Nestle Supplement 2

NUTRITION AND THE OLDER PERSON mL nectar, liquid, and pudding bolus sequentially administered in a progression of increasing difficulty (Figure 3). Cough, fall in oxygen saturation 3%, and changes in quality of voice were considered clinical signs of impaired safety and piecemeal deglutition and oropharyngeal residue signs of impaired efficacy. The V-VST is a safe, quick, and accurate clinical method with 88.2% sensitivity for impaired safety, 100% sensitivity for aspiration, and up to 88.4% sensitivity for impaired efficacy of swallows.2 Figure 4 shows the algorithm for management (screening, diagnosis, and treatment) of oropharyngeal dysphagia at the Hospital de Mataró, Barcelona, Spain.16 Videofluoroscopy is the gold standard method to study the oral and pharyngeal mechanisms of dysphagia.2,23 Videofluoroscopy is a dynamic exploration that evaluates the safety and efficacy of deglutition, characterizes the alterations of deglutition in terms of videofluoroscopic symptoms, and helps to select and assess specific therapeutic strategies. Technical requirements for clinical VFS are an xray tube with fluoroscopy and a videotape recorder. Computer-assisted methods of image analysis allow quantitative temporal and spatial measurements.9 Main observations during VFS are done in the lateral plane while the patient swallows 3 mL–20 mL boluses of at least 3 consistencies: liquid, nectar, and pudding. The patient is kept at a minimal risk for aspiration by starting the study with low volumes and thick consistencies, introducing liquids and high volumes as tolerated.9 Major signs of impaired efficacy during the oral stage include apraxia and decreased control and bolus propulsion by the tongue. Many older patients present with deglutitional apraxia (difficulty, delay, or inability to initiate the oral stage) following a stroke. This symptom is also seen in patients with Alzheimer’s dementia and patients with diminished oral sensitivity. Impaired lingual control (inability to form the bolus) or propulsion results in oral or vallecular residue when alterations occur at the base of the tongue.The main sign regarding safety during the oral stage is glossopalatal (tongue-soft palate) seal insufficiency, a serious dysfunction that results in the bolus falling into the hypopharynx before the triggering of the oropharyngeal swallow response and while the airway is still open, which causes predeglutitive aspiration.2,24 Videofluoroscopic signs of safety during the pharyngeal stage include penetrations and/or aspirations. Penetration refers to the entering of contrast into the laryngeal vestibule within the boundaries of the vocal cords. When aspiration occurs, contrast goes beyond the cords into the tracheobronchial tree (Figure 2B).The potential of VFS regarding image digitalization and quantitative analysis currently allows accurate swallow Figure 3. Algorithms of bolus volume and viscosity administration during V-VST. The strategy of the V-VST aims at protecting patients from aspiration by starting with nectar viscosity and volumes were increased from 5 mL to 10 mL and 20 mL boluses in a progression of increasing difficulty. When patients completed the nectar series without major symptoms of aspiration (cough and/or fall in oxygen saturation ≥ 3%), a less “safe” liquid viscosity series was assessed also with boluses of increasing difficulty (5 mL to 20 mL). Finally, a more “safe” pudding viscosity series (5 mL to 20 mL) was assessed using similar rules. If the patient presents a sign of impaired safety at nectar viscosity, the series is interrupted, the liquid series is omitted, and a more safe pudding viscosity series is assessed. If the patient presents a sign of impaired safety at liquid viscosity, the liquid series is interrupted and the pudding series is assessed (Figure 1C). response measurements in patients with dysphagia (Figure 2).A slow closure of the laryngeal vestibule and a slow aperture of the upper esophageal sphincter (as seen in Figure 2B) are the most characteristic aspiration-related parameters.9,10 Penetration and aspiration may also result from an insufficient or delayed hyoid and laryngeal elevation, which would fail to protect the airway. A high, permanent postswallow residue may lead to post-swallow aspiration, since the hypopharynx is full of contrast when the patient inhales after swallowing, and then contrast passes directly into the airway.2,24 Thereafter,VFS can determine whether aspiration is associated with impaired glossopalatal seal (predeglutitive aspiration), a delay in triggering the pharyngeal swallow or impaired deglutitive airway protection (laryngeal elevation, epiglottic descent, and closure of vocal folds during swallow response), or an ineffective pharyngeal clearance (post-swallowing aspiration).2 DECEMBER 2007 • 11

Table of Contents Feed for the Digital Edition of Nestle Supplement 2

Nestle Supplement Table of Contents Introduction to Weight Loss in Older Persons Diagnosis and Management of Oropharyngeal Dysphagia in the Elderly The Danger of Weight Loss in the Elderly Nutrients and Frailty

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