Predictors of Aspiration Pneumonia in Nursing Home Residents

Aspiration pneumonia is a serious problem for the elderly institutionalized person, often requiring transfer to a hospital and a lengthy stay there. It is associated with a high mortality rate and is very costly to the health care system. The current study sought to determine the key predictors of aspiration pneumonia in a nursing home population with the hope that health care providers could identify those residents at highest risk and focus more efforts on prevention of this serious disease. A cross-sectional, retrospective analysis was done, using the Minimum Data Set (MDS) nursing home assessment data for three states (New York, Mississippi, Maine) from 1993 to 1994 ( N = 102,842). Nursing home residents were aged 65+. Standardized MDS summary scales and their component items were used, including: the Activities of Daily Living (ADL) scale, the cognitive performance scale (CPS), and the Resource Utilization Groups (RUGs). Results of these analyses showed the prevalence of pneumonia among this population was 3% ( n = 3118). Results from the logistic regression models indicated 18 significant predictors of aspiration pneumonia. The strongest to weakest predictors of pneumonia were, respectively, suctioning use, COPD, CHF, presence of feeding tube, bedfast, high case mix index, delirium, weight loss, swallowing problems, urinary tract infections, mechanically altered diet, dependence for eating, bed mobility, locomotion, number of medications, and age, while both CVA and tracheotomy care were inversely predictive of pneumonia. The emergence of these significant predictors suggested a different pathogenesis of pneumonia in the elderly nursing home resident from the acute care patient or the outpatient. Nursing home residents have chronic medical conditions that gradually lead to “decompensation” in functional status, nutritional status, and pulmonary clearance. Dysphagia and aspiration are common complications of their medical conditions and may slowly worsen as their status deteriorates. Alternatively, a sudden adverse event may dramatically increase the amount aspirated or the ability to resist infection and lead to sudden decompensation. Clinical staff must identify residents with dysphagia and aspiration and work to prevent decline in functional status in all residents. They must be aware of the dangers of adverse events that lead to sudden inactivity or illness and increase the risk of aspiration pneumonia. Prevention of this disease whenever possible will reduce costs, improve health outcomes, and improve our quality of care.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/42428/1/20170298.pd

Predictors of Aspiration Pneumonia: How Important Is Dysphagia?

Aspiration pneumonia is a major cause of morbidity and mortality among the elderly who are hospitalized or in nursing homes. Multiple risk factors for pneumonia have been identified, but no study has effectively compared the relative risk of factors in several different categories, including dysphagia. In this prospective outcomes study, 189 elderly subjects were recruited from the outpatient clinics, inpatient acute care wards, and the nursing home care center at the VA Medical Center in Ann Arbor, Michigan. They were given a variety of assessments to determine oropharyngeal and esophageal swallowing and feeding status, functional status, medical status, and oral/dental status. The subjects were followed for up to 4 years for an outcome of verified aspiration pneumonia. Bivariate analyses identified several factors as significantly associated with pneumonia. Logistic regression analyses then identified the significant predictors of aspiration pneumonia. The best predictors, in one or more groups of subjects, were dependent for feeding, dependent for oral care, number of decayed teeth, tube feeding, more than one medical diagnosis, number of medications, and smoking. The role that each of the significant predictors might play was described in relation to the pathogenesis of aspiration pneumonia. Dysphagia was concluded to be an important risk for aspiration pneumonia, but generally not sufficient to cause pneumonia unless other risk factors are present as well. A dependency upon others for feeding emerged as the dominant risk factor, with an odds ratio of 19.98 in a logistic regression model that excluded tube-fed patients.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/42426/1/455-13-2-69_13n2p69.pd

Recognizing the Importance of Dysphagia: Stumbling Blocks and Stepping Stones in the Twenty-First Century

Altres ajuts: This paper results from an international interdisciplinary and interprofessional expert meeting generously supported by the BANSS-Foundation, Biedenkopf an der Lahn, Germany

The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration

This study retrospectively investigated the value of both endoscopically visible oropharyngeal secretions in the hypopharynx and swallowing frequency in the prediction of aspiration of food and liquid. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed on a total of 69 individuals that included hospitalized elderly, nonhospitalized elderly, and young normal subjects. A four-level rating scale for determining the severity of accumulated orpharyngeal secretions was developed and employed to rate subjects prior to the presentation of food or liquid during the FEES. Spontaneous dry swallows were also counted during the observation period of the FEES. It was found that the accumulation of endoscopically visible oropharyngeal secretions located within the laryngeal vestibule was highly predictive of aspiration of food or liquid. There were significantly fewer spontaneous swallows in hospitalized subjects when compared with nonhospitalized subjects. There was also a significant decrease in the frequency of spontaneous swallows in aspirating hospitalized subjects when compared with nonaspirating hospitalized subjects. Results are discussed in terms of integrating this information with clinical bedside examination techniques.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/41360/1/455_2004_Article_BF00417898.pd

Oropharyngeal dysphagia in older persons - from pathophysiology to adequate intervention : a review and summary of an international expert meeting

Oropharyngeal dysphagia (OD) is a highly prevalent and growing condition in the older population. Although OD may cause very severe complications, it is often not detected, explored, and treated. Older patients are frequently unaware of their swallowing dysfunction which is one of the reasons why the consequences of OD, ie, aspiration, dehydration, and malnutrition, are regularly not attributed to dysphagia. Older patients are particularly vulnerable to dysphagia because multiple age-related changes increase the risk of dysphagia. Physicians in charge of older patients should be aware that malnutrition, dehydration, and pneumonia are frequently caused by (unrecognized) dysphagia. The diagnosis is particularly difficult in the case of silent aspiration. In addition to numerous screening tools, videofluoroscopy was the traditional gold standard of diagnosing OD. Recently, the fiberoptic endoscopic evaluation of swallowing is increasingly utilized because it has several advantages. Besides making a diagnosis, fiberoptic endoscopic evaluation of swallowing is applied to evaluate the effectiveness of therapeutic maneuvers and texture modification of food and liquids. In addition to swallowing training and nutritional interventions, newer rehabilitation approaches of stimulation techniques are showing promise and may significantly impact future treatment strategies

Development of a Non-invasive Device for Swallow Screening in Patients at Risk of Oropharyngeal Dysphagia : Results from a Prospective Exploratory Study

Oropharyngeal dysphagia is prevalent in several at-risk populations, including post-stroke patients, patients in intensive care and the elderly. Dysphagia contributes to longer hospital stays and poor outcomes, including pneumonia. Early identification of dysphagia is recommended as part of the evaluation of at-risk patients, but available bedside screening tools perform inconsistently. In this study, we developed algorithms to detect swallowing impairment using a novel accelerometer-based dysphagia detection system (DDS). A sample of 344 individuals was enrolled across seven sites in the United States. Dual-axis accelerometry signals were collected prospectively with simultaneous videofluoroscopy (VFSS) during swallows of liquid barium stimuli in thin, mildly, moderately and extremely thick consistencies. Signal processing classifiers were trained using linear discriminant analysis and 10,000 random training-test data splits. The primary objective was to develop an algorithm to detect impaired swallowing safety with thin liquids with an area under receiver operating characteristic curve (AUC) > 80% compared to the VFSS reference standard. Impaired swallowing safety was identified in 7.2% of the thin liquid boluses collected. At least one unsafe thin liquid bolus was found in 19.7% of participants, but participants did not exhibit impaired safety consistently. The DDS classifier algorithms identified participants with impaired thin liquid swallowing safety with a mean AUC of 81.5%, (sensitivity 90.4%, specificity 60.0%). Thicker consistencies were effective for reducing the frequency of penetration-aspiration. This DDS reached targeted performance goals in detecting impaired swallowing safety with thin liquids. Simultaneous measures by DDS and VFSS, as performed here, will be used for future validation studies.Peer reviewe

Association of Neck Range of Motion and Skin Caliper Measures on Dysphagia Outcomes in Head and Neck Cancer and Effects of Neck Stretches and Swallowing Exercises

To date, there is a paucity of information in the literature regarding the association between cervical range of motion (CROM) and skin caliper measures (SCM) and swallowing outcomes in post-RT individuals with head and neck cancer. Also lacking in the literature are reports of the effect of swallowing exercises and neck stretches on changes in CROM and SCM and their associations with swallowing outcomes. The aim of this study was to assess the associations between CROM and SCM before initiation of a neck stretching and swallowing exercise program and to determine if 12 weeks of twice daily practice changes in CROM and SCM were associated with changes in swallowing outcomes in a cohort of 119 head and neck cancer survivors. Primary results revealed that at baseline, greater right and left CROM were associated with lower penetration aspiration scale (PAS) scores (r = - 0.321, p = \u3c 0.001; r = - 0.203, p = 0.026, respectively). Improved skin pliability revealed lower PAS scores (r = - 0.210, p = 0.022). After 12 weeks, there were no significant correlations between changes in CROM and SCM and PAS scores. Changes in left CROM and CROM extension had positive associations with the Head and Neck Cancer Inventory eating score (r = 0.210, p = 0.026; r = 0.245, p = 0.009, respectively). Findings appear to indicate that any improvement was not associated with changes in swallowing outcomes. Head and neck cancer survivors may perceive improved diet and swallowing skills through exercise, with respect to improved CROM extension

Association of Neck Range of Motion and Skin Caliper Measures on Dysphagia Outcomes in Head and Neck Cancer and Effects of Neck Stretches and Swallowing Exercises

To date, there is a paucity of information in the literature regarding the association between cervical range of motion (CROM) and skin caliper measures (SCM) and swallowing outcomes in post-RT individuals with head and neck cancer. Also lacking in the literature are reports of the effect of swallowing exercises and neck stretches on changes in CROM and SCM and their associations with swallowing outcomes. The aim of this study was to assess the associations between CROM and SCM before initiation of a neck stretching and swallowing exercise program and to determine if 12 weeks of twice daily practice changes in CROM and SCM were associated with changes in swallowing outcomes in a cohort of 119 head and neck cancer survivors. Primary results revealed that at baseline, greater right and left CROM were associated with lower penetration aspiration scale (PAS) scores (r = - 0.321, p = \u3c 0.001; r = - 0.203, p = 0.026, respectively). Improved skin pliability revealed lower PAS scores (r = - 0.210, p = 0.022). After 12 weeks, there were no significant correlations between changes in CROM and SCM and PAS scores. Changes in left CROM and CROM extension had positive associations with the Head and Neck Cancer Inventory eating score (r = 0.210, p = 0.026; r = 0.245, p = 0.009, respectively). Findings appear to indicate that any improvement was not associated with changes in swallowing outcomes. Head and neck cancer survivors may perceive improved diet and swallowing skills through exercise, with respect to improved CROM extension

Association of Neck Range of Motion and Skin Caliper Measures on Dysphagia Outcomes in Head and Neck Cancer and Effects of Neck Stretches and Swallowing Exercises

To date, there is a paucity of information in the literature regarding the association between cervical range of motion (CROM) and skin caliper measures (SCM) and swallowing outcomes in post-RT individuals with head and neck cancer. Also lacking in the literature are reports of the effect of swallowing exercises and neck stretches on changes in CROM and SCM and their associations with swallowing outcomes. The aim of this study was to assess the associations between CROM and SCM before initiation of a neck stretching and swallowing exercise program and to determine if 12 weeks of twice daily practice changes in CROM and SCM were associated with changes in swallowing outcomes in a cohort of 119 head and neck cancer survivors. Primary results revealed that at baseline, greater right and left CROM were associated with lower penetration aspiration scale (PAS) scores (r = - 0.321, p = \u3c 0.001; r = - 0.203, p = 0.026, respectively). Improved skin pliability revealed lower PAS scores (r = - 0.210, p = 0.022). After 12 weeks, there were no significant correlations between changes in CROM and SCM and PAS scores. Changes in left CROM and CROM extension had positive associations with the Head and Neck Cancer Inventory eating score (r = 0.210, p = 0.026; r = 0.245, p = 0.009, respectively). Findings appear to indicate that any improvement was not associated with changes in swallowing outcomes. Head and neck cancer survivors may perceive improved diet and swallowing skills through exercise, with respect to improved CROM extension

Rethinking Residue: Determining the Perceptual Continuum of Residue on FEES to Enable Better Measurement

The goal of this work was to better understand perceptual judgments of pharyngeal residue on flexible endoscopic evaluation of swallowing (FEES) and the influence of a visual analog scale (VAS) versus an ordinal scale on clinician ratings. The intent was to determine if perceptual judgments of residue were more accurately described by equal or unequal intervals. Thirty-three speech language pathologists rated pharyngeal residue from 75 FEES videos representing a wide range of residue severities for thin liquid, applesauce, and cracker boluses. Clinicians rated their impression of the overall residue amount in each video on a VAS and, in a different session, on a five-point ordinal scale. Residue ratings were made in two separate sessions separated by several weeks. Statistical correlations of the two rating methods were carried out and best-fit models were determined for each bolus type. A total of 2475 VAS ratings and 2473 ordinal ratings were collected. Residue ratings from both methods (VAS and ordinal) were strongly correlated for all bolus types. The best fit for the data was a quadratic model representing unequal intervals, which significantly improved the r 2 values for each bolus type (cracker r 2 = 0.98, applesauce r 2 = 0.99, thin liquid r 2 = 0.98, all p < 0.0001). Perceptual ratings of pharyngeal residue demonstrated a statistical relationship consistent with unequal intervals. The present findings support the use of a VAS to rate residue on FEES, allowing for greater precision as compared to traditional ordinal rating scales. Perceptual judgments of pharyngeal residue reflected unequal intervals, an important concept that should be considered in future rating scales