Effects of Tongue-Strengthening Self-Exercises in Healthy Older Adults: A Non-Randomized Controlled Trial

Validation of the conceptual framework and intervention scope of oral function rehabilitation exercise

OBJECTIVES

This study used a Delphi survey to define the concept of oral function rehabilitation exercise (OFRE) based on the International Classification of Functioning, Disability, and Health (ICF) and to categorise intervention domains for community-dwelling older adults.

BACKGROUND

While numerous studies have been conducted to improve oral function through exercise interventions, the conceptual definition of oral exercise remains unclear and there is a lack of systematic categorisation of oral exercise intervention domains.

METHODS

A preliminary model was developed based on the key findings of 19 papers selected from a prior systematic review. Its validity was confirmed through a Delphi survey conducted twice with eight expert panellists. Consensus was achieved by evaluating the validity of the OFRE conceptual framework, the accuracy of OFRE conceptual definitions, and intervention domains.

RESULTS

Through expert consensus, an ICF-based OFRE conceptual framework was developed that includes 21 factors that affect the oral health status of the older adults. The OFRE intervention domain for improving the health status consisted of oral function rehabilitation warm-up exercise, masticatory function exercise, swallowing function exercise, articulatory function exercise, salivary function exercise, and oral function rehabilitation cool-down exercise, and 11 specific intervention methods were derived.

CONCLUSIONS

The OFRE intervention can be used for planning and applying successful interventions to improve oral function and life function of older adults.

Temporal relationship between malnutrition and oral function impairment in older adults with dysphagia: A cross-lagged panel model

OBJECTIVES

This study aimed to longitudinally investigate the temporal relationship between tongue pressure and malnutrition in older adults with dysphagia and to determine the antecedent factors.

DESIGN

This is a retrospective cohort study.

SETTING AND PARTICIPANTS

In total, 177 participants aged ≥65 years with dysphagia who visited a specialized dysphagia rehabilitation clinic between 2014 and 2018 were enrolled.

MEASUREMENTS

Malnutrition was assessed based on the phenotypic criteria (unintentional weight loss, low body mass index, and reduced skeletal muscle mass) from the Global Leadership Initiative on Malnutrition framework. Tongue pressure was measured using a tongue pressure measuring device. The bidirectional association between tongue pressure and malnutrition was examined, adjusting for age, sex, cognitive function, occlusal support status, and comorbidities.

RESULTS

In the Cross-Lagged Panel Model, a significant cross-lagged effect was observed from tongue pressure to malnutrition at 6 months (β = -0.135, p < 0.001) and 12 months (β = -0.112, p = 0.028). However, the pathway from malnutrition to tongue pressure was not significant. Logistic regression analysis also revealed that baseline tongue pressure was significantly associated with malnutrition at 6 months (odds ratio [OR] = 0.91, 95% confidence interval [CI]: 0.86-0.95) and 12 months (OR = 0.89, 95% CI: 0.84-0.94). During the follow-up period, tongue pressure improved; however, the prevalence of malnutrition increased.

CONCLUSIONS

Decreased tongue pressure may precede malnutrition in older adults with dysphagia; however, a reverse relationship was not observed. The findings suggest the importance of incorporating oral function assessment as part of the risk assessment for malnutrition.

Effect of home-based tongue-strengthening exercise using a portable tool on oropharyngeal muscles in older adults with sarcopenic dysphagia: A randomised controlled study

BACKGROUND

Tongue-strengthening exercises may be used at home to strengthen swallowing-related oropharyngeal muscles in community-dwelling older adults with sarcopenic dysphagia; however, evidence of their effectiveness remains unclear.

OBJECTIVE

This study aimed to investigate the effects of a home-based tongue-strengthening exercise (hTSE) using portable tool on swallowing-related oropharyngeal muscles in community-dwelling older adults with sarcopenic dysphagia.

METHODS

Forth community-dwelling older adults with sarcopenic dysphagia were enrolled in the study. The participants were randomly assigned to the experimental and control groups. 1-Repetition Maximum (1-RM) of tongue muscle was measured in the experimental group using the Iowa Oral Performance Instrument, and hTSE was performed using a portable tool with an intensity corresponding to approximately 70%-80% of the range based on the 1-RM value (90 times/day, 5 days/week, for 8 weeks). The control group did not perform any tongue exercises. The primary outcome measures were tongue strength and thickness. The secondary outcome measure was suprahyoid muscle strength (digastric and mylohyoid muscles).

RESULTS

The experimental group showed significantly greater increases in suprahyoid muscle (mylohyoid and digastric) thickness (p = .01 and .011, d = 1.0 and .55), as well as tongue strength and thickness (p < .001 and .029, d = 2.2 and .6) than the control group.

CONCLUSION

This study confirmed that hTSE using a portable tool is effective in increasing swallowing-related oropharyngeal muscle activity in older adults with sarcopenic dysphagia. Therefore, hTSE is recommended as an inexpensive, safe, and easy-to-use therapy for sarcopenic dysphagia in older adults.

Effects of oropharyngeal exercises on the swallowing mechanism of older adults: A systematic review

PURPOSE

Age-related changes to the swallowing mechanism, or presbyphagia, may put older adults at a higher risk for developing diseases and dysphagia. Maintaining swallowing functions could help prevent frailty and facilitate healthy ageing. This review summarises and appraises the effects of oropharyngeal exercises on the swallowing functions of healthy older adults without dysphagia. It is hypothesised that these exercises will strengthen and improve the structures and functions of the normal ageing swallow.

METHOD

This review was reported according to the PRISMA 2020 guidelines. Five electronic databases (Medline, Embase, Cochrane Library, Web of Science, CINAHL) and Google Scholar were searched in June 2021. A rerun was done in January 2023. Study selection, data extraction, and quality assessment were done by two independent raters.

RESULT

A total of 23 studies were reviewed. Meta-analysis was not conducted due to the heterogenous training protocols and outcomes. Majority (n = 21) had fair quality due to incomplete reporting. Exercises targeting oral structures were implemented the most (n = 15), followed by variations of the head lift (n = 4), and effortful swallow exercise (n = 1). Others implemented combined or multiapproach exercise studies (n = 3). Apart from surface electromyography findings, statistically significant improvements in oral and pharyngeal phase swallowing outcomes such as increased lingual isometric and swallowing pressures, bite force, muscle thickness, hyolaryngeal excursion, and upper oesophageal sphincter opening diameter were reported in 95% of the studies (n = 22).

CONCLUSION

Collective evidence suggests that strength training for swallowing-related structures leads to increases in structural strength, endurance, and muscle mass. The effects of exercises on overall swallowing efficiency and safety remain unclear. Results should be interpreted with caution due to methodological limitations. Further research should examine the long-term effects of these exercises in preventing frailty and reducing the burden of dysphagia in older adults.

Clinical and electroencephalographic correlates of carbamazepine-associated hiccups in epileptic patients

Carbamazepine, a commonly prescribed antiepileptic drug, is known to induce hiccups in a subset of epileptic patients. Although relatively uncommon, can have significant clinical implications. This comprehensive review delves into the clinical and electroencephalographic correlates of carbamazepine-associated hiccups, aiming to enhance understanding and management of this neurological side effect. The authors' review synthesizes qualitative epidemiological data, revealing that carbamazepine-induced hiccups occur in a subset of patients receiving the medication, with reported incidence rates ranging from 2.5 to 40%. Despite its relatively low prevalence, hiccups pose substantial challenges for patients and healthcare providers. Complications associated with carbamazepine-induced hiccups include disruption of sleep, impaired social functioning, and decreased quality of life, underscoring the clinical significance of this side effect. Effective management strategies can be implemented through a multidisciplinary approach, including collaboration among neurologists, pharmacists, and other healthcare professionals. These may include dose adjustments, medication discontinuation, and adjunctive therapies such as diaphragmatic breathing exercises or acupuncture. Additionally, close monitoring for adverse effects and timely intervention are essential to mitigate the impact of hiccups on patient well-being. Essentially, carbamazepine-induced hiccups represent a clinically relevant phenomenon that warrants attention in the management of epilepsy. By recognizing the clinical manifestations, understanding the underlying pathophysiology, and implementing evidence-based management strategies, healthcare providers can optimize patient care and improve outcomes in this patient population.

Low tongue pressure and depression using Kihon Checklist for assessing frailty status among community-dwelling Japanese older adults: A pilot study

BACKGROUND

Evaluation of low tongue pressure is used to diagnose oral hypofunction. The pathophysiology of oral hypofunction is hypothesized to be associated with oral dysfunction related to ageing. Depression in older adults is a major problem and is related to handgrip strength, which is related to tongue pressure. We hypothesized that low tongue pressure could indicate depression mood in community-dwelling older adults.

OBJECTIVES

This study aimed to measure maximum tongue pressure and compare it to the responses to the Kihon Checklist (KCL), which is used to check mental and physical deterioration of community-dwelling older adults.

METHODS

A total of 49 community-dwelling independent older adults with stable dental condition (23 men, 26 women; median age, 79 years) answered the KCL, which contained questions on frailty status, cognitive function, nutritional and sarcopenia status. Oral function was measured to assess oral hypofunction. The relationship between tongue pressure differences and frailty status, cognitive function, nutritional and sarcopenia status was analysed using logistic regression analyses after adjusting for age and sex.

RESULTS

Nine participants (6 men and 3 women; median age, 81 years) had a tongue pressure <23.0 kPa, which was the lowest limit of the standard value of maximum tongue pressure in patients aged ≥70 years. Logistic regression analyses showed that only Question 21, which is related to a lack of fulfilment in daily life, was significantly associated with low tongue pressure (p = .027).

CONCLUSION

Low tongue pressure may be associated with sociopsychological factors in older adults.

Effects of oral function and depressive tendencies on nutritional status in older adults requiring support or low-level care: An investigation using path analysis

AIM

This study investigated the effects of differences in oral function and depressive tendencies on nutritional status in older adults requiring support or low-level care.

METHODS

In 106 older adult participants residing in nursing/care homes or participating in community-level preventive care activities, the Mini Nutritional Assessment-Short Form (MNA®-SF) for nutritional status and oral diadochokinesis (ODK), tongue pressure, and repetitive saliva swallowing test (RSST) for oral function, 15-item Geriatric Depression Scale (GDS), Diet-Related Quality of Life Scale-Short Form (DRQOL-SF), and Functional Independence Measure (FIM) were administered. Basic information, including cognitive function, was evaluated. Hierarchical MNA (dependent variable)-based multiple regression analysis was performed, followed by path analysis using factors with significant associations with MNA scores.

RESULTS

RSST, ODK, tongue pressure, FIM, and DRQOL were positively correlated with MNA scores and GDS was negatively correlated. Hierarchical multiple regression demonstrated associations with tongue pressure, GDS, FIM, DRQOL scores, and gender. Path analysis confirmed significant paths from tongue pressure to MNA, tongue pressure to FIM, and FIM to MNA (P < .001). Significant paths were confirmed from GDS to MNA (P < .01), from DRQOL to MNA (P < .05), and from gender to MNA (P < .01).

CONCLUSIONS

Tongue pressure, GDS, FIM, DRQOL scores, and gender were identified as factors that directly affect MNA. Tongue pressure showed the greatest effect and indirectly affected MNA via FIM. These findings emphasize the importance of early detection of low nutritional risk for preventing depression and oral function deterioration, and of evaluation of dietary satisfaction and improvement of quality of life in diets.

Evaluating the effect of management on patients with oral hypofunction: A longitudinal study

INTRODUCTION

Declining oral function may affect subsequent physical frailty in the older population. The aim of this longitudinal study was to summarise data on patients who underwent functional oral examination and evaluate the impact of management on patients with oral hypofunction (OHF).

METHODS

Dental outpatients aged over 65 years at their initial visit to the Niigata University Hospital received detailed assessment of seven oral function items to diagnose oral hypofunction using diagnostic criteria defined by the Japanese Society of Gerodontology. Patients with OHF at the first assessment received management including oral health guidance for low function and dental treatment. They were re-evaluated approximately 6 months later and the two assessments were compared. According to the results of the second assessment, the patients were divided into two groups: OHF improved and OHF re-diagnosed.

RESULTS

Of the 273 patients who underwent the first assessment, 86 (31.5%) were diagnosed with OHF and received management. Of those, 42 (48.8%) completed the second assessment. Comparing the first and second assessment, significant improvement was observed in oral hygiene, occlusal force, tongue-lip motor function of /pa/, mastication and swallowing. The change in values from the first assessment demonstrated a significant difference between the OHF improved and re-diagnosed groups only in occlusal force.

CONCLUSION

Management for patients with OHF can contribute to the improvement of poor oral function, and an increase in occlusal force was notable in the recovery from OHF.

Hiccups, Hypersalivation, Hallucinations in Parkinson's Disease: New Insights, Mechanisms, Pathophysiology, and Management

Parkinson's disease (PD) is a chronic, progressive neurological disorder and the second most common neurodegenerative condition. We report three common but overlooked symptoms in PD-hiccups, hypersalivation, and hallucinations-in terms of their prevalence, pathophysiology, and up-to-date evidence-based treatment strategies. Whilst all these three symptoms do occur in many other neurological and non-neurological conditions, early recognition and treatment are paramount. Whilst hiccups affect 3% of healthy people, their rate of occurrence is higher (20%) in patients with PD. Hypersalivation (Sialorrhea) is another common neurological manifestation of many neurological and other neurodegenerative conditions such as motor neuron disease (MND), with a median prevalence rate of 56% (range: 32-74%). A 42% prevalence of sialorrhea is also reported in sub-optimally treated patients with PD. Hallucinations, especially visual hallucinations, are commonly reported, with a prevalence of 32-63% in PD, and a 55-78% prevalence is noted in patients with dementia with Lewy bodies (DLB), followed by tactile hallucinations, which are indicated by a sensation of crawling bugs or imaginary creatures across the skin surface. Whilst mainstay and primary management strategies for all these three symptoms are carried out through history taking, it is also essential to identify and treat possible potential triggers such as infection, minimise or avoid causative (such as drug-induced) factors, and especially carry out patient education before considering more definitive treatment strategies, such as botulinum toxin therapies for hypersalivation, to improve the quality of life of patients. This original review paper aims to provide a comprehensive overview of the disease mechanisms, pathophysiology, and management of hiccups, hypersalivation, and hallucinations in Parkinson's disease.

The Impact of Nutrition and Oral Function Exercise on among Community-Dwelling Older People

Oral function (OF) decline in older people is associated with nutritional deficiencies, which increases frailty risk and the need for nursing care. We investigated whether the delivery of an oral function improvement program on a tablet device was as effective as delivery through a paper-based program. We also investigated the association between tongue pressure (TP) improvement and nutritional status at the baseline. The participants involved in the study were 26 community-dwelling older people with low TP, <30 kPa, aged ≥65 years, who were enrolled in a randomized controlled trial for a month in Itoshima City, Fukuoka, Japan. Oral and physical functions and body composition were measured at the baseline and at follow-up. Two-way analysis of variance revealed that body mass index (p = 0.004) increased, and maximum masticatory performance (p = 0.010), maximum TP (p = 0.035), and oral diadochokinesis /pa/ and /ka/ (p = 0.009 and 0.017, respectively) improved in a month. Participants with higher TP improvement showed an increased intake of animal proteins at the baseline: fish (p = 0.022), meat (p = 0.029), and egg (p = 0.009). OF exercises for improving TP were associated with higher animal protein intake at the baseline. This study has been registered with the UMIN Clinical Trials Registry (UMIN 000050292).

Possible Rehabilitation Procedures to Treat Sarcopenic Dysphagia

Sarcopenic dysphagia requires the presence of both dysphagia and generalized sarcopenia. The causes of dysphagia, except for sarcopenia, are excluded. The treatment for sarcopenic dysphagia includes resistance training along with nutritional support; however, whether rehabilitation procedures are useful remains unclear. In this narrative review, we present possible rehabilitation procedures as a resistance training for managing sarcopenic dysphagia, including Shaker exercise, Mendelsohn maneuver, tongue-hold swallow exercise, jaw-opening exercise, swallow resistance exercise, lingual exercise, expiratory muscle strength training, neuromuscular electrical stimulation, and repetitive peripheral magnetic stimulation. We hope that some procedures mentioned in this article or new methods will be effective to treat sarcopenic dysphagia.