Age-Related Differences in Pressures Generated During Isometric Presses and Swallows by Healthy Adults.

The aim of this prospective observational study was to determine the associations among age, maximum lingual isometric pressures, and maximum swallow pressures in specific regions of the tongue. Individuals 21 years and older who reported normal swallowing were enrolled. Seventy-one healthy adults were stratified by age into young (21-40 years), middle (41-60), and old (61-82) groups. Maximum pressures were measured for each individual during isometric tongue press tasks as well as saliva, 5, and 10 mL thin liquid bolus swallows at 5 sensors located on the hard palate: front, middle, left, right, and back. Lower maximum lingual pressures for all tasks were associated with increased age (p < 0.04). Saliva pressures exhibited a different pressure pattern than bolus swallows with pressures higher than bolus swallows on middle (p < 0.03) and back (p < 0.05) tongue sensors but not in the front. Diminished swallow pressure reserve (maximum isometric pressure-maximum swallow pressure) also was found with increased age (p < 0.03). Isometric pressures were greater than swallow pressures in young and middle age groups at both the front (p < 0.04) and back (p < 0.03) sensors, but only significantly greater at the front sensor for the oldest group (p < 0.04). Older healthy adults have lower lingual isometric pressures and lower swallow pressures than younger healthy adults. Elders have a decreased swallow pressure reserve to draw upon during occasions of physiological stress. While the exact mechanisms for age-related decline in lingual pressures remain unclear, they are likely due, at least in part, to sarcopenia. Saliva, 5, and 10 mL thin boluses also exhibit different age-related declines in pressure at specific sensors, indicating they may elicit different muscle activation patterns.

Comparison of Maximal Lingual Pressure Generation During Isometric Gross and Fine Sensorimotor Tasks in Healthy Adults.

OBJECTIVES: To (1) compare 2 distinct isometric lingual press tasks, fine sensorimotor versus gross sensorimotor, at multiple sensor locations in relation to age and sex; and (2) provide a normative data set using a lingual-strengthening device. DESIGN: Cohort study. SETTING: University. PARTICIPANTS: Healthy men and women (N=71; age range, 21-82y) recruited from the community. INTERVENTIONS: Participants were stratified by age and sex and divided into 3 age groups. Participants completed, in random order, 2 isometric tasks: (1) fine sensorimotor: tongue press maximally and discreetly against each of 5 sensors; and (2) gross sensorimotor: tongue press maximally against all 5 sensors simultaneously. MAIN OUTCOME MEASURES: Primary outcome was maximum isometric pressure in hectopascals (hPa). Secondary outcomes were time to reach peak pressure (s) and pressure gradient (hPa/s). RESULTS: Maximum pressures were significantly lower in those of older age for both fine and gross sensorimotor lingual tasks (P<.01), with the front and back sensors showing the greatest decline (35% and 45%, respectively). Pressure differences between tasks (P=.0012) resulted in the fine sensorimotor task generating higher pressures at the front sensor for all age groups. However, the gross sensorimotor task generated faster maximum pressures at all sensor locations for all age groups. For both sensorimotor tasks, subjects of older age as a whole generated less steep pressure gradients (P<.001). CONCLUSIONS: Age-related decline in tongue strength is greater at the anterior and posterior tongue. Results indicate a simpler gross sensorimotor task may be more beneficial for targeting timing as a biomechanical parameter during therapy, and the fine sensorimotor task may be more beneficial for targeting strength.

Case study: application of isometric progressive resistance oropharyngeal therapy using the Madison Oral Strengthening Therapeutic device.

PURPOSE: Isometric progressive resistance oropharyngeal (I-PRO) therapy improves swallowing function; however, current devices utilize a single sensor that provides limited information or are prohibitively expensive. This single-subject study presents results of I-PRO therapy, detraining, and maintenance using the 5-sensor Madison Oral Strengthening Therapeutic (MOST) device combined with upper esophageal sphincter (UES) dilatation. METHODS: A 56-year-old female nurse who was 27 months post stroke and subsequent to traditional behavioral interventions and UES dilatations presented limited to gastrostomy tube intake only and expectorating all saliva. She completed 8 weeks of I-PRO therapy, 5 weeks of detraining, and 9 weeks of I-PRO maintenance (reduced frequency) followed by a third UES dilatation post intervention. Data included diet inventory, lingual pressures (MOST), lingual volume (magnetic resonance imaging), postswallow residue (videofluoroscopy), UES and pharyngeal pressures (high-resolution manometry), and quality of life (QOL). RESULTS: Findings after 8 weeks of I-PRO therapy were progression to general oral diet, 15 lb weight gain, increased isometric pressures (Δ â‰¯16 kPa) with transference to swallowing pressures, increased lingual volume (8.3%), reduced pharyngeal wall residue (P = .03), increased pharyngeal pressures (Δ â‰¯ 43 mm Hg) and increased UES opening (nadir) pressures (Δ â‰¯ 9 mm Hg) with improved temporopressure coordination across the pharynx, and improved QOL. After detraining, decreased isometric pressures and reduced UES opening were noted. After I-PRO maintenance, isometric anterior lingual pressures returned to levels noted after the 8 weeks of intervention. CONCLUSION: I-PRO therapy, facilitated by the MOST device combined with instrumental UES dilatation, improved swallow safety, increased oropharyngeal intake, and facilitated UES opening while enriching QOL.

Approaches to the rehabilitation of dysphagia in acute poststroke patients.

Dysphagia occurs frequently following stroke and may result in serious health consequences including pneumonia, malnutrition, dehydration, and mortality. Prevention of these negative health outcomes requires early identification and treatment of dysphagia. The speech-language pathologist, as part of a multidisciplinary team, holds the primary responsibility for selection of an effective dysphagia rehabilitation program for these patients. Because much research has focused on patients with chronic dysphagia, this review will focus on treatment of patients within the acute phase of recovery poststroke. Although some acute patients may experience transient dysphagia that resolves spontaneously, many will go on to develop chronic dysphagia that may be prevented with provision of early and intensive treatment. An overview of dysphagia following stroke will be provided with information regarding incidence, complications, evaluation, and causes of dysphagia. A thorough discussion of evidence supporting varying approaches to dysphagia rehabilitation will follow with inclusion of several current, novel, and experimental techniques. The importance of the multidisciplinary team and regular reevaluation will be emphasized as well.

The effects of lingual intervention in a patient with inclusion body myositis and Sjögren's syndrome: a longitudinal case study.

OBJECTIVE: To report the 5-year course of a patient's swallowing disorder in the context of progressive neuromuscular disease and the effectiveness of a lingual strengthening treatment program. DESIGN: This is a case report that describes a lingual treatment protocol that was repeated 3 times over a 5-year period with and without maintenance periods. SETTING: The study was completed in 2 settings-an outpatient swallowing clinic at an acute care hospital and the patient's home. PARTICIPANT: The subject was a 77-year-old woman who was diagnosed with inclusion body myositis and Sjögren's syndrome. INTERVENTION: The patient participated in an intensive 8-week lingual strengthening protocol 3 times (at years 1, 4, and 5) and a subsequent maintenance program twice (at years 4 and 5). MAIN OUTCOME MEASURES: Three outcome measures were collected during the study: (1) lingual manometric pressures at the anterior and posterior tongue, measured by using a lingual manometric device, (2) airway invasion measured by using an 8-point Penetration-Aspiration Scale, and (3) clearance of the bolus measured by using a 3-point residue scale. RESULTS: Isometric lingual strengthening was effective in maintaining posterior tongue lingual pressure and Penetration-Aspiration Scale scores during the treatment periods. Residue scale scores did not significantly change during treatment. CONCLUSIONS: We conclude that, in this patient, lingual strengthening slowed the progression of disease-related lingual strength loss and extended functional swallowing performance. Thus, this type of intervention may hold promise as an effective swallowing treatment option for patients with neurodegenerative inflammatory diseases such as inclusion body myositis and Sjögren's syndrome.

Effects of Mendelsohn maneuver on measures of swallowing duration post stroke.

PURPOSE: The purpose of this pilot study was to determine whether intensive use of the Mendelsohn maneuver in patients post stroke could alter swallow physiology when used as a rehabilitative exercise. METHOD: Eighteen outpatients between 6 weeks and 22 months post stroke were enrolled in this prospective study using a crossover design to compare 2 weeks of treatment with 2 weeks of no treatment. Each participant received an initial videofluoroscopic swallow study (VFSS) and an additional VFSS at the end of each week for 1 month for a total of 5 studies. During treatment weeks, participants received 2 treatment sessions per day performing Mendelsohn maneuvers with surface electromyography for biofeedback. Measures of swallowing duration, penetration/aspiration, residue, and dysphagia severity were analyzed from VFSS to compare treatment and no-treatment weeks. RESULTS: Significant changes occurred for measures of the duration of superior and anterior hyoid movement after 2 weeks of treatment. Improvements were observed for duration of opening of the upper esophageal sphincter (UES), but results were not statistically significant. Measures of penetration/aspiration, residue, and dysphagia severity improved throughout the study, but no differences were observed between treatment and no-treatment weeks. CONCLUSIONS: Intensive use of the Mendselsohn maneuver in isolation altered duration of hyoid movement and UES opening in this exploratory study. Results can guide future research toward improved selection criteria and exploration of outcomes. Larger numbers of participants and variations in treatment duration and intensity will be necessary to determine the true clinical value of this treatment.

Alterations in white matter microstructural properties after lingual strength exercise in patients with dysphagia.

OBJECTIVES: Central nervous system effects of lingual strengthening exercise to treat dysphagia remain largely unknown. This pilot study measured changes in microstructural white matter to capture alterations in neural signal processing following lingual strengthening exercise. METHODS: Diffusion-weighted images were acquired from seven participants with dysphagia of varying etiologies, before and after lingual strengthening exercise (20 reps, 3×/day, 3 days/week, 8 weeks), using a 10-min diffusion sequence (9 b0, 56 directions with b1000) on GE750 3T scanner. Tract-Based Spatial Statistics evaluated voxel-based group differences for fractional anisotropy, mean diffusivity, axial diffusivity, radial diffusivity and local diffusion homogeneity (LDH). Paired t-tests evaluated treatment differences on each metric (P < 0.05). RESULTS: After lingual strengthening exercise, lingual pressure generation increased (avg increase = 46.1 hPa; nonsignificant P = 0.52) with these changes in imaging metrics: (1) decrease in fractional anisotropy, forceps minor; (2) increase in mean diffusivity, right inferior fronto-occipital fasciculus (IFOF); (3) decrease in mean diffusivity, left uncinate fasciculus; (4) decrease in axial diffusivity, both left IFOF and left uncinate fasciculus; (5) increase in LDH, right anterior thalamic radiation and (6) decrease in LDH, temporal portion of right superior longitudinal fasciculus. There was a positive correlation between diffusion tensor imaging metrics and change in lingual pressure generation in left IFOF and the temporal portion of right superior longitudinal fasciculus. CONCLUSIONS: These findings suggest that lingual strengthening exercise can induce changes in white matter structural and functional properties in a small group of patients with dysphagia of heterogeneous etiologies. These procedures should be repeated with a larger group of patients to improve interpretation of overall lingual strengthening exercise effects on cortical structure and function.

Omission of dysphagia therapies in hospital discharge communications.

Despite the wide implementation of dysphagia therapies, it is unclear whether these therapies are successfully communicated beyond the inpatient setting. The aim of this study was to examine the rate of dysphagia recommendation omissions in hospital discharge summaries for high-risk subacute care (i.e., skilled nursing facility, rehabilitation, long-term care) populations. We performed a retrospective cohort study that included all stroke and hip fracture patients billed for inpatient dysphagia evaluations by speech-language pathologists (SLPs) and discharged to subacute care from 2003 through 2005 from a single large academic medical center (N=187). Dysphagia recommendations from final SLP hospital notes and from hospital (physician) discharge summaries were abstracted, coded, and compared for each patient. Recommendation categories included dietary (food and liquid), postural/compensatory techniques (e.g., chin tuck), rehabilitation (e.g., exercise), meal pacing (e.g., small bites), medication delivery (e.g., crush pills), and provider/supervision (e.g., 1-to-1 assist). Forty-five percent of discharge summaries omitted all SLP dysphagia recommendations. Forty-seven percent (88/186) of patients with SLP dietary recommendations, 82% (93/114) with postural, 100% (16/16) with rehabilitation, 90% (69/77) with meal pacing, 95% (21/22) with medication, and 79% (96/122) with provider/supervision recommendations had these recommendations completely omitted from their discharge summaries. Discharge summaries omitted all categories of SLP recommendations at notably high rates. Improved post-hospital communication strategies are needed for discharges to subacute care.

Frontline Interventions: Considerations for Modifying Fluids and Foods for Management of Feeding and Swallowing Disorders Across the Life Span.

Purpose Individuals with dysphagia across the age continuum may require dietary modifications of fluids and foods for safe and adequate oral intake. Considerations of this frontline intervention are presented in this clinical forum dedicated to the discussion of dysphagia. Method This clinical focus article reviews the technical challenges of providing modified fluids and foods across the life span as well as the literature specific to its origins, efficacy, challenges and solutions to standardization, and the methods for ensuring quality service delivery. Conclusion Dietary modification is an often-used method of dysphagia management that presents unique challenges to the clinician for successful application. Speech-language pathologists in clinical practice across all settings must remain dedicated to evidence-based practice as they navigate service delivery of this strategy to individuals with dysphagia across the life span.

Neurophysiology of swallowing: effects of age and bolus type.

This study examined age-related changes in swallowing from an integrated biomechanical and functional imaging perspective in order to more comprehensively characterize changes in swallowing associated with age. We examined swallowing-related fMRI brain activity and videoflouroscopic biomechanics of three bolus types (saliva, water and barium) in 12 young and 11 older adults. We found that age-related neurophysiological changes in swallowing are evident. The group of older adults recruited more cortical regions than young adults, including the pericentral gyri and inferior frontal gyrus pars opercularis and pars triangularis (primarily right-sided). Saliva swallows elicited significantly higher BOLD responses in regions important for swallowing compared to water and barium. In separate videofluoroscopy sessions, we obtained durational measures of supine swallowing. The older cohort had significantly longer delays before the onset of the pharyngeal swallow response and increased residue of ingested material in the pharynx. These findings suggest that older adults without neurological insult elicit more cortical involvement to complete the same swallowing tasks as younger adults.

Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial.

BACKGROUND: Aspiration pneumonia is common among frail elderly persons with dysphagia. Although interventions to prevent aspiration are routinely used in these patients, little is known about the effectiveness of those interventions. OBJECTIVE: To compare the effectiveness of chin-down posture and 2 consistencies (nectar or honey) of thickened liquids on the 3-month cumulative incidence of pneumonia in patients with dementia or Parkinson disease. DESIGN: Randomized, controlled, parallel-design trial in which patients were enrolled for 3-month periods from 9 June 1998 to 19 September 2005. SETTING: 47 hospitals and 79 subacute care facilities. PATIENTS: 515 patients age 50 years or older with dementia or Parkinson disease who aspirated thin liquids (demonstrated videofluoroscopically). Of these, 504 were followed until death or for 3 months. INTERVENTION: Participants were randomly assigned to drink all liquids in a chin-down posture (n = 259) or to drink nectar-thick (n = 133) or honey-thick (n = 123) liquids in a head-neutral position. MEASUREMENTS: The primary outcome was pneumonia diagnosed by chest radiography or by the presence of 3 respiratory indicators. RESULTS: 52 participants had pneumonia, yielding an overall estimated 3-month cumulative incidence of 11%. The 3-month cumulative incidence of pneumonia was 0.098 and 0.116 in the chin-down posture and thickened-liquid groups, respectively (hazard ratio, 0.84 [95% CI, 0.49 to 1.45]; P = 0.53). The 3-month cumulative incidence of pneumonia was 0.084 in the nectar-thick liquid group compared with 0.150 in the honey-thick liquid group (hazard ratio, 0.50 [CI, 0.23 to 1.09]; P = 0.083). More patients assigned to thickened liquids than those assigned to the chin-down posture intervention had dehydration (6% vs. 2%), urinary tract infection (6% vs. 3%), and fever (4% vs. 2%). LIMITATIONS: A no-treatment control group was not included. Follow-up was limited to 3 months. Care providers were not blinded, and differences in cumulative pneumonia incidence between interventions had wide CIs. CONCLUSION: No definitive conclusions about the superiority of any of the tested interventions can be made. The 3-month cumulative incidence of pneumonia was much lower than expected in this frail elderly population. Future investigation of chin-down posture combined with nectar-thick liquid may be warranted to determine whether this combination better prevents pneumonia than either intervention independently.

Senescent swallowing: impact, strategies, and interventions.

The risk for disordered oropharyngeal swallowing (dysphagia) increases with age. Loss of swallowing function can have devastating health implications, including dehydration, malnutrition, pneumonia, and reduced quality of life. Age-related changes increase risk for dysphagia. First, natural, healthy aging takes its toll on head and neck anatomy and physiologic and neural mechanisms underpinning swallowing function. This progression of change contributes to alterations in the swallowing in healthy older adults and is termed presbyphagia, naturally diminishing functional reserve. Second, disease prevalence increases with age, and dysphagia is a comorbidity of many age-related diseases and/or their treatments. Sensory changes, medication, sarcopenia, and age-related diseases are discussed herein. Recent findings that health complications are associated with dysphagia are presented. Nutrient requirements, fluid intake, and nutrition assessment for older adults are reviewed relative to dysphagia. Dysphagia screening and the pros and cons of tube feeding as a solution are discussed. Optimal intervention strategies for elders with dysphagia ranging from compensatory interventions to more rigorous exercise approaches are presented. Compelling evidence of improved functional swallowing and eating outcomes resulting from active rehabilitation focusing on increasing strength of head and neck musculature is provided. In summary, although oropharyngeal dysphagia may be life threatening, so are some of the traditional alternatives, particularly for frail, elderly patients. Although the state of the evidence calls for more research, this review indicates that the behavioral, dietary, and environmental modifications emerging in this past decade are compassionate, promising, and, in many cases, preferred alternatives to the always present option of tube feeding.

A comparison of the reliability and stability of oro-lingual swallowing pressures in patients with head and neck cancer and healthy adults.

The ability to measure normality and abnormality and to accurately assess true changes in swallowing function over time, is important for the management of dysphagia. Despite this, there is a paucity of information regarding the stability and reliability of measurements tools used for dysphagia research. As both head and neck (H&N) cancer and its treatment(s) have been shown to significantly affect deglutitive tongue function, it is important that we have a reliable method to measure swallowing tongue function in this population. In this study we evaluate the reliability and stability of oro-lingual swallowing pressures captured from H&N cancer patients and from healthy, age- and gender-matched controls using the Kay Swallowing Workstation (KSW) fixed, three-transducer tongue pressure array. Significant differences between the two samples (H&N cancer and controls), with respect to mean peak oro-lingual pressures were recorded during swallowing. Furthermore, reliability of these measures was lower in H&N cancer patients. These differences highlight the importance of obtaining information about the reliability of dysphagia assessment tools with the specific population with whom they will be used.

Comparison of trained clinician ratings with expert ratings of aspiration on videofluoroscopic images from a randomized clinical trial.

Accurate detection and classification of aspiration is a critical component of videofluoroscopic swallowing evaluation, the most commonly utilized instrumental method for dysphagia diagnosis and treatment. Currently published literature indicates that interjudge reliability for the identification of aspiration ranges from poor to fairly good depending on the amount of training provided to clinicians. The majority of extant studies compared judgments among clinicians. No studies included judgments made during the use of a postural compensatory strategy. The purpose of this study was to examine the accuracy of judgments made by speech-language pathologists (SLPs) practicing in hospitals compared with unblinded expert judges when identifying aspiration and using the 8-point Penetration/Aspiration Scale. Clinicians received extensive training for the detection of aspiration and minimal training on use of the Penetration/Aspiration Scale. Videofluoroscopic data were collected from 669 patients as part of a large, randomized clinical trial and include judgments of 10,200 swallows made by 76 clinicians from 44 hospitals in 11 states. Judgments were made on swallows during use of dysphagia compensatory strategies: chin-down posture with thin liquids and head-neutral posture with thickened liquids (nectar-thick and honey-thick consistencies). The subject population included patients with Parkinson's disease and/or dementia. Kappa statistics indicate high accuracy for all interventions by SLPs for identification of aspiration (all kappa > 0.86) and variable accuracy (range = 69-76%) using the Penetration/Aspiration Scale when compared to expert judges. It is concluded that while the accuracy of identifying the presence of aspiration by SLPs is excellent, more extensive training and/or image enhancement is recommended for precise use of the Penetration/Aspiration Scale.

Swallowing and dysphagia rehabilitation: translating principles of neural plasticity into clinically oriented evidence.

PURPOSE: This review presents the state of swallowing rehabilitation science as it relates to evidence for neural plastic changes in the brain. The case is made for essential collaboration between clinical and basic scientists to expand the positive influences of dysphagia rehabilitation in synergy with growth in technology and knowledge. The intent is to stimulate thought and propose potential research directions. METHOD: A working group of experts in swallowing and dysphagia reviews 10 principles of neural plasticity and integrates these advancing neural plastic concepts with swallowing and clinical dysphagia literature for translation into treatment paradigms. In this context, dysphagia refers to disordered swallowing associated with central and peripheral sensorimotor deficits associated with stroke, neurodegenerative disease, tumors of the head and neck, infection, or trauma. RESULTS AND CONCLUSIONS: The optimal treatment parameters emerging from increased understanding of neural plastic principles and concepts will contribute to evidence-based practice. Integrating these principles will improve dysphagia rehabilitation directions, strategies, and outcomes. A strategic plan is discussed, including several experimental paradigms for the translation of these principles and concepts of neural plasticity into the clinical science of rehabilitation for oropharyngeal swallowing disorders, ultimately providing the evidence to substantiate their translation into clinical practice.

A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson's disease.

PURPOSE: This study was designed to identify which of 3 treatments for aspiration on thin liquids-chin-down posture, nectar-thickened liquids, or honey-thickened liquids-results in the most successful immediate elimination of aspiration on thin liquids during the videofluorographic swallow study in patients with dementia and/or Parkinson's disease. METHOD: This randomized clinical trial included 711 patients ages 50 to 95 years who aspirated on thin liquids as assessed videofluorographically. All patients received all 3 interventions in a randomly assigned order during the videofluorographic swallow study. RESULTS: Immediate elimination of aspiration on thin liquids occurred most often with honey-thickened liquids for patients in each diagnostic category, followed by nectar-thickened liquids and chin-down posture. Patients with most severe dementia exhibited least effectiveness on all interventions. Patient preference was best for chin-down posture followed closely by nectar-thickened liquids. CONCLUSION: To identify best short-term intervention to prevent aspiration of thin liquid in patients with dementia and/or Parkinson's disease, a videofluorographic swallow assessment is needed. Evidence-based practice requires taking patient preference into account when designing a dysphagic patient's management plan. The longer-term impact of short-term prevention of aspiration requires further study.

Dysphagia in the elderly.

The capacity to swallow or eat is a basic human need and can be a great pleasure. Older adults look forward to sharing mealtimes and participating in social interactions. The loss of capacity to swallow and dine can have far-reaching implications. With age, the ability to swallow undergoes changes that increase the risk for disordered swallowing, with devastating health implications for older adults. With the growth in the aging population, dysphagia is becoming a national health care burden and concern. Upward of 40% of people in institutionalized settings are dysphagic. There is a need to address dysphagia in ambulatory, acute care, and long-term care settings.

Effects of Device-Facilitated Isometric Progressive Resistance Oropharyngeal Therapy on Swallowing and Health-Related Outcomes in Older Adults with Dysphagia.

Swallowing disorders (dysphagia) are associated with malnutrition, aspiration pneumonia, and mortality in older adults. Strengthening interventions have shown promising results, but the effectiveness of treating dysphagia in older adults remains to be established. The Swallow STRengthening OropharyNGeal (Swallow STRONG) Program is a multidisciplinary program that employs a specific approach to oropharyngeal strengthening-device-facilitated (D-F) isometric progressive resistance oropharyngeal (I-PRO) therapy-with the goal of reducing health-related sequelae in veterans with dysphagia. Participants completed 8 weeks of D-F I-PRO therapy while receiving nutritional counseling and respiratory status monitoring. Assessments were completed at baseline, 4, and 8 weeks. At each visit, videofluoroscopic swallowing studies were performed. Dietary and swallowing-related quality of life questionnaires were administered. Long-term monitoring for 6-17 months after enrollment allowed for comparison of pneumonia incidence and hospitalizations to the 6-17 months before the program. Veterans with dysphagia confirmed with videofluoroscopy (N = 56; 55 male, 1 female; mean age 70) were enrolled. Lingual pressures increased at anterior (effect estimate = 92.5, P < .001) and posterior locations (effect estimate = 85.4, P < .001) over 8 weeks. Statistically significant improvements occurred on eight of 11 subscales of the Quality of Life in Swallowing Disorders (SWAL-QOL) Questionnaire (effect estimates = 6.5-19.5, P < .04) and in self-reported sense of effort (effect estimate = -18.1, P = .001). Higher Functional Oral Intake Scale scores (effect estimate = 0.4, P = .02) indicated that participants were able to eat less-restrictive diets. There was a 67% reduction in pneumonia diagnoses, although the difference was not statistically significant. The number of hospital admissions decreased significantly (effect estimate = 0.96; P = .009) from before to after enrollment. Findings suggest that the Swallow STRONG multidisciplinary oropharyngeal strengthening program may be an effective treatment for older adults with dysphagia.

The effects of lingual exercise on swallowing in older adults.

OBJECTIVES: To determine the effects of an 8-week progressive lingual resistance exercise program on swallowing in older individuals, the most "at risk" group for dysphagia. DESIGN: Prospective cohort intervention study. SETTING: Subjects were recruited from the community at large. PARTICIPANTS: Ten healthy men and women aged 70 to 89. INTERVENTION: Each subject performed an 8-week lingual resistance exercise program consisting of compressing an air-filled bulb between the tongue and hard palate. MEASUREMENTS: At baseline and Week 8, each subject completed a videofluoroscopic swallowing evaluation for kinematic and bolus flow assessment of swallowing. Swallowing pressures and isometric pressures were collected at baseline and Weeks 2, 4, and 6. Four of the subjects also underwent oral magnetic resonance imaging (MRI) to measure lingual volume. RESULTS: All subjects significantly increased their isometric and swallowing pressures. All subjects who had the MRI demonstrated increased lingual volume of an average of 5.1%. CONCLUSION: The findings indicate that lingual resistance exercise is promising not only for preventing dysphagia due to sarcopenia, but also as a treatment strategy for patients with lingual weakness and swallowing disability due to frailty or other age-related conditions. The potential effect of lingual exercise on reducing dysphagia-related comorbidities (pneumonia, malnutrition, and dehydration) and healthcare costs while improving quality of life is encouraging.

Nutrient intake from thickened beverages and patient-specific implications for care.

Dysphagia, or difficulty swallowing, affects more than 15 million Americans and can result in adverse and potentially fatal consequences, including poor quality of life, depression, dehydration, malnutrition, aspiration pneumonia, and airway obstruction. Although many treatment options are available, provision of thickened liquids is a common intervention for achieving slower, more controlled bolus manipulation and propulsion. To meet this therapeutic demand, commercially available products containing starch and/or gum-based components have been developed for use by patients and institutions. The nutrient content of thickened products has been neglected, although dysphagic patients are often at significant nutrition risk. Thus, there are no clinical guidelines for selection of thickened products based on patient characteristics. To consider whether such guidelines are warranted, it is necessary to quantify nutrition differences among common thickened beverages. An analysis was conducted to quantify energy, carbohydrate, and sodium provided through daily consumption of thickened beverages. To determine the relevance of these nutrition contributions in the context of total dietary intake, we compared values with dietary recommended intakes. This analysis revealed that there are substantial disparities in the nutrient content of thickened beverages. These differences suggest that product selection can be optimized based on patient-specific characteristics such as weight status and presence of comorbidities. Future research focusing on the effect of this strategy on patient outcomes will facilitate the development of evidence-based recommendations to elevate the standard of care for this population.