This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization’s classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.

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European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome.

Texture modification has become one of the most common forms of intervention for dysphagia, and is widely considered important for promoting safe and efficient swallowing. However, to date, there is no single convention with respect to the terminology used to describe levels of liquid thickening or food texture modification for clinical use. As a first step toward building a common taxonomy, a systematic review was undertaken to identify empirical evidence describing the impact of liquid consistency and food texture on swallowing behavior. A multi-engine search yielded 10,147 non-duplicate articles, which were screened for relevance. A team of ten international researchers collaborated to conduct full-text reviews for 488 of these articles, which met the study inclusion criteria. Of these, 36 articles were found to contain specific information comparing oral processing or swallowing behaviors for at least two liquid consistencies or food textures. Qualitative synthesis revealed two key trends with respect to the impact of thickening liquids on swallowing: thicker liquids reduce the risk of penetration–aspiration, but also increase the risk of post-swallow residue in the pharynx. The literature was insufficient to support the delineation of specific viscosity boundaries or other quantifiable material properties related to these clinical outcomes. With respect to food texture, the literature pointed to properties of hardness, cohesiveness, and slipperiness as being relevant both for physiological behaviors and bolus flow patterns. The literature suggests a need to classify food and fluid behavior in the context of the physiological processes involved in oral transport and flow initiation.

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The Influence of Food Texture and Liquid Consistency Modification on Swallowing Physiology and Function: A Systematic Review

ummary
Aim
To assess the pathophysiology and treatment of neurogenic dysphagia.

Methods
46 patients with brain damage, 46 with neurodegenerative diseases and eight healthy volunteers were studied by videofluoroscopy while swallowing 3–20 mL liquid (20.4 mPa s), nectar (274.4 mPa s) and pudding (3931.2 mPa s) boluses.

Results
Volunteers presented a safe and efficacious swallow, short swallow response (≤740 ms), fast laryngeal closure (≤160 ms) and strong bolus propulsion (≥0.33 mJ). Brain damage patients presented: (i) 21.6% aspiration of liquids, reduced by nectar (10.5%) and pudding (5.3%) viscosity (P < 0.05) and (ii) 39.5% oropharyngeal residue. Neurodegenerative patients presented: (i) 16.2% aspiration of liquids, reduced by nectar (8.3%) and pudding (2.9%) viscosity (P < 0.05) and (ii) 44.4% oropharyngeal residue. Both group of patients presented prolonged swallow response (≥806 ms) with a delay in laryngeal closure (≥245 ms), and weak bolus propulsion forces (≤0.20 mJ). Increasing viscosity did not affect timing of swallow response or bolus kinetic energy.

Conclusions
Patients with neurogenic dysphagia presented high prevalence of videofluoroscopic signs of impaired safety and efficacy of swallow, and were at high risk of respiratory and nutritional complications. Impaired safety is associated with slow oropharyngeal reconfiguration and impaired efficacy with low bolus propulsion. Increasing bolus viscosity greatly improves swallowing function in neurological patients.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2036.2006.03118.x

The effect of bolus viscosity on swallowing function in neurogenic dysphagia.

Accuracy of the volume-viscosity swallow test for clinical screening of oropharyngeal dysphagia and aspiration *

Dysphagia is a symptom of swallowing dysfunction that occurs between the mouth and the stomach. Although oropharyngeal dysphagia is a highly prevalent condition (occurring in up to 50% of elderly people and 50% of patients with neurological conditions) and is associated with aspiration, severe nutritional and respiratory complications and even death, most patients are not diagnosed and do not receive any treatment. By contrast, oesophageal dysphagia is less prevalent and less severe, but with better recognized symptoms caused by diseases affecting the enteric nervous system and/or oesophageal muscular layers. Recognition of the clinical relevance and complications of oesophageal and oropharyngeal dysphagia is growing among health-care professionals in many fields. In addition, the emergence of new methods to screen and assess swallow function at both the oropharynx and oesophagus, and marked advances in understanding the pathophysiology of these conditions, is paving the way for a new era of intensive research and active therapeutic strategies for affected patients. Indeed, a unified field of deglutology is developing, with new professional profiles to cover the needs of all patients with dysphagia in a nonfragmented way.

Dysphagia: current reality and scope of the problem

Dysphagia is a symptom that refers to difficulty or discomfort during the progression of the alimentary bolus from the mouth to the stomach. From an anatomical standpoint dysphagia may result from oropharyngeal or esophageal dysfunction and from other structure-related or functional causes from a pathophysiological viewpoint. The prevalence of oropharyngeal functional dysphagia is very high in patients with neurological disease: it includes more than 30% of patients having had a CVA; its prevalence in Parkinson’s disease is 52-82%; it is the first symptom for 60% of patients with amyotrophic lateral sclerosis (ALS); it affects 40% of patients with myasthenia gravis, up to 44% of patients with multiple sclerosis; up to 84% of patients with Alzheimer’s disease, and more than 60% of elderly institutionalized patients (1-5). The severity of oropharyngeal dysphagia may vary from moderate difficulty to complete inability to swallow. Oropharyngeal dysphagia may give rise to two groups of clinically relevant complications: 1. When a decrease in deglutition efficacy occurs, patients present with malnutrition and/or dehydration. 2. When a decrease in deglutition safety occurs, choking and airway obstruction develop, most commonly as a tracheobronchial aspiration that may result in pneumonia in 50% of cases, with an associated mortality up to 50% (1).

/pdf/approaching-oropharyngeal-dysphagia-46fq9z0gbe.pdf

M. De Kraa

Papers

The effect of bolus viscosity on swallowing function in neurogenic dysphagia.

Approaching oropharyngeal dysphagia

Therapeutic effect of increasing bolus viscosity in neurogenic dysphagia