R. Fong1,2, S.W.K. Wong3, J.K.L. Chan3, M.C.F. Tong1,2, K.Y.S. Lee1,2
1. Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong; 2. Institute of Human Communicative Research, The Chinese University of Hong Kong, Hong Kong; 3. Hong Kong Christian Service, Hong Kong.
Corresponding author: Raymond Fong, Rm 303, Academic Building No. 2, The Chinese University of Hong Kong, Tel: +85239439602, Email: email@example.com
J Frailty Aging 2020;in press
Published online October 13, 2020, http://dx.doi.org/10.14283/jfa.2020.56
Oropharyngeal dysphagia is a widespread condition in older people and thus poses a serious health threat to the residents of nursing homes. The management of dysphagia relies mainly on compensatory strategies, such as diet and environmental modification. This study investigated the efficacy of an intervention program using a single-arm interventional study design. Twenty-two participants from nursing homes were included and had an average of 26 hours of intervention, including oromotor exercises, orosensory stimulation and exercises to target dysphagia and caregiver training. Four of the 22 participants exhibited improvement in functional oral intake scale (FOIS) but was not statistically significant as a group. All oromotor function parameters, including the range, strength, and coordination of movements, significantly improved. These results indicate that this intervention program could potentially improve the oromotor function, which were translated into functional improvements in some participants’ recommended diets. The validity of this study could be improved further by using standardized swallowing and feeding assessment methods or an instrumental swallowing assessment.
Key words: Dysphagia, swallowing treatment, aspiration.
Oropharyngeal dysphagia is widespread in older adults (1). The risk of diseases that may lead to dysphagia increases with age and so does dysphagia (2). With aging, there is a progressive decline of muscle mass and strength as well as a decrease in connective tissue elasticity resulting in a diminishment in range of movements (3). This change with aging has been termed as primary sarcopenia whereas secondary sarcopenia refers to the same phenomenon due to diseases or a lack of nutrition (3). Swallowing dysfunction can be aggravated by sarcopenia (4). Dysphagia has adverse effects on self-esteem, socialization, and the quality of life (5). Dysphagia also has a significant impact on the nutritional status, because with difficulty in food/liquid intake, the individual is more at risk of having lowered nutritional status (2, 6). A close association has been identified between dysphagia and aspiration pneumonia (7, 8). Langmore, Skarupski (9) concluded that swallowing difficulty is a predictor of pneumonia in residents of nursing home. These findings indicate that clinicians should aim to prevent declines in swallowing in older adults to prevent nutritional and respiratory complications.
The high prevalence and fatal consequences of dysphagia in older adults have led to investigations intended to improve the prevention and management of dysphagia. One focus of swallowing rehabilitation is to improve the swallow through exercises (10). Numerous exercises targeting different structures and subsystems of the swallow have been proposed, including lingual resistance exercises, exercises on the suprahyoid muscle group and expiratory muscle strength training (2). Physiological benefit and functional gain with a reduction of frequency of malnutrition and pneumonia have been reported in older people with dysphagia after doing these exercises (2). The use of multidisciplinary interventions provides another perspective. In one study, Arahata, Oura (11) provided an average of 4.3 interventional strategies to 90 patients, including range-of-movement oromotor and swallowing structures, feeding and swallowing foods or liquids (11). The 1-year artificial nutrition-free rate was significantly higher than the historical control rates. However, that study also used interventional strategies besides swallowing therapy, including oral hygiene and other nursing interventions. The current prospective pilot study was designed to investigate the effectiveness of a set of direct swallowing therapies intended to target the swallowing functions of residents in nursing homes. The effectiveness was determined by two outcomes: Functional oral intake scale (FOIS) and a self-devised oromotor function scale.
Ethical approval was received from the Joint Chinese University of Hong Kong – New Territories East Cluster Clinical Research Ethics Committee (CREC Ref. No. 2019.699). All participants provided informed consent. This study was conducted at two nursing homes and two daycare centers from April 2018 to March 2019. Participants were included if their FOIS score was at 3-6 and was able to provide consent. Twenty-five participants meeting the inclusion criteria were recruited.
The pre-intervention assessment included a clinical swallowing evaluation for determining the FOIS score and devising the personalized treatment. The clinical swallowing evaluation consisted of communication ability screening, physical examination and swallow trials (10). The recommendation of diet was a clinical decision based on the components of the evaluation as above. The diets available in the nursing homes include puree, minced, soft and regular diet, which corresponded to IDDSI Level 4, 5, 6 and 7 respectively. The FOIS is a 7-point ordinal scale that documents the patient’s functional eating status, with 1 being fully dependent on tube feeding and 7 indicating no restriction or special preparation (10). The participants were assessed by four qualified speech therapists with 2–10 years of clinical experience in dysphagia management. These therapists also performed the intervention.
The FOIS score was the primary outcome of treatment, as the goal of the intervention was to improve the overall swallowing competence of the participants. The secondary outcome of treatment was an improvement in oromotor function. The range of movement, strength and rate of the tongue, lips, and jaw were measured. Individual scores were assigned for the measured range of movement (jaw, lips protrusion and spreading, tongue protrusion, lateralization, elevation/depression, and elevation of the velum), strength (jaw opening and closing, lip seal, tongue protrusion, lateralization, and elevation/depression), and rate of movement (jaw, lips, tongue protrusion, lateralization, and elevation/depression). Each structure was rated in each domain (range, strength and rate) using a 0 (no abnormality) – 5 (severe impairment) scale. A higher score indicated greater impairment of that domain. After excluding three more participants at this stage, the data analysis included 22 participants. The study population included 16 female and 6 male participants with a mean age of 86.13 (standard deviation, S.D.: 8.91) years. The demographics, medical conditions, pre- and post-treatment diet and the FOIS scores of the participants are listed in Table 1.
After the initial assessment, the participants were provided with a personalized intervention program targeted three main areas: oromotor exercises (range of movement, strength and coordination), dysphagia intervention (orosensory stimulation and exercises) and caregiver training. The three main areas and examples of treatment goals are detailed in Table 2. The exercises were based on the principles of resistance loading, as advocated by Sura, Madhavan (2). Although the use of thermal-tactile stimulation and its effectiveness for dysphagia management remain controversial, especially in stroke patients (12), this study applied a combination of thermal, mechanical, and chemical sensory stimuli based on the reported conclusion of Rofes, Cola (13). Each participant received an average of 26.23 hours of therapy in weekly sessions. The post-intervention assessment was conducted within 2 weeks after treatment completion and the FOIS score was calculated. The investigator who performed the post-intervention assessment was blinded to the initial FOIS score and the treatment received. Statistical analyses were performed using SPSS software ver. 23.0 (IBM, Armonk, NY, USA). The pre-treatment and post-treatment data were compared using the Wilcoxon signed rank test. A p value of <0.05 was considered to indicate statistical significance.
Of the 22 participants, 4 (18.2%) had a change of FOIS score, 16 (73.7%) remained unchanged and 2 (9.1%) regressed from the pre-intervention period. The changes in FOIS was not statistically significant (Z = -1.000, p = 0.317). For the secondary outcomes, a significant change in the range of movement (Z = -3.933, p < 0.001) with the mean difference of -4.59 (S.D. = 2.82). For strength, the mean difference was -4.57 (S.D. = 4.78) and this was also significant (Z = -3.712, p < 0.001). For rate of movement, mean difference was -4.68 (S.D. = 4.00) and this was also significant (Z = -3.830, p < 0.001).
Dysphagia management strategies for older adults, particularly residents of nursing homes, have focused largely on the use of compensatory strategies. The results of this pilot study demonstrate that a personalized treatment program could improve the function of underlying structures needed for swallowing. However, the effect on the overall swallowing function was not significant.
Although not all participants exhibited positive changes in terms of functional swallowing outcomes, significant improvements were observed in all three domains measured for the secondary outcome of the intervention program. Previous studies have supported the use of oromotor exercises for improving the swallowing mechanism (10). Specifically, lip and tongue resistive training has been shown to improve both the strengths of these structures and the swallowing ability (10). In most participants, improvements were noted across all three domains of oromotor function. This result indicates that participation in a robust weekly therapy program for six months could induce changes in the oromotor functioning of the treatment recipients. However, sensory aspects and the pharyngeal phase of swallowing also contribute to the overall swallowing competence. Therefore, a significant improvement in oromotor function alone may not induce adequate changes in the overall swallowing competence of the participants, as reflected by a change in the FOIS score.
In this study cohort, most of the participants were older than 90 years, and over half of the participants had a background of dementia. Therefore, the participants may have found it difficult to comprehend and retain the instructions for daily active swallowing exercises. Some of the exercises may have been performed only once per week during the therapy session. In other cases, some exercises might not have been possible, and only passive exercises would have been performed. Treatment compliance and issues with exercise selection due to limited cognitive ability might also explain why this treatment did not lead to changes in diet recommendations and FOIS scores, despite improvements in oromotor functioning. However, this study could not determine whether this type of intervention would only be efficacious for patients without dementia because of the small participant cohort.
The degree of cognitive impairment due to dementia, or other medical conditions, could have affected the exercise selection, treatment compliance and ultimately treatment outcome. However, no uniform documentation of the cognitive ability could be retrieved across participants for a valid comparison. In the future, all participants should undergo a cognitive screening with validated tools such as the Hong Kong Brief Cognitive Test (14). The validity of this study could be improved by the inclusion of outcome measures such as the Iowa Oral Performance Instrument (IOPI Medical LLC, Redmond, WA), videofluoroscopy, endoscopy, which would enable investigators to delineate changes in the swallowing physiology and function more objectively. However, these measures were not routinely applied to people living in local nursing homes, and therefore this analysis could not be performed. To improve the validity and reliability of future studies involving residential care homes, a standardized clinical assessment such as the Mann Assessment of Swallowing Ability or the McGill Ingestive Skills Assessment (10) could be used to standardize the documentation of changes in swallowing and related functions.
Conclusions and implications
Few studies have investigated the treatment efficacies of swallowing and feeding intervention programs designed for residents in aged-care facilities. This study provides a good foundation for further studies of larger cohorts. The ability to extrapolate the study findings to a more general population of residents in nursing homes would enable better management of the risks associated with dysphagia and the associated quality of life. Future studies could focus on investigating the treatment efficacy in patients who can comply with all prescribed active oromotor and swallowing exercises. Alternatively, dysphagic individuals may require a more intensive intervention program or a protocol involving more passive forms of treatment. The efficacies of these alternative treatment options also require further investigation.
Conflict of interest: The authors declare that there is no conflict of interest.
Acknowledgments: The authors gratefully acknowledge the input from staff members at the Cheung Fat Home for the Elderly, Shun Lee Home for the Elderly, Chin Wah Day Care Centre for the Elderly, and Sham Shui Po Day Care Centre for the Elderly, as well as the speech therapists affiliated with the Hong Kong Christian Service.
Funding: This study was based on a pilot project, the “Good to Taste: Swallowing Enhancement Project for Elderly,” carried out by the Hong Kong Christian Service. This pilot project was supported financially by The Community Chest of Hong Kong. The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of data; in the preparation of the manuscript; or in the review or approval of the manuscript.
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