The GUSS test as a good indicator to evaluate dysphagia in healthy older people: a multicenter reliability and validity study

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.

Validity and Reliability of the Swedish Version of the Gugging Swallowing Screen for use in Acute Stroke Care

The purpose of this study was to cross-culturally validate the Swedish version of the Gugging Swallowing Screen (GUSS-S) for use in the acute phase of stroke. Further, to evaluate the inter-rater reliability between different healthcare professionals. GUSS was translated into Swedish using a forward-backward method followed by expert rating to obtain content validity. For criterion validity, the GUSS-S score was compared with Flexible Endoscopic Evaluation of Swallowing (FEES) assessed with the Penetration-Aspiration Scale (PAS) in acute stroke patients (≤ 96 h after stroke onset). Convergent validity was calculated by comparison with the Functional Oral Intake Scale (FOIS) as per the comprehensive FEES assessment, the Standardized Swallowing Assessment (SSA), and the National Institutes of Health Stroke Scale (NIHSS). To evaluate inter-rater reliability, a nurse and a speech-language pathologist (SLP) independently assessed 30 patients. In total, 80 patients (32 women, median age 77 years (range 29-93) were included, mean 1.7 ± 0.9 days after admission. With a cut-off value of 14 points, the GUSS-S identified aspiration with a sensitivity of 100% and a specificity of 73% (area under the curve: 0.87, 95% CI 0.78-0.95). Spearman rank correlation showed very strong correlation between the GUSS-S and PAS (rs=-0.718, P = < 0.001) and FOIS (rs=0.720, P = 0.001) and strong correlation between the GUSS-S and SSA (rs=0.545, P = < 0.001) and NIHSS (rs=-0.447, P = 0.001). The inter-rater agreement for GUSS-S was substantial (Kw=0.67, P = < 0.001). The results indicate that the GUSS-S is a valid and reliable tool for the assessment of dysphagia in acute stroke patients by different healthcare professionals.

Can Voice Parameters Provide Cutoff Values to Predict Dysphagia in Individuals with Multiple Sclerosis?

In dysphagia assessment, along with well-defined measurements and signs, voice parameters can potentially support clinical decision as a marker, but more evidence is needed. This study aims to determine the voice parameters that can predict the risk of dysphagia and to determine optimal cutoff values in individuals with multiple sclerosis (IwMS). Seventy-six adults participated in the study, including 39 IwMS and 37 healthy individuals (HI). The study used the Dysphagia in Multiple Sclerosis Questionnaire (DYMUS), Gugging Swallowing Screen (GUSS), and Voice Handicap Index (VHI-10) and recorded voice samples using Praat programme. Voice recordings were taken pre- and post-swallowing. The voice parameters analysed are fundamental frequency (F0), standard deviation F0 (SD F0), jitter (local), shimmer (local), and harmonic-to-noise ratio (HNR). Roc analysis was performed to examine the diagnostic accuracy performance of the risk for dysphagia/penetration. The parameters of IwMS pre-swallowing differed significantly from those of HI on the VHI-10, DYMUS, GUSS scores, and jitter (local), shimmer (local), and HNR. IwMS but not HI exhibited significant differences in shimmer (local) and HNR between the pre- and post-swallowing measurements. In IwMS, GUSS revealed significant differences in shimmer (local) pre- and post-swallowing between the groups with and without dysphagia/penetration. In the ROC analysis results, the area under the curve (AUC) for shimmer (local) pre-swallowing was 73.1% (cutoff = 1.69); post-swallowing, it was 78.6% (cutoff = 1.57). In conclusion, IwMS can be associated with differences in shimmer (local) and HNR parameters, low quality of life-related to voice, and dysphagia/penetration risk. The AUC values for shimmer (local) in IwMS pre- and post-swallowing may help to strengthen diagnostic decisions of dysphagia risk.

Evaluation of the performance of screening tools for dysphagia in older adults: A diagnostic meta-analysis

This systematic review evaluated the diagnostic accuracy of multiple screening tools for dysphagia in older adults. The analysis covered 30 studies involving 13 tools and 2,697 participants. The results showed that the volume viscosity swallow test performed best in sensitivity, specificity, and area under the curve, making it a recommended screening tool. Other tools have low sensitivity, unstable results or insufficient research and need to be further validated. Overall, this study provides an important reference for the screening of dysphagia in older adults.

Prevalence of Dysphagia and Risk of Malnutrition in Elderly Living in Nursing Homes

Swallowing difficulties commonly co-occur with malnutrition in the elderly. However, there is no consensus on which assessment tools to use, and thus reported prevalence varies. The aim of this study was to survey the prevalence of dysphagia and risk of malnutrition in elderly people in nursing homes, evaluate the possible associations between swallowing function and malnutrition and survey whether there were associations between self-perceived function and the results of a screening of dysphagia. A total of 35 residents (aged 67-100 years old) without serious cognitive impairment in the general wards of two nursing homes in Gothenburg were investigated. Swallowing ability was assessed with the Gugging Swallowing Screen (GUSS) test, self-rated swallowing ability with the 4QT and the Swedish Eating Assessment Tool-10 (S-EAT-10) and risk of malnutrition with the Minimal Eating Observation and Nutrition Form-Version 2 (MEONF-II). Eleven participants (31.4%) exhibited dysphagia according to the GUSS and 10 participants (29.4%) showed moderate or high risk of malnutrition. In total 16 (46%) participants reported abnormal swallowing on 4QT and 14 (40%) participants reported abnormal swallowing on S-EAT-10. However, less than half of these had dysphagia according to the GUSS. No association was found between swallowing ability measured by the GUSS and risk of malnutrition, although a tendency towards a weak association was noted, or self-rated swallowing ability measured by the 4QT and S-EAT-10. The study found that approximately one-third of the tested participants presented with signs of dysphagia as measured with the screening instrument GUSS, even though only a few were known to have any difficulties prior to testing. This highlights that dysphagia is probably more prevalent than patients themselves and caregivers are aware of, thus, screening is of importance, to enable safer nutritional intake.

Effect of Simple Swallowing Training Program on Early Oropharyngeal Dysphagia in Community-Dwelling Older Adults: A Randomized Controlled Study

OBJECTIVES

Oropharyngeal dysphagia (OD) in community-dwelling older adults continues to be a challenge due to its insidious onset. This study developed a simple swallowing training program (SSTP) to address these issues and conducted a randomized controlled trial to explore its effect on swallowing function and quality of life.

DESIGN

Two-arm randomized controlled trial.

SETTING

AND PARTICIPANTS: A total of 248 community-dwelling older adults with OD from were included in 2024 and randomly divided into intervention and control groups.

METHODS

The SSTP was developed through expert consultation. A total of 248 community-dwelling older adults with OD were included in 2024 and randomly divided into intervention and control groups. The intervention group underwent the SSTP twice daily for 21 days, with weekends off, and the control group participants did light physical activities by themselves. The primary outcome was the Gugging Swallowing Screen (GUSS), and the secondary outcomes were the Eating Assessment Tool-10 (EAT-10), Swallowing Quality of Life questionnaire (SWAL-QoL), maximum tongue pressure, masticatory ability, bite force, and meal duration. Assessments were conducted on days 1 and 21, while meal duration was assessed every 3 days for lunch.

RESULTS

Twenty-seven participants withdrew halfway. There were no significant differences in baseline assessments (P > .05). There were significant between-group and interactive effects in the GUSS [(19.07 ± 1.38) vs (17.28 ± 2.17), Fbetween-group = 6.893, Pbetween-group = .009, Finteractive = 59.504, Pinteractive<.001], EAT-10 {[4.00 (3.00, 5.00)] vs [9.00 (7.00, 10.00)], zbetween-group = -3.502, Pbetween-group<.001; zinteractive = -6.252, Pinteractive<.001}, SWAL-QoL {[166.00 (163.00, 171.50)] vs [154.00 (150.00, 158.00)], zbetween-group = 2.681, Pbetween-group = .007; zinteractive = 5.475, Pinteractive<.001}, maximum tongue pressure {[33.10 (26.48, 36.86)] vs [28.85 (19.21, 35.77)], zbetween-group = 3.377, Pbetween-group = .001; zinteractive = -6.208, Pinteractive<.001}, masticatory ability {[176.92 (133.10, 212.91) vs [163.33 (116.66, 189.32)], zbetween-group = 4.801, Pbetween-group<.001; zinteractive = 6.979, Pinteractive<.001}. Between-group, time, and interactive effects were significant in the meal duration [(23.39 ± 4.32) vs (27.64 ± 5.63), Fbetween-group = 8.692, Pbetween-group = .004, Ftime = 138.683, Ptime< 0.001, Pinteractive = 73.196, Pinteractive<.001].

CONCLUSIONS AND IMPLICATIONS

The SSTP can effectively improve early OD and swallowing-related quality of life in community-dwelling older adults.

Efficacy of an Aspiration Prevention Program That Utilizes the Gugging Swallowing Screen in Older Patients

Purpose

Older patients have a higher risk of aspiration pneumonia and mortality if they are hospitalized. We aimed to assess the effectiveness of an aspiration prevention quality improvement (QI) program that utilizes the Gugging Swallowing Screen (GUSS) in older patients.

Patients and Methods

This retrospective cohort study was conducted in an acute medical care unit of a tertiary hospital in South Korea. The study used one-to-one propensity matching and included 96 patients who received the QI program and 96 who did not. All patients were aged 65 years or older and had risk factors for aspiration, including neurological and non-neurological disorders, neuromuscular disorders, impaired airway defenses, and dysphagia due to esophageal or gastrointestinal disorders. The primary outcomes included the duration of the fasting period during hospitalization, changes in nutritional status before admission and at discharge, in-hospital mortality, and readmission due to pneumonia within 90 days.

Results

Fasting period, changes in weight and albumin levels upon discharge after hospitalization, and length of stay did not differ significantly between patients in the GUSS and non-GUSS groups. However, the risk of readmission within 90 days was significantly lower in patients who underwent the GUSS than in those who did not (hazard ratio, 0.085; 95% confidence interval, 0.025-0.290; p = 0.001).

Conclusion

The GUSS aspiration prevention program effectively prevented readmission due to pneumonia within 90 days in older patients with acute illnesses. This implies that the adoption of efficient aspiration prevention methods in older patients with acute illnesses could play a pivotal role by enhancing patient outcomes and potentially mitigating the healthcare costs linked to readmissions.

Exploring the diagnostic accuracy and applicability of the Gugging Swallowing Screen in children with feeding and/or swallowing disorders

BACKGROUND

The Gugging Swallowing Screen (GUSS) is a bedside dysphagia screening tool that has been designed to determine the risk of aspiration in acute stroke patients. There is no evidence in the literature for the GUSS for the pediatric population. The present study aimed to determine the diagnostic accuracy of GUSS as a screening tool in the Greek language for children with dysphagia.

METHODS

Eighty-Greek-Cypriot children aged 3-12 years who had dysphagia participated in this retrospective study. The translated into Greek GUSS was administered twice (pre- and post-therapy) to each patient throughout 24 sessions of dysphagia therapy.

KEY RESULTS

The GUSS showed a high internal consistency (Cronbach's α = 0.826), good test-retest reliability (rs = 0.767), convergent validity compared to the Greek Pediatric Eating Assessment tool-10 (PEDI-EAT-10) total score (rs = -0.365), and inter-rater reliability (κ = 0.863). A total cutoff points equal to 13.00 was also calculated. Aspiration was identified by the GUSS with low sensitivity and high specificity (PPV 100%, NPV 57%, LR+ NA, LR- 0.79); dysphagia/penetration was identified with high sensitivity and low specificity (PPV 33%, NPV 100%, LR+ 0.102, LR- NA).

CONCLUSIONS & INFERENCES

The pediatric version of GUSS has been found to be a valuable tool in identifying the risk of aspiration as that of adults. It proved to be used as a good screening guide for selecting and confirming the existence of dysphagia from instrumental assessments. This is the first study of the pediatric version of GUSS, and future studies on this topic are needed.

Early Feasibility of an Activity-Based Intervention for Improving Ingestive Functions in Older Adults with Oropharyngeal Dysphagia

There is growing awareness about the use of combined strength- and skill-based swallowing training for improving swallowing physiology in the event of dysphagia. Such an approach involves focusing on coordination and timing as well as swallowing strengthening in the context of increased exercise complexity in eating and drinking activities. This study aimed to determine the early feasibility of a newly developed 12-week intervention, named the ACT-ING program (ACTivity-based strength and skill training of swallowing to improve INGestion), in older adults with dysphagia and generalized sarcopenia. In a multiple-case-study design, seven participants above 65 years of age (five women and two men) with slight to severe dysphagia and indications of sarcopenia underwent the intervention during hospitalization and in the community after discharge. The ACT-ING program met most of the feasibility marks in terms of demand (73.3% of those invited accepted participation), safety (100%), no reports of adverse events, tolerance (85.7%), usability (100%), and acceptability (100%). Three putative mediators of change (experienced autonomy support, in-therapy engagement, and perceived improvement in swallowing capacity) appeared to have been best accomplished in participants with slight to moderate dysphagia. The ACT-ING program showed preliminary evidence of early feasibility, warranting further early-phase dose articulation and proof-of-concept trials.

Multidisciplinary Assessment and Individualized Nutritional Management of Dysphagia in Older Outpatients

INTRODUCTION

The evidence on the efficacy of nutrition therapy to prevent complications of dysphagia is based on observational studies that used different tools for nutritional and dysphagia assessment, and different scales for the definition of diet textures, rendering their results incomparable and the knowledge on dysphagia management inconclusive.

METHODS

This retrospective observational study was performed in 267 older outpatients who were assessed for dysphagia and nutritional status by a multidisciplinary team at the Clinical Nutrition Unit of IRCCS INRCA geriatric research hospital (Ancona, Italy) from 2018 to 2021. GUSS test and ASHA-NOMS measurement systems were used for dysphagia assessment, GLIM criteria for the assessment of nutritional status, and the IDDSI framework to describe the texture-modified diets. Descriptive statistics were used to summarize the characteristics of the subjects evaluated. Sociodemographic, functional and clinical parameters were compared between patients with and without BMI improvement overtime by an unpaired Student's t test, Mann-Whitney U test or Chi square test, as appropriate.

RESULTS

Dysphagia was diagnosed in more than 96.0% of subjects; 22.1% (n = 59) of dysphagic subjects were also malnourished. Dysphagia was treated exclusively by nutrition therapy, prevalently by individualized texture-modified diets (77.4%). For the classification of diet texture, the IDDSI framework was used. The follow-up visit was attended by 63.7% (n = 102) of subjects. Aspiration pneumonia was registered only in one patient (less than 1%), and BMI improved in 13 of 19 malnourished subjects (68.4%). The improvement of nutritional status was primarily reached in subjects whose energy intake was increased and texture of solids modified, in younger subjects, and in those taking less drugs and not reporting any weight loss before the first assessment.

CONCLUSIONS

The nutritional management of dysphagia must guarantee both an adequate consistency and energy-protein intake. Evaluations and outcomes should be described with universal scales, in order to allow for comparison between studies and contribute to the collection of a critical mass of evidence on the efficacy of texture-modified diets in the management of dysphagia and its complications.

Prevalence and Methods for Assessment of Oropharyngeal Dysphagia in Older Adults: A Systematic Review and Meta-Analysis

BACKGROUND

This systematic review and meta-analysis aimed to estimate the pooled prevalence of dysphagia in older adults, subgrouping by recruitment settings and varying dysphagia assessment methods.

METHODS

Five major databases were systematically searched through January 2022. A random-effects model for meta-analysis was conducted to obtain the pooled prevalence.

RESULTS

Prevalence of dysphagia in the community-dwelling elderly screened by water swallow test was 12.14% (95% CI: 6.48% to 19.25%, I2 = 0%), which was significantly lower than the combined prevalence of 30.52% (95% CI: 21.75% to 40.07%, I2 = 68%) assessed by Standardized Swallowing Assessment (SSA) and volume-viscosity swallow test (V-VST). The dysphagia prevalence among elderly nursing home residents evaluated by SSA was 58.69% (95% CI: 47.71% to 69.25%, I2 = 0%) and by the Gugging Swallowing Screen test (GUSS) test was 53.60% (95% CI: 41.20% to 65.79%, I2 = 0%). The prevalence of dysphagia in hospitalized older adults screened by the 10-item Eating Assessment Tool was 24.10% (95% CI: 16.64% to 32.44%, I2 = 0%), which was significantly lower than those assessed by V-VST or GUSS tests of 47.18% (95% CI: 38.30% to 56.14%, I2 = 0%).

CONCLUSIONS

Dysphagia is prevalent in the elderly, affecting approximately one in three community-dwelling elderly, almost half of the geriatric patients, and even more than half of elderly nursing home residents. The use of non-validated screening tools to report dysphagia underestimates its actual prevalence.

Swallowing difficulty in the older adults: presbyphagia or dysphagia with sarcopenia?

Oropharyngeal dysphagia is an important cause of mortality and morbidity in older adults. It has been reported in the literature that 11-68% of older adults experience swallowing difficulties. This study aimed to investigate the presence of dysphagia in older adults, whether this dysphagia is related to age (presbyphagia) or sarcopenia by comparing it with adults. Two hundred twenty-five patients were included in this cross-sectional study. The participants were divided into two groups by age as 'adults' and 'older adults'. Sarcopenia, dysphagia and malnutrition evaluations were performed. Older adult and adult groups were compared in terms of malnutrition, dysphagia and sarcopenia. The number of patients with dysphagia was significantly higher (P = 0.007) in the older adults. In older adults, all sarcopenic evaluation parameters were found significantly lower than adults (P < 0.05). The number of older adults with malnutrition was significantly lower in patients with normal swallowing (P < 0.05). The swallowing difficulty can be detected in older adults even if it does not cause any complaint. While most swallowing disorders may be due to age-related changes, about a third may be accompanied by sarcopenia.

Prevalence of signs of dysphagia and associated risk factors in geriatric patients admitted to an acute medical unit

BACKGROUND AND AIMS

Dysphagia is a prevalent disorder among the older persons. Despite this, signs of dysphagia often go unnoticed in hospital settings. This cross-sectional study aimed at investigating the prevalence of signs of dysphagia among patients aged 65 or older in a Danish acute care setting.

METHODS

We studied 334 patients aged 65 years or older admitted to the acute medical unit (AMU) at Aalborg University Hospital, Denmark. Signs of dysphagia were assessed using bedside screening tools including the Eating Assessment Tool (EAT-10), a 30 mL Water Swallowing Test (WST) and the Gugging Swallowing Screen tool (GUSS). Other risk factors were assessed using the Eastern Cooperative Oncology Group Performance Status (ECOG-PS), the Nutritional Risk Screening 2002 (NRS), and the Charlson's Comorbidity Index (CCI).

RESULTS

Signs of dysphagia were identified in 144 of 334 (43.1%) patients. Geriatric patients with signs of dysphagia were significantly older (79.5 years [74; 85] vs. 77 years [72; 84], p = 0.025) and had higher CCI scores (3 points [2; 4] vs. 2 points [1; 4], p = 0.001) than those with normal swallowing capacity. Furthermore, a multivariate logistic regression model found signs of dysphagia to be independently associated with nutritional risk (OR = 2.169, 95% CI 1.313-3.582, p = 0.002), cerebrovascular disease (OR = 2.209, 95% CI 1.235-3.953, p = 0.008), chronic pulmonary disease (OR = 2.276, 95% CI 1.338-3.871, p = 0.002) and rheumatic disease (OR = 2.268, 95% CI 1.099-4.683, p = 0.027). Age was not independently associated with signs of dysphagia among the geriatric patients.

CONCLUSION

Signs of dysphagia were common among patients aged 65 or older in the acute care setting. Signs of dysphagia were associated with nutritional risk, higher CCI scores and specific comorbidities. These findings could indicate a need for systematic screening for dysphagia in acute geriatric patients, yet further investigation is needed to assess clinical outcomes associated with dysphagia within this population.

Is Dysphagia in Older Patients with Parkinson's Disease Associated With Sarcopenia ?

BACKGROUND

Parkinson's Disease (PD) and sarcopenia share a number of common pathways, and they can potentially affect each other.

OBJECTIVE

We aimed to investigate the relationship between dysphagia and sarcopenia in elderly patients with PD compared to healthy controls.

METHODS

This case-control study was conducted on 54 elderly PD patients and age-, sex- and body mass index-matched 54 healthy elder persons. Demographic and disease characteristics such as disease duration, stage of disease and Unified Parkinson's disease rating scale were recorded. All subjects were assessed by 10- item Eating Assessment Tool, Gugging Swallowing Screen tests and flexible fiberoptic endoscopic evaluation of swallowing (FEES) as well as Mini nutritional test short form. Also, A simplified screening tool for assessing sarcopenia (SARC-F), five times sit-to-stand and gait speed tests as well as lumbar magnetic resonance imaging (MRI) cross-sectional area of psoas and paraspinal muscles were used for evaluation of sarcopenia. Patients were divided as «with normal swallowing» or «with dysphagia» according to the FEES results. Three groups were compared among themselves in terms of evaluation methods.

RESULTS

Sarcopenia evaluation parameters were significantly higher in patient groups compared to the control group. Moreover, muscle measurements evaluated by MRI in patients with dysphagia are lower than both patients with normal swallowing and control group (p value between 0.001 and 0.011).

CONCLUSIONS

Patients with PD have lower muscle mass compared to healthy controls, and the situation is more pronounced in dysphagic PD patients.

Proposing a Value Field Model for Predicting Homebuyers’ Purchasing Behavior of Green Residential Buildings: A Case Study in China

Understanding the motivations that stimulate homebuyers’ green purchasing behavior can increase market demand for green products, especially considering the comparably low market share of green products worldwide. In this context, various studies have been conducted examining consumers’ intentions to pay for green products. Nevertheless, there is still limited research on evaluating homebuyers’ purchasing behavior toward green residential buildings. This study argues that the value of green residential buildings (GRBs) affects their adoption, and thus exerts an invisible force on homebuyers’ purchasing behavior. It also finds that field theory provides a scientific perspective on this phenomenon. Thus, this paper proposes a value field model for evaluating homebuyers’ GRB purchasing behavior based on physical field theory and psychology field theory. In particular, physical field theory provides the measurement formula, while psychological field theory explains the effect of the force stimulating homebuyers’ purchasing intention, and ultimately influencing their purchasing behavior. The initial model consisted of a field source (green perceived value), target charge (GRB demand), distance (psychological distance), and value field factor. As the value field factor was calculated to be approximately equal to 1, the final model is a composite of a field source (green perceived value), target charge (GRB demand), and distance (psychological distance). The results validate the construction of the value field model on the basis of field theory. This research contributes to the body of knowledge by analyzing GRB value and provides a clearer understanding of how GRBs and the environment combine to fulfill homebuyers’ requirements and influence their GRB purchasing behavior.