Association between oral dryness and dysphagia in community-dwelling older population

Li M., Li M., Mao E., Li M., Cui Y., Chen S.

AbstractAimsDehydration is one of the common complications of dysphagia and poses significant risks including hospitalization and mortality, but the relationship between dysphagia and dehydration has received little attention. This study aims to determine the prevalence and risk factors for dehydration of patients with dysphagia in eastern China, and to provide reference for early identification and prevention of dehydration.MethodsA descriptive, cross‐sectional design was conducted. Three hundred and thirty‐seven (n = 337) patients with dysphagia participated in the study between August and December 2022.Information relating to participants' demographic variables, nutrition, cognition, functional, hydration status and fluid intake was collected. Univariate analysis was used to examine related impact factors, and then binary logistic regression analysis was conducted to determine reliable impact factors.ResultsAmong 337 patients with dysphagia, the average age was 63.47 ± 16.96, most participants were male (72.1%) and married (91.7%). The prevalence of dehydration was calculated to be 43.9%, the mean plasma osmolality score was 293.53 mmol/L. Diseases with the highest prevalence were stroke (78.3%), followed by hypertension (63.5%). The risk for dehydration increased with older age, usage of more medicines such as diuretics and beta‐blockers, worse functional status and lower fluid intake.ConclusionThis study found a high percentage of dehydration in patients with dysphagia. Findings can provide a basis for targeted nursing interventions for clinical prevention and treatment of dehydration.

Giudici K.V.

Zhang H., Ye C., Zhang S., Yang D., Gong X., Li S., Xue W., Su J., Zhao L., Qiu Y., He X., Zhang Y., Tang M.

Abstract Background Dysphagia, or swallowing disorders, has become a growing concern due to the aging population, and health literacy plays a crucial role in active aging. However, the relationship between them remains unclear. Aims To investigate the association between health literacy and dysphagia among community-dwelling older adults in China. Methods A survey was conducted on 4462 older adults aged 65 and above in a community in Yiwu City, China, from May 2021 to January 2022. Swallowing problems were assessed using a 30 ml water swallowing test (WST) and the Eating Assessment Tool-10 questionnaire (EAT-10). The participants' health literacy was evaluated using the Chinese Health Literacy Scale (CHLS). Logistic regression and t tests were employed to measure the association between them. Results The prevalence of dysphagia was 5.70% and 7.85% as determined by EAT-10 and 30 ml-WST, respectively. The health literacy level of community-dwelling older adults was 24.4 ± 4.93 (9–45). Participants with dysphagia exhibited lower levels of health literacy (p < 0.05). The logistic regression model demonstrated an inverse association between health literacy and dysphagia (OR = 0.94, 95%CI = 0.91–0.96 for EAT-10, and OR = 0.93, 95%CI = 0.92–0.95 for WST). Moreover, this association remained significant even after adjusting for covariates. Discussion Older adults with dysphagia have lower levels of health literacy, particularly in terms of their ability to seek medical advice, acquire and evaluate medical information, and access social support resources. Conclusions Health literacy is associated with dysphagia among community-dwelling older adults. Effective interventions should be implemented to provide support in terms of both medical services and social support for this population.

Umay E., Akaltun M.S., Uz C.

Morita I., Morioka H., Abe Y., Nomura T., Nakashima S., Sugiura I., Inagawa Y., Kondo Y., Kameyama C., Kondo K., Kobayashi N.

Individuals with an objective decrease in salivary flow (objective dry mouth) may not be aware of subjective dry mouth (xerostomia). However, no clear evidence exists to explain the discordance between subjective and objective dry mouth. Therefore, this cross-sectional study aimed to assess the prevalence of xerostomia and decreased salivary flow among community-dwelling elderly adults. In addition, this study assessed several potential demographic and health status determinants of the discrepancy between xerostomia and reduced salivary flow. The 215 participants in this study were community-dwelling older people aged 70 years and above who underwent dental health examinations between January-February 2019. Symptoms of xerostomia were collected in the form of a questionnaire. The unstimulated salivary flow rate (USFR) was measured by a dentist using visual inspection. The stimulated salivary flow rate (SSFR) was measured using the Saxon test. We identified 19.1% of participants as having mild-severe USFR decline with xerostomia and 19.1% as having mild-severe USFR decline without xerostomia. Additionally, 26.0% of participants had low SSFR and xerostomia, and 40.0% had low SSFR without xerostomia. Except for the age trend, no factors could be associated with the discordance between USFR measurement and xerostomia. Furthermore, no significant factors were associated with the discordance between the SSFR and xerostomia. However, females were significantly associated (OR = 2.608, 95% CI = 1.174–5.791) with low SSFR and xerostomia, as compared to males. Age was a factor that was also significantly associated (OR = 1.105, 95% CI = 1.010–1.209) with low SSFR and xerostomia. Our findings indicate that approximately 20% of the participants had low USFR without xerostomia, and 40% had low SSFR without xerostomia. This study showed that age, sex, and the number of medications may not be factors in the discrepancy between the subjective feeling of dry mouth and reduced salivary flow.

Pérez-Jardón A., Pérez-Sayáns M., Peñamaría-Mallón M., Otero-Rey E., Velasco-Ortega E., López-López J., Martínez-González J.M., Blanco-Carrión A.

Abstract Background This study investigated the association between xerostomia and health risk behaviours, general and oral health and quality of life. Methods A cross-sectional study involving 800 adults over 65 years of age residing in Spain using a computer-assisted telephone questionnaire. The severity of xerostomia was assessed through the Xerostomia Inventory (XI). Both univariate and adjusted multinomial logistic regression were used to determine the risk (OR) of xerostomia. Results The sample comprised of 492 females (61.5%) and 308 males, with a mean age of 73.7 ± 5.8 years. Some, 30.7% had xerostomia: 25.6% mild, 4.8% moderate and 0.3% severe, the majority being female (34.8% vs 24%; p = 0.003). The mean XI was 24.6 ± 6.3 (95% CI 19.2–24.8) for those with poor health, whereas it was 17.4 ± 6.3 (95%CI 16.1–18.6) in those reporting very good health (p < 0.001). This difference was also observed in terms of oral health, with the XI mean recorded as 14.7 ± 10.7 for very poor oral health and 6.4 ± 5.4 for those with very good health (p = 0.002). Logistic regression showed that the highest OR for xerostomia was observed among adults with poor general health (2.81; 95%CI 1.8–4.3; p < 0.001) and for adjusted model the OR was still significant (2.18; 95%CI 1.4–3.4; p = 0.001). Those who needed help with household chores had 2.16 higher OR (95%CI 1.4–3.4; p = 0.001) and 1.69 (95%CI 1.1–2.7; p = 0.03) in the adjusted model. Females had a higher risk of suffering from xerostomia than males. Conclusion The strong association between xerostomia and the general and oral health status of older adults justifies the need for early assessment and regular follow-up.

Drancourt N., El Osta N., Decerle N., Hennequin M.

The purpose of this review is to investigate the relationship between oral health status and oropharyngeal dysphagia (OD) in older people and to collect a list of oral health indicators that can enable carers and health professionals to screen for risk of dysphagia in older people during oral examinations. A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol (PRISMA-P 2015) guidelines. The analysis methods and inclusion criteria were documented in a protocol published in the Prospective International Register of Systematic Reviews (PROSPERO) under the registration number CRD42020140458. A total of 19 articles published between 2002 and 2020 were retained by the search criteria for the qualitative synthesis. Eighteen studies demonstrated at least one positive association between an oral health component (dental, salivary and/or muscular) and dysphagia. This review highlights that oral health and OD are associated but was not able to determine causality. The lack of scientific evidence could be explained by the observational approach of the majority of the studies and the irrelevant choice of oral health indicators. A relationship may exist between oral health and dysphagia, but this review highlights the lack of valid and standardized oral health indicators that would be needed to assess the impact of oral health on the overall health status of individuals.

Suzuki M., Kimura Y., Otobe Y., Koyama S., Terao Y., Kojima I., Masuda H., Tanaka S., Yamada M.

Dysphagia has received much attention as a factor that affects caregiver burden. However, few studies have examined how its severity can affect caregiver burden. This study aimed to examine the effect of dysphagia severity on caregiver burden.A cross-sectional online survey was carried out among family caregivers. We assessed caregiver burden using the Zarit Burden Interview. The dysphagia severity was assessed using the Functional Oral Intake Scale, and the caregivers were divided into three groups based on care receivers' oral intake status (levels 1-3: tube-feeding group; levels 4-6: texture-modified food group; level 7: normal group). To investigate the relationship between caregiver burden and dysphagia severity, univariable and multivariable logistic regression analyses were applied to caregiver burden.The Zarit Burden Interview was significantly higher in the texture-modified food group, and the proportions of high caregiver burden reached 25.2%, 39.5% and 23.4% in the normal group, texture-modified food group and tube-feeding group, respectively. The multivariable analyses applied to caregiver burden (reference, normal group) showed that the texture-modified food group was significantly associated with caregiver burden (OR 1.55, 95% CI 1.04-2.32), whereas the tube-feeding group had no relationship with caregiver burden (OR 0.68, 95% CI 0.31-1.49).Our study showed that the intake of texture-modified food significantly affected caregiver burden even after adjusting for confounding factors, whereas the use of tube feeding did not increase caregiver burden. These results suggest that it is necessary to consider dysphagia severity to reduce dysphagia-related caregiver burden. Geriatr Gerontol Int 2022; 22: 870-875.

Khoury C., Samot J., Helmer C., Rosa R.W., Georget A., Dartigues J., Arrivé E.

This work aimed to describe the nutritional status of French older adults (age ≥ 90 years) and studied the association between oral health and nutritional status. A cross-sectional study was carried out in 2014 among the participants of a cohort on cerebral and functional aging in France at their 25-year follow up (the PAQUID cohort). Nutritional status (Mini Nutritional Assessment [MNA]) and oral health status (number of decayed, missing, and filled teeth [DMFT], number of posterior occluding pairs, xerostomia [Xerostomia Inventory], and prosthetic rehabilitation) were recorded at the participants’ living places by two dentists. Univariate and multivariate logistic regressions were used to explore the association between oral health and nutritional status, with adjustments for potential confounders. Odds ratios (OR) were estimated with their 95% confidence interval (CI). 87 participants were included in the analyses: 74.7% were females and the mean age was 94.1 years (± 3.0). Malnutrition or risk of malnutrition (MNA < 24) was present in 23 participants (26.4%), with only one having malnutrition. The mean DMFT score was 26.5 (± 5.3). The mean number of posterior occluding pairs was 1.5 (± 2.3). Twenty-one participants had xerostomia (24.1%). Only 8.1% of the participants had all their teeth or adequate dentures; 47.1% had inadequate dentures, while 44.8% had no dentures despite tooth loss. After adjustment, xerostomia (OR = 8.79; 95% CI = 2.38–39.10; p = 0.002) was found to be associated with malnutrition or risk of malnutrition. Being at risk of malnutrition was common among people ≥ 90 years old and was associated with xerostomia. NCT04065828.

Ohara Y., Iwasaki M., Shirobe M., Kawai H., Edahiro A., Motokawa K., Fujiwara Y., Kim H., Ihara K., Obuchi S., Watanabe Y., Hirano H.

To the best of our knowledge, the association between xerostomia and physical frailty has not been studied in Asian countries. This prospective cohort study aimed to investigate the longitudinal association between xerostomia and the incidence of physical frailty in Japan.

Wolf U., Eckert S., Walter G., Wienke A., Bartel S., Plontke S.K., Naumann C.

Risk factors for oropharyngeal dysphagia (OD) in elderly patients are mainly central nervous system (CNS) and structural organic diseases or presbyphagia. We analysed the OD prevalence and association of OD with multimorbidity and polypharmacy using real-life data to complete this spectrum, with a focus on further and iatrogenic risk. This was a cross-sectional retrospective study based on a random sample of 200 patients admitted to a geriatric hospital. Data analysis included diagnoses, the detailed list of drugs, and an intense clinical investigation of swallowing according to Stanschus to screen for OD in each patient. The mean patient age was 84 ± 6.5 years. The prevalence of OD was 29.0%, without an effect of age, but a higher rate was found in men and in nursing home residents and an elevated risk of pneumonia. OD risk was slight in diabetes mellitus and COPD, and pronounced in CNS diseases. A relevant OD association was found, even after adjusting for CNS diseases, with antipsychotics, benzodiazepines, anti-Parkinson drugs, antidepressants, and antiepileptics. Further risk of OD was found with beta-blockers, alpha-blockers, opioids, antiemetics, antivertiginosa or antihistamines, metoclopramide, domperidone, anticholinergics, loop diuretics, urologics, and ophthalmics. From real-life data in patients with and without CNS diseases, we identified drug groups associated with a risk of aggravating/inducing OD. Restrictive indications for these drugs may be a preventative contribution, requiring implementation in dysphagia guidelines and an integrative dysphagia risk scale that considers all associated and cumulative medication risks in addition to diseases.

Madhavan A.

Purpose Traditionally, etiology of dysphagia is thought to be related to multiple medical diagnoses including stroke, head and neck cancer, degenerative neurological conditions, and so forth. However, community dwelling older adults (CDOA) can present with dysphagia in the absence of any specific etiology. The purpose of this research was to develop a multidimensional framework to help identify those CDOA at risk for dysphagia of nonspecific etiology. Method Pertinent literature was examined to identify support for the proposed framework and to explain how the various elements support the model. Results Several factors that are not traditionally thought to be associated with dysphagia can both initiate and exacerbate symptoms of swallowing difficulties. Swallowing difficulties may be subtle and underreported. Monitoring for symptoms related to preclinical dysphagia may be helpful for early identification. Conclusions Dysphagia in CDOA is complex and multidimensional. Clinicians working with older adults will benefit from considering elements described in this multidimensional framework to better understand the etiology of swallowing deficits and improve management. Supplemental Material https://doi.org/10.23641/asha.14150078

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.

Nishida T., Yamabe K., Honda S.

Malnutrition is a core symptom of the frailty cycle in older adults. The purpose of this study was to investigate whether dysphagia influences nutrition or frailty status in community-dwelling older adults. The study participants were 320 Japanese community-dwelling older adults aged ≥65 years. All participants completed a questionnaire survey that included items on age, sex, family structure, self-rated health, nutritional and frailty status, and swallowing function. Nutritional status was categorized as malnourished, at risk of malnutrition, and well-nourished based on the Mini Nutrition Assessment-Short Form. The participants were then classified into a malnutrition (malnourished/at risk) or a well-nourished group (well-nourished). Frailty was assessed using the Cardiovascular Health Study criteria. The participants were then divided into a frailty (frail/pre-frail) or a non-frailty group (robust). Dysphagia was screened using the 10-item Eating Assessment Tool. Multiple logistic regression analysis was conducted to determine whether dysphagia was associated with nutritional or frailty status. The results revealed that dysphagia influenced both nutrition (odds ratio [OR]: 4.0; 95% confidence interval [CI]: 1.9–8.2) and frailty status (OR: 2.3; 95% CI: 1.0–5.2); therefore, the swallowing function would be an important factor for community-dwelling older adults on frailty prevention programs.

Estupiñán Artiles C., Regan J., Donnellan C.

Older adults with dysphagia are at a higher risk of experiencing serious complications where dysphagia is not identified and adequately managed. Nursing personnel are critical for timely identification and management of dysphagia and prevention of these subsequent serious complications in residential care settings. To identify dysphagia screening tools used in residential care and to establish whether validated and used as per guidelines, their diagnostic accuracy and reliability and to identify the prevalence rate of dysphagia in this setting. A scoping review based on Arksey & O'Malley (2005) methodological framework. An electronic search of databases CINAHL, Pubmed and Scopus was conducted. Reference lists were checked in all identified articles for additional studies. Peer-reviewed publications describing the process of identifying dysphagia and using a screening protocol in residential care settings were considered for inclusion. All identified studies were screened by reading of titles, keywords and abstracts. Those articles that were deemed eligible for inclusion were read in full. Nineteen quantitative studies and one mixed-methods study out of 1,674 articles were included in the review. Thirteen different instruments for dysphagia screening were identified, with the Modified Water Swallow Test being the most commonly used. Other diagnostic procedures, such as fiberoptic endoscopic evaluation of swallowing, pulse oximetry or cervical auscultation, were implemented along with the administration of a dysphagia screening tool in six studies. The 3-Ounce Water Swallow Test, the Yale Swallow Protocol and the Gugging Swallowing Screen were identified as the instruments with the best clinical accuracy values. The reported prevalence of dysphagia in this setting ranged from 15% to 70%. Formal dysphagia screening in residential care settings is not common practice. The dysphagia screening tools identified in this review are not validated for use in this setting. The implementation of dysphagia screening protocols specific to this population may facilitate identification of dysphagia and avoid complications.