Association of positive screening for dysphagia with nutritional status and long-term mortality in hospitalized elderly patients

Combined systematic screening for malnutrition and dysphagia in hospitalized older adults: a scoping review

BACKGROUND

Dysphagia affects about 40% of patients admitted to acute geriatric wards, as it is closely associated with diseases that rise in prevalence with advancing age, such as stroke, Parkinson's disease, and dementia. Malnutrition is a highly associated predictive factor of dysphagia as well as one of the most common symptoms caused by dysphagia. Thus, the two conditions may exist simultaneously but also influence each other negatively and quickly cause functional decline especially in older adults. The purpose of this review was to determine whether institutions have established a protocol combining screenings for dysphagia and malnutrition on a global scale. If combined screening protocols have been implemented, the respective derived measures will be reported.

METHODS

A scoping review was conducted. A systematic database search was carried out in January and February 2024. Studies were included that examined adult hospitalized patients who were systematically screened for dysphagia and malnutrition. The results were managed through the review software tool Covidence. The screening of titles and abstracts was handled independently by two reviewers; conflicts were discussed and resolved by consensus between three authors. This procedure was retained for full-text analysis and extraction. The extraction template was piloted and revised following feedback prior to extraction, which was carried out in February 2024.

RESULTS

A total of 2014 studies were found, 1075 of which were included for abstract screening, 80 for full text screening. In the end, 27 studies were extracted and reported following the reporting guideline PRISMA with the extension for Scoping Reviews.

CONCLUSION

Most of the studies considered the prevalence and association of dysphagia and malnutrition with varying outcomes such as nutritional status, pneumonia, oral nutrition, and swallowing function. Only two studies had implemented multi-professional nutrition teams.

Usefulness of barium sulfate and iohexol as contrast agents for VFSS in visualizing components of swallowing predictable of poor outcomes

Barium sulfate and iohexol are commonly used as contrast agents for videofluoroscopic swallowing study (VFSS). This study compared their usefulness as contrast agents in visualizing components of swallowing predictable of subsequent pneumonia and unintentional weight loss after VFSS. This was a randomized, controlled, crossover trial. The two contrast agents were alternately used in the same participants, and the order in which the contrast agent was tested first was randomly assigned. After VFSS, we followed the participants for 3 months and the association between VFSS findings of each contrast agent and the subsequent pneumonia and unintentional weight loss were analyzed. A total of 30 participants were included in the analysis. We recorded 11 cases of subsequent pneumonia and 13 of unintentional weight loss. Regarding the risk of subsequent pneumonia after VFSS, only the oral transit time and number of swallows tested with barium sulfate indicated significant differences between participants with and without subsequent pneumonia. For unintentional weight loss, oral transit time and pharyngeal wall coating after swallowing tested with barium sulfate, as well as oral transit time, nasal penetration, residue in the valleculae, PAS scores, and number of swallows when testing with iohexol demonstrated significant differences between those with and without unintentional weight loss.

Clinical and functional assessment in patients admitted with pluripathological dysphagia according to the mode of feeding: Through a gastrostomy tube or oral

INTRODUCTION

Multipathological patients are a vulnerable population with high comorbidity, functional impairment, and nutritional risk. Almost 50% of these hospitalized patients have dysphagia. There is no consensus on whether placement of a percutaneous endoscopic gastrostomy (PEG) tube provides greater clinical benefit. The purpose of this study was to know and compare 2 groups of multipathological patients with dysphagia according to the mode of feeding: PEG vs. oral.

METHOD

Retrospective descriptive study with hospitalized patients (2016-19), pluripathological, with dysphagia, nutritional risk, over 50 years with diagnoses of: dementia, cerebrovascular accident (CVA), neurological disease, or oropharyngeal neoplasia. Terminally ill patients with jejunostomy tube or parenteral nutrition were excluded. Sociodemographic variables, clinical situation, and comorbidities were evaluated. Bivariate analysis was performed to compare both groups according to their diet, establishing a significance level of p < .05.

RESULTS

1928 multipathological patients. The PEG group consisted of 84 patients (n122). A total of 84 were randomly selected to form the non-PEG group (n434). This group had less history of bronchoaspiration/pneumonia (p = .008), its main diagnosis was stroke versus dementia in the PEG group (p < .001). Both groups had more than a 45% risk of comorbidity (p = .77).

CONCLUSIONS

multipathological patients with dysphagia with PEG usually have dementia as their main diagnosis, however, stroke is the most relevant pathology in those fed orally. Both groups have associated risk factors, high comorbidity, and dependence. This causes their vital prognosis to be limited regardless of the mode of feeding.

Prevalence of Oropharyngeal Dysphagia in Adults in Different Healthcare Settings: A Systematic Review and Meta-analyses

Oropharyngeal dysphagia (OD) is prevalent in the elderly and persons with complex medical conditions, resulting in considerable medical and psychosocial consequences and reduced quality of life. Many prevalence studies regard OD in relation to age or diagnosis. Knowledge on the prevalence of OD in different healthcare settings is lacking. This systematic review aimed to estimate the prevalence of OD in adults admitted to hospitals, rehabilitation facilities, nursing homes, and palliative care facilities through meta-analyses. A systematic literature search was completed including all dates up to March 30, 2021. The methodology and reporting were based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Forty-four out of 1,956 screened articles were deemed eligible. Considerable heterogeneity in definitions of OD and type and quality of selected outcome measures were observed. Overall within-group pooled prevalence estimates for OD determined by meta-analysis were 36.5% (95% CI 29.9 - 43.6) in the hospital setting, 42.5% (95% CI 35.8 - 49.5) in the rehabilitation setting, and 50.2% (95% CI 33.3-67.2) in nursing homes. No OD prevalence data were identified for palliative care facilities. Results for between-group analyses of OD prevalence estimates in the hospital setting were non-significant for type of assessment method, diagnostic group, and type of hospital ward, but indicated significantly higher prevalence estimates in nursing homes when using screening compared to patient-report. Future research should provide OD prevalence data for palliative care, achieve consensus in OD-related terminology when performing prevalence studies, and use screening and assessments with optimal diagnostic performance and psychometric properties.

History and Science behind the Eating Assessment Tool-10 (Eat-10): Lessons Learned

INTRODUCTION

Oropharyngeal dysphagia (OD) is an underdiagnosed medical condition with a high prevalence in populations such as patients with frailty, neurological disease, or head and neck pathology. Potential barriers to its diagnosis include lack of (or low) awareness of the existence and severity of the condition, the hidden nature of the condition within the 'normal ageing' process, clinical limitations, and socioeconomic reasons. Consequently, an effective treatment is not systematically offered in a timely manner, and complications, such as dehydration and respiratory infections or aspiration pneumonia, can arise. To overcome this issue, the early use of screening questionnaires to identify people at risk of swallowing disorders represents the cornerstone of preventive medicine. Several screening tools have been created but few are widely used in clinical practice. The Eating Assessment Tool-10 (EAT-10) was developed as a quick, easy-to-understand, and self-administered screening tool for OD.

METHODS

A literature review was conducted in five databases with no restrictions on the language, date of publication, or design of the study to identify aspects of the validation, applicability, and usefulness of EAT-10.

RESULTS AND CONCLUSIONS

Transcultural adaptation and translation studies, as well as studies involving various types of patients with dysphagia in different settings have shown the validity and reliability of EAT-10 in relation to the gold standard and other validation tools. The use of this standardised screening tool could be used as a primary screening instrument of dysphagia in routine clinical practice across a wide range of diseases and settings and thereby increase the likelihood of early diagnosis and management of a condition that lead to serious complications and impaired quality of life.

Impact of dysphagia and malnutrition on the survival of hospitalized patients

INTRODUCTION

Oropharyngeal dysphagia (OD) and malnutrition (MN) are highly prevalent among hospitalized patients, with significant clinical repercussions.

OBJECTIVES

To assess the prevalence, survival and factors associated with OD and MN in hospitalized patients with a high risk of OD.

METHODS

A cross-sectional observational study with 82 patients aged ≥70 years and with the possibility of oral feeding admitted in 4 services of a third level hospital during 3 months. The Nutritional Risk Screening 2002 test (NRS-2002) was performed to detect nutritional risk and the volume-viscosity screening test (V-VST) for OD evaluation. Data were collected on the clinical suspicion of OD, days of hospital stay, the number of readmissions and other socio-demographic data.

RESULTS

50.6% had OD and 51.9% MN. In 48.8%, there was underdiagnosis of OD. The median number of days of admission was higher among patients with MN (19.5 days vs 13 days, p = 0.02). Of the total readmissions, 70.8% had MN compared to 29.2% that did not (p = 0.03). Survival among patients who did not survive one year after admission was lower when OD was given (Sig. = 0.04).

CONCLUSIONS

More than half of the population studied has OD, as well as DN, which increases the rate of readmission and decreases survival at the year of admission. Although there are specific screening methods, their use is not widespread, making it difficult to diagnose OD and its therapeutic intervention.

Dysphagia Prevalence, Time Course, and Association with Probable Sarcopenia, Inactivity, Malnutrition, and Disease Status in Older Patients Admitted to an Emergency Department: A Secondary Analysis of Cohort Study Data

There is evolving evidence for an association between dysphagia and sarcopenia in older adults. For optimizing the acute health care initiative across health care settings, this study investigated prevalence and time-course of dysphagia in older patients admitted to an emergency department (ED) as well as its association with parameters for probable sarcopenia, inactivity, malnutrition, disease status, and systemic inflammation. A secondary analysis of data from the FAM-CPH cohort study on acutely admitted older medical patients (n = 125). Data were collected upon ED admission as well as four and 56 weeks after discharge. Using the Eating Assessment Tool cut-off score ≥ 2, signs of dysphagia were present in 34% of the patients at ED admission and persisted in 25% of the patients 56 weeks after discharge. Signs of dysphagia at 56-week follow-up were significantly (p < 0.05) associated with probable sarcopenia (low handgrip strength (OR = 3.79), low leg muscle strength (OR = 8.14), and low physical performance (OR = 5.68)) and with baseline swallowing inactivity (OR = 5.61), malnutrition (OR = 4.35), and systemic inflammation (OR = 1.33). Signs of dysphagia in older patients admitted to an ED was prevalent, persisted 56 weeks after discharge, and was associated with probable sarcopenia and related conditions; all modifiable targets for management of dysphagia in older patients.

The Influence of Dysphagia on Nutritional and Frailty Status among Community-Dwelling Older Adults

Malnutrition is a core symptom of the frailty cycle in older adults. The purpose of this study was to investigate whether dysphagia influences nutrition or frailty status in community-dwelling older adults. The study participants were 320 Japanese community-dwelling older adults aged ≥65 years. All participants completed a questionnaire survey that included items on age, sex, family structure, self-rated health, nutritional and frailty status, and swallowing function. Nutritional status was categorized as malnourished, at risk of malnutrition, and well-nourished based on the Mini Nutrition Assessment-Short Form. The participants were then classified into a malnutrition (malnourished/at risk) or a well-nourished group (well-nourished). Frailty was assessed using the Cardiovascular Health Study criteria. The participants were then divided into a frailty (frail/pre-frail) or a non-frailty group (robust). Dysphagia was screened using the 10-item Eating Assessment Tool. Multiple logistic regression analysis was conducted to determine whether dysphagia was associated with nutritional or frailty status. The results revealed that dysphagia influenced both nutrition (odds ratio [OR]: 4.0; 95% confidence interval [CI]: 1.9-8.2) and frailty status (OR: 2.3; 95% CI: 1.0-5.2); therefore, the swallowing function would be an important factor for community-dwelling older adults on frailty prevention programs.

Analysis of Quality of Life and Nutritional Status in Elderly Patients with Dysphagia in Order to Prevent Hospital Admissions in a COVID-19 Pandemic

(1) Background: Oropharyngeal dysphagia (OD) is currently recognized as one of the geriatric syndromes due to its high frequency in older people and its associated complications, which have a direct impact on quality of life. The main objective is to determine the effectiveness of telehealth consultation for the re-evaluation of nutritional status and quality of life assessment in older people diagnosed with OD associated with active use of thickeners to prevent hospital admissions in a COVID-19 pandemic. (2) Methods: an observational, descriptive, and longitudinal study that included a sample of 33 subjects with age equal or superior to 65 years diagnosed with OD with conserved cognitive capacity. The nutritional status was evaluated through the Mini-Nutritional Assessment (MNA) questionnaire and biochemical parameters and, the quality of life was determined through the Swallowing Quality of Life (SWAL-QOL) questionnaire. (3) Results: Thirty-three older patients with OD were recruited (54.5% women), with a mean age of 83.5 ± 7.6 years. The main cause of OD in the study population was neurodegenerative disease (51.5%), followed by cerebrovascular disease (33.3%), and other causes (15.2%). Sixty point six percent of patients were found to be at risk of malnutrition. The MNA score was significantly correlated to albumin (r: 0.600, p < 0.001) and total proteins (r: 0.435, p = 0.015), but not to total cholesterol (r: -0.116, p = 0.534) or lymphocytes (r: -0.056, p = 0.758). The mean total score of the SWAL-QOL was 75.1 ± 16.4 points. (4) Conclusions: the quality of life of the subjects related to the use of a thickener is good. Although the body mass index (BMI) and average biochemical, nutritional parameters of the subjects are within the range of normality, the MNA has detected a high percentage of subjects with the risk of malnutrition, which suggests the need for continuous re-evaluation in these patients, demonstrating the viability of the telematic route in this research.

Utility of the EAT-10 in the detection of dysphagia in high-risk hospitalisation units at a university hospital: a cross-sectional study

Introduction

Introduction: the objective was to assess the utility of the Eating Assessment Tool (EAT-10) in hospitalisation units with patients at high risk of dysphagia. Patients and methods: a cross-sectional study was conducted in the Neurology and Internal Medicine wards; patients with admission < 24 hours and in a terminal stage of disease were excluded. In the first 24-48 hours of admission the presence of dysphagia as assessed with the EAT-10, the risk of malnutrition as assessed with the Malnutrition Universal Screening Tools (MUST), and comorbidities using the Charlson index were screened. Results: a total of 169 patients were recruited (76.0 years, 52 % women); 19.5 % were at risk of malnutrition. The EAT-10 instrument could be administered in 80.6 % of the patients, and was positive in 26.6 % (women 34.1 % vs. men 18.4 %; p = 0.025). When comparing patients with higher comorbidity with those with a lower Charlson index, a lower response rate to EAT-10 was observed (78.4 % vs. 93.9 %; p = 0.038), without differences in screening positivity (28.3 % vs. 19.4 %; p = 0.310). The prevalence of dysphagia risk was higher in the Internal Medicine unit than in the Neurology unit (30.4 % vs. 19.6 %; p = 0.133), as was the percentage of cases in which screening could not be performed (21.1 % vs. 11.1 %; p = 0.011). There were no significant differences in risk of malnutrition, mortality, hospital stay, or readmission according to the EAT-10. Conclusions: The EAT-10 has limited utility in the studied hospitalisation units due to a high rate of unfeasible tests, especially among patients at higher risk of dysphagia.

Utility of the Eating Assessment Tool-10 (EAT-10) in Evaluating Self-Reported Dysphagia Associated with Oral Frailty in Japanese Community-Dwelling Older People

OBJECTIVES

The aim of the present study was to verify the associations between dysphagia as screened by the Eating Assessment Tool-10 (EAT-10) and indicators in the 100-mL water swallowing test (WST) or medical history among community-dwelling older people.

STUDY DESIGN

A cross-sectional study.

SETTING AND PARTICIPANTS

The study participants were 202 community-dwelling older Japanese adults aged ≥65 years.

MEASUREMENTS

We investigated the participants' basic attributes, including age, sex, body mass index, medical history (cerebrovascular disease, respiratory disease: chronic obstructive pulmonary disease [COPD], and history of pneumonia within the previous year), and number of prescribed medications. Dysphagia assessment was performed using the EAT-10 and the 100-mL WST as subjective and objective examinations, respectively. The 100-mL WST used four indicators (SC: swallowing capacity, VS: volume per swallow, TS: time per swallow, and choking signs). Patients with and without dysphagia according to the EAT-10 were divided into two groups according to a cutoff score of 3, and the two groups were then compared in terms of their characteristics including medical history and 100-mL WST indicators. A multiple logistic regression model was used to determine whether the indicators of the 100-mL WST or medical history were independently associated with dysphagia in the EAT-10.

RESULTS

The multiple logistic regression analysis revealed that dysphagia in the EAT-10 was independently associated with male sex (odds ratio [OR] = 2.78; 95% confidence interval [CI] = 0.98-7.90), COPD (OR = 14.68; 95% CI = 3.14-68.85), and VS and TS in the 100-mL WST (OR = 0.85; 95% CI = 0.80-0.90 and OR = 3.03; 95% CI = 1.78-5.16, respectively).

CONCLUSIONS

Our results revealed that the EAT-10 was independently associated with the 100-mL WST and respiratory disease. We propose that swallowing rehabilitation incorporating respiratory training could be effective for older people screened using the EAT-10.