Portal de Periódicos da CAPES

PREVALENCE OF OROPHARYNGEAL DYSPHAGIA AND IMPAIRED SAFETY AND EFFICACY OF SWALLOW IN INDEPENDENTLY LIVING OLDER PERSONS

2011; Wiley; Volume: 59; Issue: 1 Linguagem: Inglês

10.1111/j.1532-5415.2010.03227.x

1532-5415

Mateu Serra‐Prat, Gregorio Hinojosa, D. Ferreiro López, Marta Juan, Ester Fabré, Dorte S. Voss, Marta Calvo, Vanessa Marta, Laura Llahí Ribó, Elísabet Palomera, Viridiana Arreola, Père Clavé,

Child Nutrition and Feeding Issues

To the Editor: Oropharyngeal dysphagia (OD) is a frequent clinical condition in older people and one that can produce two types of potentially severe complications: alterations in the efficacy of swallowing, which may cause malnutrition or dehydration, and impaired safety of swallow, which may lead to aspiration to the respiratory tract with consequent high risk of pneumonia.1-3 OD is a risk factor for pneumonia in older adults, an indicator of pneumonia severity, and a risk factor for mortality from pneumonia.4, 5 The question has been raised as to whether older persons should be routinely screened for dysphagia.4 A clinical method of assessing patients with clinical signs of dysphagia—the Volume-Viscosity Swallow Test (V-VST)—using boluses of different volumes and viscosities administered in a progression of increasing difficulty has been developed and validated.6 Few studies have reported the prevalence of dysphagia in the independently living elderly population,7-9 and these studies have used a variety of nonvalidated instruments based on self-reported dysphagic symptoms, thus not reporting the real prevalence of dysphagia because the sensitivity and specificity of the tests were not taken into account. A population-based, cross-sectional study of the true prevalence of OD, impaired efficacy of swallowing, impaired safety of swallowing, and aspiration in the independently living, older population using the V-VST is presented. Persons aged 70 and older were randomly selected from a primary care center database in Mataró (Barcelona, Spain). Institutionalized persons or those in palliative care or with a life expectancy of less than 3 months were excluded. Trained general practitioners clinically assessed OD using the V-VST. The test assesses several clinical signs of swallowing efficacy (impaired labial seal, oral or pharyngeal residue, and piecemeal deglutition) and safety (changes in voice quality, cough, or ≥3% decrease in oxygen saturation measured using a finger pulse oximeter) with boluses of 5, 10, and 20 mL at nectar (270 mPa/s), liquid (20 mPa/s), and pudding (3,900 mPa/s) viscosities. The sensitivity of V-VST is 98% for dysphagia, 92% for impaired efficacy of swallow, 88% for impaired safety, and 100% for aspiration when compared with the criterion standard of videofluoroscopy.6 To estimate "real" prevalence, the sensitivities mentioned above, the specificity of V-VST, previously assessed in 15 healthy volunteers (the lower limit of the 95% confidence interval (CI) was considered as corresponding to 94%), and the total number of positive and negative V-VST results in the study sample were taken into account. Two hundred fifty-four persons were recruited (66% participation rate) (mean age 78.2±5.6; 136 (53.5%) men, 118 (46.5%) women). Prevalence of signs of OD was 27.2% (95% CI=21.7–32.7) over the whole sample, signs of impaired efficacy of swallow were present in 20.5% (95% CI=15.5–25.5), signs of impaired safety in 15.4% (95% CI=11.0–19.8), and signs of aspiration in 6.7% (95% CI=3.6–10.0). No significant differences between the sexes were observed in the prevalence of signs of OD, impaired efficacy, and impaired safety of swallow, but they were more prevalent in participants aged 80 and older than in those aged 70 to 79 (36.4% vs 21.7%, P=.01; 30.3% vs 14.0 %, P=.002; 21.2% vs 11.9%, P=.05, respectively). Likewise, the following true population prevalences were estimated: dysphagia, 23.0% (33.0% in ≥80 vs 16.6% in 70–79); impaired efficacy of swallow, 16.8% (28.3% vs 9.5%); impaired safety of swallow, 11.4 % (18.6% vs 6.8%); and aspiration, 0.74% (4.4% vs 0%). Signs of OD were statistically associated with older age, low functional capacity (Barthel score), neurodegenerative diseases, treatment with benzodiazepines, depression, low walking speed, and low overall quality of life, although only low functional capacity showed an independent association with dysphagia or impaired safety of swallow when adjusted for other covariables. Older age, low functional capacity, and malnutrition or "at risk" of malnutrition showed an independent association with impaired efficacy of swallow (see Table 1). As far as the authors of this letter know, this is the first study that has reported the "real" prevalence of dysphagia in independently living older persons using a validated clinical method and considering its diagnostic accuracy. It confirms that a large number of older persons in the community have OD and are at risk of nutritional and respiratory complications. Dysphagia is associated with substantial morbidity, poor functionality, impaired quality of life, and high mortality.10 Multiple underlying factors are involved in its development, and it does not fit into one specific disease category, so it must be considered a "geriatric syndrome." This study supports routine screening for dysphagia in older persons. This project was partially sponsored by a grant from the Fundació Salut del Consorci Sanitari del Maresme and by grants from the Spanish Ministry of Science and Innovation (FIS PI05/1554 and PS09/01012). Conflict of Interest: All authors declare that they have no conflict of interest in relation with the present study. Author Contributions: M. Serra-Prat: study concept and design, analysis and interpretation of data, preparation and review of manuscript. G. Hinojosa, M.D. López, M. Juan, E. Febrer, D. Voss, M. Calvo, V. Marta, L. Ribó: acquisition of data and review of manuscript. E. Palomera: data analysis and interpretation and review of manuscript. V. Arreola: training and review of manuscript. P. Clavé: study concept, interpretation of data, preparation and review of manuscript. Sponsor's Role: The sponsor played no role and did not interfere in any way with the design, recruitment, data collection, analysis, or preparation of manuscript.