Editorial| Volume 19, ISSUE 9, P736-740, September 2018

Dysphagia in Frail Older Persons: Making the Most of Current Knowledge

  • Nicole Rogus-Pulia
    Address correspondence to Nicole Rogus-Pulia, PhD, CCC-SLP, University of Wisconsin, Madison, WI 53705.
    Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI

    Division of Otolaryngology-Head and Neck, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI

    Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI
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  • Rainer Wirth
    Marien Hospital Herne, Department for Geriatric Medicine, Ruhr-Universität Bochum, Bochum, Germany
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  • Philip D. Sloane
    Department of Family Medicine and Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC

    Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
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      Dysphagia and related problems with oral intake must certainly be numbered among the important geriatric syndromes.
      • Zimmerman S.
      • Sloane P.D.
      JAMDA's new Editors-in-Chief present a vision for the journal of post-acute and long-term care medicine.
      They, like other geriatric syndromes, become increasingly common as people age, are especially prevalent in aging-related conditions such as stroke and Alzheimer's disease, and are usually multifactorial.
      • Inouye S.K.
      • Studenski S.
      • Tinetti M.E.
      • et al.
      Geriatric syndromes: Clinical, research, and policy implications of a core geriatric concept.
      In developing evidence-based approaches to such common aging problems, the scientific community goes through a sequence of investigative steps. We begin by identifying and defining the problem. Next, we use the tools of epidemiology to identify the problem's prevalence, correlates, and prognosis overall and in subpopulations. At the same time, we apply laboratory investigative tools to gain a better understanding of the physiological and pathological processes involved, and we use this information to develop and evaluate clinical tools to assess the risk factors and facilitate accurate diagnosis across care settings. Finally, we develop and field test interventions to ameliorate and/or accommodate the deficits associated with the syndrome.
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        • Zimmerman S.
        • Sloane P.D.
        JAMDA's new Editors-in-Chief present a vision for the journal of post-acute and long-term care medicine.
        J Am Med Dir Assoc. 2018; 19: 1-3
        • Inouye S.K.
        • Studenski S.
        • Tinetti M.E.
        • et al.
        Geriatric syndromes: Clinical, research, and policy implications of a core geriatric concept.
        J Am Geriatr Soc. 2007; 55: 780-791
        • Newman R.
        • Vilardell N.
        • Clave P.
        • et al.
        Effect of bolus viscosity on the safety and efficacy of swallowing and the kinematics of the swallow response in patients with oropharyngeal dysphagia: White paper by the European Society for Swallowing Disorders (ESSD).
        Dysphagia. 2016; 31: 232-249
        • Langmore S.E.
        • Pisegna J.M.
        Efficacy of exercises to rehabilitate dysphagia: A critique of the literature.
        Int J Speech Lang Pathol. 2015; 17: 222-229
        • Logemann J.A.
        • Gensler G.
        • Robbins J.
        • et al.
        A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson's disease.
        J Speech Lang Hear Res. 2008; 51: 173-183
        • Laciuga H.
        • Rosenbek J.C.
        • Davenport P.W.
        • et al.
        Functional outcomes associated with expiratory muscle strength training: Narrative review.
        J Rehabil Res Dev. 2014; 51: 535-546
        • Martin-Harris B.
        • Garand K.L.F.
        • McFarland D.
        Optimizing respiratory-swallowing coordination in patients with oropharyngeal head and neck cancer.
        Perspect ASHA Spec Interest Groups. 2017; 2: 103-110
        • McKenna V.S.
        • Zhang B.
        • Haines M.B.
        • et al.
        A systematic review of isometric lingual strength-training programs in adults with and without dysphagia.
        Am J Speech Lang Pathol. 2017; 26: 524-539
        • American Speech-Language-Hearing Association (ASHA)
        National Outcomes Measurement System: Adults in Healthcare–Skilled Nursing Facility National Data Report 2017.
        ASHA, Rockville, MD2017
        • Thomas D.R.
        Hard to swallow: Management of dysphagia in nursing home residents.
        J Am Med Dir Assoc. 2008; 9: 455-458
        • Nichols J.
        Aspiration risks can make meals hard to swallow.
        Caring Ages. 2015; 16: 5
        • Dziewas R.
        • Beck A.M.
        • Clave P.
        • et al.
        Recognizing the importance of dysphagia: Stumbling blocks and stepping stones in the twenty-first century.
        Dysphagia. 2017; 32: 78-82
        • Morley J.E.
        Dysphagia and aspiration.
        J Am Med Dir Assoc. 2015; 16: 631-634
        • Michel A.
        • Verin E.
        • Gbaguidi X.
        • et al.
        Oropharyngeal dysphagia in community-dwelling older patients with dementia: Prevalence and relationship with geriatric parameters.
        J Am Med Dir Assoc. 2018 May 31; ([Epub ahead of print])
        • Miarons M.
        • Clave P.
        • Wijngaard R.
        • et al.
        Pathophysiology of oropharyngeal dysphagia assessed by videofluoroscopy in patients with dementia taking antipsychotics.
        J Am Med Dir Assoc. 2018; 19: 812
      1. Wirth R, Pourhassan M, Streicher M, et al. The impact of dysphagia on mortality of nursing home residents: Results from the nutritionDay Project [published online ahead of print May 16, 2018]. J Am Med Dir Assoc.

        • Almirall J.
        • Rofes L.
        • Serra-Prat M.
        • et al.
        Oropharyngeal dysphagia is a risk factor for community-acquired pneumonia in the elderly.
        Eur Respir J. 2013; 41: 923-928
        • Payne M.
        • Morley J.E.
        Editorial: Dysphagia, dementia and frailty.
        J Nutr Health Aging. 2018; 22: 562-565
        • Cabre M.
        • Serra-Prat M.
        • Palomera E.
        • et al.
        Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia.
        Age Ageing. 2010; 39: 39-45
        • Clave P.
        • Arreola V.
        • Romea M.
        • et al.
        Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration.
        Clin Nutr. 2008; 27: 806-815
        • O'Horo J.C.
        • Rogus-Pulia N.
        • Garcia-Arguello L.
        • et al.
        Bedside diagnosis of dysphagia: A systematic review.
        J Hosp Med. 2015; 10: 256-265
        • Martino R.
        • Silver F.
        • Teasell R.
        • et al.
        The Toronto Bedside Swallowing Screening Test (TOR-BSST): Development and validation of a dysphagia screening tool for patients with stroke.
        Stroke. 2009; 40: 555-561
        • Wirth R.
        • Dziewas R.
        • Beck A.M.
        • et al.
        Oropharyngeal dysphagia in older persons—From pathophysiology to adequate intervention: A review and summary of an international expert meeting.
        Clin Interv Aging. 2016; 11: 189-208
        • Maeda K.
        • Akagi J.
        Sarcopenia is an independent risk factor of dysphagia in hospitalized older people.
        Geriatr Gerontol Int. 2016; 16: 515-521
        • Sporns P.B.
        • Muhle P.
        • Hanning U.
        • et al.
        Atrophy of swallowing muscles is associated with severity of dysphagia and age in patients with acute stroke.
        J Am Med Dir Assoc. 2017; 18: 635.e631-635.e637
        • Lin L.C.
        • Wu S.C.
        • Chen H.S.
        • et al.
        Prevalence of impaired swallowing in institutionalized older people in Taiwan.
        J Am Geriatr Soc. 2002; 50: 1118-1123
        • Park Y.H.
        • Han H.R.
        • Oh B.M.
        • et al.
        Prevalence and associated factors of dysphagia in nursing home residents.
        Geriatr Nurs. 2013; 34: 212-217
        • Sarabia-Cobo C.M.
        • Perez V.
        • de Lorena P.
        • et al.
        The incidence and prognostic implications of dysphagia in elderly patients institutionalized: A multicenter study in Spain.
        Appl Nurs Res. 2016; 30: e6-e9
        • Riquelme L.
        Managing dysphagia in long-term care settings: Clinical considerations.
        Perspect Swallow Swallow Disord (Dysphagia). 2013; 22: 107-117
        • Matthews F.E.
        • Arthur A.
        • Barnes L.E.
        • et al.
        A two-decade comparison of prevalence of dementia in individuals aged 65 years and older from three geographical areas of England: Results of the Cognitive Function and Ageing Study I and II.
        Lancet. 2013; 382: 1405-1412
        • Volicer L.
        • Seltzer B.
        • Rheaume Y.
        • et al.
        Eating difficulties in patients with probable dementia of the Alzheimer type.
        J Geriatr Psychiatry Neurol. 1989; 2: 188-195
        • Rogus-Pulia N.
        • Malandraki G.A.
        • Johnson S.
        • et al.
        Understanding dysphagia in dementia: The present and the future.
        Curr Phys Med Rehabil Rep. 2015; 3: 86-97
        • Hathaway B.
        • Vaezi A.
        • Egloff A.M.
        • et al.
        Frailty measurements and dysphagia in the outpatient setting.
        Ann Otol Rhinol Laryngol. 2014; 123: 629-635
        • Kojima G.
        Prevalence of frailty in nursing homes: A systematic review and meta-analysis.
        J Am Med Dir Assoc. 2015; 16: 940-945
        • Sakoda Y.
        • Ikegame S.
        • Ikeda-Harada C.
        • et al.
        Retrospective analysis of nursing and healthcare-associated pneumonia: Analysis of adverse prognostic factors and validity of the selection criteria.
        Respir Investig. 2014; 52: 114-120
        • Ugajin M.
        • Yamaki K.
        • Hirasawa N.
        • et al.
        Prognostic value of severity indicators of nursing-home-acquired pneumonia versus community-acquired pneumonia in elderly patients.
        Clin Interv Aging. 2018; 9: 267-274
        • Hollaar V.R.
        • van der Putten G.J.
        • van der Maarel-Wierink C.D.
        • et al.
        Nursing home-acquired pneumonia, dysphagia and associated diseases in nursing home residents: A retrospective, cross-sectional study.
        Geriatr Nurs. 2017; 38: 437-441
        • Nakagawa N.
        • Saito Y.
        • Sasaki M.
        • et al.
        Comparison of clinical profile in elderly patients with nursing and healthcare-associated pneumonia, and those with community-acquired pneumonia.
        Geriatr Gerontol Int. 2014; 14: 362-371
        • Nogueira D.
        • Reis E.
        Swallowing disorders in nursing home residents: How can the problem be explained?.
        Clin Interv Aging. 2013; 8: 221-227
        • Tamura B.K.
        • Bell C.L.
        • Masaki K.H.
        • et al.
        Factors associated with weight loss, low BMI, and malnutrition among nursing home patients: A systematic review of the literature.
        J Am Med Dir Assoc. 2013; 14: 649-655
        • Kayser-Jones J.
        • Pengilly K.
        Dysphagia among nursing home residents.
        Geriatr Nurs. 1999; 20 (quiz 84): 77-82
        • Milte R.
        • Shulver W.
        • Killington M.
        • et al.
        Struggling to maintain individuality—Describing the experience of food in nursing homes for people with dementia.
        Arch Gerontol Geriatr. 2017; 72: 52-58
        • Park Y.H.
        • Bang H.L.
        • Han H.R.
        • et al.
        Dysphagia screening measures for use in nursing homes: A systematic review.
        J Korean Acad Nurs. 2015; 45: 1-13
        • Steele C.M.
        • Greenwood C.
        • Ens I.
        • et al.
        Mealtime difficulties in a home for the aged: Not just dysphagia.
        Dysphagia. 1997; 12 (discussion: 51): 43-50
        • Gilmore-Bykovskyi A.L.
        • Rogus-Pulia N.
        Temporal associations between caregiving approach, behavioral symptoms and observable indicators of aspiration in nursing home residents with dementia.
        J Nutr Health Aging. 2018; 22: 400-460
        • Kjelle E.
        • Lysdahl K.B.
        Mobile radiography services in nursing homes: A systematic review of residents' and societal outcomes.
        BMC Health Serv Res. 2017; 17: 231
        • Kind A.
        • Anderson P.
        • Hind J.
        • et al.
        Omission of dysphagia therapies in hospital discharge communications.
        Dysphagia. 2011; 26: 49-61
        • Harel Z.
        • Silver S.A.
        • McQuillan R.F.
        • et al.
        How to diagnose solutions to a quality of care problem.
        Clin J Am Soc Nephrol. 2016; 11: 901-907
        • Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH)
        Dysphagia Management Policy.
        NHS Clinical Quality Group, Doncaster, UK2016
        • Tanner D.C.
        Lessons from nursing home dysphagia malpractice litigation.
        J Gerontol Nurs. 2010; 36: 41-46
        • Suh M.K.
        • Kim H.
        • Na D.L.
        Dysphagia in patients with dementia: Alzheimer versus vascular.
        Alzheimer Dis Assoc Disord. 2009; 23: 178-184
        • Clayton N.A.
        • Carnaby G.D.
        • Peters M.J.
        • et al.
        Impaired laryngopharyngeal sensitivity in patients with COPD: The association with swallow function.
        Int J Speech Lang Pathol. 2014; 16: 615-623
        • Daniels S.K.
        Swallowing apraxia: A disorder of the Praxis system?.
        Dysphagia. 2000; 15: 159-166
        • Pearson W.G.
        • Langmore S.E.
        • Yu L.B.
        • et al.
        Structural analysis of muscles elevating the hyolaryngeal complex.
        Dysphagia. 2012; 27: 445-451
        • Pearson W.G.
        • Hindson D.F.
        • Langmore S.E.
        • et al.
        Evaluating swallowing muscles essential for hyolaryngeal elevation by using muscle functional magnetic resonance imaging.
        Int J Radiat Oncol Biol Phys. 2013; 85: 735-740
        • Pearson Jr., W.G.
        • Molfenter S.M.
        • Smith Z.M.
        • et al.
        Image-based measurement of post-swallow residue: The normalized residue ratio scale.
        Dysphagia. 2013; 28: 167-177
        • Martin-Harris B.
        • Brodsky M.B.
        • Michel Y.
        • et al.
        MBS measurement tool for swallow impairment—MBSImp: Establishing a standard.
        Dysphagia. 2008; 23: 392-405
        • Hutcheson K.A.
        • Barrow M.P.
        • Barringer D.A.
        • et al.
        Dynamic Imaging Grade of Swallowing Toxicity (DIGEST): Scale development and validation.
        Cancer. 2017; 123: 62-70
        • Pisegna J.M.
        • Borders J.C.
        • Kaneoka A.
        • et al.
        Reliability of untrained and experienced raters on FEES: Rating overall residue is a simple task.
        Dysphagia. 2018 Mar 7; ([Epub ahead of print])
        • Martin R.E.
        • Goodyear B.G.
        • Gati J.S.
        • et al.
        Cerebral cortical representation of automatic and volitional swallowing in humans.
        J Neurophysiol. 2001; 85: 938-950
        • Mihai P.G.
        • von Bohlen Und Halbach O.
        • Lotze M.
        Differentiation of cerebral representation of occlusion and swallowing with fMRI.
        Am J Physiol Gastrointest Liver Physiol. 2013; 304: G847-G854
        • Mihai P.G.
        • Otto M.
        • Platz T.
        • et al.
        Sequential evolution of cortical activity and effective connectivity of swallowing using fMRI.
        Hum Brain Mapp. 2014; 35: 5962-5973
        • Connor N.P.
        • Russell J.A.
        • Jackson M.A.
        • et al.
        Tongue muscle plasticity following hypoglossal nerve stimulation in aged rats.
        Muscle Nerve. 2013; 47: 230-240
        • Kletzien H.
        • Russell J.A.
        • Leverson G.E.
        • et al.
        Differential effects of targeted tongue exercise and treadmill running on aging tongue muscle structure and contractile properties.
        J Appl Physiol (1985). 2013; 114: 472-481
        • Ciucci M.R.
        • Russell J.A.
        • Schaser A.J.
        • et al.
        Tongue force and timing deficits in a rat model of Parkinson disease.
        Behav Brain Res. 2011; 222: 315-320
        • Schaser A.J.
        • Wang H.
        • Volz L.M.
        • et al.
        Biochemistry of the anterior, medial, and posterior genioglossus in the aged rat.
        Dysphagia. 2011; 26: 256-263
        • Pitts T.
        • Morris K.
        • Lindsey B.
        • et al.
        Co-ordination of cough and swallow in vivo and in silico.
        Exp Physiol. 2012; 97: 469-473
        • Gross A.
        • Ohlemacher J.
        • German R.
        • et al.
        LVC timing in infant pig swallowing and the effect of safe swallowing.
        Dysphagia. 2018; 33: 51-62
        • Hinchey J.A.
        • Shephard T.
        • Furie K.
        • et al.
        Formal dysphagia screening protocols prevent pneumonia.
        Stroke. 2005; 36: 1972-1976
        • Bray B.D.
        • Smith C.J.
        • Cloud G.C.
        • et al.
        The association between delays in screening for and assessing dysphagia after acute stroke, and the risk of stroke-associated pneumonia.
        J Neurol Neurosurg Psychiatry. 2017; 88: 25-30
        • Burgos R.
        • Breton I.
        • Cereda E.
        • et al.
        ESPEN guideline clinical nutrition in neurology.
        Clin Nutr. 2018; 37: 354-396
        • Carnaby G.
        • Hankey G.J.
        • Pizzi J.
        Behavioural intervention for dysphagia in acute stroke: A randomised controlled trial.
        Lancet Neurol. 2006; 5: 31-37

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