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We aimed to fine-tuning the Timed Water Swallow Test (TWST) screening procedure to provide the most reliable prediction of the Flexible Endoscopic Evaluation of Swallowing (FEES) assessment outcomes, with age, sex, and the presence of clinical signs of dysphagia being considered in the assessment. Participants were healthy people and patients with suspected dysphagia. TWST performance and participants' reported dysphagia symptoms were assessed in terms of their utility in predicting the outcome of a FEES assessment the same day. The FEES assessors were blinded to the nature of the TWST performance. The water swallowing capacity levels and clinical observations during a screening performance that were indicative of dysphagia/no symptoms in FEES were determined. Convergent validity was assessed as the agreement with the Functional Oral Intake Scale (FOIS) in the FEES assessment. TWST predicted FEES findings (aspiration and dysphagia) with a sensitivity of 72 and 45% and a specificity of 75% and 80%, respectively. Extended analysis of the TWST procedure (eTWST) identified aspiration (sensitivity = 92%, specificity = 62%) and dysphagia (sensitivity = 70%, and specificity = 72%) more accurately and showed a high correlation with FOIS (ɸ = 0.37). Excellent inter-rater reliability was further observed (Kw = 0.83). The extended evaluation of TWST performance has superior criterion validity to that of TWST. eTWST displayed high convergent validity and excellent interrater reliability. We therefore believe that eTWST can be highly relevant for clinical dysphagia screening.

Objectives: To investigate the relationship between malnutrition and potential contributing factors such as poor oral health, dysphagia and mortality among older people in short-term care.

Methods: This cross-sectional study is a part of the multidisciplinary multicentre project SOFIA (Swallowing function, Oral health and Food Intake in old Age), which includes older people (≥65 years) in 36 short-term care units in five regions of Sweden. Nutritional status was measured with version II of the Minimal Eating Observation and Nutrition Form (MEONF-II), oral health with the Revised Oral Assessment Guide (ROAG), dysphagia with a water swallow test, and the mortality rate was followed for 1 year. Data were analysed using descriptive analysis and logistic regression models to calculate odds ratios for the association between malnutrition and these factors.

Results: Among the 391 participants, the median age was 84 years and 53.3% were women. Mortality rate was 25.1% within 1 year in the total group, and was higher among malnourished participants than among their well-nourished counterparts. Severe dysphagia (OR: 6.51, 95% CI: 2.40–17.68), poor oral health (OR: 5.73, 95% CI: 2.33–14.09) and female gender (OR: 2.2, 95% CI: 1.24–3.93) were independently associated with malnutrition.

Conclusion: Mortality rate was higher among malnourished people than those who were well nourished. Severe dysphagia, poor oral health and female gender was predictors of malnutrition among older people in short-term care. These health risks should be given more attention in short-term care with early identification.

The Dysphagia Outcome and Severity Scale is used both clinically and within dysphagia research, internationally. Although it was developed using videofluoroscopic swallowing studies, it is frequently used to rate Flexible Endoscopic Evaluations of Swallowing. The validity and reliability of DOSS-use with FEES, however, has not previously been evaluated. This study investigated the validity and rater reliability of clinicians using DOSS to rate FEES. Eleven Speech-Language Pathologists (SLPs) with varied dysphagia experience were recruited to review and DOSS-rate 17 soundless FEES (198 bolus swallows) recorded from 11 heterogenic dysphagic patients (2 cases with repeat FEES) and 4 healthy adults. The SLPs DOSS-ratings were compared against the initial comprehensive dysphagia evaluation (including patient diagnosis, interview, cranial nerve and complete FEES assessment) with Functional Oral Intake Scale (FOIS) and DOSS outcome measures. The SLPs were blinded to patient details and comprehensive dysphagia examination. Re-randomised rating of FEES cases occurred two weeks later (intra rater reliability). Criterion validity for DOSS-ratings (compared against comprehensive dysphagia evaluation with FOIS and DOSS) were strong–very strong (r_s= 0.858 and 0.936 respectively; p < 0.001). Inter rater reliability demonstrated high agreement (α = 0.891), also intra rater reliability demonstrated almost perfect agreement (Kw = 0.945). This study’s results, with strong–very strong criterion validity and high rater reliability by SLPs, adds to the evidence for DOSS-use with FEES. Future validity research comparing DOSS with both FEES and VFSS simultaneously is recommended.

The Timed Water Swallow Test (TWST) and the Test of Mastication of Solids (TOMASS) are dysphagia screening procedures that have been shown to be reliably assessed from video. The reliability of the procedures performed over telemedicine has not previously been assessed. TWST and TOMASS outcomes in two situations (both face-to-face and over telemedicine) were compared for 48 participants (aged 60-90; 27 with clinical conditions and 21 older persons). Both testing situation and test performed order were randomized, and all assessment procedures were performed within 3 h of each other. The results indicated a high level of agreement between face-to-face and telemedicine screening outcomes for TWST and TOMASS, respectively. The assessments indicated an 83% and 76% agreement in classifications of individual participants as within or outside normal limits for the TWST and TOMASS for the two test situations. The TWST showed a balanced distribution in differing classification in telemedicine (0.16-0.19 error rates). The TOMASS procedure classified more participants as outside normal limits over telemedicine compared to face-to-face administration. Agreement in the observed number of swallows was substantially lower than other outcome measures, which is attributed to increased difficulty in observing this property over video. Most participants (60%) reported that they would prefer telemedicine over face-to-face assessments, and 90% viewed the procedure as more accessible than expected. All participants were satisfied with the telemedicine procedures. The results suggest that clinical assessment of dysphagia over telemedicine using the TWST and TOMASS are viable alternatives to face-to-face administration of the procedures.

Purpose: To provide normative data on swallowing capacity (mL/s) in people older than 60 years using the Timed Water Swallow Test (TWST), stratified by sex. Intra- and inter-rater reliability for swallowing time in TWST was further investigated.

Method: A total of 165 participants, aged 60 years and above, were included in the study. The time taken to consume 150 mL of tap water and the swallowing capacity (mL/s) was observed in a clinical context using the TWST. Video recordings of the performances were collected for 118 of the 165 participants for inter-rater reliability testing, of which a random set of 25 performances were assessed for intra-rater reliability. Analysis of the agreement between TWST rated by an in-person clinician and rated from a video recording was further evaluated.

Result: There were significant age and sex effects observed for swallowing capacity. The average reduction in swallowing capacity in the investigated age range (60-92 years) was 8.8 and 7.3 mL/s for women and men respectively. The results showed high inter-and intra-rater reliability and agreement between the clinical assessment and the video recording.

Conclusion: The presented measurements indicate a clear effect of age on swallowing capacity and that women may be expected to have lower capacity scores than men when tested using TWST. The provided norms can be used as reference points in the clinical identification of people at risk of dysphagia in the older population.

BACKGROUND: Swallowing dysfunction (dysphagia) significantly impacts patient and medical outcomes. In Sweden, there is no comprehensive outcome measure for dysphagia that incorporates holistic assessment and dysphagia impact on a person's impairment, function and participation. The Dysphagia Outcome and Severity Scale (DOSS) was developed and validated (in English) and incorporates the World Health Organisation's (WHO) aforementioned, International Classification of Functioning (ICF) aspects. This study translated then evaluated the validity and reliability of the Swedish version, DOSS-S.

METHOD: Translation occurred based on WHO recommendations. The Content Validity Index (CVI) of the translated version (DOSS-S) was assessed twice by 11 (multi-professional) dysphagia experts. Criterion validity and rater reliability was calculated using 18 Speech Pathologists assessing patient cases from International Dysphagia Diet Standardization Initiative-Functional Diet Scale (IDDS-FDS) research.

RESULTS: Very high CVI values (0.96-0.99) for the linguistic correlation, and high CVI values (0.84-0.94) for applicability correlation were achieved. High criterion validity of DOSS-S with IDDSI-FDS was demonstrated (r_s = 0.89, p < 0.01), with very high inter and intra rater reliabilities (ICC > 0.90).

CONCLUSION: The DOSS-S demonstrated very high validity values, and very high inter and intra rater reliability. This research contributes to improved dysphagia management by providing interprofessional dysphagia clinicians with a validated scale to identify patient progression, communicate dysphagia status between regions and countries, and document patient outcomes using an ICF framework.

Background: Swallowing difficulties in the oral cavity or pharynx (i.e., oropharyngeal dysphagia) are a common problem in the aging population, which may result in severe consequences, such as malnutrition, aspiration pneumonia, and mortality. Identifying oropharyngeal dysphagia and its associated factors is essential for establishing better healthcare policies in nursing homes. In this study, we aimed to describe the oropharyngeal dysphagia prevalence among nursing home residents, and to investigate the association between dysphagia and potentially related factors in a large survey of nursing home residents in Sweden, including individuals with various degrees of cognitive impairment. A secondary aim was to compare findings between years on oropharyngeal dysphagia and its associated factors.

Methods: This study is based on two cross-sectional surveys performed in 2007 and 2013, including 4,995 individuals living in nursing homes in the Region of Västerbotten, Sweden. Data were collected from caregivers’ reports regarding swallowing ability, nutritional status, chewing ability, and other baseline characteristics, such as cognitive function and activity of daily living (ADL). Data were analyzed using logistic regression models to calculate the odds of the association between oropharyngeal dysphagia and associated factors.

Results: Oropharyngeal dysphagia was reported in 14.9% (95% CI: 13.9–16.0) of the nursing home residents. An adjusted model revealed that oropharyngeal dysphagia was associated by severe cognitive impairment (OR: 1.56, 95% CI: 1.14–2.12) and ADL independence (OR: 0.81 95% CI: 1.82–2.66) among nursing home residents. We also identified the following as independently associated factors of dysphagia: reduced nutritional status (OR: 1.84, 95% CI: 1.49–2.27), artificial nutrition (OR: 6.33, 95% CI: 2.73–14.71), and clinical signs of aspiration (OR: 10.89, 95% CI: 8.40–14.12).

Conclusions: Oropharyngeal dysphagia was reported among approximately 15% nursing home residents and was associated with cognitive impairment and ADL capability. Furthermore, reduced nutritional status and artificial nutrition were also associated with oropharyngeal dysphagia. Implementing routine protocols in nursing homes may help detect oropharyngeal dysphagia and manage oropharyngeal dysphagia among residents.

Purpose: To establish normative data of crackers common in the Scandinavian and international markets for use in the Test of Masticating and Swallowing Solids (TOMASS), and to investigate possible sex and age effects on masticatory performances.

Method: 234 healthy participants (>20 years of age) were asked to either ingest the Göteborgskex Guld Marie™ cracker (n = 234) or to ingest both a Guld Marie cracker and a Tuc Original™ cracker (n = 115). Quantifiable measures of masticatory performance (number of bites, number of chewing cycles, number of swallows, and total time) were observed during TOMASS for each participant, directly on-site or by video recording.

Result: There were no significant differences in masticatory performances between the crackers. Significant age effects were observed for all masticatory measurements, except for the number of swallows. The results showed insufficient support for an effect of sex, and that results obtained on-site and from video recordings were highly correlated.

Conclusion: These findings suggest that similar masticatory performance is to be expected when performing TOMASS using the evaluated crackers. The age of the participant affects TOMASS performance, but the effect of sex is considerably smaller.

Background: Oral and pharyngeal swallowing dysfunction are common complications in acute stroke patients. This primary aim of this study was to determine whether oral neuromuscular training improves swallowing function in participants with swallowing dysfunction after stroke. A secondary aim was to assess how well results of the timed water-swallow test (TWST) correspond with swallowing dysfunction diagnosed by videofluoroscopy (VFS).

Methods: This was an intention-to-treat two-centre prospective randomized open-label study with blinded-evaluators (PROBE) design. At 4 weeks after stroke onset, participants with swallowing dysfunction were randomized to 5 weeks of continued orofacial sensory-vibration stimulation with an electric toothbrush or additional oral neuromuscular training with an oral device (Muppy®). Participants were examined with TWST, a lip-force test, and VFS before (baseline), after 5 weeks’ treatment (the end-of-treatment), and 12 months after treatment (follow-up). The baseline VFS results were compared with the TWST results. The primary endpoint was changes in swallowing rate assessed using TWST, from baseline to the end of training and from baseline to follow-up based on intention-to-treat analyses. The secondary endpoint was the corresponding changes in lip-force between baseline, the end of treatment, and follow-up.

Results: The participants were randomly assigned as controls (n = 20) or for intervention with oral neuromuscular training (n = 20). After treatment, both groups had improved significantly (intervention, P < 0.001; controls, P = 0.001) in TWST but there was no significant between-group difference in swallowing rate. At the 12-month follow-up, the intervention group had improved further whereas the controls had deteriorated, and there were significant between-group differences in swallowing rate (P = 0.032) and lip force (P = 0.001). A TWST < 10 mL/sec at baseline corresponded to VFS-verified swallowing dysfunction in all assessed participants.

Conclusion: The 5-week oral neuromuscular training improved swallowing function in participants with post-stroke dysphagia compared with the controls 12 months after intervention, but there was no between-group difference in improvement immediately after treatment. TWST results corresponded with VFS results, making TWST a feasible method for identifying persons with swallowing dysfunction after stroke. Larger randomized controlled trials are required to confirm our preliminary positive long-term results.

Trial registration: Retrospectively registered at ClinicalTrials.gov: NCT04164420. Registered on 15 November 2019.

Objectives: this prospective, cluster randomised, controlled trial investigated the effect of oral neuromuscular training among older people in intermediate care with impaired swallowing.

Methods: older people (≥65 years) with swallowing dysfunction were cluster randomised according to care units for 5 weeks of neuromuscular training of the orofacial and pharyngeal muscles or usual care. The primary endpoint was the change in swallowing rate (assessed with a timed water swallow test) from baseline to the end-of-treatment and 6 months post-treatment. The secondary endpoints were changes in signs of aspiration during the water swallow test, and swallowing-related quality of life (QOL). An intention-to-treat principle was followed, and mixed-effects models were used for data analysis with the clustered study design as a random factor.

Results: in total, 385 participants from 36 intermediate care units were screened, and 116 participants were randomly assigned to oral neuromuscular training (intervention; n = 49) or usual care (controls; n = 67). At the end of treatment, the geometric mean of the swallowing rate in the intervention group had significantly improved 60% more than that of controls (P = 0.007). At 6 months post-treatment, the swallowing rate of the intervention group remained significantly better (P = 0.031). Signs of aspiration also significantly reduced in the intervention group compared with controls (P = 0.01). No significant between-group differences were found for swallowing-related QOL.

Conclusions: oral neuromuscular training is a new promising swallowing rehabilitation method among older people in intermediate care with impaired swallowing.

Trial registration: ClinicalTrials.gov: NCT02825927.