Move over Presbyphagia, there’s a new sarcopenic dysphagia in town

Title: The Prevalence and Prognosis of Sarcopenic Dysphagia in Patients Who Require Dysphagia Rehabilitation

Author: Wakabayashi, H., Takahashi, R. & Murakami, T.

Journal: Journal of Frailty and Aging

Year of Publication: 2018

Purpose: “The purpose of this study was to assess the prevalence and prognosis of sarcopenic dysphagia in patients who require dysphagia rehabilitation”

Population: adult patients with dysphagia, receiving dysphagia treatment at an acute-tertiary hospital in Japan

Inclusion: > 65 years old; prescribed dysphagia rehabiliation by physiatrists; could provide informed consent

Exclusion: moderate or severe conscious disturbances and/or higher brain dysfunction; patients with missing values (handgrip strength, tongue pressure)


 

This one took me by surprise and was initially picked because of the short length (ya know how you just grab an article to pass the time?) and the topic of sarcopenia + dysphagia intrigues me. So anything that could have the potential to help me determine why someone has dysphagia and what to do about it gets a “save” in my book.

Literally the very first thoughts I had before reading were “Is there a difference between sarcopenic dysphagia and presbyphagia?” “What’s the difference and just how are they different?”

Turns out, there is! After a quick search for just those thoughts, I was led to the authors’ first publication that defines just that. Unfortunately, the article is not public access as of now (still working on obtaining a copy and am excited to review it soon!), but just the abstract enlightened me:

“Presbyphagia refers to age-related changes in the swallowing mechanism in the elderly associated with a frailty in swallowing. Presbyphagia is different from dysphagia. Sarcopenic dysphagia is difficulty swallowing due to sarcopenia of generalized skeletal muscles and swallowing muscles. Age-related loss of swallowing muscle mass becomes evident in the geniohyoid muscle and tongue.”  Abstract, Presbyphagia and Sarcopenic Dysphagia: Association between Aging, Sarcopenia, and Deglutition Disorders.  https://www.ncbi.nlm.nih.gov/pubmed/27049901

Apparently, one can have “whole-body” sarcopenia, and sarcopenic dysphagia which affects specifically the loss of muscle mass/function of skeletal and swallowing muscles, and have both along with dysphagia from a related disease/disorder (e.g. TBI, stroke, cancer, etc.). Obviously these individuals of at least age 65 likely have other multiple factors, but talk about your 1-2 punch?!

Back to the current article that is trying to look at how common sarcopenic dysphagia is and what the prognosis would be….


What exactly were they looking at to find changes (if any) and what may have contributed to them?

  • sarcopenia “types”  (one group=”probable sarcopenic dysphagia+possible sarcopenic dysphagia,” one group=”no sarcopenic dysphagia“)
  •  Barthel Index for activities of daily living
  • Geriatric Nutritional Risk Index (GNRI) for nutritional status
  • BMI / current body weight / ideal body weight / total energy intake
  • “maximum tongue pressure-measuring instrument” for tongue pressure
  • Food Intake Level Scale (FILS)

So basically, a lot of similar measurements we look at either clinically or what we read in the research (BTW the population setting is in Japan hence the comparisons). Quick note, FILS is very similar to our version of the Functional Oral Intake Scale (FOIS), however as far as I know there haven’t been any studies comparing the two (if you know they’re out there send ’em my way!!).

It should also be noted that in order to define and diagnose “sarcopenic dysphagia,” the authors used a “reliable and validated 5-step diagnostic algorithm” which included the following:

       1. whole body sarcopenia (skeletal muscle strength)                                                                     2. whole body sarcopenia (skeletal muscle mass)                                                                           3. presence of dysphagia                                                                                                                       4. causes of dysphagia                                                                                                                           5. swallowing muscle strength

I can’t really get too much more into that algorithm because I’ll be honest that I haven’t heard or seen much about it, but it is interesting to see if this will or already is something being commonly used?!

After all the “stats magic” comparing the differences between:

  • those patients with and without sarcopenic dysphagia
  • if there were any correlations in patients’ FILS, GNRI, age, Barthel Index, energy intake, and a C-reactive protein (sorry don’t have the slightest idea about that last one)
  • if discharge FILS could be independently associated with patients having sarcopenic dysphagia (after they filter out the “others” like age, sex, and the initial FILS)

What did they find?

sarcopenia table

The quick and dirty of it is the 2 groups (some type of sarcopenic dysphagia or no sarcopenic dysphagia) had significantly differed in a lot of the original measures the investigators looked at (e.g. initial/discharge FILS, BMI, handgrip strength, calf circumference, serum albumin, along with those listed above). The sarcopenic group also had lower FILS at initial and discharge, meaning their functional oral intake was lower from the beginning to the end when compared to anyone that was not determined to have the swallow muscle wasting disorder.

Lastly, after looking back and piecing out (mathematically speaking) if age, gender, the initial FILS, and the presence of sarcopenic dysphagia could have contributed to the discharge FILS score, the authors found that all but age were independently associated. 

“This is the first study examining the prevalence and prognosis of sarcopenic dysphagia in patients who require rehabilitation. The prevalence of sarcopenic dysphagia was 32%. Sarcopenic dysphagia was independently associated with poor swallowing function at discharge.”  p. 3

My main qualm that I’m trying to debate in my head is the last statement. In my mind, I would have liked a different terminology or “swallowing function as it relates to diet/intake” since it seems they are using more of a scale for oral intake as their ‘prognosis’ indicator. Yes, it can measure dysphagia severity, but I guess my mind just tends to think of physiological swallow function when I see that term being used.

I also couldn’t help but have additional questions when the authors introduced a broad idea of patients categorized as “generalized nonspecific dysphagia” as the main cause versus specific etiology (e.g. surgery, stroke, etc.) as having probable/possible sarcopenic dysphagia due to deconditioning/frailty because “no obvious causes of dysphagia were observed.” Is this population really the ones to look for sarcopenic dysphagia then?

“Sarcopenic dysphagia may be included in ‘something else’ and in dysphagia caused by advanced age. Therefore, it appears that sarcopenic dysphagia is a common cause of dysphagia. The possibility of sarcopenic dysphagia should be suspected in all older patients with dysphagia.”  p. 4

I am so curious to hear others’ perspectives and thoughts on this? Should we have standard measures we look at to distinguish sarcopenic dysphagia? Should we start having protocols or screenings for those that are over a certain age? Are we really brushing off the “it’s just aging” issues that really may be presbyphagia and now, possibly sarcopenic dysphagia?

Before maybe going that far, I think while the article could help step us into yet another new direction for who/what/how/when/why to see in our medical facilities, there’s a few more things to consider….


Limitations:

The authors only looked at one location which happened to be an acute hospital with length of stay ~12 days, obviously limiting if the conclusions can be generalizeable, even if they did have over 100 participants. One other thing I felt seemed strange was the fact that all patients were scheduled for their speech therapy, with session doses from 2-5 times a week, and durations ranging between 20-40 minutes in length. Since my “rehabilitation” cap is usually always on, that big of a range to me could make a difference based on the nature of rehabilitation..

Patients who had an obvious cause of dysphagia were excluded from the study.However, patients with stroke, brain injury, neuromuscular disease, head and neck cancer, or connective tissue disease were still included if it was considered that their dysphagia was mainly attributed to age, activity, nutrition, invasion, or cachexia-related sarcopenia. Personally, I really would have liked to know more about just how they made this determination (especially because as a clinician I for sure know that it can be so dang hard to pinpoint exactly why this is happening!?!).

The authors also agreed their exclusion of patients who had “consciousness disturbances” and “higher brain dysfunction” due to inability to provide informed consent also could have impacted the prevalence number claimed.

How can you use this article?!?

I am very sure there are other possibilities for limitations or little details that may have been overlooked or could have been improved to make the study stronger, I’d love to hear other opinions or thoughts!! Or if you’ve heard of any of the measures used?!?



But for now, I can say that I am looking forward to future studies where we can distinguish sarcopenic dysphagia from presbyphagia across multiple facility settings (skilled nursing, rehab hospitals, LTACH, etc.) and also what our field takes away from this in the growing need for interdisciplinary intervention. How do you think increased collaboration could help with finding and receiving these individuals? I already know my other rehabilitative colleagues and medical staff are aware I could talk their ears off, but now I have a new reason to burst into the department office and strike up a conversation with new material 😀

creepy neighbor

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Takeways:

  • “These data are important, because sarcopenic dysphagia can be treated with a combination of rehabilitation and aggressive nutrition care intervention, with an energy intake of approximately 35kcal/kg/day (ideal body weight) to improve muscle mass and function.”
  • “rehabilitation, including resistance exercises of the swallowing and general muscles, and aggressive nutrition intervention to increase muscle mass
    and strength should be performed in patients with sarcopenic dysphagia.”

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Article Referenced:

Wakabayashi, Hidetaka & Takahashi, R & Murakami, T. (2018). The Prevalence and Prognosis of Sarcopenic Dysphagia in Patients Who Require Dysphagia Rehabilitation. The journal of nutrition, health & aging. 23. 10.1007/s12603-018-1117-2.

https://www.ncbi.nlm.nih.gov/pubmed/30569074

 

 

 

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