Temporal Analysis of Factors Associated with EAT-10 in Outpatients with Oropharyngeal Dysphagia from a Tertiary Care Clinic

Reliability and Validity of the Chinese Mandarin Version of the 10-Item Eating Assessment Tool in Community-Dwelling Older Adults

OBJECTIVES

This study aimed to culturally adapt and validate the Chinese Mandarin version of the 10-Item Eating Assessment Tool (EAT-10-CM) for Chinese community-dwelling older adults.

METHOD

A total of 346 Chinese community-dwelling older adults participated in this study, with 47 individuals included in the second testing phase. Reliability was assessed through internal consistency and test-retest reliability. Validity analysis covered several aspects: instrument validity, convergent validity, concurrent validity, content validity, and discriminant validity. Instrument validity was assessed by comparing EAT-10-CM scores between participants with and without oropharyngeal dysphagia (OD). Convergent validity was evaluated by comparing the EAT-10-CM with the Dysphagia Handicap Index (DHI). Concurrent validity was assessed by comparing the EAT-10-CM with the Penetration-Aspiration Scale. Content validity was examined using the content validity index, based on the input of 10 expert reviewers. Discriminant validity was analyzed using receiver operating characteristic (ROC) analysis to determine the optimal cutoff value.

RESULTS

The Cronbach's alpha for the total scale and individual items was > 0.9, indicating excellent internal consistency. Test-retest reliability was assessed using Pearson's correlation analysis, which showed a strong correlation (r > .7), demonstrating good stability over time. Significant differences in EAT-10-CM scores were observed between participants with OD and healthy individuals, supporting the instrument's ability to differentiate between these groups. The EAT-10-CM showed significant correlations with the DHI and the Penetration-Aspiration Scale (p < .001). The content validity index was 0.95 for the scale and ≥ 0.8 for each item. ROC analysis determined an optimal cutoff value of 3.00, with corresponding sensitivity and specificity values of 0.865 and 0.940, respectively.

CONCLUSIONS

The EAT-10-CM is a culturally adapted and validated instrument specifically for Chinese older adults with good reliability and validity. The optimal cutoff value of 3.00 provides a useful threshold for clinical assessment.

The Efficacy of Outpatient Swallowing Therapy: A Retrospective Longitudinal Cohort Study

Oropharyngeal dysphagia is an independent predictor of poor outcomes in many health conditions and can be targeted directly through swallowing therapy. This study aims to explore the outcomes of outpatient swallowing therapy in clinical practice across a diverse cohort of patients. This was a retrospective, single-site longitudinal cohort study. Patients 18 years or older with dysphagia who completed 7-8 weeks of outpatient swallowing therapy with a pre- and post-treatment videofluoroscopy were included. Therapy employed a progressive swallowing exercise regimen based on the Systematic Exercise for Treatment of Swallowing (SETS) protocol. Outcome measures included the pharyngeal components of the Modified Barium Swallow Impairment Profile, penetration-aspiration scale scores, and diet recommendations using the International Dysphagia Diet Standardization Initiative. 152 patients were included. Swallowing therapy improved all MBSImP component scores except 1, 7, and 13. Therapy improved total pharyngeal impairment scores by 2.66 points (p < .001) and total oral impairment score by 1.41 points (p < .001). Odds of elevated aspiration risk were reduced by 49% (p < .001). Patients were more likely to be on an unmodified food consistency after completion of therapy (OR 26, p = .004), but liquid consistency was not altered (OR 2.0, p = .57). Overall, 44% of patients in the cohort with an efficiency issue improved, and 50% of patients at risk for aspiration pre-therapy improved. Completing a 7-8 week course of exercise-based outpatient swallowing therapy is effective at improving multiple measures of swallowing physiology, safety and efficiency. It can also enable relaxation of diet consistency restrictions based on the IDDSI framework.

Can EAT-10 Become EAT-5? Improving Measurement Efficiency of Dysphagia with Item Response Theory

OBJECTIVES

To assess: (1) the Eating Assessment Tool (EAT-10) with item response theory (IRT) to determine which individual items provide the most information, (2) the extent to which dysphagia is measured with subsets of items while maintaining precise score estimates, and (3) if 5-item scales have the differing discriminatory ability, as compared to the parent 10-item instrument.

METHODS

Prospectively collected data from 2,339 patients who completed the EAT-10 questionnaire during evaluation at a tertiary care otolaryngology clinic were utilized. IRT analyses provided discrimination and location parameters associated with individual questions. Residual item correlations were also assessed for redundant information. Based on these results, three 5-item subsets were further evaluated using item information function curves. Areas under receiver-operator characteristic curves (ROC-AUC) were also calculated to evaluate the discriminatory ability for dysphagia-related clinical diagnoses.

RESULTS

Item discrimination parameter estimates ranged from 1.71 to 5.46, with higher values indicating more information. Residual item correlations were determined within item pairs, and location parameters were calculated. Based on these data, in combination with clinical utility, three 5-item subsets were proposed and assessed. ROC-AUC analyses demonstrated no significant difference between the EAT-5-Alpha subset and the original 10-item instrument for discriminating dysphagia as a primary diagnosis (0.88, 0.88). The EAT-5-Clinical subset outperformed the original 10 instruments in ROC-AUC for aspiration. The EAT-5-Range subset was significantly associated with problems with thin liquids.

CONCLUSIONS

IRT analyses distinguished three proposed 5-item subsets of the EAT-10 instrument, supporting shorter survey options, while still reflecting the impact of dysphagia without significant loss of discrimination.

LEVEL OF EVIDENCE

3 (Diagnostic testing with consistently applied reference standards, partial blinding). Laryngoscope, 133:3327-3333, 2023.

Eating Assessment Tool (EAT-10) Scores to Detect Self-Reported Dysphagia in Brazilians

The Eating Assessment Tool (EAT-10) detects swallowing impairments (dysphagia) self-reported by patients according to their perception. This noninvasive, inexpensive, self-administered instrument is quickly and easily filled out. The objective of this investigation was to evaluate the scores, sensitivity, and specificity of the method to define self-reported dysphagia in Brazilians. EAT-10 scores were evaluated in 443 healthy individuals (273 women and 170 men), aged 20 to 84 years, with no swallowing difficulties or diseases, and 72 patients with diseases that cause dysphagia (35 women and 37 men), aged 29 to 88 years. Each of the 10 instrument items has a 0-4 rating scale, in which 0 indicates no problem and 4, a severe problem; total results range from 0 to 40. The median EAT-10 score of healthy subjects was 0 (range: 0-20), and that of patients was 14.5 (range: 1-40). Considering a ≥ 3 cutoff score to define dysphagia risk, it was self-reported by 97.2% of patients with dysphagia and 9.5% of no-disease individuals (97.2% sensitivity and 90.7% specificity). The positive predictive value of the test was 63% and the negative predictive value was 99.5%. Healthy women had higher scores (median 0, range: 0-20) than healthy men (median 0, range: 0-8, p < 0.01) and more results indicative of self-reported dysphagia (11.7%) than healthy men (5.9%). The EAT-10 cutoff score to detect self-reported dysphagia in Brazilians should be 3, as previously considered. Healthy women complain more of self-reported dysphagia than healthy men. The test has high sensitivity and specificity.

Discriminant Ability of the Eating Assessment Tool-10 to Detect Swallowing Safety and Efficiency Impairments

OBJECTIVES/HYPOTHESIS

Quick, sensitive dysphagia screening tools are necessary to identify high-risk patients for further evaluation in busy multidisciplinary amyotrophic lateral sclerosis (ALS) clinics. We examined the relationship between self-perceived dysphagia using the validated Eating Assessment Tool-10 (EAT-10) and videofluoroscopic analysis of swallowing safety and efficiency.

STUDY DESIGN

Prospective, observational, longitudinal study.

METHODS

Individuals with ALS completed the EAT-10 and a videofluoroscopic swallowing study. Duplicate, independent, blinded analyses of the validated Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale were performed to index swallowing safety and efficiency (mild dysphagia: DIGEST ≥ 1, moderate dysphagia: DIGEST ≥ 2). A between-groups analysis of variance with Games-Howell test for post-hoc pairwise comparisons was performed to examine EAT-10 scores across dysphagia severity levels. Receiver operator characteristic curve analysis, area under the curve (AUC), sensitivity, specificity, positive-negative predictive values (PPV, NPV), and odds ratios (OR) were derived.

RESULTS

Four hundred and thirty five paired EAT-10 and DIGEST scores were analyzed. Mean EAT-10 score was 8.48 (95% confidence interval [CI]: 7.63-9.33). Individuals with dysphagia demonstrated higher EAT-10 scores (mild: 4.1 vs. 11.3, moderate: 6.0 vs. 17.5, P < .001). Mean EAT-10 scores increased across DIGEST levels (D0: 4.1, D1: 7.9, D2: 15.1, D3: 20.4, D4: 39.0). For mild dysphagia, an EAT-10 cut score of 3 was optimal: AUC 0.74 (95% CI: 0.69-0.78; sensitivity: 77%; specificity: 53%; PPV: 71%; NPV: 60%; OR: 3.5). An EAT-10 cut score of 7 optimized detection of moderate dysphagia: AUC 0.83 (95% CI: 0.78-0.87; sensitivity: 81%; specificity: 66%; PPV: 39%; NPV: 93%; OR: 8.1).

CONCLUSION

The EAT-10 is an easy-to-administer dysphagia screening tool with good discriminant ability for use in ALS clinics.

LEVEL OF EVIDENCE

2 Laryngoscope, 132:2319-2326, 2022.

Accuracy of an epidemiological oropharyngeal dysphagia screening for older adults

OBJECTIVE

The aim of this study was to determine the accuracy of an epidemiological screening questionnaire for oropharyngeal dysphagia in older people.

BACKGROUND

Determining the cut-off point and the accuracy of the self-reported epidemiological questionnaire for screening oropharyngeal dysphagia in older adults is important for mass screening, which may estimate the prevalence of oropharyngeal dysphagia.

MATERIALS AND METHODS

This was a cross-sectional diagnostic study with a convenience sample of 70 older adults over 60 years of age of both sexes, aged between 60 and 90 years (mean age 69.2; SD, 7.6). It used a screening questionnaire with nine ordered items response options resulted in a score ranging from 0 to 18. The criterion test was the fiberoptic endoscopic evaluation of swallowing, with analysis of the receiver operating characteristic (ROC), with a 5% significance level.

RESULTS

Oropharyngeal dysphagia frequency by the criterion test was 73%, with no significant difference between age and sex. The area under the ROC curve was 0.88 (95% confidence interval: 0.79-0.98) above the cut-off point 3. This screening questionnaire showed good parameters of sensitivity (80%), specificity (89%), positive predictive value (95%), negative predictive value (63%), positive likelihood ratio (7.64), negative likelihood ratio (0.22) and accuracy (83%).

CONCLUSIONS

This questionnaire may be a satisfactory screening tool for estimating the prevalence of oropharyngeal dysphagia in older adults.

Oral diadochokinesis and associated oro-facial function in young and old German mother-tongue speakers: A cross-sectional study

Objectives

The aims of this study were to compare oral diadochokinesis and to test associations with oro‐facial functional parameters in healthy young and old German speakers.

Background

Oral diadochokinesis is a key component in the concept of oro‐facial hypofunction and relates to tongue and lip motor function but may depend on the linguistic background.

Materials and methods

Healthy German speakers with a minimum of 20 teeth were recruited to form a young (<60 years) and an older group (≥60 years). Oral diadochokinesis was assessed as the number of repetitions/s for the monosyllables /pa/, /ta/ and /ka/ to evaluate movement capacity of the lip, the anterior region of the tongue and the posterior region of the tongue, respectively. Maximum voluntary lip force, maximum voluntary bite force, masticatory performance, maximum voluntary tongue pressure, xerostomia and swallowing function were assessed with validated instruments. Results are presented as median (IQR).

Results

Sixty participants formed the younger group (n = 35, 30.0 years [24.0‐49.0]) and the older group (n = 25, 64.0 years [62.0‐72.0]). Counts/s of /ta/ were different between age groups (younger group: 6.0 vs older group: 5.4) but not for syllables /pa/ (younger group: 6.0 vs older group: 5.8) and /ka/ (younger group: 5.6 vs older group: 5.0). The oral diadochokinesis with /pa/ was overall associated with maximum voluntary lip force; oral diadochokinesis performed with /ta/ was associated with tongue pressure, and oral diadochokinesis with /ka/ with swallowing function. Masticatory performance was not associated with oral diadochokinesis but with maximum voluntary bite force, xerostomia and with maximum voluntary tongue pressure.

Conclusions

The published thresholds for oral diadochokinesis should be reconsidered in non‐Japanese mother‐tongue speakers. However, they still play an important role in the overall concept of oro‐facial functional assessment.

Oral function in amyotrophic lateral sclerosis patients: A matched case-control study

BACKGROUND & AIMS

Patients with amyotrophic lateral sclerosis (ALS) develop swallowing difficulties with the progression of the disease. The present study aimed at comparing oral function and body composition between ALS patients and healthy controls, and at evaluating which parameters are the most discriminant between both groups.

METHODS

We included ALS patients at the start of their multidisciplinary follow-up at the Geneva University Hospitals and healthy age-, gender-, and dental status-matched adults. We assessed the severity of the disease through the ALS Functional Rating Scale and the swallowing difficulties through the EAT-10 score. We performed an intraoral examination of the dental status, and measured chewing performance, bite, lip and tongue force, saliva weight, and body composition. Group comparisons were performed with t-tests or Mann-Whitney tests as appropriate. Linear discriminant analysis was used to determine the most discriminant parameters between groups.

RESULTS

Twenty-six ALS patients (bulbar onset: n = 7, median (IQR) ALS Functional Rating Scale: 37 (11)) were included. The ALS patients had a significantly lower chewing performance (p < 0.001), lip force (p < 0.001), tongue force (p = 0.002), saliva weight (p < 0.004) and fat-free mass index (p < 0.001) as compared to the healthy individuals, and a higher EAT-10 score (p < 0.001). In ALS patients, a low chewing performance was correlated with a low bite (r = -0.45, p < 0.05)) and tongue force (r = -0.59, p < 0.05). The most discriminant parameters between both groups, by order of importance, were chewing performance, fat-free mass index and saliva weight and allowed the calculation of a discriminant function.

CONCLUSION

Compared to healthy controls, ALS patients have significant alterations of oral function and body composition. The most discriminant parameters between both groups were chewing performance, fat-free mass index and saliva volume. It remains to be demonstrated whether oral parameters predict outcome. CLINICAL TRIAL REGISTRY: clinicaltrials.gov, identifier: NCT01772888.

Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part I: Management, Diagnosis, and Follow-up

Dysphagia is one of the most common and important complications of stroke. It is an independent marker of poor outcome after acute stroke and may become chronic after the acute period and continues to affect all aspects of the patient's life. Patients with stroke may encounter any of the medical branches in the emergency room or outpatient clinic, and as in our country, there may not be specialists specific for dysphagia, such as speech-language pathologists (SLP), in every hospital. This study aimed to raise awareness and create a common opinion of medical specialists for stroke patients with dysphagia. This recommendation paper has been written by a multidisciplinary team and offers 45 recommendations for stroke patients with dysphagia. It was created using the eight-step Delphi round via e-mail. This study is mostly specific to Turkey. However, since it contains detailed recommendations from the perspective of various disciplines associated with stroke, this consensus-based recommendation paper is not only a useful guide to address clinical questions in practice for the clinical management of dysphagia in terms of management, diagnosis, and follow-up, but also includes detailed comments for these topics.

Dysphagia, voice problems, and pain in head and neck cancer patients

PURPOSE

Head and neck cancer (HNC) and its treatment can leave devastating side effects with a relevant impact on physical and emotional quality of life (QoL) of HNC patients. The objectives were to examine the amount of dysphagia, voice problems, and pain in HNC patients, the impact of sociodemographic, behavioral, and clinical factors on these symptoms, the psychometric properties of the EAT-10, and the relationship between these symptoms and QoL variables.

METHODS

HNC patients attending for regular follow-up from 07/2013 to 09/2019 completed questionnaires (Eating Assessment Tool-10 (EAT-10); questions from the EORTC QLQ-C30 and EORTC H&N35) on dysphagia, voice problems, pain, fatigue, and QoL collected with the software OncoFunction. Associations between prognostic factors and symptoms were tested with analyses of variance (ANOVAs). Associations between the symptom scales and QoL variables were expressed with Pearson correlations.

RESULTS

Of 689 patients, 54.9% suffered from dysphagia, the EAT-10 proved to be a reliable measure. The mean voice score was 37.6 (± 33.9) [range 0-100], the mean pain score 1.98 (± 2.24) [range 0-10]. Trimodality treatment was associated with the highest dysphagia scores. Dysphagia, voice problems, and pain significantly correlated with each other, the highest association was found for dysphagia and pain (r = 0.51). QoL was strongly correlated with dysphagia and pain (r = - 0.39 and r = - 0.40, respectively), while the association with voice problems was weaker (r = - 0.28).

CONCLUSION

Dysphagia is an important symptom in HNC patients greatly affecting patients' QoL and significantly correlating with voice problems and pain.

Is Dysphagia Under Diagnosed or is Normal Swallowing More Variable than We Think? Reported Swallowing Problems in People Aged 18-65 Years

Purpose

Dysphagia prevalence in younger community dwelling adults and across nations is sparse. We investigated the prevalence of swallowing problems in an unselected cohort of people aged 18–65 years.

Methods

The EAT-10 Assessment Tool was converted into an anonymized online survey. Invitations were e-mailed to author contacts and onwards dispersal encouraged. Analysis was performed using non-parametric test for group comparison (Mann–Whitney U) and Spearman’s rho correlation.

Results

From March 2014 to October 2017: 2054 responses (32 reported ages outside of 18–65 or undeclared) from Africa, Asia, Australasia/Oceania, Europe, and North and South America. Responses: 1,648 female, 364 male, (10 reported as both), median age 34, (range 18–65, mean 37.12, SD 12.40) years. Total EAT-10 scores: median 0 (range 0–36, mean 1.57, SD 3.49). EAT-10 score ≥ 3 (337) median 5 (range 3–36, mean 7.02 SD 5.91). Median age 36 (range 19–65, mean 37.81, SD 13.21) years. Declared sex was not statistically significantly associated with non-pathological vs. pathological EAT-10 score (p = 0.665). Female scores (median 0.00, mean 1.56, SD 3.338) were significantly higher than for males (median 0.00, mean 1.62, SD 4.161): U (Nfemale = 1648, Nmale = 364) = 275,420.000, z = − 2.677, p = 0.007. Age and EAT-10 score were not associated: females r_s = − 0.043, p = 0.079, N = 1648, males r_s = − 0.003, p = 0.952, N = 364. Considerable impact on people: “I take ages to eat a main course … This is embarrassing and I often leave food even though I am still hungry.” (no diagnosis, EAT-10 = 17).

Conclusion

Concerns regarding swallowing exist in people undiagnosed with dysphagia, who may feel uncomfortable seeking professional help. Dysphagia may be under reported resulting in a hidden population. Subtle changes are currently seen as subtle markers of COVID-19. Further work is required to ensure that what is an essentially normal swallow does not become medicalized.

Validity and reliability of the French version of Eating Assessment Tool (EAT-10)

OBJECTIVE

To develop a French version of the Eating Assessment Tool (Fr EAT-10) and to assess its internal consistency, reliability and clinical validity.

METHODS

Fifty-six patients referred in the Swallowing Clinics of CHU Saint-Pierre Hospital (Brussels) and EpiCURA hospital (Ath, Belgium) for dysphagia were enrolled and completed fiberoptic endoscopic evaluation of swallowing and videofluoroscopy. Seventy-three asymptomatic subjects were included in the study. To assess reliability, Fr-EAT-10 was completed twice within a 7-day period. Validity was assessed by comparing Fr-EAT-10 scores with the scores of dysphagia handicap index (DHI) in all individuals. Normative value of EAT-10 was calculated and the receiver operating characteristic (ROC) curve was used to determine the best Fr-EAT-10 threshold associated with aspiration.

RESULTS

Fifty-two patients completed the study. Cronbach's alpha was 0.95 indicating a high internal consistency. Test-retest reliability was high in the entire cohort (rs = 0.921). The correlation between Fr-EAT-10 total scores and DHI was high (rs = 0.827) indicating a high external validity. Patients had a significant higher score of Fr-EAT-10 than the controls (p < 0.001) exhibiting a high internal validity. The analysis of normative data reported that a score of Fr-EAT-10 > 3 should be considered as abnormal. The correlation between Fr-EAT-10 and the occurrence of aspiration is significant (rs = 0.327, p < 0.05). According to the ROC curve; aspirations need to be highly suspected for patients with Fr-EAT-10 ≥ 17.

CONCLUSION

The Fr-EAT-10 developed in this study is a reliable and valid self-administered tool in the evaluation of dysphagia in French-speaking patients.