Nestle Supplement 2

NUTRITION AND THE OLDER PERSON ing a set of obligate muscles that always participates in this motor response and that is initiated with the contraction of the mylohyoid muscle.7 The OSR is a primitive reflex produced by a central pattern generator located in the medulla oblongata that can be activated by central (cortex) or peripheral (mechanoreceptors innervated by the internal branch of superior laryngeal nerve) afferent inputs.7 Once activated, the central pattern generator stimulates the efferent motor nuclei involved in the swallow response, mainly the hypoglossal (XII) motor nuclei and the nucleus ambiguous (IX, X).7 The duration of the whole oropharyngeal swallow response in healthy humans7 is in the range of 0.6 second–1 second. Healthy subjects present a short reaction time in the submental muscles,8 short swallow response (GPJO–LVO < 740 milliseconds), fast laryngeal vestibule closure (LVC < 160 milliseconds), and fast upper esophageal sphincter opening (UESO 35 cm/second) and strong bolus propulsion forces (> 0.33 mJ).9 In contrast, neurological patients show slow bolus velocity (< 22 cm/second) and weak bolus propulsion forces (< 0.20 mJ) causing post-swallow residue.9 Also, older people with oropharyngeal dysphagia present even more impaired tongue propulsion forces (< 0.14 mJ) and slower bolus velocity (< 10 cm/second).1 Thereafter, dysphagia in the elderly is associated with impairment in efficacy and safety of swallow caused by weak tongue propulsion and prolonged and delayed swallow response. Pathogenesis of impaired safety is related to a delay of several physiologic protective reflexes in oropharyngeal reconfiguration (mainly laryngeal vestibule closure) caused by a slow neural swallow response and is associated with several risk factors, such as aging, neurodegenerative diseases, confusion, dementia, and drugs. Pathogenesis of impaired efficacy is related to alterations in bolus propulsion caused by a weak muscular tongue squeeze associated with sarcopenia and weakness.1 DIAGNOSIS In many hospitals, there is a large discrepancy between the high prevalence, morbidity, mortality, and costs caused by nutritional and respiratory complications of functional oropharyngeal dysphagia and the low level of human and material resources dedicated to dysphagic patients. Dysphagia with oropharyngeal aspiration is usually not considered an etiologic factor in elderly patients with community-acquired pneumonia14,15 or in elderly patients with malnutrition. 16 Diagnosis and management of oropharyngeal dysphagia requires a multidisciplinary approach. A dysphagia multidisciplinary team should include several professional domains: nurses, speech-swallow therapists, gastroenterologists, ENT specialists, neurologists, surgeons, rehabilitation physicians, dietitians, radiologists, geriatricians, etc. The goals of a multidisciplinary dysphagia team include 1) early identification of elderly patients with dysphagia; 2) diagnosis of any medical or surgical etiology for dysphagia that may respond to specific treatment, the exclusion of ENT and esophageal tumors, and gastroesophageal reflux and its complications; 3) characterization of specific biomechanical events responsible for functional dysphagia in each patient; and 4) the design of a therapeutic strategies set to provide the patient with safe and effective deglutition or the provision of an alternative route to oral feeding based on objective and reproducible data.2,16 The involvement of patients’ families in the DECEMBER 2007 • 9

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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