Incidence of dysphagia-related safety incidents in older adults across feeding methods: A systematic review and meta-analysis

Braun R.G., Arata J., Gonzalez-Fernandez M.

Physiatrists play a vital role in post-stroke dysphagia management not only by providing guidance on the risks, benefits, and efficacy of various treatment options but also as advocates for patients' independence and quality of life . While swallow study results are often discussed broadly by acute stroke clinicians as "pass/fail" findings, physiatrists need a more nuanced working knowledge of dysphagia diagnosis and treatment that encompasses swallow pathophysiology , targeted treatment strategies, and prognosis for recovery. To that end, this review summarizes current clinical practice guidelines on dysphagia, nutrition and oral care, risks and benefits of differing enteral access routes, prognostic factors , and approaches to rehabilitation.

Hashida N., Tamiya H., Korematsu M., Fujii T.

AbstractObjective Head and neck cancer (HNC) treatment causes dysphagia, which may lead to aspiration pneumonia (AP). Thickened fluids are widely used to prevent aspiration in patients with dysphagia; however, there is little evidence that they can prevent AP. This study aimed to clarify the differences between restriction of oral intake of fluids (R), only thickened fluids (TF), and no restriction of fluids (NR) for AP in patients with dysphagia after HNC treatment. Methods We retrospectively studied 654 patients with dysphagia after HNC surgery between 2012 and 2021. Of these, 255 had some restriction of fluids. The development of possible AP and administration of antibacterial drugs were used as outcomes. Multivariate linear regression and propensity score matching analyses were performed. Results The mean patient age was 64 ± 13, 67 ± 11, and 68 ± 10 years, while the Dynamic Imaging Grade of Swallowing Toxicity score 3–4 was 2.8%, 27.5, and 53.3%% water in NR, TF, and R groups, respectively. AP was diagnosed or suspected after starting oral intake in 37 (9.3%), 11 patients (15.9%), and 45 (17.6%) and antibacterial drugs were administered in 11 (2.8%), 7 patients (10.1%), and 25 (9.8%) in NR, TF, and R groups, respectively. R and TF had significant negative impacts on AP. Conclusions Fluid restrictions may not reduce the risk of AP or affect the administration of antibacterial drugs. Medical staff should bear in mind that fluid restrictions do not necessarily prevent AP in patients with HNC.

Hurtte E., Young J., Gyawali C.P.

Dysphagia is an important clinical symptom that increases in prevalence with age. Both oropharyngeal and esophageal processes can contribute to dysphagia, and these can be differentiated with a careful history. Neuromuscular processes are more prevalent than structural causes in oropharyngeal dysphagia, therefore, investigation should start with a modified barium swallow. In contrast, structural processes dominate in esophageal dysphagia, and endoscopy can offer biopsy and therapy by way of dilation. Manometry is performed for esophageal dysphagia when no structural etiology is found. Specific management of dysphagia is dependent on the etiology and mechanism of dysphagia.

Reyes‐Torres C.A., Castillo‐Martínez L., Ramos‐Vázquez A.G., Cassis‐Nosthas L., Zavala‐Solares M., García‐de‐la‐Torre G., Serralde‐Zúñiga A.E.

AbstractBackgroundOropharyngeal dysphagia (OD) is common among older adults. Some studies have evaluated the efficacy of a texture‐modified diet on mortality but with short‐term follow‐up. We aimed to evaluate the effect of a texture‐modified diet and controlled bolus volume on all‐cause mortality after 12 months in older persons with OD.MethodsThis secondary analysis of a randomized clinical trial included patients aged ≥60 years with a diagnosis of OD. They were concurrently and randomly assigned to receive either a texture‐modified food diet and controlled bolus volume (intervention group) or standard treatment (control group) with 12 months of follow‐up. Secondary outcomes were oral intake, weight, handgrip strength, phase angle, and aspiration pneumonia. Kaplan‐Meier analysis and the Cox proportional hazards model were used for mortality analysis.ResultsA total of 127 participants (intervention group: 64 and control group: 63) were recruited, with a mean age of 76 years. The probability of all‐cause mortality was significantly lower in the intervention group (n = 8, 12%) than in the control group (n = 18, 29%) (hazard ratio = 0.36 [95% CI = 0.16–0.86]; P = 0.01). There were 5 (7.9%) and 10 (16.1%) aspiration pneumonia events in the intervention and control groups, respectively (not significant) in 12 months of follow‐up. Changes were observed in protein consumption (P = 0.01), body weight (P = 0.04), body mass index (P = 0.004), handgrip strength (P = 0.02), and phase angle (P = 0.04) between the treatment groups.ConclusionCompared with the standard treatment, the dietary intervention improved efficacy by limiting nutrition complications, aspiration pneumonia, and all‐cause mortality.

Volkert D., Beck A.M., Cederholm T., Cruz-Jentoft A., Hooper L., Kiesswetter E., Maggio M., Raynaud-Simon A., Sieber C., Sobotka L., van Asselt D., Wirth R., Bischoff S.C.

Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats.To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons.This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process.We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counselling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach.A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used.

Banda K.J., Chu H., Chen R., Kang X.L., Jen H., Liu D., Shen Hsiao S., Chou K.

<b><i>Introduction:</i></b> Oropharyngeal dysphagia (OD) is a serious health condition associated with poor survival and quality of life in adults aged 60 years and older. Comprehensive assessment and management of OD could lead to better and improved health outcomes for older adults. Therefore, we performed the first meta-analysis to determine the pooled prevalence of OD and risk of pneumonia, malnutrition, and mortality. <b><i>Methods:</i></b> Databases including Ovid-MEDLINE, Web of Science, Embase, PubMed, Cochrane, and CINAHL were searched up to January 2021. Data analysis was conducted using logistic-normal for prevalence rate and DerSimonian-Lard random-effects models for outcomes and associated factors of OD, providing odds ratio (OR) and corresponding 95% confidence interval (CI). <b><i>Results:</i></b> The pooled prevalence of OD in 39 studies with 31,488 participants was 46% associated with higher pooled OR for risk of pneumonia 2.07 (95% CI, 1.58–2.72), malnutrition 2.21 (95% CI, 1.43–3.41), and mortality 2.73 (95% CI, 1.62–4.60). Geriatric syndromes including fecal incontinence 6.84 (4.955–9.44), immobility syndrome 6.06 (5.28–6.96), pressure ulcers 4.02 (2.46–6.56), sarcopenia 3.10 (1.89–5.09), urinary incontinence 2.75 (1.81–4.19), frailty 2.66 (1.16–6.13), delirium 2.23 (1.73–2.87), and falls 1.47 (1.19–1.81) and comorbidities including dementia 3.69 (2.36–5.78) and stroke 1.92 (1.47–2.52) were associated with OD. <b><i>Conclusion:</i></b> Early identification and management of OD should consider geriatric syndromes and neurogenic comorbidities to prevent malnutrition and pneumonia and reduce mortality in adults aged 60 years and older.

Thiyagalingam S., Kulinski A.E., Thorsteinsdottir B., Shindelar K.L., Takahashi P.Y.

Dysphagia, which is a geriatric syndrome affecting 10% to 33% of older adults, is commonly seen in older adults who have experienced a stroke or neurodegenerative diseases such as Alzheimer or Parkinson disease. Patients diagnosed as having dysphagia can experience malnutrition, pneumonia, and dehydration. Patients can also experience increased rates of mortality and long-term care admission. Providers can identify the specific type of dysphagia for treatment in approximately 80% of patients by asking 5 questions in the patient's history: What happens when you try to swallow? Do you have trouble chewing? Do you have difficulty swallowing solids, liquids, or both? Describe the symptom onset, duration, and frequency? What are the associated symptoms? Providers can then request a videofluoroscopic swallow study or a fiberoptic endoscopic evaluation of swallowing for further evaluation of oropharyngeal dysphagia. If providers are diagnosing esophageal dysphagia, barium esophagraphy or esophagogastroduodenoscopy (EGD) can be used as part of the assessment. Patients can be treated for oropharyngeal dysphagia by using compensatory interventions, including behavioral changes, oral care, dietary modification, or rehabilitative interventions such as exercises and therapeutic oral trials. Providers often address treatment of esophageal dysphagia by managing the underlying etiology, which could include removal of caustic medications or using EGD as a therapeutic modality for esophageal rings. High-quality, large research studies are necessary to further manage the diagnosis and appropriate treatment of this growing geriatric syndrome.

Tang D., Yuan F., Ma X., Qu H., Li Y., Zhang W., Ma H., Liu H., Yang Y., Xu L., Gao Y., Zhan S.

The risk and prognosis of aspiration pneumonia (AP) after endoscopic submucosal dissection (ESD) are inconsistent among studies. We aim to estimate the incidence, risk factors, and outcome of AP in patients after gastric ESD.PubMed, EMBASE, Cochrane Library, and Web of Knowledge were searched for relevant articles from inception until April 2020. Data involving the incidence, risk factors, and outcomes were extracted. Pooled incidence, odds ratios (ORs), or standardized mean difference (SMD) and 95% confidence intervals (CIs) were calculated.Forty records involving 48 674 subjects were finally included. The pooled incidence of AP after gastric ESD was 1.9% (95% CI, 1.2-2.7) via the double arcsine transformation method and 1.6% (1.1-2.5%) via the logit transformation method. Risk factors analyses revealed that old age (OR, 2.52; 95% CI, 1.99-3.18), comorbid pulmonary disease (2.49; 1.66-3.74), comorbid cerebrovascular disease (2.68; 1.05-6.85), remnant stomach (4.91; 1.83-13.14), sedation with propofol (2.51; 1.48-4.28), and long procedural duration (count data: 5.20, 1.25-21.7; measurement data: 1.01, 1.01-1.02) were related to the occurrence of AP. Patients with AP had a longer hospital stay (SMD, 0.56; 95% CI, 0.25-0.87) than those without AP.About 1.9% (1.2-2.7%) of the patients who receive gastric ESD may develop AP, resulting in prolonged hospital stay. More attention should be paid in patients who are older; have comorbidities such as pulmonary diseases, cerebrovascular diseases, or gastric remnant; or require a long procedural duration or deep sedation with propofol.

Masaki S., Kawamoto T.

Background The long-term outcomes of artificial nutrition in older people with dysphagia remain uncertain. Enteral nutrition via percutaneous endoscopic gastrostomy (PEG) is one of the major methods of artificial nutrition. Enteral feeding is indicated for patients with a functional gastrointestinal tract. However, total parenteral nutrition (TPN) is often inappropriately chosen for artificial nutrition in Japan, even in patients with a functional gastrointestinal tract, as PEG has recently been viewed as an unnecessary life-prolonging treatment in Japan. This study aimed to compare the long-term outcomes between PEG and TPN. Methods This single-center retrospective cohort study investigated long-term outcomes in older patients with dysphagia who received PEG or TPN between January 2014 and January 2017. The primary outcome was survival time. Secondary outcomes were oral intake recovery, discharge to home, and the incidence of severe pneumonia and sepsis. We performed 1-to-1 propensity score matching using a 0.05 caliper. The Kaplan–Meier method, log-rank test, and Cox regression analysis were used to compare the survival time between groups. Results We identified 253 patients who received PEG (n = 180) or TPN (n = 73). Older patients, those with lower nutritional states, and severe dementia were more likely to receive TPN. Propensity score matching created 55 pairs. Survival time was significantly longer in the PEG group (median, 317 vs 195 days; P = 0.017). The hazard ratio for PEG relative to TPN was 0.60 (95% confidence interval: 0.39–0.92; P = 0.019). There were no significant differences between the groups in oral intake recovery and discharge to home. The incidence of severe pneumonia was significantly higher in the PEG group (50.9% vs 25.5%, P = 0.010), whereas sepsis was significantly higher in the TPN group (10.9% vs 30.9%, P = 0.018). Conclusions PEG was associated with a significantly longer survival time, a higher incidence of severe pneumonia, and a lower incidence of sepsis compared with TPN.

Hase T., Miura Y., Nakagami G., Okamoto S., Sanada H., Sugama J.

Food boluses in the pharynx without enough bolus formation sometimes cause aspiration among older adults; however, the relationship between food bolus-forming ability and incidence of aspiration pneumonia is unclear.To investigate the relationship between food bolus-forming ability and incidence of aspiration pneumonia by evaluating the condition of chew-swallow managing food transported into the pharynx.A prospective observational study conducted in a nursing home for the elderly between April 2016 and February 2018. Seventy-three residents who swallowed thickened liquids and consistent boluses without aspiration were included. Food boluses were graded into three categories in the pharynx using videoendoscopic evaluation. Boluses that retained their original shape were defined as Grade 1. A mixture of large and small boluses was defined as Grade 2. Boluses that had completely transformed into a paste were defined as Grade 3. The relationship between the bolus formation grade and incidence of aspiration pneumonia over 6-month follow-up was investigated.Seventeen residents developed aspiration pneumonia. The incidence rate of aspiration pneumonia was highest among residents with Grade 1 boluses, at an incidence rate of .187 cases per person-month (95% confidence interval (CI): 0.097-0.359). Cox regression showed residents with Grade 1 boluses had a hazard ratio of 4.548 (1.393-14.85) for incidence of aspiration pneumonia compared with residents who had Grade 2 or 3 boluses.Insufficient food bolus-forming ability predicted high incidence of aspiration pneumonia. Healthcare professionals should evaluate the food bolus-forming ability, as well as swallowing function, to prevent aspiration pneumonia.

Yasui H., Onozawa Y., Kawabata T., Kawai S., Fukutomi A., Yamazaki K., Hamauchi S., Machida N., Todaka A., Tsushima T., Yokota T., Furuta M.

Abstract Background The nutritional status of patients with esophageal squamous cell carcinoma (ESCC) harboring dysphagia is often poor. The efficacy and safety of enteral nutrition (EN) versus total parenteral nutrition (TPN) have not been addressed in patients with ESCC requiring nutritional support during definitive chemoradiotherapy (dCRT). Methods We performed a retrospective analysis of 51 locally advanced unresectable ESCC patients with dysphagia receiving EN (n = 28) or TPN (n = 23) during dCRT between 2009 and 2016. Results Patient characteristics in EN vs. TPN were as follows: median age (range), 67 (34 to 82) vs. 66 (57 to 83); ECOG performance status 0/1/2, 11/15/2 vs. 7/14/2; dysphagia score 2/3/4, 11/15/2 vs. 14/8/1; and primary tumor location Ce/Ut/Mt/Lt/Ae, 4/6/14/3/1 vs. 2/2/16/1/2. Median changes in serum albumin level one month after dCRT were +8.8% (−36 to 40) in EN and −12% (−64 to 29) in TPN (P = 0.00377). Weight, body mass index, and skeletal muscle area were not significantly different between the groups. Median durations of hospitalization were 50 days (18 to 72) in EN and 63 days (36 to 164) in TPN (P = 0.00302). Adverse events during dCRT in EN vs. TPN were as follows: catheter-related infection, 0 vs. 6 (27%); aspiration pneumonia, 3 (11%) vs. 2 (9%); mediastinitis, 3 (11%) vs. 1 (5%); grade ≥3 neutropenia, 6 (21%) vs. 14 (64%) (P = 0.00287); and febrile neutropenia, 0 vs. 6 (27%) (P = 0.00561). Conclusions EN may be advantageous for improving serum albumin level, and reducing hematological toxicity and duration of hospitalization compared with TPN during dCRT in ESCC patients.

Tilling E.J., El Tawil S., Muir K.W.

Background and Purpose— Intracerebral hemorrhage (ICH) has a poorer prognosis than acute ischemic stroke (AIS). However, clinician perception of prognosis may influence treatment decisions and adversely affect outcome. On acute CT, the conspicuity of ICH compared with AIS may lead clinicians to overestimate severity and influence prognostic evaluation. We investigated whether clinicians’ estimates of volume, severity, and prognosis from acute imaging differed between ICH and AIS. Methods— CT scans from participants with acute ICH or ischemic stroke were reviewed. Volume was calculated using the ABC/2 method and automated volumetric analysis via specialized imaging software. ICH cases were matched with AIS cases for lesion volume, based on acute (<6 hours) CT for ICH, and 24-hour CT for AIS. Blind to clinical information, clinicians estimated lesion volume to the nearest 5 mL, graded lesion severity from 1 (mild) to 5 (very severe), and estimated 30-day prognosis using the modified Rankin Scale. Results— We compared 33 ICH cases with 33 volume-matched AIS cases. Clinicians overestimated ICH volume and underestimated AIS volumes: mean differences (estimated−actual volume) were +8 mL (±30) for ICH and −8 mL (±27) for AIS ( P <0.001). Observers rated ICH to be of greater severity and poorer prognosis compared with AIS cases: 109 of 265 (41%) ICH cases rated severity categories 4 or 5 compared with 36 of 257 (14%) AIS, P <0.001; estimated modified Rankin Scale of 0 to 2 in 125 of 265 (47%) ICH compared with 190 of 257 (74%) AIS, P <0.001. Results were unaffected by presence of intraventricular blood. Estimated severity and prognosis for ICH remained significantly worse compared with AIS after adjustment for estimated volumes. Conclusions— Clinicians overestimated ICH volume and severity compared with AIS of equivalent volume and also assigned significantly worse prognosis independent of volume estimates.

Beck A.M., Kjaersgaard A., Hansen T., Poulsen I.

Jaafar M.H., Mahadeva S., Tan K.M., Chin A., Kamaruzzaman S.B., Khor H.M., Saedon N.I., Tan M.P.

A barrier to gastrostomy feeding exists among Asian clinicians and caregivers due to negative perceptions regarding complications. We compared clinical and nutrition outcomes in older dysphagic Asian patients with nasogastric (NG) or gastrostomy tube feeding using a pragmatic study design.The choice of enteral tube access was determined by managing clinicians and patients/caregivers. Comparisons of tube feeding methods were made during a 4-month period, adjusting statistically for inherent confounders.A total of 102 participants (NG: n = 52, gastrostomy: n = 50) were recruited over 2 years from 2013 to 2015. Subjects on long-term NG tube feeding were older (82.67 ± 7.15 years vs 76.88 ± 7.37 years; P < .001) but both groups had similar clinical indications (stroke: 63.5% NG vs 54% gastrostomy; P = .33). After adjustment for confounders, gastrostomy feeding was associated with fewer tube-related complications (adjusted odds ratio [aOR] = 0.19; 95% confidence interval [CI] = 0.06-0.60) and better complication-free survival rate (aOR = 0.32; 95% CI = 0.12-0.89) at 4-month follow-up. Anthropometric and biochemical nutrition parameters improved significantly in both groups at 4 months, but no significant differences were observed at the end of the study.Gastrostomy feeding is associated with a greater 4-month complication-free survival and lower tube-related complications compared with long-term NG feeding in older Asians with dysphagia. However, no differences in nutrition outcomes were observed between NG and gastrostomy feeding at 4 months.

Xiaorong G., Ning S., Yao Y.

Abstract The aim of this study was to evaluate the clinical efficacy of early enteral nutrition support (EENS) on nitrogen balance and National Institute of Health stroke scale (NIHSS) in elderly patients with acute cerebral stroke and dysphagia. Sixty-eight patients diagnosed with acute brain stroke (ABS) were retrospectively analyzed in our hospital database. Of the included 68 ABS subjects, 37 patients were given early EENS within 72h after ABS diagnosis (experiment group) and the other 31 cases were given a regular liquid diet (control group). The nitrogen balance 1, 2, 3 and 4 weeks after EENS were -4.3 ± 1.3, -3.4 ± 1.1, -2.6 ± 1.2 and -2.0 ± 1.1(g/d) respectively for the experiment group and -8.5 ± 3.1, -7.0 ± 2.4, -6.2 ± 1.5 and -5.7 ± 1.1 (g/d) respectively for the control group. This indicated that the nitrogen balance in the experimental group was significantly higher than that of the control group (p<0.05). After treatment, the NIHSS score were 7.3 ± 2.3 and 7.4 ± 2.4 in the experimental and control groups respectively with statistically significant difference (p<0.05). The risk of developing regurgitation, diarrhea and ventosity in the experimental group were significantly lower than that of the control group (p<0.05). EENS can quickly improve the burden of ABS in elderly patients, elevate the nutritional level and reduce the risk of related complications.