Developing a Protocol for Quantitative Analysis of Liquid Swallowing in Children.

PURPOSE: Objective measures in videofluoroscopic swallow studies (VFSSs) can quantify swallow biomechanics. There are a wide array of validated measures studied in infants, children, and adults. There is a need for a pediatric VFSS protocol that consists of a small number of vital, time efficient, and clinically relevant measures. In this study, we aimed to establish a standard protocol for quantitative VFSS analysis in children. METHOD: Protocol development began with a systematic literature review, which identified 22 quantitative and eight descriptive measures available in the literature. A pediatric VFSS database of 553 children was collected using a standardized VFSS protocol. Studies were evaluated using the 30 previously reported measures covering displacement and timing parameters as well as penetration-aspiration and residue. Measures were tested for rater reliability and internal consistency. Measures meeting acceptable values for protocol inclusion were included in the final protocol (Cronbach's alpha > .53). RESULTS: Interrater and intrarater reliability of 17 measures met acceptable reliability levels. During internal consistency testing, we removed six further measures based on Cronbach's alpha levels indicating that two or more measures were equivalent in measuring the same aspect of swallow biomechanics in children. A VFSS protocol of reliable, valid, and obtainable objective quantitative (n = 6) and descriptive measures (n = 3) with separate protocols for young infants (≤ 9 months) and older children was established. CONCLUSIONS: A standardized quantitative VFSS protocol for children has been developed to suit two age groups (≤ 9 and > 9 months old). Consistent VFSS administration and reporting support assessment over time and across disease groups. Future research should focus on how this information can be used by clinicians to produce individualized treatment plans for children with swallowing impairment.

Connecting hapu mama (pregnant women) early to a lead maternity carer: striving for equity using the Best Start-Pregnancy Tool.

Introduction In Aotearoa New Zealand, lead maternity carers (LMCs) provide maternity care through pregnancy and birth, until 6 weeks' postpartum. An early LMC connection in pregnancy is associated with better maternal and perinatal health outcomes. However, hapu mama (pregnant women) may experience barriers to engaging with LMC, delaying screening, risk assessments, and education. These barriers contribute to inequitable health outcomes for Maori mama and pepi (Maori mothers and babies). A pro-equity approach to maternity care is warranted. Aim To investigate the LMC plan at the first point of contact with a primary care provider once pregnancy is confirmed, as well as selected risk factors to maternal and perinatal health for Maori and non-Maori hapu mama. Methods Data entered by primary care providers into the Best Start-Pregnancy Tool were analysed for 482 pregnant women from November 2020 to December 2021. Results Most hapu mama planned for midwifery care. About one-third of hapu mama had engaged with a midwife before their first GP visit after a confirmed pregnancy. Maori hapu mama were more likely to present with risk factors to maternal and perinatal health than non-Maori hapu mama. Discussion Primary healthcare providers have an expectation to connect hapu mama to a LMC by 10 weeks' gestation. More research is needed to identify how to best support Maori hapu mama to access a LMC early in pregnancy. The Best Start Kowae is an accessible online tool (currently in an implementation phase) for primary care providers and LMCs that promotes equitable health outcomes for Maori mama and pepi.

Self-reported Swallowing and Nutrition Status in Community-Living Older Adults.

More New Zealanders are forecast to grow older in the community, ranging in levels of abilities and needs. Many health conditions can affect swallowing function or nutrition status in older age. However, older adults may not be aware of risk factors and when to seek help. A nationwide survey was conducted of self-reported swallowing ability and nutrition status in community-living New Zealanders aged 65 years and older to assess whether undisclosed swallowing and nutrition problems exist. Respondents completed an amalgamated questionnaire including two validated screening tools: Eating Assessment Tool (EAT-10) and Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN-II). A convenience sample of 1020 adults aged 65-96 years old was obtained. Mean EAT-10 score was 2.15 (SD = 4.3); 22.1% scored above the normative score (3 or more). Mean SCREEN-II score was 48.50 (SD = 6.5); 46.9% scored below normal (< 50 for adults under 85 years old, < 49 for adults over 84 years old). EAT-10 scores significantly correlated with SCREEN-II scores (p < 0.001). Scores did not correlate with age or differ between age groups. Significantly more respondents with medical history associated with dysphagia disclosed swallowing and nutrition problems (p < 0.001). This data suggest increased prevalence of swallowing difficulties in older age is attributed to health conditions and medications, rather than ageing itself. Swallowing complaints from community-living older adults should not be ignored or attributed to the normal ageing process. This study supports routine nutrition screening in older adults.

A Systematic Review of Physiological Changes in Swallowing in the Oldest Old.

Age-related swallowing changes are well-researched in deglutology, usually distinguishing those over 60 years as older aged. World-wide, older adults are healthier and forecast to live longer: many over 85 years. It is necessary for clinicians to understand healthy swallowing changes in this 'oldest old' in order to appropriately manage swallowing complaints in older patients. This systematic review collated and critically appraised studies investigating swallowing changes in adults over 85 years using instrumental assessment. Criteria for inclusion were healthy subjects over 85 years. Exclusion criteria included studies focused on anatomy and oral processing. Studies published until December 2018 were retrieved from BIOSIS, CINAHL, Embase, Medline, and Scopus, totaling 2125 articles. During data screening, 64% of studies investigating age-related swallowing changes were excluded, as the oldest old were not recruited. After PRISMA screening, 44 articles met criteria. These were further reviewed for data extraction, bias and quality. Main quantitative age-related changes in swallowing included increases in delay in swallow onset, bolus transit times, duration of UES opening, pressure above the UES and UES relaxation pressure, and reduction in pressure at the UES. Few studies detected increased residue or airway compromise in the form of aspiration. Results were not easily comparable due to differences in age ranges, methods for deeming participants 'healthy', measures used to define swallowing physiology, and swallowing tasks. Age-related swallowing changes are identified that do not compromise safety. The oldest old are underrepresented in normative deglutition research. It is essential future studies plan accordingly to recruit those over 85 years.

Swallowing function in advanced age.

PURPOSE OF REVIEW: To present current literature regarding swallowing function in advanced age, including healthy ageing, dysphagia and trends in multidisciplinary team service delivery. RECENT FINDINGS: Normative studies support swallowing efficiency but greater variability in healthy advanced age, through to 100 years old. Deviations from normative data and symptoms of dysphagia leading to aspiration or nutritional risk, imply swallowing disorder, rather than simply the ageing process. Quantitative and qualitative studies are emerging that promote management of swallow dysfunction for an ageing society, including innovative assessment, home treatment, swallowing exercise and optimized mealtimes. SUMMARY: Current literature on swallowing function in advanced age provides multidisciplinary perspectives and initiatives, with clear commitment to improving quality of life for older adults. The diversity of the older population and serious consequences of swallowing difficulties calls for routine screening tools for swallowing impairment and malnutrition risk. Representation of 'oldest old' in future normative studies is essential to guide swallowing management in adults over 85 years old.

What is a normal pharynx? A videofluoroscopic study of anatomy in older adults.

PURPOSE: Structural and functional pharyngeal changes occur with age. How these affect swallowing in healthy older adults is not well defined. This study presents quantitative pharyngeal anatomic features in healthy adults using videofluoroscopic study of swallowing (VFSS). This will help our understanding of the normal changes in swallowing that occur with age and illustrate what may constitute normal variation compared with abnormal swallow function. METHODS: 138 mixed gender adults with no history of dysphagia were recruited and underwent a standardized VFSS protocol. Parameters including age, BMI, and gender were correlated with the presence of a cricopharyngeal bar, spinal changes and pharyngeal wall thickness at rest. RESULTS: 46% of participants had notable spinal changes. 8% of participants demonstrated cricopharyngeal bars and 12% of subjects revealed osteophytes. Age positively correlated with the presence of a cricopharyngeal bar (rs = 0.281, p < 0.001) and presence of osteophytes (rs = 0.334, p < 0.001). The incidence of cricopharyngeal bars in adults over 70 years old was 16%. CONCLUSIONS: A significant number of healthy adults with no swallowing complaints have variant pharyngeal anatomic findings such as cervical vertebral osteophytes and cricopharyngeal bars. This must be taken into account when assessing patients with dysphagia complaints to avoid misattribution of symptoms to these potentially asymptomatic variants. This ensures correct recommendations are made regarding management including diet modification, compensatory strategies, and surgical intervention.

Dysphagia Onset in Older Adults during Unrelated Hospital Admission: Quantitative Videofluoroscopic Measures.

New-onset swallowing difficulties in older patients during unrelated hospital admissions are well recognized and may result in prolonged hospital stay and increased morbidity. Presbyphagia denotes age-related swallowing changes which do not necessarily result in pathological effects. The trajectory from presbyphagia to dysphagia is not well understood. This retrospective observational study compared quantitative videofluoroscopic measures in hospitalized older adults aged 70-100 years, reporting new dysphagia symptoms during admission (n = 52), to healthy asymptomatic older (n = 56) and younger adults (n = 43). Significant physiological differences seen in hospitalized older adults but not healthy adults, were elevated pharyngeal area (p < 0.001) and pharyngeal constriction ratio (p < 0.001). Significantly increased penetration (p < 0.001), aspiration (p < 0.001) and pharyngeal residue (p < 0.001) were also observed in the hospitalized older cohort. Reasons for onset of new swallow problems during hospitalization are likely multifactorial and complex. Alongside multimorbidity and polypharmacy, a combination of factors during hospitalization, such as fatigue, low levels of alertness, delirium, reduced respiratory support and disuse atrophy, may tip the balance of age-related swallowing adaptations and compensation toward dysfunctional swallowing. To optimize swallowing assessment and management for our aging population, care must be taken not to oversimplify dysphagia complaints as a characteristic of aging.

Effect of Lee Silverman Voice Treatment (LSVT LOUD®) on swallowing and cough in Parkinson's disease: A pilot study.

PURPOSE: Lee Silverman Voice Treatment (LSVT LOUD®) is an effective therapy for phonation in Parkinson's Disease (PD) but little is known about any additional spread of effects to swallowing and cough function. This pilot study examined the effect of LSVT LOUD on pharyngeal swallowing parameters and reflexive cough strength. METHODS: Twenty participants (14 men, 6 women; mean 68years, SD3.5) with PD referred for LSVT LOUD with complaints of voice deterioration were recruited. Mean duration of PD was 6yrs., SD 3. Self-reported Eating Assessment Tool-10 scores ranging from 0 to 25 (normal<3). Prior to LSVT LOUD, 1-week post- and 6-months post-treatment, participants undertook a videofluoroscopic study of swallowing and aerodynamic measures of involuntary cough. RESULTS: All participants completed the LSVT LOUD programme; 3 participants were lost to follow-up at 6-months. All participants made significant gains in average sound pressure level (dB SPL). Aspiration was not observed. Pharyngeal residue (p<0.05) and pharyngeal area at rest reduced (p<0.01) while maximal opening of pharyngoesophageal segment (PES) (p<0.05) and PES opening duration (p<0.05) significantly increased. There was a significant improvement in involuntary cough peak expiratory flow rate and peak expiratory flow rise time. All changes were maintained at 6-months. CONCLUSION: LSVT LOUD demonstrates additional spread effects on pharyngoesophageal deglutitive function and involuntary cough effectiveness in people with mild PD referred with voice complaints. Consequently, LSVT LOUD has potential to provide additional benefits for swallowing safety and efficiency in this patient group.

Esophageal Swallowing Timing Measures in Healthy Adults During Videofluoroscopy.

OBJECTIVES: Establishing the range of normal esophageal bolus transit times (ETT) is valuable when distinguishing pathology from normal variance, especially in elderly patients, and has not been documented for paste or pill. The aim of this study was to measure esophageal transit of liquid, paste, and pill during upright videofluoroscopy. METHODS: One hundred eighteen healthy adults (mean age 54; range 20-98 years; SD = 21.40) with no complaints of dysphagia completed a videofluoroscopy with esophageal visualization including 20 ml liquid barium, 5 ml paste, and pill. RESULTS: Mean ETTs were: 20 ml fluid, 10.7 seconds (SD = 13.6, median = 5.76, IQR = 4.33, range, 2.0-60.0); pill, 25.3 seconds (SD = 24.0, median = 12.70, IQR = 49.81, range, 1.0-60.0); paste, 28.6 seconds (SD = 23.31, median = 17.47, IQR = 53, range, 4.0-60.0). Age was significantly associated with increasing 20 ml fluid ETT (P < .001) but not pill (P = .58) or paste ETT (P = .12). Fluid ETT over 10 seconds occurred in 10% of participants between 20 and 59 years, in comparison to 35% over 60 years (P < .001). CONCLUSIONS: These normative values provide a standardized protocol and guidance in interpretation when completing esophageal visualization as part of videofluoroscopy. While measuring fluid ETT may support referral for further specialist investigations, slower paste and pill ETT may be normal findings. Age-related slowing in fluid ETT was seen in healthy adults. Further investigation of ETT is needed in both normal and dysphagic subjects.