Nutrition Publication

NNIW72 - Stepping Stones to Living Well with Dysphagia

Editor(s): J. Cichero, P. Clavé. Clinical Nutrition Series 72

Dysphagia or swallowing disorders affect tens of millions of people in Europe and the USA. Unfortunately, many cases remain and are often undiagnosed. Therefore the NNI organised a workshop entitled "Stepping Stones to Living Well with Dysphasgia" bringing together an international, multidisciplinary group of experts to discuss the latest scientific findings.

Related Articles

Definition, Prevalence and Burden of Oropharyngeal Dysphagia: A Serious Problem among Older Adults Worldwide and the Impact on Prognosis and Hospital Resources

Author(s): J. Cichero, K.W. Altman

The etiology of oropharyngeal dysphagia can be broad, and includes aging with atrophy, debilitation, stroke, neurodegenerative and muscular diseases, tumor and postsurgical deformity, as well as effects due to medications and drying of the mucosal membranes. Pathophysiology depends on the multiple causative factors, including the cortex and neural connections to generate the swallow, as well as the oropharyngeal musculature. While chronic debilitation and age may result in nutritional deficiency and poor hydration, the other causes generally present with aspiration risk more acutely. Bacteriologically, aspiration pneumonia is usually polymicrobial with a predominance of Gram- negative enteric bacilli. However, there is emerging evidence to suggest that odontogenic sources may complicate the severity of bacterial load. The principles behind science- based interventions are primarily aspiration assessment with bedside evaluation, and ultimately modified barium swallow (videofluoroscopy) or functional endoscopic evaluation of swallowing (with or without sensory testing). Each has its advantages and logistical concerns. Intervention and rehabilitation is unique to the patient’s needs, but may include reconditioning and therapy with a speech and language pathologist, and surgical options. The emerging roles of neuroplasticity and external neuromuscular stimulation are also discussed.

Identifying Vulnerable Patients: Role of the EAT-10 and the MultidisciplinaryTeam for Early Intervention and Comprehensive Dysphagia Care

Author(s): K. Kaspar, O. Ekberg

There is underdiagnosis and low awareness of dysphagia despite that the condition is modifiable and poorly managed symptoms diminish psychological well- being and overall quality of life. Frontline clinicians are in a unique position to be alert to the high prevalence of swallowing difficulty among elderly, evaluate and identify those who need intervention, and assure that individuals receive appropriate care. Proper diagnosis and treatment of oral- pharyngeal dysphagia involves a multidisciplinary healthcare team effort and starts with systematic screening of at- risk patients. The presence of a medical condition such as acute stroke, head and neck cancer, head trauma, Alzheimer’s disease, Parkinson’s disease, pneumonia or bronchitis is adequate basis for predicting high risk. Systematic screening of dysphagia and resulting malnutrition among at- risk older adults is justified in an effort to avoid pneumonia and is recommended by clinical practice guidelines. Systematic screening with a validated method (e.g. the 10- item Eating Assessment Tool, EAT- 10) as part of a comprehensive care protocol enables multidisciplinary teams to more effectively manage the condition, reduce the economic and societal burden, and improve patient quality of life. In fact, care settings with a systematic dysphagia screening program attain significantly better patient outcomes including reduced cases of pneumonia (by 55%) and reduced hospital length of stay.

The Volume-Viscosity Swallow Test for Clinical Screening of Dysphagia and Aspiration

Author(s): L. Rofes, V. Arreola, P. Clavé

Background: Oropharyngeal dysphagia (OD) is a major complaint among many patients with neurological diseases and in the elderly, but is often underdiagnosed. The volumeviscosity swallow test (V- VST) is a bedside method to screen patients for dysphagia.Methods: The V- VST was designed to identify clinical signs of impaired efficacy (labial seal, oral and pharyngeal residue, and piecemeal deglutition) and impaired safety of swallow (voice changes, cough and decrease in oxygen saturation ≥3%). It starts with nectar viscosity and increasing bolus volume, then liquid and finally pudding viscosity in a progression of increasing difficulty to protect patients from aspiration. Results: The V- VST allows quick, safe and accurate screening for OD in hospitalized and independently living patients with multiple etiologies. The V- VST presents a sensitivity of 88.2% and a specificity of 64.7% to detect clinical signs of impaired safety of swallow (aspiration or penetration). The test takes 5– 10 min to complete. Discussion and Conclusion: The V- VST is an excellent tool to screen patients for OD. It  combines good psychometric properties, a detailed and easy protocol designed to protect safety of patients, and valid end points to evaluate safety and efficacy of swallowing and detect silent aspirations.

Videofluoroscopic Swallow Study: Techniques, Signs and Reports

Author(s): M. Bülow

Management of oropharyngeal swallowing dysfunction often requires both a clinical and an instrumental examination. A videofluoroscopic swallowing study is an instrumental examination that often could be a good option and a very useful tool for the swallowing clinician. At Skåne University Hospital, Malmö, Sweden, the name of such examination is therapeutic videoradiographic swallowing study (TVSS). A TVSS examination should always be performed in collaboration between a speech language pathologist and a radiologist. During the examination, the patient is seated in an upright position, but the examination can also be performed with the patient lying down. The TVSS examination can be performed both in frontal and lateral projection. Test material with varied consistencies as well as different therapeutic strategies can be tested during the examination. Any oral and/or pharyngeal dysfunction can be defined, for example a delay in the initiation of the pharyngeal swallow or an absent pharyngeal swallow, pharyngeal retention, penetration, and silent aspiration. After the examination, an analysis is performed, and it is studied how different textures affect the physiology of swallowing. A report is then written in which the actual dysfunction is described in detail, and recommendations regarding modified textures and swallowing techniques are given.

Pathophysiology, Relevance and Natural History of Oropharyngeal Dysphagia among Older People

Author(s): P. Clavé, L. Rofes, S. Carrión, O. Ortega, M. Cabré M. Serra-Prat, V. Arreola

Oropharyngeal dysphagia (OD) is a very frequent condition among older people with a prevalence ranging from mild symptoms in 25% of the independently living to severe symptoms in more than 50% living in nursing homes. There are several validated methods of screening, and clinical assessment and videofluoroscopy are the gold standard for the study of the mechanisms of OD in the elderly. Oropharyngeal residue is mainly caused by weak bolus propulsion forces due to tongue sarcopenia. The neural elements of swallow response are also impaired in older persons, with prolonged and delayed laryngeal vestibule closure and slow hyoid movement causing oropharyngeal aspirations. OD causes malnutrition, dehydration, impaired quality of life, lower respiratory tract infections, aspiration pneumonia, and poor prognosis including prolonged hospital stay and enhanced morbidity and mortality in several phenotypes of older patients ranging from independently living older people, hospitalized older patients and nursing home residents. Enhancing bolus viscosity of fluids greatly improves safety of swallow in all these patients. We believe OD should be recognized as a major geriatric syndrome, and we recommend a policy of systematic and universal screening and assessment of OD among older people to prevent its severe complications.

Complications of Oropharyngeal Dysphagia: Aspiration Pneumonia

Author(s): J. Almirall, M. Cabré, P. Clavé

The incidence and the prevalence of aspiration pneumonia (AP) is poorly defined. It increases in direct relation with age and underlyng diseases. The pathogenesis of AP presumes the contribution of risk factors that alter swallowing function and predispose the orofaryngeal bacterial colonization The microbial etiology of AP involves Staphylococcus aureus, Haemophilus influenzae and Streptococcus pneumoniae for community-acquired aspiration pneumonia and Gram-negative aerobic bacilli in nosocomial pneumonia. It is worth bearing in mind the relative unimportance of anaerobic bacterias in AP.When we choose the empirical antibiotic treatment we have to consider some pathogens identified in orofaringeal flora. Empirical treatment with antianaerobics should only be used in certain patients. According to some known risks factors the prevention of AP should include measures in order to avoid it.

Importance of Nutritional Support in Older People

Author(s): E. Sánchez García, E. Montero Errasquín, C. Sánchez Castellano, A.J. Cruz-Jentoft

Proper nutrition is an essential part of successful aging and may delay the onset of diseases. Nutrition-related problems in older subjects have been long time ignored; being a good nutritional status an essential component of health and a relevant part of therapeutic plans of most chronic diseases. Moreover, food and nutrition are a relevant aspect of most cultures and are strongly linked with individual lifestyles.Research has proved that nutritional intervention can improve outcomes in many clinical scenarios. This is especially true for older individuals with different acute and chronic conditions and diseases, or with malnutrition. Nutritional intervention can provide sufficient energy, protein and micronutrients, maintain or improve nutritional status, reduce morbidity and increase survival. Evidence is still lacking on the impact of nutritional intervention on physical and mental function, and on quality of life, very relevant outcomes for older individuals. Nutritional screening and assessment should become part of health care of both healthy and sick older people. Nutritional counseling and intervention should be embedded in a general care plan that takes into account all aspects of an aging person. Nutritional programs that aim for high compliance should be individualized, and would have to consider every aspect of old age: beliefs, attitudes, preferences, expectations, and aspirations.

Exercise-Based Approaches to Dysphagia Rehabilitation

Author(s): C. M. Steele

Rehabilitative techniques for dysphagia (swallowing impairment) increasingly employ exercise, modeled on methods used to train muscles in sports medicine.  Three techniques, in particular, show promise for improving muscle strength and function related to swallowing: the Shaker exercise, expiratory muscle strength training, and tongue-pressure resistance training.  All three techniques invoke principles of task specificity, muscular load, resistance, and intensity, and aim to achieve functional changes in swallowing through changes in muscle physiology derived from strength or endurance training.  To date, studies of treatment benefit arising from these techniques involve small sample sizes; this is particularly true of randomized studies with controls receiving standard treatment or experiencing spontaneous recovery.  Nevertheless, a review of the available literature shows that improvement of penetration-aspiration is a common finding for individuals with dysphagia receiving one of these three treatment approaches.  Although hypothesized as an expected outcome of swallow muscle strength training, improvements in post-swallow residues are noted to be uncommon as an outcome of these exercise-based approaches. The available evidence suggests that exercise-based approaches to swallowing rehabilitation do succeed in changing muscle strength and function, but generalization to true swallowing tasks may be somewhat limited.

Therapeutic Approach to Malnutrition and Sarcopenia

Author(s): R. Peláez

Sarcopenia is a syndrome characterized by the progressive loss of muscle mass and strength with a risk of undesirable effects such as physical disability, poor quality of life and death, and it is a major contributing factor of disability and loss of independence in the elderly. Its etiopathogenics include different mechanisms that are both intrinsic to the muscle itself and related to changes in the central nervous system, as well as hormonal and lifestyle factors. Several hormones and cytokines affect muscle function and mass. The reduction in testosterone and estrogens associated with ageing speeds up the loss of muscle mass. Growth hormone is also involved in the loss of lean body mass. Although sarcopenia does not completely revert with exercise, the absence of physical activity accelerates muscle mass loss. Diagnosing sarcopenia is hindered by a lack of reliable methods for measuring muscle mass. Different strategies have been tested for its treatment: testosterone replacement therapy/other anabolic androgens, estrogens in women, growth hormone, nutritional treatment and exercise. Of all the therapeutic options available, only resistance training with or without nutritional supplementation has shown its efficacy in increasing skeletal muscle mass.

The Physiology of Deglutition and the Pathophysiology and Complications of Oropharyngeal Dysphagia

Author(s): C. Steele

The opening session of the 2nd International Conference on Oropharyngeal Dysphagia featured a series of invited talks reviewing the definition of dysphagia, its prevalence and its pathophysiology. The discussion arising from these talks focused heavily on the current underrecognition of dysphagia as a significant concern for older adults, particularly those over 75. The burdens associated with dysphagia in this sector of the population were recognized to be substantial, both in social/psychological terms and in terms of economic consequences for the healthcare system. The importance of developing swallow screening protocols as a routine method for the early identification of dysphagia and aspiration was explored. The idea of launching political initiatives aimed at increasing awareness and the utilization of appropriate dysphagia healthcare codes was also discussed.

Screening and Clinical Assessment of Oropharyngeal Dysphagia

Author(s): R. Martino

Dysphagia is common after stroke, and has been associated with serious consequences such as pneumonia, malnutrition, dehydration and even death. There is emerging evidence that early detection with screening may reduce these consequences. As clinicians, it is our responsibility to strive to service our patients with the best evidence and implement screening protocols that are reliable, valid and feasible.

Nutrition Assessment and Intervention in the Patient with Dysphagia: Challenges for Quality Improvement

Author(s): J. B. Ochoa

Dysphagia, a symptom characterized by difficulty swallowing, is an independent predictor of poor outcome, worsening morbidity, increasing the risk for hospital readmissions, health care costs and mortality. Dysphagia is a result of a number of illnesses including neurological diseases, after surgery for head and neck pathology, observed in the intensive care unit after prolonged endotracheal intubation among others, and is particularly frequent in the elderly. Dysphagia increases the incidence of malnutrition, which in turn delays patient recovery. Treatment of dysphagia can be successful, but requires the use of multidisciplinary teams. A focus on the management of malnutrition including prevention and treatment is essential. Perhaps the biggest challenge is the lack of awareness of the presence of dysphagia and malnutrition, so that only a minority of patients are identified and successfully treated. We propose that better identification and treatment of dysphagia could occur with the systematic implementation of clinical practice improvement processes with a consequent decrease in morbidity, mortality and cost.

Oropharyngeal Dysphagia Pathophysiology, Complications and Science- Based Interventions

Author(s): K. Altman

The etiology of oropharyngeal dysphagia can be broad, and includes aging with atrophy, debilitation, stroke, neurodegenerative and muscular diseases, tumor and postsurgical deformity, as well as effects due to medications and drying of the mucosal membranes. Pathophysiology depends on the multiple causative factors, including the cortex and neural connections to generate the swallow, as well as the oropharyngeal musculature. While chronic debilitation and age may result in nutritional deficiency and poor hydration, the other causes generally present with aspiration risk more acutely. Bacteriologically, aspiration pneumonia is usually polymicrobial with a predominance of Gram- negative enteric bacilli. However, there is emerging evidence to suggest that odontogenic sources may complicate the severity of bacterial load. The principles behind science- based interventions are primarily aspiration assessment with bedside evaluation, and ultimately modified barium swallow (videofluoroscopy) or functional endoscopic evaluation of swallowing (with or without sensory testing). Each has its advantages and logistical concerns. Intervention and rehabilitation is unique to the patient’s needs, but may include reconditioning and therapy with a speech and language pathologist, and surgical options. The emerging roles of neuroplasticity and external neuromuscular stimulation are also discussed.