Editor’s Note: This text is a transcript of the course, Sarcopenia, Frailty and Dysphagia, presented by Angela Mansolillo, MA, CCC-SLP, BCS-S.
After this course, participants will be able to:
- Explain the inter-relationships between sarcopenia, frailty, and swallowing disorders
- Identify three potential contributing factors to sarcopenic dysphagia in their elderly patients
- Describe two strategies to improve outcomes in individuals with sarcopenic dysphagia
In this course, I will discuss swallowing disorders in our patients with sarcopenia and frailty. Sarcopenic dysphagia may or may not be a new term for you. It's a relatively recent entry in dysphagia literature, so we'll spend some time talking about different terms and what they mean. But I thought it might be helpful to start with why we care about this in the first place.
Understanding the Impact
A recent observational study was conducted looking at patients hospitalized for hip and/or femur fractures (Allen et al., 2020). The sample was comprised of over 2000 people with a fracture without dysphagia and approximately 165 people with a fracture with dysphagia. When the groups were compared, they found that those individuals with fracture and swallowing disorder were older, which may not be surprising. Additionally, they had longer lengths of stay, higher mortality rates, higher pneumonia rates, and it cost more to take care of them. So, there are a number of impacts on our more frail patients who have swallowing disorders in terms of quality outcomes (e..g., length of stay), health outcomes (e.g., pneumonia, mortality rates), and financial consideration. The financial considerations are usually not our biggest concern, but they are certainly something notable as we think about identifying at-risk folks and making sure they get the careful evaluation and treatment that they need.
Defining Some Terms
I want to review some terminology because it can be confusing. Terms are used interchangeably when in fact, they mean different things. The first term is anorexia of aging, which is an age-related reduction in appetite and, therefore, caloric and protein intake. It may result in failure to thrive. That doesn't always happen, but it can.
The term failure to thrive for adult clients refers to the inability to maintain their functional status. In other words, your clients are in a state of decline. This is often characterized by poor appetite, weight loss, and low intake. It is often accompanied by changes in mobility, limitations in mobility, and limitations in the ability to participate in activities of daily living.
You may also have seen the term 'cachexia,' particularly in patients with cancer diagnoses. In fact, there's a very specific cancer cachexia. But in more general terms across diagnostic populations, physicians and registered dieticians often use cachexia to refer to the weight loss and muscle wasting that is specifically associated with disease or illness.
There is also the concept of functional reserve. Most activities of daily living do not require all of our energy. In fact, we're functioning at about 30% of our full capacity for most ADLs, and what is left in reserve is called functional reserve. As we age, it is quite normal for the amount of functional reserve to start to diminish. Therefore, we would expect that in elderly clients, there would be less functional reserve available. That becomes important when considering the overlay of swallowing impairments, frailty, or sarcopenia.
The next term is presbyphagia. These are age-related changes in swallow function seen in our elderly clients. This is not swallowing impairment, dysphagia, or disordered swallowing. It refers to the sensory changes and muscular changes that occur in swallow function as people age. Similar to functional reserve, we need to be aware of presbyphagia because as people age, their swallow will be less efficient. Their chewing and bolus manipulation will be less efficient. Again, it is not impaired or disordered but it is less efficient. If or when we see sarcopenic changes and frailty overlaid on that, there will be more of a likelihood of disability.
Sarcopenic is the term used to refer to a progressive, generalized loss of muscle mass and muscle function. These are specific changes to the musculature, and that can be larger skeletal muscles as well as smaller head and neck muscles.
The final term is frailty which is more difficult to define. There is a lot of variability in the literature regarding how this term is used and defined. But generally, we see frailty referring to individuals who have some accumulation of abnormality. This means that many different things are going on in many different areas, and the individual has less functional reserve and less ability to use compensations. As a result, a decline in function begins to occur. Eventually, these individuals reach a critical point where many of their systems start to fail.
What Do We Know About Frailty?
What do we know about patients with frailty and patients with sarcopenia? We know that frailty is multidimensional, meaning there is the potential for impairments in a lot of different areas; respiration, gastrointestinal functioning, swallow function, mobility, ability to do ADLs, cardiac function, etc. Also, it's largely a geriatric syndrome. Occasionally, I see children that I would characterize as frail, but in general, it's considered to be a geriatric syndrome.
Several factors potentially impact frailty in these individuals. There are physical factors such as disease processes, nutritional compromise, changes in muscle functions, strength and mobility, and vestibular issues. There are also psychological issues such as the stress that the individual may be under, mood disorders, or the absence of coping strategies. There are social factors to consider as well. What kind of social resources does this individual have? What are their financial resources, education, social contacts, etc? A more isolated individual is often at higher risk.
There may be cognitive changes as part of this process. Cognitive frailty refers to individuals who have some cognitive decline. However, that does not need to be present for an individual to have a diagnosis of frailty. But, cognitive changes can accompany a diagnosis of frailty.
What does this mean functionally? It means these individuals are more likely to fall. If you work with the elderly, you know that a fall is often a precipitating event for a cascade of problems that come with hospitalization and lack of mobility. Frail individuals are also at higher risk of illness because their immune system is compromised. They tend to have a higher degree of disability overall. They're more likely to be hospitalized. They're more likely to require residential care and skilled nursing facilities. They have higher mortality as well.
What Do We Know About Sarcopenia?
Sarcopenia refers to the muscle changes that occur as people age, the actual deterioration of muscle function and muscle mass. Prevalence data suggests that there is some variability. But, in general, there's a trend toward more sarcopenia as people age, meaning the older people get, the more likely they will have some sarcopenic changes.
Sarcopenia, like frailty, is a predictor of fall risk, fractures, and functional decline. Sarcopenia often predicts frailty. It's important to note that when you think about frailty, you think of that very low-weight, malnourished individual. But sarcopenia and malnutrition don't always occur in folks with significant weight loss. People who are obese can have sarcopenic changes and may be frail as well. There is also a growing body of evidence suggesting that sarcopenia is a predictor of swallowing impairment in the elderly, which is important to us as SLPs.
Potential Causes of Sarcopenia
Sarcopenia has several different potential causes. One or more of these might be present in any particular individual. There are nutritional causes such as low protein intake, low caloric intake, issues with absorption of calories or protein, and the anorexia of aging mentioned earlier.
There are some issues with activity. This is the patient who has prolonged periods of bed rest because of an illness or a disability, who has immobility, who's deconditioned, and who maybe has always led a more sedentary lifestyle. These factors would contribute to sarcopenia as we age as well.
Several specific disease processes cause sarcopenia. Bone and joint disease seem obvious, but also cardiac and respiratory conditions, neurological disorders, cancers, liver and kidney disease, etc.
Finally, there are iatrogenic causes. This includes medications, particularly for those individuals when polypharmacy is an issue. We see a lot of elderly patients who have multiple medications from multiple specialists, and no one is really looking at the interrelationships and interactions between those medications. Being hospitalized is a potential cause of sarcopenia, which is related to the activity and disease process.
The Gut Connection
If you have heard me speak before, you have probably heard me say that what happens in one part of the body affects what happens in other parts of the body. Therefore, we can't just think about swallow function because swallowing doesn't occur in a vacuum. Swallowing occurs in the context of a physical body that has many different systems working interactively. Thus, what happens in one part of the body affects what happens in other parts of the body.
I'm very interested in the role of the digestive system when it comes to swallowing. An article by Nardone et al. (2021) provides an excellent review of the interrelationships between the digestive microbiome and muscle function. The microbiome in the gut, in the digestive system, is very complicated. There are good bacteria, and hopefully not so many bad bacteria. There's a wide variety of bacteria. The microbiome in your digestive system is very individualized and has many different roles to play. It impacts digestion and metabolism, but it also impacts muscle function. Any sort of inflammation in the digestive system can impact muscle function. It can trigger muscle weakness and muscle atrophy.
The microbiome also plays an important role in the development of the immune system in babies and children, as well as maintenance of the immune system throughout our lifespan. If there is a disruption in the microbiome, there is likely to be an accompanying disruption in immune system function. That will have implications for muscle function and may potentially trigger some sarcopenic changes. Additionally, the digestive system is responsible for metabolizing many different nutrients, including proteins.
We also need to consider respiratory muscle function. Because swallowing occurs in the context of other systems, the concept of respiratory sarcopenia has been identified. This occurs in individuals with whole body sarcopenia muscle changes that have specifically impacted the respiratory musculature, which includes the muscles of the core that are responsible for respiration and potentially the muscle of the diaphragm. Respiratory sarcopenia can result in changes in respiratory muscle strength, diaphragmatic thinning, and therefore inefficiencies in diaphragmatic functioning. Functionally, these individuals have lower peak expiratory flow rates, lower maximum inspiratory pressures, and lower maximum expiratory pressures. So, many of the respiratory markers that we look at are going to be impacted. This can potentially impact breathing-swallow coordination as well.
What About Swallowing?
This is where the swallow function piece comes in. As SLPs, we identify and treat swallow impairments in individuals with specific ideologies; head and neck cancer, stroke, neuromuscular disease, etc. But, in this course, we are referring to a dysphagia that is occurring in the context of multiple potential causes and without a single sort of unifying underlying diagnosis. This is a swallowing impairment that is related to a gradual, perhaps more significant at times, steady functional decline. Therefore, in the rest of this course, I want to discuss the relationships between frailty and sarcopenia, and swallow function.
There is a large body of evidence that suggests frailty is associated with swallow impairment, specifically with aspiration and nutritional compromise. (Wakabayashi, et al, 2015; Hathaway, et al 2014; Takeuchi, et al, 2014; Banda et al, 2021; Sella-Weiss, 2021, Bahat et al, 2019). (There is data from 2014-2015 that was published in 2020. Research around hospital data takes several years to compile. So, we are often looking at data from four or five years ago). A review of records from the Healthcare Cost and Utilization Project was conducted. A national inpatient sample of hospitals and healthcare facilities around the country submitted data to this project. Data was gathered from 6 million hospital discharges in patients 50 years old or older during 2014-2015. The dysphagia prevalence overall in the sample was 4% which fits with a lot of other data that we've seen in terms of dysphagia prevalence. But, the dysphagia rate in frail individuals was significantly higher. In folks who had a diagnosis of frailty, dysphagia prevalence was as high as 11%. That is a significant difference. We know that these folks are going to be at much higher risk for swallow impairment.
There is also an older study from 2010 that assessed a small sample of 45 frail elderly patients (Rofes et al., 2010). They did Videofluoroscopic Swallow Studies with these individuals and found a lot of impairment such as residue, laryngeal penetration, aspiration, and a number of specific physiological deficits, including issues with tongue propulsion and impaired hyolaryngeal excursion. The muscles of the tongue and the muscles responsible for hyolaryngeal excursion seem to be particularly susceptible to sarcopenia. However, this is an area that requires more information.
A more recent, larger study of 190 individuals with frailty was conducted by Chang and Kwak in 2021. They performed swallow studies as well and tried to ensure that the190 subjects did not have another potential cause for their dysphagia. In other words, these were people who had not had strokes or head and neck cancer, etc. The subjects were followed for three months.
The pneumonia rate was approximately 25% in this group, which is pretty high. So, these were people who had swallow impairment that was presumably the result of their frailty. When the researchers went back and looked at who was getting sick based on penetration-aspiration scale (PAS) scores, those with PAS scores of three, seven, or eight had the highest likelihood of developing a pneumonia.
As a reminder, a PAS score of three indicates that an individual has had penetration without aspiration but didn't clear the penetration. Scores of seven and eight are those individuals who have aspiration that they don't clear either with or without an attempt to clear. Those were the folks who seem to be at the highest risk in terms of pneumonia in this frail population.
Hip Fracture Population
There have been a few studies that have looked at the hip fracture population. We typically see them in acute care. A person comes in with a fracture, they have their surgery (or perhaps they don't have their surgery because they're not a candidate), and nursing tells you they failed their swallow screen or they noticed swallow impairments. So, this is in an at-risk population. Depending on the study, the prevalence of dysphagia in folks with hip fractures is 34-55%. But there is some agreement in the literature about the risk factors:
- Preexisting neurological conditions
- Preexisting respiratory conditions
- Delirium in the hospital
- Those who were dependent on care
- Those receiving residential care prior to admission
- Those who had some impairment in ADLs prior to admission
If you want to develop a screening process in your facility to identify folks in the hip fracture population who might be at higher risk for dysphagia, these are the factors to consider.
Choking Risk in Frail Elderly
Choking risk increases in the frail elderly as well, and there are several causative factors such as loss of dentation, dentures that don't fit, and fatigue associated with eating, particularly fatigue associated with chewing as well as generalized fatigue in terms of postal stability and maintaining a safe, appropriate head position. Medications are another factor to consider in predicting a higher choking risk. Some medications have a sedating effect that definitely put the frail elderly at risk.
Sarcopenia and Dysphagia
Let's look at some research on the relationship between sarcopenia and dysphagia. Remember there are changes in muscle mass and swallowing impairment, and the literature agrees that sarcopenia is a risk factor for swallow impairment. Specifically, there is tongue weakness, changes in range of motion of the tongue, pharyngeal muscle weakness, presence of a larger pharyngeal lumen, and upper esophageal sphincter weakness. There is a general decrease in endurance across the swallowing musculature for movements required for safe swallowing.
There is a study that looks specifically at tongue strength (Maeda and Akagi, 2015). They measured maximum tongue pressure and found that when it was reduced outside of the norm, that was more likely to be associated with reduced nutritional status. The patients were not getting enough nutrients and enough of a variety of nutrients. Tongue strength was also associated with sarcopenia due to changes in skeletal muscle mass, and more functionally with changes in activities of daily living and swallow impairment.
Some other studies have looked at specific muscles. Feng and colleagues (2013) looked at the mass of the geniohyoid muscle and found that when it was decreased, it contributed to aspiration. Ogawa and colleagues looked at the mass in the digastric muscle and found that when that was reduced, it was associated with dysphagia (2021). But an earlier study by Ogawa and colleagues actually found that tongue muscle atrophy was more predictive than the changes in the geniohyoid. However, currently, there is no evidence to suggest a specific muscle or a specific set of muscles is the marker; and that's the only factor to consider. Therefore, we need to think about this as more of a generalized decrease in muscle function associated with frailty. It can be tricky to figure out which came first. Do we have a patient who develops whole body sarcopenia and that impacts the swallow muscles and the respiratory muscles and that results in swallowing impairment, or does the swallow impairment come first, resulting in malnutrition, which then leads to the sarcopenia?
Does Pneumonia Come First?
There is some evidence to suggest that aspiration pneumonia could be a precipitating factor. When folks have a pneumonia, they're more likely to have some muscle atrophy across respiratory skeletal swallow musculature. Could that be a precipitating factor for some individuals? That is difficult to answer definitively because with sarcopenia, frailty, and swallowing, there is a constellation of impairments. There is a generalized, steady decline in function.
Defining Sarcopenic Dysphagia
This leads us to the term sarcopenic dysphagia, which is a relatively new term. Originally described by the Japanese Society of Dysphagia Rehabilitation in 2014, they define sarcopenic dysphagia as the presence of swallow impairment in the context of generalized sarcopenia. There are also documented changes in loss of muscle mass via imaging. This is an individual in whom other causes of dysphagia have been excluded or at least considered to be non-contributory. So, a patient who had a stroke would not be given the diagnosis of sarcopenic dysphagia. There may be some characteristics of sarcopenic dysphagia for that patient, but they would not be given this diagnosis because they have this other significant contributing factor.
More recently, in 2019, the definition was fleshed out a bit. It still refers to dysphagia caused by whole-body sarcopenia and changes in swallow musculature. It still excludes patients who have other potential causative diagnoses like neuromuscular disease. But the definition clarifies that this diagnosis does include sarcopenia that may be of one or more different causes. For example, it could be sarcopenia related to nutritional compromise, it could be sarcopenia related to disease, ot it could be sarcopenia related to changes in movement and activity. It could be all of the above.
Malnutrition and Aging
Nutrition is a factor, and we know that nutritional compromise is a problem in the elderly. We don't have a good handle on what the prevalence is because it varies with the setting. In general, hospitalized patients and residents of skilled nursing facilities tend to have higher prevalence rates of malnutrition. Community-dwelling elderly have less of an issue than folks receiving inpatient or residential care. But the malnutrition rate in community-dwelling elderly does increase for those receiving home health services. Clearly, there's a relationship between nutritional compromise and disability, as well as nutritional compromise and medical status overall.
Why are we seeing malnutrition in the elderly? It happens because of those multifactorial causal factors such as physical impairments and impairments in ADLs (e.g., the person is unable to prepare food or go to the grocery store as frequently as they used to), illness, medication side effects, and dental problems. Many individual factors could be contributing to malnutrition, including some that we haven't identified yet. Certainly, oral function is an important factor. Teeth are so important for managing higher texture foods that have better nutrition. When a person has dental pain, dentures that don't fit, or missing teeth, they will avoid those harder to chew foods. So they're eating fewer fruits and vegetables, they're getting less fiber, and they're more likely to depend on those softer, easier to chew foods that have more saturated fats and more cholesterol.
Another term in the literature related to this population is 'oral frailty'. Oral frailty is defined as a combination of these factors:
- Poor oral health
- Poor dental health
- Periodontal disease
- Difficulties in chewing
As we think about the nutritional consequences, there is an interesting and fairly recent study that compared individuals who had swallow impairment with sarcopenia and individuals who had swallow impairment without sarcopenia (First Ozer et al, 2021). Surprisingly, the individuals with sarcopenic dysphagia had lower BMIs, lower albumin levels, and lower hemoglobin levels. So, there is a closely tied relationship between frailty, sarcopenia, swallow impairment, and nutritional consequences. Those lower hemoglobin levels are important as we think about breathing-swallow coordination. Hemoglobin is responsible for oxygen saturation and carrying oxygen where it needs to go. Therefore, individuals who have lower hemoglobin levels are likely to have some breathing-swallow discoordination.
Fatigue is a factor. Another recent study looked at healthy, "older" and "younger" volunteers (Brates and Molfenter, 2021). They measured lingual pressures before and after eating. In addition, measured lingual pressures were associated with a pre-meal fatigue task. They had individuals doing tongue presses to fatigue the tongue before eating. There was a difference between pre-meal and post-meal in older subjects only.
The younger subjects in the study did not demonstrate any tongue fatigue due to eating. But when they added that pre-meal fatigue task, there were changes. There was fatigue in both the younger group and the older group. So, the tongue can get tired, which is important to think about in terms of bolus propulsion and bolus manipulation and swallow safety.
Respiratory musculature can fatigue as well. Respiratory sarcopenia is a term used to specifically identify patients who have muscle mass loss in the muscles responsible for respiration. A longitudinal study from last year looked at patients with pneumonia and healthy controls and found that those who had reductions in inspiratory and expiratory muscle strength were actually at higher risk for pneumonia (Okazaki et al, 2021). That is certainly something to keep in mind.
Think about the potential cycle. A patient gets sick and gets pneumonia. There's an inflammatory process that occurs. There's some potential nutritional compromise. All of that results in sarcopenia; muscle loss. That puts the patient at risk for an exacerbation of pneumonia or another pneumonia later on. We can see how patients can get caught in this cycle.
Sensory changes occur as we age as well. It is part of normal aging and not something we would define as being impaired. There are changes in olfactory sensation that causes decreased smell and taste. There are changes in some sensory perception that can result in changes in texture recognition and texture manipulation as well. We can see changes in preference. As people get older, they might prefer foods that have higher taste or are saltier in order to compensate for that production and taste perception. They might avoid foods they liked before but are not as appealing to them given these changes in sensation.
I said earlier that cognitive changes are not necessarily part of this profile but certainly can be. Changes in cognitive function, even temporary changes, can contribute to swallowing difficulty. Those folks are clearly on our radar. Changes in ability to attend, to make good decisions, to use compensatory strategies, and patients who are a bit more impulsive are factors that impact swallow safety.
In fact, in 2009, Dr. Leder and his group, as part of the development of the Yale Swallow Screening Protocol, demonstrated that patients who were disoriented and had difficulty following directions were at higher risk of aspiration. So, we know that cognition is a factor. It's not always part of the frailty sarcopenia profile, but it can be a factor for some clients.
A Japanese study by Hagglund and colleagues looked at folks 65 years old or older who had been admitted to inpatient rehabilitation services. In this group, they identified anorexia of aging in about half of the patients and poor oral health in more than half of the population. They found a strong correlation between the two. So, good oral health is an important general health predictor.
Many individual characteristics come into play. Everybody likes and dislikes different food and drinks. Mood can also be a factor. There are individual differences in the willingness and interest in preparing food and the ability to prepare food. Participation in oral hygiene routines, access to good oral and dental healthcare on a routine basis, variability with medications, and mealtime schedules are very individualized. For example, I have never in my life, from the time I was a child, had any interest in eating breakfast. My mother and grandmother were always trying to feed me, but I have never been a breakfast eater and probably never will be. However, for other people, breakfast is their biggest meal. Again, we have to consider a lot of these individual characteristics in terms of intake.
As we think about dysphagia in the context of frailty and sarcopenia, there are multiple potential contributing factors such as nutritional compromise, sensory changes, cognitive changes, oral health changes, generalized fatigue, and low endurance. All of these factors can potentially contribute to swallow impairment in these individuals.
Additionally, we might need to consider COVID. A recent single case review was published on an 85-year-old male who was healthy, active, well nourished, and contracted COVID (Can et al, 2021). He was admitted to the hospital and had a six-week hospital stay but never required ICU-level of care or intubation. He had a low appetite, low intake throughout the hospitalization, and limited mobility. This was all very similar to many of our COVID patients. Again, he had six weeks of nutritional compromise and mobility compromise related to his COVID infection. After that six weeks, he was discharged home but was readmitted three days later with what he described as a new onset of swallow difficulty. He underwent an endoscopic swallow study, and they found pharyngeal residue and impaired pharyngeal motility. This had not been identified during his six-week hospital stay. After a review of his hospital records and discussion with the patient, it was concluded that the COVID hospitalization, the low intake, and the lack of mobility associated with that six-week hospitalization resulted in sarcopenia, which then resulted in dysphagia for this individual. This single case study demonstrates the decline we will see in patients with frailty, sarcopenia, and swallow disorders.
What Can We Do
As we consider intervention, some are outside our scope of practice as SLPs.
- Exercise – swallowing; whole body
- Pharmacological interventions
- Dental/Oral health interventions
- Diet Modifications
There are nutritional interventions, swallow exercises (that is within our scope), pharmacological interventions, oral health interventions, diet modifications, and preventative strategies. But clearly, it is a multidisciplinary team effort to reduce the effects of sarcopenia on swallow impairment, treat the effects of sarcopenia on swallow function, and hopefully prevent swallow impairment and sarcopenia from occurring.
Let's start with considering nutritional interventions. Generally, "aggressive nutrition therapy" is recommended. The energy requirement recommendations are greater than or equal to 30-kilo calories per kilogram, per day and greater than or equal to 1.2 grams of protein per kilogram per day.
Here is an example. If you had a patient who weighed 100 pounds, that's about 45 kilograms. They would require about 1,400 calories per day and about 50 grams of protein. To put that in context, the general recommendation of protein intake for healthy people is about 0.8 grams per kilogram of weight per day. So you can see that these have been increased, which is why it's called aggressive nutrition therapy. We're trying to replace calories. We're trying to replace protein in these individuals to rebuild muscle mass and muscle function.
Some other recommendations have been published regarding supplementation. Again, in a study by Shimizu and colleagues (2021), they provided greater than 30 calories per the patient's ideal body weight. So, their target body weight per day or more. This was done largely through increasing portion size. Results of the study showed that they achieved better nutrition in 70% of the participants in the study. In addition to improved nutritional markers, they also showed improved swallow function. They didn't specifically measure swallow function in the study, rather they used advancing diet levels as a marker. There was also improvement in ADLs as measured in FIM scores. This aggressive intervention, in terms of caloric and protein supplementation, has the potential for some important outcomes, including improvement in swallow function.
In Conjunction with Exercise
Nutritional interventions seem to work well when provided in conjunction with exercise. When nutritional supplementation and exercise are combined, we get better outcomes than exercise alone. If we want the exercise to result in an improvement in muscle function, we have to give the body fuel. So, exercise plus nutritional intervention yields better outcomes.
One study looked at general strength training and activities to build endurance through physical therapy interventions (Nagano et al, 2020). In addition to improvements in endurance, there was improved tongue strength and improved oral intake. Again, exercise plus nutrition seems to be the way to go.
Resistance exercise is the goal. Exercising against resistance helps to stimulate hormones, enhances the benefits of nutritional interventions, and has the potential to reverse muscle loss. We don't know this specifically regarding swallow function, but research shows improvements in the skeletal muscles.
Swallow Exercise. What does resistance exercise look like in terms of swallow exercises? The exercises in our toolbox that would be considered resistance exercises include:
- Shaker/Head lift exercise
- Chin tuck against resistance
- Masako/Tongue hold exercise
- Mendolsohn maneuver
- Iowa Oral Performance Instrument (IOPI), Lingual press
- Expiratory Muscle Strength Training (EMST)
I'm not going to go into these in detail. But these are the exercises that would be considered resistance exercises. My favorite exercise is the effortful swallow, which is not technically a resistance exercise. It does result in some increase in pressure, so it may have some utility for folks with sarcopenic dysphagia. It is probably more of a skill retraining tool. Therefore, in individuals with sarcopenic dysphagia, effortful swallow may not necessarily be the way to go.
There are some options for pharmacological interventions. There aren't any specific drugs that are prescribed to treat sarcopenia, to treat muscle loss, but physicians and pharmacists work together to reduce those drugs that might be increasing fall risk. There's some evidence to suggest that vitamin B12 might have some protective effect against sarcopenia. Some studies have also looked at hormone supplementation, which may have an impact on muscle function, but the authors concluded that the side effects outweighed the benefits in those studies. Vitamin D supplementation might have some preventative effects in terms of preventing sarcopenia and may potentially enhance the effects of exercise. So, vitamins B12 and D may have some preventative roles to play.
Oral Health Interventions
As I mentioned earlier, good oral care and dental care for patients is so important. We want to identify and remediate oral health problems as quickly as possible. Interventions from our colleagues in occupational therapy and physical therapy help improve independence and promote better oral care.
There are a couple of oral health assessment tools that you can include as part of your clinical assessment. These are downloadable and in the public domain:
- Oral Health Assessment Tool (OHAT) - https://www.cgakit.com/ohat
- Brief Oral Health Assessment Tool - https://hign.org/sites/default/files/2020-06/Try_This_General_Assessment_18.pdf
Diet modification should be carefully considered for individuals with sarcopenic dysphagia. We need to weigh the risks and benefits:
- Potential for further disuse atrophy?
- Potential impact on medication availability?
- Access? Need for assistance?
- Risk of dehydration, nutritional compromise related to decreased intake? (Remember, 30kcal+/kg/day!)
We must carefully consider the potential consequences of dietary modification in individuals with sarcopenic dysphagia. If we bring the diet levels down and they are too restrictive, then we may be adding to that disuse atrophy because the person doesn't need to use those muscles. We need to think very carefully about disuse atrophy in this population.
We also need to be mindful of the potential for nutritional compromise. If we bring a diet down to puree and your patient doesn't eat it because it's not appealing, we may be making things worse. We may be exacerbating the nutritional compromise and therefore exacerbating the sarcopenia. So, we must carefully consider our dietary modifications and restrictions in this population.
There are many things that we can do as a team to prevent sarcopenic dysphagia and prevent sarcopenia and frailty:
- Increase activity levels, particularly among hospitalized individuals, those in LTC
- Provide ongoing nutritional support, screening
- Advocate for access to dental care, oral hygiene programming
- Pharmaceutical oversight
We can provide activities to increase mobilization and activity in patients who are hospitalized and patients who are in skilled nursing facilities. We can show that patients are getting screened for swallow dysfunction and nutritional compromise. We can advocate for access to dental care and oral care. And, we can advocate for good pharmaceutical oversight to reduce some of the effects of polypharmacy in this population.
Questions and Answers
Can we use the term sarcopenic dysphagia in our charting since it appears to be a diagnostic term? Would we say something about swallow muscle atrophy consistent with sarcopenic dysphagia in a patient who's already received a sarcopenia diagnosis from an MD? Or how might we work that into our reports and notes?
If you think back to that official diagnosis of sarcopenic dysphagia, the defining characteristic is documented muscle mass loss as documented via imaging. We may not always have that. But I would say that when the patient has a diagnosis of generalized sarcopenia and the absence of other potential causative factors of dysphagia, we would treat it as if it were sarcopenic dysphagia. In terms of how we document it, it does make sense to use terminology like "characteristic of..." and "consistent with..." because we're not going to have that actual diagnosis.
How about the term oral frailty? Is that something that we can use?
It's a fairly well-defined term, and assessment of oral frailty is fully within our scope. So, I would say that that would be an appropriate term to use.
Do patients with respiratory sarcopenia benefit from respiratory trainers like the breather or other inspiratory-expiratory muscles strength training?
It's not a very well-studied population yet, but yes, they do seem to benefit from that resistance exercise. Absolutely.
You talked about muscle strength's impact on pneumonia. Have you seen this same impact in infants?
I can't say that I have. But, that's just based on my own clinical experience. There are no studies that I'm aware of that looked at that potential impact in anything other than the elderly population. In terms of my personal clinical experience, I wouldn't say that I've been able to define it as clearly as being related to pneumonia. Often those babies are compromised, they're premature, they're low birth weight, etc. There are a lot of other factors that make it more complicated and a little harder to weed out exactly what might be going on.
Allen, J., Greene, M., Sabido, I., Stretton, M., & Miles, A. (2020). Economic costs of dysphagia among hospitalized patients. The Laryngoscope, 130(4), 974–979.
Bahat, G., et al (2019). Association between Dysphagia and Frailty in Community Dwelling Older Adults. The Journal of Nutrition, Health & Aging, 23(6), 571–577.
Bahia, M. M., & Lowell, S. Y. (2020). A Systematic Review of the Physiological Effects of the Effortful Swallow Maneuver in Adults With Normal and Disordered Swallowing. American Journal of Speech-Language Pathology, 29(3), 1655–1673.
Banda, K. J., et al (2021). Prevalence of Oropharyngeal Dysphagia and Risk of Pneumonia, Malnutrition, and Mortality in Adults Aged 60 Years and Older: A Meta-Analysis. Gerontology, 1–13. Advance online publication.
Bennett, A., et al (2014). Prevalence and impact of fall-risk-increasing drugs, polypharmacy, and drug-drug interactions in robust versus frail hospitalised falls patients: a prospective cohort study. Drugs & Aging, 31(3), 225–232.
Brates, D., & Molfenter, S. (2021). The Influence of Age, Eating a Meal, and Systematic Fatigue on Swallowing and Mealtime Parameters. Dysphagia, 36(6), 1096–1109.
Can, B., et al (2021). Sarcopenic dysphagia following COVID-19 infection: A new danger. Nutrition in clinical practice: Official publication of the American Society for Parenteral and Enteral Nutrition, 36(4), 828–832.
Cangussu, L. M., et al. (2015). Effect of vitamin D supplementation alone on muscle function in postmenopausal women: a randomized, double-blind, placebo-controlled clinical trial. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 26(10), 2413–2421
Cereda, E., et al (2016). Nutritional status in older persons according to healthcare setting: A systematic review and meta-analysis of prevalence data using MNA®. Clinical nutrition (Edinburgh, Scotland), 35(6), 1282–1290.
Cha, S et al (2019) Sarcopenia is an independent risk factor for dysphagia in community-dwelling older adults. Dysphagia, 34, 692-97
Chang, M. C., & Kwak, S. (2021). Videofluoroscopic Swallowing Study Findings Associated With Subsequent Pneumonia in Patients With Dysphagia Due to Frailty. Frontiers in Medicine, 8, 690968.
Chen, K. C., et al (2021). Sarcopenic Dysphagia: A Narrative Review from Diagnosis to Intervention. Nutrients, 13(11), 4043.
Cichero J. (2018). Age-Related Changes to Eating and Swallowing Impact Frailty: Aspiration, Choking Risk, Modified Food Texture and Autonomy of Choice. Geriatrics (Basel, Switzerland), 3(4), 69.
Cohen, S. M., et al. (2020). Association Between Dysphagia and Inpatient Outcomes Across Frailty Level Among Patients ≥ 50 Years of Age. Dysphagia, 35(5), 787–797.
Cruz-Jentoft, A. J., & Sayer, A. A. (2019). Sarcopenia. Lancet (London, England), 393(10191), 2636–2646.
de Sire, A., et al (2022). Sarcopenic Dysphagia, Malnutrition, and Oral Frailty in Elderly: A Comprehensive Review. Nutrients, 14(5), 982
Etter, N. M., & Madhavan, A. (2020). Changes in Motor Skills, Sensory Profiles, and Cognition Drive Food Selection in Older Adults With Preclinical Dysphagia. Journal of Speech, Language, and Hearing Research: JSLHR, 63(8), 2723–2730.
Feng, X., et al (2013). Aging-related geniohyoid muscle atrophy is related to aspiration status in healthy older adults. The Journal of Gerontology. Series A, Biological sciences and medical sciences, 68(7), 853–860)
Fırat Ozer, F., et al (2021). Relationship Between Dysphagia and Sarcopenia with Comprehensive Geriatric Evaluation. Dysphagia, 36(1), 140–146.
Fujishima, I., et al (2019). Sarcopenia and dysphagia: Position paper by four professional organizations. Geriatrics & Gerontology International, 19(2), 91–97.
Ganapathy, A., & Nieves, J. W. (2020). Nutrition and Sarcopenia-What Do We Know? Nutrients, 12(6), 1755.
Hägglund, P., et al (2019). Older people with swallowing dysfunction and poor oral health are at greater risk of early death. Community Dentistry and Oral Epidemiology, 47(6), 494–501.
Hathaway, B., et al (2014). Frailty measurements and dysphagia in the outpatient setting. The Annals of Otology, Rhinology, and Laryngology, 123(9), 629–635.
Huang, E. Y., & Lam, S. C. (2021). Review of frailty measurement of older people: Evaluation of the conceptualization, included domains, psychometric properties, and applicability. Aging Medicine (Milton (N.S.W)), 4(4), 272–291.
Hung, H. C., Colditz, G., & Joshipura, K. J. (2005). The association between tooth loss and the self-reported intake of selected CVD-related nutrients and foods among US women. Community Dentistry and Oral Epidemiology, 33(3), 167–173.
Hutcheson, K. et al (2018). Cough strength and expiratory force in aspirating and nonaspirating postradiation head and neck cancer survivors. The Laryngoscope, 128(7), 1615–1621.
Hutton, B., Feine, J., & Morais, J. (2002). Is there an association between edentulism and nutritional state? Journal (Canadian Dental Association), 68(3), 182–187.
Komatsu, R., et al (2018). Aspiration pneumonia induces muscle atrophy in the respiratory, skeletal, and swallowing systems. Journal of Cachexia, Sarcopenia and Muscle, 9(4), 643–653.
Kunieda, K.,et al. (2021). Relationship Between Tongue Pressure and Pharyngeal Function Assessed Using High-Resolution Manometry in Older Dysphagia Patients with Sarcopenia: A Pilot Study. Dysphagia, 36(1), 33–40.
Leder, S. B., et al (2009). Answering orientation questions and following single-step verbal commands: effect on aspiration status. Dysphagia, 24(3), 290–295.
Liu, C. J., & Latham, N. K. (2009). Progressive resistance strength training for improving physical function in older adults. The Cochrane database of systematic reviews, 2009(3), CD002759.
Love, A. L., Cornwell, P. L., & Whitehouse, S. L. (2013). Oropharyngeal dysphagia in an elderly post-operative hip fracture population: a prospective cohort study. Age and Aging, 42(6), 782–785.
Madsen, G., et al (2020). Prevalence of Swallowing and Eating Difficulties in an Elderly Postoperative Hip Fracture Population-A Multi-Center-Based Pilot Study. Geriatrics (Basel, Switzerland), 5(3), 52.
Maeda, K., & Akagi, J. (2016). Sarcopenia is an independent risk factor of dysphagia in hospitalized older people. Geriatrics & Gerontology International, 16(4), 515–521.
Mateos-Nozal, J., et al (2021). Oropharyngeal dysphagia in older patients with hip fracture. Age and Aging, 50(4), 1416–1421.
Nagano, A., et al (2021). Respiratory Sarcopenia and Sarcopenic Respiratory Disability: Concepts, Diagnosis, and Treatment. The Journal of Nutrition, Health & Aging, 1–9. Advance online publication.
Nagano, A., et al (2020). Effects of Physical Rehabilitation and Nutritional Intake Management on Improvement in Tongue Strength in Sarcopenic Patients. Nutrients, 12(10), 3104.
Nardone, O. M., et al 2021). Inflammatory Bowel Diseases and Sarcopenia: The Role of Inflammation and Gut Microbiota in the Development of Muscle Failure. Frontiers in Immunology, 12, 694217.
Nomoto, A., et al(2022). Poor oral health and anorexia in older rehabilitation patients. Gerodontology, 39(1), 59–66.
Ogawa, N.,et al. (2021). Digastric muscle mass and intensity in older patients with sarcopenic dysphagia by ultrasonography. Geriatrics & Gerontology international, 21(1), 14–19.
Oh J. C. (2021). Systematic Effortful Swallowing Exercise Without External Resistance Does Not Increase Swallowing-Related Muscle Strength in the Elderly. Dysphagia, 36(3), 465–473.
Okazaki, T.,et al (2021). Respiratory Muscle Weakness as a Risk Factor for Pneumonia in Older People. Gerontology, 1–10. Advance online publication.
Rofes, L., et al (2010). Pathophysiology of oropharyngeal dysphagia in the frail elderly. Neurogastroenterology and motility: the official journal of the European Gastrointestinal Motility Society, 22(8), 851–e230.
Sella-Weiss O. (2021). Association between swallowing function, malnutrition and frailty in community dwelling older people. Clinical nutrition ESPEN, 45, 476–485.
Sheiham, A., & Steele, J. (2001). Does the condition of the mouth and teeth affect the ability to eat certain foods, nutrient and dietary intake and nutritional status amongst older people? Public Health Nutrition, 4(3), 797–803.
Sheiham, A., et al (1999). The impact of oral health on stated ability to eat certain foods; findings from the National Diet and Nutrition Survey of Older People in Great Britain. Gerodontology, 16(1), 11–20.
Shimizu, A., Fujishima, I., Maeda, K., Wakabayashi, H., Nishioka, S., Ohno, T., Nomoto, A., Kayashita, J., Mori, N., & The Japanese Working Group On Sarcopenic Dysphagia (2021). Nutritional Management Enhances the Recovery of Swallowing Ability in Older Patients with Sarcopenic Dysphagia. Nutrients, 13(2), 596.
Takeuchi, K., et al (2014). Nutritional status and dysphagia risk among community-dwelling frail older adults. The Journal of Nutrition, Health & Aging, 18(4), 352–357.
Uchitomi, R., Oyabu, M., & Kamei, Y. (2020). Vitamin D and Sarcopenia: Potential of Vitamin D Supplementation in Sarcopenia Prevention and Treatment. Nutrients, 12(10), 3189.
Wakabayashi H. (2014). Presbyphagia and Sarcopenic Dysphagia: Association between Aging, Sarcopenia, and Deglutition Disorders. The Journal of Frailty & Aging, 3(2), 97–103.
Wakabayashi, H., et al (2015). Head lifting strength is associated with dysphagia and malnutrition in frail older adults. Geriatrics & Gerontology International, 15(4), 410–416.
Wakabayashi, H., & Sakuma, K. (2014). Comprehensive approach to sarcopenia treatment. Current Clinical Pharmacology, 9(2), 171–180.
Wakabayashi, H., Kishima, M., Itoda, M., Fujishima, I., Kunieda, K., Ohno, T., Shigematsu, T., Oshima, F., Mori, T., Ogawa, N., Nishioka, S., Yamada, M., Ogawa, S., & Japanese Working Group on Sarcopenic Dysphagia (2021). Diagnosis and Treatment of Sarcopenic Dysphagia: A Scoping Review. Dysphagia, 36(3), 523–531.
Woo J. (2018). Nutritional interventions in sarcopenia: where do we stand? Current Opinion in Clinical Nutrition and Metabolic Care, 21(1), 19–23.
Yamada, M., et al 2012). Nutritional Supplementation during Resistance Training Improved Skeletal Muscle Mass in Community-Dwelling Frail Older Adults. The Journal of Frailty & Aging, 1(2), 64–70.
Zhu, Y., & Hollis, J. H. (2014). Tooth loss and its association with dietary intake and diet quality in American adults. Journal of Dentistry, 42(11), 1428–1435.
Mansolillo, A. (2022). Sarcopenia, Frailty and Dysphagia. SpeechPathology.com. Article 20530. Available at www.speechpathology.com