Nestle Supplement 2

NUTRITION AND THE OLDER PERSON laryngeal vestibule; 30% present with aspiration; half of them without cough (silent aspirations); and 45% with oropharyngeal residue.1 It is accepted that detection of aspiration at VFS is a predictor of pneumonia risk and/or probability of rehospitalization.23 It is also well known that not all patients who aspirated at VFS develop pneumonia, and impairment in host defenses, such as abnormal cough reflex,14,28 impaired pharyngeal clearance,22 amount and bacterial concentration of aspirate, and weakened immune system, also strongly contributes to the development of aspiration pneumonia.15 Impairment of cough reflex increases the risk of aspiration pneumonia in stroke patients. 28 The microbial etiology of AP involves Staphylococcus aureus, Haemophilus influenzae, and Streptococcus pneumoniae for community-acquired aspiration pneumonia and Gram-negative aerobic bacilli in nosocomial pneumonia.15 It is worth bearing in mind the relative unimportance of anaerobic bacteria in AP.15 Increased incidence of oropharyngeal colonization with respiratory pathogens is caused by impairment in oral care and decrease in salivary clearance.22 Surprisingly, in the clinical setting, oropharyngeal dysphagia and aspiration usually are not considered etiologic factors in elderly patients with pneumonia.14,15 Impairment in swallowing efficacy may reduce oral feeding and lead to malnutrition unless nutritional status is monitored and specific dietetic strategies are introduced to enhance caloric intake. Up to 30% of neurological patients and up to 35% of frail elderly patients with dysphagia present malnutrition with strong relationships between severity of dysphagia and incidence of malnutrition.1,9 Studies found undernutrition among hospital patients leads to extended hospital stays, prolonged rehabilitation, diminished quality of life, and unnecessary healthcare costs and identified functional oropharyngeal dysphagia as a major contributor to malnutrition.29 Recent guidelines on the indications of enteral nutrition in geriatrics also highlighted the role of dysphagia causing undernutrition in older patients.29 Dehydration is also a frequent complication of dysphagia in elderly patients with oropharyngeal dysphagia. 30,31 Dehydration and increased plasma osmolarity showed a significant association with mortality in elderly patients with stroke.31 Figure 5 shows the pathophysiology of complications of dysphagia associated with malnutrition and dehydration. TREATMENT Treatment of dysphagia in the elderly varies greatly among centers.This variability can contribute to some con- troversy on the effect of swallowing therapy in preventing malnutrition and AP. In addition, few studies address these unanswered questions. A recent review found there is insufficient data to determine the effectiveness of treatments for dysphagia in preventing AP in older adults.26 In contrast, other authors found treatment of dysphagia is cost effective and the use of dysphagia programs is correlated with a reduction in AP rates.23 Management strategies for oropharyngeal dysphagia in older patients may be grouped into 4 major categories that may be simultaneously applied to the treatment of each individual patient.32 During VFS, a combination of strategies may be selected to compensate for each patient’s specific deficiency, and its usefulness to treat the patient’s symptoms may be explored. Swallow therapy aims to improve the speed, strength, and range of movement of muscles involved in the swallow response and to modify the mechanics of swallow to improve bolus transfer and avoid or minimize aspiration. It should be remarked that the largest body of literature relates to swallow therapy in older patients after strokes.23 Management of dysphagia is not an exact science, and a combination of clinical expertise and the best available evidence-based medicine is usually needed to mange elderly patients with oropharyngeal dysphagia because neither alone is sufficient to dictate decisions on treatment of individual patients.1,23 Preserved cognitive function is needed to apply some of the strategies. Nutritional and respiratory status should be monitored in dysphagic patients in order to assess the efficacy of treatments. Postural strategies. Verticality and symmetry should be sought during the patient’s ingestion.Attention must be paid to controlling breathing and muscle tone. Postural strategies are easy to adopt—they cause no fatigue and allow modification of oropharyngeal and bolus path dimensions. Anterior neck flexion protects the airway;33 posterior flexion facilitates gravitational pharyngeal drainage and improves oral transit velocity; head rotation toward the paralyzed pharyngeal side directs food to the healthy side, increases pharyngeal transit efficacy, and facilitates UES aperture;34 and deglutition in the lateral or supine decubitus protects from aspirating hypopharyngeal residues. Change in bolus volume and viscosity. In patients with neurogenic dysphagia and also in elderly patients, reductions in bolus volume and enhancement of bolus viscosity significantly improve safety signs, particularly regarding penetration and aspiration.9 Viscosity is a physical property that can be measured and expressed in international system units by the name of Pa.s. The prevalence of penetrations and aspirations is maximal with water and thin fluids (20 mPa.s) and decreases with nectar (270 mPa.s) and pudDECEMBER 2007 • 13

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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