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Dysphagia in Older and Frail Adults

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A special issue of Geriatrics (ISSN 2308-3417). This special issue belongs to the section "Geriatric Rehabilitation".

Deadline for manuscript submissions: closed (31 July 2018) | Viewed by 89767

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Special Issue Editor

Prof. Dr. David G. Smithard

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Guest Editor

1. Geriatric Medicine, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, Woolwich SE18 4QH, UK
2. Centre for Exercise and Active Rehabilitation (CEAR), University of Greenwich, London SE9 2UG, UK
Interests: dysphagia; frailty; care homes; stroke; swallowing rehabilitation
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Special Issue Information

Dear Colleagues,

Dysphagia is becoming an epidemic that will put a pressure on health and social care. The very old and frail cohort of the wider population are increasing in number and presently make up 12–15% of the adult population. Frailty and associated sarcopenia, along with dysphagia, are geriatric giants. There is increasing awareness of the contribution of frailty and sarcopenia to dysphagia.

This Special Issue will focus on the importance of dysphagia in frail older people. Papers in all areas pertaining to dysphagia including studies/ reviews in the areas of basic science, epidemiology, etiology and consequences (nutrition, function, sociological) of dysphagia in those living at home, or with dementia, long term conditions and care home residents, and the rehabilitation or prevention of dysphagia clinical studies, pharmacological and non-pharmacological interventions, as well as cognitive and psycho-social elements.

High quality original research and review articles in any of these areas will be considered. We are particularly keen on highlighting the novel and innovative approaches in the assessment, prevention, management, and rehabilitation of older people with dysphagia.

Dr. David G. Smithard
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Geriatrics is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 1800 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

Dysphagia
Swallowing/deglutition
Frailty
Sarcopenia
Nutrition
Psychological
Rehabilitation
Aetiology
Ethics
Epidemiology
Prevention

Published Papers (10 papers)

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Editorial

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2 pages, 130 KiB

Open AccessEditorial

Dysphagia in Frail Patients Is Not Frailty Dysphagia

by David G. Smithard

Geriatrics 2018, 3(4), 82; https://doi.org/10.3390/geriatrics3040082 - 19 Nov 2018

Cited by 3 | Viewed by 4479

Abstract

Society revolves around food, both as a physical necessity and a social nicety; thus, eating and drinking (and, hence, swallowing safely) have become a cornerstone of social life. [...] Full article

(This article belongs to the Special Issue Dysphagia in Older and Frail Adults)

Research

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12 pages, 759 KiB

Open AccessArticle

Preliminary Development of a Screening Tool for Pre-Clinical Dysphagia in Community Dwelling Older Adults

by Aarthi Madhavan, Giselle D. Carnaby, Karishma Chhabria and Michael A. Crary

Geriatrics 2018, 3(4), 90; https://doi.org/10.3390/geriatrics3040090 - 07 Dec 2018

Cited by 9 | Viewed by 8156

Abstract

Evidence suggests that community dwelling older adults (CDOA) are at risk for dysphagia (swallowing difficulties). Dysphagia is often unidentified until related morbidities like under nutrition or pneumonia occur. These cases of unidentified dysphagia, prior to any clinical intervention, may be termed ‘pre-clinical dysphagia’. Identifying pre-clinical dysphagia is challenged by the lack of validated tools appropriate for CDOA. This study addresses preliminary development of a novel patient reported outcome (PRO) screening tool for pre-clinical dysphagia. Initially, 34 questions were developed from literature review and expert opinion. Following pilot testing (n = 53), the questionnaire was revised and tested on 335 additional CDOA. Face validity, content validity, item analysis, reliability (internal consistency), and construct validity (exploratory factor analysis) measures were completed. Psychometric validation resulted in a 17-question PRO tool. Construct analysis identified a three-factor model that explained 67.345% of the variance. Emergent factors represented swallowing effort, physical function, and cognitive function. The results revealed strong construct validity and internal consistency (Cronbach’s α = 0.90). A novel, simple PRO incorporating multiple function domains associated with aging demonstrated strong preliminary psychometric properties. This tool is more comprehensive and aging-focused than existing dysphagia screening tools. Inclusion of multiple domains may be key in early identification of pre-clinical dysphagia. Full article

(This article belongs to the Special Issue Dysphagia in Older and Frail Adults)

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10 pages, 585 KiB

Open AccessArticle

Taste Perception and Water Swallow Screen Results in Old-Old Women

by Rachel W. Mulheren, Ianessa A. Humbert, Anne R. Cappola, Linda P. Fried and Marlís González-Fernández

Geriatrics 2018, 3(4), 83; https://doi.org/10.3390/geriatrics3040083 - 20 Nov 2018

Cited by 1 | Viewed by 5260

Abstract

Changes in both swallowing and taste commonly occur in advanced age, though the relationship between the two is unknown. This study examined the association between a water swallow screen test and taste identification and intensity rating. Participants included 47 community-dwelling women aged 85–94 years. Participants completed three trials of a water swallow screen and were observed for signs of aspiration, which, if present, indicated failure. Four pure taste stimuli at low and high concentrations and water were presented, and participants selected one of five taste labels and rated their intensity on the generalized Labeled Magnitude Scale. Ratios of intensity ratings were computed for each taste stimulus to compare the perception of low and high concentrations. The association between water swallow screen failure, correct taste identification, and taste intensity ratio was evaluated with logistic regression modeling, with mediating factors of frailty and number of comorbidities. Failure of three water swallow screen trials was associated with a higher taste intensity ratio for caffeine (bitter) and a lower taste intensity ratio for sucrose (sweet). Correct identification of taste, frailty, and number of comorbidities were not associated with failure of any number of water swallow screen trials. Intensity ratings of certain tastes may be associated with swallowing in old-old women. Heightened vigilance in this population may be necessary to prevent complications related to dietary intake. Full article

(This article belongs to the Special Issue Dysphagia in Older and Frail Adults)

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12 pages, 1026 KiB

Open AccessFeature PaperArticle

Pilot of a Charter to Improve Management of Medicines and Oral Care for Residents with Dysphagia in Care Homes

by Jacqueline E. Morris, Frances Hollwey, Dharinee Hansjee, Rachel A. Power, Richard Griffith, Timothy Longmore, David G. Smithard, Eleanor Dann-Reed and David J. Wright

Geriatrics 2018, 3(4), 78; https://doi.org/10.3390/geriatrics3040078 - 15 Nov 2018

Cited by 6 | Viewed by 5831

Abstract

Research in care homes has demonstrated that medication management practices in patients with dysphagia and those receiving medicines covertly may be inappropriate, illegal, and potentially cause harm. This paper presents the results of a feasibility study piloting a resident and healthcare professional best practice charter to improve such practices in care home residents with dysphagia. A charter was developed through a multi-professional expert panel, implemented in one care home, and then piloted in 22 homes in England, Wales, and Northern Ireland. A website was setup and developed iteratively to support the process. Care home staff and residents provided initial feedback on the implementation process and on perceived outcomes six months post implementation. A total of 16 (88.9%) out of 18 respondents from nine homes for six months reported a positive response to the charter. More than 80% of responses regarding the implementation process, impact on staff confidence, and perceived usefulness of the charter were positive. Perceived effectiveness and usefulness could, however, be further improved especially the perceived effect on frequency of medication review, which is reliant on external stakeholder involvement. The charter and supporting website were well received with respondents believing that it was useful, staff showing more confidence, and residents having enhanced care. Approaches to enhancing the charter’s effectiveness were identified. Full article

(This article belongs to the Special Issue Dysphagia in Older and Frail Adults)

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11 pages, 647 KiB

Open AccessFeature PaperArticle

Dysphagia Onset in Older Adults during Unrelated Hospital Admission: Quantitative Videofluoroscopic Measures

by Marie Jardine, Anna Miles and Jacqui Allen

Geriatrics 2018, 3(4), 66; https://doi.org/10.3390/geriatrics3040066 - 03 Oct 2018

Cited by 27 | Viewed by 9543

Abstract

New-onset swallowing difficulties in older patients during unrelated hospital admissions are well recognized and may result in prolonged hospital stay and increased morbidity. Presbyphagia denotes age-related swallowing changes which do not necessarily result in pathological effects. The trajectory from presbyphagia to dysphagia is not well understood. This retrospective observational study compared quantitative videofluoroscopic measures in hospitalized older adults aged 70–100 years, reporting new dysphagia symptoms during admission (n = 52), to healthy asymptomatic older (n = 56) and younger adults (n = 43). Significant physiological differences seen in hospitalized older adults but not healthy adults, were elevated pharyngeal area (p < 0.001) and pharyngeal constriction ratio (p < 0.001). Significantly increased penetration (p < 0.001), aspiration (p < 0.001) and pharyngeal residue (p < 0.001) were also observed in the hospitalized older cohort. Reasons for onset of new swallow problems during hospitalization are likely multifactorial and complex. Alongside multimorbidity and polypharmacy, a combination of factors during hospitalization, such as fatigue, low levels of alertness, delirium, reduced respiratory support and disuse atrophy, may tip the balance of age-related swallowing adaptations and compensation toward dysfunctional swallowing. To optimize swallowing assessment and management for our aging population, care must be taken not to oversimplify dysphagia complaints as a characteristic of aging. Full article

(This article belongs to the Special Issue Dysphagia in Older and Frail Adults)

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8 pages, 510 KiB

Open AccessFeature PaperArticle

An Acute Model of Care to Guide Eating & Drinking Decisions in the Frail Elderly with Dementia and Dysphagia

by Dharinee Hansjee

Geriatrics 2018, 3(4), 65; https://doi.org/10.3390/geriatrics3040065 - 02 Oct 2018

Cited by 9 | Viewed by 9174

Abstract

People with dementia frequently develop dysphagia (swallowing impairment), which causes them to be at high risk of aspiration pneumonia, resulting in hospital admissions. These individuals are advised against alternative nutrition and hydration as this does not eliminate the risk of developing chest infections. The purpose of this study was to establish the impact on length of stay by having a protocol to guide eating and drinking despite aspiration risks (risk feeding). A risk-feeding protocol was developed and implemented in a hospital setting. The quality improvement methodology of Plan-Do-Study-Act (PDSA) was employed to evaluate the impact of a protocol on the length of stay in patients with dementia and aspiration pneumonia. Annual audits (2016–2018) on the time taken from admission to when a route of nutrition was established were conducted, with adaptations made to the protocol. There was a reduction in nutrition planning times with each year. On closer evaluation of the data, improved nutrition planning times for this cohort impacted on a shorter length of stay. Having a model of care in place to guide feeding decisions in dementia coordinates care, as demonstrated in timely decision-making. For patients who are admitted with aspiration pneumonia and dementia, a decreased length of stay is evident. Full article

(This article belongs to the Special Issue Dysphagia in Older and Frail Adults)

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9 pages, 496 KiB

Open AccessFeature PaperArticle

The Prevalence of Oropharyngeal Dysphagia in Acute Geriatric Patients

by Dorte Melgaard, Maria Rodrigo-Domingo and Marianne M. Mørch

Geriatrics 2018, 3(2), 15; https://doi.org/10.3390/geriatrics3020015 - 26 Mar 2018

Cited by 49 | Viewed by 9816

Abstract

Oropharyngeal dysphagia (OD) is underdiagnosed and undertreated in many geriatric centers. The aim of this study is to explore the prevalence of OD in acute geriatric patients. The outcome was mortality during hospitalization, mortality, and rehospitalization within 0–30 and 31–180 days of discharge. A total of 313 consecutive acute geriatric patients (44.1% male, mean age 83.1 years (SD 7.8)) hospitalized from 1 March to 31 August 2016 in the North Denmark Regional Hospital were included in this study. The volume-viscosity swallow test and the Minimal Eating Observation Form-II were conducted for each patient in order to screen for OD. A total of 50% patients presented with OD. In the group of patients with OD, significantly more lived in nursing homes; had a lower weight, DEMMI score, and handgrip strength; and smaller circumference of arms and legs compared with non-dysphagia patients. Patients with OD presented an increased length of stay in hospital of one day (p = 0.70). Intra-hospital mortality was 5.8% vs. 0.7%, (p < 0.001) compared with patients with no symptoms of OD. OD is prevalent in acute geriatric patients, and the mortality is 34% within six months of hospitalization. Screening for OD should be given more attention and included in geriatric guidelines. Full article

(This article belongs to the Special Issue Dysphagia in Older and Frail Adults)

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Review

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19 pages, 988 KiB

Open AccessReview

Systematic Review of Pharyngeal and Esophageal Manometry in Healthy or Dysphagic Older Persons (>60 years)

by Charles Cock and Taher Omari

Geriatrics 2018, 3(4), 67; https://doi.org/10.3390/geriatrics3040067 - 05 Oct 2018

Cited by 25 | Viewed by 6264

Abstract

We undertook a systematic review of swallowing biomechanics, as assessed using pharyngeal and esophageal manometry in healthy or dysphagic older individuals aged over 60 years of age, comparing findings to studies of younger participants. PRISMA-P methodology was used to identify, select, and evaluate eligible studies. Across studies, older participants had lower upper esophageal sphincter (UES) resting pressures and evidence of decreased UES relaxation when compared to younger groups. Intrabolus pressures (IBP) above the UES were increased, demonstrating flow resistance at the UES. Pharyngeal contractility was increased and prolonged in some studies, which may be considered as an attempt to compensate for UES flow resistance. Esophageal studies show evidence of reduced contractile amplitudes in the distal esophagus, and an increased frequency of failed peristaltic events, in concert with reduced lower esophageal sphincter relaxation, in the oldest subjects. Major motility disorders occurred in similar proportions in older and young patients in most clinical studies, but some studies show increases in achalasia or spastic motility in older dysphagia and noncardiac chest pain patients. Overall, study qualities were moderate with a low likelihood of bias. There were few clinical studies specifically focused on swallowing outcomes in older patient groups and more such studies are needed. Full article

(This article belongs to the Special Issue Dysphagia in Older and Frail Adults)

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14 pages, 1044 KiB

Open AccessReview

The Burden of Dysphagia on Family Caregivers of the Elderly: A Systematic Review

by Ashwini M. Namasivayam-MacDonald and Samantha E. Shune

Geriatrics 2018, 3(2), 30; https://doi.org/10.3390/geriatrics3020030 - 10 Jun 2018

Cited by 40 | Viewed by 8802

Abstract

With the rapid increase in the elderly population, there is a simultaneous increased need for care provided by family caregivers. Research in the field of head and neck cancer has indicated that caring for patients with dysphagia can impact a caregiver’s quality of life. Given that many older adults present with dysphagia, one can assume that their caregivers are equally, if not more greatly, affected. The purpose of this systematic review was to examine all relevant literature regarding the caregiver burden in caregivers of community-dwelling older adults with dysphagia. A review of relevant studies published through April 2018 was conducted using search terms related to dysphagia, caregiver burden, and older adults. The search yielded 2331 unique abstracts. Of the 176 abstracts that underwent full review, four were accepted. All reported an increase in caregiver burden due to presence of dysphagia in care recipients. Worsening feeding-related behaviors were associated with burden, and the use of feeding tubes was more frequently associated with “heavy burden”. The presence of dysphagia in community-dwelling older adults is a factor leading to an increased burden among caregivers. Although aspects of dysphagia play a role in the caregiver burden, the specific reasons for the increased burden are unknown. Clinicians should be aware of dysphagia as a source of the burden, and future studies should further define the relationship between dysphagia and the caregiver burden in order to develop comprehensive approaches to care. Full article

(This article belongs to the Special Issue Dysphagia in Older and Frail Adults)

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Other

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10 pages, 224 KiB

Open AccessCommentary

by Julie A. Y. Cichero

Geriatrics 2018, 3(4), 69; https://doi.org/10.3390/geriatrics3040069 - 12 Oct 2018

Cited by 104 | Viewed by 20588

Abstract

Reductions in muscle mass and strength are well known complications of advancing age. All muscles of the body are affected, including those critical to chewing and swallowing. A diagnosis of frailty and its features of weakness and unintentional weight loss are particularly relevant to the aging swallowing system. Age related changes to eating and swallowing function means that there is a natural tendency for elders to self-select ‘soft’ foods due to loss of dentition and fatigue on chewing. However, it is not well known that tooth loss and poor dental status is associated with increased choking risk, especially as people age. In fact, people over 65 years of age have seven times higher risk for choking on food than children aged 1–4 years of age. Texture modified foods are provided clinically to reduce choking risk and manage dysphagia. Although certain food textures offer greater swallowing safety, they significantly restrict food choice. This commentary paper will highlight age-related changes to the eating and swallowing system, noting especially those that are relevant for frail elders. Swallowing impairments also affect the ability to manage liquids, and aspiration risk in healthy and frail elders is also discussed. Modified food textures that are most often recommended by clinicians to maintain sufficient oral intake and reduce choking risk will be described, while also highlighting the nutritional challenges associated with these foods and offering some solutions. The ethical challenges associated with balancing the autonomy of choice of food textures with swallowing safety will be addressed. Full article

(This article belongs to the Special Issue Dysphagia in Older and Frail Adults)

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