Factors and Outcomes Associated With Dysphagia in Hospitalized Persons With Dementia

ObjectivesDysphagia is prevalent in older adults with dementia, particularly in the acute care setting. The objective of this study was to use an innovative approach to extract a more representative sample of patients with dysphagia from the electronic health record (EHR) to determine patient characteristics, hospital practices, and outcomes associated with dysphagia in hospitalized persons with dementia.DesignA retrospective study of hospitalized adults (aged ≥65 years) with dementia was conducted in 7 hospitals across the greater New York metropolitan area.Setting and ParticipantsData were obtained from the inpatient EHR with the following inclusion criteria: age ≥65 years; admitted to one of 7 health system hospitals between January 1, 2019, and December 31, 2019; and documented past medical diagnosis of dementia (based on International Classification of Diseases, Ninth Revision).MethodsA diagnosis of dysphagia was defined as nurse documentation of a positive bedside swallow screening, nurse documentation of “difficulty swallowing” as reason for not performing bedside swallow screening, and physician documentation of a dysphagia diagnosis.ResultsOf adults with dementia (N = 8637), the average age was 84.5 years, 61.6% were female, and 18.1% were Black and 9.3% Hispanic. Dysphagia was identified in 41.8% (n = 3610). In multivariable models, dysphagia was associated with invasive mechanical ventilation [odds ratio (OR) 4.53, 95% CI 3.55-5.78], delirium (OR 1.53, 95% CI 1.40-1.68), increased length of stay (B = 3.29, 95% CI 2.98-3.60), and mortality (OR 4.44, 95% CI 3.54-5.55).Conclusions and ImplicationsGiven its high prevalence, underrecognition, and associated poor outcomes, improving large-scale dysphagia identification can impact clinical care and advance research in hospitalized persons with dementia.     

Dysphagia in multiple system atrophy consensus statement on diagnosis,prognosis and treatment

Multiple system atrophy (MSA) is a neurodegenerative disorder characterized by a combination of autonomic failure plus cerebellar syndrome and/or parkinsonism. Dysphagia is a frequent and disabling symptom in MSA and its occurrence within 5 years of motor onset is an additional diagnostic feature. Dysphagia can lead to aspiration pneumonia, a recognized cause of death in MSA. Guidelines for diagnosis and management of dysphagia in MSA are lacking. An International Consensus Conference among experts with methodological support was convened in Bologna to reach consensus statements for the diagnosis, prognosis, and treatment of dysphagia in MSA. Abnormalities of the oral and pharyngeal phases of swallowing, esophageal dysfunction and aspiration occur in MSA and worsen as the disease progresses. According to the consensus, dysphagia should be investigated through available screening questionnaires and clinical and instrumental assessment (videofluoroscopic study or fiberoptic endoscopic evaluation of swallowing and manometry) at the time of MSA diagnosis and periodically thereafter. There is evidence that dysphagia is associated with poor survival in MSA, however effective treatments for dysphagia are lacking. Compensatory strategies like diet modification, swallowing maneuvers and head postures should be applied and botulinum toxin injection may be effective in specific conditions. Percutaneous endoscopic gastrostomy may be performed when there is a severe risk of malnutrition and pulmonary complications, but its impact on survival is undetermined. Several research gaps and unmet needs for research involving diagnosis, prognosis, and treatment were identified.     

First Japanese autopsy case showing LRRK2 mutation G2019S and TDP-43 proteinopathy

This is the first Japanese autopsy case of Leucine-rich repeat kinase 2 (LRRK2) G2019S mutation with atypical TDP43 proteinopathy. Our case is important that presented clinically dysphagia and pathologically TDP-43 proteinopathy. TDP43 may play an important role of clinical presentation with LRRK2 G2019S mutation carriers.     

Disorders of swallowing

Disorders of swallowing are very common and, when looked for, occur regularly in most branches of surgery. Dysphagia is often not the patient’s presenting complaint and can be easily missed. The consequences of missed or delayed diagnosis of dysphagia can be insidious but profound and, in some cases, fatal. The investigation and treatment of these patients is normally highly multidisciplinary, potentially involving gastroenterology, general surgery, otolaryngology, acute medicine, stroke medicine, paediatrics, speech and language therapy (SLT) and dietitians. While this article is aimed at surgeons and will thus concentrate mostly on those conditions seen by surgeons, it must be remembered that the most common cause of dysphagia is a neurological disturbance and is managed by physicians and SLT. That said, the incidence of these conditions rises with age, as does the incidence of many surgically treatable conditions. It is therefore common to assess a patient with a known neurological condition for the presence of a second pathology affecting their swallow. A basic knowledge of non-surgical conditions is therefore useful.     

Attentional resource allocation and swallowing safety in Parkinson's disease: A dual task study

BackgroundAspiration pneumonia is a leading cause of death in persons with Parkinson's disease (PD). Despite this, the mechanisms underlying dysphagia in this population are unclear. To date, researchers have not investigated the effects of varying cognitive demand on objective measures of swallowing safety. This study assessed whether swallowing safety could be disrupted by increasing cognitive demands during the task of swallowing.MethodsTwenty participants with moderate PD and dysphagia were tested while completing a novel dual task experimental paradigm under videofluoroscopy. In the dual task condition, participants swallowed 10 cc of thin liquid barium while completing a digits forward task.ResultsFour females and 16 males completed the study. Results revealed differential effects to swallowing safety based on baseline measures of cognitive flexibility and attention. Participants with mild impairment in cognitive flexibility and attention demonstrated cognitive-motor interference with worsening of both swallowing and cognitive performance. In contrast, participants who were most impaired in the domains of cognitive flexibility and attention improved swallowing safety in the dual task condition. Additionally, decreased swallow timing durations existed in the dual task condition compared to the single task condition.ConclusionsThe results of this study support the hypothesis that supramedullary drive can influence the swallowing plan. Additionally, this study highlights the need for cognitive taxing during swallowing evaluations.     

Swallowing disturbances in Parkinson's disease: A multivariate analysis of contributing factors

BackgroundSwallowing disturbances are an important issue in Parkinson's disease (PD) as several studies have shown that they are associated with increased risk of aspiration pneumonia and mortality. Information about factors related to swallowing disturbances, such as disease duration, age at assessment and concomitant dementia, is limited and would be useful for their management.MethodsAll consecutive PD out-patients evaluated at a movement disorders clinic over a 7-year period (2007–2014), were included in the present retrospective study. Presence of symptomatic swallowing disturbances was assessed using the specific item of the Non Motor Symptom Questionnaire.ResultsIn the whole PD population (N = 6462), prevalence of symptomatic swallowing disturbances was 11.7% (95%CI, 10.9–12.5). Multivariable logistic regression analysis (adjusted for education) disclosed a significant interaction between disease duration and gender (P = 0.009). In both gender strata, swallowing disturbances were significantly associated with longer disease duration and dementia (P < 0.001 for all). A significant effect for age at assessment was also found in male patients. In non-demented patients, swallowing disturbances were associated with male gender, age and disease duration (P < 0.02 for all). In demented patients an association was found only with male gender (P = 0.018) and disease duration (P < 0.001).ConclusionsGender, age, disease duration and dementia all seem to contribute to the occurrence of swallowing disturbances independently. However, the role played by these factors in sub-groups of patients stratified by gender and concomitant dementia suggests that swallowing disturbances are likely related to different neuro-degenerative patterns within the brain. The underlying mechanisms deserve further investigation.     

Swallowing assessment in myotonic dystrophy type 1 using fiberoptic endoscopic evaluation of swallowing (FEES)

This study describes the swallowing function of patients with myotonic dystrophy type 1 (DM1) and the effect of bolus consistency on swallowing in this group. The aim of the study is twofold: (a) to identify which (and to what extent) swallowing variables change for DM1 patients relative to healthy control subjects and (b) to examine whether the degree of oropharyngeal dysphagia is associated with disease severity. Forty-five consecutive DM1 patients and ten healthy subjects underwent a swallowing assessment, at Maastricht University medical Center in the Netherlands. The assessment included a standardized fiberoptic endoscopic evaluation of swallowing (FEES) protocol using different bolus consistencies. Clinical severity of the disease was assessed using the muscular impairment rating scale (MIRS). Significant differences were found between patients and controls for all FEES variables. The magnitude of these differences depended on the bolus consistency. The odds of a more pathological swallowing outcome increased significantly with higher MIRS levels. In conclusion, swallowing function is found to be significantly altered in DM1 patients. The results emphasize the importance of conducting a detailed swallowing assessment in all patients, even those with mild muscle weakness.     

Risk and prognostic factors for pneumonia and choking amongst Parkinson’s disease patients with dysphagia

ObjectiveTo evaluate the time to hospitalisation and baseline factors associated with pneumonia/choking in Parkinson’s Disease (PD) patients.BackgroundAlthough dysphagia and pneumonia are common problems in PD, scarce research has been performed.MethodsA total of 194 PD patients who underwent a VFS evaluation were retrospectively selected. The mode of feeding and admissions for pneumonia/choking were analyzed. Baseline clinical and demographic variables were compared between feeding groups. Kaplan-Meier survival analysis was performed to estimate time to pneumonia/choking. Clinical variables significantly associated with pneumonia/choking free survival were identified using Cox regression.ResultsHospitalisation for pneumonia/choking occurred in 89 out of 194 patients, with the highest admission rate in rejected enteral feeding group (66.7%), followed by enteral feeding (61.8%) and oral feeding (38.8%) groups. The estimates of median time to event were 11, 14, and 47 months for rejected enteral feeding, enteral and oral feeding groups respectively (log-rank test p < 0.001). The rejected enteral feeding group had the highest risk of pneumonia/choking (HR 4.61, 95%CI:2.33–9.08, p < 0.001), followed by enteral feeding group (HR 2.29, 95%CI:1.25–4.19, p = 0.007), when compared to oral feeding group after adjusting for possible confounders. A stepwise Cox regression showed that the rejected enteral feeding (HR 4.89, 95%CI:2.19–10.88, p < 0.001), enteral mode of feeding (HR 2.43, 95%CI:1.11–5.32, p = 0.026), and Charlson weighted index of co-morbidity (HR 1.27, 95%CI:1.03–1.58, p = 0.028) were independently associated with higher hazard of pneumonia/choking.ConclusionsCompliance to feeding recommendations is important to reduce the risk of hospitalisation for pneumonia/choking. The recommended mode of feeding and comorbidity index was significantly associated with pneumonia/choking risk.     

整体护理对脑卒中后吞咽障碍康复的价值

脑卒中后吞咽障碍是脑卒中常见的严重症状之一.目前表明,脑卒中后吞咽障碍发病原因主要为皮质下行纤维、吞咽皮质中枢、延髓吞咽中枢及锥体外系损伤.临床常表现为发音困难、饮食后呛咳噎食、构音障碍、营养不良、吸入性肺炎,增加住院时间、加重经济负担,并严重威胁患者生命健康及生活质量.因此对脑卒中后吞咽障碍的康复护理要求需提出更高的...