Effects of Oral Management on Elderly Patients with Pneumonia.

OBJECTIVES: In this study, we examined the factors influencing the presence or absence of dental intervention in patients with pneumonia in an acute-care hospital, focusing on oral intake and its status. DESIGN: Observational study. SETTING: Teikyo University School of Medicine, Mizonokuchi Hospital. PARTICIPANTS: Patients ≥65 years of age who were admitted to the Teikyo University School of Medicine, Mizonokuchi Hospital between January 1, 2018 and December 31, 2019 with pneumonia who were referred to the Department of Rehabilitation with suspected dysphagia were included in the study. Fifty patients who underwent dental intervention were compared with 50 controls who had received no dental interventions prior to the opening of the dental department. MEASUREMENTS: Time series matching was retrospectively performed using the Oral Health Assessment Tool (OHAT). From the medical records, age at admission, sex, pneumonia severity classification (age, dehydration, respiratory failure, orientation disturbance, and blood pressure [A-DROP] score), body mass index, Charlson's Comorbidity Index, OHAT, functional oral intake scale (FOIS) score at admission and discharge, and the length of hospital stay were retrieved; FOIS level ≥4 was defined as established oral intake. RESULTS: The number of patients in the control group before matching was 179. Twelve patients with missing information and seven patients who died in the hospital were excluded from this study. Multivariable logistic regression analysis showed that dental intervention (odds ratio 3.0, p = 0.014) was associated with the establishment of oral intake at discharge. Multiple logistic regression analysis showed that dental intervention was a significant factor for FOIS at discharge (p = 0.002) and the length of hospital stay (p = 0.039). CONCLUSION: Oral management with dental intervention was associated with establishing oral intake and reducing hospital stay in patients with pneumonia, regardless of pneumonia severity or comorbidities.

The Mass of Geniohyoid Muscle Is Associated with Maximum Tongue Pressure and Tongue Area in Patients with Sarcopenic Dysphagia.

OBJECTIVES: We investigated the associations about the mass of geniohyoid and tongue muscle and the maximum tongue pressure in patients with sarcopenic dysphagia using ultrasonography. DESIGN: Cross sectional study. SETTING: 5 hospitals including 3 acute and 2 rehabilitation hospitals and 1 older facility. PARTICIPANTS: 36 inpatients with sarcopenic dysphagia. MEASUREMENTS: Ultrasonography was performed for geniohyoid muscle and tongue. The area for geniohyoid and tongue muscles in sagittal plane and the mean brightness level (0-255) in the muscle area were calculated. Maximum tongue pressure as strength of swallowing muscle were investigated. Partial correlation coefficient and multiple regression analysis adjusting for age and sex were performed. RESULTS: The mean age was 81.1 ± 7.9. Men were 23. The mean BMI was 19.0 ± 4.1. The mean maximum tongue pressure was 21.3 ± 9.3 kPa. The mean cross sectional area for geniohyoid muscles was 140 ± 47 mm2. The mean brightness for geniohyoid muscle was 18.6 ± 9.0. The mean cross sectional area for tongue muscles was 1664.1 ± 386.0 mm2. The mean brightness for tongue muscles was 34.1 ± 10.6. There was a significant positive correlation between area of geniohyoid muscle and maximum tongue pressure (r = 0.38, p = 0.04). Geniohyoid muscle area was an explanatory factor for maximum tongue pressure (p = 0.012) and tongue muscle area (p = 0.031) in multivariate analysis. CONCLUSIONS: Geniohyoid muscle mass was an independent explanatory factor for maximum tongue pressure and tongue muscle mass.

Factors associated with masseter muscle quality assessed from ultrasonography in community-dwelling elderly individuals: A cross-sectional study.

BACKGROUND: Associations between masseter muscle thickness(MMT) and limb muscle thickness, and between grip strength and MMT, as well as tooth-loss, have been reported previously. The previous study also showed that masseter muscle mass could be a better marker of sarcopenia than psoas muscle mass. Although the association between MMT and muscle strength is also known, the quality of the masseter muscle were not assessed in detail previously. We examined the relationship of masseter muscle echo intensity (MMEI) with skeletal muscle, physical function, and nutrition status, in order to determine whether MMEI could be a good indicator of these parameters. METHODS: We assessed 139 community-dwelling elderly individuals (men: 65, women: 74). Age, body mass index (BMI), skeletal muscle mass index, grip strength, walking speed, calf circumference, tooth-loss (Eichner classification), occlusal force, MMT, and MMEI were obtained. In multiple regression analysis, MMEI were set as dependent variables. RESULTS: Multiple regression analysis revealed BMI (p < 0.05), grip strength (p < 0.01), walking speed (p < 0.01), and MMT (p < 0.01) as factors with significant association with MMEI. CONCLUSIONS: MMT is related to occlusal force and MMEI. MMEI was related strongly to grip strength and walking speed, but not to tooth-loss. However, MMEI, which is easily determined ultrasonographically, could be a good indicator of grip strength and walking speed, and thus may be predictive of dynapenia.

A new evaluation of masticatory ability in patients with dysphagia: The Saku-Saku Test.

OBJECTIVE: In the elderly and patients with dysphagia, masticatory problems often cause aspiration or choking. Although simple methods to predict aspiration and silent aspiration exist, methods for evaluating the masticatory function of patients with dysphagia are lacking. Accordingly, we developed a simple test to assess the chewing and swallowing ability of patients with dysphagia. METHODS: One hundred and five patients with dysphagia were included. We used the Saku-Saku Test (SST), in which patients were asked to eat a rice cracker, and evaluated the quality of mandibular rotation during mastication. We studied the participants' ability to grind, aggregate, and swallow using videoendoscopic evaluation (VE) and investigated its association with mandibular rotation. RESULTS: The SST showed good reliability between two examiners, with a kappa coefficient of 0.80. 92.4% of the patients ate the rice cracker without aspiration. The SST showed a high sensitivity of 73.3% and specificity of 93.3% for the degree of grinding. The degree of food bolus aggregation had a sensitivity of 45.0% and specificity of 90.6%, and aspiration had a sensitivity of 25.0% and specificity of 84.5%, both of which showed high specificity. CONCLUSIONS: The results of this study suggested that the SST might be simple and useful for identifying patients with dysphagia who are able to masticate, even if they do not eat foods that need chewing and could be used before starting these patients on foods that need chewing.

The relationship between jaw-opening force and the cross-sectional area of the suprahyoid muscles in healthy elderly.

We conducted a clinical cross-sectional study to examine the relationship between jaw-opening force and the cross-sectional area of the suprahyoid muscles and whole skeletal muscle mass. Subjects were healthy 39 males and 51 females without dysphagia and sarcopenia, aged 65 years and older. Jaw-opening force was measured three times using a jaw-opening sthenometer; the maximum of these three was taken as the measurement value. The cross-sectional area of the geniohyoid and anterior belly of the digastric muscles were evaluated using ultrasonography. The skeletal muscle mass index, gait speed and grip strength were evaluated according to the diagnostic criteria of the Asian Working Group for Sarcopenia. For each sex, a multiple regression analysis determined the factors that affect jaw-opening force. Jaw-opening force was associated with the cross-sectional area of the geniohyoid muscle in males (regression coefficient [ß] = 0.441, 95% confidence interval [CI] = 14.28-56.09) and females (ß = 0.28, 95% CI = 3.10-54.57). Furthermore, in females only, jaw-opening force was associated with the skeletal muscle mass index (ß = 0.40, 95% CI = 3.67-17.81). In contrast, jaw-opening force was not associated with the cross-sectional area of the anterior belly of the digastric muscle in either sex. In healthy elderly males and females, jaw-opening force was positively associated with the cross-sectional area of the geniohyoid muscle. However, the jaw-opening force was positively associated with the skeletal muscle mass index only in females.

Evaluation of swallowing ability using swallowing sounds in maxillectomy patients.

Maxillectomy for oral tumours often results in debilitating oral hypofunction, which markedly decreases quality of life. Dysphagia, in particular, is one of the most serious problems following maxillectomy. This study used swallowing sounds as a simple evaluation method to evaluate swallowing ability in maxillectomy patients with and without their obturator prosthesis placed. Twenty-seven maxillectomy patients (15 men, 12 women; mean age 66.0 ± 12.1 years) and 30 healthy controls (14 men, 16 women; mean age 44.9 ± 21.3 years) were recruited for this study. Participants were asked to swallow 4 mL of water, and swallowing sounds were recorded using a throat microphone. Duration of the acoustic signal and duration of peak intensity (DPI) were measured. Duration of peak intensity was significantly longer in maxillectomy patients without their obturator than with it (P < .05) and was significantly longer in maxillectomy patients without their obturator than in healthy controls (P < .025 after Bonferroni correction). With the obturator placed, DPI was significantly longer in maxillectomy patients who had undergone soft palate resection than in those who had not (P < .05). These results suggest swallowing ability in maxillectomy patients could be improved by wearing an obturator prosthesis, particularly during the oral stage. However, it is difficult to improve the oral stage of swallowing in patients who have undergone soft palate resection even with obturator placement.

Effect of an impaired oral stage on swallowing in patients with Parkinson's disease.

We investigated the swallowing function in patients with Parkinson's disease (PD) using deteriorated tongue control because patients with PD frequently exhibit an impaired oral stage of swallowing and the tongue movement affects oral and pharyngeal stage. In total, 201 patients with PD (106 men, 95 women; mean age 70·6 ± 8·0 years; median Hoehn-Yahr Stage III) were studied. The patients swallowed 10 mL of liquid barium under videofluorography, and their oral transit time (OTT) was measured. Based on 20 healthy controls (mean age 70·3 ± 7·8 years) with an OTT + 2 standard deviation (0·89 + 2 × 0·46) of 1·81 s, the patients with PD were divided into 167 patients with an OTT < 1·81 s and 34 patients with an OTT ≥ 1·81 s. Swallowing function was compared between the groups and assessed using logistic regression analysis. The following factors were significantly associated with oral stage impairment in both groups: tongue-to-palate contact, tongue root-to-posterior pharyngeal wall contact, premature spillage into the pharynx, aspiration and onset of swallowing reflex. Logistic regression analysis showed that tongue root-to-posterior pharyngeal wall contact, onset of swallowing reflex and aspiration were independent factors. PD patients with prolonged OTT displayed poor lingual control and decreased range of motion of the tongue due to bradykinesia and rigidity. Such problems in the oral stage affected the subsequent pharyngeal stage of swallowing with aspiration. Lingual movement in the oral stage thus appears to play an important role in the sequential movement of swallowing in PD.

Predictive Factors Associated with Oral Intake Ability in Gastrostomy Patients Under Long-Term Care.

OBJECTIVE: To determine the physical indicators associated with oral intake status and swallowing function in gastrostomy patients under long-term care. DESIGN: Cross-sectional study. SETTING: Thirty-one hospitals that perform gastrostomy insertion, replacement and management. PARTICIPANTS: A total of 117 respondents from 31 hospitals in Japan underwent gastrostomy tube replacement and management between September 2012 and January 2014. Each participant underwent a gastrostomy at least 6 months prior to the study, and received long-term care either at home, a care facility, or a hospital. MEASUREMENTS: We conducted a questionnaire survey at Japanese hospitals and used the data obtained from 117 respondents for analysis. The survey was conducted using a questionnaire form that collected information about the following items: oral intake status, sex, age, disease history, number of days elapsed since gastrostomy, residence status, modified Rankin Scale score, consciousness, oral hygiene status, articulation and phonation, voluntary saliva swallow, Modified Water Swallow Test, and Food Test. RESULTS: Results revealed significant differences in modified Rankin Scale scores, sputum production, articulation and phonation, and voluntary saliva swallowing between patients who were orally fed and those who were not. Moreover, sputum production and voluntary saliva swallowing were strongly associated with oral intake status. Finally, sputum production, articulation and phonation, and voluntary saliva swallowing were strongly associated with swallowing function test results. CONCLUSION: Results from this study suggested that sputum production, articulation and phonation, and voluntary saliva swallowing could be used as indicators for estimating oral intake status and swallowing function in gastrostomy patients under long-term care.

An examination of factors related to aspiration and silent aspiration in older adults requiring long-term care in rural Japan.

Swallowing disorders are a growing problem among the elderly in long-term care (LTC), and they can cause aspiration pneumonia. In order to detect swallowing disorders early, simple tools are needed to assess aspiration and silent aspiration (SA). To compile a sample of elderly people requiring LTC, and categorise them as having suspected aspiration and/or SA using simple screening tools. In addition, oral ability, severity of dementia, vital functions and nutritional status were compared in these groups. A total of 393 elderly people in LTC (89 men and 304 women; age ranging from 65 to 100 years) were included in the study. The modified water swallow test, cervical auscultation and cough test were used to assess swallowing function. The participants were categorised as having suspected aspiration and/or SA, and the following assessments were performed: (i) oral ability (lips function, tongue function, rinsing and gargling ability), (ii) dementia severity, (iii) vital functions and (iv) nutritional status. Suspected aspiration was apparent in 50.5% of patients, of which 24.0% had suspected SA. Those with suspected aspiration showed worsened oral ability, dementia severity, vital functions and nutritional status. Similarly, those with suspected SA showed worsened dementia severity, vital functions and nutritional status. Logistic regression analysis revealed that lip closure, lingual movement and rinsing ability were significantly associated with suspected aspiration. Dementia severity was the best predictor of suspected SA. Simple screening tools can be used to identify suspected aspiration and SA, which may facilitate early detection of aspiration pneumonia or swallowing disorder risk.

The effects of ADL on recovery of swallowing function in stroke patients after acute phase.

This study aimed to examine the association between the degree of recovery from dysphagia and changes in functional independence measure (FIM) items in stroke patients after acute phase by conducting a historical cohort study, because none explains the effects of activities of daily living (ADL) on recovery of swallowing function. Study patients included hospitalised stroke patients after acute phase in whom dysphagia was confirmed (n = 72). Change in nutritional intake method score was examined for association with age, days from stroke onset to admission, length of hospital stay and change in FIM score. Moreover, to examine characteristics of patients who were removed from tube feeding, all patients who required tube feeding at the time of admission were divided into two groups comprising those who required tube feeding at discharge and those who did not. A significant and positive association was observed between change in nutritional intake method and FIM for all items other than self-care of bathing, locomotion of stairs and problem solving. Patients who were removed from tube feeding were significantly younger than those who required tube feeding at the time of discharge (P < 0.041) and also showed significantly higher FIM scores for transfer and all cognitive FIM items at the time of admission (P < 0.05). This study demonstrated that nutritional intake methods improve in conjunction with FIM improvements in patients with dysphagia following the acute phase of stroke. Our results suggest that the age and cognitive function may influence the recovery of patient ability of oral intake.

Effects of reclining posture on velopharyngeal closing pressure during swallowing and phonation.

Velopharyngeal closure plays an important role in preventing air pressure leakage during swallowing and phonation from oropharynx to nasopharynx. Levator veli palatini muscle activity is influenced by oral and nasal air pressure, volume of the swallow bolus and postural changes. However, it is unclear how velopharyngeal closing pressure is affected by reclining posture. The purpose of this study was to investigate the effects of reclining posture on velopharyngeal closing pressure during swallowing and phonation. Nine healthy male volunteers (age range, 27-34 years) participated in this study. Velopharyngeal closing pressure during a dry swallow, a 5-mL liquid swallow, a 5-mL honey-thick liquid swallow and phonations of /P∧/ and /K∧/ were evaluated in an upright posture and at reclining postures of 60° and 30°. A manometer catheter was inserted transnasally onto the soft palate, and each trial was repeated three times. A solid-state manometer catheter with an intra-luminal transducer was used to evaluate the amplitude and duration of each trial, and data were statistically analysed. Average amplitudes during dry and liquid swallows were significantly lower in reclining postures compared with the upright posture, but the amplitude was not significantly different during the thick liquid swallow. Average durations were not affected by postural changes. The amplitudes during phonations were lower in reclining postures, but the differences were not significant. Velopharyngeal closure is significantly affected by reclining posture. This suggests that velopharyngeal closing pressure may be adjusted according to afferent inputs, such as reclining posture and bolus viscosity.

Inter- and intra-rater reliability in fibroptic endoscopic evaluation of swallowing.

Fibroptic endoscopic evaluation of swallowing (FEES) is a useful way for dentists to evaluate oropharyngeal dysfunction. However, no study has paid attention to inter- and intra-rater reliability of FEES evaluation about oropharyngeal dysfunction. The purpose of this study is to verify whether dentist who trained and experienced for evaluation of dysphagia could diagnose oropharyngeal function with FEES. Nine dentists independently evaluated FEES images of 10 cases four times each. At first, evaluators performed the first evaluation without consulting the evaluative criteria. Subsequently, evaluators independently re-evaluated at 1-week intervals for three consecutive weeks, consulting the evaluative criteria. And then, inter- and intra-rater reliability was calculated. Cohen's Kappa was used to assess reliability. The results found that overall inter-rater reliability was 0·35±0·04 (first evaluation), 0·45±0·05 (s), 0·44±0·05 (third) and 0·46±0·04 (fourth). Most of inter-rater reliability related to aspiration was moderate to high, but lower for categories that evaluated timing of swallowing and mastication. In contrast, intra-rater reliability was moderate to high for overall categories, at 0·53±0·04 (first vs. second evaluation), 0·55±0·04 (first vs. third), 0·53±0·04 (first vs. fourth), 0·55±0·03 (second vs. third), 0·60±0·03 (second vs. fourth) and 0·78±0·03 (third vs. fourth). FEES is reliable for experienced dentists to diagnose oropharyngeal function. Moreover, repeated evaluation with the aids of evaluative criteria is useful to improve the reliability of FEES.