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Swallowing dysfunction among older people in short-term care: prevalence, effect of intervention, and risk of mortality
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Speech and Language Therapy. Umeå University, Faculty of Medicine, Department of Odontology.ORCID iD: 0000-0002-2254-7862
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Objectives: Swallowing dysfunction (dysphagia) is a common, but often neglected condition among geriatric patients that can cause severe complications such as malnutrition, aspiration pneumonia and death. The aims of this thesis were to (i) describe the study design and method of the multidisciplinary and multicenter project SOFIA (Swallowing function, Oral health, and Food Intake in old Age), (ii) study the prevalence of and the relationship between swallowing dysfunction and risk of undernutrition among older individuals in short-term care, (iii) study the effect of oral neuromuscular training on swallowing dysfunction among older individuals, and (iv) to investigate the association between poor oral health, swallowing dysfunction and mortality.

Methods: This thesis includes four original papers that are all part of the SOFIA project. Paper Iis the study protocol. In total, 391 individuals aged 65 or older, from 36 short-term care units were included in the project. At baseline the participants’ status regarding swallowing function (assessed with the Timed Water Swallow Test, TWST), oral health (using the Revised Oral Assessment Guide, ROAG) and nutrition (assessed with the Minimal Eating Observation and Nutrition Form-version II, MEONF-II) were assessed and collected by calibrated professionals. Clinical data were also collected. Paper IIwas a cross-sectional study where the baseline assessments of the participants’ swallowing function and nutritional status were obtained and the relationship analyzed. Paper IIIwas a cluster randomized, controlled trial (cRCT) that included 116 participants identified with swallowing dysfunction in paper II. These participants were randomly assigned to either usual care (control group) or oral neuromuscular training (intervention group). All participants were assessed at baseline, after five weeks’ training and six months after end-of-treatment, regarding swallowing function and swallowing-related quality of life (QOL). Paper IVwas a prospective cohort study where all participants were followed-up 1-year after inclusion to investigate risk factors for mortality by analysis of the associations between swallowing dysfunction, poor oral health, and 1-year survival. 

Results: Paper II:The median age of the 391 participants was 84 years (Interquartile range [IQR] 11) and 209 (53%) were females. In total, 248 of the 385 (64%) participants showed swallowing dysfunction, and risk of undernutrition was observed in 91 of 390 (23%) participants. The adjusted logistics regression model revealed that participants with swallowing dysfunction had significantly higher odds of undernutrition than those with normal swallowing (Odds ratio [OR]: 1.74, 95% Confidence interval [CI] 1.04 to 2.92, P=0.034).Paper III: At end-of-treatment, a linear mixed model showed significant between-group differences of changes in swallowing efficacy between baseline and after completed treatment period (Ratio 1.60, 95% CI 1.15 to 2.29, P=0.007); indicating a 60% higher swallowing efficacy in the intervention group compared with the control group. Paper IV: A mixed effects Cox model showed that swallowing dysfunction and poor oral health were both independently associated with 1-year mortality (adjusted Hazard Ratio [aHR]: 1.67, 95% CI 1.02 to 2.75,P=0.041 and aHR: 1.98, 95% CI 1.07 to 3.65, P=0.029, respectively). In addition, swallowing dysfunction and poor oral health in combination predicted the highest mortality rate (35%, P<0.001).

Conclusion: Swallowing dysfunction is highly prevalent and a risk factor for undernutrition among older people in short-term care. Oral neuromuscular training improves swallowing dysfunction and is thus a promising method of swallowing rehabilitation for older people with impaired swallowing. Swallowing dysfunction and poor oral health are independent risk factors for 1-year morality among older people in short-term care. Therefore, systematic screening and intervention to improve swallowing dysfunction and poor oral health are important to achieve healthy aging and to prevent undernutrition and early death.

Abstract [sv]

Sväljningsdysfunktion (ibland benämnt dysfagi) är ett vanligt, men ofta förbisett tillstånd bland äldre individer. Dysfunktion vid sväljning kan orsaka svåra komplikationer såsom näringsbrist, viktförlust, lunginflammation och för tidig död. Enkla behandlingsmetoder vid sväljsvårigheter saknas och är efterfrågade. Neuromuskulär behandling med munskärm innebär stimulering av muskler och nerver i ansiktet, munnen och svalget, och har nyligen visats vara effektivt vid behandling av sväljsvårigheter. Det saknas dock kunskap om metoden fungerar bland äldre personer.

Syftet med avhandlingen är att i) beskriva metoderna och designen i det multidisciplinära, multicenter projektet SOFIA (Swallowing function, Oral health, and Food Intake in old Age), ii) beskriva förekomsten av och analysera samband mellan sväljningsdysfunktion och risk för undernäring bland äldre som vistas på korttidsboende, iii) undersöka utfallet av en ny träningsmetod med munskärm för äldre individer med sväljsvårigheter samt iv) analysera dödlighet relaterat till dålig munhälsa och sväljningsdysfunktion.

Delstudie 1 är en metodstudie där det övergripande SOFIA-projektet beskrivs. Totalt inkluderades 391 äldre individer från 36 korttidsboende från fem regioner (län) i Sverige som uppfyllde inklusionskriterierna: 65 år eller äldre, vistats på korttidsboende minst tre dagar, förstår svenska och kan delta i de kliniska undersökningarna. Individer i livets slutskede eller med måttlig till svår kognitiv svikt exkluderades. Efter inklusion i SOFIA-projektet bedömdes samtliga deltagares status avseende sväljfunktion, risk för undernäring, munhälsa och delaktighet i sin allmänna dagliga livsföring (ADL). Kliniska och socioekonomiska data samlades också in för varje deltagare. Delstudie 2 var en deskriptiv tvärsnittsstudie, där förekomsten av sväljningsdysfunktion och risk för undernäring undersöktes bland de äldre. Vidare undersöktes om sväljningsdysfunktion ökade risken för undernäring. I Delstudie 3 erbjöds de äldre som uppvisade sväljningsdysfunktion vid basbedömningen deltagande i en behandlingsstudie. De som tackad ja till deltagande randomiserades till fem veckors munskärmsträning eller till rutinvård utan munskärm. Varje deltagares sväljfunktion och sväljrelaterad livskvalitet bedömdes före och efter munskärmsträningen samt sex månader efter avslutad intervention. Delstudie 4 var en longitudinell kohortstudie. Ett år efter första bedömningen av deltagarna gjordes ett utdrag från dödsregistret och relationen mellan dålig munhälsa och sväljningsdysfunktion analyserades med överlevnad som utfall.

Resultaten visade att nästan två tredjedelar (64%) av de äldre i korttidsboende har en sväljningsdysfunktion och var fjärde (23%) löper risk för undernäring (delstudie 2). Sväljningsdysfunktion är en riskfaktor för undernäring (delstudie 2). De äldre som tränade med munskärm i fem veckor visade sig förbättra sväljfunktionen signifikant jämfört med kontrollerna (delstudie 3). Både sväljningsdysfunktion och dålig munhälsa, oberoende av varandra, visade sig ge högre risk för dödlighet inom ett år bland äldre på korttidsboende (delstudie 4). Även att ha lågt kroppsmasseindex (BMI) visades vara en riskfaktor för tidig död.

Resultaten i denna avhandling visar att både sväljningsdysfunktion och dålig munhälsa medför en högre risk för dödlighet bland äldre som vistas på korttidsboende. Detta ger starkt stöd för att diagnostik av och omvårdnad vid sväljsvårigheter och dålig munhälsa behöver förbättras bland äldre i korttidsboende. Vidare visar resultaten att sväljningsdysfunktion och risk för undernäring är vanligt förekommande och att munsskärmsträning är en ny potentiell behandlingsmetod vid nedsatt sväljfunktion bland äldre. Implementering av munskärmsträning vid sväljningsdysfunktion kan minska riskerna för näringsbrist, uttorkning och lungkomplikationer samt för tidig död.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2019. , p. 60
Series
Umeå University odontological dissertations, ISSN 0345-7532 ; 142
Keywords [en]
swallowing disorder, dysphagia, elderly care, intermediate care, undernutrition, oral health, treatment, rehabilitation, quality of life, mortality risk, survival
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:umu:diva-157341ISBN: 978-91-7855-034-0 (print)OAI: oai:DiVA.org:umu-157341DiVA, id: diva2:1296301
Public defence
2019-04-12, Hörsal B, Byggnad 1D, 9 trp, Norrlands universitetssjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2019-03-21 Created: 2019-03-14 Last updated: 2019-03-29Bibliographically approved
List of papers
1. Study protocol for the SOFIA project: Swallowing function, Oral health, and Food Intake in old Age: a descriptive study with a cluster randomized trial
Open this publication in new window or tab >>Study protocol for the SOFIA project: Swallowing function, Oral health, and Food Intake in old Age: a descriptive study with a cluster randomized trial
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2017 (English)In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 17, article id 78Article in journal (Refereed) Published
Abstract [en]

Background: Extensive studies have shown that older people are negatively impacted by impaired eating and nutrition. The abilities to eat, enjoy food, and participate in social activities associated with meals are important aspects of health-related quality of life (HRQoL) and recovery after illness. This project aims to (i) describe and analyze relationships between oral health and oral HRQoL, swallowing ability, eating ability, and nutritional risk among older individuals admitted to short-term care; (ii) compare the perceptions that older individuals and staff report on care quality related to oral hygiene and eating; and (iii) study the feasibility and effects of a training program for people with impaired swallowing (i.e., dysphagia).

Methods/Design: This project consists of two parts, which will be performed in five Swedish counties. It will include approximately 400 older individuals and 200 healthcare professionals. Part 1 is a cross-sectional, descriptive study of older people admitted to short-term care. Subjects will be assessed by trained professionals regarding oral health status, oral HRQoL, eating and nutritional risk, and swallowing ability. Swallowing ability will be measured with a teaspoon test and a swallowing capacity test (SCT). Furthermore, subjects and staff will complete a questionnaire regarding their perceptions of care quality.

Part 2 is a cluster randomized intervention trial with controls. Older participants with dysphagia (i.e., SCT <10 ml/s, measured in part 1) will be recruited consecutively to either the intervention or control group, depending on where they were admitted for short-term care. At baseline, all subjects will be assessed for oral health status, oral HRQoL, eating and nutritional risk, swallowing ability, and swallowing-related QoL. Then, the intervention group will receive 5 weeks of training with an oral screen for neuromuscular training focused on orofacial and pharyngeal muscles. After completing the intervention, and at six months post-intervention, all assessments will be repeated in both study groups.

Discussion: The results will make important contributions to rehabilitation knowledge, including approaches for improving swallowing function, oral health, and food intake and for improving the quality of oral care for older people.

Keywords
Aged, Deglutition, Eating, Oral health, Quality of health care, Quality of life, Oral screen, Short-term re, Swallowing disorders
National Category
Dentistry
Identifiers
urn:nbn:se:umu:diva-133748 (URN)10.1186/s12877-017-0466-8 (DOI)000397463200003 ()28335729 (PubMedID)
Available from: 2017-05-08 Created: 2017-05-08 Last updated: 2019-03-14Bibliographically approved
2. Swallowing dysfunction as risk factor for undernutrition in older people admitted to Swedish short-term care: a cross-sectional study
Open this publication in new window or tab >>Swallowing dysfunction as risk factor for undernutrition in older people admitted to Swedish short-term care: a cross-sectional study
Show others...
2019 (English)In: Aging Clinical and Experimental Research, ISSN 1594-0667, E-ISSN 1720-8319, Vol. 31, no 1, p. 85-94Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Swallowing dysfunction and risk of undernutrition increase the risk of pneumonia, morbidity, and mortality. Short-term care is an unexplored care context, where many older people stay yearly.

AIM: This cross-sectional study aimed to describe and analyze the relationship between swallowing dysfunction and risk of undernutrition among older people in short-term care, including potential gender-related differences.

METHODS: In total, 391 people (209 women), aged ≥ 65 years (median age 84 years) and admitted to short-term care in five Swedish counties participated. They went through a timed water swallow test to assess swallowing dysfunction, including abnormal swallowing capacity and signs of aspiration (i.e., cough and voice change). Risk for undernutrition was assessed using the Minimal Eating Observation and Nutrition Form-version II.

RESULTS: Swallowing dysfunction was observed in 248 of 385 (63%) participants, including abnormal swallowing capacity in 213 of 385 (55%) and aspiration signs in 127 of 377 (34%). Abnormal swallowing capacity was more frequent among women (p = 0.030), whereas men with normal swallowing capacity exhibited signs of aspiration more frequently (cough p = 0.038, voice change p = 0.004). Risk of undernutrition was found in 91 of 390 (23%) participants, more frequently among women (p = 0.007). A logistic regression model revealed an increased risk of undernutrition among older people with abnormal swallowing capacity (OR 1.74, 95% CI 1.04-2.92, p = 0.034).

CONCLUSIONS: The high prevalence of swallowing dysfunction and risk of undernutrition highlight the need for a systematic screening program and feasible treatment to improve swallowing function for adequate and safe food intake among older people in short-term care.

CLINICAL TRIAL REGISTRATION: This study was registered with ClinicalTrials.gov on July 4, 2016, under NCT02825927.

Place, publisher, year, edition, pages
Springer, 2019
Keywords
Aspiration, Dysphagia, Elderly care, Gender, Malnutrition, Swallowing disorders
National Category
Geriatrics Dentistry Nutrition and Dietetics
Research subject
Geriatrics; Odontology; Caring Sciences
Identifiers
urn:nbn:se:umu:diva-146928 (URN)10.1007/s40520-018-0944-7 (DOI)000457534400011 ()29663160 (PubMedID)2-s2.0-85045421560 (Scopus ID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2013-2127The Kamprad Family Foundation, 20132115
Available from: 2018-12-01 Created: 2018-12-01 Last updated: 2019-03-14Bibliographically approved
3. Effects of oral neuromuscular training on swallowing dysfunction among older people in intermediate care - a cluster randomized, controlled trial
Open this publication in new window or tab >>Effects of oral neuromuscular training on swallowing dysfunction among older people in intermediate care - a cluster randomized, controlled trial
(English)Manuscript (preprint) (Other academic)
Keywords
swallowing disorders, dysphagia, rehabilitation, quality of life, elderly care
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-157339 (URN)
Available from: 2019-03-14 Created: 2019-03-14 Last updated: 2019-09-20
4. Older people with swallowing dysfunction and poor oral health are at greater risk of early death
Open this publication in new window or tab >>Older people with swallowing dysfunction and poor oral health are at greater risk of early death
Show others...
2019 (English)In: Community Dentistry and Oral Epidemiology, ISSN 0301-5661, E-ISSN 1600-0528Article in journal (Refereed) Epub ahead of print
Abstract [en]

Objectives: We investigated the associations between swallowing dysfunction, poor oral health and mortality among older people in intermediate care in Sweden.

Methods: This prospective cohort study investigated 391 older people in 36 intermediate care units (clusters). Swallowing function was assessed with the timed water swallow test (TWST), and oral health with the revised oral assessment guide (ROAG) at baseline. Data were collected on age, sex, education level, multimorbidity, cognitive impairment, care dependency and body mass index (BMI). Time to mortality was recorded during the following year. The mixed effects Cox regression model with cluster as a random factor was used to estimate hazards ratios (HR) with 95% confidence intervals (CI).

Results: The median age of the participants was 84 years (interquartile range [IQR]: 11), and 53.3% were females. Mortality within one year was 25.1%. In the adjusted model, swallowing dysfunction and poor oral health were both independently associated with mortality (adjusted HR [aHR]: 1.67, 95% CI 1.02‐2.75; P = .041 and aHR: 1.98, 95% CI 1.07‐3.65; P = .029, respectively). Participants with combined swallowing dysfunction and poor oral health showed the highest mortality (35.0%) and 2.6 (95% CI 1.15‐5.89; P = .022) times higher mortality risk than those with normal swallowing function and good oral health (13.0%).

Conclusions: Swallowing dysfunction and poor oral health were identified as independent risk factors for mortality in older people in intermediate care. Although further studies are required to verify these findings, they suggest that systematic assessment of swallowing function and oral health status should be performed for care considerations.

Keywords
mortality, swallowing disorders, oral hygiene, oral care, elderly care
National Category
Geriatrics Dentistry
Identifiers
urn:nbn:se:umu:diva-157340 (URN)10.1111/cdoe.12491 (DOI)000482105300001 ()
Note

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Available from: 2019-03-14 Created: 2019-03-14 Last updated: 2019-09-16

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