significatius relacionats amb EET. Conclusions i inferències: EET és una teràpia segura i eficaç per a pacients grans amb DOCPI. Després d'un any de seguiment, els pacients amb DOCPI van millorar en gran mesura la seguretat de la deglució i es va reduir la necessitat d'espessir el líquid en aquests pacients.Introducción: La disfagia orofaríngea crónica posterior a un ictus (DOCPI) se asocia a una función sensitiva / motora orofaríngea deteriorada. Nuestro objetivo fue evaluar el efecto de la estimulación eléctrica transcutánea (EET) a intensidad sensorial (SES) y motora (NMES) sobre la seguridad de la deglución, residuo orofaríngeo y los resultados clínicos en pacientes con DOCPI en un ensayo controlado aleatorizado de seguimiento de un año. Justificación científica: Durante muchos años la disfagia orofaríngea adquirida post ictus, se ha tratado mediante tratamientos convencionales, que compensan la deglución, pero no logran una modificación de la respuesta motora orofaríngea de la deglución. Hipótesis y Objetivos: La disfagia orofaríngea en la fase crónica del ictus (≥3 meses de evolución) secundaria a una disfunción severa sensitiva y motora de la faringe causa una importante alteración de la respuesta motora orofaríngea y una alta prevalencia de aspiraciones, penetraciones y residuo orofaríngeo. La estimulación eléctrica transcutánea tanto a nivel sensorial (SES) como motor (NMES), es un tratamiento efectivo en pacientes con disfagia orofaríngea en la fase crónica del ictus. Es una estrategia de tratamiento segura y tolerable sin efectos adversos que permite reducir el uso de espesantes necesarios para mantener una deglución segura. Las mejoras terapéuticas se mantienen a corto, medio y largo plazo. Métodos: Estudio prospectivo, abierto, aleatorizado, controlado con tres grupos de tratamiento (Clinicaltrials.gov: NCT02379182). Noventa pacientes (aceptando un riesgo alfa de 0,05 y un riesgo beta de 0,2 en una prueba bilateral, se consideró que se requerían 30 sujetos de cada grupo) con DOCPI y alteración de la seguridad de la deglución fueron aleatorizados para: a) tratamiento compensatorio (TC), b) TC + SES, c) TC + NMES. Los pacientes de los grupos de EET fueron tratados con dos ciclos de tratamiento (con 6 meses de diferencia) con 15 sesiones de EET de 1 hora durante dos semanas y, el grupo de TC siguió recomendaciones de adaptación de dieta y viscosidad de líquidos. Se les realizó un seguimiento de 4-5 evaluaciones clínicas y videofluoroscopia (VFS) durante un año. Resultados clave: Pacientes DOCPI en estado basal con una media de 74,1 ± 11,5 años, puntuación de NIHSS 3,64 ± 4,07, puntuación de Rankin modificada 2,6 ± 1,68. La escala de penetración-aspiración (PAS) basal fue de 4,61 ± 1,75, el tiempo de retraso hasta el cierre del vestíbulo laríngeo (LVC) de 396,4 ± 108,7 ms, el tiempo de retraso de apertura de esfínter esofágico superior (UESO) 280,4±115,4 y los signos de eficacia alterados del 92,4%. Los parámetros de deglución de los grupos EET mejoraron significativamente después del primer tratamiento y al año de seguimiento: prevalencia de pacientes con una deglución segura (p <0,001), PAS medio (p <0,001), tiempo hasta la LVC (p <0,01), y reducción de necesidad de espesantes (p <0,001). Después del segundo ciclo de tratamiento a los 6 meses, no hubo mejoras significativas en comparación con el primer ciclo de tratamiento. Los pacientes en la TC presentaron una mejora menos intensa de los signos de alteración de la seguridad de la deglución, sin cambios significativos en el tiempo hasta la LVC ni en UESO. No se observaron diferencias entre los grupos para la mortalidad a 1 año (6,1%), las infecciones respiratorias (9,6% de los pacientes), el estado nutricional y funcional, la calidad de vida y las tasas de reingreso hospitalario (27,6%). No se observaron eventos adversos significativos relacionados con EET. Conclusiones e inferencias: EET es una terapia segura y eficaz para pacientes mayores con DOCPI. Después de un año de seguimiento, los pacientes con DOCPI mejoraron en gran medida la seguridad de la deglución y se redujo la necesidad de espesar el líquido en estos pacientes.Background: Chronic post-stroke oropharyngeal dysphagia (CPSOD) is associated with impaired oropharyngeal sensory/motor function. We aimed to assess effect of sensory (SES) and motor (NMES) transcutaneous electrical stimulation (TES) on safety of swallow, oral pharyngeal residue and clinical outcomes in patients with CPSOD in a one-year follow up randomized controlled trial. Scientific justification: For many years, post-stroke oropharyngeal dysphagia has been treated by conventional treatments, which compensate for swallowing, but do not achieve a modification of the oropharyngeal motor response. Hypothesis and Objectives: Oropharyngeal dysphagia in the chronic phase of stroke (≥3 months of evolution) secondary to severe sensory and motor dysfunction of the pharynx causes a significant alteration of the oropharyngeal motor response and a high prevalence of aspirations, penetrations and residual oropharyngeal. Transcutaneous electrical stimulation, both sensory (SES) and motor (NMES), is an effective treatment in patients with oropharyngeal dysphagia in the chronic phase of stroke. It is a safe and tolerable treatment strategy without adverse effects that allows reducing the use of thickeners necessary to maintain safe swallowing. Therapeutic improvements are maintained in the short, medium and long term. Methods: A prospective, open, randomized, controlled study with three treatment groups (Clinicaltrials.gov: NCT02379182).Ninety patients with CPSOD and impaired safety of swallow were randomized to: a) compensatory treatment (CT), b) CT+ SES, c) CT+ NMES. Patients of TES groups were treated with up to two cycles (6 months apart) of 15x1 hour TES sessions over two weeks and, the TC group followed recommendations for adaptation of diet and fluid viscosity. Were followed up with 4-5 clinical and videofluoroscopic (VFS) assessments during one year. Key results: Baseline CPSOD with a mean of age 74.1±11.5 years, NIHSS Score 3,64±4,07, modified Rankin Score 2.6±1.68)Baseline penetration-aspiration scale (PAS) was 4.61±1.75, delayed time to laryngeal vestibule closure (LVC) 396.4±108.7ms, delayed time to upper esophageal sphincter opening 280,4±115,4 and impaired efficacy signs 92,4%. Swallowing parameters significantly improved after the first treatment and at 1 year follow up in SES and NMES groups: for prevalence of patients with a safe swallow (p<0.001), mean PAS (p<0.001), time to LVC (p<0.01), and need for thickening agents (p<0.001). After de second round of treatment at 6 months there were not significant improvements compared to the first treatment round. Patients in the CT presented a less intense improvement of signs of impaired safety of swallow without significant changes in time to LVC. No differences between groups were observed for 1-year mortality (6.1%), respiratory infections (9.6% patients), nutritional and functional status, QoL and hospital readmission rates (27.6%). No significant adverse events related to TES were observed. Conclusions & inferences: TES is a safe and effective therapy for CPSOD older patients. After 1-year follow up, TES greatly improved the safety of swallow and reduced the need for fluid thickening in these patients

A Systematic and a Scoping Review on the Psychometrics and Clinical Utility of the Volume-Viscosity Swallow Test (V-VST) in the Clinical Screening and Assessment of Oropharyngeal Dysphagia

(1) Background: The volume-viscosity swallow test (V-VST) is a clinical tool for screening and diagnosis of oropharyngeal dysphagia (OD). Our aims were to examine the clinical utility of the V-VST against videofluoroscopy (VFS) or fiberoptic endoscopic evaluation of swallow (FEES) and to map the V-VST usage with patients at risk of OD across the years since it was described for the first time, carrying a systematic and a scoping review. (2) Methods: We performed both a systematic review (SR) including studies that look at the diagnostic test accuracy, and a scoping review (ScR) with articles published from September 2008 to May 2020. Searches were done in different databases, including PubMed and EMBASE from September 2008 until May 2020, and no language restrictions were applied. A meta-analysis was done in the SR to assess the psychometric properties of the V-VST. Quality of studies was assessed by Dutch Cochrane, QUADAS, GRADE (SR), and STROBE (ScR) criteria. The SR protocol was registered on PROSPERO (registration: CRD42020136252). (3) Results: For the diagnostic accuracy SR: four studies were included. V-VST had a diagnostic sensitivity for OD of 93.17%, 81.39% specificity, and an inter-rater reliability Kappa = 0.77. Likelihood ratios (LHR) for OD were 0.08 (LHR-) and 5.01 (LHR+), and the diagnostic odds ratio for OD was 51.18. Quality of studies in SR was graded as high with low risk of bias. In the ScR: 34 studies were retrieved. They indicated that V-VST has been used internationally to assess OD's prevalence and complications. (4) Conclusions: The V-VST has strong psychometric properties and valid endpoints for OD in different phenotypes of patients. Our results support its utility in the screening and clinical diagnosis and management of OD

Acute and subacute effects of oropharyngeal sensory stimulation with TRPV1 agonists in older patients with oropharyngeal dysphagia: a biomechanical and neurophysiological randomized pilot study

Background: Older people with oropharyngeal dysphagia (OD) present a decline in pharyngeal sensory function. The aim of this proof-of-concept study was to assess the biomechanical and neurophysiological effects of acute and subacute oropharyngeal sensory stimulation with transient receptor potential vanilloid 1 (TRPV1) agonists (capsaicinoids) in older patients with OD. Methods: We studied the effect of a single dose versus multiple doses (2 weeks) of oral capsaicin treatment (10 –5 M) or placebo in 28 older patients with OD (81.2 ± 4.6 years) using videofluoroscopy (penetration-aspiration scale [PAS], timing of swallow response) and electroencephalography (EEG) (latency and amplitude of pharyngeal event-related potential [ERP]). Results: Acute stimulation by capsaicinoids 10 –5 M did not improve swallow function and did not produce significant changes in pharyngeal ERP. In contrast, after 10 days of treatment, patients presented a clinically relevant and statistically significant reduction in the laryngeal vestibule closure (LVC) time (22.5%, p = 0.042), and in the PAS (24.2%, p = 0.038), compared with the placebo group. EEG results showed a reduction in the latency of the N1 peak (28.6%, p = 0.007) and an increase of the amplitude of the P1-N2 (59.4%, p = 0.038) and the N2-P2 (43.6%, p = 0.050) peaks. We observed a strong and significant correlation between the reduction in the latency of the N1 peak and change in LVC time after subacute treatment ( r = 0.750, p = 0.003). Conclusions: After 2 weeks of treatment, oropharyngeal sensory stimulation with capsaicinoids induced cortical changes that were correlated with improvements in swallowing biomechanics in older patients with OD. These results further show that sensory stimulation by TRPV1 agonists can become a useful pharmacological treatment for older patients with OD

Assessment of Swallowing Disorders, Nutritional and Hydration Status, and Oral Hygiene in Students with Severe Neurological Disabilities Including Cerebral Palsy

Background: Special needs schools (SNS) educate children and young people with major neurological disabilities who are at high risk of oropharyngeal dysphagia (OD) and malnutrition (MN). We aimed to assess the prevalence of OD, MN, dehydration (DH), and oral health (OH) in students at an SNS. Methods: A cross-sectional observational study was conducted at SNS L’Arboç, Catalonia, Spain. We assessed (a) demographics, health status, comorbidities, and gross motor function classification system (GMFCS), (b) swallowing function, oral-motor evaluation, masticatory capacity, and EDACS classification for eating and drinking abilities, (c) nutritional and DH status (anthropometry, bioimpedance and dietary records), and (d) OH (Oral Hygiene Index Simplified). Results: A total of 33 students (mean age 13.3 years; 39.4% level V of GMFCS) were included. Main diagnosis was cerebral palsy at 57.6%. All students presented OD, 90.6% had impaired safety, 68.7% were at levels II–III of EDACS, and 31.3% required PEG; furthermore, 89.3% had chronic MN, 21.4% had acute MN, 70% presented intracellular DH, and 83.9% presented impaired OH. Conclusion: MN, DH, OD, and poor OH are highly prevalent conditions in students with cerebral palsy and other neurological disabilities and must be specifically managed through nutritional and educational strategies. The multidisciplinary team at SNS should include healthcare professionals specifically trained in these conditions