Comparisons of Temporal Characteristics of Respiration and Swallowing Coordination between Young and Elderly

Objectives: The relationship between breathing and swallowing is very dynamic during swallowing and these are highly temporally coordinated to protect the airway. The ability to protect airways during swallowing deteriorates with aging. In this study, we attempted to compare the breathing-swallowing pattern and temporal change in the respiration and swallowing coordination between young and elderly adults in Korea.Methods: A total of 80 normal people, including 40 young and 40 elderly people participated in this study. For measurement of breathing and swallowing coordination, Digital Swallowing Workstation^TM was used during a 5 mL water swallowing task. Temporal parameters related to breathing-swallowing including AS (acoustic start), AP (acoustic peak), AD (acoustic duration), SAS (swallowing apnea or respiration pause start), SAD (swallowing apena duration), sES (submental sEMG start), sEP (submental sEMG peak), sED (submental sEMG duration). Additionally, DHI (Dysphagia Handicap Index) was evaluated for self-assessment of the degree of difficulty swallowing.Results: Older adults displayed delayed swallowing-related acoustic signal measurements, swallowing apnea measurements, surface EMG measurements, and delayed sequential coordination time of swallowing-related structures during swallowing. There were no significant differences according to gender. Furthermore, a significant positive correlation was observed between the total K-DHI scores and as well as swallowing apnea duration in the elderly.Conclusion: In the older population, the different breathing-swallowing pattern from that of young adults may increase the risk of dysphagia. In addition, swallowing delays due to aging can be an indicator of elderly swallowing disorders. Moreover, an increase in apnea time during swallowing may be a phenomenon that appears as a mechanism for airway protection in the elderly. However, the high correlation between apnea time and K-DHI score in the elderly may make it difficult to maintain respiration for a long time during swallowing as the respiratory function decreases due to aging, which may increase the risk of experiencing symptoms such as choking and affect the degree of subjective swallowing disorder. This suggests that even if classified as a normal elderly person without a pathological swallowing disorder, swallowing training is needed to prevent swallowing disorders and to enhance swallowing ability for older people with degraded swallowing-related abilities.

Cross-Cultural Adaptation and Validation of the Italian Version of the Dysphagia Handicap Index (I-DHI)

The Dysphagia Handicap Index (DHI) is a valid Health-related Quality of Life (HRQOL) questionnaire for patients with oropharyngeal dysphagia (OD) of heterogeneous etiologies. The study aimed at crossculturally translating and adapting the DHI into Italian (I-DHI) and analyzing I-DHI reliability, validity, and interpretability. The I-DHI was developed according to Beaton et al. 5-stage process and completed by 75 adult OD patients and 166 healthy adults. Twenty-six patients filled out the I-DHI twice, 2 weeks apart, for test–retest reliability purposes. Sixty-two patients completed the Italian-Swallowing Quality of Life Questionnaire (I-SWAL-QoL) for criterion validity analysis. Construct validity was tested comparing I-DHI scores among patients with different instrumentally assessed and self-rated OD severity, comparing patients and healthy participants and testing Spearman’s correlations among I-DHI subscales. I-DHI interpretability was assessed and normative data were generated. Participants autonomously completed the I-DHI in maximum 10 min. Reliability proved satisfactory for all I-DHI subscales (internal consistency: α > .76; test–retest reliability: intraclass correlation coefficient > .96, k = .81). Mild to moderate correlations (− .26 ≤ ρ ≤ − .72) were found between I-DHI and I-SWAL-QoL subscales. Construct validity proved satisfactory as (i) moderate to strong correlations (.51 ≤ ρ ≤ .90) were found among I-DHI subscales; (ii) patients with more severe instrumentally or self-assessed OD reported higher I-DHI scores (p < .05); and (iii) OD patients scored higher at I-DHI compared to healthy participants (p < .05). Interpretability analyses revealed a floor effect for the Emotional subscale only and higher I-DHI scores (p < .05) for healthy participants > 65 years. In conclusion, the I-DHI is a reliable and valid HRQOL tool for Italian adults with OD.

Self-Perception of Voice and Swallowing Handicap in Parkinson’s Disease

Background: Hypokinetic dysarthria and dysphagia are known features of Parkinson’s disease; however, self-perception of their handicapping effects on emotional, physical, and functional aspects of quality of life over disease duration is less understood. Objective: 1) Based upon patient self-perception, to determine the relationship of the handicapping effects of dysphagia and dysphonia with time since diagnosis in individuals with Parkinson’s disease; 2)To determine if there is a relationship between voice and swallowing handicap throughout the course of Parkinson’s disease. Method: 277 subjects completed the Dysphagia Handicap Index and the Voice Handicap Index. Subjects were divided into three groups based on disease duration: 0–4 years, 5–9 years, and 10 + years. Results: Subjects in the longer duration group identified significantly greater perceptions of voice and swallowing handicap compared to the shorter duration groups. There was a significant positive correlation between the DHI and VHI. Conclusion: Self-perception of swallowing and voice handicap in Parkinson’s disease are associated with later stages of disease and progress in a linear fashion. Self-perception of voice and swallowing handicap parallel each other throughout disease progression in Parkinson’s disease. Individuals may be able to compensate for changes in voice and swallowing early while sensory perceptual feedback is intact. Results support early targeted questioning of patient self-perception of voice and swallowing handicap as identification of one problem indicates awareness of the other, thus creating an opportunity for early treatment and maintenance of swallowing and communication quality of life for as long as possible.

Dietary risk factors and therapy outcomes of swallowing-related problems in laryngopharyngeal reflux: patients’ perspectives

Background This was a prospective cohort that included 60 gastro-esophageal reflux disorder patients with suspected laryngopharyngeal reflux-related symptoms (e.g., sore throat, throat clearing, globus sensation, cough, dysphonia, and dysphagia). The diagnosis was confirmed using history taking, clinical laryngoscopic examination, and upper endoscopy guided by the Reflux Symptom Index (RSI). Patients were treated with proton pump inhibitors and prokinetics for 12 weeks. The aim of the current study was to explore the dietary risk factors in laryngopharyngeal reflux patients and to assess the response to therapy on swallowing-related problems by comparing the baseline pre-treatment and post-treatment values of RSI and Dysphagia Handicap index (DHI). Results Analysis of data regarding the role of diet as a risk factor for reflux revealed that 33 patients (55%) are eating meat, 56 patients (93.3%) eating fat, 45 patients (75%) eating sweet, 55 patients (91.7%) eating spicy food, 52 patients (96.7%) eating fried food, 34 patients (56.7%) drinking tea, 51 patients (85%) eating big meals, 21 patients (35%) drinking fruit juices, 54 patients (90%) eating sour foods, 51 patients (85%) eating citrus fruits, and 22 patients (36.7%) smokers. There was a statistically significant decrease in Reflux Symptom Index scores and an increase of Dysphagia Handicap Index scores after 12 weeks on proton pump inhibitors and prokinetics. Conclusion Different dietary factors were present in LPR patients. A short period of empiric anti-reflux treatment has a significant improving effect on Reflux Symptom Index and Dysphagia Handicap Index scores from baseline to 12 weeks post-treatment. Further research is needed to investigate longer times of treatment for the complete resolution of symptoms.

New Technique of Posterior Fixation of Tube With Fibrin Sealant Prevents Dysphagia in Patients Undergoing Sleeve Gastrectomy

Introduction This study compared the effects of posterior fixation (PF) of the remnant tube with fibrin tissue glue to prevent sharp angulation and gastric twist and traditional techniques on postoperative dysphagia and vomiting. Methodology In total, 200 patients scheduled to undergo laparoscopic sleeve gastrectomy (LSG) as a bariatric surgical intervention were randomly classified into 2 groups (LSG + PF and LSG alone). We compared postoperative dysphagia symptoms among patients who underwent PF and those who did not. The Dysphagia Handicap Index (DHI) results were compared statistically among these groups. Results The study included a total of 191 patients (85.9% (n = 164) women and 14.1% (n = 27) men) who underwent LSG for obesity. The groups were similar in terms of the patient demographics. The DHI scores of the LSG + PF group were statistically significantly lower than those of the LSG alone group. Conclusion Adoption of a standardized method of PF with a standardized surgical procedure after LSG considerably reduced the rate of surgical complications.

An Investigation of the Factor Structure of the Persian Version of the Dysphagia Handicap Index

Background: Oropharyngeal dysphagia harms all aspects of a person’s life, including behaviors, activities, and social situations. Quality of life is a multidimensional concept. The dysphagia handicap index (DHI) is a patient-reported outcomes tool that evaluates the different dimensions of quality of life in three physical, emotional, and functional factors in English-speaking countries. The validity of the Persian version of the dysphagia handicap index (DHI) has been evaluated in a study, but the reliability and factor analysis of the Persian version has not been investigated in any study. Objectives: This study aimed to investigate the factor structure analysis and reliability of the Persian version of the dysphagia handicap index (P-DHI). Methods: In this cross-sectional study, 100 patients with oropharyngeal dysphagia (mean age 55.69 ± 15.04, 53 women) completed the dysphagia handicap index (DHI). The severity of dysphagia was defined as follows: 1 for no dysphagia (normal), 2 and 3 for mild, 4, and 5 for moderate and 6 and 7for severe. Construct validity was examined by confirmatory factor analysis (CFA). Cronbach’s alpha and intraclass correlation coefficient (ICC) were performed to evaluate the internal consistency and test-retest reliability of the P-DHI, respectively. Results: The results of CFA provided support for a second-order three-factor model of P-DHI (χ2 = 484.61, df = 273, (P = 0.0001), χ2/df = 1.77; CFI = 0.901; RMSEA = 0.088 and SRMR = 0.010). The Cronbach’s alpha for physical, functional, and emotional subscales and total score were 0.751, 0.836, 0.773, and 0.900, respectively. The test-retest reliability of the P-DHI for the total score and subscales was high (ICC: 0.952 - 0.988). Furthermore, a significant relationship was found between the P-DHI total score and self-reported severity of dysphagia (P = 0.0001), while there were no relationships between P-DHI total score and age (P = 0.223), sex (P = 0.936), level of education (P = 0.113), disease duration (P = 0.126). Conclusions: The P-DHI is a reliable and valid instrument for assessing the disabling effects of swallowing disorders on the one’s Quality of Life in Iranian patients with oropharyngeal dysphagia due to a variety of diseases. Also, the CFA findings provide support for the tree-factor structure of the P-DHI and the use of the subscales as distinct variables.

Swallowing Outcomes in 7 Patients Following Endoscopic Cricopharyngeal Myotomy With Primary Closure

Cricopharyngeal spasm and pharyngeal pouch can result in severe dysphagia symptoms that can have a significant impact on a patient’s quality of life. Several surgical interventions have been demonstrated including balloon dilatation, botox injection, and open and endoscopic cricopharyngeal myotomy. The aim of this case series is to describe our technique for endoscopic cricopharyngeal myotomy and compare pre- and postoperative swallowing outcomes using objective swallowing questionnaires in a small series of patients. Seven patients diagnosed with cricopharyngeal spasm or grade 1 pharyngeal pouch on barium swallow were prospectively observed. MD Anderson Dysphagia inventory (MDADI) and Dysphagia handicap index (DHI) were given to patients before and after their operation. All patients underwent the same surgical technique with the cricopharyngeal bar divided and the defect closed with dissolvable sutures. Mean inpatient stay was 7 days (range 1-8) and mean time to resumption of soft diet was 4 (range 1-7) days. All patients resumed oral diet before discharge. MDADI scores showed improvement across all domains, however only the emotional score achieved statistical significance ( P = .04). Dysphagia handicap index scores showed a statistically significant improvement across functional, emotional, and total domains. Postoperative chest infection treated with oral antibiotics occurred in 3 patients (43%) and no other complications were documented. In conclusion, endoscopic cricopharyngeal myotomy with primary sutured endoscopic closure can result in a significant benefit to patient’s swallowing symptoms, emotional well-being, and quality of life.

Swallowing Disorder in Multiple Sclerosis: Modified Version of the Screening Tool

Objective: Dysphagia is commonly encountered in Multiple Sclerosis (MS). It can consequently cause severe complications such as the increased risk of dehydration, malnutrition and aspiration pneumonia that associated with an increased risk of death in the late stages of the disease. These complications can be prevented with an effective screening protocol. The Dysphagia in Multiple Sclerosis (DYMUS) is the only questionnaire developed specifically for patients with MS. The aim of the present study was translation and cross-culturally adaptation of DYMUS for the Persian population and estimation of the questionnairechr('39')s reliability and validity. Also, we investigated the frequency and severity of dysphagia in the patients referring to the Tehran MS Society and its association with the course of MS, disease duration, and Expanded Disability Status Scale (EDSS). Materials & Methods: This is a methodological and descriptive-analytic study. The statistical populations consist of the patients with MS referring to the Tehran Multiple Sclerosis Society in 2018. The study sample consisted of 108 patients who were selected through a convenient sampling method. The research instruments consisted of 10-items DYMUS questionnaire (in the first part of the study, translated and its psychometric properties examined), Dysphagia Handicap Index and a demographic information questionnaire. In methodological section, translation and cross-cultural adaptation were fulfilled and the Confirmatory Factor Analysis (CFA) was used to assess the construct validity and to test the goodness-of-fit of the presented model. The association between the DYMUS and Dysphagia Handicap Index (DHI) scores investigated to convergent validity. ‏ The inter-item correlation matrix was calculated to assess the homogeneity of the questionnaire items. Kuder - Richardson (KR-20) was measured to assess the internal consistency of the questionnaire. Also, the test-retest procedure was conducted on the 19 subjects understudy to assess the reliability. Finally, the frequency and severity of dysphagia and its association with the course of MS, disease duration, and EDSS was investigated. KR-20 reliability coefficient, Intraclass Correlation Coefficient (ICC), inter-item correlation matrix, Mann-Whitney U test and rank correlation coefficient or Spearmanchr('39')s were used to inferential statistical analysis. Results: Analysis of the inter-item correlations matrix indicated a positive correlation between all items, exception item 10. Based on the results of the inter-item correlation, item 10 had the lowest correlation coefficient that was deleted from the questionnaire. CFA results confirmed the two-factor model of DYMUS, “dysphagia for solids” and “dysphagia for liquids”, and revealed that the item 10 was minimally contributing to the measurement of "dysphagia of solids" and internal consistency increased after the deletion of this item. Also, the solution of the 9-item Model was the best goodness-of-fit indicator for the sample. The obtained results from the convergent validity indicated a positive significant correlation between the DYMUS and DHI (rs=0.693, P<0.001). A KR-20 reliability coefficient of the DYMUS was 0.856, indicating high internal consistency of the Persian translation of the questionnaire items. Test-retest reliability was excellent with 0.965 value. The results also showed that 65.7% of multiple sclerosis patients had a swallowing disorder. In terms of the dysphagia severity, 25.9% of participants had mild dysphagia, and 39.8% of participants had alarming dysphagia. DYMUS values were significantly correlated with disease duration (rs=0.198, P= 0.040), and EDSS (rs=0.235, P= 0.014) and significantly higher mean scores were observed in the patients with secondary progressive than the other subgroups of multiple sclerosis. Conclusion: The Persian adjusted 9-item questionnaire was demonstrated to be a simple, consistent, valid and reliable tool for the detection of patients who need more specific instrumental evaluations of swallowing. Also, about the dysphagia is very frequent in these patients, it is important that clinicians monitor these patients carefully even in early stages of the disease‏ for early detection and planning a rehabilitation program to the prevention of serious subsequence complications.